Interviewer:
Hi Dr. Amanatullah!
Dr. Derek Amanatullah:
Hi again thanks for having me.
Interviewer:
Of course! You mentioned in some of our previous conversations that before you even start to consider any sort of joint replacement surgery, you might have your patients attempts for some lifestyle changes that will fix the pain and the issues that are going through so let’s talk about some of the lifestyle changes that you recommend one by one and we’ll start with we talked to was a little bit about why that’s important lifestyle change to make before you consider replacement of that of the joint.
Dr. Derek Amanatullah:
Yeah I think there’s lots of different lifestyle changes that patients might consider. There’s lifestyle changes related to pain and I think there’s lifestyle changes related to optimizing their health before you would think about having the surgery and so we want to kind of do all those together.
When we think about lifestyle changes with think about weight loss, low impact exercise are getting mobile or any ambulatory and then utilizing an ambulatory assisted gate aid like dean or a Walker we do those things to help mitigate team because they control the amount of force that we put across the knee weight loss decreasing the amount of energy that the NY absorbed with each step using the cane or of a Walker in the opposite hand helps off load the joint when that joint hits the ground with your hand so when your left knee hits the ground your right hand goes forward so that’s the best place to have that keen to decrease the force and then low impact exercise because walking swimming and biking are gonna put less force on your knee than tennis golf basketball except drop even running jogging stair climbing except of those have a lot of force.
We also worry about optimizing your health so we might talk about losing weight, stopping smoking controlling your medical problems like diabetes or a terrific relation or heart failure. So those are all the things that might come into consideration when we think about.
Lifestyle changes or medical optimization for pain control prior to surgery.
Interviewer:
Now you authored a paper specifically about smoking and why that’s important when to get under control. Talk to us a little bit about that particular aspect.
Dr. Derek Amanatullah:
As this smoking is very interesting there’s lots of publications besides ours waiting to smoking as a risk factor for surgery.
And for like two hypotheses about this one is that the carbon monoxide inhaled during smoking actually impairs oxygen flow to wounds increasing the risk of wound healing complications in infection there’s also the possibility that the nicotine from smoking actually acts as a base of constrictor narrowing the vessels around the wound also inhibiting wound healing and may be contributing to inspection we found this true in knee replacements were smokers had a higher rate of infection and implant revision as a result so.
What we would like to do is if there are many many medical issues going on diabetes obesity hypertension and smoking. Smoking oftentimes even though it’s really hard to quit can be one of the things that we can modify it to make the patient more healthy in more amenable to surgery and it’s something that we know that we can move them from a smoker and a non smoker category that all of a sudden we can get some benefits with respect to how well they were performed.
The extra benefit for this is unfortunately with smoking eventually smoking we know will kill you whether it be in the scene that cancer or okay I can list a million things. So we’re lucky in orthopedic surgery that we can offer something the patient might see is that concrete benefit now to help them with their joint replacement and having them be healthy that ultimately overall if they can actually stop smoking for their joint replacement may stay stop smoking and save their life.
So for me, not only in the short term benefits of stopping smoking work while the long term benefits couldn’t far outstripped the short term benefits we’re just lucky that we can present it with this kind of early immediate benefit for patients.
Interviewer:
It seems like that one is really important not only for the surgery but just for life after surgery and you know going up to the rest of the persons that existence.
Dr. Derek Amanatullah:
Yeah I agree. You know the good part about where we practice medicine is that everyone has free choice I think that you know everyone gonna decide to make different decisions it’s kind of my job resent them how those decisions are interacting with them and what things that they can change to change the outcomes of the surgery they’re thinking about me and then maybe they began thinking about how those things have been affecting their life.
And I think there’s a lot of the things we’ll talk about are very similar to that obesity is a very similar type of scenario actually.
Interviewer:
Talk a little bit about the big scary a word opioids how does that factor into a lifestyle change that you would recommend someone make before they consider joint replacement surgery.
Dr. Derek Amanatullah:
So opioids not lot of people have heard about the opiate epidemic going on there’s many things contributing to this but unfortunately or fortunately opioids are really a great way to control pain they just come with a lot of side effects.
Specifically they can call something called sensitization, meaning when you take an opioid over time you need more opioids because the same amount of pain relief. That’s very interesting because what it means is that if you start an opioid for chronic pain relief it’s actually hurting you. You’re needing more medicine you’re accumulating more side effects from the opioids confusion urinary retention and you’re needing more medicine to control your pain over time.
Very interesting study shows that patients basically after elected joint replacement about three percent three to seven percent of those patients remain addicted to opioids. That’s from the sensitization effect we’re not trying to make that happen it happens additionally before surgery.
By taking a lot of open and you’re making it harder for us to control your pain because when you experience pain saying now without opiates it might be a three out of ten. Having been on chronic opioids over time it could be a seven out of ten for the same stimulus because your body is walking your receptors are craving the opioid and they’re responding quickly and fast work to try to grab as much of it as possible so it takes more medicine to control your pain.
Increasing the side effects and risks after surgery prolonging that paid the sensitization or even addiction period after surgery. So why will do its work well, we don’t want them to be the mainstay of treatment we now offer in what’s called multi modal care for to lot of patients are really has it and it’s a lot of medicines we use a lot of different medicines Tylenol and anti inflammatory medicine near Ron ten.
And maybe an opioid all four together to decrease the side effects of each one and trying to mitigate this opioid utilization so that we can keep our patients off some medicines the long run that might be bad but minimizing those medicines before surgery going to be the best thing for sure because now all the sudden bring the best position to control your pain before surgery.
Interviewer:
I know we talked quite a bit in the past about the use of physical therapy but touch on that one more time in terms of using it out before a joint replacement surgery what role does it have if any?
Dr. Derek Amanatullah:
That’s who I would you can tell I have a couple of publications in this area I’m pretty me a list like about physical therapy prior to total joint replacement I know it’s a recommendation of the academy of orthopedic surgery in many other places I think that’s for many different reasons.
What I want you to imagine if you have arthritis in your hamper your need that damages the cartilage. And that cartilage doesn’t get better by exercising.
What gets better the things surrounding that cartilage meaning if you have tendonitis in your hip or tendonitis around your knee or strengthening your quadriceps muscle maybe your knee feels a little less stable on less unstable that maybe you can make the pain better but I don’t think by any means physical therapy is addressing the arthritis I think it’s stress addressing pain related and non arthritic things.
So in general I think rehabilitation or doing rehabilitation before surgery really is not really worth your time you’re not going to be able to therapy away again the arthritis and it turns out that if you build yourself up to ten out of ten let’s say strength. When I do surgery I’m gonna knock you back down to two or three so we need to build back up from surgery.
Building yourself up to fifteen out of ten getting even stronger than you think you would ever do I’m still gonna knock it down to three because you’re still going to have that surgery so I would say the therapeutic for after surgery unless there’s some reason to think there’s came from another source other than the arthritis then of course we should take care of that.
Interviewer:
Now some people come to you in such bad condition with their joints that you see them in a wheelchair talk a little bit about what kind of lifestyle changes recommends for that person before a joint replacement surgery.
Dr. Derek Amanatullah:
Yes the really interesting problem so you’ll sometimes we can help people who are in a wheelchair what what you have to think about is what’s actually putting them in a wheelchair.
We know people don’t like to be dependent they love to be independent. And I have patients who actually would have a hip resection right knee fusion. And they refused to go in a wheelchair they they will are adamantly independent they will, despite all odds, rather walk with a Walker then use a wheelchair.
What you have to imagine is the energy that somebody uses to walk changes dramatically when you get in a wheelchair takes in a way less energy to emulate around and walking with a yet fusion or a hip resection or in need fusion.
And so what that means is that you have to be very concerned about weakness so hip and knee replacement can’t fix weakness. What they can fix is pain. What they can restore his motion. They can’t fix weak muscles they can’t fix nerves that aren’t firing to those muscles. And so when we see a person in a wheelchair for sure pain could be driving them there.
But there’s an independence issue going on that person’s motivation to get out of that wheelchair that thing based solely on squash. Additionally it may be a nerve or muscle problem on top of arthritis or painful joint replacement that’s doing that sweet be extra careful to look for impinging on the spinal cord nerve impingement muscle atrophy or or something all myopathy which is where the muscles aren’t really firing correctly and so tests like an MRI of the spine tasks like an EMG or a nerve conduction thirty that electoral myopathy to make sure the nerves and muscles are firing correctly because we don’t want to do a big surgery replace the hip that has a risk of infection dislocation fracture loosening all these things are in the replacement has the same.
And then that person never walks because there’s a dominant issue on top of the hip or knee replacement. So whenever someone comes in a wheelchair I would love to see that they are doing some walking around the house of the Walker there are using their muscles and working and trying as hard as they can to stay independent.
The other thing to know is that going into a wheelchair for every day you’re in that wheelchair it’s going to take two to three days to get out from deep conditioning so someone’s been in a wheelchair for three years, five years, that the road ahead is not limited by my hip or knee replacement limited by the de conditioning the fatigue of that wheelchair.
So we think hard we want to help everyone we can we want so many everyone who can walk the walk and everyone to be as independent as possible. Well the we don’t want to subject them to any undue risk, and the risk that you would undertake without the hope of walking again or that you need a different procedure to help you walk like a spine decompression so wheelchair for me is that a reason to think extra heart it’s not a reason to not intervene who want to make sure we give the patient the right expectations and that they have the right motivation to get as independent as they possibly can.
Interviewer:
Thank you so much as always for sharing today, Dr. Amanatullah!
Dr. Derek Amanatullah:
Great have nice day.
