8. CMs: The open secret about maintaining health and achieving recovery

It is no secret that I believe it is critical to ones’ overall health and safety to avoid surgical intrusions into the knee to begin with.  Intrusions include those “Quick and easy”, “Simple”, “Just a cleaning” surgical strategies that require incisions and insertions of metal ranging from exploratory arthroscopies to partial knee, total knee and eventually, revision knee replacements.  Successfully avoiding a knee replacement until it is absolutely your last recourse is worth any effort and energy required.

“Easier said than done when you have knee pain!” you may understandably reply. True, if every step or two you take leaves you wincing then something is wrong and something needs to be done. My last blog (#7) discussed the need to review all options to ensure that you have a fair and decent diagnosis of your pain before making potentially life-changing decisions. But, what do you do in the meantime, before, during and after a decision? Invest your time in building up and maintaining your core muscles, or CMs.  I would also add-in calf and ankle muscle strengthening exercises for full-measure.

The core muscle group includes all muscles in your back, abdomen, hips and upper thighs.  They enable you to balance, to remain stable or resume stability after a twist, a leaning, or a fall.  Core muscles support and stabilize the spine while also enabling the shoulder, spine, pelvic, hip and knee joints to fulfill their duties, and usually with less pain (among others: Journal of Orthopedic and Sports Physical Medicine,  www.jospt.org/doi/full/10.2519/jospt.2018.7365).

core-muslesBy their large group sizes, CMs offer the illusion of leading us to believe that they are in decent, if not excellent shape.  They continue holding us up, keeping us walking, allowing us to lift and twist.  Aqua gym, carrying groceries while closing the car door, and lifting the grandchildren seem to offer few or no problems.  Hmmm…Knee pain has a way of seducing our minds, as well as our CMs, into believing they are strong when, in fact everyday that they are not specifically exercised their strength diminishes. If you suffer knee pain and naturally reduce your activity level but do not maintain specific CM exercises, you will soon learn that these diminished muscles contribute to your knee pain and affect knee rehabilitation, especially after a surgical intervention. This fact became painfully clear to me when I was ordered to lift my leg after knee revision surgery. For three days,  I not only struggled with this simple exercise, I strained a groin muscle trying to activate my thigh muscles and then lift my leg.  I had been protecting my knee from pain for so long that I neglected the rest of my body, and especially my core muscles.  Better to keep your CMs fit and ready for anything than to allow them to rest along with your painful joint.  Like throwing the babe out with the bathwater, too much is at stake and too much is lost by ignoring this vital group of protectors when you have specific knee joint pain.

Simple Quick CM check

Lay on a firm surface. Bend one knee and place that foot on the surface next to your other straightened knee. Keeping your feet 90 degrees from your ankle, lift the straight leg about 30 degrees and hold it for ten seconds.  As you lift pull your navel back towards your spine,  Slowly bring the leg down all the way to the floor.  Repeat ten times.  If your thigh muscles begin to shake, if your lower back begins to ache, if your stomach muscles feel the strain, then you know more attention to your CMs is required.

Better to know now than later so you can do something about it.

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I have been relearning over the course of these past nine months that building up and maintaining my core is what allows me to walk, and then to walk evenly. Core muscles have ensured that my thigh muscles can lift and hold my leg, bend my knee and bear weight at different angles. Core muscles compensate when the joint is loose, offering balance and leverage.  My tendency to fear being jostled or pushed, actually tripping, or worst of all, falling (Blog 4) has decreased the more I have increased time building my core muscles.  Four months after my knee revision surgery, I have actually begun forgetting my cane occasionally since my CMs are – now- doing their job. Twice this week, I had to walk back to get my cane that, for so long, was an extension of my arm.

Many core muscle exercises are offered online and at your local gyms, YM/WCA’s etc. Your physical therapist will certainly be able to show you a collection of exercises tailored to your particular therapeutic needs.  The investment needed to get that kind of advice, and the discipline you will need to maintain your exercise program will not let you down.  Without trying to be cute, ‘get a leg’ up on self care by paying attention to your CMs.  Doing so will bring a certain kind of agility, strength and physical confidence that can make the difference between suffering and repairing.  Slowly but surely.

young-woman-stretching-in-a-park_4460x4460

Additional Resources among many:

7. Total Knee Replacements leading to revisions. The Stats. The Questions.

Back in the early 1970’s, I recall Mr. Keever, a robust, good old family friend sitting in the passenger seat of his parked pick-up truck in our driveway.  His wife was inside having a quick catch-up coffee with my mother.  When I went out to say hello to him, I found him uncharacteristically leaning on the dashboard close to tears.  He pointed to his knees, mumbled “Knee replacements” and added that he was in too much pain to join us.  He waved me away. “Wow!” I said to myself. “I hope I never have to have that!”

Image result for photos, knee replacements

In fact, in 2003 when I was 47 years old, memories of Mr. Keever came back to me when I was struggling with chronic knee pain.  My then tried and trusted orthopedic doctor, Dr. U. cavalierly declared after my umpteenth visit to him:  I really wish you would just allow yourself to have a total knee replacement (TKR).  They are easy!  We implant the metal and the plastic cartilage.  When you wear out the plastic, we just pop them out and pop in another set!  Admittedly, his confidence and that last line sold me.  I later learned I was one of his first TKR patients. He needed the experience as much as I needed a resolution my pain.

Fast forward to early spring, 2018 when my orthopedic surgeon, Dr. B. broke the news to me that ‘popping in and out’ a set of plastic discs was not possible, that I had been fed the wrong information.  Instead he enthusiastically described a revision procedure calendar:  Yes, there are risks, but let’s assume the (first) revision will last ten years.  You will be 72 by that time.  You can have another revision then.  In fact, you will still have time for another after that assuming you are…you know, still here (alive)!

Image result for photos,revised  knee replacements

Deciding to have a total knee replacement and then a total knee revision is more complicated than that and should be more thoughtfully decided – although current and projected numbers suggest otherwise.

TKR AND TKR REVISIONS STATS.  THEY MAY SURPRISE YOU.

Various sources have published statistics on long-term primary and revision rates for TKRs.  Sources I have found useful over time include:

The Total Knee Replacement (TKR) procedure, in the USA, was developed in the 1970s and then disseminated across referral centers and then community hospitals in the 1980s and 1990s.  By 2014, TKR utilization exceeded 650,000 cases annually in the US and many more worldwide (Katz JN, Editorial, Arthritis Rheumatol. 2014 Aug;66(8):1979-81. doi: 10.1002/art.38688).

Healthline conducts their own surveys using Medicare and private pay records as well as data from the U.S Department of Health and Human Services Agency for Healthcare Research and Quality (AHRRQ).  They also rely on meta-analyses of worldwide joint registry databases. Healthline data indicates that growth in the use of TKRs has occurred primarily in patients 45–64 years of age. TKR utilization increases dramatically in the age group 50–59 years of age and primarily among women

To assess revision rates, Healthline analyzed approximately 1.8 million (USA) Medicare and private pay records to find that the rate of revision for all age groups within five years from surgery is about 7.7 percent. The rate increases to 10 percent for those age 65 and older. Healthline also found a somewhat parallel number WORLDWIDE based on a meta-analysis of international joint registry databases (2011):  the revision rate is 6 percent after five years and 12 percent after ten years.  People are turning to revisions worldwide and the numbers are not decreasing.

Leaping ahead, the American Academy of Orthopedic Surgeons (ASSOS) anticipate that by 2030 projected growth of dependency on TKRs will increase by up to 189 percent, or 1.28 million procedures annually. (The ASSOS clarifies that these numbers are always shifting but not substantially from the pattern set)

Similar gains by 2030 are expected for revision TKRs, growing by 190 percent or 120,000 procedures.

By 2060, primary TKRs  are expected to reach 2.60 million (382 percent increase), while revision TKRs s are expected to reach 253,000 (400 percent increase).

The mean age for primary total knees has declined significantly from 68 years to 65.9.

Females continue to make up the majority of patients at 55-62%.

It is interesting to note that a study in Europe found approximately 20% of all TKRs were judged to be inappropriate when using a combination of assessments including a formalized Osteoarthritis Index pain and physical function scores, radiographic features, knee motion and laxity measures, and age factors from patient pre-surgery histories.  The same research was completed in the USA and found that one-third of TKR procedures were deemed unnecessary.  (Riddle DL, Jiranek WA, Hayes CW. Arthritis Rheumatol. 2014 Aug;66(8):2134-43. doi: 10.1002/art.38685).

[In an editorial rebuttal to the above study, it was pointed out that, because a universally shared set of assessment criteria has not yet fully been developed and therefore not shared, the findings should not be considered conclusive.  (Katz JN, Ibid)]

OK, THOSE ARE THE STATS.  NOW WHAT?

How do we, the clients, make sound decisions about our health before we become the patients?  We can begin by exploring our true options. They tend to be wider than the traditional orthopedic community is able, or in some cases willing, to lead you to think. Knees are connected to hips and spines, core muscles, ankles, shoulder blades.  They are responsive to climatic humidity and emotional highs and lows, diets and/or lack thereof. Cells have memory.  What is a flinch? A shudder? Anxiety, but a physical response to deep empathy or remembering trauma or disgust.  What your body is struggling with is an ecosystem full of important issues we, as body stewards, have to understand before we sign off on an irremediable change in our lives and in our lifestyles.

YOUR PERSONAL CHECK LISTS

Consider the below unofficial checklists following your first round of traditional x-rays.

A.  You have chronic pain but your Scans show NO structural changes to the joint:

  • Test for rheumatoid arthritis, bursitis, fibromyalgia, lupus etc.
  • See Osteopath for body alignment issues and corrections
  • See Podiatrist for foot/ankle/knee issues and corrections
  • See a Physical Therapist for muscle strengthening and additional alignment exercises
  • Meet w/ Stem Cell Orthopedic Specialist to assess options (For trained doctors in your area go to http://www.regenexx.com)
  • Soften or remove high impact physical activities, incorporate core muscle exercises
  • Add-in alternative low-impact activities
  • See Acupuncturist for pain management
  • See Dietician for nutritional assessment
  • Lose weight for joint health
  • Adapt home layout for easier movement
  • Consider replacing manual car with an automatic one

B.  You have chronic pain and your Scans SHOW structural changes to the joint:

  • Accept that lifestyle changes must be made
  • Assess Orthopedic options
  • Assess Stem Cell Orthopedic options (For trained doctors in your area go to http://www.regenexx.com)
  • Incorporate all healing activities (Osteopath, Nutritionist, Podiatrist, Physical Therapist) listed above
  • Replace all high impact physical activities with leg/core muscle strengthening exercises
  • Lose weight
  • Adapt home layout for easier movement
  • Replace manual car with an automatic.
  • Then decide on joint repair options and /or continue with modified lifestyle

Full body scans, if affordable, can be considered for assessing bone on bone relationships not only in the knees but elsewhere in the body that affects your ergonomic stature.  Osteopathic medical doctors offer holistic points of view on these scans and accompanying strategies.  Changing your physical patterns of behavior may be critical to your long term joint life: does an afternoon of downhill skiing really need to be on your agenda?  What about the pleasures of simple yoga, swimming or isometrics?   If limited knee flexion and instability prove to be the outcomes of arthritis does a change in diet, strengthening of your core muscles and use of acupuncture help, for now? Remember,  certain kinds of (older) manual cars automatically (pun intended) create a persistently odd hip/knee/ankle alignment.  Can you exchange cars for your long term mobility’s sake?

Does fear of chronic pain veil periods of painlessness? Does the undesirable demand to change personal behavior first cave to the desire for a professional, aka legitimate and  immediate ‘fix’ now – when, in the back of your mind, might be the nudge to wait? In the end, do the gains (from surgery) outweigh the harms now and into the future?

The more boxes you tick off that complete a full scan of honest mind/body/ environmental concerns, the more confidence you will have going into your total knee replacement, if that is the final solution.  The same absolutely applies for when you assess the need for a revision of your knee – though by then the evidence tends to be unquestionable.  The emotional collateral that you amass on your journey to the operating theater is the collateral you will rely on during the repair phase, both times.  Protecting yourself from undue joint replacement is worth the effort and the money and the time since once you start on this path there is no turning back.  Take it slow if you can.  For now, you can be the client, not the patient, looking for answers that are right for you.

This is a big topic.  More can be said.  What do you say?

6. An Alternative to Knee Replacements

Legs, Walking, Walk, Limbs, Motion

My husband and I recently strolled the Rome film studios of Cinecittà. As film buffs we found the tour fun. I also found it sobering. Walking is a privilege I, of course, took for granted most of my life. Even my joint replacements offered good years of exercise though I should have slowed down some in order to give my joints more ‘shelf-life’. Now, I am thankful for days that are pain free.

Please consider a few lessons learned about knee replacements for ridding yourself of pain: orthopedics is an industry as well as a medical field of study and one currently tied to implant manufacturers first, regenerative medicine, or stem cell therapy, second or third. Knee replacement should only be a decision made when all else fails. In the States, replacements are being offered at far too young an age when in fact, they only last between 10-15 years before your bone or their metals begin to crumble. Mine lasted 14 good years. The revised surgery I succumbed to four months ago, with a non active lifestyle, will give me another ten years I am told. The options after that? Revised replacement of my revised total knee by perhaps age 72, joint fusion, and/or a wheelchair.

If I could do it all over again, and now with stem cell therapy as a viable option, I would invest in stem cell therapy and as soon as a joint problem becomes chronic. My older brother took this route a few years ago with his left knee and within three months of a week’s worth of medical care, returned to biking, skiing, and windsurfing.  By investing in adult stem cell therapy, he also invested in more time to rely on his own body’s natural resources during his later years when invasive surgery is unarguably more traumatic. In comparison, I have used up my body’s options by relying on metal joint replacements and see a future surrounded by equipment, and limited exercise options currently including swimming and weight lifting.

Consider saving for stem cell treatment for inevitable joint pain. Look up the newest research by visiting www.regenexx.com, the Mayo Clinic, or the Galeazzi Institute in Milan where I completed my revised knee replacement and began once again with hands-on lessons in the relationship between body, science, and health.

5. Chronic Pain

Natural pain

The doctors said that healing from a revision knee replacement surgery would take at least 6 months to a year.  I nodded in agreement before I had the surgery.  Now, I hang my head in frustration, almost despair.

These feelings are not because of the days, weeks, and now months spent hoping to awake to feel nothing.

They are not in the quiet glances or overt stares at me by people on sidewalks, restaurants or public transit here in Bangkok.

It is not in my audacity to demand a seat on the metro or in my carefully slow pace forced on others so that I do not trip, fall or twist on the uneven pavement or as I go down stairs.

And it is not in finding myself sensitive to the irony of  infinitives that now require careful renegotiation:  To Walk, To Move, To Meet, To Hike, To Run, To Shop, To Sightsee, To Sleep.

It is in the pain. Chronic pain.  Four full months after surgery, the physical and acute squeezing of a negative life force through the tendons, up the muscles and between the fascia is the ‘it’ that brings me and my daily life to a halt. Gripping the cane or the crutch ferociously, I strive to find a chair, a bench, or, caught  on the road, the fastest way to get home so I can put the bloody leg up to rest, hoping a phone doesn’t ring or the bathroom does not need me so that I can have some uninterrupted time to rest.

More to the point, I rush home so I can stop.  Stop moving, stop straining, stop feeling the pain.

After months of this kind of pain, I review my life and dismally realize that I feel like I have stopped contributing, stopped being in the stream of lives around me. Stopped exploring, stopped chatting.  Stopped seeking the company of others – stopped being meaningful.

Not too long ago I used to find shelter in my aloneness.  It did not feel lonely, it felt essential to my healing. Now, this pattern of aloneness does not seem to abate:  I feel the confines of my apartment as much as I feel the doubts of success this surgery promised to provide.  For many more than six months since the metal joint first slipped,  I have been wrestling with pain, with mobility – negotiating with it every moment of the days, and sometimes the nights.  It always wins.  My life is in the hands of the worst part of my physical self.  Bodily pain: mobility captured, caged, controlled, limited.  My reaction, left unguarded, allowed to be undisciplined, becomes the worst my mind can generate: depression, despair, loneliness, irrelevance, nothingness as I sit within my walls.

Of those who ask about our lives since we moved to Bangkok,  I try to keep the answer honest but upbeat with alternative news that from time to rare time is a form of truth.  The pool is a sanctuary, a haven; the food, incredible; the sites, unbelievable.  Some might call this flick of truth diplomacy.  In truth I simply crafted  a story lived by the someone else I had hoped to be by now.  Yes, my life has overall been rich, full, lucky. But, my reality is underwritten by an unfortunate outcome of the surgery.  How long inquiring people remain in my life depends on their capacity to believe that I am more than the pain that stifles my life.  And success in my life requires moving beyond the pain and crafting a revised lifestyle that does not allow pain to be its centerpiece.  That feat, however remains a daily, sometimes mountainous task.

Some days are better than others.

Today, I am staying home for a “Knee-First” day (see Blog 3) to rest completely, having cancelled my plans to visit a Thai language school. What ‘staying home’ means is that I am to do nothing, absolutely nothing that requires walking except to complete a few exercises. The pool sits above me, on the 8th floor, waiting.  I drool over it but keep myself locked in this apartment to give this leg, once again, the time it needs to stop aching, to stop speaking in the various dialects of pain: pain when standing, pain when walking, pain when leaning too far forward or too long in a sitting position.  While my Thai language is very limited, I have become quite fluent in the language of pain.

I can assure you that this knee will heal enough to give me the pleasure of a few minutes of painless walking, and just as quickly, the illusion that I have passed into the phase of full repair, now able to thrive, plan, ‘do’. This is when I am at my best.  I make plans. I see the possibilities in front of me with the excitement of a starved person in a grocery store.  But then the tendons freeze, the muscles ache into shooting pain and rise to meet my new metal knee seemingly with a malignant laugh.

Pain like this teaches you to let go of plans, and start over. It teaches you, despite it all,  to never give up on the day that will come when the pain is marginal at least or non-existent, at best.

And so the wrestling match continues. Today, I must live in the pain and allow it to master me. Tomorrow, I will live with the pain and get on with life joining how many others in this world who struggle with the same: pain and less pain.

4. FEAR

Stairs and LightDaily fear.  Given options, I typically prefer a  “Be Calm, Soldier On” attitude when repairing from a physical trauma, especially if the entire process is relatively brief.  But, to return to full mobility, a revised joint recipient needs to maintain a physical discipline of bending, strengthening and lengthening stubborn body parts up to and beyond a year to experience decent results.  But physical therapy is not all that is required, by a long shot.  Added to this regime is the need to calculate walking distances, arrange alternative forms of transportation, allow the house to collect dust until ready to use hard-earned mobility to clean it.  Plain and simple acquiescence to the norms of this new regime also is a critical requirement to this revised lifestyle.  I find that fear, now, is a norm and takes on more poignant, ‘ever present’ attention when managing recovery.

Perhaps prior experience lends to my stubborn hold on fear.  Working full-time after my first knee replacement, I turned a corner in a recently mopped, but no warning signed hallway, and promptly fell on all fours, fracturing my kneecap on the two-year old knee replacement. I was immobilized for four full months, bearing no weight on that leg, still raising two boys and managing a townhouse, while taking work disability to try to make up for my lost salary.  I returned to work in a knee brace that required an additional two months of wear and then proceeded with 6 months of physical therapy.  Al tol, I added another year of recovery to my recovery process.  Thankfully, I did repair.  But I have no illusions about the change of lifestyle a break forces on adults, their families and their professional lives.

We know that fear serves the important purpose of sensing danger and threats to ones’ existence.  Joint revisions naturally incorporate fear to sense real threats found in everyday life: fast moving crowds, uneven pavement and steps, intrepid traffic, disrespected pedestrian walk-through zones (‘zebra-stripes’) and slippery walkways all contribute to daily worries, daily fears.  Slipping in the shower, banging the knee into a coffee-table, getting up from a chair too quickly can all result in acute moments of pain and possible damage to the joint. These daily fears, week after week, now three months running wear on me. Never have I wanted to incorporate more mind shifting substances (marijuana, medicinal and otherwise, sleep enhancers, alcohol, mediation, relaxation music, massage, etc…) into my daily life as I have now, following joint revision surgery.

Threaded through these management methods lies a cemented acceptance that whatever happens, has to be accepted.  Seeking to absolutely control present day dangers and their accompanying speculation, forecasting, and anticipated consequences is an illusion.  Fear creates the concern and alertness, as well as produces the strategies, the diligently designed ‘protection plans’ needed to potentially alleviate each situation.  But these plans cannot ensure avoidance of all possible accidents. They help us move forward though.  And, put into practice, these plans become behavioral patterns now common in ones’ life.  When I got on the back of the motorcycle the other day (Blog 3) and easily placed the crutch between my shoulder and my chest, and rested its base on my foot, that was a quick, almost mindless act culminating from weeks of practice. I looked comical, but I felt secure – as much as one can on fast-moving motorcycles weaving their way through moving traffic at rush hour… We can only try to minimize threats to ourselves with strategic planning and ‘safety-first’ decision-making, put into practice often enough to create confident, adjusted, behavioral patterns – ideally supported by calm-inducing moments in the day, as we live our revised lives.

Today, my husband and I will use the metro system to meet a real estate agent in a southern section of Bangkok.  I will put on my light-weight cross-shoulder bag, and walk an additional 400 meters from the metro to get to the door of the apartment complex.  This will be the first visit of 5 we will make today in the same neighborhood.  While I have point-blank reminded the agent three times that I have limited mobility she continues to assume that I can walk as far as she can, youngster that she is.  Lack of empathy, determination to succeed in her profession, stubbornness or dull headedness motivates her as much as fear of pain and of damaging my joint again motivates me.  We will take a metro and Tuk Tuks or small electric rickshaws as often as we can. I will let my husband see the apartments while I sit in a coffee shop waiting for his reviews and his photos.

So, again, fear and strategic thinking must go hand in hand, never trumping the other. Otherwise, ‘housebound’ will be my lifestyle far too soon in my mind and in my life.

EXERCISES today

Saving myself for the adventure later today, I limit my morning routine to straight-legged lifts and knee bends.  When we return, and depending on my pain threshold, I will try to go up to the pool for the rest of my routine as listed in Blog 2.

Onward readers!  How is your day going?

3. A ‘Knee First’ Day

cropped-tuscany-sunrise1.jpgAdmittedly, my little adventure last night on the metro expanded to include looking at an apartment we are thinking of renting. Getting to it required two more sets of metro stairs, standing on the metro and climbing back down two flights of stairs plus walking an additional kilometer al tol.  This enlarged adventure came to a grinding halt when I started to walk from our last metro stop home. The tibia plateau on the lower leg began to shoot with pain and the thought that I was ruining my knee quickly got the better of me.  We took a Tuk Tuk, or a small motorized rickshaw the rest of the way home, and thankfully.  This morning, I paid the price by not being able to stand on my leg for any amount of time.  I cancelled a well-planned morning out looking at several apartments and settled on the couch for a day of serious rest. This means mindfully making decisions for the betterment of my knee, and not for my mind, others, and  “… house, home or hearth”.  Putting the knee first takes a certain kind of healthy selfishness and honesty, moving only if the knee allows me to or only if my bladder requires me to.  The illusion of ease putting the knee first is harder than I once thought, especially when feeling responsible for other matters in my life.  Given the trauma of working through a knee replacement and then a revised knee replacement finally settled in my mind that ‘knee first’ thinking is not only OK, but essential if the future is to be as orthopedically-free as one can be with joint replacements.

Exercises today

  • Anything that keeps me off my feet. Today that included organizing my photos online; answering some emails, (trying to) sign up for a grocery delivery service, watching some Netflix (online) and closing my eyes for awhile.
  • Practicing letting go of images and thoughts that leave me feeling older than I am, alone and permanently immobile.
  • Thanking those elements and people in my life that help me to feel hopeful and capable. Today, I am particularly appreciative of the working internet, my caring husband and my ever listening friend Jean. A big shout out goes to the real estate agent who readily and graciously agreed to postpone viewing the list of apartments she had arranged for us to visit today. I have something to look forward to and, given her lack of concern about the listings, allows me to feel patient for my own recovery from this hiccup.  We will soon get out there and on with settling in this city, thanks to her patience, that can also now be mine.

2. Revised Knee, revised life, unless moving house

                            Moving Chair                                       

Lesson relearned:  Establishing strength and stamina requires discipline – and a long, uninterrupted period of time, daily.

After ten days in the hospital, I lost a great deal of exercise time because we needed to complete a major move from Rome, Italy to Bangkok Thailand. Between July 12 when I had revision knee surgery and  September 24 when we flew out of Italy, we had to do what moving people have to do: sell many of our household items, arrange for movers, pay off utilities, demolished our car, thin out our supplies, scrub down the apartment and say goodbye to choice friends.  Thanks to a three-week visit from my sister, I was able to incorporate some physical therapy between these essential moving demands and was allowed a bit more rest in between activities.  And, thanks to a rolling office chair, I  was able to roll around the house doing what I needed to do when my knee was too tired or painful from bearing my weight walking or standing.  Even with the pushing and pulling required by the rolling chair, and my three-day a week PT sessions followed by some thera-band work at home, I did not know just how much I had regressed.

When I arrived in Bangkok, the first appointment I made was with an orthopedic specialist in revision surgery.  He made quite clear that I needed to resume physical therapy as if I had just completed surgery – I had regressed that much due to moving distractions. Thanks to his sound PT direction, I am now feeling stronger and more confident.

Here is what I now strive for daily, finally after 11 weeks and 4 days since my surgery.

Exercise routine for Strengthening 

100 Straight legged lifts = Straighten leg, lift 30-40 degrees off firm couch, bed,or  bench, with toes lifting towards knee.  Hold for ten seconds, leg down (completely!), repeat. Pull heel towards wall in front of you to help position the leg correctly.  Quads should feel tight and the knee should feel strong. Watch for hyper extension of the knee and adjust.

100 Hamstring lifts = On same firm couch, bed or bench and with firm rolled blankets or pillow or cushion under your pelvis, bend knee towards buttocks to a 25-70 degree angle.  Feel for an angle that tightens your thigh muscles and pulls from your buttocks, keep lower pelvis pressed into the cushion so that your lower back straightens rather than crushes your lower vertebrae. Hold bend for ten seconds, bring leg down (completely), repeat. Hams should feel nicely tightened after this routine.  Check for more shapely legs in a week!

 Exercises for Stretching

1)  Straight legged bend = Sitting straight backed, legs straight out in front of you, lean chest towards knees keeping back straight – feel the stretch for 10-20 seconds, release. Repeat.

2) Knee Bends =  Stand and with hand or belt,  grasp ankle and bend knee behind you, hold until the knee joint tells you to stop and or/ the front quad stretch has been exhausted.  Repeat 2 more times, several times a day.

3) Various Yoga twists that massage the spine and that stretches the Iliotibial Band

Exercises in a Pool

1) All stretches named above, using the ladder into the pool to hold the ankle or to flatten both feet to reach for a Hamstring/Iliotibial stretch.

2) Bicycle motion for endless periods of time (usually between 10-20 minutes).

3) Straight legged crawl kick with or without a floating device (5-10 minutes). If you are a swimmer, enjoy swimming the crawl but mind the need for straight legs while doing it.

4) Kickboard drops = With kickboard, hold board down with revised knee leg, let board rise, push down, lift and push down repeatedly (i.e.3 sets of 20 per).

5)  Walk backwards in water levels that you are comfortable with. The lower the level the more weight your knee bears (5 minutes) .

6)  Walk forwards (5 minutes).

7) V to l – shaped sitting kick =sitting in deeper end of pool, press lower abdomen muscles towards spine using arms to hold you up, separate legs from hips to either side of your torso, turning feet toward each other press legs together.  Turning feet away from each other, push legs apart. Repeat (60 times).

8) Leg Pulls = In lower end of pool, bend knees and lower body so that when the legs straighten out in front of you your chest to neck remain out of the water. Bend knees, take revised leg and straighten it out in front of you with the heel down on the pool floor.  Require the leg to pull you forward until your straightened leg is now bent under you. Repeat with other leg. Right then left.  Feel the quads tighten and the ham strings work (5 minutes).

Walking:  1.5 hours today in humid Bangkok.  Home rest of the day. Still stiff legged and out of balance. Lower leg pain restrains me from walking anymore than I have today.

Golden Rule: Do not feel pain to gain strength. Feel tightening and then release. Feel for agreement by the knee to accept these exercises. No acute pain allowed, and no additional swelling encouraged. Tailor these exercises to your needs. Enjoy your icepacks afterwards if needed.

CHALLENGES:

I have about one hour’s worth of walking stamina to manage the out of doors in humid Bangkok.  Having the stamina to walk to metro stops and to grocery stores and back are currently a real challenge. Pavement is bad, sidewalks are crowded and traffic does not stop for pedestrians, even if they use the zebra-stripes….Today, I will take the metro two  stops and back, with a half hour walk in between and a meeting in the late afternoon, a few stops north.  I trust this will work….?

What do you do on a daily basis?  What are your Challenges?