Making decisions about knee replacement as an older person with multiple conditions

No, well, I mean I mentioned it to the doctor saying, “Would physiotherapy help?” And he said to me, “It might do and I could refer you to the hospital but,” he said, “I’m telling you at the moment, even physiotherapy, the waiting list is 12 months so if you required physiotherapy, it would be best if you tried to go privately.”

But I haven't - well, I mean I’ve had people's recommendations but I haven't found one and so the doctor gave me some exercises to do every day to help, and so I’ve been doing those every day.

How’ve you found those? Is there any impact on your knee doing them?

Well, it- I don’t think it depends on my knee itself, I think the whole idea is to strengthen the muscles around my knee to try to support it. The pain in the knee itself is pretty constant, I manage to do them but I can’t say it’s not painful when I’m doing them.

Well, that’s where it got a little bit complicated because again, my doctor had referred me to [town] physio.

And I had a similar letter to the one I’d had from [hospital] Orthopaedic Department which more or less read to me as if we won’t be able to see you for some- how long is a piece of string - kind of thing.

So, I did, having had all that contact that I’ve mentioned with [private healthcare organisation], you know, until relatively recently we haven’t really used over however many years we’ve been members. I had noticed that physiotherapy was one of the things that they had in their magazine and sort of advertised.

And I contacted them and yes, you know, straight away, off we went.

About two years before that I saw the GP and was recommended for some physiotherapy, so that goes back a bit, probably two or three years now.

Can I ask more about what was that physiotherapy like for you?

Well, it was it was a group physiotherapy session, so it was a little bit helpful, I think it sort of kept my knees moving but it didn’t do anything very beneficial. And in fact, it got as far as them recommending to have a steroid injection in one of my knees, but that was cancelled because Covid came along. And they weren’t doing that sort of thing.

It came about because I was aware of having to wait a long time to see anybody and I just felt I needed to be doing something about my knees, so I booked to go to a physiotherapist, that was a private one as well. Just to keep something going before I had the orthopaedic appointment.

And do you still see that physiotherapist or stay in touch with them as you’re doing the exercises at home?

I’m now just doing the exercises at home. I have an option to go back if I feel I want to, but at the moment I’m just continuing to do the exercises.

And I did beg the doctor to let me go to proper physio exercise class, so that I managed to get the proper exercise in before I had the operation. And my surgeon said, “Wonderful. Absolutely brilliant.” Wished all his patients would do it because it helps, considerably.

Can you remember how you—

So, and there was afterwards. Sorry.

No, that’s brilliant. I was wondering how you first knew about that exercise class that you had to sort of ask the doctor for.

It was a physio, a physio friend that I had donkey’s years ago that happened, you know, get in touch. And she was saying how you doing? And I was, "urggh, you don’t wanna, really wanna know.” But you know, I told her and she said, “Oh, well, you know, there is exercises that you can get in onto a course.” But they didn't really want me to. “Oh no, they’re all full. No, you can’t.”

And so I think I mentioned it to the surgeon on one of my visits and I had to go up for an X-ray or something. And I mentioned it to him. I said, “I wanted to do them.” He said, “Oh yes, so you should.” And then he put the wheels in motion. All of the sudden there was a place for me.

That’s brilliant.

[Laughs] So I started going. Yeah, ‘cause it was exercises that I’ve never even seen before or done before.

And it helped absolutely wonderful. So, I, I hope they’re still around and I’ll be able to do some more before I have this operation. ‘Cos I don't know how long I’ll have to wait. I’m expecting to wait up to another two years before I get this operation by the way things are going.

What sort of exercises? You said they were really good and there were some that you’d never known about before. Would you mind telling me a bit more about those?

Oh, there was, oh my gosh, there were loads of them. It wasn’t ones that I could come home here and do. It was things that was, in their room down there in their physio room like this great big, huge great big ball thing that we had to sit up and sit on and stand up and with your arms crossed over your shoulders and you know, so you got no help in doing it. So, your legs had to work. Your knee had to work to get you up and down.

Then there was something we had to do with the parallel bars, and then there was like steps up across like a platform and then down again. And you had to do that so many times, like you go up and down stairs, but you only do that like, you know, once or twice a day and you don’t think about it do you? But this was, it’s only about four steps, but it was like a little, little four steps and a platform across and then four steps down the other side.

So, you had to keep on doing it. You had to do it for like ten minutes each time. It was like, you did a, a round circuit like so you just kept changing to every different obstacle, if you know what I mean?

And that went on for an hour. That was an hour once a fortnight I think it was. I think it was once a fortnight I had to go. And it was amazing. Absolutely amazing. The knee was better when it, when it come to be actually operated on, it was better than what it was when I started.

So, physiotherapy can offer several different things to patients with osteoarthritis.
They can improve range of movement at joints, so sometimes joints get stiff and they get restricted with osteoarthritis, and physios can give exercises which can help improve that and also manual therapy techniques, which is where they mobilise and manipulate the joints with their hands. Massage, that can be helpful.

They can also improve the strength and the coordination around joints, which has been shown to be really important in people with osteoarthritis. That generally enables people to feel more supported, and steady and improve their function, ability to walk etc, ability to use upper limbs for everyday tasks.

And the final thing that physiotherapy can offer, which sometimes comes as a by-product of the other two that I've just mentioned, is pain relief. So, a joint that moves well, that is stronger, generally tends to hurt less when you ask things of it.

But there are other things that physios can offer: electrotherapy, acupuncture, usually in conjunction with exercise and manual treatments, that can help to reduce pain and inflammation around and within joints.

Physiotherapy definitely has a role in early osteoarthritis. So, when people first start to get symptoms, they may have had an X-ray that shows early changes within the joint.

Patients can make real progress with physiotherapy during that phase, because there's limited damage to the joint. The majority of the pain probably comes from the capsule, which is the sleeve around the joint, and physiotherapy can make changes to that. So, it's much easier to improve range of movement around a joint when you don't have bone-on-bone restrictions, if you like. And also, I suppose, the earlier you treat these things, the less muscle wasting and deconditioning will happen. So, do you see what I mean? It's not like you're taking the patient right back to a really limited state.

And as the osteoarthritis progresses, I think physiotherapy can still help. But I think it's less likely to make as much of a difference later on, although I wouldn't ever rule it out completely because as we know, the degree of osteoarthritic change on an X-ray doesn't always marry up with the amount of pain and disability a patient has.

So, I think, yeah, I think it's always worth thinking about, but probably more effective in the early stages.

So, there's a lot of interest around rehabilitation. And the general consensus is that the fitter and stronger you are before an operation, the better you will do following surgery. So, if you can go into an operation with a knee that's got good movement, with a joint that's well supported by muscles, and from a metabolic-, from a fitness point of view, you're in a good place. It probably fosters a good outcome following an operation.

Well, when I went back, obviously with my six week - after having had my left knee replaced, I told the consultant, that I was having great difficulty. Actually, I could walk very well but the pain I was getting was sitting, and in bed particularly at night, I couldn't move my leg without being in awful pain.

That’s when he recommended me for physiotherapy at the hospital and the physiotherapist, when I first went, tried to get me to move my knee and I couldn't move it when she bent it. The pain used to shoot down from my knee into my foot and she said, “You’ve got- you've got a, a nerve trapped there, and I’m not going to push it.”

So that’s when she suggested that she do acupuncture and so, as I said, I went for - I think - five weeks running and now I get 20 minutes, half an hour, and it did seem to alleviate it. 

Then they suggested I should go to the gym. I, I think I went about four or five times, at the end of which I was referred back to the consultant and, you know, it was fine; all the pain had gone.

Did you have any physiotherapy after your right knee was replaced or for either of your shoulders?

Yes. Oh yes, I did, yeah. Not for long, not for as long as I’d like to have, but I got them to like write it down on a piece of paper so that I could carry them on.

And they gave me these lovely strappy band things that you can push and you know, elastic band things? So, I kept up all the exercises even after they gave up. ‘Cause they can’t keep it up, they’ve got so many on their books. They can only let you have physio for about a fortnight after the op and then they gotta go onto somebody else.

So, I just asked them to write them all down so that I could carry them on after they’d gone.

That’s good.

…and it helped. It helped. Definately.

So, the physiotherapy, well, the physiotherapy begins with the prehabilitation really doesn't it, and then it's picked up again by the ward physiotherapists in the hospital.

So, what they do is they start exercises early. They can also work on treatments to reduce swelling and inflammation; cryo cuffs [cold compression], for example, can be used. They'll also work on a patient's mobility. So, they'll help them to get in and out of bed, up and out of the chair, walking initially usually with a Zimmer frame, usually, and then the patient is progressed on to elbow crutches and usually discharged on elbow crutches.

Most centres that I've worked in routinely refer all patients that have had a knee replacement for outpatient physiotherapy, and that's usually done on an urgent basis which should be no longer than a few weeks. So that the patient can be picked up and there's very little gap in their rehabilitation.

What will then happen is probably a bit variable from centre to centre and from clinician to clinician. But it would usually involve progression of exercises already started on the ward, so gradually building up somebody's strength, somebody's function. Those exercises will be done at home. But and how often the patient has outpatient treatment in terms of how often they attend is probably based on several factors really, but largely around the needs of the individual. So, some people are quite happy to be set a programme, to go home and to work on it, you know, based on their understanding of exercise, interest in exercise, experiences. Other patients need more guidance and would prefer to attend on a regular basis. I think it's really important that patients have that conversation with their therapist so that the program is tailored to what they need. And that can involve getting in the gym, sometimes there are classes that are put on, you know, group sort of exercise.

So certainly, the first three months are really important. We know that at that three-month point, most patients have healed very well. You know, they've got good movement, they're back to a reasonable level of function. But beyond that, I always encourage patients to be - for lots of different reasons - but to be continuing with some form of regular exercise to keep themselves fit and strong.

Well, physiotherapy yes, they gave me a few exercises, which yeah, I can do and I did. But I didn’t find, find them too beneficial in as much as that it wasn’t rigid enough for me. And that’s why I went to the osteopath. And he gave me-, well apart from how he manipulates your back and everything else, I found it was quite, quite a relief. I know it’s £40 odd quid a time, but I found that very beneficial when he gave me three specific exercises to do.

Okay.

Which I found very, very beneficial and easily to do, easy to do. Didn’t need any equipment for it or anything. It’s good.

No, I'm a bit cynical I'm afraid where physiotherapy’s concerned.

I always think that’s just a stalling tactic, because everybody you sort of speak to that’s been to physio, doesn't seem to think it does as much good as they thought it might have done, or if any good. 

And I honestly think that just generally for me, walking, and then occasionally I have a session where I go up and down the stairs, because we've got a stairs in our house, but we live downstairs rather than upstairs, our bedroom and everything’s downstairs.

So occasionally I have a session of walking up and down the stairs and making sure if I come to any stairs, that I walk up and down them properly, if that doesn't sound too cynical, whatever?

The GP was quite good, and they knew that I’d had a problem before with my hip, my knee, my half knee, and I mean he did say, “Yes, I think we’ll refer you.” But of course I didn’t get referred to the [hospital], I mean this is a long time back now, I got referred to [intermediary organisation] which are a company that deal with the physio side.

So he- the GP - said he was referring to the [hospital]. But it never got to the [hospital], it just got to [intermediary organisation] which is the next step.

And then for something like seven months I was- I’d had an occasional visit to the physio, and they would give me a few different moves to sort of practise at home, but the appointments were quite short, and more or less you're told what to do, rather more than them watching how you do it because their time is so limited.

And eventually- you know, they- because I was told at that point by the physio, there’s a possibility you can work with this, have physio, and then learn to live with the pain.

And I’d said that I thought, yeah, I was happy to give it a go, I mean, I was more than happy to try, but I did feel that if it was bone on bone rubbing on- and so forth, that it was very difficult then to say, ‘you've got to learn to live with that pain and that you could find your way to living a normal life without having any surgery.’

And yes, in the end I just had to say to them, “Look, you know, I am doing my exercises, I am doing this, I am still having problems and really I feel that perhaps now I’ve given it a go and maybe it might be better to go to the [hospital] to see what they felt.”

And I had to push that a bit, but having had it done with my- the first knee, this is before I had the hip done, and the hip and knee-

Oh, okay, yeah.

—and having had it done with the first knee, I just felt that I needed that.

The GP then sent me back for another physio referral, cos I kind of lost the plot with it.

So it’s maybe about two years ago that the GP referred me back, and that started the process of physio again. Cos as soon as they send you back, they put you back in the physio loop, which is just, “Try these exercises, try more exercises,” you know? You get rubber band, “Stretch your knee, stretch your knee,” you know? And I’m just thinking “Why? [laugh] It’s the exercise that’s killing me knee."

Well that again was a referral. And they then gave me a set of exercises which I did, and then let it lapse. Well not let it lapse, it just sort of expired, and then I just said, “No, it’s not getting any better.”

And I thought, you know like it ran its course and then just said, “Okay that’s it.” And it felt like I was, like I’d made a little bit of progress, and then it’s just rapidly got worse, you know, so I went back again.

And then it was more physio. They were absolutely adamant that it was down to me to make it, that you should not, the lady I saw, “You can definitely fix this,  it’s- you’ve only got mild arthritis, you’ve only got mild arthritis, if you do all these exercises it’ll be fixed.”

So, I did the exercises and it just seemed to wreck me knee. Seriously.

Oh well, the physio now has been, sorry I’m saying the physio- I’m saying still doing physio, I’m still, you know making sure that I do the exercises just to keep the knee mobile, but obviously, we’ve decided now that it’s not going to get any better with physiotherapy.

With the second knee, my left knee - four years ago, I said - I went to her and when the referral went through, the hospital asked me to do a physiotherapy course of so many weeks, which didn’t help at all. And it was a -  it made it worse if anything.

And exercises, because there was exercises that you use your legs more. And it wasn’t any good for me. And I went back to her after I’d finished a course and she referred me straight back to this hospital. And I was taken in, you know, and had it done and that was it.

But the physiotherapy course before that was just a waste of time because it was bone, and it was all to do with muscles, and they could hear my bones cracking. The guy that was doing it said, “Is that you? Is that you, your knee?” I said, “Yes, it is.” He said, “Oh.”

And I thought ‘no, I shouldn’t,' you know? I didn’t think that was, I didn’t think that was a good idea for me. But I had to go through it so I could be re-referred again. You know?

So, like I was a bit a bit miffed to be honest, but it had to be, I had to do it because I was triaged to do it. So to be honest I thought it was a waste of time.

But I haven’t had it with this one because this leg, well so far, because when I spoke to the referral guy - physiotherapist actually - he saw my x-rays and I think he realised it would be a waste of time.

And [so] he referred me back to the surgeon.