Question: I have had knee pain for years and was preparing to visit my orthopedic physician to discuss joint replacement surgery. My consultation was then cancelled in March due to COVID-19. Since that time, my mobility has worsened as I have been self-isolating at home and my activity level has been reduced. When my surgeon re-opened, he suggested a course of rehabilitation before undergoing knee replacement surgery. I am discouraged that he wants to delay surgery even longer! Can you tell me why I should be doing rehab prior to surgery?
As counties reopen from COVID-19, surgeons are beginning to resume elective procedures to help their patients who unfortunately had to delay care. Other people who have been suffering from chronic knee or hip pain may be looking forward to meeting with a physician soon to discuss joint replacement surgery options. However, due to precautionary self-isolation and reduced activity during the pandemic, many people have become deconditioned over this time. This effect is often worsened in patients dealing with chronic hip or knee pain as activity tends to be painful.
Prehab for Deconditioning and Range of Motion
Deconditioning prior to a major surgery (such as joint replacement) can be a big problem. One of the priorities after joint replacement surgery is to get the patient up and moving as rapidly as possible. This reduces the risk for bad side effects of surgery, such as pneumonia, bed sores, and blood clot development, and helps jump start the healing process. Some strength loss is expected following surgery; after all, the surgeon did just cut a big hole through your leg! Entering the operating room with as much strength as possible helps mitigate the expected strength loss. When a surgical candidate’s strength is lacking due to deconditioning, getting out of bed safely and participating in post-surgical rehabilitation becomes more challenging.
Another concern following joint replacement is restoring the joint range of motion. Post-surgical instructions regarding range of motion after joint replacement often vary by surgeon and the specific surgical procedures completed. In most cases, the goal is to safely return the patient to a range of motion that allows for completion of normal daily activities without significant functional limitation. Deconditioning can be problematic as range of motion may be limited due to low activity level prior to surgery. For instance, many patients have difficulty fully straightening their knees prior to knee replacement surgery; however, full knee extension range of motion is critical for safe walking without using a cane or walker. Like strength, range of motion losses are also expected following surgery due to swelling, pain, and muscle guarding, so maximizing joint movement prior to surgery leads to greater movement tolerance and can partially mitigate this effect.
Ultimately, if deconditioning has occurred over the last few months, or if you were deconditioned to begin with, your joint range of motion and leg strength are likely less than what your surgeon wants them to be. Your surgeon wants you to do well during and after surgery; his reputation is on the line after all! He knows that by improving these attributes ahead of time, better outcomes can be expected. Additionally, post-operative rehabilitation (post-hab!) will likely be easier and progress is often faster as a result.
Other Benefits of Prehab
There are other less obvious benefits of prehab. For instance, patients receive education about their condition and expectations regarding post-operative care/restrictions before the surgery, enabling them to ask questions specifically about the rehabilitation process. This is beneficial as it gets the patient mentally focused and prepared for a significant surgical event. Patients become familiar with walkers and canes and learn to use them effectively before they are absolutely required to. Finally, prehab may help reduce hospital stay time and may allow you to be discharged straight to an outpatient therapy facility rather than an inpatient facility. Given the ongoing COVID pandemic, your physician would likely prefer you to get out of a hospital setting as soon as you are safely able.
Ultimately, think of prehab as prep work for the surgery. If your surgery and subsequent rehabilitation were a test, prehab would be the studying beforehand to ensure you passed. In a lot of cases, the extra work initially goes a long way and you will likely be happy you were prepared. Every prehab is different depending on the specific needs of each patient and we work to tailor each program to deliver optimal results after surgery. If you have any further questions regarding the prehab process and what it will entail, please do not hesitate to contact an Access therapist, who would be able to provide more specific details based on your case.
Eric Fontaine, PT, DPT
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