5th Update – The Breakthrough

19Jul – 26 Jul 07, Thu – Thu, D51 – D58. The 8th week.

Continued to gradually increase the range of motion (ROM) on the CPM machine and was able to breakthrough the previous pain barrier at 85° - could now reach 110° and more. At this angle, my body is quite contorted and uncomfortable, as can be seen in the photo.

No Pain, No Gain

At the 5th physiotherapy session in NUH, I increased the pedaling angle to 270° on the cycle machine, but still couldn’t pedal it a full round. The physio tried to put me onto another knee exercising machine, but my knee flexion angle was still not high enough to get onto the machine. He asked me to work on increasing the knee flexion on my home cycle machine and to continue to increase the partial load bearing on my right leg. He said I have to work out on the other machines in order to make further progress.

Tried several days at home to push the pedal on the cycle machine and finally, I managed to breakthrough the second pain barrier by forcing the pedal full round of 360°. With this breakthrough, I now have another means to improve the flexion of the knee, as well as to get some workout on the cycle machine. There is some soreness and pain, but as the saying goes - no pain, no gain. My daily exercise routine now includes the followings:

1) Straight leg raising with 2 kg ankle weight
2) Side leg raising with 2 kg ankle weight
3) Back leg raising with 2 kg ankle weight in prone position
4) Back knee flexing with 2 kg ankle weight in prone position
5) Leg raising sitting on a chair, flexing the knee
6) Ankle - calf muscle flexing using an elastic band
7) Horizontal towel-assisted heel slide and knee bending
8) Crunches and isometrics
9) Morning sit-ups, 205 to 505 times
10) Upper limbs workout using 2 kg dumbbell
11) Cycling slowly at zero resistance, 20 to 30 mins
12) Ambulating with crutches with partial load bearing.

4th Update – Putting My Foot down

13 Jul – 18 Jul 07, Fri – Wed, D45 – D50. The 7th week.

Have been increasing the flexion range of motion (ROM) gradually by 5° a day, from 30° to 60° on the CPM machine. Felt a little soreness in the knee, but otherwise, it was not really painful. Have also started to put my operated foot down on the floor. Got pins and needles feeling whenever you put any pressure on the foot. The medical term for this symptom is called paraesthesia. This is probably caused by the long period of non-weight bearing and the nerves have "fallen asleep’’. I read that this is quite normal and it will gradually fade away after putting repeated pressure on the foot. During my daily session of sunshine, I would deliberately put the foot down on the hot pavement. The burning sensation would overwhelm this pins and needles discomfort.

Went for my 4th physiotherapy session yesterday. It was a long session, lasting almost 2 hrs. Have progressed to doing a series of leg exercises with ankle weight. The physio noted the good progress I’ve had with the ROM on the CPM machine, but said he wanted to test the limit of the flexion. He put my leg on the Gym’s CPM machine and started raising the flexion angle beyond 60° – stopping only when the pain came on at 85°. Next he set me on a cycling machine. I tried but could only pedalled about 180°. Putting pressure on the pedal from the good left leg, my stiffened right knee joint was forced to flex as far as possible within the pain limit. This was alternately repeated in the reversed direction. This is what I call self-inflicted torture :-( There are many machines in the Ortho Gym which I saw other patients using. I’ll probably be using these machines in due course – there’ll be many more painful episodes to overcome. To keep up with the momentum and the ‘good’ progress, I’ll be going to the Ortho Gym again this coming Sat…

On a cycling machine - forcing the right knee to flex

Every morning, upon waking, in addition to the leg exercises, I would be doing the crunches & sit-ups – these exercises help to give the body some workouts. I would move both my arms, as well as slide out the healthy leg during the sit-ups – this is also like swimming breaststroke with one leg or simulating the rowing action. The trick is to move all the limbs and upper body, and yet not strain the operated leg. Did 610 sit-ups on Sunday - why 610? I originally intended to do only 305, but since I felt good and energetic that morning, I thought I could add another 100 or 200, but ended up doing another 305 sit-ups instead :-)

3rd Update – The 6th Week, Turning Point?

5 Jul – 12 Jul 07, Thu – Thu, D37 – D44. The 6th week.

The 6th week – this is the turning point, when the semi-liquid cells start to consolidate into semi-solid form. Someone mentioned that this cartilage cell implantation is like filling a pothole with normal cement. You use a formwork to keep the cement in place; it will achieve initial setting over a day or so and achieving the final full strength over 28 days. The time frame for cell remodeling takes much longer, 6 weeks for “initial setting” and 2 to 3 years for recovery to full strength. In my case, owing to the severity of the cartilage damage and my age, my time frame may be more likely to be on the slow setting mode.

Saw the Prof this morning. He said he intended the rehab programme to be slow during the first 6 weeks, capping the range of motion (ROM) to 30° for my case. As the wound healing appeared to be good, he said I could now commence increasing the ROM from 30° to 90° over the next couple of weeks and intensify my workouts in the Ortho Gym. He extended my hospitalization leave until 10 Aug 07.

During my physiotherapy session yesterday – the physio mentioned that my leg muscles have shrank by at least 1 cm owing to atrophy from disuse. He said he would want to start the active motion and weight training as soon as possible, in addition to isometric exercises. I heard that this is going to be tough and painful. At home, I’ve also been exercising conscientiously – was able to reach 505 sit-ups. My family felt that I shouldn’t strain my back – but not to worry. My sit-ups are not full sit-ups, more like ¾ relaxed form of sit-ups - something like swimming butterfly stroke, dry swimming on the bed. At over 200 sit-ups, I would start sweating and my heartbeat could reach over 110 per minute, almost like getting an aerobic workout. To reach the lower aerobic range for a normal person, the minimum heart rate can be estimated from the following formula: (220 – your age) x (0.65), and with deep breathing.

2nd Update – The 5th week of Rehab.

30 Jun – 4 Jul 07, Sat – Wed, D32 – D36. The 5th week.

Yesterday was the 5th week since my operation. My knee was progressing well, though a bit slow. Last weekend, with the help of a friend, I was able to travel and attend a classmate’s son wedding dinner in a hotel, bringing along my tripod footrest. Getting out of the house and meeting some old friends really uplifted my spirit after having been cooped up at home for so long. Many of them were not aware of my recent operation and said they would definitely read this blog. After enquiring about each other’s well being, it dawned on me that my ’ordeal’ seemed pale in comparison to what two of them have gone through. One suffered from compressed nerves in the spine and was painfully bedridden for one whole month in hospital, injected with painkilling morphine until he got high and doctor has to change drug to prevent him from getting an addiction. He has since recovered. Another was in and out of hospital last year and had already undergone 6 operations on his fluid-swollen leg owing to chronic diabetes. Despite all his problems, his PhD study (and thesis) is almost completed – we really admire his persevering efforts and spirit. He has lost a lot of weight but is still cheerful and independent, moving around steadily with the aid of a walking stick.

I’m getting stronger each day, could raise my leg without pain. Continued with my daily exercises conscientiously. I’ve been doing numerous leg raising exercises and have also progressed from 155, 205 and now 305 sit-ups, this morning. Went for my second physiotherapy session in NUH yesterday afternoon. The physio measured the angle of my bent knee without the brace, for range of motion improvement – but it still read only 30°, meaning it hasn’t improved much yet. Continued with the use of EMS - electronic (electrical) muscle stimulator treatment on my thigh. The EMS sent weak electrical pulses via 4 gel electrode pads causing muscular contractions. Together with my own tightening of the quadriceps, it would exercise the thigh muscles. I was also able to flex the ankle tensioned with elastic band 100 times, did 50 sideway leg raising and 25 backward leg raising in prone position. Physio observed that my thigh quadriceps muscles still looked ‘wasted’ – atrophied from disuse. He wanted me to go to the Ortho Gym weekly to rebuild the muscles. I read that such muscle atrophy is similar to that experienced by astronauts after their prolonged stints in space at zero gravity conditions.

Gel Electrodes Pads of the EMS

Found the following articles useful:

References:

KNEEGuru – Principles of Knee Rehab
http://www.kneeguru.co.uk/html/gym/principles/objectives.html

UpToDate, USA - Physical therapy for knee problems
http://patients.uptodate.com/topic.asp?file=bone_joi/7872

Centre for Sports and Shoulder and Elbow Surgery – Osteoarthritis Rehabilitation
http://www.sportsshoulderelbow.com.sg/faq_5.php

Alexandra Hospital, Singapore - Electrical Muscle Stimulation (EMS)
http://www.alexhosp.com.sg/disease_info_details.asp?id=227