The Arthritis NewsletterFall 2014
Getting Back to NormalBy Gerry Sheanh
In which Dr. Marie Westby and Dr. Catherine Backman investigate attitudes and outcomes concerning rehabilitation following total hip and knee replacement surgeries.
Recovery from any surgery has its own set of issues, but for those undergoing joint replacement surgery, rehabilitation over a long period of time is often necessary to help the body to adapt. In their focus group study of patient and health professional views on rehabilitation practices and outcomes following such surgeries, Dr. Marie D Westby and Dr. Catherine L Backman identified six key themes: communication among patients and medical professionals, managing expectations, positive patient attitude, wide-ranging support, barriers to recovery and getting back to normal. While each theme contains its own set of complexities, it is the back to normal theme that concerns us here, because normal tends to mean different things to different people.
Dr. Westby states, “Discrepancies in how patients and surgeons rate a “successful surgery” have been reported in several papers. While surgeons are interested in whether the surgery has resulted in pain relief and if the patient is satisfied with the results – each qualitative or subjective measures – there is still a focus on the technical aspects and surgical outcomes. That is, the “fit and fixation” of the implant.
“In the long term, our own Canadian Joint Replacement Registry (www.cihi.ca/cjjr) only requires surgeons to report data on number of joint replacement procedures, type of implant used, bearing surface (e.g. metal, ceramic), method of fixation (e.g. cemented), length of hospital stay, complications (e.g. blood clot) and a patient’s age, gender, Body-Mass Index (BMI) and primary diagnosis. There is no patient satisfaction, self-reported function, participation in meaningful life roles (e.g. return to work), or quality of life data included, which makes long-term monitoring of these very important aspects of patient functioning impossible to track.”
One surgeon interviewed in the study said: “Well, the main indication for joint replacements is disabling pain and stiffness, and so the most important outcome is pain relief.” [56 M, SURG]
Another observed, “I recognize that it’s a professional conflict to a certain extent but the ultimate responsibility for the outcome falls to the hands of the surgeon and if the therapist from the patients’ perspective makes them worse or doesn’t do a good job, it doesn’t really matter because they still blame the surgeon in a sense for their poor outcome.” [55 M, SURG]
Patients, on the other hand, are interested in more than physical healing and elimination of joint pain, generally looking at more qualitative issues than do many surgeons. Patients want more than elimination of pain and the regaining of movement; they want to return to the activities they enjoyed before the original joint deteriorated to the point of replacement as well as a sense of normalcy that is sometimes difficult to define, but is nevertheless desired. For many, this includes a return to physically demanding jobs or recreational activities, while for some, it just means being viewed as a normal person by family and friends.
Dr. Westby reinforces this view in asserting, “In my research and clinical experience, patients want to resolve the arthritis-related pain they were experiencing leading up to the surgery, to be able to walk with greater ease and for longer distances, to meet their expectations around resuming valued occupational and leisure activities, and to achieve greater independence and less reliance on family and friends to help with day-to-day activities in the home and community.
In essence, patients who have undergone a join replacement surgery want to be heard, want to participate in their own recovery and want surgeons and health care professionals to view them as more than just a knee or a hip that needs fixing. One occupational therapist summarized the feelings of patients well:
“It would be really nice if they came through the whole process without looking upon it as an enormous nightmare, that things have gone smoothly. You can’t always predict everything I realize, but that they had a sense of confidence and a sense of control in the whole thing so that it’s been a worthwhile process.” [44 F, OT]
Though there is a difference in how surgeons and patients may define success, or normalcy, Dr. Westby believes there are some things a surgeon can do to support the patient in recovery. These include:
“1. Encourage patients to take an active role in their recovery. I would like to see surgeons help patients understand that while replacement of the painful, arthritic joint will go a long way towards relieving their pain and improving their walking ability and day-to-day function, it is only a step in the full recovery and rehabilitation process. Surgery alone will not result in stronger muscles, better cardiovascular fitness, normal walking patterns and reduced risk of falls, all of which are compromised in the months and usually years leading up to the need for surgery.
“If surgeons did more to advise patients on the importance of participating in a structured rehabilitation program and then doing the recommended exercises for at least a year after surgery, it would help patients better understand their role in their recovery and the commitment needed to achieve optimal results.
“2. Promote the value of “pre-hab”. Despite the equivocal research findings on the benefits of pre-hab exercise, I’ve NEVER had a patient tell me that doing exercises and increasing overall fitness level before surgery was a waste of time. Current practice does not reflect this nor are there publicly funded programs for patients to attend. Staying active and performing some basic pre-operative exercises are “encouraged” through a patient education booklet but there is little to no individual guidance or support unless a patient seeks this out through private routes.”
“3. Talk about being physically active before AND after surgery. “Active Living for Life” is a concept all health professionals should be advocating for their patients. Surgeons should be yet another member of the patient’s healthcare team that encourages and provides guidance on living a physically active life. Surgeons may also use the numerous and helpful resources available for physicians and health professionals to promote physical activity and discourage sedentary behaviour or prolonged periods of sitting or lying. Exercise is Medicine and the Canadian Orthopaedic Foundation are both good resources.”
“Whatever their definition of “normal” is, we need to understand that some patients are happy with being able to move around their homes in less pain, have a better night’s sleep and simply get out of the house to run errands. For others, normal is resuming full-time work, hiking, traveling and returning to an almost pre-arthritis lifestyle (within reason for their age, other health conditions and previous experience or skill level). It’s very individual and context-specific.”
Reference: Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis: a focus group study, by Marie D Westby and Catherine L Backman BMC Health Services Research 2010, 10:119 doi:10.1186/1472-6963-10-119 http://www.biomedcentral.com/1472-6963/10/119