Advice re: my father's swift decrease in mobility - arthritis & Synvisc

March 4, 2013 1:24 PM

My father (age 79) has gone from keeping a cane in the car for occasional use to steady himself (through 2012) to being in terrible pain and needing a walker around the house (the latter after a Synvisc injection to the knee 2 weeks ago, knee swelling, and falling - again - at home alone). So far he hasn't broken anything in his falls, but I live 90 minutes away from him and he lives alone. He's accustomed to being quite active and has often been mistaken for a man 10-15 years his junior.

His doctor has prescribed PT and Tramadol (the latter of which helps the pain but makes him foggy enough to worry about falling again through inattention). The arthritis is in his knee and spine (spurs at the base of his spine), and he has sciatica. He's elevating his leg in bed (as recommended by his doctor), but is still waking every couple of hours from the pain/discomfort. This also contributes to his grogginess - he is not sleeping terribly well (he is continuing to use his CPAP for intermittent apnea, as he has done for several years). He also has Meniere's Disease, so he's been having vertigo from prioritizing joint comfort over mindfulness about turning slowly and only in ways that don't aggravate the Meniere's. If it's pertinent, perhaps I should mention that he has had heart surgery (stents) and is under treatment for Barrett's Esophagus.

The Synvisc injection follows a cortisone injection last summer, which helped for a few months, but early January his pain and mobility issues got markedly worse, seemingly suddenly (at Christmas he was only slightly less comfortable than he had been for many months), by his own report and my observation. This was the reason for going in for the injection, and now - instead of the pained walking with the cane (his reason for getting the Synvisc injection) - he's far worse (see above) and the knee is swollen.

In short, this is a man who is accustomed to being able to do everything on his own, and has been able to until very recently. I realize that he's nearly 80, but is this a temporary set-back or will he likely be dealing with this lack of mobility for the rest of his life? I'm worried about him becoming depressed, because he's such an independent, active person (until this year swam weekly and walked a mile every other day - which to my mind is quite good), despite being overweight (not obese) and - I suppose - elderly. I'm particularly conscious of the fact that the walker he's using was used by my mother (his late wife of 50 years) during the late stages of brain cancer (the cause of her death 7 years ago). What can I do to support him best? Does he need a second opinion? Patience? A long-term treatment plan?

For now I'm taking the approach of "The doctor said the injection might take 6 weeks for you to feel the effects, let's focus on getting you to that point and then we can re-assess," and ensuring he feels as cared for as possible (calling daily, talking through anything he might need external help with, like driving). He is continuing to go to follow-up appointments and is a good advocate for his own health in general, but I'd like to be able to contribute more than simply comforting him. This may be a wish I can't fulfill, though - I recognize that.

Thank you in advance for any advice you can offer me - I know that YAN(Dad's)D and YA(likely)NAD, but I'd be very grateful for any words of wisdom/experience.

posted by pammeke to Health & Fitness (10 answers total)

Sorry, one addendum: his PCP has been a bit dismissive of his pain level, and has essentially told him that he's old now and should expect this kind of thing. Dad's found that very disheartening (and a bit insulting), and I'm wondering if this reflects a lack of interest on the doctor's part (Dad's PCP for several decades, and no spring chicken himself) or a direct, no-nonsense approach.
posted by pammeke at 1:27 PM on March 4, 2013

Both of my parents (in their 60s) went dutifully through Synvisc injections before eventually each having double knee replacement surgeries. While they both experienced relief from cortisone shots, they both said Synvisc was very painful (the actual injection, not the recovery) and offered little relief from their knee pain. Is he seeing an orthpedist in addition to his PCP? It might be time for him to get the opinion of a specialist. Your father shouldn't have to live with this kind of pain, especially if his doctor isn't fully hearing his concerns.
posted by gladly at 1:37 PM on March 4, 2013

Seems to me he needs x-ray by competent ortho doctor...and perhaps, if that shows nothing, MRI. I had twisted my knee, got x ray and the incompetent doctor told me if that showed nothing I would get MRI...Instead, he sent me for PT, and the pain persisted. Went to another doctor, who sent me for MRI, and a tear discovered. I recovered and walk 3-5 miles with ease, and I am going on 84
posted by Postroad at 1:49 PM on March 4, 2013

PT should be helpful, both with decreasing pain and helping him be safer and stronger at home. He should have exercises both for strengthening his muscles and improving his balance. He may also want to work on getting a referral to an orthopedist at the same time- it can take a while to get in to see one depending on where he is. The exercises may take several weeks to make a difference especially since he's had several months of pain. (IAAPT- not your Dad's)
If he is physically able to withstand it, he may want to consider joint replacement. My grandmother is a year out from double knees at age 92 and is moving better than ever. It takes a lot of hard work to get through, but may be worth it- 79 is not super old. Don't listen to that PCP!
posted by bookrach at 4:12 PM on March 4, 2013

I agree with the other suggestions that have been made (second opinion, ortho specialist, the fact that the PT is a good thing, knee replacement MAY be a consideration for someone very active without other major medical problems but only an orthopedist could judge if this is reasonable in an elderly person like your dad who has heart disease!).

I just wanted to add, I get particularly concerned about reports of falling old people. Have you been through his house very carefully and ensured that all possible safety hazards have been addressed? Does he have to do a lot of stairs? Can these be avoided? Are there other hazards like slippery floors? Can you get rid of throw rugs that could catch a toe or a walker? Are there nonslip rubber mats in the bathroom floors, tub/shower? Are there railings installed in the shower and next to the toilet (towel bar doesn't count)? What about a bench in the shower? Any clutter on the floors, or electrical cords that could be tripped over? Anything he could run into on his way from his bed to the bathroom? Is the way to the bathroom well lit? Does he have a medical alert necklace he could use if he falls and cannot get up? Smoke detectors/CO detector functional? Just a few thoughts.
posted by treehorn+bunny at 5:12 PM on March 4, 2013

One other point: are his medications put into those plastic day-by-day containers? If he's sleepy/confused from his OSA and tramadol, forgetting meds or taking incorrectly could be a concern. If he forgets he took his tramadol already, for example, then takes an extra, could increase the risk of falls.
posted by treehorn+bunny at 5:15 PM on March 4, 2013

I am wondering if he has been on advil a long time for his arthritis. It can promote Barrett's Esophigitis. It also depletes folic acid. My need for b vitamin supplements went way, way down when I got of ibuprofen therapy. He may also have a magnesium deficiency. Meniere's tends to involve tinnitus which, at least for some people, improves with magnesium supplements. I think getting him on the right supplements would help mitigate some of his issues.

If he has taken advil for a long time for his arthritis, talk to his doctor about the possibility it promoted his Barrett's Esophigitis and consider another therapy. Also, some people respond well to nutritional supplements to feed their joints. My tendon issues improved with consuming a packet of gelatin in hot water daily for a year or two.
posted by Michele in California at 6:42 PM on March 4, 2013

Thank you all so much for your thoughtful & very helpful responses. Writing this on the fly, just off the phone with him, they've done a CAT scan today (no hairline fractures around the pelvis, their primary concern), the arthritis/spurs findings come from pre-Synvisc x-rays, and tomorrow they'll be setting up an MRI appointment, as well as scheduling a social worker (?) to come into his home to help with things as needed. Because of my mother's illness, we do have a shower bench and rails around the toilet (he also put the raised seat back a few weeks ago, which he found more comfortable). I do need to go through the house and move some items around - he's a collector of sorts, and there are definitely some pieces of furniture which likely need to be stored elsewhere, at least for now. He does have a pill box organized by day of week and AM/PM - he's very fastidious about this, having administered 4 daily pill timings for my mother during her illness (a different, more intricate box). Because of the heart disease, his PCP & ortho have both been hesitant to recommend knee surgery for several years now, since he started having (comparatively minor) issues, but I'm heartened to hear that - pending their approval, this may be a good option for him. He is (has always been) fairly active, and has kept active in retirement also.

Again, thank you all *so* much for your advice already - I truly appreciate it. (Hoping this reply isn't too disjointed - typing on my phone.)
posted by pammeke at 6:46 PM on March 4, 2013

I can only address the Synvisc and this is based only on my experiences. I was unable to walk because of stage three osteo in my left knee(bone on bone in three places). A cortisone shot just inflamed it more, and my ortho suggested synvisc. I went home and googled, and read many people reporting experiences similar to your fathers; extreme pain during the injection and the condition getting worse rather than getting better.
From my cursory research, it seemed like the issue was most frequently with the single injection rather than the series of three injections.
I convinced my ortho to go with Euflexxa instead (it is the same as Synvisc except it is synthetically derived and it is the series of three weekly injections) I went from being completely immobile to being able to walk immediately following the first injection. After the third injection i was up to 90%, and even running again (which I later realized was pushing it).
The injections are virtually painless, and they lasted 8-9 months the first time and about a year the second round. I just finished my third round and am doing great and I truly hope that they continue to work because otherwise a TKR is my only option.
Maybe consider looking into one of the other HCA injections (like I said, Euflexxa works very well for me) or at least get a docs opinion on trying one of the others before going for the drastic step of the knee surgery.
posted by newpotato at 7:02 PM on March 4, 2013

Thank you all again. I've tried to select the "best answers" which seem to have been most helpful - at least in the short term - to my father, but I have found all of them valuable and I know that we will refer to them in the coming weeks/months. He has a consultation lined up with a recommended doctor regarding a possible knee replacement, although he is keen to avoid it (and all surgery) if possible - and will rely on his cardiologist (who put in his stents and has been an excellent adviser to him) to make a recommendation in that regard. Today they drained his knee and gave him a cortisone shot (same as he had in '08 with good results), which has given him some relief although his mobility remains roughly the same for now. I'll continue to monitor his situation, visit to go over his medications & supplements in detail (as recommended), remove potential obstacles from his pathways around the house (also recommended), and will continue to encourage him to pursue other resources/opinions/options.
posted by pammeke at 2:53 PM on March 5, 2013