INJURY & REHAB: training clients post-joint replacement
With our ageing population, and the increase in older people working out, you are more likely than ever to find yourself training clients with joint replacements.
According to the Australian Orthopaedic Association’s 2015 annual report, the number of both hip and knee replacements are increasing each year, with 43,183 hip replacements and 54,277 knee replacements reported to the registry in 2014. Despite them being performed more often, they remain a major surgery requiring appropriate rehabilitation. Understanding the post-op recommendations and precautions is vital for you and your client to return to training both safely and confidently.
Reasons for joint replacements
In general terms, the purpose of a joint replacement is to remove diseased or broken parts of the joint and replace them with artificial parts. The goals of replacement surgery are therefore to:
- decrease pain
- improve joint range of movement
- improve overall function.
The most common reason for this is osteoarthritis, and surgery are usually elective when conservative treatments are no longer effective.
Another major reason a joint replacement is required, in particular of the hip joint, is due to a fracture, most commonly a broken femoral neck. The most common risk factor for sustaining a hip fracture is osteoporosis, and this should be flagged early on in your client’s training history and kept in mind during their return to training post-op.
The different types of replacements
There are three main types of replacement for both the hip and the knee; total, partial and revision.
- Total hip replacement involves replacing the femoral head (ball of the hip joint) as well as the acetabulum (socket of the hip joint).
- Partial hip replacement, in which only the femoral head is replaced, most commonly due to a fracture, as mentioned above. In some instances these fractures are managed with dynamic screws, however the decision will depend on the severity, patient’s age and surgeon’s opinion.
- Revision surgery for reasons including loosening of the parts, dislocation, fracture or infection.
- Total knee replacement involves replacing the complete joint surface of the femur and tibia.
- Partial replacement of the femoral and tibial joint surface on either the inner or outer side (most commonly the inner/medial side due to biomechanical loading)
- Revision surgeries are performed for similar reasons to the hip.
The role of a physio
While still an inpatient, the physio’s role is to get the patient moving. Depending on the type of surgery, they may be allowed to weight-bear immediately, often starting with the use of a gutter frame and physical assistance by the physio and nursing staff. The physio will then guide their range of motion exercises and educate them in regard to movement precautions, icing and compression.
Hip precautions are very important post-op, and it is essential that the patient is frequently reminded to not bend the hip further than 90 degrees; not twist the hip inwards (internal rotation); and not cross the midline of the body (abduction).
The reason for the precautions is to avoid a dislocation of the new hip, which unfortunately is not uncommon. The duration the precautions need to be adhered to varies, depending on the surgeon and client (in particular if they have a history of dislocations), with some lasting only six weeks and others recommending to avoid long term. For a fractured femoral neck managed with a dynamic screw as mentioned above, there are usually no hip precautions. Hence why it is important for you to be aware of the type of surgery and consider potential precautions when you are designing training programs for these clients.
As a physio, the main recommendations I highlight to patients in regard to avoiding the above movements include:
- sitting in a higher chair where their hips are always higher than their knees
- using a cushion to elevate the hips when sitting, if a low chair is unavoidable
- using a pick up stick to pick things up from the floor
- alternatively, if a pick up stick will not suffice, bending down with the non-operative hip only by extending the operated leg out behind, keeping it straight
- avoiding bending to put shoes on by wearing supportive shoes that slip on/off and utilising a shoe horn with a long handle (or having someone help put them on)
- sleeping with a pillow between their legs if they are a side-sleeper (to avoid the leg coming across the midline).
After discharge home (usually with either a frame or crutches), the physio will work with the patient through an outpatient role with the goal of progressing their gait aid (e.g. frame > crutches > one crutch/stick > no aid) and commonly recommend activities including hydrotherapy, stationary bike and clinical Pilates in the initial stages.
Monitoring for complications is also another important role, in particular for infection and deep vein thrombosis (DVT). Personal trainers should also be on the look out for signs of a DVT, which include pain, swelling, warm/red skin and tenderness (usually around the calf). A DVT can lead to life-threatening conditions such as a pulmonary embolism, so if you are suspicious at all, send them straight to the doctor. Signs of infection (around the scar) include redness, warmth, tenderness to the touch, pus or drainage and bad odour, and potential fever/chills. If you are concerned, recommend that they cease training and consult a doctor as soon as possible.
Returning to training post-op
Whether they are a past client returning to you post-op, or a new client with a history of a joint replacement, the following points are important:
- Check with them regarding any remaining precautions (as mentioned this can vary person to person). If they have been advised to avoid flexion past 90 degrees then adapt either the exercise e.g. avoid deep squats, or the equipment, e.g. raise the seat of the exercise bike.
- Despite the surgeon and physio’s best efforts, they may have residual joint stiffness that can limit certain movements, for example lacking full knee extension can alter hamstring length and strength and may be associated with weak quads. Therefore it is important to monitor their technique on certain exercises, e.g. a dead lift, to avoid compensating and incorrectly loading other regions such as their lower back.
- After knee replacement, many people find it difficult to kneel (even months or years later) post-op depending on their range of motion, pain levels and fear of damaging the prosthesis. If they are unable to kneel, adapt your exercises to seated or standing position if possible.
- Swelling can persist for several months post-op and can be managed using ice and compression garments. The benefits of compression are well documented, in particular the effect on blood flow and circulation, therefore wearing a compression garment during activity can assist in reducing swelling during and after activity.
Top tips for clients with joint replacements
1. Touch base with their physio and don’t hesitate to ask any questions, no matter how basic, in particular with regards their precautions. The client will appreciate you being careful and it could also assist in regard to your liability should something unfortunate happen in your presence (for example if your client dislocates their hip).
2. Keep in mind that other joints, including shoulders, can also undergo joint replacements. The precautions and rehab procedures can vary dramatically depending on the surgery. So again, don’t be afraid to check in with their physio or even their surgeon.
3. Focus on functional training that will help them improve day to day, as having difficulty with the simple things, such as stairs or standing from sitting, are often the reason they had their joint replaced in the first place.
4. Keep in mind that often those who underwent elective joint replacements for osteoarthritis may also be suffering in other joints of their body. Non-weight bearing exercises, such as the bike or cross-trainer will be more favourable for these clients.
5. Be mindful of your clients’ comorbidities and incorporate training principles to address these. For example, balance exercises for falls prevention in clients with osteoporosis may assist in preventing a fracture that leads to a joint replacement. After all, prehab is the new rehab!
Phebe Corey is a physiotherapist and the founder of Articfit Joint Supportive Compression Wear. Phebe was a semi-finalist in The Australian Women’s Weekly Women of the Future competition in 2015 for her brand and vision of empowering women to stay active. articfit.com