Meet Sandra...

Sandra is one of my favourite people. Not just because of her fun, enthusiastic personality but also because over the past 6 months or so her application to engaging in Physiotherapy represents just how effective Physiotherapy can be if we modernise and personalise the way we approach treatment or Rehabilitation.

I asked Sandra if I could share her story & she was thrilled!

When Sandra and I met she was struggling with really debilitating knee pain. She had seen an Orthopaedic consultant privately, had been diagnosed with Osteoarthritis (OA) and it was recommended that she would need a Total Knee Replacement. She was too young however so it was advised she cope as long as possible until the inevitable came around. The future was bleak. Sandra loves to be outside, she cycles, loves to walk in the countryside over challenging terrain and has an active job where she's on her feet a lot. She does a lot of travelling with work, has a busy family life with grown-up children and needs to be fit and active.

Sandra was aware of the perceived implications of OA. Google it and you'll see certain themes - words like 'degenerative', 'wear and tear', 'ageing', 'irreversible' and 'painful' may be commonly be found. Management? Try getting stronger, but the seed is planted that eventually you are likely to require surgery.

Sandra was initially pretty down-beat as anyone would be. Would this be the beginning of a regression in independence, fitness, quality of life? It already was to a point and showed no signs of getting easier. What are the options? Are there any?!

In my opinion, guided heavily by the most modern research into OA, physical conditioning and the long-standing effects of Pain (See "Pain; help or hindrance blog) we should be managing conditions such as this in a different way. We could describe OA by using words such as 'normal', 'adaptive', 'safe', 'controllable' and 'often pain-free'. OA is not a wearing away of bone; we do not work like break pads in a car and get thinner with use - regular use can help keep the body conditioned and can stimulate a strengthening process within bone and other joint structures (so 'wear and tear' is a very mis-leading and potentially harmful term!) On top of this, OA is not always painful, it can be of course, but it's not a given; the reported numbers of pain-free people with signs of OA in their knees, shoulders, backs and necks are staggering.

So what do we know?

Pain is a protective response; once triggered it can lead to reduced muscle power and increased sensitivity (pain goes up and triggering the alarm is made much easier - this is defence mechanism). Pushing through pain can stimulate a more sensitive alarm system, which we don't want. But if we do nothing we're left potentially weaker / more sensitive still. So what's the answer??

How about embracing simplicity and changing our focus?

Find out what you can currently tolerate, and stick to a planned routine regularly. This must be tolerable - no big spikes in pain, but it must be done as a matter of priority on a regular basis.

Back to Sandra...

Sandra and I discussed this at length. Sandra knew exercise was necessary but was struggling to find a balance - exercise that didn't aggravate. Also there was probably a part of her that was influenced by all the negativity surrounding OA and its degenerative nature.

If I can't change bone and bone is the issue, how is this going to make a difference anyway?

This is a really good question that needs addressing head-on. OA is a change to bone. Pain is a protective process linked to your nervous system. They are not the same thing. They are not synonymous and they can exist separately. Let's not think about the bone, let's think initially about reducing pain, and then let's build.

Sandra and I started with simple exercises in a clinic environment; basic knee movements, muscle contractions with the emphasis being on pain-free (or tolerable) and done frequently. We had weekly reviews where we made subtle tweaks to the exercise program initially and we kept this up for a few months. What we witnessed was a gradual decline in pain.

No cure, no lightbulb moment, no quick fix, just hard work and perseverance with great results.

Sandra is now in the Gym every week. Having never used a Gym before and not considering herself a typical 'Gym-user', her initial apprehension has been replaced with delight at what she's now capable of! She can squat with 40kg on her back! She can cycle, walk and swim without concern. She knows her limits but also knows that improvements are completely achievable if we follow certain guidelines.

Has her OA changed? Has the bone changed? No

Has her pain changed? Dramatically!

What about her quality of life? Significantly.

What about her optimism for the future? When we met Sandra was concerned she'd no longer be able to work with things the way they were. Now, She's recently changed roles and has no intentions of slowing down physically. She has planned her retirement and on day 1 of her new retired life is going to Kenya on Safari for 3 weeks. Walking, hiking, exercising daily. She would never have thought this possible when we first met.

What made the difference? In the medical world we're so focussed on structure. What hurts? Is is bone / ligament / muscle / nerve etc. When do we ever talk about pain?? Pain can exist without structural change and often does. Structural change can exist without pain and often does. Why do we link the two instinctively?!

As we've mentioned earlier, pain is a protective response. It's influenced by lots of different factors - what we feel, what we've been told, our fears, apprehensions etc. If we've been told it's OA and only going to get worse it changes how we approach it? We're likely to do less, avoid certain activities, assume the worst. If we're told you can reduce pain, we feel more optimistic and our approach to management changes.

We did nothing special with Sandra other than change our way of looking at her current predicament. Could you do the same thing?

As always, comments welcome!

Matt