December 12, 2018
Today marks the fifth month after my recent revision TKR surgery (and ninth surgery on my left knee) and I am feeling very, very hopeful. Today, auspiciously, I also forgot to take my walking cane with me to the local market about 92 meters to and from my apartment. So, I walked home with two small bags of groceries and absolutely no need for a cane. I was so euphoric that I wrote to my surgeon back in Milan, Italy and told him all about this new phase of self-sufficiency that I am clearly entering.
But, despite my progress, I remain resolute not to assume I can return now to swimming with flippers and swiftly walking long distances or dodging traffic and deftly sidestepping potholes. The key to my longevity with this revised TKR is to adapt a more sedentary lifestyle, punctuated with daily exercises and occasional visits with physical therapists (PTs). In fact, my success lies with the PTs as much as with my own discipline to follow their directives. Without PTs, I might be able to heal by relying on all the exercises I acquired over the years. But with good PTs comes the coaching, the reality checks, and the encouragement needed for the long haul. And without a doubt, my revision TKR has been a long haul.
Yesterday, I spent 60 minutes in physical therapy doing a range of seemingly simple things: walking up and down a short set of stairs and then a set of deep stairs; standing for minutes at a time on an incline in order to achieve an extreme stretch of my calf muscles; ‘walking consciously’ by activating as many of my core muscles as possible; standing on my toes ( 3 sets of 5) and then the hardest one, stepping forward on one foot, while tapping the opposite foot forward and backward (5 times each side) before taking another step. To top off this seemingly benign routine, I rested while having a painless 15 minute ultrasound treatment followed by 20 minutes of a hot-packed bed rest. Yet, I limped out of the clinic in more pain than when I walked in. Even more odd was the fact that I felt light and happy, secure in knowing that I was once again moving forward in healing and closer to a cane free existence.
Every time I invest in exercise I also invest in proving the adage, ‘Two steps forward, one back’. Every week I witness improvements in my strength, my balance, my stamina and my capacity to function confidently. But, with a revised TKR I could not do it alone. I need a good PT.
I deeply appreciate a good PT. In fact, good PTs are so important to ones’ recovery that they can quickly earn the possessive title of ‘My PT’. If a PT does not earn my trust or regard, I find myself using an article dubbing them ‘The PT’ or ‘A PT’. Over the years, the distinction between ‘My PT’ and ‘The PT’ / ‘A PT’ has made the difference between healing and thriving or just getting by.
What makes for a good PT? I have come to believe that a good PT knows their science, first and foremost. They punctuate this knowledge with empathy for the physical and emotional journey one takes after an injury and they convey that empathy easily, authentically and directly. They have command of your repair program. Yet, they are also flexible, patient and willing to adjusting the specific program to your needs based on the inevitable daily or weekly issues that can interrupt it. They know the subtle differences between coaching and teaching and between patronizing and encouraging the patient to push themselves as best they can. For example, today I actually could walk further and longer than last week. But, I lost stamina half way through the toe tapping exercise. So ‘My PT’, Pratayana quickly steered me back to the bench where I rested and where she substituted the exercise for another. While I still walked out sore, I was confident that I was improving while not imposing unnecessary damage on the new joint.
In contrast, back in the USA when I was healing from my first TKR, the therapist goaded me to finish every exercise no matter how painful it was because we needed to ‘stay with the program’. She also insisted that she bend my knee even though I had been doing very well on my own with the use of a large ball to help me with this fundamental range-of-motion exercise. Insisting that I lay on my stomach while she bent my knee, she clearly also insisted on being the one in control. It probably didn’t help that I had the peculiar need to see my knee bend in order to bend it to its fullest range, and preferably with that ball right in front of me. While I suggested using the ball she insisted on her own approach. Sure enough, she also eventually and finally gave up trying to improve my range of motion and announced that “I can do nothing else for you! I don’t know what else I can do.” I returned to my ball, at home, and I did finish my thrice weekly program, with her, though often enough in tears. I was not only an object for the therapist to manipulate, but I was also responsible for upholding her program, regardless of my physical state while doing it. I often left that clinic swearing, and swearing that I would never return, no matter how many patronizing “Good Job!” judgments were also lobbed my way. In those days, I did not have the courage to definitively speak up or to leave. Now, age and experience has its privileges. Today, I would do both and without a doubt. A good therapist conveys a desire to partner with you, controls the impulse to judge and has the knowledge base to try different approaches to the problem.
In turn, a good patient will team up with a therapist and communicate clearly and honestly what works, what doesn’t, and what aches from what pains.
A therapist becomes a good therapist if they are also professionally allowed to design and manage the patient’s specific repair program. But this is not always the case wherever one lives. In Milan, Italy during my ten-day hospital stay following the revision surgery, I had a very decent team of therapists who adhered to a generic tried and true therapy program, but they had to report to the surgeons and could not apply techniques without first consulting them. After I returned home to Rome I teamed up with Angela who did her best within the limited range of responsibility prescribed to her by the surgeon. But she was visibly frustrated when she could not move forward from incision management and apply additional techniques because she did not have written permission from the surgeon back in Milan. When I finally intervened and asked the surgeon for permission to use Angela’s recommended program, he said no, I don’t need it, just carry on with incision management. Granted the incision was almost 9 inches long and needed management but the total joint and core muscle structure also needed attention (see blog 8).
The fact is surgeons do not have time to ‘know it all’, both of their own surgical studies and of physical therapy. Most physical therapists in Bangkok and in the States are in charge of determining the therapy program of each patient. Their pride and skills show up in the programs they design and implement to meet patient needs. And, that program is also subject to periodic team reviews assuring both the therapist and the patient that they are on the right track for full recovery.
Sometimes, the inabilities of a physical therapist have an effect on the clinic and on the surgeon in charge. Again in Rome, following my first TKR on the right knee, I was briefly in the hands of a very young and inexperienced physical therapist who clearly did not know the first thing about managing a total knee replacement. He was timid, applied inappropriate exercises to the fresh implant and paid no attention to incision management. And, unfortunately, he was the only therapist in the surgeon’s clinic. After I returned home from my first visit with him, I quickly set up my own gym in the living room, secured a stationary bicycle for daily use in the backyard and commenced with my own set of exercises – and sought another therapist with whom to check- in occasionally. I also informed the surgeon of my actions. I am sure that I was not the only patient to communicate concerns about that particular PT, but I do take as evidence of the need for open communications the fact that the surgeon, a few years later, hired a second therapist who became the clinic’s Director of PT. Kudos to the surgeon for eventually waking up.
A really good therapy clinic will provide handouts of the exercises they expect you to practice at home. This is an empowering element to any decent therapeutic program – reinforcing information back to the client for home-based use. Yet, surprisingly this form of education is not practiced by every clinic or hospital. Here, in Bangkok at the esteemed Bumrungrad Hospital, surprisingly they do not offer handouts. Instead, I go to each session armed with paper and pen to write down what I have been doing. Back at the Galeazzi Institute in Milan, the head therapist sent me back home with several pages of illustrated handouts to follow. Though back in Rome I had to ask for a written list from my gym and pool therapists. But after two and one half months of waiting for it, I gave up. Back in America on the other hand, I was able to form a thick file of illustrated handouts based on all that the PTs gave me. It was and is part and parcel of their service. That file of handouts became the guidebook I referred to years later when I ran away from the inexperienced therapist in Rome. While I did not appreciate the lack of flexibility by my American therapist managing my first TKR, I do appreciate their orientation towards patient education. All those handouts reinforce the skills learned as well as the responsibility to apply what has been learned.
Somewhere in-between these differing PT practices lies the same intention among good PTs world-wide: to help the patient recover and become physically self-sufficient. Good PTs have figured out the balancing act required between helping and hindering and between pushing and pulling a patient towards self-sufficiency. Ultimately, a good therapist will say, “It’s up to you. Practice, rest and then practice again. I willingly serve as your guide until you do not need me anymore.”
I have less than a month left of physical therapy before I am on my own. I am confident that ‘My PTs’ will let me go without my feeling concern for losing them.