Ceasing aggressive physical therapy after total knee replacement

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Total knee replacement (TKR) is an elective surgical procedure performed on patients affected by knee joint diseases, such as end stage osteoarthritis.  The demand for TKR in the United States has increased, which increased the demand for optimal results, such as increase range of motion, decrease incidence of infection, etc., after TKR.

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“Above (Far left picture) is what a normal knee looks like. The next picture (middle picture) is what an arthritic knee would like.  The last picture (far right picture) is what a knee replacement would look like.”

 

Evidence suggests that aggressive physical therapy after TKR, is ideal to obtain full range of motion post-operatively.  http://orthopedics.about.com/od/kneereplacement/qt/stiffness.htm. Yet, as orthopedic surgeons continue to perform TKR, they are finding that this evidence is false. http://www.lascolinasrehab.com/services/accelerated-recovery/orthopedic-blog/orthopedic-blog/2013/01/07/rehabilitation-after-a-total-knee-replacement. Patients are unable to achieve full range of motion after aggressive physical therapy because they are causing an inflammatory response in their knee that thickens the soft tissues surrounding the TKR, and decreases the patient’s range of motion.  

 

Surgeons at Hospital for Special Surgery (HSS) found that patients that do not undergo physical therapy have better outcomes then those that do.  HSS instructs patients and physical therapist not to perform aggressive physical therapy after TKR.  Yet, they are reluctant to listen to the surgeons’ opinions and believe friends, or old methods, as oppose to being open to new information.  

 

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“Passive exercise is always good! Never let anyone force your knee back!”

 

In order to combat this issue, we as public health officials should stop aggressive physical therapy. We can do this by educating physical therapists and patients through social support groups, which would provide experiences from patients who have gone through passive/aggressive physical therapy.  Also, we can ask HSS to share their experience and understanding with aggressive physical therapy through seminars/classes, which would help increase awareness.

 

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26 Responses to “Ceasing aggressive physical therapy after total knee replacement”

  1. tribaldwin Says:

    Very interesting example of how we as physicians based on empirical data try to change common community behavior. This is evidenced every day with demands for annual pap smears in women, desires for PSA tests, and bunk about immunizations causing autism.

    In your research how do they characterize active vs. passive range of motion exercise for the knee? Is there a clear difference between aggressive active therapy and pushing a knee to point of resistance or pain? It is my experience that in knee rehab you can set the automated knee flexor and extender to a specific angle of flexion or extension. How does one go through passive range of motion?

  2. jayeawatson1 Says:

    As a physical therapist who works often with patients in this population I do not necessarily agree. First the term “aggressive physical therapy” should be clearly defined. Immobility and totally relying on just passive ROM does not enable active muscle movement and does not facilitate return that would otherwise be present if this patient were to be moving sooner. I would like to see greater research. The detriment of engaging in solely passive range of motion far outweighs the “consequences” of engaging in more active range of motion exercises. Contracture formation is greater, muscular atrophy is greater, sensitization increases, all of which makes it even more difficult for one to actually progress when it comes to working on activities such as ambulation. I am not saying passive ROM is ineffective but as far as I know it should ALWAYS be used in conjunction with an active form of therapy.

    1. Importance of Attenuating Quadriceps Activation Deficits after Total Knee Arthroplasty

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311712/

    2. Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches.

    http://www.ncbi.nlm.nih.gov/pubmed/18448878

    • duggals2013 Says:

      Aggressive physical therapy, is a form of therapy that is performed on patients and inflicts extreme amounts of pain on the patient. Patients should let pain be their guide when undergoing physical therapy. If they are in extreme amounts of pain then that therapy could pose to be harmful as oppose helpful. We have seen many patients that have had great success without physical therapy after TKR and many patients who have had trouble with physical therapy after TKR. For example, one patient was discharged from the hospital after a TKR and the follow day had a gallbladder attack, which caused him to be admitted into a hospital. This patient did not undergo physical therapy and came to see us at 8 weeks post-operatively. At that time he presented with full range of motion and extension.

      You are right a patient should have active physical therapy, but not in such a manner where they are screaming in pain as the physical therapist pushes his/her knee back. Active therapy should be performed where the patient easily bends and straightens his/her knee, with out the physical therapist inflicting pain on the patient.

      Unfortunately, there isn’t much research done in this field, but many orthopedic surgeons recommend that patients undergo passive physical therapy and should use pain as their guide when performing exercise or therapy. If the patient experiences pain, then they should stop the exercise or therapy, as what they are doing is not helping them but hurting them. Yet, I think we should publish something soon about this, and perhaps have other physical therapist learn from the physical therapists at Hospital for Special Surgery. Please don’t think that I think other physical therapists are wrong in doing what they are doing, but through the classes given by Hospital for Special Surgery’s physical therapists other physical therapist will understand why majority of the orthopedic surgeons are asking for their TKR patients to undergo passive physical therapy, as oppose to aggressive physical therapy.

  3. mcwigginsmd Says:

    Very interesting post. I think this definitely warrants further study and I’m not sure whether there will be a generalizable answer for all patients. Total joints patients come with their own unique set of characteristics and challenges to rehab. As far as knees are concerned, most orthopedists will tell you the main predictor of postop ROM is preop ROM, so it is unlkely that all patients will regain full motion with a very conservative PT regimen. In addition, factors such as age, weight, level of activity etc, limit the amount of motion needed for patients to acheive the level of mobility they are looking for. I agree that PT shouldn’t be aggressive to the point of pain, however pain tolerance also varies widely for orthopedic patients. Some can handle a very intense regimen whereas others can’t even stand to be touched lightly on the operative extremity. Conditions such as complex regional pain syndrome must be taken into account as well. Overall, I am of the opinion that any generalization must be done cautiously as you will always run the risk of missing the outliers.

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  5. Debbie Lanspery-Carson Says:

    I am currently going through PT for TKR. Part of my therapy includes aggressive forceful bending of my knee by the therapist. I have never felt such pain in my life! I already have anxiety issues and take anti anxiety medications and I have to double it just to go to PT. I can handle everything else I do there even with the muscle pain, but the aggressive therapy at the end of each session makes me writhe with pain and even when I’m begging the therapist to stop, she keeps going! I don’t even want to go back. After this forced bending I have pain and swelling the rest of the day and can barely move. I have to take more pain killer after ward just to be able to sleep that night. I am going to talk to my doctor today about removing that particular activity from my therapy routine. I don’t think my therapist will be happy because she seems to be unhappy with me as I beg for her to stop and then refuse to let her do it again right after that. If I had known about this ahead of time, I’m not sure I would have had the surgery.
    Debbie

  6. Kathryn Ennis Says:

    OK, as a TKR patient I agree with passive therapy with ROM exercises. Every time I am performing these exercises, I am screaming and crying with pain. I spend a whole day icing and it never completely takes away the swelling. I am now going to switch gears with my PT. I believe I will push to a point of pain but not crying and screaming. It is not normal. It just does not make sense. I believe letting up a little, I will be able to manage my pain meds, the swelling, my sleep, and ROM. I have been up for days trying to make sense out of this aggressive therapy approach that has left me sleepless, in agony, making very small ROM gains, and depressed……and not to mention swollen all the time. I believe there is a small disconnect when it comes to surgeons and PT’s understanding and relating when they simply have never experienced this surgery.

  7. Mahesh MSA Says:

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  8. xuanzhang92 Says:

    This posting catches my eyes by the knee pictures. The comparisons of the normal, broken and artificial knees very clear and straightforward to cut into the topic. One problem is about the links. Could they change to a hyperlink format?

    The evidence against the aggressive physical therapy seems not scientific enough. And if more information about the passive physical therapy is provided, like definition, and how to manage post surgery patients, it could be better. Furthermore, not enough social behavior interventions to solve this problem are provided. The posting mentions public health officials should take action, but from my perspective, interventions could be from some other levels, like strengthening the service from community health representatives, educating and training the residents for individual level interventions, as well as policy improvement from hospital and government level.

    Reference
    An article for fun: http://mepbis.org/docs/pbis1-RtI-Hawken.pdf

  9. fasttracktotalkneesystem Says:

    Interesting blog comment. I am a PT and I completely understand the over aggressive nature of some active assisted therapy. there is a way to be aggressive as possible stay away from increase swelling and pain and get excellent results. I have a book on Amazon that talks about this and explains the 7 principles of recovery. Too long to post here. A link to my book for those who might have more interest. http://goo.gl/Advk97

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  11. Janice Gabriel Says:

    I had a total knee replacement on my right knee 8 weeks ago. I find myself at a mental (and physical) crossroad when it comes to aggressive vs. passive physical therapy following TKR. On one hand I can understand the mindset of aggressive physical (lose it if you don’t use it, no pain-no gain) but as a post-op TKR patient the pain and swelling that comes with this aggressive therapy feels like it sets me back each time. In my pursuit of “fair and balanced” information I happened upon a website called BoneSmart that advocates what I consider to be the other extreme (don’t sit up when you can lie down, etc.) that appears to appeal to the people that are looking for an excuse to not engage in any type of rehabilitation that causes them the slightest discomfort. I believe that everything should be done in moderation which has led me on this quest for additional insights. I would like to see more research done by doctors and physical therapists who can let themselves explore the possibility that they may be doing it all wrong. Perhaps both ways can be effective ….I don’t know. What I do know is that my pain level and swelling have increased since the therapy has gotten more aggressive. Additionally, there seems to be a disconnect between the doctor-patient-physical therapist when it comes to understanding individual thresholds for pain. I am convinced that there is not a “one size fits all” method for recovering from a TKR. I’m just trying to find the size that fits me and it seems that I am on this path alone without the assist of my doctor or physical therapist.

  12. Penni Jakus Says:

    After having two TKR’s two years apart, I fully agree that non-aggressive is the way to go in PT. I had very aggressive PT for my first knee and suffered unimaginable pain and swelling. After 4 months of that, 3x/week, I had to have a MUA (Manipulation under anesthesia) which left me with a 110 degree ROM, not great, but functional.

    What a difference for my second TKR that I had done 7 months ago. Let me tell you I was DREADING the PT, but the protocol has changed, at least around here (Syracuse, NY), and non-aggressive PT was utilized, to my delight and amazement. The therapist would help with the bend only if I requested it, and I got to 125 degrees in 4 weeks. I continue to work out at the gym to keep what ROM I have going. The theory I was told, is that the patient does all the bending themselves, therefore training the muscle themselves.

    I am living proof the non-aggressive PT is not necessary.

  13. Josephine Fox Says:

    “I happened upon a website called BoneSmart that advocates what I consider to be the other extreme (don’t sit up when you can lie down, etc.) that appears to appeal to the people that are looking for an excuse to not engage in any type of rehabilitation that causes them the slightest discomfort.”
    This is my forum and I fully admit to mantras in the very early stages of joint replacement recovery include this one. But it’s aimed at people who over do it to a crazy extent in the belief that more is better and “no pain no gain” is the credo to live by.

    I would also freely admit that I have had two TKRs, 5 years apart, and did NO exercises at all for either of them and my outcomes are excellent, 135/-5 in both cases.

    I have encouraged my members to back off any exercise or activity that increases pain, swelling, stiffness or anything else similar. Of the numerous members who have followed this advise, they have gone from a grossly swollen leg with threats of having to have an MUA (pointless when the reason for the poor ROM is swelling!) and now ‘spread the word’ to other members. In no way do we encourage people to do nothing or be a couch potato. Normal activities are the order of the day and it pays dividends in spades!

    Anyone is more than welcome to come and see for themselves and to read the forum Library where these approaches are put down in writing.

    Oh yes, am I am collecting a file of people who have had serious injuries as a result of aggressive therapy including torn quads and a lifetime with CRPS.

    I am also in the process of writing a paper to be delivered at the British Orthopaedic Congress later this year, discussing this very thing.

  14. Kamaldeep Singh Says:

    It’s really a very interesting post. Last month I go for joint replacement.No one will tell you that you should go joint therapy after joint replacement surgery.I think i can make your joint more strong.

    http://partaniclinic.com/arthroscopy-joint-replacement-in-jaipur/

  15. Cheryl Buhler Says:

    I had both aggressive on my right leg and when it came to my left I quit after two sessions and did the excercises at home. No difference at all.I have great range of motion and its been almost 3 and 3 and a half years .I can walk again and climb rocks at the beach and in concert halls. Aggressive therapy is a crock asfar as I’m concerned.I think it could be harmful.

  16. Josephine Fox Says:

    Interestingly, we on BoneSmart have been encouraging members to avoid the “no pain no gain” mantra in favour of “no pain MORE gain”! Over the past 10 years a number of members have be grateful for this advice and reported an increase in ROM and overall pain scores, not to mention better physical, emotional and mental health.

    To test this out, when I had my knees done (2009 and 2015) I did NO exercising whatsoever, not even so much as a single heel slide and both times got excellent results. I see no reason at all that people should expect to be brutalised in order to get what they will get by treating their knees gently. Not to mention the dangers inherent in such treatment – we have cases of members having their quads tendon torn, of long term, chronic disorders such complex regional pain syndrome cause by such treatment.

    It has a financial aspect too as PT adds considerably to the overall cost of the surgery.

  17. Josephine Fox Says:

    Sorry, that should read “and a decrease overall pain scores”

  18. Alleta Keokuk Says:

    Alleta Keokuk
    I am leaning toward the non aggressive therapy. My experience has been that I get extreme pain and thus have a set back for several weeks, which increases stiffness and loss of mobility gained after weeks of movement. I also have found that for some reason my PT has discouraged water therapy. I recall getting in a pool on my own and how good my knee felt afterwards. Any comments?

  19. Deltta Christina Says:

    I had tkr 5 weeks ago and totally believe in non aggressive recovery! I set a boundary at PT based on common sense and still progress swimming!y😊 Pain that brings tears to your eyes is just crazy and actually counterproductive, not to mention overkill! I may need to quit going to PT because it’s expensive anyway. Love the new knee! And love the blog/forums at BoneSmart!

  20. Linda Bowers Sutch Says:

    I had bilateral tkr 4 months ago. The right knee has been great since day 1. The left had a DVT which went to my lungs and the left knee also bled for 10 days. I went to “rehab” (nursing home) for 4 days and demanded to go home. They only worked on my upper body strength which I had no problem with. I had in home PT for 2 weeks with no problem. I went to outpatient PT up until a week ago. They pushed my knees so hard at the end of each session, I was in tears. Then they were both swollen and hot for two days. My left knee rom was still 90. My doctor told me to stop if I didn’t think it was doing any good. Since then, no pain, no swelling, no inflammation. I’ve been walking every day, stretching, and riding the recumbent bike. Well, yesterday my feet went all the way around. Today, I even pushed the seat closer and had no ptoblem. I’m pretty sure that aggressive PT was doing more harm than good and pushing me towards an MUA. I go back to the doctor in 5 weeks and I’m sure he will be pleased with my progress.

  21. Victoria Nelson Says:

    On earlier posts I read that people thought ‘BoneSmart advocates a ‘don’t sit up when you can lie down’ attitude that appears to appeal to the people that are looking for an excuse to not engage in any type of rehabilitation that causes them the slightest discomfort’. This is an inaccurate assumption and if you are wrong about me, you are likely wrong about others.

    I joined BoneSmart for moral support after being abused by a Physio Terrorist who injured it through forcing my knee to do things it was not able to do yet at 5 days post op. The day after surgery I had 0 extension and my ROM was at 60. At 5 days I had 0 extension and my ROM was at 80 and still recovering … she told me my results weren’t good enough and that I would have to have an MUA. (She isn’t a doctor and I have found out since then that I was doing great.) I told her NOT to touch me but she kept lifting my surgical leg and dropping it, telling me to catch it so it didn’t hit the bed. She made fun of me when I grunted in pain and made sarcastic comments. She triggered an infection with the abuse and she set me back three weeks with her aggressive physio. I was reduced to a ROM of 40 which was less than I started out with and I have had to fight for every bit of ROM I have had since then. I never used the twit’s abuse as an excuse not to do my exercises and in fact, if anything, they have had to hold me back because I was gung ho from the word go to get up, get my ROM, and get on my feet and go!

    The next set back was caused when another PT gave me elastic bands that were too strong and my leg shook and wobbled when I tried to use them and I said they were too strong, he was then going to increase them and make them stronger! WTH? I stopped him from doing it and I was told to use the ones that were already too strong and pulled the tendons in the back of my knee which set me back for another two weeks. That is 5 weeks of not being able to do any physio due to injuries caused by the PTs in 3 months. So basically I could only do physio for 7 weeks in the first 3 months.

    I still have problems with the pulled tendons in the back of my knee and my knee is pretty stiff but I keep moving it. I quit doing all the aggressive physio that hurt and I took a more relaxed approach after the abusive mishaps and now at 3 1/2 months post op I have exceeded their expectations because of dropping physio and doing things on my own. I have even been on the bike twice and my knee has gone around each time … I ‘biked’ for 20 minutes the second day on it. I have no knee caps so I was told I would be more limited and likely only have 90 – 100 ROM. I exceeded that at 110 on my own and with assistance I reached about 125 or more according to my PT so I know I can do that on my own at some point as well. I will be striving for as much ROM as my knee can get. I think 120 ROM and 0 extension are pretty good for someone without knee caps who had a 5 week set back caused by physio terrorists!

    I can endure a lot of pain and will push myself to and through it by myself. Pain is actually less painful and easier to deal with when it isn’t being inflicted on me by someone else. When my other knee gets done I am not contacting physio at all and will do what I can on my own so that I am not set back by their overly aggressive antics. I expect my other leg will recover much quicker and with a lot less pain due to swelling and inflammation caused by the abuse. If and when I reach the point where I might need some assistance I will contact them for it.

  22. Karl Khaki Salvani Sarceno Says:

    Hi!

    I’m a Physical Therapist and a strong advocate for self treatment. Patients should be taught how to treat themselves. As movement specialists, a PT’s role is to guide the patient to his/her recovery. Sometimes, We think we know what’s best for our patients when in fact the patients know themselves the most. Let the patient’s pain be the guide.
    I will stick with the topic on hand which is post op PT TKR. The incision that the doctor inflicted to the patient to replace the knee needed to close. We cannot force the closure, only time can do that. That’s why we have guidelines. 7 days acute where patient needs the PRICE principle- pain meds, rest, icing, compression and elevation. 7-21 days sub acute where patient starts doing gentle exercise to patient’s tolerance. This is where quad sets, and heels slides come to play where you encourage tissue healing by active compression and gentle active stretching by self.
    Encouraging the patient to be the most active participant in the rehab process is very important. Depending on the patient’s tolerance, there are tons of knee flexion exercises. But a knowledgeable PT knows which of the exercises to give the patient at what time of healing that patient is to optimize recovery.
    Forcing a knee to bend is like peeling a wound. THINK OF A CUT KNUCKLE. … How would you let that cut heal? By keeping the knuckle straight! If you keep bending the knuckle, chances are you will keep reopening the cut and the healing period is disrupted and delayed.
    Also common sense dictates if it’s too painful, STOP IT!

  23. Surgivisor Says:

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  24. Alina Babaian Says:

    I am also a PT with 27 years of experience.
    I could never understand when in the past (old school ideas) I would see therapists treating a pt weighed down with 10 lb weight to aggressively stretch any part of the body. Its just wrong!
    I never bought into this idea, there are better ways.
    I agree with Karl. Also if you have pain there is a reason, you may have other things going on that need some hands on attention. Quad tightness, TFL tightness, scarring of soft tissue, patella immobility, adhered scar tissue along incision. PT should assess you knee and the structures around it and treat them in conjunction with your “self active ROM”. . ROM should be to tolerance, you should feel stretch not increased pain. There is some surgical pain just from the trauma of surgery, so early on there may be pain hence the pain meds. however exercise and stretches should not increase your pain , you definitely should not be crying or screaming in pain. If you have an overly active day you may experience some dull achiness at night. Right after surgery first 2 weeks need to ensure swelling is managed, it should gradually improve. We should not forget that many patient have had dysfunction in Knee that has led to arthritic changes/pain/tightness that then in turn requires surgical intervention. Just because the knee is replaced does not mean the structures/muscles around it are also fixed. This is were Physical Therapy is very helpful to retrain your body to integrate the surgical Leg back into the body.
    There are some people who naturally improve. Then there are some who will do the opposite left to their own devices. I have seen both.
    I am currently in home care most pts I see need daily guidance from PT to progress safely and appropriately . In last 5 years I have had 2 pts that just improved with out much intervention. I have aso seen pts on first visit that if not for PT intervention and education were headed for disaster.Obviously I believe in Physical Therapy. If you don’t feel your Therapist is helping you don’t give up on Physical Therapy get one who is responsive to your needs and concerns and is open minded to educate themselves. Hope this is helpful.

  25. scoreboardexpert Says:

    I am so happy I found this. I had tkr on March 20. I am about 8 weeks out. I am stuck at -5 from straight and 100 bend.
    I literal hate going to pt. The pain is excruciating when he forces my leg to bend. This has been 3 times a week for 5 weeks. No more rom. I only take pain pills for therapy then I make certain I take enough. There has to be a better way.
    The evening after therapy I can’t walk. Ice all night. The next day it is still very sore and painful. This pt place has all kinds of awards and keeps telling me it’s necessary. I called my doctor and he said let him do it..so I put up with it.
    Two weeks after my surgery my knee felt good. I was not taking pills because I felt No pain. Now with this therapy I have constant pain again ( like before surgery). I am so discouraged and depressed it’s not even funny. Work keeps calling asking when I can come back. I don’t know.
    What path should I take now? Join a gym and do it myself? Help,
    Bob

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