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Knee replacements in the brain – the patient’s side

By David Butler Patient examples 13 Feb 2014

John Barbis, aging Philadelphian PT had a bilateral knee replacement 4 months again. I have just watched him scurry though the snow like a squirrel and run up stairs like a five year old. He can sit on his haunches and he has been doing all this for months.

John says  “……I felt immediate ownership of my new knees  after surgery. But I had prepared well – more my mind than the rest of my body. I started two months before the surgery.  I did left/right knee discrimination exercises 3 times a day, I visualised the surgery, I visualised the IV going in, then going under and waking up. I did lots of mindfulness , the UCLA mindfulness project. I visualised my knees moving after the surgery and I imagined how they would move much more than they did before. I imagined that  I would have pain, but I reasoned that it would not be pain related to any danger to my knees. I knew medication would be available if I needed it.”

“Having seen knee replacement surgeries before was helpful. I knew they would be bending my knees full range in the operating theatre and I knew it would only be swelling and sensitivity that would limit me post-surgery  and this would be temporary and a part of the healing process. I knew the only way I could hurt myself was if I fell. I visualised walking normally as soon as I woke.  I only used a walker at night for a few days, but I didn’t want use it as I wanted a normal walking pattern using my arms as soon as possible”.

“The new knees were all mine as soon as I woke up and I was glad to say  goodbye to the old ones. I wanted to be in total control. I didn’t want anyone pushing on my knees.  There is no reason why someone else should have to push on someone’s knee to get range of motion”.

“I knew there would be nociception, I knew there would be neural flares but I knew they could be made safe. I avoided the total knee education class offered – it was scary”

“Overall,  I worked on my brain more than working on my knees”

Any questions – John would be pleased to answer.



  1. Wow that’s an inspiration for when my turn comes……… This is a powerful reminder that a positive outcome does not depend on a rigid application of protocols but fluid acceptance of the individuals uniqueness and there personal ability to accept and adapt to their changing environment whether that change be internally, in the form of “New knees” or externally in the way they present their knew knees to the world………

  2. blanaidcoveney

    Hi David
    This is a wonderful success story and food for thought for those of us treating patients heading towards the inevitable path of joint replacement. All of which are predictors of poor outcome. Do you think this had a positive effect on his immune systems response to the surgery and therefore his recovery?

    The act of taking ownership of his new knees and relishing saying goodbye to the old ones has to be the ultimate way of owning your own recovery. Well done.

  3. Love this David and John. It was a pleasure meeting you at CSM David. Hopefully we can educate more patients on the brains powerful role post surgery. John what was your primary method to move your new knees?

  4. My primary mode for working at flexion was to sit at the front of a chair with arms. Bring my feet back producing sufficient flexion to produce just a bit of nociception ( pain). Do a press up on the arms of the chair so that the pain went away, then move one foot back an inch and begin to lower myself to the point where the pain would be just a bit greater than the pain I experienced when I was sitting ( my butt usually got to the seat). held that for about 10 seconds than pushed myself back up. I varied that between 5-10 reps depending on how “irritable” the knee was at that point. Then I would do the other knee. After I did the flexion, i just sat at the end of he chair extended my knee as to the point of of onset of nociception and then manually/actively pushed my knee into extension ( later I used a five pound sand bag to help apply additional force, especially as I got closer to the final couple of degrees). Again about the same reps. I did that every two- three hours. In the early stages I added ice afterward, but after about two weeks, the ice was only necessary if the knees were a little irritated from being on my feet too much and too active. I also tried to time my medication use so that I got the most analgesia after, not during the exercise. I wanted to know what my knees were telling me during the exercise, but I did want them to be quiet afterward.

    I was determined to try to introduce weight bearing and normal gait patterns as rapidly as I could. That is why I focused on trying to stay away from the walker and use a four-point reciprocal gait with the crutches. I reasoned that the inhibitory sensory mechanisms would work best if I resumed normal motor patterns as soon as I can. From watching patients coming back from knee surgeries, I felt that the walkers, although stable and adding an added margin for reducing the probability of a fall, produced an abnormal gait pattern that patient often had a difficult time stopping after removal from the walker. I also thought going to crutches with the bilateral knees would make the attainment of going up and down stairs safer and easier. I did practice using the crutches and the four point gait once or twice a day before surgery so that I felt immediately comfortable with their use afterward.

  5. davidbutler0noi

    A brief note: one interesting thing is that John had both knees operated on at the same time. Many people who require bilateral TKRs have them staged. In the latest journal of Pain, it was shown that in a group who had the second TKR one week after the first, there is more pain at rest and more pain medications are required for the “second knee” ( Kim, M-H et al 2014 Pain 155:22-27). The authors suggest central sensitisation and increased sensitivity to analgesics may be responsible for the findings.


  6. This is so wonderful how it just blows everything that has to do with protocols right out of the water. I just never felt comfortable with them and, in my junior years got into so much trouble not following them. Now I’m to old, arrogant and equipped with cutting edge knowledge and gut instinct to care……within the confides of common sense, treat the person and not the pathology and the biology will rise to the occasion….thank you John for sharing your experience with us. You have given more, with your story to the movement of the NOI than a thousand scientific articles……..

  7. davidbutler0noi

    I agree. I thought that one very important comment that came out of the interview is John’s comment that noone should ever have to push on another person’s knee to get range of motion.


  8. Hi John, As I am about to have a knee replacement my daughter sent me your piece re your surgery. She felt it my be of interest to me. It is a great thought provoking piece and thank you. I have started on my physical side of the exercise but now I will try to get my mind into the right place to face this operation. isn’t if strange how people like to tell you all the negative things before you have surgery, it is so refreshing to read your positive thoughts
    Margaret in Australia

  9. Thanks so much for posting this. I am 45 and have needed a replacement for around the last 5 years, but have been too scared and not in the right headspace to go ahead with it. This is given me some great ideas to think about,

  10. Great article, and some interesting food for thought regarding how important pre-op time is.

    Any suggestions for how to approach those who come to your clinic with a TKR in the past (and are currently having issues)?

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