When former President Bill Clinton was running for the office, his campaign strategist, James Carville, told Clinton that the main issue in the campaign was not foreign policy, or trade relations. It was money. He said, "It's the economy stupid!"
When people hurt, they don't care too much about how strong their legs are, how far they can walk, or how many steps they can climb.
What they care about is not hurting. And if you have osteoarthritis of the knee and hurt long enough, badly enough, you'll likely turn to the knife as a solution. You'll opt for a knee replacement.
But here's a twist.
In a recent study, only about 75% of people were satisfied with their knee replacement.1
And why is that do you suppose?
It's not because they lacked function. There was no correlation between functional capacity and activity of daily living and satisfaction.
It was pain.
Those who still had painful knees, were less satisfied.
But, that's partly because they expected to be pain-free from the surgery and then weren't.
Satisfaction comes from what I call "framing". Four Seasons does it. Their corporate guiding principle is to treat others how you wish to be treated. That's the frame. And they really live it. They know your name. The staff is exceptional at remembering what you liked and didn't from one visit to the next. A very tough frame to live in but somehow they do. Amazon is another good example of great framing. I order something and they send me an email that explains that I should get the item in 3-5 business days. Ok, so that's the frame. The next day, it's on my door step. I'm blown away.
The most important predictor of post-operative success is pre-operative framing.
If I tell you that the operation is simple, you'll be up and going in a few days and your knee will feel great and you can get back to doing the things you like to do, if I set that frame, and then your motion comes back like a snail scaling a mountain, you hurt for nine months, walk with a cane, and are generally grumpy, I think you'll agree we have a problem and a poor frame and you're dissatisfied.
But here's the problem with framing. It takes time and skill. It's called "bedside manner" by some. If the surgeon or his assistant is all doom and gloom, you may not opt for surgery. So, there's a bit of an art to helping people understand the range of possibilities. And once the frame is set, and it will be set one way or another either consciously or not, it's almost impossible to re-frame the deal.
Pre-operatively, people have high expectations of both pain relief and levels of function (like golfing, dancing, hiking). In fact, 41% believed that after surgery, they would have little to no pain and be able to dance or play golf or go for a hike. But, five years later, only 14% were able to do those things.2
But, pain relief following a knee replacement can take over a year to achieve. I wonder how many patients get that information and of those who do, actually get it. I mean really hear it. I suspect what most people think is that,"Gee, I get this thing replaced, and I'm good to go!"
Maybe.
The other thing that needs to be discussed is the expectation of higher functional levels. Yes, if your knee hurts less, you might be able to be more physical, but remember that your knee is not like the alternator in your car. It's a biological thing. You can hurt from surrounding muscles, tendons, fascia. Your muscles can hurt and for sure are weak after surgery. You have to re-train your body to be able to perform at a higher level. You need strength, balance, power, flexibility, and agility.
Sometimes you have to have a joint replacement (but there's some very interesting work going on with PRP and osteoarthritis). But if you do, make sure that you understand the frame or you may end up dissatisfied.
PS - here's the latest on my knee recovery.
1. Vissers, M., I. de Groot, et al. (2010). "Functional capacity and actual daily activity do not contribute to patient satisfaction after total knee arthroplasty." BMC Musculoskeletal Disorders 11(1): 1212. Nilsdotter, A. K., S. Toksvig-Larsen, et al. (2009). "Knee arthroplasty: are patients' expectations fulfilled? A prospective study of pain and function in 102 patients with 5-year follow-up." Acta Orthop 80(1): 55-61.