Total Hip Replacement – Part 1 Preparation for surgery

My journey started about five years ago. As a massage therapist, I was increasingly aware that the range of movement in my hips was poor. But as a reduction in range of movement is often gradual, I was able to rationalise with myself that nothing was wrong except that I was getting older.  I was 45!

My poor range of motion was particularly noticeable on abduction (moving my leg out to the side) and medial rotation (twisting my hip inwardly).  I was also in some discomfort if I had to walk for any length of time. The crunch came when I was running down the stairs and a crippling pain in my left hip forced my hip to give way.  I was able to steady myself but I was unnerved. A subsequent trip to the doctor and then the X-Ray unit showed I had arthritis of the hip joints and hypoplasia. Hypoplasia is a condition when the hip socket hasn’t properly formed and can lead to advanced degeneration of the hip joint. As a result of this diagnosis, I was determined to keep as fit and active as possible, as that was my best hope of maintaining my quality of life. I didn’t know how inevitable a hip replacement was, but it wasn’t something I relished so I implemented a consistent regime of massage, chiropractic, acupuncture and exercise, as well as a healthy diet with the emphasis on unprocessed home cooked food packed full of nutriton and supported with supplements. I’d like to think that all my efforts to stay as fit and healthy paid off, but ultimately there isn’t a parallel universe where there’s a Tracy Russell, who doesn’t exercise, eats take-ways and munches on pain killers to compare my progress to!

Five years on and the cracks were beginning to show! I knew it was time to have my hips looked at again. This is a list of the classic tell-tale signs of arthritis of the hip, that I experienced. It is not a definitive list of all possible symptoms, simply a list of those symptoms I experienced.

  • pain in the joint on weight bearing, particularly going upstairs
  • difficulty flexing the hip to raise the foot, to climb over obstacles, with either a straight or a bent leg
  • walking with a limp
  • muscle aches on over left gluteals, ilio tibial band and lateral left knee on walking more than 100 metres
  • fixed flexion deformity making lying supine uncomfortable
  • leg length difference
  • sharp pain and stiffness when making the first step, moving from sitting to standing
  • exhaustion at the end of the day, but exhaustion in the context that I was still running my busy massage therapy clinic, as well as running a home with 2 beautiful but demanding children

So it was with resignation, as I couldn’t continue living like this, that I sought advice from my GP. He referred me to the musculoskeletal unit at the Freeman Hospital, Newcastle. So on 13th December 2013, after a short consultation, examination and review of my X-rays, I was told that both my hips would need to be replaced. A part of me expected to be told that the left hip needed replacing. But there was also a part of me that was living in hope that there was a quick and easy resolution to my problems which wouldn’t need drastic intervention such as surgery. I definitely didn’t see two hip surgeries coming!

The waiting list for surgery was about 18 weeks. So part of my strategy for coping with these overwhelming emotions, was to work out a plan to be as prepared, that is as fit physically and emotionally as possible, for surgery. The plan below covers the strategies I put in place to get me through the impending 18 weeks. But as Rabbie Burns so eloquently put it, ‘the best-laid schemes o’ mice an’ men, gang aft agley’. A letter arrived at the end of January informing me that my surgery had been pulled forward to February 13th 2014 – in two and a half weeks!

Regardless, the plan was important whether I was having the surgery in February or April. A date in February just gave it more urgency. Here is what I did. My plan covered three main areas:

  • to ensure that my muscles were as strong as possible. Not only the leg muscles but after surgery I would need strong core and upper body.
  • to ensure that my body, but particularly my hips, were as mobile as possible.
  • to ensure that my general health was as good as possible to cope with the surgery and help the recovery process
  • to ensure that I nurtured myself emotionally to cope with the roller-coaster of emotions, that were to come. I felt that looking after my emotions would aid the recovery process.

THE PLAN

The Physical

  • 1 swim a week. Starting at 30 lengths of front crawl and building to 50 lengths. Front crawl is a tricky stroke to get the hang of but so much better for your fitness and your hips than breaststroke. Check out  http://www.swimming.org/swimfit/health-front-crawl/ for some great tips. There’s also a useful training video, which really helped me.
  • 1 cycle a week on a stationery bike. Starting at 5 kilometres and building to 10 kilometres. As with the swimming, I kept an eye on the time to maximise the fitness benefits, but I wasn’t a slave to the clock. Some days I could hardly turn the pedals at first, so it wouldn’t have been sensible to push it too hard and then be in pain later. But there wasn’t a session when I didn’t feel better after getting off the bike than before I had got on it. This definitely helped with my mobility and with my strength.
  • 1 leg strengthening session. Leg strengthening exercises focused on isolating muscles using equipment at the gym to develop quadriceps (leg extension), hamstrings (hamstring curl) and calf muscles (seated calf machine).
  • 1 upper body strengthening session to strengthen chest, back and arms. As well as the feel good factor from doing these exercises, I was hoping that, with a good strong upper body, I would be more mobile using crutches, post-surgery.
  • 3 times a week Pilates to promote core strength and mobility. For this I used My Pilates Guru app. I have done pilates for many years so I would say I knew the basics but I found this app really helpful in structuring the sessions and saving me from too much repetition and getting bored.
  • Regular chiropractic treatments helped to minimise the discomfort in my back, which was compensating for the fixed flexion deformity in the left hip and the leg length difference.
  • Regular massage therapy with Isabel Mineyko , my lovely associate at The Therapy Rooms. These treatments helped to relieve the discomfort in the gluteals and lateral left knee.

The Nutrition

  • My basic principles for healthy eating were continued during this pre-op phase. I mainly eat home-cooked family friendly meals. I eat 6-8 portions of vegetables and fruit a day, with the biggest proportion being vegetables. Thankfully I love dark leafy greens and they seem to be one of the foodstuffs that is universally considered healthy. (Please don’t tell me there is some new research suggesting that dark leafy greens are bad for you!) I eat 2-3 portions of fish a week and keep red meat and smoked foods to a minimum. I find a diet low in carbohydrates, which is very popular at the moment, very difficult to maintain but try to vary the type of carbohydrate I eat and keep my carbohydrates as unrefined as possible. I try to include essential fatty acids daily in my diet from not only oily fish but also nuts and seeds.
  • I have also believed that whilst the majority of our nutrition should come from good old honest food, I have always found a good multi-vitamin and mineral supplement, a vitamin C supplement and a fish oil supplement very helpful to my overall general level of fitness. In the lead up to the operation, on the advice of my health practitioner, I added to this Solgar’s Ultimate Bone Support and Pharma Nord’s Bio-Glucan Plus, to support my immune system.
  • I was conscious of the fact that, as movement and exercise became more and more difficult, so was keeping my weight under control. And as everyone knows, carrying excess weight is detrimental to arthritic joints. I used My Fitness Pal to keep a check on my calorie intake. But, in all honesty, I didn’t have the time or the emotional energy to be too zealous with this one. I also wanted to ensure that my diet is packed with nutrients which isn’t always easily married to calorie counting. And I often use food as a comfort, so inevitably, during this stressful time I did resort to food. The good news is that despite becoming less active and eating occasionally to comfort myself, I didn’t gain weight during this lead up to surgery.
  • 24 hours prior to surgery I started taking the homeopathic remedy, arnica, which is thought to be helpful for bruised and traumatised tissue.

The Emotional Side

It’s often when faced with a big challenge that you realise how strong you are but it is also when you find out what your weaknesses are. Facing Total Hip Replacement was certainly one of those challenges that was going to highlight the chinks in my emotional self. After the diagnosis, I experienced various emotions not dissimilar to The Five Stages of Grief, described by Elizabeth Kubler-Ross  in her pioneering book, On Death and Dying.  The five stages of grief, is the series of emotional stages that someone experiences when faced with impending death or other extreme, awful fate. The stages are shock, denial, intense concern, despair and finally recovery. After the initial shock and denial that this was really happening to me, I got locked in to a loop of intense concern, where I couldn’t think of anything other than my impending surgery and despair. The following things helped enormously :

  • talking to people who had successfully undergone THR and being encouraged by their stories of how the surgery had transformed their lives.
  • I got the chance to speak with my surgeon, a week before the operation to discuss issues I had. This was invaluable as I had ‘technical’ questions about the surgery which only he could answer. The questions such as ‘what happens to the muscle attachments and ligaments that are attached to the bone that is removed?’ could only be answered by the surgeon. In doing so, he allayed my fears that key attachments would not be disrupted.
  • visualising myself post surgery, being fit, well and active.
  • taking Bach Rescue Remedy daily but also when waves of panic overcame me.
  • meditating on a regular basis. I particularly liked Complete Relaxation Lite: Guided Meditation for a Happy, Stress Free Life. I found his voice soothing. But as we are all different, I suggest doing your own investigation to find a CD or app that suits.
  • planning and sorting out so that my home life and my business would run as smoothly as possible whilst I was out of action. I won’t bore you with the details but, for me, part of the anxiety was about what was going to happen to The Therapy Rooms whilst I was out of action. By sorting this out (as much as you can, in advance) I began to be less stressed about the operation.
  • I used the help and support from a reflexologist, chiropractor and massage therapist, which not only supported me physically but also provided invaluable support emotionally.

So the big day is looming. I’ve done as much as I possibly can to prepare myself. The next stage is the surgery and the critical 6 weeks post operation!

2013 Bupa Great North Run – Post-Event Massage by The Therapy Rooms

The Therapy Rooms’ Tracy Russell was on hand to give post-event massage therapy at the 2013 Bupa Great North Run on Sunday 15th September.

The Great North Run has become a national institution, and this year, as always, the host city, Newcastle upon Tyne, welcomed some of the finest athletes (amateur and professional) in the world.  It is a half marathon, so is somewhat less demanding than a full marathon, but will attract many first-timers so training and recovery are really key to avoiding injury.

Tracy and The Therapy Rooms were invited to support the runners who were fundraising for Calvert Trust and was on hand to welcome these wonderful people at the finishing line.

Post-event massage can really help to minimize muscle strain and help speed up recovery after a really demanding event.  But what does it involve?

Here is Tracy’s photo diary from the Calvert Trust’s marquee

After a big event, muscles will already be challenged so the level of pressure applied to the tissues is very important in post-event massage – too light and there is little effect and too deep and there is a risk that damage can be done to the already challenged muscle fibres.

Light Effleurage on IT Band
Light Effleurage on Iliotibial Band

Intense exercise causes micro-fine tears in the fibres, which, if allowed to heal correctly, helps to make the muscles stronger. But deep tissue work on muscles that have been intensely exercised can aggravate the muscles and interfere with the healing process.

Taking this into consideration, I needed to devise a treatment that would gently encourage the healing process.  With potentially 26 runners to treat over a relatively short period of time, I estimated that I could only spend about 10 minutes on each runner. I was also quietly hoping that they were all of varying ability so that they wouldn’t all turn up at the same time!
So the main techniques I used for my Post Great North Run Massage were Effleurage and Active Isolated Stretching (AIS).
Effleurage is a very gentle massage technique where you skim or touch the muscles very lightly with a series of gentle strokes, often to prepare the muscles for deeper massage therapy.
Active Isolated Stretching
Active Isolated Stretching on Hamstrings

Use of AIS is particularly useful in post event recovery.  The Active Isolated Stretching Method is a method of stretching the muscles in focused bursts of two seconds.

The client is asked to contract the opposing muscle that needs to be stretched. So for example, if the therapist wished to apply AIS to the hamstrings, the client would raise her leg. This sends a signal to the brain that in order to contract the quads, there has to be a relaxation in the muscle in opposition, i.e. the hamstrings.  The fancy name for this is reciprocal inhibition.

The therapist will then apply a passive stretch to the hamstrings and holds this stretch for 2 seconds – long enough for the brain to register the tightness of the hamstrings and send messages to relax them, but not so long that and damage to the tissues can be done.

Active Isolated Stretching
Active Isolated Stretching on Quads

Holding a stretch for more than 2 seconds can trigger a myotatic stretch reflex and deprive the muscle of oxygen, which is the last thing you would want after you have just run a half marathon.

This process of active movement, passive stretch and 2 second hold is then repeated as many times as is needed.

For more information about AIS, have a look at www.stretchingusa.com. It’s a great technique to use as a massage therapist, but it is also possible to use as a self help technique whether your a professional athlete, an occasional jogger or have a creaky joint.

Tracy was really proud to support The Calvert Trust and the half-marathoners raising funds for this important charity because of the important work they do and the respite care they provide at their beautiful activity centre at Kielder Water & Forest Park.

26 runners completed the 2013 Bupa Great North Run to raise much needed funds for The Calvert Trust and of those runners, Tracy attended to 16 in total.

Why Computer Posture May be Giving you Back Pain

Good computer posture is something that we’re all aware of, but only when we remember it.

The computer: one of the most common tools in modern life…

Poor Computer Posture
Poor Computer Posture

… and a device which forces the user into a terrible postural position.

When our parents told us to ‘sit up straight’ at table, they actually had a good point. Correct (healthy) posture means to sit or stand with a straight back.  Why?

Simply put, this is the position of least stress for our bones and muscles – the position they are designed to work most effectively in.

The head should look forward, not down, hanging its weight from the posterior neck muscles.  The neck should be upright, not tilted forward or back and straining. The shoulders should be pulled back to open up the chest.

The problem with the laptop is that to use it, all these things cannot be true…  The arms tend to come forward, straining the mid back muscles and tightening the pectorals. The neck is permanently bent forward to study the screen.

If you’re suffering from back pain, check your posture!

Like many people you probably spend hours in front of a computer every day – so make sure you’re doing it right.

I’ve found a really great article you might like to read to learn more about what you’re doing wrong and how to put it right.

“Your job shouldn’t be a pain in the neck—at least not literally. Yet two out of three office workers have felt physical pain in the last six months, according to a new survey released by the American Osteopathic Association (AOA).

The survey compiled responses from about 1,000 office workers ages 18 and older across the U.S. The results also showed that in the past 30 days, 62 percent of respondents had felt pain in their lower backs, 53 percent in their necks, 38 percent in their shoulders, 33 percent in their wrists, and 31 percent in their upper backs. …”

If you’d like to read more, follow this link  http://blog.womenshealthmag.com/scoop/correct-posture/

Why Quadriceps Switch Off

In my article about knees, I mentioned that knee problems can be associated with the quadriceps muscles ‘switching off’.  I wasn’t terribly happy with this state of affairs – as a big fan of how the body works, I didn’t understand why we would switch off our own muscles, when we quite obviously needed them.  It just didn’t make sense.  So I set about investigating and this is what I came up with.

1. It seems that fluid or swelling in the knee, reduces the ability of the quads to fire up (Fahrer H, et al.  Knee effusion and Reflex Inhibition of the Quadriceps. A Bar to Effective Retraining. Journal of Bone and Joint Surgery 70 – B 1988)

In this study, excess fluid was removed from the knee using a needle, and there was an immediate increase in the strength of the quadriceps.   The critical amount appears to be about 15ml of excess fluid (about a tablespoon) on the knee, which will reduce efficacy.  This would not equate to a huge swollen knee, in fact I doubt if most people could spot if their knee was carrying an extra 15mls of fluid.

2. A study by Young in 1980 found that people who had injured their knee had a certain degree of muscle wastage.  The injuries were various including fractures, torn cartilage, ligament damage.  All of the injuries had been repaired and the patients were considered to have recovered.

Evidence pointed to the fact that the leg with the damaged knee was significantly smaller than the non-injured leg. Ultrasound revealed that the smaller leg size was due to the wasting of the quadriceps.

(Young et al Measurement of Quadriceps Muscle Wasting by Ultrasonography. Rheumatology and Rehabilitation 19(3): 141-48, 1980)

3.   A significant amount of the research  supports the theory that knees which are osteoarthritic have substantially weaker quadriceps.  Various studies compare ‘good’ knee to ‘bad’ knee; pairs of osteoarthritic knees to pairs of non-arthritic knees.  Repeatedly, the evidence suggests that knees suffering from arthritis have smaller, weaker quadriceps.

4. The final sub-section of this line of thinking is the role of pain in the function of the knee.  Research points to the fact that the quadriceps will switch off if there is pain on movement.  Clearly this may be related to the three conditions above but Jim Johnson in his book, Treat your Own Knees, feels that it is worth mentioning separately.  I’m not convinced, as I think it is unlikely that there will be many cases where there is knee pain yet there is no existence of fluid, osteoarthritis or existing damage to the knee.  But muscle weakening may be in part to the pain, separate to the other conditions.

Johnson quotes a bizarre study by Bertil Steiner, who applied pressure on to the side of one patient’s knee.  (The patient had a tumour on the side of his knee). Pressure on to the knee and therefore the tumour caused excruciating pain and the quadriceps gave out.  For the purposes of completeness and to reassure anyone who was worried about this poor man (as I was), the tumour was removed, the patient made a full recovery and his quadriceps quickly restored to normal function. Hopefully enough so that he could run away from Bertil Steiner!!

So to summarise, quadriceps that are weakened and wasting may be due to :

  • swelling
  • having had injuries, fractures
  • trauma to ligaments
  • arthritis
  • knee pain

So this research points to why we lose the strength and capacity of our quads. But the indications are that with the right rehabilitative exercises, we can have strong quads and avoid this catch-22 situation, that swollen arthritic painful knees turn the quadriceps off and without fully functioning quadriceps we risk getting swollen, damaged arthritic knees.

Knee Pain and Possible Treatments

knee photoAs massage therapists, we often see clients with painful knees. Professionals working with knees often bandy around the term VMO as the possible cause of the pain but what exactly does it mean. It stands for Vastus Medialis Obliquus but to most of us that makes us none the wiser.  The Vastus Medialis is one of four quadricep muscles that lie on the anterior of the thigh:

  • Rectus Femoris
  • Vastus Lateralis
  • Vastus Intermedius
  • Vastus Medialis

The main function of these muscles is to extend the knee, so it is fundamental in walking, running, squatting, etc but all of these muscles have unique roles in supporting and stabilising the knee.

The vastus medialis originates from the tendon of Adductor Magnus and inserts into the tibial tuberosity via the patella tendon (as do all the quadricep muscles). The oblique fibres of the Vastus Medialis have been singled out and therefore given special mention because they perform and important role in stabilising the kneecap (patella) and ensuring that it tracks properly.  Weakness and mis-firing of these muscle fibres mean that when the knee is straightened, the patella doesn’t track properly in the patella groove causing painful achy knees and, over time, long term damage to the surrounding structures.

But why is the VMO consistently showing up as weak and not firing properly and how can we ‘switch’ it back on.

First of all, you must determine whether your VMO is contracting :

  1. Sit with your legs out in front of you and a rolled up towel under your knee (the knee should be slightly bent)
  2. Put your fingers over the area of VMO (as shown above right).
  3. Push your knee down into the towel (so that your knee straightens and the foot lifts off the couch)
  4. You should feel a strong contraction under your fingers
  5. If the muscle does not contract, continue to practice whilst pressing down gently on the muscle and concentrating on contracting the fibres underneath your fingers.

If the muscle does contract, you can continue with strengthening exercises:

  • Sitting on a chair with the knees bent, palpate the VMO. Start to slowly straighten the knee and ensure the VMO contracts. Maintain the contraction throughout the movement as you fully straighten the knee and bend it again. Repeat this twice daily until you can maintain a strong constant contraction 10 times in a row.
  • Place a large ball (such as a football) in between your knees and squeeze it.
  • Try performing a squat against a wall by sliding your back down the wall until your knees are at a right angle (your shins should remain vertical).
  • Try Peterson step ups. This exercise is difficult to explain so this demo is helpful. http://m.youtube.com/watch?v=UUYBhnN6IJA

Trigger Points… and the role of Massage Therapy in recovery

No, nothing to do with guns and aiming, although Trigger Point Therapy – as anyone who has experienced it will testify – is far from painless!

A Trigger Point is defined as

‘A hyper-irritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band’.

In essence, it is an especially tender spot similar to a muscle knot. Like a normal knot, it prevents the muscle from fully extending, and generally weakens its performance, but on top of this, a Trigger Point has the potential to send referred pain to other areas of the body.

The referred pains caused by a Trigger Point can be extremely acute, sometimes bad enough to send the sufferer to the doctor. The problem this causes is that while the pain might be in the upper arm, the Trigger Point, its source, might be at the base of the shoulder blade, and so the painful area itself would not be presenting any obvious lesions or tensions that could be causing the pain, and so the pain can either be misdiagnosed as other conditions such as Angina or a Migraine, or they might be simply told they are imagining it, or given pain killers and told it will no doubt stop at some point…

Image

Again, much like a muscle knot, a Trigger Point can develop through repetitive stresses on a muscle, such as the position, poor posture or a particular job puts it into. There can also be predisposing factors such as recent over-exercise, or an injury to the muscle.

The Signs
Sufferers from an active Trigger Point can experience a range of symptoms such as poor sleep, weakness in the affected muscle, numbness or even a noticeable feeling of depression.

The Treatment
A Massage Therapist will use a combination of palpation to find the exact point, pressurisation (the painful part) for up to 7 seconds at a time, followed by strokes to the surrounding area to encourage a ‘flow and flush’ reaction within the muscle.  Used together, these can dispel the point and thus relieve the pain in the affected area. This can often take more than one treatment, but once identified, the point can be pursued until it is smoothed. Treatment is more effective if the patient is motivated to self help as well – by exercising and stretching regularly and keeping to a good nutritional plan.