Putting Off Surgery
After delaying her knee replacement surgery for five years, Judy is finally starting to feel better. She tried to manage the pain with over the counter medications, but the impact of the chronic pain on her life continued to grow. “I kept putting it off and putting it off,” says Judy. “But it got to the point where I was in constant pain; I could hardly walk. I finally felt like I needed to do something about it.”
Judy had undergone a less invasive arthroscopic knee surgery a few years prior, so she already had a relationship with her orthopedic surgeon. He recommended she have the surgery after a set of x-rays showed Judy’s left knee had degenerated to bone-on-bone due to age and osteoarthritis. The joint damage had also led to the formation of bone spurs. She was in pain every day, was struggling on the stairs, and could no longer do her daily activities without feeling pain and hearing cracking and popping in her knee. She was taking pain killers on a regular basis to get through the day.
Although the condition was painful, Judy thought she could manage with over the counter medication. She learned to live with the pain in her knee for about five years. During a routine check-up, her primary care doctor noticed she was having a difficult time getting around. He helped her fill out a series of questions called Patient-Reported Outcome Measures (PROMs) for knee pain, where she scored a 48 out of 100 on the Knee Osteoarthritis Outcome Score (KOOS). A score of 48 meant she had severe difficulty doing routine activities like rising from a chair or putting on socks. Her primary care doctor urged her re-think the surgery.
After putting it off for half a decade, Judy finally scheduled a total knee replacement at Brigham and Women’s Faulkner hospital. She was relieved her knee would be fixed, but she knew surgery was only the beginning. The first few weeks after surgery are very painful, and the healing process to full recovery can take 4-6 months. “I understood that it was going to be a long process to get back on my feet—I mean really get back on my feet,” says Judy.
Judy stayed in the hospital two days, briefly transitioned to a Spaulding Rehabilitation Facility, and then returned home. She was visited by both an at-home nurse as well as an at-home physical therapist through the Partners at Home program. At-home nurses check on patients to make sure their incision is healing properly and to manage their pain. The physical therapist works more on getting patients up and moving again. Margaret (“Meg”) Griffith, PT, DPT, Judy’s at-home physical therapist, explains that the at-home recovery period is a crucial step in the healing process. “In the hospital physical therapy is always really basic. Can they get out of bed? Can they walk 25 feet?” says Griffith. “Home care is the next step: getting her a little more mobile, getting her knee moving a little smoother, and just being able to negotiate her home surroundings with the hope that we can get her independent.”
Healing at Home
Griffith enjoys going to people’s homes because it usually feels more relaxed compared to the surgical ward. “They’re less stressed out,” she says. “You can take it at their pace.” Sometimes patients take a little while to get back up on their feet, but Judy was getting around pretty well and was ready to get back into action. “At the beginning it was rather painful trying to get on board with it,” says Judy. “But after a while it stops being as painful. It gets better.”
Without access to a large therapy room full of equipment, a lot of at-home physical therapy relies on improvised tools. “It’s whatever fits in your car,” says Griffith. “I even brought a little skateboard my kids had to help her with range of motion of her knee so there was less friction.” She also utilizes foam for balance activities or resistance bands for strength training. Griffith met with Judy for about a month, but explains that patients can regularly receive home care for 60 days—or even longer for complicated cases like strokes or severe breaks. The recovery process is dependent on overall health, but depends even more on how much effort the patient puts towards their own recovery. “Judy was a very good patient,” says Griffith. “Of course there were days she would tell me she didn’t want to do certain exercises. She did things on her own terms, but generally she really wanted to work with me.”
Transitioning to “Normal”
Judy’s progress was steadily increasing, and she could see for herself how much she had progressed. While at home, Judy utilized a walker to help her around. By the time Griffith cleared Judy for transition to an outpatient rehabilitation clinic at Brigham and Women’s Faulkner Hospital, she was using a cane. “At that point, I didn’t really need the cane. I took it out on long walks just to make sure, you know, if I felt a little nervous or a little shaky,” says Judy.
Judy’s outpatient physical therapist Kristen Benya, PT, DPT, explains that outpatient physical therapy is the final step to getting patients truly back to normal. “We really focus in on finalizing range of motion gains, strength gains, and getting them back to everyday life,” says Benya.
“Judy was awesome,” she says. “She always had a little joke or a little comeback if she was a little nervous about an exercise—I was always laughing with her.” One key aspect of the patient-therapist relationship is trust. Outpatient physical therapy is usually the point where patients need to push themselves more to keep progressing. Patients must rely on physical therapists to know when it’s safe and appropriate to push forward and when to stop and let the body rest. “For Judy, we just went at her pace. She really took autonomy over her therapy process and just ran with it,” says Benya.
Judy continued her outpatient physical therapy for about two months before she felt back to normal. Benya explains Judy actually had two more weeks of sessions scheduled, but Judy decided she was where she needed to be. “She walked in beautifully and said I’m done, I’m good to go,” says Benya. “She was ready.” Judy was right: her score on the Knee Osteoarthritis Outcome Score (KOOS) had increased from 48 to 75 out of 100 representing only mild difficulties with her knee in her daily activities. The role of the physical therapist is more complex than just prescribing a treatment regimen. It’s showing patients what they’re capable of doing, and then helping them improve their own bodies. Benya says, “It’s about teaching them and giving them the autonomy to do it for themselves.”