CT Success by the numbers???

[zimney3pt]

Just got done seeing a total knee patient that saw his operating physician yesterday to get his staples out. The physician wanted to make sure I knew that we needed to get the knee to 125 degrees of flexion.

The sharing of this with the patient to bring back to me I was very thankful. The patient is willing to do what ever we have to in order to get to 125 it doesn't matter how much it hurts. My thought was is this patient any less a person if he only gets 115 degrees? What can he do with 125 that he can't with 115 or even 100 degrees? If he gets to 125 but has constant pain and unable to do the things he wants better and more of a successful outcome then if he only gets 110 degrees with no pain and returns to riding bike and hiking like he wants to? Is success for the patient, surgeon and PT purely in a number (125), are we failures if we don't get to that number (I'm afraid this surgeon has created that thought virus in this patient), yet accomplish what the patient stated he wanted to be able do, which is return to work, ride bike and go hiking with his wife?

I have often thought are we successful based purely on a number? I ran the 800m in High School and College. I was fortunate to have good genetics, some good coaching and training to be able to run under 2 minutes consistently in college (1:52 was my best). My thoughts wonder who would be seen as having a more successful race - me running 2:05 considering I have run much faster or the runner who ran 2:10 when their previous best was 2:20?

Is success just in a number???

[Jackson]

Originally Posted by zimney3pt

Is success just in a number???

Absolutely, I agree with you 100%. About the time I started studying SS, I also had a total knee pt that taught me through the same thought process you just described. Short hx of the pt: mid 40's, former collegiate gymnast, now ran the floor in a large factory. Apparently had quite a bit of varus at the knee which was corrected, but he couldn't flex beyond ~90* in sitting or prone prior to surgery per his report. His surgeon told him 115* was his goal, but when he got to 102* at D/C after 4 weeks, he was absolutely extatic. I can't say that initially I was we had not reached our goal. However, he pointed out that he could now walk with his wife for a mile in the park without hurting or limping, he could climb a tree stand to hunt without feeling unstable and possibly falling, he was able to sit in the car and drive for more than 2 hours without wanting to cut his leg off. I was ok with 102*, and never heard from the surgeon, so assume he was as well.

Functional goals without increased pain should always be more important than hitting the number.

Nick

[joebrence9]

Kory,
Did the surgeon send you this patient pre-surgically? Do we know what his flexion was prior to being cut? Won't this effect the post-surgical motion?

Maybe we should ask the surgeon to participate in a study...I have an idea: We should measure his perceived disability by wearing a brace for a day which limits him to flexion to 110 degrees..We then have him fill out a pain VAS and disability index... The next day, we remove the brace, allowing full ROM but hook up some electrodes and induce nociceptive somatosensory stimuli with all weightbearing activities. Again, have him complete the pain VAS and disability index.

I wonder if he would still think the same way??????

[amacs]

I recall some outcome measure under discussion which required the patient to walk a certain distance, I don't remember which, but it seemed to me it was very arbitrary and based upon a research setting which needed a discreet figure. It had nothing to do with could the patient get to the nearest shop or those mundane everyday things that are otherwise taken for granted.

ANdy

[nari]

I know of someone (aged 72)who had 150 degrees of flexion before the TKR and 120 afterwards. The bonus was there was virtually no pain. The downside was his limited function - unable to squat and sit on the floor. That was the challenge for him to overcome, and it was very disappointing for him. Function sacrificed for no pain. A dubious deal, perhaps, for him.

There are 150 degree implants, built specially for Muslims so they can fully kneel for prayer. This was found out after the event.

Andy, there is a test where if a person can walk 10 metres they can go home. Can't recall its name, but it was very strictly applied to the elderly. The distance was supposedly the 'right' distance for safety. Of course it was done on a smooth, uncluttered hallway and it had nothing to do with negotiating furniture and corners. It annoyed me, and nearly every OT I came across.

Nari.

[Barrett Dorko]

I don't know of course, but I wouldn't be surprised if the surgeon had been previously influenced by some enthusiastic, perky, cheerleady, muscle-bound, mesodermally-minded, glad-handy (take you pick(s)) therapist who said that they could always get this.

The therapist was a great salesperson.

Also an idiot.

[amacs]

Originally Posted by Barrett Dorko

I don't know of course, but I wouldn't be surprised if the surgeon had been previously influenced by some enthusiastic, perky, cheerleady, muscle-bound, mesodermally-minded, glad-handy (take you pick(s)) therapist who said that they could always get this.

The therapist was a great salesperson.

Also an idiot.

There was probably also a nice smiley sales person from the orthopaedic implant company who has no idea what pain is but has an expense account and a quota to fill.

ANdy

[Jon Newman]

Total Knee Arthroplasty: Range of Motion across Five Systems

Schurman, David J MD; Rojer, David E MD

Clinical Orthopaedics & Related Research: January 2005 - Volume 430 - Issue - pp 132-137

Range of motion after total knee arthroplasty is an important variable in determining clinical outcome. The goal of this study was to assess range of motion across five types of posterior-stabilized knee prostheses used sequentially in the same institution during 17 years. The hypothesis was that absolute flexion would improve in newer models of this basic prosthesis design. Only primary knee arthroplasties in patients with osteoarthritis were evaluated. A retrospective analysis was done. Three hundred fifty-eight knees with osteoarthritis were reviewed. The average arc of motion was 103° before surgery and 111° after surgery. Absolute flexion was clinically similar but improved from before surgery (110°) to after surgery (113°). No difference was found when comparing improvements in range of motion among the different types of prostheses used. This study did not show that any knee system made a difference in determining the final range of motion postoperatively. Height emerged as a predictive factor of absolute flexion. Preoperative range of motion is the most important variable in determining improvements in range of motion, with height playing a secondary role.

Level of Evidence: Prognostic study, Level II-1

Does anyone have any other sources that suggest the gain in ROM from pre-op to long term post-op is more than about 10 degrees?

[Jon Newman]

Originally Posted by nari

There are 150 degree implants, built specially for Muslims so they can fully kneel for prayer. This was found out after the event.

Perhaps it wouldn't have mattered.

J Bone Joint Surg Br. 2010 Oct;92(10):1429-34.
Does the new generation of high-flex knee prostheses improve the post-operative range of movement?: a meta-analysis.
Mehin R, Burnett RS, Brasher PM.
Source
Abbotsford Regional Hospital and Cancer Centre, 2080 McCallum Road, Abbotsford, British Columbia, Canada. rmehin@hotmail.com
Abstract
A new generation of knee prostheses has been introduced with the intention of improving post-operative knee flexion. In order to evaluate whether this goal has been achieved we performed a systematic review and meta-analysis. Systematic literature searches were conducted on MEDLINE and EMBASE from their inception to December 2007, and proceedings of scientific meetings were also searched. Only randomised, clinical trials were included in the meta-analysis. The mean difference in the maximum post-operative flexion between the 'high-flex' and conventional types of prosthesis was defined as the primary outcome measure. A total of five relevant articles was identified. Analysis of these trials suggested that no clinically relevant or statistically significant improvement was obtained in flexion with the 'high-flex' prostheses. The weighted mean difference was 2.1° (95% confidence interval -0.2 to +4.3; p = 0.07).

PMID: 20884983

[welcome nowhere]

This reminds me of a recent patient I saw after a total knee. She came to me after about a month of home PT, with range of motion approximately -5 to 115. Pain was mild, but limited her walking, strength was nearly a non-issue, and swelling was mild as well. She was in great shape, especially for her age.

But, either her doctor or her home PT put thoughts in her head that she needed to be at 0 degrees like her other knee. She came in for around 10 visits, mainly to improve her endurance a bit as she took after her husband and the surgery set her back a bit and was having some difficulty in that area and to relieve a little of her lingering pain that the home PT did not acknowledge directly. She did great. But every single session, multiple times within each session, she would focus on her extension and why it wasn't as straight as the other and would it be like that forever. She could not separate that from her thoughts, and it produced some fear in her, along with thinking she needed it to be straight in order to walk up and down her stairs better.

[keithp]

As I have been reading over the last month, TKRs are the population that most readily comes to mind when I try determine what I have been doing right, and what I have been doing wrong. Admittedly, I have previously prided myself on getting what I considered to be good outcomes in my TKR patients, close to 125 flexion, near full ext. Again, admittedly, patients had screamed in pain, performed prone hangs for 10 mins and stretched their knees on stairs (think of a lunge) while sweating profusely. All in search of the mighty holy grail of 0-130. Pain relief was the cold pack at the end of a session and me patting them on the back and telling a patient that pain is something they forget in 6 months (i.e. women KNOW how painful child birth was, but can no longer perceive HOW painful it was 6 months later). I can only imagine how you are cringing at reading the words.

Fast forward to today...I had a patient come in and tell me that she was experiencing pain in the EXACT same place now as prior to surgery; this was disconcerting to her. Instead of telling her that this is to be expected, to push through it, and she will feel better in a few months...I did not push her knee that was only missing 3 degrees of extension. I decided to talk to her about her pain, and why it was likely "feeling" the same now as before (association in the brain between activity and perception of pain) and what she can do to help her brain begin to wrap itself around the idea that motion need not be painful. She then spent 20 minutes participating in some meso-based strengthening activities (all thru a pain-free range) and I sent her home. Next time she comes in I am gong to look at her common peroneal nerve more closely at the fib head as I am fearing that her OA/TKR pain may be related.

To make a long story longer: I am now feeling tugged back and forth by my past and future selves. I know that increasing ROM and strength is VERY important, but I am developing a much better understanding of pain and realize that the objectives that I set forth during an eval (decrease pain, increase ROM and MMT) cannot always be harmonious...which leaves me in a far less comfortable place now, than I was 3 months ago. Such is the way of cognitive dissonance I suppose.

To be honest...I am having a hard time letting go of some numbers (ROM in particular) when weighed against pain. Maybe it is the old blue-collar upbringing (would stand to reason) that says that to do something in pain is better than to not do it all...but, have I been pushing my own personal values (potentially harmful and dysfunctional ones, at that) on patients who may not feel the same way? Ugh...that 12 step program would certainly be helpful at times like these.

(hope this isn't a hijack)

Respectfully,
Keith

[joebrence9]

I am now feeling tugged back and forth by my past and future selves. I know that increasing ROM and strength is VERY important, but I am developing a much better understanding of pain and realize that the objectives that I set forth during an eval (decrease pain, increase ROM and MMT) cannot always be harmonious...which leaves me in a far less comfortable place now, than I was 3 months ago. Such is the way of cognitive dissonance I suppose.

I agree to an extent Keith...As I stated in another thread, I approach things with a "Maitland" mindset...Maitland stated patients were either Pain or Stiff Dominant. Despite many post-op TKA patients having pain as a complaint, they are also very stiff. They often have two conflicting, chief complaints (in Maitlandese, "comparable signs"). I think that we must work on these patients mesodermally to an extent, while also taking into account their pain. We should not just "crank the hell" out of a knee to achieve an optimal range. And we also cannot simply attempt to modulate their pain because they will not regain a functional range. This is a procedure which should take into account ectodermal and mesodermal principles in its treatment. We should attempt to restore the patients to where they want to be functionally without inducing additional nociception.

[Jason Silvernail]

Dr Brence-
Chief Complaint /= Comparable Sign

[zimney3pt]

I can only imagine how you are cringing at reading the words.

No, just reflecting on how many times I did the same thing. And knowing your patients are glad that you are thinking and practicing differently today.

To make a long story longer: I am now feeling tugged back and forth by my past and future selves. I know that increasing ROM and strength is VERY important, but I am developing a much better understanding of pain and realize that the objectives that I set forth during an eval (decrease pain, increase ROM and MMT) cannot always be harmonious...which leaves me in a far less comfortable place now, than I was 3 months ago. Such is the way of cognitive dissonance I suppose.

I always go back to "sore but safe". With a total knee is a good chance there is going to be some pain, most likely there is plenty of inflammation post surgery (nothing spices up the nerve more than some inflammatory soup) probably some mechanical deformation of the nervous tissue and potentially some peripheral and/or central sensitization based on history. But the ROM and strength you are trying to gain is it safe/non-threatening to the patient? Can they get to the edge of the movement where there still is freedom of the movement before it changes into protection?

When I sort through cognitive dissonance I know it will continue to help my patients as I have always strived to do. Becoming comfortable with uncertainty may sound simple but is not easy.

[amacs]

Originally Posted by zimney3pt

Becoming comfortable with uncertainty may sound simple but is not easy.

That seems to me to be a key issue.

ANdy

[joebrence9]

Thanks Jason....Will clarify

Comparable sign = "A comparable joint or neural sign which is a combination of pain, stiffness, and/or spasm which the examiner finds on examination and considers to be comparable with the patients symptoms". Maitland, 1991

[Diane]

Sounds like the Maitland equivalent of a chirosubluxation.

[tonyf315]

RE: comparable sign...My understanding was always basically, find a motion that hurts (or is stiff), do your technique(s) and retest said motion to see if it's better or not...

[Ken Jakalski]

Hi Kory!

I have often thought are we successful based purely on a number? I ran the 800m in High School and College. I was fortunate to have good genetics, some good coaching and training to be able to run under 2 minutes consistently in college (1:52 was my best). My thoughts wonder who would be seen as having a more successful race - me running 2:05 considering I have run much faster or the runner who ran 2:10 when their previous best was 2:20?

Is success just in a number???

I'm strealing this! Very good stuff...and a 1:52 is a very good time.

[amacs]

Originally Posted by zimney3pt

I have often thought are we successful based purely on a number? I ran the 800m in High School and College. I was fortunate to have good genetics, some good coaching and training to be able to run under 2 minutes consistently in college (1:52 was my best). My thoughts wonder who would be seen as having a more successful race - me running 2:05 considering I have run much faster or the runner who ran 2:10 when their previous best was 2:20?

Is success just in a number???

May be it is in a culture where success is measured by numbers - how much you earn for example would be a common denominator. Western culture loves numbers makes it easy to pigeon hole ppl and keep them in an orderly pile where they can be stratified, codifed, insured, measured, controlled(?)

maybe its not the numbers that are the problem its what we think of or value as success

ANdy
who stops on the brink of ranting - again.

[Diane]

ANdy, please feel free to rant.

[keithp]

Originally Posted by joebrence9

We should attempt to restore the patients to where they want to be functionally without inducing additional nociception.

Originally Posted by zimney3pt

No, just reflecting on how many times I did the same thing. And knowing your patients are glad that you are thinking and practicing differently today.

I always go back to "sore but safe".

When I sort through cognitive dissonance I know it will continue to help my patients as I have always strived to do. Becoming comfortable with uncertainty may sound simple but is not easy.

Thanks for your input guys...it is funny (although not "HaHa" funny) how despite having numerous textbooks throughout my professional life, a patient-centered book ("Explain Pain) coupled with some input from SSers can change the mindset of this clinician away from simply "looking at the numbers" to determine what is, or is not, a successful outcome (and then applying the most scientifically defensible methods to attain that outcome).

Respectfully,
Keith

[TexasOrtho]

I've had one patient who attained slightly more than 125 with a unicompartmental prosthesis. Honestly when patients get loads of motion (particularly hyperextension) I get a bit anxious about prosthetic failure. My median outcome for flexion is probably 110 plus/mnus 5 degrees.

The doctor wanting 125 sounds like a lunatic regardless of his/her influences.

[zimney3pt]

Originally Posted by Ken Jakalski

Hi Kory!



I'm strealing this! Very good stuff...

Steal away, Ken, I've taken plenty of your stuff as well...We'll call it even

[keithp]

Originally Posted by TexasOrtho

I've had one patient who attained slightly more than 125 with a unicompartmental prosthesis. Honestly when patients get loads of motion (particularly hyperextension) I get a bit anxious about prosthetic failure. My median outcome for flexion is probably 110 plus/mnus 5 degrees.

The doctor wanting 125 sounds like a lunatic regardless of his/her influences.

I can say that this has been regionally specific for me. In the NYC suburbs I was regularly D/Cing patients with 125 flex, and I felt as though I was "missing the mark" with anything less. When I moved more north and away from the city (by 4 hours), my patients "all of a sudden" started yielding something closer to 110-115. My guess was that it was a product of:

1. difference in patients pre-op (the patients up north wait longer, and go in without pre-hab which was common in NYC)
2. body-type: downstate OA seemed more "activity-dependent" while upstate OA seemed more associated with obesity. Pt's that MDs down-state wouldn't even touch (to prevent their outcomes from looking poor) were regularly coming into my clinic now
3. Quality of the surgeon

Respectfully,
Keith

[maddog]

I'd like to throw out another question please, which I think is appropriate to this thread.

I am seeing a woman s/p R TKA who is making good progress and nearing discharge. She had the L knee done a few years ago and had a subsequent surgery to "clean up adhesions," and was quite concerned this time around that the same did not happen. She lacks about 10 degrees of extension on the L. She is 72 yo, RN at a SNF and plans to return to work full time in late August.

My question is regarding the asymmetry now present with the R achieving full extension while the L is lacking 10 degrees. Any thoughts about the difference between the two. I spoke with an orthopedist about this (not the surgeon, who is away on medical leave), and he said to go for full extension on the R.

Any thoughts are more than welcome, and hope this is appropriate to this thread. If not, I will certainly repost in a new thread.

Respectfully, Tom

[Jon Newman]

ROM gains have been noted up to 2 years post-op. I'll find the source if you're interested. Perhaps she just isn't on someone else's time frame.

I think the MD's imposition of a specific ROM is their (sort of pathetic) version of "setting expectations".

Things I'd like to know are:

What was the patient's ROM prior to surgery?

What was the patient's ROM after closing while still under anesthesia/spinal block?

What is "enough" for the patient given their desires?

But even after knowing that, I have to wonder if gaining ROM is the whole point of going to the PT. I view my role differently. Much to some MD's chagrin, I'm not their thug that extracts ROM payments from their clients.

[tonyf315]

Originally Posted by Jon Newman

ROM gains have been noted up to 2 years post-op. I'll find the source if you're interested. Perhaps she just isn't on someone else's time frame....Much to some MD's chagrin, I'm not their thug that extracts ROM payments from their clients.

I wasn't aware of the 2 year time frame Jon, thanks!

and RE: not being a thug, I feel the same way!

[TexasOrtho]

Regularly getting to 125? That's pretty impressive Keith. Most of the published data I've seen is in the neighborhood of 105-110 degrees.

[tonyf315]

hey since we're on this topic of expected range post TKA, does anyone know anything published about expected extension range? I've traditionally been shooting to get within 10 degrees of full extension or better but just curious?

[keithp]

Originally Posted by TexasOrtho

Regularly getting to 125? That's pretty impressive Keith. Most of the published data I've seen is in the neighborhood of 105-110 degrees.

As a young professonal, I really bought into the notion that I was seeing patients from the best surgeons in the world (i.e. Hospital for Special Surgery) and that was the main reason for the good outcomes.

In retrospect, I suspect that my patients presented differently pre-op then they do now. I had numerous patients who were still active and were looking to use their TKRs to maintain an active lifestyle more so than to alleviate debilitating pain. I imagine that they were going into surgery with ROM that was already at 115-120 and just didn't want their tennis game to suffer anymore...maybe this would account for the difference in outcomes? I was also in a smaller clinic (2 FT PTs...so maybe the sampling over my 3 years there was too small with only approx 10 TKRs per year?)

Regardless, I remember being very surprised when I started to see a sig change in my own outcomes when I moved from one geographic locale to another.

Respectfully (your thug in recovery),
Keith

[Jon Newman]

Originally Posted by Jon Newman

ROM gains have been noted up to 2 years post-op. I'll find the source if you're interested.

Ok, this was less compelling than I remembered but here's the reference anyway. It's certainly plausible.

Time-dependent improvement in functional outcome following LCS rotating platform replacement.

Nerhus TK. Heir S. Thornes E. Madsen JE. Ekeland A.

Acta Orthopaedica. 81(6):727-32, 2010 Dec.

BACKGROUND AND PURPOSE: Long-term follow-up studies after total knee replacement (TKR) using an LCS rotating platform have shown survival rates of up to 97%. Few studies have evaluated short-term functional outcome and its improvement over time. We determined the time course of functional outcome as evaluated by the knee injury and osteoarthritis outcome score (KOOS) over the first 4 years after TKR using the LCS mobile bearing. PATIENTS AND METHODS: 50 unselected patients (mean age 70 (40-85) years, 33 women) with osteoarthritis in one knee underwent TKR with an LCS mobile bearing. Data were collected by an independent investigator preoperatively and at 6 weeks, 3 months, 6 months, 1 year, 2 years and 4 years postoperatively. KOOS, a self-assessment function score validated for this purpose, and range of motion (ROM) were determined at all follow-ups. RESULTS: The mean KOOS pain score increased from 43 before surgery to 66 at 6 weeks and 88 at 2 years. It was 84 at 4 years. The mean KOOS activities of daily living score (ADL) increased from 49 before surgery to 73 at 6 weeks, then gradually to 90 at 2 years. It decreased to 79 at 4 years. Mean passive ROM was 112degrees before surgery, 78degrees at departure from hospital, and then gradually increased to 116degrees at 2 years and 113degrees at 4 years. INTERPRETATION: Recovery after TKR is time-dependent. Most of the expected improvement in pain and function is achieved at 6 months postoperatively, but some further improvement can be expected up to 2 years postoperatively. ROM will also gradually improve up to 2 years after TKR, and reach the same level as before surgery.

[keithp]

Originally Posted by tonyf315

hey since we're on this topic of expected range post TKA, does anyone know anything published about expected extension range? I've traditionally been shooting to get within 10 degrees of full extension or better but just curious?

Indeed, this would be good info to have. Question though...how are these studies accounting for variability in the rehab experience of the patients, and how do they determine what is the "best" rehab experience in obtaining the best "numbers"? How much does the rehab experience truly matter? In the end, how reliable are they and can they be generalized to our expectations?

(Of course, my questions are somewhat rhetorical as I will try to look it up later)

Respectfully,
Keith

[keithp]

Originally Posted by keithp

How much does the rehab experience truly matter?

Okay...some answers that I found so far:

Total knee arthroplasty rehabilitation protocol: What makes the difference?*1

Chitranjan S. Ranawat MD*†a, Amar S. Ranawat MD† and Amor Mehta BS†
a From the *Department of Orthopaedic Surgery,Lenox Hill Hospital, and †Ranawat Orthopaedic Center, NewYork, New York.

The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximize range of motion,develop muscle strength, and provide emotional support. Over 85%of total knee arthroplasty (TKA) patients will recover knee function regardless of which rehabilitation protocol is adopted. However, the remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited preoperative motion, or the development of arthrofibrosis. This subset will require a special, individualized rehabilitation program that may involve prolongedoral analgesia, continued physical therapy, additional diagnosticstudies, and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at the Ranawat Orthopaedic Center over the past 10 years in more than 2,000 TKAs.

...and...

Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty

Kramer, John F. PhD; Speechley, Mark PhD; Bourne, Robert MD; Rorabeck, Cecil MD; Vaz, Margaret MSc

One hundred sixty patients (mean age, 68 ± 8 years) having primary total knee arthroplasty were assigned randomly to two rehabilitation programs: (1) clinic-based rehabilitation provided by outpatient physical therapists; or (2) home-based rehabilitation monitored by periodic telephone calls from a physical therapist. Both rehabilitation programs emphasized a common home exercise program. Before surgery, and at 12 and 52 weeks after surgery, no statistically significant differences were observed between the clinic- and the home-based groups on any of the following measures: (1) total score on the Knee Society clinical rating scale; (2) total score on the Western Ontario and McMaster Universities Osteoarthritis Index; (3) total score on the Medical Outcomes Study Short Form; (4) pain scale of the Knee Society clinical rating scale; (5) pain scale of the Western Ontario and McMaster Universities Osteoarthritis Index; (6) functional scale of the Western Ontario and McMaster Universities Osteoarthritis Index; (7) distance walked in 6 minutes; (8) number of stairs ascended and descended in 30 seconds; and (9) knee flexion range of motion, on either the per protocol or the intent-to-treat or the analyses. After primary total knee arthroplasty, patients who completed a home exercise program (home-based rehabilitation) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (clinic-based rehabilitation). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs.

In both instances, the bold is mine. I am curious if ROM measures in the second study are differences pre/post surgery, or just gross ROM measures.

Respectfully,
Keith

[zimney3pt]

Just an update on my patient. Apparently success is by the number, to some.

My patient went back to the physician for his 6 week follow up visit and they decided to do a manipulation under anesthesia. We had only achieved 115 degrees in my 5 weeks working with him, so I guess this wasn't good enough.

His physician told him that there was a lot of scar tissue and that they see this a lot in men more then women, especially in men that are not retired and still working. (would need to search to find the research on this as I am not aware of it, so please pass it on if anyone has it)

My next curious question will be if he comes back here for therapy? This physician group has their own POPTS. I'm guessing "their" therapists might be able to push hard enough on the knee to get to 125 and be successful.

[joebrence9]

My patient went back to the physician for his 6 week follow up visit and they decided to do a manipulation under anesthesia. We had only achieved 115 degrees in my 5 weeks working with him, so I guess this wasn't good enough.

Want to place a bet on what his knee flexion will be after the manip??? I bet the manip will "rip up" all of the scar tissue thats holding that knee back...yea right...

Why didnt the doc just put them on a steroid pack or diuretic and see if that helps first??? Your pt could just have some post-surgical swelling...but I guess the surgeon can bill for the manip...hmmm

[keithp]

I am not sure what I am looking for in posting this...a confessional of sorts, perhaps.

I pushed a knee for the first time in well over a year. He is 10 days out and at 80 degrees.

Over the last 1+ years, I have had just as good (anecdotal) results now as I would have when I pushing on patients daily. I have discovered that patients often respond incredibly to patient-centered conversation, education, and encouraged movement without stressing over the numbers. Explaining to patients how they will follow a natural course and that the therapy field often over-medicalizes the rehab experience (treating apparent defects in the presence of defense and inflammation) often leads to nodding approval.

This gentleman, however, has been different. He started with 90 degrees flexion one week ago, but has lost motion over the week. I am reluctant to believe that he has been as active a participant as I have recommended. Initially, I thought the biggest obstacle for this patient was his pain...he has the exact same pain after surgery as he did before, and he has concerns that something is wrong. I have tried (in a variety of ways) to explain to him that there is nothing to be concerned about (and why), but his most positive response was, "I understand what you are saying, but I don't believe you."

Anyway...the PT who tries to not increase nocioception, did just that yesterday. I suppose, I figured that the last thing that patient wants is an MUA.

After he screamed, I was dismayed; I had failed him...

...then...he wiped his brow, smiled, and said, "Back to 90 degrees, huh? Wow, I betcha we broke up some scar tissue with that one."

I can assure you that I have NEVER mentioned scar tissue to him; now I wonder what I will do with this patient at my next visit...

Respectfully,
Keith

[Greg Lehman]

Kory started this thread with a post about his 800 meter runs in 1:52. I am training to run a 5km race in under 20 minutes. To me this is a lofty goal that I set two years ago. I regularly do difficult 5-6 800 meter repeats in 2:50 to 3 minutes (1:52 just blows my mind). These hurt. They hurt a lot and they hurt the whole time I am running. But I know that they lead to something. I know that the pain I feel during the workout and after the workout helps me with the incredible pain that I will feel when I run that 5 km run. And that 5 km run will hurt and I want it to hurt. The more pain I can tolerate the lower my time. Time is my outcome measure and I want a low value for purely arbitrary but relevant to me reasons.

Does Keith's patient place the same value on his excruciating "knee workout" that I place on my excruciating 800 meter workouts? Can they both lead to the same thing - an attainment of some arbitrary, albeit meaningful, goal that exists without long term pain?

I think they can.

[zimney3pt]

Don't worry Greg, that 800 time would not just hurt me at this point in my life, it would kill me.

I'm curious if I would have had understanding of the "The Central Governor theory" a little back in my college racing days if it would have helped me go faster or slower or made no change.

You make an interesting point about Keith's patient. Keith stated he may not have been as active a participant as possible. Could this new "push" on the mobility trigger him to take a more active roll? Could that be the left side of the matrix key to open up mobility on the right side of the neuromatrix? Isn't the complexity of uncertainty with patients fun!

[TexasOrtho]

This article might add something to the discussion. Note the average premanipulative ROMs were 66-99. Also worth noting in this article that the AVERAGE knee flexion at a 10 year follow-up after MUA was 86!!!

That's better than <50 but it still sucks.