Birabi NB, PT PhD*
Consultant Physiotherapist, Former Visiting Senior Lecturer Department of Medical Rehabilitation. University of Maiduguri, Maiduguri, Borno State, Nigeria
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Mrs M.A was referred to physiotherapy for the rehabilitation of function post Right (R) Knee Arthroscopy. The referring surgeon described her over the phone as a difficult patient and that her case was of great concern to the company she works for. A 39 years old professional with frayed lateral and medial meniscus; lateral meniscial tears with medial femoral condral defect. She was also referred to a psychiatrist 10 days before surgery who managed her for 3 days as Spectral Analysis (Neurofeedback and Central nervous system vital signs assessment) was indicative of anxiety and/or depression. She regretted going in for surgery and lacked confidence in her work environment. Outcomes: By the 18th therapy session of Physiotherapy at the end of week 6, Pain reduced from Score 10 to Score (4) VAS, Muscles' strength increased from Grade 2/2+ to 4/4+ Oxford muscle grading, Range of motion increased from 00 -1000 to 00 -1200 which is the normal; Function improved from non weight bearing crutch walking wearing 0.5 inch sandal to normal gait wearing inch foot wears. Built confidence and settled at work with team members such that she could work outstation; Life events scale score reduced from 549 to 289. However at week 10 she reported back with exacerbation of pain, score (10) as a result of handling a household emergency. Conclusion: The occurrence together of musculoskeletal conditions and mental disorders in the same person often complicates treatment and management plans. Clinical management of people with comorbid conditions can be more complex and time consuming than for those with single conditions. Mental health status of patients should be assessed prior to surgery, and physiotherapists irrespective of specialty areas of practice should take cognisance of the fact that anyone referred for rehabilitation should be managed with holistic and biopsychosocial approaches in the context of the WHO International Classification of Functioning, Disability and Health.
Knee-arthroscopy, mental-disorder, pain, muscle-strength, range-of-motion
Patient presented 4 weeks post (R) knee arthroscopy with a referral slip, non-weight bearing [NWB] crutch walking, having on, a pair of 0.5 inch flat sandals, looking depressed and complaining bitterly that she was told by the surgeon who performed the surgery that she will be about her normal activities of daily living [ADL] 1 week post surgery and this was now 4 weeks post surgery. Referral slip contained no information other than request for post surgery physiotherapy rehabilitation of function.
History of Complain
Had (R) knee pain for 5 months before she opted for surgery. She had twisted her (R) knee while walking on the beach 12 years ago and was treated conservatively. Had pain relief and was symptom free until 5 months ago.
On enquiry, she says she cannot bear body weight on the (R) lower limb because she feels the limb giving way after a few steps. Pain within and around the joint with tightness at the posterior aspect. Score (10) on the Visual Analogue Scale (VAS), 1-10.
With the affected limb placed on the Physiotherapist's left thigh, the (R) knee was warm to touch; slightly swollen- Circumference Left (L) 42 cm (R) 46 cm. Reference point 4 cm above the patella.
Range of Motion: extension to flexion [ROM] (L) 00-1200; (R) 00-1000 [free]; 00-1100 [forced]. Her normal full ROM is taken as that of the unaffected left (L) limb.
Quadriceps [front thigh] muscles strength: Grade 2+; Hamstrings (back thigh) muscles Grade 2. Normal muscle grade (Oxford) is 5.
Weight: 78 kg Height: 1.5M BMI: 34.7 kg/m2.
• Inability to carry out normal activities of daily living, work and home.
• Her Work team members' perception of her staying at home too long after surgery is that she is playing truancy.
• She has no hope that she will be able to have a planned house warming party in the next 2 weeks as she is not sure she will be on her feet.
• Regrets going for the surgery.
Physiotherapy commenced on first visit with the following interventions
• She was educated on the surgery she had and time for expected goals and outcomes to be achieved.
• Goals on rehabilitation were set in agreement with her (the patient).
• Counselled on her being an active participant for the achievement of these goals and that her case is not primarily first of such, bearing in mind individual differences.
• Re-assured that the Physiotherapist is highly committed to the achievement of these goals.
• Pain relief and gentle Active Mobilization Exercises.
• Self management and pain management strategies, programme of therapeutic exercises were prescribed for home use.
She gave up unprompted and walked back out without the pair of crutches after the first physiotherapy session.
Her case file was requested for, and the following were the documentations.
A 39 years old professional who has a 10 years old child from a failed marriage. Was recently in a relationship that she thought would result in another marriage but it broke down just before she had surgery. She was referred to a psychiatrist 10 days before surgery, who managed her for "severe depresssive disorder with psychotic symptoms"
The Psychiatrist's Notes
F32.3 severe depressive disorder with psychotic symptoms diagnosis was made.
Problems identified were-
• Fatigue and feeling of numbness.
• Poor concentration and attention.
• Job insecurity.
• Lack of a confidant.
• Poor communication with people.
• Paranoia- she believes she is being used.
• Social withdrawal.
• Lacks confidence and self esteem.
Spectral Analysis ( Neurofeedback and Central nervous system vital signs assessment) were indicative of anxiety and or depression.
Psychiatrist's Treatment Protocol
• Training and therapy for 3 consecutive days. All sessions were well tolerated.
• Patient was placed on Risperdal 2 mg daily and had a 3 monthly follow-up appointment.
Compared to the first assessment she had reduced symptoms especially paranoia; had a better working relationship and is well settled in her new residence. With regards to life events scale, the score is reduced from 549 to 289.
The Surgeon's Notes
• Frayed lateral and medial meniscus with lateral meniscial tears. Medial femoral condyle had a condral defect.
• Partial menisectomy of lateral meniscus with femoral condroplasty and shaving of both menisci was done. It will take 6 months for condral defect to fill in.
• Physiotherapy was prescribed for 6 weeks, next day after surgery.
The simultaneous occurrence of health conditions can happen by chance; some conditions can co-exist in one person by coincidence, without any causal relationship between them. However, often health conditions occur together because of some direct or indirect causal relationships between them. There is growing recognition that functional limitations and chronic pain associated with musculoskeletal conditions predispose people to a variety of mental health problems. Long-term functional limitations and activity restrictions may contribute to anxiety, depression and feelings of helplessness. Most of the clinical and community studies that have shown credible relationships between musculoskeletal conditions and mental disorders have been specific conditions and disorders, such as arthritis and depression (AIHW, 2010).
Managing the Comobidity
The occurrence together of musculoskeletal conditions and mental disorders in the same person often complicates treatment and management plans. While some issues remain specific to each condition or disorder, the standard treatment of mental disorders may need to be modified in view of the physical changes associated with a musculoskeletal condition or the medication used for its treatment. Similarly the management of the musculoskeletal conditions may need to be modified in the presence of a mental disorder. Clinical management of people with comorbid conditions can be more complex and time consuming than for those with single conditions (AIHW, 2010).
Pain Relief; Progressive mobilization, strengthening and Functional Exercises three times weekly; Home programme of exercises. Counselling was an integral part of every physiotherapy session and follow-up at home with telephone calls.
6th Physiotherapy session, end of Week 2 of physiotherapy: Pain score reduced to (7) and she requested if she could put on a 2 inch footwear she brought to show us, in preparation for her housewarming party. She was given the go ahead with the proviso that if she feels discomfort/pain during the party, she should go back on her flat sandals. She invited the therapists in the practice verbally and by telephone short messaging with a week's notice.
At the next [7th] physiotherapy session she reported the house warming party went well, pain did not get worse to cause any discomfort with the 2 inch footwear. She also appreciated the telephone short messaging of regrets for inability to attend her housewarming party on the day of the party which the Lead Physiotherapist sent her.
9th session, end of Week 3: she reported pain score of (5).
10th session, start of Week 4, pain score (4) and only below the patella especially when ascending and descending the stairs to her office. Introduced an electrically produced deep pain relief modality, progressive muscles strengthening and squatting exercises to achieve full Range of Motion(ROM) in flexion, to the interventions used for her management.
Gains in pain relief seem to plateau at score (4) at Weeks 4,5, 6 and she was quite happy with herself exuding confidence.
At the end of the 18th session: Muscle strength of Quadriceps [front thigh muscles] was Grade 4+; Hamstrings [back thigh muscles] was Grade 4; ROM 0® - 120® Extension to Flexion. She was off scheduled physiotherapy for the next four weeks because she was going to work out of primary station.
Week 10 she reported back with exacerbation of pain, score (10) as a result of handling a household emergency.
On objective Re-assessment: Inability to squat, says she fells sever pain going up the stairs to her office. Muscles Strength remained Grade 4+ and Grade 4
The electrically produced deep pain relief was re-introduced; and by Week 14 she reported no pain relief, however was using trendy foot wears alternating between 3 inch and 4 inch high.
She was reminded of the post surgery note of the operating surgeon, how that it will take 6 months for condral defect to fill in; counselled on self management of pain. Referred back to the surgeon for a review. An MRI was requested by the surgeon. She kept postponing going to have it done while receiving physiotherapy until 3 weeks later. Results show fluid collection but the surgeon decided against any surgical intervention even aspiration. The cycle of physiotherapy intervention for pain relief and rehabilitation of functions started again.
She attained Score(3) VAS pain, after another set of 18 therapy sessions for 6 weeks, then went abroad on vacation for 4 weeks. She comes for physiotherapy according to her, only when she has strained the knee while carrying out some activities at work or home. She was provided with a knee support and cautious about discharging her, waiting for the opportunity to engage her in a counselling session to that effect when the window opens. Presently she seems happy with foot wears of 3 inch and 4 inch, confident in herself and settled at work.
On presentation, patient was to be managed as a case of helplessness resulting from limitation of function post surgery which is observed in most patients who require rehabilitation. However, on requesting for her case file the notes indicated that she was a patient with mental disorders.
It is accepted that people with mental health conditions may take longer to respond to treatment and it is often necessary to first develop appropriate rapport with the individual particularly in an environment where they are always being 'talk to' and rarely, if ever touched (Pope & Greensil, 2008). This was what the researcher sought to achieve by asking the patient to place the affected limb on the Physiotherapist's left thigh. Physiotherapists are able to positively impact on the well-being of people with mental health conditions through health promotion, providing assistance with pain and chronic disease management and facilitating self-management and dealing with the co-morbidities associated with mental illness (Australian Physiotherapy Association Position Statement, 2011).
Physiotherapists are highly trained and experienced in managing physiological conditions such as musculoskeletal conditions and those working in the mental health sector were among the first to apply holistic and biopsychosocial approaches to physiotherapy assessment and intervention. These approaches are well known within the physiotherapy profession and are utilized in other areas including complex pain management (Skelly, 2003).
The role of physiotherapy in the field of mental health includes the evaluation and treatment of patients with pain, somatoform disorders, anxiety, depression, personality disorders, acquired brain injury, dementias, behaviour problems, eating disorders, addictions and others (Conesa, 2014). Physiotherapists who have specialist knowledge and experience in the mental health field use physical activity and manual techniques to support personal and social independence to manage anxiety and to develop healthier lifestyles to counteract the higher levels of co-morbidity for cardiac, respiratory, diabetes and weight management (WalesOnline, 2010).
It was observed in the course of the therapy sessions oftentimes her emotions were unstable. She hardly kept her scheduled time of appointment. She was always anxious, complaining that her wait time before therapy was long and not ready to vacate the treatment cubicle for another patient to be attended to when her therapy session is over. She had difficulties in self-regulation of emotions and self regulation by emotions, paying attention to instructions, rather makes several phone calls during physiotherapy. She also had significant impairment in the workplace as perceived by her complains of her team members' perception of what appeared to be an extended period of recuperation.
She had the symptoms of depression initially - feeling of unhappiness, hopelessness, pessimism; feeling of low self-esteem, worthlessness, guilt (regrets of deciding to go in for surgery); unexplained physical symptoms or pain that seem not to respond to treatment. Although the pain she had responded to intervention from Week 2, but significant pain relief of score (4) achieved after 4 weeks was sustained for 6 weeks. Another significant pain relief of score (3) after 6 weeks of a second set of physiotherapy has been sustained till present. A 44 yrs old female who works in the same company as this patient was managed in our practice for post knee arthroscopy rehabilitation. She achieved pain relief score of (2) after 3 weeks but had knee muscles strength of Grade 3+ (Quadriceps) and Grade 3+ (Hamstrings). She was discharged with "home program of exercises", instructed to call if she has any challenges and the practice was in touch with her by telephone. She only called to order for weights through the practice for building her muscles' strength. She comes by the practice from time to time to render appreciation (Table 1).
|Week post Arthroscopy/ Physiotherapy session||Pain Score||Muscles [Quads/Hamstrings] Strength||Range of Motion[ROM]||Functional Ability|
|4 [1st visit-physio]||10||2+/2||0° -100°/110°||0.5inch Footwear; NWB Crutchwalking; Could not squat|
|6/2weeks physio||7||Not measured||Not measured||2.0inch footwear; Walking without crutches|
|7/ 3weeks physio||5||Not measured||Not measured||Attempts squatting|
|8/ 4weeks physio||4||3/2+||0° - 112°||Attempts squating|
|10/6 weeks physio||4||Not measured||Not measured|
14/ 10weeks physio
0° - 120°0
Pain limits squatting
3/4inch footwear. Squats fully
Pain scored with Visual Analogue Scale [VAS]
Oxford Muscle grading for muscle strength.
Range of Motion [ROM] of the unaffected knee is the baseline for her ROM.
Table 1: Showing Physiotherapy Outcomes
Although there are individual differences, they both had Right Knee arthroscopy but no history of mental illness of the previously managed case. Indeed this case being presented was managed the same period with three younger men aged 30 yrs, 33 yrs and 35 yrs whose leisure time pursuit is football. Also none of them had history of any history of mental illness. They all have had sustained pain relief achieved after a period of 3 to 12 weeks and have not returned to physiotherapy due to exacerbation.
However a study to determine which patient's clinical and demograghic factors are associated with short-term rate of recovery from arthroscopic partial meniscectomy in the year following surgery showed that neither advanced age nor increased BMI had any influence on patient recovery over time, while gender was implicated with women having significantly poorer recovery scores than men (P < 0.04). Additionally, differences in variables indicating extent of meniscal tear and resection did not influence recovery scores over time, and the only surgical factor that impacted all three recovery variables was extent of osteoarthritis (P < 0.02) It was concluded that female gender and worse osteoarthritis are associated with a slower rate of short-term recovery from arthroscopic partial meniscectomy, while age, obesity, and amount of meniscal tear/ resection showed no association with rate of recovery throughout the first year postoperatively (Nauert, 2012).
From this case study, occurrence together of musculoskeletal conditions and mental disorders in the same person truly complicates treatment and management plans. Clinical management of people with comorbid conditions can be more complex and time consuming than for those with single conditions. However physiotherapists irrespective of specialty areas of practice should take cognisance of the fact that anybody referred for rehabilitation should be managed with holistic and biopsychosocial approaches in the context of the WHO International Classification of Functioning, Disability and Health. Otherwise a patient for rehabilitation who has some behavioural challenges could be considered a "difficult patient". For this case studied it does appear there was an existing mental disorder which got complicated with surgery rather than resulted from surgery. However, literature suggests that often health conditions occur together because of some direct or indirect causal relationships between them and long-term functional limitations and activity restrictions may contribute to anxiety, depression and feelings of helplessness (AIHW, 2010).
New research suggests prior mental health conditions can affect the recovery from total joint replacement surgery. Two new studies, presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), suggest understanding an individual’s mental health status is an important factor for achieving the best outcome after surgery.
The knowledge is meaningful for obtaining improved clinical and generic (patient-satisfaction) outcomes — two measures that will influence future reimbursement schedules for surgeons. One paper, derived from a study of 97 men and women who received minimally invasive total knee replacement (TKR) surgery, suggested men with anxiety traits — defined as a high level of anxiety unrelated to a stressful event — had higher post-operative pain ratings resulting in longer hospital stays. Women were found to generally report higher post-operative pain levels than men, and women were consistently less satisfied with pain control. However, researchers found that some old presumptions did not hold up to the new findings. Specifically, postoperative pain or pain medication use in either men or women was not linked to reports of anxiety or even “catastrophizing” (an extreme response to stress). In summary, researchers believe a patient’s mental health status should be assessed prior to surgery and taken into consideration during post-operative care (Fabricant, Rosenberger, & Ickovics, 2008).
Further studies should be carried out in our environment on several subjects with or without mental disorders on whom knee surgery is to be performed with a view to monitoring the post surgery recovery time of normal functions as it relates to home and work. Also an initial assessment of the patient's mental health status prior to surgery should be considered, although this might be an additional cost for engaging the services of the psychiatrist.
I declare that there is no conflict of interest in carrying out this report.
Consent to Publish the Outcome of My Rehabilitation Post Knee Surgery Objectives: I understand and consent to publishing the process of my rehabilitation and outcomes with the objective of sharing my experience which might improve methods of rehabilitation of persons with my condition in future, after analysing the strengths and weaknesses.
Potential Risk: I understand that there are no potential risks to my personality as my true identity will not be divulged: my name will be substituted by initials that are not mine, my profession and workplace will not be stated.
Subject's signature …………………………. Date …………………
AIHW.(2010). When musculoskeletal conditions and mental disorders occur together.AIHW bulletin,80, Cat.no.AUS 129. Canberra: AIHW. Viewed 9 May 2014<http://www.aihw.gov.au.publication-detail/?id=6442468392>
Australian Physiotherapy Association Position Statement.(2011). Mental Health and Physiotherapy. Downloaded 7/05/2014 from www.physiotherapy.asn.au
Conesa,A.G. (2012). Physiotherapy in Mental Health. www.fundacionalzheimur.org/.../Physiotherapy%20in%20mental%20heal.... Downloaded 6/05/2014
Fabricant, P.D., Rosenberger, P.H., &Ickovics, J.R. (2008).Predictors of Short-term Recovery Differ from Those of Long-term Outcome After Arthroscopic Partial Meniscectomy. Arthroscopy, 24(7), 769-778.
Nauert, R. (2012).Orthopedic Surgery Outcomes Influenced by Mental Health.Psych Central. Retrieved on October 17, 2014, from http://psychcentral.com/news/2012/02/09/orthopedic-surgery-outcomes-influenced-by-mental-health/34651.html
Pope, C., &Greensil, S. (2003). Physiotherapists support mental healthcare. Physiotherapy,89(7), 452.
Skelly, M. (2003).Physiotherapists ahead in Mental Health.Physiotherapy, 89(7), 451.
Walesonline.(2010). How physiotherapy is playing a key role in mental health. www.walesonline.co.uk/.../health/how-physio-playing-key-role-1. Downloaded 6/05/2014.