Last week I saw a shocking case of a 68 year old lady who had a right total knee replacement six months ago. She was unable to walk for more than five minutes, could stand for approximately 10 minutes (but weight bearing predominantly on the left leg), had a 30º flexion contracture and was generally miserable. She is an intelligent lady with reasonable insight who had been informed on three subsequent reviews by her orthopaedic surgeon that things were progressing satisfactorily adn to “keep doing what she was doing”.
Despite the obvious curiosity regarding the type of outcome measure the surgeon was using (apart from the obvious one of surviving the operative procedure!!), I drilled a little deeper to see if there were complicating co-morbidity factors, recent change in her function subsequent to surgical follow-up – which may not have been evident on the three previous surgical reviews. Despite my best efforts I was unable to determine any other subsequent factors associated with a recent change in clinical features.
Incidentally, this lady is a keen golfer routinely playing 18 holes three times a week and continued to do so with pain until two months pre-surgery. (why did she opt for surgery I hear you say –and that discussion is for another day!!) She remained active in golf club management and was highly motivated to return to playing, but realised that her current situation completely prohibited this.
What struck me most about this somewhat shocking state of affairs, was that this lady had had no active rehabilitation other than the immediate post-operative input sufficient to allow her to be discharged from hospital. It was apparently on the repeated instructions of the surgeon to continue “doing what she was doing”, as things were going well.
I raise this issue now, because I have seen an increasing trend in recent years of patients presenting some months post-surgery reporting little or no active rehabilitation and little or no guidance from the surgeons regarding what is required to regain function. In my 22 years of clinical practice it is not surprising to find some orthopaedic surgeons relatively “pro-physio” whilst others somewhat indifferent. What I found most shocking in this case was the abdication of what I would call ‘a duty of care’ to do what is best for the patient.
I would fully acknowledge that we may not have sufficiently robust randomised controlled clinical trials to validate the use of post-operative rehabilitation in hip replacement surgery, knee replacement surgery, lumbar spine discectomy and anterior cruciate rehabilitation, but these are all specific examples of clinical cases which I have seen in the last number of years, where patients have been expected to find their own way through self-directed rehabilitation program. What does this tell us about surgeons insight into understanding human function and the multiple components such as strength, range of motion, proprioception, co-ordination, motor control, endurance and dynamic loading capacity which this kind of ‘wait and see’ management plan leaves to chance.
In the off chance that I was seeing a skewed clinical case load of resistant conditions, I have discussed this issue with several of my colleagues over recent years, only to discover that it is not an isolated situation. It is often dictated by the attitude of the surgeon, the extent of rapport between physiotherapy and surgical departments and the environment in which care is provided (public versus private). Whilst one could conceivably argue in a public setting that cost saving measures dictate that routine follow-ups and rehabilitation not be part of the standard protocol unless patients are exhibiting complications, it is a particularly hard strategy to justify in the private sector. If insurance companies are covering the cost of treatment and the surgical procedure has been performed without complications, surely it is in the best interests of all concerned to follow a pre-emptive strategy optimising return to function in as quick as possible time, as opposed to waiting for complications to develop.
I would fully acknowledge that these economics may not be applicable to all facets of public sector delivery, and wonder if this is now a case of Evidence Based Practice distorting the clinical realities of patient satisfaction, compliance, and exercise capacity to actually deliver optimal functional outcomes.
Whilst no fan of spurious litigation which encourages claims of negligence and malpractice, I wonder how long it will be before this aspect of duty of care is explored in the courts – if it hasn’t already been?
I think it comes down to matching expectations of surgeon, patient and rehabilitation specialist in order to ensure that there is a congruent match between the acceptable outcomes.
I remain baffled by the concept that a replacement or reconstructed joint can recover spontaneously to its optimal level by a self-directed program in the majority of patients – even with technical detail on what the objectives are. I have treated many physiotherapists over the years and re-enforce this view that it is not always easy to see the “wood from the trees” as a patient and that’s in a client group with specific knowledge .
I would love to know if any of our readers have had similar experiences or knowledge of a body of evidence which could be presented to surgeons for the type of cases I have described above. Maybe this is a reflection of the profile of physiotherapy rather than a commentary on Orthopaedic surgeons? I would love to hear your comments.
Enjoy the clinical challenge.
Much has been written on the pathophysiology of patella femoral pain and hence the multitude of treatment strategies to rehabilitate it.
Of course patella femoral pain is not a single clinical entity but in fact constitutes a spectrum of pathology encompassing the entire extensor mechanism and involving structures such as the quadriceps insertion, the iliotibial band, the retropatellar articular surface, the patella tendon, the infra-patella fat pad and the medial joint line/retaniculum. Each of these distinct anatomical structures show their own inflammatory characteristics and healing response times. The challenge from a therapeutic perspective is to identify:
1) The structures reproducing symptoms.
2) The mechanism underlying the tissue irritation.
3) Rational protocols for effective rehabilitation.
The pioneering work of Jenny McConnell in the 1980’s on this area precipitated an explosion of research evaluating local muscle imbalance around the patella. More specifically the ratio of muscle activity between VMO (Vastus Medialis Obliquus) and the VL (Vastus Lateratus). This conceptual model of patella maltracking suggests as an impairment of dynamic restraint around the patella and has fostered much heated debate and clinical research since originally proposed.
However, the alignment of the patella within the patellar grove is profoundly influenced by lower limb alignment and consequently evaluation of these components must be an integral part of any examination process for extensor mechanism dysfunction.
Both extremes of foot malalignment – namely excessive pronation and excessive supination – by virtue of the torque converter mechanism through the tibia, induce tibial rotation, which essentially changes the patella tendon insertion strain and distorts the relative position of the tibia relative to the femur. Likewise femoral malalignment with respect to the tibia, most notably excessive internal rotation has the effect of lateralising the patella with respect to the vertical and potentially precipitating a sequence of effects along the lateral joint line from lateral retinaculum tightness, fibular head restriction, peroneal nerve vulnerability, medial retinaculum and tibio-femoral joint line overload.
It is therefore incumbent upon treating clinicians to quantify the limb alignment status as accurately as is possible. In my opinion assessment of the tibial and femoral components of lower limb alignment are a clinical priority over the alignment of the patella within the patellar grove. The rational of utilising vastus medialis obliquus contractions (VMO) to realign a lateralised patella when the under lying mechanical dysfunction is a distortion of tibia femoral alignment, is obviously irrational as well as anatomically impossible!. Therefore attempts to quantify patella tilt, prominence or angulation is an exercise in searching for effect rather than cause. US physiotherapist Gary Gray refers to this phenomena as the train on the track. Preoccupation with regard to detail of the patella position (train) without adequate attention to tibiofemoral alignment (track) results in an uncomfortable ride with neither patient nor therapist likely to reach their destination!.
Do you have the tools to adequately assess limb alignment mechanics and the appropriate treatment arsenal to influence recovery?
How do you prioritise your treatment strategy in patello-femoral dysfunction?
Share your thoughts and comments with other therapists.
Rise to the clinical challenge.
As one on the frontlines for 20 years the concept of “flags” was useful to provide a strategy for integrating multiple elements into patient management strategies. Unfortunately , much like pain management programs recognition has driven a hands off strategy of patient management on the basis that “manual therapy” is either ineffective or creates dependance in this patient group.
The converse view is that manual therapy and functionally specific rehabilitation can be used directly as a cognitive-behavioural strategy to address specific patient complaints / functional impairments. As physiotherapists we need to recognise that any interactions we have with patients have cognitive / emotive connotations and there is no practical reason why physical means cannot be used to facilitate this approach as an adjunct or an alternative to psychotherapy techniques
Those who attended the “Decade of the Flags” conference in Keel university at the end of 2007 will know that primary care clinicians can now no longer hide behind professional boundaries as an excuse not to challenge patients distorted beliefs or facilitate rehabilitation programs which are tailored to their needs.
This obviously poses clinical challenges but the facts won’t go away by passing the buck.
What do you find the most challenging aspects of of this situation?
The topic of ACL rehabilitation has revieved great attention particularly in regard to accellerated programs.
What is an accellerated program?
Do you know how to structure one?