The morning after a bilateral knee replacement Roger Scott was up and walking by 7.
Joint patients at St. John’s Medical Center aren’t babied after surgery. Instead they’re treated like the otherwise-healthy people they are, expected to meet rigorous requirements to start rehabilitation as soon as possible.
“We think of them as well people,” said Jaime Jackson, orthopedic program manager for St. John’s Peak Joint and Spine Center. “Well people don’t lay in bed.”
Jackson said research backs that approach to improving outcomes and satisfaction in joint-surgery patients. A 2000 study in a 200-bed Maryland hospital found that telling patients “they are not sick, they only have bad joints” is an important personal touch, according to a paper written by Dr. Marshall Steele, an orthopedic surgeon who has developed programs around the country, and Mary McLean, a registered nurse.
Local practitioners took that approach when launching the St. John’s Peak Joint and Spine Center two years ago.
And Dr. Angus “Gus” Goetz, Scott’s surgeon, said he has seen it get joint-replacement patients back to their normal lives faster. When he started practicing 27 years ago, joint surgery patients would be “in bed for a week,” he said.
“These patients are healthy,” Goetz said. “They just want to be more healthy.”
To be discharged from St. John’s now, patients are asked to get out of bed, get to the bathroom, walk up and down stairs and get dressed, all with minimal or no help.
Better pain control medications help to block pain fibers in the nerves when anesthesia wears off, making those goals a little easier to achieve.
But even with some pain the process is worth it for Scott.
The 62-year-old probably logs more miles during the summer than most people. He did the Teton Crest Trail two years ago with his wife, Mary Gibson Scott, former superintendent of Grand Teton National Park.
He counted 250 miles last year alone.
“We know practically every trail in the park,” he said.
But by the time of his bilateral knee surgery in August he could barely enjoy a Sunday morning walk around Phelps Lake.
“It was 6 miles of misery,” Scott said. “Every step hurt.”
His knees were bowed and unstable, and walking was more of a painful “wobble,” he said.
Even a walking stick couldn’t correct a previous ACL surgery in his right knee and arthritis in his left, rendering favorite hikes like Paintbrush Divide to Cascade Canyon tricky. Wanting to stay active, Scott knew surgery was inevitable.
Although he considered scheduling surgery in Salt Lake City, “it feels like they know me here,” he said.
Both of Scott’s shoulders were replaced at St. John’s, making him a familiar face around the hospital halls. At this point, his wife jokingly calls him “bionic Roger.”
Throughout the surgery and rehabilitation process Mary Gibson Scott was the primary caregiver for her husband — an important part of the surgery. A caregiver helps patients do what they can’t do on their own right away but also makes sure not to take responsibility for the healing process entirely. That helps maintain a sense of normalcy.
“I owe her big for this,” Scott said before his operation.
As an active person who wants to continue his outdoor pursuits Scott “represents a classic Jackson Hole patient,” Goetz said.
That is something considered from the start, when patients meet as a group and are introduced to the process of the procedure. It’s then they learn the supplies they’ll need to gather before surgery to help keep them mobile, active and as self-sufficient as possible as they recover.
Jackson, the orthopedic program manager, knows that pushing patients means they will feel better sooner. Moving is better for their lungs, reduces the risk of blood clots and hastens their recovery, she said.
Getting up and going, Goetz said, also releases natural opiates in the form of endorphins induced by exercise.
“That’s why we make them move now,” he said. “It’s revolutionary.”
When a more rigorous recovery process was first implemented, Jackson thought there might be pushback. But now patients ask her why they aren’t up even faster.
“We set a high expectation,” she said. “And education is a huge part of that.”
Patients get a book and take a class before surgery. The unified message, Jackson said, helps them know what to expect.
A faster return to normal
The morning after surgery Scott was dressed in his own clothes, another recommendation in Steele’s study. Jackson has observed that wearing everyday outfits helps patients feel they are getting back to normal faster.
Then it was time to get walking.
A placard on the wall gives each patient a winter sports athlete — skiers, skaters, snowmobilers and more — to track progress. Walking routes along the halls are mapped out so patients know exactly how far they’ve come and how far they have to go. The goal is to reach 2,000 feet, or the top of the Grand Teton on the placard, before they are discharged after surgery.
Scott started working toward that goal mere hours after his bilateral knee replacement.
“I walked down the hall last night,” he said, the morning after his surgery. “My knees are stiff, but it feels good. I’m surprised at how quickly I could walk without pain.”
Goetz did five joints on Aug. 14 — both of Scott’s knees, another knee and two shoulders. The next day those patients met for group therapy.
“It creates a sense of camaraderie,” Goetz said. “It also creates friendly competition.”
Physical therapy in groups has numerous benefits for patient satisfaction and improved outcomes. Steele and McLean’s research found that “grouping people together during therapy and other activities tends to reduce the anxieties and concerns of individual patients and can have a significant impact on the rehabilitation process.”
Jackson and a team also examine these metrics locally. They meet quarterly to review data from 152 hospitals for inspiration and compare rehabilitation metrics, following the Stryker Performance Solutions-based approach, the hospital’s program consultant that helps hospitals implement best practices.
Doing it together
Jackson said group physical therapy sounded crazy at first, but it reduces patients’ sense of isolation after their operations.
“It helps them feel like a normal human,” she said. “There’s that mentality part. If they aren’t happy in their room they’re happier when they get in here. If they want to scream together they can.”
Three months after surgery the group meets again in a reunion with family and patient coaches to “compare notes and learn from each other when they’re home,” Goetz said.
The first cohort session started with group ankle pumps, a move that mimics walking and helps prevent blood clots. The Beach Boys played on the radio as five people worked out in plush chairs, side by side.
On average patients walk 874 feet before being discharged, and 100 percent of patients walk at least 300 feet or more before going home. That helps St. John’s to be a top-ranked rehab facility and third in the Stryker Performance Solutions database for short length of stay.
After a warm-up, weights are added. Scott said that he still felt pretty good and that his gait felt “completely different” in a good way. He and his wife joked that they should wish his knees a happy birthday.
Next to him, Pinedale resident Treva Hutchinson tried to remember to breathe through the pain. She came up for her knee surgery with her husband, Jim, who supported her through the process.
“What’s next? You never know,” she said of the class.
She had her other knee replaced seven years ago, also at St. John’s. This time, she said, “it’s a lot easier.”
The change may have something to do with the group therapy model, something implemented in the program two years ago.
“This is different,” Hutchinson said. “I like it. The nerve block is also new. That’s nice.”
Physical therapist Lindsay Tolle laughed and cautioned her against getting too optimistic.
“It’s going to hurt,” she said. “You better be warned.”
After their first physical therapy session of the day, patients and their caregivers gathered for lunch. Dubois resident Ann Eckart, recovering from shoulder surgery, said it had become too painful for her to enjoy activities like hosting the golf tournament she and a friend have put on for the last 50 years.
“I won’t be able to go,” she announced ruefully.
Not this year, anyway.
Still, she raised her glass and offered a toast. “Cheers, everyone. I hope you all recover quickly.”
Although Scott hasn’t seen any of the patients in his group since the day after his surgery, numbers were exchanged at the time of the first therapy session.
Six weeks after his surgery Scott said that “the knees are doing really well” and that he’s “not getting a whole lot of pain” as he works to build his strength back up again. Dr. Goetz told Scott he was happy with the way his recovery is going.
“I’m happy,” Scott said. “I know this takes time. That’s the thing: It takes patience. It’s not going to come overnight. You have to do the PT. And PT doesn’t always feel so good.”
“I feel like already I’m walking a hell of a lot better than I did before the operation,” he added. “Walking straight and having a level gait is amazing after stumbling all over the place before.”