Hip Fracture 5: Physical Therapy

(Last updated on: April 15, 2020)

Recovering from a Hip Fracture…

The focus of this blog is Physical Therapy. It’s the fifth part of a multi-blog article:

Following each of my hip surgeries I received therapy to get me, literally, back on my feet. After the pelvic repair I had therapy during my week in the hospital, followed by seven weeks of rehab at a nursing home. And after returning to Michigan I had outpatient therapy near my home.

After the second surgery, hip replacement, I had three days of hospital therapy followed by two weeks of therapist visits to my home. Then once again I transitioned to outpatient therapy.

Therapists, Great, Good and Hmmm

During my journey of recovery from fall, pelvic repair and hip replacement I gained much experience. In all, I was treated by several dozen occupational and physical therapists.

At first glance one might confuse occupational therapy (OT) and physical therapy (PT). The former deals with tasks such as dressing, toileting and climbing stairs; the latter with joint strength and flexibility. However, these activities overlap and interact.

But it’s not that complicated. As a hip fracture patient I observed a simple pattern. The OT folks mostly worked above the waist, and PT therapists with the lower body.

Since my first surgery was in Honolulu, far from home, the hospital discharged me to a rehab facility. The Villas was excellent in many ways. However, I came to disrespect their approach to therapy.

            Advice to Businesses: Don’t Outsource Your Core Competence!

I have previously grumbled about retirement homes that outsource what should be a core competence – skilled nursing – to outside services. Now, I will repeat that grumble for rehab facilities like The Villas who outsource their therapists.

I learned that therapy outsourcing is the rule rather than the exception in Hawaii. Many facilities use one provider, Genesis Rehab Services. It’s part of Genesis HealthCare, a public company headquartered in Pennsylvania. Genesis operates 500 skilled nursing facilities and 1,700 therapy locations in 47 states.

            The Perils of Outsourcing Physical Therapy

I would argue that therapy is a core competence of any rehab facility and should not be outsourced. I observed some apparent disadvantages of outsourced therapy while I was in Honolulu:

  • The therapists at the rehab facility were independent contractors, not employees. In contrast, while I was in The Queen’s Hospital all the therapists were hospital employees.
  • The independent therapists complained about earning much less than they had in California, despite Hawaii’s higher cost of living. A grumpy therapist is not the ideal caregiver for patient recovery.
  • Unlike my experience at the hospital, at The Villas I had no regular therapist or therapists. Instead, I had a rotating team of over a dozen individuals, who sometimes coordinated my care with each other, and sometimes didn’t. Each individual was a trained, dedicated caregiver. However, overall my treatment was fragmented.
  • The therapists were a mixture of certified therapists and assistant therapists. Thus their skill level and experience varied in an unpredictable way. You couldn’t tell who was which except by asking them, or by observing how much independence they exercised in their therapies.
  • My therapy plan and progress reports were treated as company proprietary information by the therapists. I was not allowed to have a copy, or even to read them, despite The Villa’s stated commitment that patients are able to participate in the planning of their care. I later wrote to The Villa’s general manager, praising their nursing care but criticizing their handling of the therapy function.

            The Merits of Insourcing

physical therapyWhen I returned to Michigan I transitioned from institutional care with therapy, to living at home with outpatient therapy. Beaumont Hospital operates a therapy service just one block from my home. So I hustled over there, carrying my script for services, to cross-examine its supervisor.

I learned that they had 8 certified therapists plus two assistants. Each was a full-time employee of Beaumont Hospital and there was very little annual turnover in the staff. I was assigned to a physical therapist, Sarah Steffens, whom I found to be competent, communicative and creative. The only downside I found was that Sarah was in very high demand, with a full calendar. Fortunately, as a retiree my schedule is flexible and I was able to adapt when Sarah needed to make a change.

Medicare covers about two dozen outpatient therapy sessions following hip surgery. I started with two appointments per week but Sarah was able to stretch out the schedule out as the year progressed. Thus I had the guidance and motivational benefit of her assistance (and full Medicare coverage) all the way until my winter vacation in mid-December.

            DIY Therapy

After I had the second operation, hip replacement, I tried to arrange rehab with the same excellent therapist. Her schedule was full so I was assigned to another therapist. But after only two sessions, the outpatient therapy center shut down; the entire staff transferred to Beaumont Hospital to assist with coronavirus patients.

Therefore, at present I am my own therapist, using what I learned during more than a year of physical therapy sessions. I perform one set of two dozen exercises each day. I also take a walk through the neighborhood, gradually increasing the distance. I’m now up to one-mile walks, without needing to use a cane. I hope to return to Nola’s and my regular routine of walking several miles per day.

Physical Therapy as a Career

When you have aches and pains, or surgery recovery, you can expect physical therapy to be part of your treatment program. And as noted above, physical therapy embraces a range of skill levels and job structures.

All physical therapy jobs require certain personal qualities. To be successful a therapist needs a commitment to helping patients, excellent listening skills, and physical fitness. But the therapist also needs considerable training.

            Categories of PT Jobs

Therapists and assistants differ in their amount of training and requirements. These differences naturally affect the amount of money they earn:

  • Physical Therapist. This job starts with a bachelor’s degree including classes in anatomy, chemistry and biology. Then comes a master’s or doctor’s degree requiring 2 to 3 years study. You must then acquire a license in each state where you choose to work, a license which you must renew every two years. Some states will also require a residency program which may last 9 months to three years. The monetary reward for this preparation is a job that is highly in demand and pays an average of $88,880 per year.
  • Physical Therapy Assistant. A physical therapy assistant must have a two-year associate degree. They must pass a state licensing exam and will often have a requirement for continuing education. The assistant works under the supervision of a physical therapist. (My observation in Hawaii is that the assistant cannot lay out a plan for therapy, or prepare the reports necessary for insurance reimbursement.) As befits their lesser training, the average assistant earns $57,750, 35% less than a physical therapist.
  • Physical Therapy Aide, Physical Therapy Technician. You may even be entrusted to the hands-on care of an aide or technician. These are unlicensed folks how have graduated from high school and have at most some on-the-job training. Whatever they do is not reimbursable by most insurance, including Medicare. The median annual pay for these jobs is $26,240.

            PT Job Options

A licensed physical therapist has many choices of where and when to work. Here are a few options I have seen or read about:

  • Hospital. Pros: regular hours, good pay, good benefits. Cons: every week, a new patient, no chance to see great improvements from your therapy.
  • Outpatient Clinic. Pros: good pay, continuing patient relationships. Cons: may require long hours with risk of burnout.
  • Independent Contractor. Working as an independent contractor for a staffing agency allows the therapist to choose their hours and schedule. However, this flexibility may require you to buy your own benefits.
  • Snowbird Lifestyle. Many “snowbird” retirees winter in Florida or the Southwest. And when the retirees come into town, they bring with them the need for physical therapy. Therefore, some therapists choose to move their jobs with the seasons. Apart from figuring out where to live, such folks need to maintain therapy licenses in multiple states.

            A Good Bet for Family Members?

Is physical therapy a good career choice for younger relatives and friends? If they have the aptitude for a career in health care, physical and occupational therapy are attractive options for an energetic, personable young adult. Therapists don’t require as many years of education and training, and avoid the risks and yuck factors that come with nursing and doctoring. However, they have good flexibility to choose where and how to work.

The lower categories of therapy (assistant, aide, technician) are much more limiting. However, the full physical therapist designation is an attractive option for those who can afford the educational requirements.

Progressive Weight Bearing – the Key to Healing

Physical therapy, as befits a branch of medical care, is mind-numbingly complicated and varied. A physician writes a prescription for physical therapy with certain qualifications and limits. And then the therapist applies the script to the individual patient with a wide range of exercises and movements.

The progression of weight bearing gives a hint at how complex therapy can be.

After an orthopedic procedure, it’s important to gradually put the body back to work, using its muscles and supporting its own weight. Weight loading helps build bone strength and bone mass. At the same time, if too much stress is applied too quickly, it can cause delayed healing and non-union of bones. The physician must judge how much force is safe for the patient to apply, and then gradually increase that as healing progresses.

Here are some possible weight bearing restrictions following orthopedic surgery on one side of the body:

            Non Weight Bearing

The foot on your surgical side should carry none of your body weight. Walking requires crutches or a walker, with the gait that a one-legged person might use. Avoiding weight on the leg tends to mean bending the knee to lift the foot so that it barely touches the floor. The hamstring contracts, and later on it’s difficult to straighten that leg again.

            Toe Touch Weight Bearing

TTWB also requires the use of crutches or a walker. Therapists consider TTWB as limiting the surgical leg to no more than 20% of total body weight (sometimes, 10 to 20%). This allows the surgical leg to be fully extended in a more natural walking posture, so long as almost all of the body weight is supported by the other leg and the arms. TTWB is a common restriction when the patient is recovering from a broken acetabulum (hip joint), and was the restriction that I followed in Honolulu for the first 6 weeks after my February 2019 surgery.

            Partial Weight Bearing XX%

After healing is underway, the doctor may deem that the patient can tolerate additional weight bearing, up to some XX% of body weight. I reached 50% PWB in Hawaii after 6 weeks of TTWB rehab. After a week of 50% weight bearing the staff deemed that I could safely negotiate stairs and airplane aisles using crutches. Thus I was permitted to return to Michigan.

            Weight Bearing As Tolerated

In early 2019 in Michigan, my orthopedist took a full set of x-rays and prescribed that I could use “weight bearing as tolerated.” This meant, so long as I didn’t suffer pain, I could put any amount of weight on the surgical leg. Of course, I was not trying to prove anything to anybody, including myself. Therefore I had no need to put more than my full body weight on the surgical leg.

            Can You Press Your Body Weight?

In 2019 and 2020, I have spent many weeks under a 50% weight bearing restriction on my left leg. I quickly learned that just getting around is quite tiring!

Consider: Suppose that I’m using a walker. I weigh about 170 pounds, so I’m allowed to bear 85 pounds on my left leg.

When I walk, each time my right foot moves, my full body weight is supported by my left (surgical) leg and my hands. To limit my left leg to 85 pounds, each of my hands has to press downwards with a force of 42.5 pounds. If I were lifting up 42.5 pounds, it’s as if I were lifting 5 one-gallon jugs of milk with each hand. So you can see how strong a downward push this is. And I have to push down this way with every step of my right foot.

No wonder just walking is so tiring! And it makes me wonder how women manage limited weight bearing after joint surgery. After all, women tend to be stronger in the lower body, just as men are stronger in the upper body. Therefore, for many people 50% weight bearing could be an extremely difficult prescription to follow.

No, it’s not the same as bench-pressing your full body weight. It’s only half that! But I still find that it tires me out…

Joint Motion Restriction

Following my hip replacement surgery February 14, 2020, Dr S prescribed 50% weight bearing. Apparently, since my pelvis was well healed, the mere replacement of the ball and socket could stand the higher weight allowance. This was good from my point of view, since more weight bearing meant faster healing of my bones following the surgery. On March 23 in a telephone consultation he increased my weight bearing to 100%, hooray!

However, weight bearing is not the entire story. Following hip replacement, dislocation is one of the three principal risk factors (the others being nerve damage and infection). To avoid hip displacement, I must restrict my leg motions for three months after surgery, to provide plenty of time for healing. I cannot twist my leg, cross my knees or ankles, or bend with less than a 90 degree angle between thigh and torso.

These limitations sound simple enough, but they bring practical inconveniences. Since I can’t bring my left knee to my chest, I can’t put on my left sock except by using a “sock aid,” a clever assistive device that I pictured in the second blog of this series. Moreover, since I can’t twist my leg to put my left foot within reach, there’s simply no way I can tie shoelaces on my left foot. Rather than bother Nola every time I don a shoe, I have eschewed my usual lace-up sneakers and I’m wearing slip-on shoes for the time being.

Hey, Shortie!

It’s a bit off topic, but as I worked with physical therapists I became more observant of my own body. And learned about one of the side effects of getting older – shrinkage.

No, I’m not commenting on my jeans getting tighter, which could have other causes. But rather, the fact that each time a doctor’s assistant measures my height, it seems to be less. What started at six feet has declined to 5’9″ at last count. I will turn 80 this year, so some height loss is to be expected. But since one of the principal side effects of getting older is death, I’m not ready to complain just because I have to stand on my tippy toes to reach some things.

The cause of height shortening is apparently the compression of the intervertebral discs of the spine and cartilage in the joints, plus some fracturing or loss of bone.

When I fell and broke my hip, the impact forced my femur into my pelvis. That not only broke the pelvis in several places, it damaged the end of the femur, where the ball is located that is part of the hip joint. Dr Lee cautioned me that because the femur was damaged, it would gradually erode at the end and become shorter. This process would continue until the next surgery, hip replacement.

            Leveling My Gait

It’s not wise to walk, or hobble, around with legs of different lengths. Besides uglifying the gait, the offset can cause mountains of back and hip pain. Therefore, when I first saw Dr Schramski in April 2019, I asked him to determine my leg differential. He helped me discover that due to my injury, my left leg was functionally 3/8″ shorter than the right one. I bought an excellent set of adjustable heel lifts and one of those brought my hips back into alignment.

As the months passed and I continued with physical therapy, my left leg continued to shorten. The rate of shortening seemed to accelerate as time went by, causing me to add additional 1/8″ layers to the heel lift. By the time December arrived I was using ¾” of lift in my left shoe to keep my hips even.

Dr Schramski cautioned me that he might not be able to completely correct my left leg length when performing hip replacement. The reason is that the nerves draw up as the leg shortens, and it’s not always possible to stretch them out without causing considerable pain.

However, so far as I can tell, Dr S’ surgery hit the mark exactly without causing a nerve problem. I am now standing and walking with no heel correction. Of course, I haven’t regained the three inches lost during past years!

The Future

At present, my local physical therapy center is still closed, with all therapists assisting the coronavirus crisis at the hospital. My “range of motion” is restricted to avoid dislocation but I hope to have that limit removed or eased in mid-May. Hopefully, by then businesses in Michigan will be returning to normal, post-virus. Thus I’ll be able to resume physical therapy to help me regain full range of motion in my left hip. So when I study the calendar, I’m likely to remain in “recovery mode” until late summer.

This concludes for now the story of my hip fracture and subsequent physical therapy. I wish you good health, and whatever you do, don’t fall!

Image Credits:
– Handstand gymnastics by OpenClipart-Vectors on pixabay.com
– Stretch by Clarissa Carbungco on unsplash.com
– Photo of Mars Wellness heel lift by Art Chester

Comments

Hip Fracture 5: Physical Therapy — 2 Comments

  1. Hi Art, Thanks for the excellent description of your series of interactions with the docs and others as treatment for your hip injury proceeded. It’s hard for me to believe that slipping on the steps leading to a building, in excellent weather, could have produced such a serious outcome! Best of good wishes for a continuing good recovery!
    It’s also hard to believe that so much time has passed since we lived across the street from one another and commuted to Bell Labs in a Corvette or a Porsche!
    Dick

    • Actually, Dick, I slipped on a flat sidewalk! But Nola thinks I might have skidded on a wet leaf left from earlier rain. Nevertheless your point is exactly right: a small slip can cause a big problem!

      It is amazing that so many years have rolled past. Here’s to many more!

      Art