Over the last week I have been treating a man post TKR. When I initially consulted him during the pre-op assessment, he seemed very eager to undergo a fast rehabilitation process. He knew a lot about TKRs as he had his right knee replaced a number of years ago. Unlike most patients who have little to no expectations of what to expect after surgery, he was quite adamant with his. He told me he would gain 90 degrees knee flexion range Day 1 Post Op (while his epidural was in situ) and that he would like to use one of the exercise bikes in the outpatient department in the final days of his hospital stay. We covered his post-op exercises and he ensured me he would do these 3 times a day without fail. His optimism was refreshing, however I did warn him not to have too high expectations as this surgery may be different to his last.
Day 1 post op he reached 85 degrees on the CPM.
I did not see him Day 2 but my supervisor did. My supervisor mentioned that the man had refused to do his exercises and had basically told him he did not want physiotherapy. My supervisor had left the man, feeling there was not much else he could do.
Then came Day 3. When I visited him he looked upset and disheartened. He mentioned how he had fallen of the bed earlier that morning. He felt it was too painful to do any of his exercises. He was stubborn and challenged everything I asked him to do. Again, it appeared that he was not going to do physiotherapy that day.
Having known his expectations prior to surgery and seeing his loss of heart at current, I chose not to walk out of the room just yet. So I reminded him of his goals and expectations. He agreed that he wanted to continue with these. I told him he must trust us physios so we can help him achieve his goals. He reluctantly agreed.
So step by step we covered every post-op exercise, right down to the last repetition. If he initially said it was too painful, I’d ask him to try just one. Usually once he achieved the first one, he got a thirst for more repetitions. Then we would set an aim (eg certain number of reps). He usually would achieve this plus one more (just to be one up on me probably). He ended up completing his entire exercise program when on the previous day he would not do even one exercise.
During this session I had spent a lot more time than I probably should have on the man. But at least I had reinspired him to continue being active with his rehabilitation process.
In the future I aim to spend more time in the pre-op assessment for a THR/TKR in reiterating not to set many expectations immediately after surgery. Realistic goals may be set, however they should not have a timeline attached to them, as each recovery process differs. This includes those patients who've already undergone surgery on the opposite limb (as the second rehabilitation process often differs from the first). After surgery I will continually remind the patient that they should still have a good long term outcome but they must maintain compliance and motivation in the meantime.
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2 comments:
well done coyle for persevering. i think it is important to realise that we don't just treat but we also need to motivate and encourage our patients using realistic goals. It probably would have been a good idea to establish reasonable baseline expectations to prevent your patient becoming disheartened however, like you said, some patients are just so stubborn. i have found setting short term and long term goals together with your patient helps with expectations and motivation.
It sounds like you did a great job - from my experience it's really important to educate the patient who has had one knee/hip replaced that the 2nd one may not have exactly the same outcome, or especially that it may not take the same time to recover. Persistance with the exercises is the key, and whilst it can be disheartening that recovery is not as fast as expected I think just reinforcing and reminding the patient that they should still have a good outcome down the track is important in maintaining compliance and motivation. You managed to do that, and although it didn't happen as quick as you would have liked (missing a day or 2 of exercise), you still had him back on track quickly.
Also being honest with the patient and telling them that the outcome/timeline will not necessarily be the same as the previous op is critical to gain the patient's trust - since you told him that before he saw things were not going as he hoped, it would have been easier for him to trust your education.
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