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When to Push Range of Motion After Surgery

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One of the more common questions we get is how to know when to push range of motion after surgery, and when to back off.

You don’t want your patients to fall behind and get tight, but sometimes the harder you push the worse they get!

Luckily, we have some tips to know when and how to push range of motion when you need it.

To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 272: When to Push Range of Motion After Surgery

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Show Notes


Transcript

Student:
Hey, Champion team. With postoperative knees, how aggressive are you with pushing for range of motion? How much pain is appropriate? I’ve had patients scared to push and in pain when trying to get this motion back. So we back off, but then they struggle to achieve the ranges that I would consider adequate.

MIke Reinold:
I love it. Great question, Kim, and Kim from Washington.

Lenny Macrina:
Yeah. Lots of Kims.

MIke Reinold:
Yeah. I think that’s probably one of the most common dilemmas, especially with some early career professionals that are trying to figure this out, is how hard to push. We kind of hear that a lot of time with range of motion, how hard to push. And what I really like about the way Kim phrased this question sometimes is she’s battling pain or discomfort with the patient and the concept that if she feels like she doesn’t push, they get behind and range of motion, which is quite valid. Right. She’s got to find that little blend a little bit. Who wants to start this one off? Let me see.

Lenny Macrina:
I can, if you want. I don’t mind.

MIke Reinold:
You know Lenny’s going to, if nobody else does. [crosstalk 00:03:40]

Lenny Macrina:
Small hesitation, I’m in.

MIke Reinold:
Right. All right. What do you got, Len?

Lenny Macrina:
Here we go. No, I mean I get this question a lot. I got a lot of DMs. I got one the other day about this, actually. I think I put a video or two out on my YouTube channel about it because I think it’s, like Mike said, it’s one of those common things. A lot of it comes down to feel and experience with bending knees, moving shoulders, things of that nature. It looks like I am aggressive when I’m pushing on knees… And maybe the students can even comment too. That might be interesting to get their perspective because we have a few people right now that have some stiffness in their knees or whatever, and I will let them bend and then I bend and then get feedback from the patient to see how aggressive one of us is.

Lenny Macrina:
And it’s usually more aggressive, but it feels like a better aggressive. Meaning I get to the end point, but I’m not ramming it. I more or less kind of get to the end and kind of get a nice, easy stretch into that end point. So it looks like I’m super aggressive, but I’m actually not as aggressive as you think. And I kind of hold that position at end range for a second or two and I’m monitoring the patient. I’m watching them, believe it or not. I’m doing all this and I’m also kind of getting their immediate feedback. Yes?

MIke Reinold:
Can I jump in on that, Len, because I actually think that I’ve witnessed this quite a bit. Where you and I do range of motion, whether it be a knee or a shoulder… And it’s the other therapist too, but I’ve specifically noticed this with Lenny and I. We’re doing our range of motion and I think, to the students, it looks like we’re doing it fast. And you said aggressive, but I would add fast. Right? And they’re like, man, they’re going so fast. But what they don’t realize is that, let’s say with knee range of motion, this entire spectrum of range of motion, is we’re fast through that empty nonsense end feel that’s irrelevant but then when we get there, we kind of slow down and then slowly, gradually kind of get to that end range.

MIke Reinold:
I feel like the students see our speed and try to emulate our speed throughout the entire range of motion and don’t realize that if they’re struggling at a hundred degrees in knee flection, we’re fast from zero to 90, but then we have this slow ramp-up here. I’ve witnessed that, actually. It’s funny you say that. And that’s one of those things we say is you got to be a little bit more smooth towards that end range.

MIke Reinold:
So that’s an interesting, really good first point. It’s not about necessarily how much you push, but maybe it’s also how you push, which is a good way of doing it. I’d say that may be your first thing, Kim, is that if there’s discomfort, maybe you can do something with how smooth you are or how gradual you are with that push. Maybe you can actually see, are they really a hyper reactive knee and they’re having pain with the range of motion in general, or is it maybe you could be just a little bit smoother or maybe ease into it a little bit. Maybe that’d be a first start. I think I saw Dave first. So what do you got Dave?

Dave Tilley:
The only thing I want to add is that I learned from you guys really early, when I started working at Champion is you guys have… It’s not this big, all right, now we’re going to push and you go super hard. You have a fluid conversation. You guys are chatting and you’re doing emotion first. I think that’s a mistake I used to make was all right, here comes the big stretch. And people were terrified. You guys have a three to five minute conversation with somebody and you’re sneaking in a couple hard pushes every once in a while. I think that makes it a lot easier. That’s just my two cents.

Lenny Macrina:
Those are the conversations that I’m finding out if they’ve watched Squid Game or what they’re doing with their lives. I’m having those conversations. Honestly. And I’ve said that to the students. We want to take their mind off the fact that I am bending their knee and trying to obtain end range motion. And those are the conversations I’m having, those mindless, “Tell me about your kids” or “Did you watch Squid Game this week” or whatever… Not to date the episode, but like…

MIke Reinold:
Squid Game was like four years ago, Len.

Lenny Macrina:
I know. I’m still a big fan. But it’s little things like that. It’s little tricks to get people to… They’re anxious about this. They’re anxious about getting their motion, their pain, their range of motion, their swelling. You can do anything you can to play tricks on these people to get them to relax. And then you’ll be able to get that little end feel, that end point that you’re looking for to get that nice stretch. Yeah, Lisa?

MIke Reinold:
I just want to say too…

Lisa Lowe:
Scaduto can go first.

MIke Reinold:
I just wanted to say just real quick too, that I feel like Lenny is really like… This is the most pop culture reference he’s had in a while. You’ve talked about Squid Game for several episodes in a row right now. I’m pretty impressed by that.

Lenny Macrina:
I don’t watch a lot of TV, so if I do, I want people to know.

MIke Reinold:
I mean, that was pretty good. So yeah. What do you got, Mike?

Mike Scaduto:
Well, first of all, Lenny is all Squid Game all the time. I’ve seen [inaudible 00:08:18] and now on the podcast. But I would say important consideration, I know I’ve worked with Lenny for a while and if you follow Lenny on social media, you see that he does a lot of flexion in the seated position with the knee off the table. So maybe patient position is playing into discomfort as well. If you’re bending a knee in supine, that may cause a little more compression to the joint. In seated off the table, the femur is a little more stabilized. Maybe you can add slight distraction force, that would make it a little more comfortable as well. And you can control tibial rotation, which could lead to some more comfort in bending the knee. I think positioning is important.

MIke Reinold:
I like that. I like where this episode’s going, right. Because Kim asked, should she push? And what we’re answering is maybe how she could push better, which I think is really helpful tips. Great stuff, Mike. What do you got Lisa?

Lisa Lowe:
This is more personal experience, but when people were bending my knees, and they were very painful, I will say I was put on my belly. I was put on my back with my hip up and cranking that way. I was put in a lot of positions that are really, really, really hard to trust that anyone’s going to keep you in a comfortable and not over push. I had people over push, more people who are used to working with knee replacements kind of just crank into it, and then I got so much swelling, I lost range for like a week. It is a really, really fine balance.

Lisa Lowe:
But I think, honestly, once I finally convinced people that they should just let me sit on the edge of the table and bend my knees that way, my life got a lot better and I gained a lot more range because I could sit there and actually relax. And kind of everything that Mike just said of that little bit of distraction for us and all of those things, it really makes a huge difference. And you’re not putting the patient in a position where they feel fully overpowered or that they can’t see what’s happening, which I think just makes it easier to sort of take whatever that end range push is for that moment that you get it rather than feeling like someone’s just cranking on your joint for, you know…

MIke Reinold:
Yeah. It’s trust, right? There’s a little bit of guarding. Can I ask a question, Lisa? So you said your knee swelled up a little bit and you had some setbacks with over aggressive range of motion. This is a good example because you’re a physical therapist. You get this. Do you remember at the time, was it painful range of motion?

Lisa Lowe:
Oh, yeah. And it was in my head, right? Because we’re taught in school, you need to be aggressive, you need to help these people get range. And I think, and maybe I’m wrong here, but I think that more applies to a knee replacement rather than an ACL or some sort of smaller, not metal on metal knee. I think the therapist who was working with me at the time was much, much more accustomed to work with knee replacements. So I think that the difference of the end feel there when it’s still bone on bone and messed up ligaments and menisci and everything, I think there’s a really big difference there when you’re working with metal on metal that are beautiful joint surfaces that move against each other really nicely. I was just laying there gritting my teeth because I knew that I had to let somebody help me get this range. And so maybe we haven’t tried this yet and maybe this was going to help.

MIke Reinold:
Yeah. You know what that makes me think right there is… We talk about this a lot with the students. It’s better to be slow and gradual and have a mild discomfort with a push over time and slowly gain motion than to wait, get tight and then have to crank on it because then you’re battling that. I think that’s another decent tip with that too. You don’t want to get to the point where you have to crank because if you don’t crank the person’s going to be stuck in need of manipulation. I think that’s another thing they fear too. What do you think, Pope?

Dan Pope:
I was going to say, I think what Lisa said there was pretty important. If someone’s stiff and you keep pushing through that and they’re swelling more and they’re getting worse, maybe that intensity is too much. You can look at the other exercises. Maybe you’re doing too much to cause too much swelling. Maybe there’s not enough quad strength. There could be maybe some other reasons why.

Dan Pope:
The other thing is that if someone’s stiff, they’re not making progress, one of the first things on my mind is okay, well they spend maybe 30 minutes to an hour somewhere between one and three times a week in PT. We probably have to do some more education about the frequency of mobility at home, right? Maybe that’s a big thing. I tend to try to push a little bit more frequency over intensity, just cause I don’t like to crank on knees, maybe I’m being a baby and I got to push a little bit more. That’s usually my first go to, but if that’s not working obviously you could push harder. And then the last piece is… Lenny does this all the time, I probably need to do this a little bit more, he measures all the time. He really knows if that change in intensity, frequency, whatever it is, adding low, low, long duration, whatever he did to try to increase mobility is actually making a difference. And then you can keep tweaking over the course of time with that knowledge.

MIke Reinold:
Yeah. Awesome. Did you have something too, Kev?

Kevin Coughlin:
Yeah. I just wanted to add… One thing I think we do here that’s helpful for making the range of motion feel comfortable is starting with some heat and some tissue prep, and then maybe some massage to really put them in the best position to feel good with the range of motion.

MIke Reinold:
I like that. All great tips, right. And a lot of things we tried to help Kim with here was some things to help her when she’s dealing with this progression. But I don’t know if we answered her question yet. Her question was when do we push? I think we gave her some good tips on how to push, but we didn’t quite answer that. Len, do you want to lay the hammer down and give her your guidance? This is the ending of the episode guidance that everyone’s been waiting 15 minutes for is when do you know when to push and when to back off?

Lenny Macrina:
Right. I think I try not to get there, where I have to do it, but it definitely happens. I am building up into the point where if they are three, four, five weeks out and they’re not hitting their goals, meaning they don’t have 120 plus degrees of range of motion, depending on if it’s a ACL or a knee place or something like that, then I will probably be a little bit more aggressive. But up until then I am assessing end feel. How is that coming? How’s their pain? How’s their swelling? How are they responding? How are they doing stuff at home, like Pope mentioned. Again, I’m never super aggressive at end range, I don’t think.

Lenny Macrina:
And maybe again, the students, I will talk to today when I get to work… But yesterday we had somebody and I think I was less aggressive on somebody who I needed to be aggressive on because I just don’t think the benefit is there. I get to that end point, I give a little stretch into the end range and then I get out. I just do that numerous times and it seems to work. Don’t be super aggressive at that end range, like Mike mentioned earlier, and I think you’re going to see better results if you just kind of get into that end point, hold it and then bring it out, but not at a quick velocity. You’re constantly monitoring pain and swelling and all that. Yeah.

MIke Reinold:
I like that. And like Dan said too, it’s probably frequency over intensity, so you add that. I think, in general, Kim, it’s probably better to be more frequent and a little bit more restricted with how hard you’re pushing initially. The only time I would say that we probably get really aggressive with pushing is literally when we’re at the point where we are so far out in a timeframe and we are literally faced with: if you don’t get your motion back, we’re going to have some sort of procedure, either manipulation or a clean out type thing or something like that. The goal is to avoid that. So it sounds like it’s a combination of understanding the healing constraints and the time of the procedure, as well as probably having a good feel of that end feel.

MIke Reinold:
Then hopefully you take all these great tips-this a great episode with a bunch of tips-and that’ll help a little bit. Great question, Kim. If you have a question like that and you want us to vaguely answer it and beat around the bush the whole time, then keep going to mikereinold.com, click on that podcast link and ask away. We will do our best to try to specifically answer your questions. But sometimes, Kim, it’s a big topic. And I actually think that was better. There is no right or wrong answer. Some procedures, some people need to be pushed harder than others, but hopefully if you take all these tips, that’ll be a little bit better. Awesome. All right. Thanks so much. See you on the next episode.

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