Practise what you preach
Published on 15 November 2010
Professor Mike Hurley thought he knew all there was to know about rehabilitation after joint replacement surgery. Then he had a hip operation and found he had to fend for himself...
A long time ago during a misspent (though highly enjoyable) youth I had a serious motorcycle accident. My right leg was smashed in several places, including my right hip which was shattered and dislocated. The surgeons, having saved my leg (and my life) confidently predicted I would develop osteoarthritis and need hip surgery in my forties. If saving my life and my leg was down to the surgeons, getting me back to full function was down to the skill, hard work and encouragement from the physiotherapists. After months in hospital I was discharged, and I began daily physiotherapy, consisting of many, many hours of exercise to mobilise my joints, build up my muscles and learn to walk again. It was hard work, with lots of discomfort and sometimes pain, but I learnt how effective and necessary exercise is to regaining function.
The physiotherapists did a fantastic job. In fact they were so inspiring I became one! I worked as a physiotherapist for some years, before taking a research post investigating how best to manage chronic joint pain – so that by the time I got old, the old would be better looked after. So much for altruistic, selfless researchers dedicating their lives to the benefit of others!
Over subsequent years my joint pain followed the course typical of someone with slowly developing osteoarthritis – episodes of pain and stiffness, which became more frequent and more severe. To minimise the consequences of pain and its impact I learnt to live with it, cope with it and manage it. Reluctantly I reduced or refrained from some activities – football, running – to prevent the risk of additional joint damage. However, doing nothing is as bad as doing too much, and makes you painfully stiff and weak. So I exercised “informally” through physical activity (particularly regular walking) to control pain, maintain joint mobility, function and independence.I coped very well for nearly 30 years, but in late 2008 the pain became so bad, so persistent, my limp so embarrassing and my life so disrupted I went to my GP, had an x-ray that revealed severe joint degeneration and was referred for surgery. In September 2009 I had a hip resurfacing operation.
Our much maligned (sometimes justifiably) NHS was excellent. My surgical, nursing and hospital care was magnificent. A physiotherapist came the day after the operation, showed me some exercises and got me up on crutches, which I did reluctantly and grumbling. In the early stages things were depressingly slow, painful and frightening. I dwelt on all the bad things that could happen – I’d get a blood clot, dislocate my hip, rip the sutures open, fall. While on crutches the easiest, commonest of activities – going to the toilet, washing, standing up, sitting down, stairs, dressing, going out, making a cup of tea, the simplest chores – required help, effort and time. The world around me moved frighteningly fast without due regard for me and my predicament! I survived of course. Nothing burst open or popped out, and I gradually came to realise what I could do, how to do things and cope with my temporary situation.
From previous experience I knew the importance of exercise. So I was surprised and disappointed at the little advice I received about exercise, which was vague, with no written instructions and no follow up. Knowing I was a physiotherapist specialising in exercise therapy maybe the physiotherapists assumed I knew what to do, or maybe they felt embarrassed giving me advice. No matter who you are, at times like this your confidence and beliefs are undermined. I needed to be told exactly what to do, when, how, how often, how many, how long for and how to progress. I needed reassurance I was doing the correct things correctly. I wasn’t getting what I needed to get me back to full recovery – adequate rehabilitation.
“I wasn’t getting what I needed to get me back to full recovery – adequate rehabilitation.”
I did the exercises I had been shown in hospital, bending my knee as far as I could, tensing the muscles in my thigh and buttock, strengthening the muscles around my hip – especially ones which take your leg out to the side (the abductors) and which move your leg backwards (the extensors) because these are very important. Unfortunately I often forget to exercise (“busy doing nothing”), so I set my mobile phone alarm to go off every two hours and remind me to exercise. Over the next couple of weeks I increased the exercises, but they soon became boringly repetitive. I needed more interesting exercises to stimulate me physically and mentally. But what? I searched internet websites dedicated to arthritis and hip surgery. Some were poor and inappropriate – one American guy told me how he was back running triathlons within 6 weeks of his operation – no thanks. Others were excellent with lots of useful practical advice, with descriptions and photos of exercises to do and how and when to progress. I got into a habit of doing some simple exercises regularly, though not religiously. There were many occasions when the alarm was ignored when it went off, but many more occasions when it wasn’t ignored and I wouldn’t have done the exercises without the alarm reminding me and pricking my conscience. They were hard work, often a burdensome chore, requiring self-discipline, effort and time, but I persevered and felt better for doing them. As I improved I reduced the time I spent doing these “formal” exercises, instead exercising “informally” by walking, having days out, doing any enjoyable physical activity.
It’s almost a year since my operation and I feel great. Sometimes I have twinges of pain, but not like before. It doesn’t wake me at night, I can get on with my life and people comment how well I’m walking these days. I have difficulty picking things up off the floor, sitting down and standing up from low seats, and “running” is an embarrassing skip, but I’m told things are likely to continue improving for another year (touch wood).
“The exercises were hard work, often a burdensome chore requiring self-discipline, effort and time...”
Coincidentally, a friend who is a GP had a hip operation about the same time as me. When I met him recently he was having lots of pain at night, unable to do many things and walking with a pronounced limp. The surgeons were happy with the operation and couldn’t explain his problems. I asked what rehabilitation he’d had, what exercises he had been given. He seemed surprised to be asked this and said he’d done nothing because he hadn’t been told to do anything. As a physiotherapist, the lack of guidance and advice about exercise-based rehabilitation is frightening and very depressing. Maybe it’s a coincidence I was doing well and he wasn’t. Maybe it isn’t. If you only get surgery without getting rehabilitation you’re only getting half the intervention.
“Exercise is not a cure all. It requires hard work. But it works.”
I was very lucky to have the knowledge skills and confidence to know and find out what to do and then do it. Most people are not as lucky as me. My personal and clinical experience taught me the importance exercise can have in reducing pain and restoring normal function. Exercise is not a cure all. It requires hard work, time and effort. But it works.
Mike Hurley is Professor of Rehabilitation Sciences at the St George’s University of London.