Tips From Author of The Knee Book: A Guide to the Aging Knee (Part 2/2)

Luna was honored to recently sit down with Dr. Adam Rosen, who talked through some of the points discussed in his book on how to best take care of injured or aging knees.

Here are Dr. Rosen's answers to frequently asked questions by patients with knee injuries:

You offered some thoughts on OTC medications, CBD, and supplements. Can you share those? What about collagen supplements?

Dr. Rosen: “I’m very open-minded with that a lot…because if you look at a lot of drugs, you know, a lot of drugs weren’t just designed in a lab. A lot of drugs were plants or things that we find in nature that were then modified by pharmaceutical companies. And a lot of patients have desires to use homeopathic medicine or naturopathic medicine or other supplements. I think they’re great… but again, supplements, they should never take the place of modern day healthcare. Just like for cancer - if someone has cancer, you might need surgery, chemo, radiation; it doesn’t mean forgo that and try some herbal remedy to cure your cancer. But, if that as an adjunct will help the symptoms, I think it’s important. So, you know, weight loss strengthening is all important and things like anti-inflammatories have been shown to be helpful. Taking them may help, but there’s not the clear science. And it’s hard, because as a doctor, when we say ‘There’s not scientific evidence,’ nowadays patients will say, ‘Well, I saw [it] on the internet.’ And there’s a scientific method, so if someone does a study with 20 patients, that’s not statistically significant, but if they have a power analysis or hundreds of thousands of patients with a placebo or who are blinded, and there’s a true answer, that’s the statistical study that we’re looking for to put our name and our license behind to say ‘Ah, this will work.’

Now, CBD is a separate topic, and I’m really interested in CBD because for years I had patients that came and asked about CBD, and I think I probably gave a lot of the same answers that many doctors give: ‘Well, it might not, we’re not sure…’ We were probably a lot more cautious before 2018, because the pharm bill came out in 2018 which made it legal to grow hemp for medicinal purposes. The other hard part though, which I told patients, is that if I tell you to buy, say, Ibuprofen, whether or not you buy Advil, Motrin, or generic Ibuprofen at Bond’s or Costco or on Amazon, I pretty much know what you’re getting, and the safety of those pills. If you get CBD from your neighbor, from your kids, from Walmart, from Amazon, from the dispensary, who knows what’s in it? And that was always the fear - there’s data that shows that it may help on lots of different receptors, but the safety and purity…that’s the hard thing for us to understand.

So I think studies in the near future may be really helpful for knee replacement patients, but it’s gonna be interesting to see with some of these new products and well-designed studies how much it helps patients with CBD. Because 1 in 5 patients are using CBD already, and so many of them are afraid to bring it up. So I’ve really made a habit to ask people if they’re using it, and you see a sigh of relief in a lot of people, like ‘Oh, yes, I was using it but I didn’t want to tell you.’ And some patients are against it, which is fine, great, you know, don’t use it, you don’t have to. But it’s an adjunct that I think may make a big difference in the near future.”

How do you spot a good PT vs. a not so great one?

Dr. Rosen: “So many years ago… I tried - and I think, like many surgeons, we’re really algorithmic in how we think - I tried keeping track of therapists, therapy centers, zip codes… What I found was, it was pretty much impossible (at least for the human mind) to figure out a good vs. a bad therapist on a general sense, because I would have a patient that would tell me, ‘Oh, I love this therapist, they were so aggressive, they pushed me really hard,’ and they had a great outcome. And then the next patient, I say ‘Oh, in your area, there’s this great therapist,’ and they go to them, and come back and tell me, ‘I hated the therapist! He/she was so aggressive, they pushed me so hard, I had all this pain.’

So, I think a good therapist looks at every patient, and it’s kind of the way that I describe therapists to patients, [where] most of the patients, if you give them exercises, can do them, like ‘Here, if you follow the instructions, this is what you do.’ And that’s not the goal of the therapist, it is to help them, but if we start everybody at the same spot, in a week or 2, you may be doing great with extension. But you may be struggling with flection. So a good therapist recognizes that, and then says, ‘OK, we’re going to spend 60-70% of your time on flection. Because you’ve already mastered the extension, so we’re going to modify your program for you.’ And they’re also gonna notice, ‘Oh, you’re struggling with walking or getting off the walker or the cane - it’s because you’re weak. You have an extensor lag - OK, we’re gonna work on quad strengthening. Or, you have an extensor lag because you had quad inhibition.’ So those are the greatest ones where they’re really dedicating the therapy and making it directive to each individual patient based on their deficiencies. And I think it’s hard for a therapist, because, like us, the therapists work with the patients more intimately right after surgery… so me and the therapists, we’re gonna hurt you, and we’re not not understanding your pain.

We understand that you’re in pain, but all of us understand that if we put you through some pain or discomfort, it is to make you better. And if we don’t push you because you hurt and we back off because you’re uncomfortable, you’re gonna have a bad outcome for the rest of your life. So we’d rather push you, even if it causes some pain for 6 or 8 or 10 weeks, as opposed to not pushing you, and having you in pain for the rest of your life. So, there’s a lot of empathy that comes with that. [Overall], I think a good therapist listens and modifies, but still pushes patients to get that good outcome.”

You wrote that motion, endurance, and strength are the keys to knee health. Post recovery, talk about your expectations for rehab. What does recovering look like, when done right?

Dr. Rosen: “So nowadays, compared to years ago… I mean, it used to be 5-7 days in the hospital, lay in bed for a day or 2 with full catheters, and patients just had a lot of pain, and the outcomes were not that good. So nowadays, aggressive physical therapy [has] changed so much. I remember when I started asking therapy to do therapy day of surgery here at our hospital, and people thought I was crazy. And we now know that that makes a big difference - getting patients up quickly decreases pain, decreases stiffness, decreases the risk of scar tissue forming. And when we look at the sequence, though, the biggest and most important first thing to do is the range of motion. Because if patients get range of motion, they tend to have less chance of scar tissue developing. They also tend to get more mobilization of the soft tissue over the scar, they have less pain, they improve their gate cycle, pain goes down. And what I’ve also seen is when patients get better range of motion, the other big side effect we see with this surgery is difficulty sleeping. I find that as the motion improves, patients’ sleep improves also, so the motion is key.

The second thing we tend to work on is the strengthening because, especially guys, they’re all focused on weight and pounds and leg lifts, but I always tell them, ‘If you focus on strengthening in the beginning, and you put that ahead of range of motion, you may be really strong, but now in 6 or 12 weeks if you try to get motion, it’s too late because the bleeding in the knee (that blood, which sort of coagulates and forms like pudding, and then solidifies into a leather rope), we can’t get that out.

So now the knee won’t bend or straighten well… [therefore], motion first, strength second, and then endurance is last because endurance is something that can come with time. And even if you lack endurance, it may take a year or 2 to get that back, but you don’t want to try walking really far to build up in endurance, to come home in pain and swelling, which now inhibits your ability to get range of motion, because that final outcome at the end of the day is not gonna be as good as it could have been if you focused on the motion first. So always motion first.”

Why do you refer to Luna? Why is Luna a good option for those recovering from a total knee replacement?

Dr. Rosen: “Using Luna, I think there’s 2 sides that I find helpful…one from the surgeons’ side, and one from the patients’ side. I think for any surgeons that are curious, there’s a lot of paperwork that’s involved in this day in age, and I think healthcare is so beyond the IT world from everywhere else, there’s still faxes and so much paperwork and signing for home health and things like that… and it’s just cords and cords of pieces of paper with lots of useless information. So, from the perspective of my work side of things with Luna - it’s great that it’s all digital, I get the templates [with] easy to see progress of how my patients are doing with their HOOS and KOOS scores, and how many visits they have remaining.

And as far as signing off on those patients, it makes it really easy to quickly see, click, and go. It’s a very efficient model of doing the documentation necessary, but [also] giving me a useful template and dashboard so I can watch and follow the patients’ progress. The vast majority of patients that we would see would come in and say, ‘They didn’t do much, they checked my blood pressure, they had me walk around my room.’ The thing that I’ve seen with Luna, which helps me a lot with the patients and I think it helps the patients the most: patients are getting that aggressive physical therapy from Day 1. So, they are even coming in on the day of surgery, and they’ll say, ‘Yeah, Luna already contacted me, and I already know what day and time they’re showing up.’ And that used to be a huge issue with scheduling. But also, the patients are coming in and just telling me the Luna therapists they worked with were great, they were aggressive, they had them motivated, they were progressive in their exercises as they were able to, they were walking far… and I’m seeing it [after] one month when patients come into follow up, they are leaps and bounds ahead of the ballgame from where they were before.

It was 2 weeks of at-home, and 4-8 weeks of outpatient; I’m seeing many patients do 4 weeks of Luna, because they’re getting the aggressive home physical therapy model from Day 1, and they’re done [with] therapy in 4 weeks. So it’s shortening their recovery, and I’ve heard nothing but good responses. Being able to have a therapist come to their home has been instrumental in getting them the care they need.”

If you're interested in purchasing Dr. Rosen's book on the aging knee, you can order it through this link.