COVID-19 and Hip and Knee patients

Posted on: April 28, 2020
by: rhksurgery

PART II: How can I manage my hip and knee pain at home while I wait?

For those awaiting surgery, the pain management options during the time of social distancing and mass closures has changed the way we deal with arthritic pain. The main ways of dealing with arthritic hip and knee pain involve the following:

  • Pharmacologic pain control
  • Targeted physiotherapy
  • Overall exercise and mobility maintenance
  • Injections
  • Pharmacologic pain control

First, it is natural when in pain to reach for over the counter medication. Topical medications are often the easiest and safest to start. For example, topical diclofenac (Voltaren), or other anti—inflammatory gels/rubs are great. These over the counter compounds are often first line treatments, and stronger ones can be ordered by your family physician, if needed. These can be used several times a day.

Next, acetaminophen (Tylenol), can be safely administered to most people. It is a first line recommendation for arthritic pain, by all major orthopaedic bodies. The reason some people find it ineffective, is that they under-dose Acetaminophen.

WARNING: if you have major liver issues, take other medications or allergies, consult your family doctor before taking acetaminophen.

If you have no issues, a good regime is to take 2 extra strength tablets (500mg x 2) in the morning, and another 2 in the afternoon. 2 more tablets can be added in the evening before bed, if you have trouble sleeping. This dosing will bring the daily total to 3000mg of acetaminophen, well below the daily max of 4000mg (8 extra strength 500mg tabs).

Anti-inflammatory medications are also very effective first line treatments for arthritic pain. These include over the counter medications like ibuprofen (advil) and naproxen (aleve). These medications are usually taken once or twice a day.

WARNING: If you have a cardiac history, high blood pressure, gastric reflux, kidney issues, bleeding disorders, take blood thinner or have medical allergies, consult your family doctor before taking any anti-inflammatories.

If you have no issues, an over the counter anti-inflammatory coupled with acetaminophen (they work on different pain pathways and help each other) is a great way to start.

If you find that anti-inflammatories worked great initially, but you require higher doses, prescription ones can be more effective. These are often referred to as NSAIDs (Non-steroidal Anti-Inflammatory Medications). Many of these also have built-in stomach protectors as well, and may be better for daily use. Examples of these included Celecoxib, Naproxen, Arthrotec, Diclofenac and Indomethacin. In general, these should be taken with food, and supervised by your family doctor.

Overall, the above combination of daily dosed acetaminophen and NSAIDs is a very effective combination for first line treatment. ***Please consult your family doctor before starting any new medications.***

I haven’t mentioned narcotics, which are generally opioid based medications. These are prescription only and a last resort as they are addictive, have multiple dangerous side effects and have to be closely monitored. There has been a lot of negative press about the use and abuse of narcotic/opioids, and I personally do not prescribe them pre-operatively.

  • Targeted physiotherapy

Physiotherapy is a great way to strengthen affected arthritic joints, both in preparation for surgery, and to avoid it altogether. As a joint deteriorates, the muscles around it weaken with disuse, causing pain, stiffness and sometimes inflammation. By supporting the joint through restoration of range of motion, and increased strength, pain can be controlled. Ideally this should be done under the guidance of a certified professional.

The world of COVID-19 has made the profession pivot and join the world of virtual care. In many ways, this is better as it allows you to schedule an assessment and appointments on your own time and do the programs outlined at home with minimal equipment.

The Downsview Orthopaedic and Arthritic center is next to my office, and is an excellent clinic offering virtual care:
https://downsviewoac.com

As an Orthopaedic Consultant at the Medcan Clinic, those patients who have been assessed by myself there are eligible for virtual care by contacting the foillowing:
http://www.medcan.com/our-services/health-essentials/physiotherapy/

For those that just need a basic at home program, and some physiotherapy guidance, a great resource for information is the American Academy of Orthopaedic Surgeons. An online printable program is available here:
HIP: https://orthoinfo.aaos.org/globalassets/pdfs/2017-rehab_hip.pdf
KNEE: https://orthoinfo.aaos.org/globalassets/pdfs/2017-rehab_knee.pdf

Remember that before all new exercise, you should consult with your family doctor. Overall, physiotherapy should allow you to create a guided, self-administered rehab protocol to strengthen your affected joint.

  • Overall exercise and mobility maintenance

Exercise beyond physiotherapy is essential for arthritic pain management. As we age, the benefits of regular activity are even more important. Movement, be it scheduled and structured, or recreational and fun, has so many mental and physical health benefits, its beyond the scope of this blog to list.

Non-impact cardiovascular exercise is one key to maintaining muscular endurance and strength. Biking (outdoor or stationary), an elliptical machine and swimming are my favorite “big three”, as these are generally easy, safe and accessible (more limited now with COIVD-19).

While waking has many health benefits, it may be too painful for those with severe hip and knee pain, thus limiting the benefit they can get from it as a primary form of exercise.

I personally have knee pain and have found that an exercise bike best suits my schedule and has helped redevelop muscles lost from disuse. Many online sites offer exercise bikes in all shape and sizes and price ranges.

For beginners, or those with extreme difficulty ambulating a “peddler” may be the way to start. I recently purchased this inexpensive and compact model for my mom. With amazon we had it 24 hours later – so there are no excuses in terms of access! It fits anywhere and is easy to use:
https://www.amazon.ca/Folding-Exercise-Peddler-Electronic-Display/dp/B002VWJYSE/ref=sr_1_1?dchild=1&keywords=peddler&qid=1588002182&sr=8-1

There are many, many models available, I suggest to check out the reviews.

If you are looking high end, I cannot say enough about the Peloton bike. Its’ expensive and requires a monthly membership (which my wife and 3 kids also now use). However, if you aren’t getting enough motivation on your own, or pushing yourself hard, the thousands of virtual spin classes (both live and recorded) offer a great variety and intensity:
https://www.onepeloton.ca/bike

Given that COVID019 has closed most gyms, regular resistance exercise has changed how we work out. My personal favorite apps and tools are as follows:

The Peloton app: This is currently FREE for 90 days. It’s great for home workouts, biking, running, yoga and stretching. It can link to a smart device to track vitals and progress. It DOES NOT require purchase of a bike (but if you own one its free with your subscription).
https://www.onepeloton.ca/app

The 7-minute workout by Johnson and Johnson. This app was scientifically designed by exercise physiologists to mix a balanced variety of exercises in a controlled fashion with no home equipment. It can be really basic, starting with a simple 7-minute workout, or its intensity advanced for higher end users. I like using it when I don’t have time to do a full workout, am in a hotel, or at the end of a routine as a “finsher”. It’s really, really good – and FREE.
https://7minuteworkout.jnj.com

Yoga is a great way to restore mobility and develop core strength. As arthritis progress in the hip and knee, stiffness is a common complaint. Overall, as a mainly sedentary society, we don’t stretch enough in general, and yoga is one way to help. There are many, many Yoga apps/programs available. My wife currently uses the Asana Rebel app, after trialing several different programs. They have a 14-day free trial period and a variety of programs, price ranges and classes. The link to the app is here:
https://apps.apple.com/ca/app/asana-rebel-get-in-shape/id1067860796

Finally, The Medcan LiveWell site has information on nutrition, exercise and healthy habits. In addition, they are providing free at home virtual workout sessions on their social media account. These are 45 minute body-weight only exercise classes by experienced, certified trainers. They are fun, intense and something new. They are Mondays and Wednesdays at 6:30 PM live, and available online for 24 hours after. Click her to join, it’s free:
https://www.instagram.com/medcanlivewell/?hl=en

Hopefully this offers some guidance as we adjust to a new normal and are looking for answers. We continue to advocate for our patients, sharing their frustrations, and look forward to helping them safely once possible.

I apologize for the length of this blog – part 4) Injections will be added soon!