“The World of Joint Replacements”“The World of Joint Replacements” ... these individuals to keep up their exercise regime in the hopes of returning back to a pain free functional

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© LeapFit Training Professionals 2016

“The World of

Joint Replacements”

A ONE OF A KIND COMPREHENSIVE GUIDE

FOR FITNESS PROFESSIONALS

Understand joint replacements

Design safe, effective exercise programs

Develop joint replacement classes to meet the

rapidly growing demand

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PREFACE

THE WORLD OF JOINT REPLACEMENTS Developed and written by Jody Kennett

Copyright 2005

All rights reserved

For more information on the one day post rehabilitative joint replacement course or consulting services to start your own joint

rehabilitation class contact Jody Kennett:

Telephone: 604-448-2410 Email: [email protected]

No portion of this document may be reproduced, stored in a retrieval

system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without the prior written permission of the

writer.

The information in this manual is distributed on an “as is” basis, without warranty. While every precaution has been taken in the

preparation of this content, the author shall have no liability to any person or entity with respect to any liability, loss, or damage caused or

alleged to be caused directly or indirectly by the instructions contained in this material.

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TABLE OF CONTENTS

Introduction 1-2

1.0 Introduction to Joint Replacements 3-7

1.1 What is a Joint Replacement 3

1.2 Causes of Joint Damage Leading to Joint Replacement 4

1.3 Symptoms & Signs Indicating Joint Replacement Surgery

May Be Required 5

1.4 Statistics Related to Joint Replacement 6

2.0 Types of Joint Replacements 8

3.0 Knee Replacement 9-14

3.1 Anatomy of the Knee Joint 9-10

3.2 Total Knee Replacement (TKR) 10-11

3.3 Knee Replacement Surgical Procedure 12

3.4 Types of Total Knee Replacement 12-14

3.5 Partial Knee Replacement=Unicompartmental Knee

Replacements 15

4.0 Assessment & Consultation 16-20

5.0 Program Design for Pre & Post-Op Knee 21-39

5.1 Key Components for Exercise Prescription 21-23

5.2 Pre-Op Exercise Guidelines 24-26

5.3 Post-Op Exercises Guidelines 27-30

5.4 Sample Exercises Pre and Post-Op 31-34

5.5 Sample of the Physiotherapy Exercises 35

5.6 Sample Exercises Options / Progressions 36

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TABLE OF CONTENTS

6.0 Hip Replacement 41-46

6.1 Anatomy of the Hip Joint 41-42

6.2 Total Hip Replacement and Hip Resurfacing Surgery 43-44

6.3 Types of Hip Replacements 45-46

6.4 Hip Implants 47

7.0 Hip Assessment & Consultation 48

8.0 Program Design for Pre and Post-Op Hip 49-57

8.1 Pre and Post Op Hip Exercises 49

8.2 Sample Post Op Physiotherapy Exercises 50

8.3 Post-Operative Hip Replacement Exercises 51

8.4 Pre Program Design 52-55

8.5 Post Op Program Design 56-58

9.0 Training Principles 59-60

10. Exercise Progressions 61-63

11. Precautions and Contraindications 64-65

12. Cardiovascular Program Design 66-70

12.1 Cardiovascular Exercise – Where to Start? 65

12.2 Cardio Machine Recommendations 66

12.3 Appropriate Cardiovascular Training Times 66

12.4 Heart Rate Training Zones 67

12.5 Warm-UP and Cool-Down 68

13. Gait Analysis 70-72

13.1 Biomechanics of Normal Gait 69

13.2 Gait Abnormalities 70

14. Balance 73-75

14.1 Balance Training for Joint Replacement Patients 72

14.2 Balance Exercises 74

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TABLE OF CONTENTS

15. Posture Assessment 76-77

16. Points of Interest 78-81

17. Build a Successful Joint Replacement Program 81-92

17.1 Key Components 81

17.2 Designing a Successful Joint Replacement Class 82

17.3 Program Framework 83

17.4 Designing Specific Class Details 84

17.5 Equipment Checklists 85

17.6 Scope of Practice 89

17.7 Record Keeping 90

17.8 Program Evaluation & Feedback 90

17.9 Creating a Positive Atmosphere for Healing 92

17.10 Social Functions 93

17.11 Personal Instructors Have a Unique Role 91

18. Appendix 93-105

Appendix A: Gait Analysis Observation Check List 93

Appendix B: Posture Graphic 94

Appendix C: Physio Referral Form 95

Appendix D: Information Release Form 96

Appendix E: Health Screening/Par-Q 97

Appendix F: Medical Release Form 98

Appendix G: S.O.A.P. Client Analysis 99

Appendix H: Joint Rehab Evaluation Review 100

Appendix I: Certificate of Graduation 101

Appendix J: Report Card 102

Appendix K: Joint Rehab Training Card 103

Appendix L: Nutrition Guidelines for Healthy Joints 104

Appendix M: Shoe Selection: Biomechanic Design 105

19. Glossary 106-107 20. Works Cited 108

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THE WORLD OF JOINT REPLACEMENTS - INTRODUCTION

The inception of this course started ten years ago when I began to lead a class for joint replacement patients and realized in my research that there was very little information and no specific guidelines in post rehabilitation for hip and knee patients. I realized through my years of teaching, liaising with physiotherapists, and researching joint replacements that I had developed a knowledge base that I felt needed to be shared because of the growing demand for community programs to help individuals continue their post rehabilitation past the time frame given by our medical system. It has been amazing to see the results these participants have achieved in the areas of function, confidence, and increased quality of life by continuing to exercise one to two years post operation. Statements made by clients and physiotherapists inspired my passion to create this manual: “...other hospitals are modeling after our program and especially how we have linked with community exercise programs..”, “We are so lucky to have this program because my friend cannot find anything like this where she lives.”, “..I have become so much stronger and more capable than I was three months ago post surgery and I know it is due to this program.” I wondered how I could share the knowledge and expertise I had gained with other instructors and if it was possible to spread the success we have seen in participants to more people outside of our community. Well, the dream has begun and you are now a part of carrying out the vision of creating a better quality of life for those who are living with advanced arthritis or recovering from a joint replacement. I have ten years’ experience working in the fitness industry as a personal trainer working with special populations. My credentials include the Health and Wellness Certificate from SFU, BCRPA Personal Trainer, and A.C.E. Clinical Exercise Specialist. I have been the lead instructor of the post rehabilitative joint replacement program for the District of West Vancouver for 9 years. Initially there were only two participants registered. Now, the program has grown from one to six classes per week, typically running at full capacity with 12 participants, all year long. Additional classes I have instructed include: the Healthy Heart Phase IV, Youth Weight Training, Women on Weights, and Girl Power. The knowledge, professionalism, sincerity and supporting nature of the instructors involved from the beginning has spread the word of this excellent program to meet the growing demand for knee and hip joint replacement rehabilitation classes. It was first initiated by Meghan Drew and Tracy Wakaluk. Then Erin Guppy took an active role in forging a partnership with the physiotherapists at Lions Gate Hospital who have been great to collaborate with and who have played an integral role in educating patients to continue their post rehabilitation in the community.

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THE WORLD OF JOINT REPLACEMENTS INTRODUCTION

There are two other key individuals who fostered the growth of this program. The first one, Donna Hutchinson, was our progressive manager, who always said ‘yes’ to all of our ideas making things happen in a timely manner. The second one, Susan Collier, played an integral role in both the growth and success of the program by demonstrating a high level of professionalism, dedication, sincerity, knowledge, and holistic thinking. Lastly, Marie Westby, BSc PT and PHD candidate, has been an outstanding resource and has contributed her knowledge and expertise in reviewing the content as well as providing scientific articles to support the information within this manual.

In 2004-2005 more than 58,000 Canadians underwent a primary joint replacement. Between 1995 and 2005 there has been an increase in the rate of knee replacements for the 45 to 54 age group where it has doubled for males at 125% increase and almost tripled for females at an increase of 174%. Hip replacements in this same age group have also seen the largest increase with 53% increase for males and 41% for females.

The interesting and problematic aspect of helping joint replacement recipients is that every aspect of joint replacements from pre-op exercise to surgery to post rehabilitation is still in the developing stages. There are many individuals experiencing great results following knee and hip joint replacement surgery, but there are also cases of great struggling post rehabilitation causing these individuals to keep up their exercise regime in the hopes of returning back to a pain free functional capacity. It is these individuals who will be seeking continued guidance and support and therefore, there is a significant demand in the fitness industry for instructors who choose to become proficient in all the areas of joint replacement pre and post rehabilitation.

This one of a kind comprehensive manual has been designed to provide fitness professionals with all the knowledge and detailed exercises they need to deliver one-to-one and/or group training for the growing numbers of knee and hip replacement clients.

This manual covers basic joint anatomy, information on the types and methods of joint replacements and a detailed outline of all aspects of joint replacement from pre-operation to post operation. The goal of this manual is to provide you with the skills and knowledge you will need to design and implement your own joint replacement exercise programs. The accompanying one day workshop is designed to give you practical time to practice the exercises in this manual and to give you a greater understanding of the joint replacements.

Thank you for playing an integral part in your community by helping clients achieve dramatic improvements in flexibility and strength which will result in greater mobility and independence for these individuals.

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SECTION 1: INTRODUCTION TO JOINT REPLACEMENTS

1.1 WHAT IS A JOINT REPLACEMENT?

Joints are formed where two or more bones meet and are connected by a

fibrous capsule and reinforced by ligaments and tissue. Where two bones are

in contact with each other, they are covered with articular cartilage that

allows almost frictionless movement and absorbs some of the joint forces.

When this cartilage becomes damaged or diseased by arthritis, it causes the

joint to become stiff and painful. Pain develops when the cartilage no longer

protects the bone surfaces and the bone and other tissues become damaged. A

replacement is required once the arthritis advances in to its progressive stage

where the joint pain becomes disabling. The deterioration of the joint from

osteoarthritis causes loss of function and a reduction in the quality of life for

the individual living with arthritis.

A joint replacement is an artificial joint called a prosthesis that replaces an

arthritic or damaged joint. The prosthesis is typically comprised of both

metal alloys (titanium, cobalt chromium) and plastic polymers (high density

polyethylene) which are attached directly to bone with either a cement type

adhesive or a porous coated surface that allows bone to grow through. Hip

replacements have also been made with ceramic materials. These metal,

plastic, and ceramic materials are durable, wear resistant, and

biocompatible.

Hip and knee replacements are the most common joints being replaced;

however, shoulders, ankles, and fingers can also be replaced. The focus of

this manual will be on hip and knee replacements.

A joint replacement is usually the last resort in a patient’s attempt to treat

their pain. The pain and stiffness in their joint has usually reached a level

whereby their quality of life has been drastically altered. When the simple

activities of daily living such as walking, getting up out of a chair, climbing

stairs, and getting out of a car become labor intensive tasks, it is time to

consider surgery. Usually replacement candidates have tried numerous other

healing avenues including weight loss, walking aides, exercise, pain killers,

and alternative medicine before pursuing surgery. People choose to have

their joints replaced to decrease pain and to regain independence in activities

of daily living (ADL). It is at the stage where the pain has continued to

escalate causing a domino effect of decreased mobility, muscle atrophy, and

changes in gait which leads individuals to the option of surgery.

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1.2 CAUSES OF JOINT DAMAGE LEADING TO JOINT REPLACEMENT

The four most common causes leading to joint replacement surgery are

Osteoarthritis, Traumatic Arthritis, Osteonecrosis and Inflammatory

Arthritis.

i) Osteoarthritis (OA) Osteoarthritis is the progressive weakening and

degeneration of the articular cartilage on the contact surfaces of the

bone which then produce stiffness, pain, swelling, inflammation,

decreased mobility, and deformity from the articular surfaces rubbing

directly on each other as well as resultant inflammatory responses. A

few of the risk factors contributing to osteoarthritis are metabolic,

mechanical, injury, repetitive or excessive stresses from sports or

occupations, and obesity.

ii) Post Traumatic Arthritis is usually caused by a single traumatic injury

such as a bone fracture that alters joint alignment or joint forces,

compression or crush injury to cartilage, ligament injuries, and

possibly multiple minor traumatic episodes resulting in marked

instability.

iii) Osteonecrosis which refers to bone that has died is another cause for

joint replacement. Avascular Necrosis, which refers to the lack of or

absence of blood supply to the joint, can cause death of bone tissue

leading to the need for a replacement. It occurs most commonly in the

femur.

iv) Inflammatory Arthritis which includes both Rheumatoid Arthritis and

Ankylosing Spondylitis

Rheumatoid Arthritis (RA) is an autoimmune disease of the synovial

tissue found in joints, bursae, and tendon sheaths. The synovium

becomes swollen and inflamed which leads to cartilage breakdown and

joint destruction. It primarily affects the small joints of the hands,

feet, as well as wrists, elbows, ankles, knees, and cervical spine. RA

affects about 1% of the population and can start at any age and is most

common in women aged 40 to 50 years. There can be periods of time

where there are flare ups when the disease symptoms are present and

when the disease is not active or in a remission state.

Ankylosing Spondylitis (AS) is another form of inflammatory arthritis

which can cause severe hip joint damage requiring replacement.

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1.3 SYMPTOMS & SIGNS INDICATING JOINT REPLACEMENT SURGERY MAY BE

REQUIRED

Severe Groin pain for individuals with hip joint arthritis

Pain in the joint upon weight bearing / walking

Inability to sleep at night due to pain in the joint

Medications and other conservative treatments are no longer

alleviating the pain

The pain from arthritis limits and alters the normal daily routine to

the extent where visiting friends or going to work or shopping is

difficult

Activity is restricted to the point where getting out of a chair, going up

stairs, getting off the toilet, and getting up off the floor is painful and

challenging

Disabling loss of range of motion affecting gait, posture, and function

Feeling of stiffness first thing in the morning and after sitting or

standing for long periods

Crepitus in the joint upon movement both in weight bearing and non

weight bearing

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1.4 STATISTICS RELATED TO JOINT REPLACEMENT

The following statistics are compiled from the Canadian Joint Replacement

Registry (CJRR) from the Canadian Institute for Health Information (CIHI).

These statistics were obtained from the CJJR 2006 report for the year end

2005.

Diagnostic Cause for Replacement Hip Knee

Degenerative Osteoarthritis 81% 93%

Osteonecrosis 6%

Inflammatory Arthritis 4%

Post-traumatic Osteoarthritis 1% 2%

Childhood Hip Problem 4%

Acute Hip Fracture 3%

Old Hip Fracture 3%

Other 1% 1%

The following demographics were taken from the CJRR and provided by the

CIHI. The statistics shown were last recorded for the year 2004-2005.

Increases in Knee and Hip Joint Replacements Total Number of Knee and Hip Replacements 2004-2005 58,714

Total Number of Knee Replacements 2004-2005 33,590

Total Number of Hip Replacements 2004-2005 25,124

Total Percentage Increase in TKR from 1994-1995 124.8%

Total Percentage Increase in THR from 1994-1995 52%

Percentage Increase in TKR for Women since 1994-1995 125%

Percentage Increase in TKR for Men since 1994-1995 125%

Percentage Increase in THR for Women since 1994-1995 48%

Percentage Increase in THR for Men since 1994-1995 57%

The following demographics were taken from the CJRR and provided by the

CIHI. The statistics shown were last recorded for the year 2004-2005.

Increases in Knee and Hip Joint Replacements Total Number of Knee and Hip Replacements 2004-2005 58,714

Total Number of Knee Replacements 2004-2005 33,590

Total Number of Hip Replacements 2004-2005 25,124

Total Percentage Increase in TKR from 1994-1995 124.8%

Total Percentage Increase in THR from 1994-1995 52%

Percentage Increase in TKR for Women since 1994-1995 125%

Percentage Increase in TKR for Men since 1994-1995 125%

Percentage Increase in THR for Women since 1994-1995 48%

Percentage Increase in THR for Men since 1994-1995 57%

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The majority of hip and knee replacements (30% and 37% respectively) are

performed on patients in the 65 to 74 year age group followed by the 75 to 84

year age group with 27% and 28% respectively. The following table

represents the number and distribution of total knee and hip replacements by

age group and sex for the year 2004-2005. The statistics were taken from the

CJRR and provided by the CIHI.

Age Statistics for Hip and Knee Joint Replacement

Age Female TKR Male TKR Female THR Male THR

<45 217 156 519 640

45-54 1624 905 1212 1452

55-64 4751 3238 2595 2471

64-74 7229 5259 4350 3346

75-84 5786 3506 4591 2448

>85 596 323 1090 410

The table below outlines the percentage increases for total knee and hip

replacements by age group and sex. The percent changes are a 10 year

comparison representing the increase from 1994-1995 to 2004-2005.

Percentage Increases of Total Knee and Hip Replacements

Age group Female TKR Male TKR Female THR Male THR

<45 51% 56% 14% 36%

45-54 327% 229% 95% 110%

55-64 189% 156% 59% 56%

65-74 78% 97% 17% 37%

75-84 129% 131% 67% 68%

>85 150% 181% 109% 116%

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SECTION 2: TYPES OF JOINT REPLACEMENTS

The fixation of the implant in joint replacement surgery refers to whether the

implant is cemented or cementless. Cemented implants mean that a doughy

polymer substance somewhat like a bone cement or glue has been used to

secure the implant into the bone. Cementless fixations refer to joint

replacement surgeries where the prosthesis has a porous coating on the

surface which promotes bone in growth. Total Knee Arthroplasty uses

cement as the gold standard with survival rates of 94% - 98% for 10 to 14

years. Cementless TKA are not as common anymore because they have not

been able to show reliable bone in growth.

Total Hip Arthroplasty (THA) varies from TKA in that cemented implants

show similar survivorship to cementless for the femoral component. However,

the acetabular component in the hip replacement shows similar survival

rates at 10 years, but then the cementless implant produces greater longevity

at 15 years. To summarize, a cemented or cementless femoral stem will

produce similar survival rates in THA, but the cementless technique is

preferable for most of the acetabular reconstructions.

THA - the cemented femoral stem has 98% survivorship at 10 years

and 93% at 25 years / cementless femoral stems produce comparable

results

THA - the cemented and cementless acetabular component have

similar survivorship at 10 years of 95% - 100% respectively

THA – The cementless acetabular component has increased

survivorship rates at 15 years (70%-95% cemented vs. 85%-94%

cementless)

TKA – The Cemented technique is the gold standard in TKA

A Hybrid Hip Replacement or Hemiarthroplasty describes a prosthetic

that has a combination of cemented and uncemented implants. The

femoral shaft is cemented and the acetabular prosthetic component is

uncemented or vice versa.

A Cementless THR has prosthesis ends that are covered with a porous

coating providing a rough surface that our bone finds compatible and

grows through. Sometimes a coating of hydroxyappatite is used which

is a mineral that makes bone hard and strong. This bone in growth

which occurs describes how our living bone actually binds to and grows

against metal. The prosthesis is held in place both by the fit and

eventually the in growth of bone into the prosthesis. Since it takes

longer for bone to grow through the implant in a cementless joint there

may be restrictions on full weight bearing (FWB) for up to 12 weeks

post operation depending on the surgeon.

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SECTION 3: KNEE REPLACEMENT

3.1 ANATOMY OF THE KNEE JOINT

Understanding the anatomy of the knee and the muscles, bones, and tissues

affected by total knee arthroplasty (TKA) will give you the knowledge needed

to develop a safe and effective exercise program.

Strengthening all the muscles around the knee helps to stabilize the joint and

to increase its function and the individual’s confidence in his/her stability to

do activities of daily living (ADL). The patient that decides to be proactive

and exercise prior to surgery may be able to postpone the need for surgery,

increase their quality of life until the operation day, and maximize his/her

opportunity for a faster recovery post surgery.

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The muscles you need to be aware of that support and activate the knee joint

are as follows:

Muscle

Origin

Insertion

Action

Semimembranosus Ischial Tuberosity Tibia Flexion

Semitendonosus Ischial Tuberosity Tibia Flexion

Biceps Femoris Ischial Tuberosity Fibular head Flexion

Gracillis Pubic Tubercle Tibia Flexion

Sartorius ASIS Medial to Tibial

Tubercle

Flexion at hip

and knee and

externally

rotates hip

Rectus Femoris Anterior Inferior

Iliac Spine

Tibial Tuberosity Extension

Vastus Lateralis Linea Aspera

Femur Tibial Tuberosity Extension

Vastus

Intermedius

Anterior Femoral

Shaft Tibial Tuberosity Extension

Vastus Medialis

(VMO)

Linea Aspera

Femur Tibial Tuberosity Extension

Tensor Fascia

Latae (TFL)

*influences

stability of the

knee in extension

Iliac Crest Illiotibial Band

Assists in knee

extension; flexes,

internally

rotates, and

abducts hip

Illiotibial Band

(IT Band) Ilium

Lateral Tibial

condyle & head

of fibula

Stabilizes knee

joint

The bones involved in the knee joint are the femur, tibia, fibula, and the

patella. The ligaments surrounding the knee joint are the posterior and

anterior cruciate ligaments as well as the medial and lateral collateral

ligaments. (PCL, ACL, MCL, LCL) These ligaments will be stretched or

damaged to some degree in the advanced stages of Osteoarthritis.

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3.2 TOTAL KNEE REPLACEMENT (TKR)

(also referred to as tricompartmental knee replacement)

The TKR includes the following 3 components of the prosthesis:

1) femoral component is made of cobalt chromium metal which can be

either cemented or cementless (Cemented is the gold standard)

2) tibial plateau is a two piece component of metal and plastic and the

metal is usually titanium or cobalt; whereas the tibial spacer or

bearing is a special grade polyethylene plastic

3) the patella may or may not be replaced depending on its condition;

however, if it does require a replacement then a plastic implant is

inserted on the backside of the patella attached with bone cement

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3.3 KNEE REPLACEMENT SURGICAL PROCEDURE

The knee is placed in a flexed position during surgery exposing all the

surfaces of the joint and then an incision between 6 to 12 inches long is made

right across the anterior aspect of the knee joint. The incisions may be made

medial parapatellar (through the quadriceps tendon), by vastus splitting

(through the vastus medialis muscle) or by subvastus (medial to the vastus

medialis). Once the incision has been made, the patella is then pulled over to

the side and the damaged cartilage and bone of both the tibial plateau and

the femoral condyles is removed and replaced with the prosthesis. A metal

and plastic implant is placed on to the tibial plateau and a metal implant

component is inserted into the femur. If the patella is also affected, then it

too can be replaced with a prosthetic or just resurfaced depending on the

severity of damage to the patella.

The ACL is excised and depending on the damage and type of prosthesis, the

posterior cruciate ligament may or may not be removed. The surgeon makes

measurements to ensure the right fit and then prior to closing the incision,

the surgeon will bend and rotate the knee to test for appropriate range of

motion. The entire surgery takes approximately 90 minutes.

There are a few factors from the impact of surgery that may impact

rehabilitation post surgery. They include the type of fixation, type and extent

of bone cuts, soft tissue balancing, whether patellar resurfacing has occurred,

and the type and degree of misalignment preoperatively.

3.4 TYPES OF TOTAL KNEE REPLACEMENT

The type of knee replacement chosen is based on the patient’s physical

condition, the amount of damage to their joint, and their bone health. The

surgeon makes the decision of which prosthetic model will be used.

Posterior Stabilized Knee Implant or Cruciate Sacrificing

In the Posterior Stabilized (PS) knee implant, the posterior cruciate

ligament (PCL) is removed. The substitute implant has a protrusion

from its tibial component which connects with a cam and post bar on

the femoral component. This PCL substituting implant acts just as the

normal PCL does in limiting forward movement of the femur on the

tibia and promoting backward movement of the femur on the tibia.

This type of replacement may have a greater range of motion in flexion

and more predictable kinematics compared to the Cruciate Retaining

(CR) knee implants. Long term studies show ROM does not differ

between Cruciate Sacrificing and Retaining implants.

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Cruciate Retaining Knee Implants

In this type of replacement, the PCL is retained. It is thought to

contribute to better proprioception post surgery. These implants do

not allow for as much range of motion in knee flexion as the PS knee

implants. Some surgeons will excise the PCL and use the PS knee

implant even if the PCL is functioning well because it is believed the

decreased range of motion in the CR knee implant is strictly due to a

PCL that has been affected by the damaged joint and cannot provide as

much stability and function as it should.

Research studies have shown no difference in gait or stair climbing

abilities in the CR vs Cruciate Sacrificing procedures.

Minimally Invasive Knee Surgery (MIS)

This type of surgery gained its name because the incision is 4 to 6 inches as

compared to an 8 to 10 inch incision used in TKR. Also, there is less blood

loss, a shorter hospital stay, and a smaller area of tissue traumatized by the

surgery due to the smaller incision. The surgeons can perform the surgery by

using x-rays for guidance and special surgical equipment. There is no

guarantee that these joints function better and their longevity will be

unknown for at least 10 more years since this surgical procedure is new. This

surgical option is reserved for the slim patient and for someone with small

joints as the incision size will only permits for a small prosthetics to fit

through.

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Medial Pivot (MLP) Knee Implant, Rotating Platform, Mobile Bearing Knee

Implant

This is a relatively new concept implant. The femoral component is

created to model the femur, but the medial compartment of the tibial

component is created asymmetrically to allow for a gentle medial pivot

of the knee joint in flexion. It is too soon to compile an accurate data

sample, but patients who have had two different knee replacements on

each knee feel the medial pivot implant feels most like their original

knee. The rotating platform is thought to lead to improved mechanics

and less wear on the parts.

High Flex Knee

The High Flex Knee is another newer prosthetic design that allows for

greater knee flexion up to 155 degrees which is more than the

traditional design. Modifications that have been made to the tibial and

femoral components permit good joint contact throughout high flexion

activities. This type of knee replacement is used for patients whose

lifestyles involve activities such as kneeling in prayer or physical

activities requiring greater knee flexion.

Gender Specific Implant

This type of implant is extremely new and used in the female patient. It has

a smaller femoral component and recessed patellar groove thought to better

reflect the female anatomy. There is no research yet to support its

effectiveness.

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3.5 PARTIAL KNEE REPLACEMENT =UNICOMPARTMENTAL KNEE REPLACEMENT

The unicompartmental knee replacement is also referred to as a

partial knee replacement where only the medial or lateral portion of

the knee is replaced. Both the PCL and ACL are kept in tact. UKA is

performed on individuals who are aged 60 and older.

This surgery will only be performed on individuals with the following

requirements:

must only have osteoarthritis in one compartment of the knee

either medial or lateral (there must be no damage to the other

compartment)

both collateral ligaments need to be intact

the patient must have an in tact ACL

patient must have good knee flexion of 110 degrees

cannot have inflammatory/rheumatoid arthritis

You will notice partial knee replacements heal quicker, are usually less

painful, and normally will have greater ease and increased range of

motion in knee flexion compared to TKR patients.

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SECTION 4: ASSESSMENT & CONSULTATION

The assessment and consultation is an integral step prior to designing an

exercise program. It allows the instructor crucial one-on-one time with the

client to obtain valuable medical information. The consultation will also

allow the instructor to develop a good understanding of the client’s flexibility,

strength, and functional abilities. Also, it provides time for the client to

communicate his/her goals and areas of concern that need special attention

and work to improve the quality of his/her life.

1) Objectives of the Pre Course Consultation

It is a one hour comprehensive meeting to obtain background medical

information, and asses their range of motion (either visually or obtain

from their physiotherapist), strength, functional ability, gait, and

balance.

The consultation provides an excellent opportunity for the personal

trainer to have one-on-one focused time with the new participant

allowing for an in depth analysis of their goals and areas he/she needs

to strengthen which will guide the exercise selection process.

Use the consultation to take the client through the Hip and or Knee

Assessment Checklist to obtain an overall snapshot of the areas where

they are weak and/or tight that need to be improved for daily function

and to decrease pain.

It will provide the client with a less intimidating, slower paced

introduction to learn some of the exercises they will be doing in class.

This one hour consult gives the client an opportunity to share their

expectations and also acts as a determinant to see if the class is

suitable for the individual or if they would prefer and/or require one-

on-one instruction.

Registration and confirmation of payment can be completed during the

consult.

The consult provides time to explain the class design.

During the consult, it is important to advise the client of the

instructor-to-participant ratio and to clearly state that it is not

personal training. Advise the client that they will need to be able to be

independent for some of the class.

The instructor will gain enough information on the client’s physical

ability to be able to guide them to the appropriate class level if there

are options.

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2) Pre Course Consultation Procedures

You will want to obtain all of the following information in your one hour

consultation to provide a comprehensive summary of the client’s medical

history, current ability, and problem areas that require attention. Some of

these will include: Appendix E: Sample of Questionnaire, Posture Assessment

(see pages 75 to 76), Gait Assessment (see pages 69 to 71) and the Knee and

Hip Assessment Checklists, pages 20 and 47 respectively.

a) Screening and Medical Clearance: When is medical clearance required

or mandatory?

Be aware of the specific medical clearance regulations provided by the

professional organization that certifies you, such as BCRPA, ACE,

ACSM. Most organizations require that you obtain medical clearance

from the client’s doctor if they have any serious medical condition

including, but not limited to the following and/or fit any of the other

criteria:

Heart concerns (heart attack, stroke, arrhythmia, pacemaker, valve

repair etc.)

Blood Pressure (high blood pressure or even abnormally low blood

pressure)

High Cholesterol

Diabetes

Cancer

Osteoporosis

Sedentary, overweight, or a beginner exerciser

Male over the age of 45, female over the age of 50

If there is doubt as to whether medical clearance is needed, it is always

safer to take the time to obtain medical clearance. It also encourages

the individual to take part in their health goals and visit their doctor

who will be able to ensure it is safe for the client to begin an exercise

program. Give the client a brochure on the class and what it entails to

give to their doctor so that he/she is clear on what their patient is

participating in.

b) Screening and Medical Clearance: Medical Approval Form

Provide the client with a form they can take to their doctor that includes

asking for their current resting heart rate, blood pressure, medications,

and any other areas of concern. The form will include a place for their

doctor to sign and approve their patient’s participation in exercise. See

Appendix F for a sample Medical Release Form

18


19



c) Screening and Medical Clearance: Health Screening/Questionnaire

General Information:

Date of Consultation (important for follow up)

Name

Birthday

Physician Information

Physiotherapist Contact Information

Emergency Contact

Heath Information:

Par-Q (Dr’s approval form if required)

Medications

Formal overall health check list

Joint affected (scheduled date of surgery manipulation, operation)

Leg length discrepancy (assessed by physiotherapist as it is in their scope of practice)

Knee ROM (flexion / extension degree of range)

Details of surgery: total or partial replacement and restrictions from

surgeon/physio

Current treatment (ice, pillow, physio exercises etc)

Use of cane, crutch, walker (weight bearing status or restrictions)

Walking ability (how far, how long, discomfort level)

Balance ability, perceived limits and difficulty with balance (recent

falls/stumbles)

Activities of daily living, hobbies, occupation(return to work goals), lifestyle

Nutrition (rate on a scale of 0-10, 3 areas for improvement)

Alcohol consumption

Smoker (can slow down healing, increased risk of osteoporosis)

Caffeine Intake (increased risk of osteoporosis)

d) Functional Abilities: Activities of Daily Living (ADL)

It is important to ask the client specific questions as to how they feel

they are doing and where they are still having difficulty in their daily

routine in terms of physical capabilities. It is amazing how important

the details they provide will be to the exercise programming. The

feedback they provide will help in designing the appropriate exercises

to help improve their functional abilities and their overall quality of

life. For example, if a client says he/she is still having difficulty

climbing stairs, an exercise program geared towards ensuring

adequate knee flexion, isotonic Quadricep strength in mid range, and

weight transfer and balance will be important.

20



Some of the sample questions to ask the client in order to obtain

specific details on his/her current limitations are as follows:

1. Where are you finding you have difficulty in your daily routine?

2. How much difficulty do you have getting off a chair, on and off the

toilet, and going up and down stairs?

3. Is it challenging dressing yourself: putting your pants, socks, or

shoes on?

4. What are the physical demands of your job/hobby and where do you

feel you need to improve to be better able to do those tasks?

e) Goals

The goal section is important because it allows the client to participate

in their recovery process and it gives both the instructor and

participant a target. Some people require assistance here because they

are completely unfamiliar with physical goals such as increasing

flexibility, increasing cardiovascular function etc. Lead these people

with specific questions and help them phrase their goal. It may also be

helpful to reconfirm what they have stated as their goal. They may

state their goals in terms of their concerns or difficulties and this is

where summarizing what they have said can help identify their goals.

The following is an example to help guide the client to a specific goal:

“I have heard you say you feel out of breath going up a small hill and

that bothers you, so maybe one of the goals that you would like to

achieve is to increase your cardiovascular capacity?”

21



KNEE ASSESSMENT CHECK

1. Knee Range of Motion Degree of Flexion R _____ L _____

(measure seated, supine) Degree of Extension R _____ L _____

2. Assessment of Visual and Tactile quad strength difference (girth)

Visual R ____________________ L ____________________

Palpation R ____________________ L ____________________

3. Knee Function / Strength

Exercise Observation

1. Sit to Stand

2. 1 Leg Shuttle / Leg Press

3. Step Up Platform / 1 Riser

5. VMO Firing Supine Foam Knee Extension

6. Adductors Small Ball Squeeze

7. Gluteus Medius Clam Shell

4. Incision: well healed, not red __ healed, still red __ very red/tender __ red, not

healed __

5. Level of Current Pain (0-10 scale): At rest __________ Walking

__________

7. Gait (use Gait checklist)

_______________________________________________________________________

_______________________________________________________________________

8. Postural Observations (use checklist/diagram)

________________________________________________________________________

________________________________________________________________________

9. Balance Ability (Rocker Board, during gait, natural observation, perceived

ability)

________________________________________________________________________

________________________________________________________________________

10. Other / Comments

________________________________________________________________________

________________________________________________________________________

22


SECTION 5: PROGRAM DESIGN FOR PRE & POST- OP KNEE REPLACEMENTS

STEPS TO SELECTING EXERCISE PROGRAMMING FOR THE PRE-OP KNEE

1) Assess knee flexibility and extension to help guide exercise selection.

2) Assess functional ability with exercises like the sit to stand and step ups.

3) Assess visual and tactile atrophy of muscles comparing both legs.

4) Choose uni limb exercises to balance the strength of opposing limbs.

5) Think about and program exercises for the support muscles such as the

vastus medialis obliques, gluteus medius and minimus, and adductors.

6) A huge part of the pre-op exercise prescription is to maintain range of

motion and to oil the joint with range of motion exercises. Stationary

cycling is excellent to keep range of motion, oil the joint, improve

cardiovascular function, and provide some short term pain relief.

An individual may come to you in severe pain at an extremely advanced

phase of joint deterioration who might only be able to do the bike and non

weight bearing exercises or who may be best suited to a pool program.

5.1 KEY COMPONENTS FOR EXERCISE DESIGN IN THE PRE AND POST-OP KNEE

The key elements of an individual’s health and ability that must be assessed

in order to create a successful program for either knee or hip replacements

are outlined below. The flexibility and strength goals for knee and hip

replacements differ. Therefore, they will be discussed separately. The

remaining four components (cardiovascular, gait, balance, posture) have

similar training principles for both knee and hip replacements and therefore

exercise recommendations for these will be presented simultaneously.

1) Flexibility

2) Strength

3) Cardiovascular

4) Gait

5) Balance

6) Posture

Flexibility

Did you know that maintaining flexibility pre surgery can help individuals

obtain better flexibility and function post surgery? ROM continues to be a

priority post surgery as well especially for knee replacement participants

because flexion allows for ease of movement on stairs and getting in and out

of chairs or off the toilet seat. In addition, flexibility in extension is also

important for normal gait mechanics.

23



Flexibility at the knee and hip joint greatly affects gait, posture, and overall

function in daily activities. Changes or compensations that occur in gait due

to decreased ROM can cause back pain and limit an individual’s endurance

while walking. Having the appropriate flexibility in a joint allows for normal

function of daily activities. Imagine a knee that cannot bend past 45 degrees

and then try to imagine what it is like trying to go up or down stairs.

Practice walking with your knee in a permanent semi flexed position. How

does a knee that cannot extend fully impact your gait?

Having full range of motion through a joint allows for strength to be built

through the entire range which provides for full functional ability. An

example of this can be demonstrated when a client sits down on a chair

without using their hands or cane. Most likely the last third or quarter of

his/her sit down phase will end with a flop to the seat uncontrollably. When

the joint is able to be worked at that end range of their flexibility, the client

will be able to build strength through his/her full range of motion.

Pre-Op Knee Flexibility Goals

The main focus of your flexibility programming for the pre-op knee client

is the following:

1) Knee Flexion ( Quadricep stretching, especially rectus femoris )

2) Knee Extension ( Hamstring stretching)

3) Gastrocnemius and Soleus stretching (especially gastrocnemius)

4) Illiotibial Band (usually will be tight)

Post-Op Knee Flexibility Goals

You will see one of three problems in a post-op knee replacement. Either

the client will have difficulty with knee flexion or the knee will not extend

or straighten or a combination of both. The post-operative client will come

to you having come from the physiotherapists at the hospital with an

exact degree of range of motion they have in flexion and possibly in a

negative degree for knee extension. Less than full knee extension is called

a flexion deformity (FD).

Average flexion in a healthy knee joint 140 degrees

Optimal post surgery knee flexion 90-120 degrees

Knee flexion required to walk on level surfaces 65-70 degrees

Knee flexion required to climb stairs normally 83 degrees

Optimal extension in a healthy knee joint 0 degrees

Knee Extension post-op (usually 0-5 degrees) 0-15 degrees

24



Measuring Range of Motion

A Goniometer measures range of motion around a joint. The client will

most likely come to you with a degree of flexion or extension number that

was given to them by his/her physiotherapist. It is helpful to know what

range of motion they currently have so that their exercise program can be

tailored to their functional ability and areas they need to improve upon.

Unless you have had specific training in the use of a goniometer, it is not

in the personal trainer’s scope of practice to assess joints with a

goniometer. Also, there can be significant interrater variance even among

trained therapists.

Sometimes knee replacement participants will be extremely focused on

the range of motion they have in their knee to an unhealthy extent. Try

to minimize the focus on an exact degree of flexion/extension and instead

focus their attention on the function they need or require for activities of

daily living and for their recreational pursuits.

Also, there is a concern as to whether it is realistic for the client to be able

to maintain or achieve the same range of motion in their knee that the

surgeon and physiotherapist at the hospital have recorded. The surgeon

measures the range of motion when the patient is under a local anesthetic

and the physiotherapist measures the range after they have treated and

worked on the joint; therefore, these measurements may be unattainable

by the client on their own or outside of the therapeutic environment.

25



5.2 PRE-OP KNEE EXERCISE GUIDELINES

Goals of Program Design:

Non Weight

Bearing

are the best choice unless no pain is felt during or after exercise

with weight bearing exercises

Strength

Quadricep strengthening exercises are crucial

(strengthen in pain free range)

Gluteus Medius and Adductor group strengthening

Hamstrings, Gastrocnemius, and Soleus are usually tight,

but should be assessed for strength

Flexibility

Find Flexibility limitations and stretch tight muscles

(Quadricep, Hip Flexor, Hamstring, Calves, IT Band)

Know limitations in flexibility and extension of the knee

and prescribe exercises to optimize and maintain range

Cardiovascular

Maintain aerobic capacity – the upright or recumbent bikes

are the best choices; they are non weight bearing and allow

for the best range of motion for the joint (the treadmill can be

used for short periods or longer as long as pain is minimal)

Inflammation

The level of pain

will influence goals

Know whether they are experiencing inflammation and

proceed with the appropriate steps of rest, medical

supervision/medication, & physiotherapy

Core To prevent back pain or pelvic instability from gait changes

Gait Educate client on gait mechanics to reduce load on the knee

The 6 Components of the Exercise Program for the Pre-Op Knee:

1. Cardiovascular

2. Strength

3. Flexibility

4. Balance

5. Gait

6. Core

1. Cardiovascular:

Recumbent Bike or

Upright Bike

are the best option as long as the client can perform a full

revolution pain free and without compensatory hip engagement

Treadmill can be used if there is no pain upon weight bearing and gait

technique should be emphasized (monitor post workout pain)

Elliptical (no

research yet

supporting)

should only be used if there is no pain; the client should be

stronger before using the Elliptical; it is typically best to introduce

this after strength and aerobic capacity have increased

Active, Passive

Trainer (APT)

If the knees are too uncomfortable on all the other equipment,

then the APT can be used to obtain some aerobic conditioning

26



2. Strength Exercises:

Quadricep Leg Press or Shuttle Unilateral (Single leg) & Bilateral

Circle Foam Knee Extension supine (small ball option set

between legs and above knee joint)

Prone Knee extension lifting knee off bench while tightening

quadriceps muscle and holding 5 sec (make sure no pain in lying)

Bridge lift Supine (option with small ball or band )

Standing band knee extension – tie band around pole and leg in

split stance; back leg begins on toes and then tighten quad and

extend knee holding contraction for 5 seconds

Sit to Stand facing mirror with foam blocks (option with small

ball between knees or band around thighs) or Wall Slides

Advanced - Seated small ball squeeze with single leg hip

flexion, knee extension contracting quad and holding 5 seconds

Adductor Seated on a chair or ball squeezing small ball and hold 5 seconds

Gluteus Medius Clam Shell (progression with band)

Gluteus Maximus Seated on Ball gluteal squeezes and hold 5 seconds

Prone ankle bent ball squeeze with gluteal squeeze & hold

Hamstring Unilateral Leg Curl Seated full pain free range using machine,

or in a chair with a band or cable

Advanced: Step Ups and Ball Squats may be painful pre-op so monitor

individually. Squats could be implemented in pain free range as ¼ to ½

squat.

3. Flexibility: (30-60 second hold; 1-3 reps; light to mod intensity; breathe)

Muscle Seated Lying

Quadricep

Chair seated sideways with 1

leg drop off and gently

pulling ankle up toward seat

Prone or side lying heel to bum

quad stretch assisted with towel,

band or hand

Hip Flexor

Seated sideways on chair on

foam blocks with knee bent

at 90 degree angle and place

knee under hip or slightly

behind

Lying on bench/bed with

supporting knee tucked to chest

and drop other leg off bench

supported by foam blocks under

foot

Calf Split Stance straight knee

and bent knee / incline board

Hamstring Seated at edge of chair 1 leg

straight and lean forward

Wall / towel / Band straight leg

stretch

IT Band Lying Supine leg crossover with

lateral shift

Gluteal Maximus Leg cross and lean forward Lying leg cross and pull to chest

Adductors Seated on floor back on wall Supine knee fall out feet together

27



4. Balance: (avoid any of the balance exercises that cause pain)

* It is important to have a fixed bar or railing next to the client along with

close supervision when performing these balance exercises.*

1) Rocker Board – both directions soft knees, wide to narrow stance,

weight transfer side to side and forward and back

2) Sit Fit Cushion

3) ½ foam roller

4) 1 leg balance on floor (this exercise will most likely be too painful pre-

op and should only be performed if there is no pain and if the client has

good pelvic stability and glutei activation)

5. Gait:

Re-educate and train on the basic fundamentals of proper gait mechanics

6. Core:

Teach clients how to engage their core and give them exercises to practice

training the core

28



5.3 POST-0P KNEE EXERCISE GUIDELINES


Strength

Regain strength in Quadricep and VMO, Gluteus Medius &

Maximus, Hamstring, Calf, & Adductors of both legs (Hip

flexor should also be assessed for strength)

Flexibility

Assess whether knee flexion and extension is limited and

select exercises to meet goals of ROM

Educate and focus on stretching to increase ROM

and function

Cardiovascular Gradually increase cardiovascular endurance

Gait Educate and emphasize proper gait mechanics

Balance Balance training to bring back the client’s proprioception and

confidence of their new joint

Inflammation Monitor inflammation and pain

The 6 Components of Exercise Prescription for the Post-Op Knee:

1. Cardiovascular

2. Strength

3. Flexibility

4. Balance

5. Gait

6. Core

1. Cardiovascular:

Recumbent Is the best option to increase range of motion; the seat distance

can be adjusted dependent on the client’s ease of knee flexion

Upright bike Use as a second option over the recumbent bike when knee ROM

is limited or when it feels better for the client

Treadmill Is great to help focus on gait; gradual increase in time then speed

focusing on technique first and monitoring pain and inflammation

Elliptical

Is excellent to increase aerobic capacity, but the bike and

treadmill should be first choices when selecting cardio equipment

The client needs strength and aerobic endurance to begin and

therefore it is best to introduce later in to their program

Rower

Is too low for most client’s post-op and technique needs to be

strong in order to obtain a good cardio work out, but it could be

added in at a later time for those with good knee ROM and for

those who can perform good technique

29




Quad Unilateral Leg Press or Shuttle and Bilateral

Sit to Stand with foam blocks facing mirror (small ball between

knees or band around thighs option)

Supine lying or seated circle foam knee extension and hold 5

seconds with option of small ball squeeze

Prone Knee extension; quad contraction and hold

Seated on chair or ball, small ball squeeze with single leg hip

flexion and knee extension and hold (advanced on ball; must

have strong core)

Step Ups – start with platform and progress to 1 riser and then to

2 risers as strength permits

*be mindful of the

quad to hamstring

strength ratio

Step up and over and down – platform first near something to

hold – will train the quad in the eccentric phase and give the

client strength and confidence going down stairs

Ball Squat (start with ¼ squat) This is advanced and is for the

client who is stronger and who has good balance and no swelling)

Hamstring Unilateral leg curl machine or chair/band/ cable leg curl with

focus on full ROM before strength

Ball Bridge Supine feet up on ball with advanced option of curl

in and extremely advanced option to 1 leg curl in

Gluteus Medius Clam Shell (Side lying and option to advance with band)

Side Leg Raise as long as glute med fires (best to start with clam)

Adductors Ball squeeze and hold seated on chair or ball

Gluteus Maximus Squeeze and hold seated on chair or ball in front of mirror or

prone ankle squeezes or supine bridge

Calf Raises only if weak or atrophied or needed to help with retraining of toe

off phase in gait / may be contraindicated if tight

Hip Flexor Is usually tight, however asses just in case strengthening is

needed

Tibialis Anterior Plays an important role for gait, balance, and fall prevention

* A special note about drop squats: Drop squats are an excellent exercise to

help the quadriceps work efficiently and automatically and can be chosen as

an exercise selection for individuals who are fit. Generally they have not

been a good exercise for knee replacement clients due to joint instability.

* A special note about lunges: Lunges are a great way to strengthen quads

and have been helpful for participants needing to regain strength to get up

and down off of the floor; however, this should be used as an advanced

exercise and not prescribed until many months post-op. It has often caused

pain for participants post exercise and then they generally stop doing them.

30



3. Flexibility: (Reminder that muscles can be tight and also weak)

Quadricep

(knee flexion)

Seated sideways on chair, foam

blocks support knee and pull ankle

to seat

Prone or side lying heel to bum

quad stretch assisted with towel,

band or hand

Seated on Ball with small ball

between the knees, have the client

gently roll forward into knee

flexion keeping heels on the floor

(the client may need to start with

feet 1-2 feet from ball)

Hip Flexor Seated sideways on chair with

knee bent at 90 degree angle

aligned under hip or slightly

behind, may use foam blocks

under knee, extend upper body,

tighten glutes

Lying on bench/bed with

supporting leg bent or knee

tucked to chest, then drop other

leg off bench and have foam

blocks under foot to support leg

Calf Split stance behind chair both

straight leg and bent knee or

option to do seated with band

under toes and pulling up

Hamstring Seated with 1 leg extended and 1

leg bent, lean forward with back

tall

Wall / towel / Band straight leg

stretch

IT Band

Lying Supine – Right leg crosses

over left and then shift both legs

to the left, opposite action when

stretching left leg

Glutes

Seated leg cross placing ankle of

1 leg over knee of other leg and

lean forward slightly

Lying Supine knees bent and

cross ankle over opposite knee

and then pull crossed leg to chest

Adductors

Seated on floor on foam block

with back supported by wall

Supine bent knee fall out with

soles of feet together

31



4. Balance:

1) Rocker Board – both directions soft knees

2) Backward Walking – floor

3) Sit Fit Cushion

4) 1 Leg Balance on floor (this exercise should only be performed if there

is no pain and if the client has good pelvic stability through core and

glutei activation)

5. Gait:

1) It is extremely important to emphasize and educate the client on

proper gait mechanics. As personal trainers, we cannot diagnose a

client’s gait pattern, but we can use the checklist as a guide to give to

the client to take to a physiotherapist. Refer to the Gait section for

more details.

2) Nordic Poles may be great to help clients improve their gait.

6. Core:

1) With changes in gait and posture due to pain and compensation, core

training will help center and balance the client. Helping them engage

their core and obtain pelvic stability may possibly prevent secondary

pain from occurring in other areas like the back.

32



5.4 SAMPLE EXERCISES FOR THE PRE-OPERATIVE KNEE

A. Muscle: Quadricep

Action: Extension of the knee joint

1) Sit to Stand (foam block

optional)

2) 1 and 2 Leg press and/or Shuttle

3) Supine knee extension over foam (refer to pg 36 for picture)

4) Hip Flexion with knee extension sitting on chair or ball, holding

knee extended for 3 to 5 seconds if possible and with the option of a

small ball between knees to help fire the VMO

33




Action: Extension of the knee joint continued

5) Standing knee extension / straightener with band and quad

contraction or option to do prone knee extensions with quad

contraction and hold 5 seconds

6) Bridge from the floor or a bench -

options of using a band around the

thighs to fire the glut meds or a

small ball between the knees to fire

the VMO and adductor muscles

7) Step Ups and/or Step Downs

(these may be painful pre-op and so should only be done if no pain is

felt)

8) Ball Squats are usually painful

pre-op, but they can be implemented

if there is no pain felt and if good

form is demonstrated

(option with small ball between

knees or a theraband around the

thighs depending on adductor or

gluteus medius weakness)

9) Knee Extension Machine (controversial)

This is an open chain exercise and so is not functional. There is a lot of

controversy over its usefulness and related functional ability to real

life movement patterns. It also increases shearing forces on the knee

and can strain the PCL.

34



B. Muscle: Hamstring

Action: Knee flexion

1) Single Leg Curl seated in chair with band working through full

range of motion

2) Single leg curl seated in chair with cable/pulley

3) Seated leg curl machine, single leg

(the emphasis should be on single leg

curl to make sure the two legs

maintain equal strength; option to do

double leg curl)

This is an open chain exercise and it

can place an increase on the

anterior/posterior shear forces

through the knee. Therefore, closed

chain knee flexion is preferable.

4) Bridge with legs up on ball

with or without knee flexion

5) Isometric hamstring exercise-prone hip extension from mat/bench

or over ball

Supporting Synergistic Muscles:

C. Muscle: Gluteus Medius

Action: Abduction

1) Clam Shell

Keep pelvis aligned

Set lower abdominals

35



Supporting Synergistic Muscles continued…

C. Muscle: Gluteus Medius

Action: Abduction continued

2) Side Leg Raise

D. Muscle: Adductors (these muscles are important to strengthen to help

balance out the pull on the knee from the strong lateral knee muscles)

1) Ball squeeze and hold

2) Flex ring squeeze and hold

3) Side lying adduction straight leg lift

E. Muscle: Gastrocnemius and Soleus (these muscles are usually tight, but do

need to be assessed in case they require strengthening)

1) Standing calf raises from floor or raised platform or calf bar with

the option for 1 and 2 leg (option of ball against the wall)

2) Single leg calf raise on leg press or shuttle machine

F. Muscle: Tibialis Anterior

1) Standing Dorsi Flexion Toe Pull Ups

2) Lying straight leg band wrapped around foot dorsi flexion

36



5.5 POST-OP PHYSIOTHERAPY HOSPITAL/HOME EXERCISE PROGRAM FOR

TOTAL KNEE REPLACEMENT

It is really beneficial to know what types of exercises the client has been

given at the hospital, how long they have been doing them, and how much

they are continuing to do them once they have begun with you. It is helpful to

know which exercises they have been doing and the challenge they provide.

Also, the client will need to know which of the new exercises they are now

doing in the gym that duplicate ones they may still be doing at home. Some

clients will keep up all their home physio exercises on the alternate days to

the classes and they may find themselves getting stiff and sore from over

training. These clients will need to be informed on the importance of rest for

healing and recovery.

There will be some physiotherapy exercises that should be maintained at

home and there will be others that they will need to understand have been

replaced with their new program. The following list demonstrates the variety

of physical therapy exercises they may be doing already:

1. Heel Slides / Knee Flexion supine seated drawing heel to buttock

2. Chair Knee Flexion bending operated knee drawing heel back to chair

3. Static Quadricep contraction supine with straight leg and holding

4. Knee extension over rolled towel and hold

5. Standing Knee flexion balancing only on non-operated leg

6. Gastrocnemius / Soleus stretch

7. Prone self-assisted knee extension (patient pushes the operated leg

down to straight with the other leg for a mild to moderate stretch

8. Prone self-assisted knee flexion (patient lies on tummy and bends

operated knee and applies pressure with the other leg to assist)

9. Seated knee self-mobilization knee flexion and knee extension (non

operated leg assists operated leg)

10. Hamstring stretch

11. Quadricep stretch

12. Stationary lunge movement gently forward with operated leg

13. Step Ups forward, backward, sideways

14. Clam shell

15. Biking and walking with gradual increase in time/distance

16. Ice after exercise and daily to decrease swelling

17. Wall Slides

37



5.6 SAMPLE EXERCISES FOR POST OPERATIVE KNEE STRENGTHENING

(Intermediate to Advanced: at least 6 weeks post-op)


Action: Extension of the knee joint

1) Sit to Stand (foam block optional)

*make sure the client does not push off

with their hands; the correct form is

unlike this picture where the client will

have their arms at their side

2) 1 and 2 Leg Press and/or

Shuttle

3) Supine knee extension over foam (can

be done earlier on in post rehabilitation

as well)

38


SECTION 5: PROGRAM DESIGN FOR PRE & POST- OP

KNEE REPLACEMENTS


CONTINUED

4) Hip flexion with knee extension sitting on chair or ball holding knee

extended for 3-5 seconds if possible with the option of a small ball

between knees to help fire the VMO.

5) Standing knee extension / straightener with band and quad

contraction or option to do prone knee extensions with quad

contraction and hold 5 seconds

6) Bridge from the floor or a bench

with options of using a band around

the thighs to fire the glut meds or a

small ball between the knees to fire

the VMO and adductor muscles

7) Step Ups and/or Step Downs

(start with platform only and add

risers as client is able to step up and

down with good form maintaining a

level pelvis and without pain)

39




CONTINUED

8) Ball Squats- add a small ball here if their knees flare out or add a

band around their thighs if the knees fall into their midline for clients

who are unable to direct their knees on their own. This exercise can be

performed to a 90 degree bend and smaller ranges of motion gradually

building up to 90 degrees.

9) Knee Extension Machine (controversial): This is an open chain

exercise and so is not very functional. On occasion, it may serve a

purpose for a specific client or be the only exercise that helps fire the

quadricep; however there is a lot of controversy over its usefulness and

related functional ability to real life movement patterns. It increases

shearing forces across the knee.

Advanced Exercise Options for Quadricep

1) Stationary Lunge (only if no pain is felt, rarely given) This

exercise is usually only given to participants wanting the

confidence and ability to get down to the floor and know they

can get back up.

2) 1 Leg Dip squat off riser (can be used at an intermediate level)

3) Rocker Board Squats

40




CONTINUED

B. Muscle: Hamstring

Action: Knee flexion

1) Single leg curl seated in chair with band working through full range

2) Single leg curl seated with cable/pulley

3) Seated leg curl machine with single leg curl and double (the

emphasis should be on single leg curl to make sure the two legs

maintain equal strength with option to do double leg curl) Closed chain

knee flexion exercises are preferred over the leg curl machine due to

shearing forces produced in the knee

4) Bridge with legs up on ball with or without knee flexion

5) Isometric hamstring exercise - prone hip extension from mat/bench

or with the option over ball

Advanced Exercise Options for Hamstring

1) 1 Leg Bridge on ball with option of curl in

2) Cables Hip Extension on Riser / or advanced option to do on ½

foam

3) Dynamic Exercises such as lunges, squats

Note: See Section 10 for Specific and Appropriate Exercise Progressions for

Joint Rehabilitation Clients and more Post-operative Knee Replacement

exercises; see Section 11 for Contraindications and Precautions

41


SECTION 6: HIP REPLACEMENT

6.1 ANATOMY OF THE HIP JOINT

ANATOMY OF THE HIP JOINT

Muscle Origin Insertion Action

Gluteus Maximus Posterior Ilium Greater

Trochanter

Extends the Hip

Gluteus Medius Iliac Crest Greater

Trochanter

Abduction Hip

Gluteus Minimus Iliac Crest Greater

Trochanter

External Rotation

Abduction

Semimembranosus Ischial

Tuberosity

Tibia Extends Hip Joint

Semitendonosus Ischial

Tuberosity

Tibia Extends Hip Joint

Biceps Femoris Ischial

Tuberosity

Fibular Head Extends Hip Joint

Tensor Fascia

Latae

Iliac Crest

Femur

Flexes Hip Joint,

extends knee,

abducts hip

Illiotibial Band Ilium Fibula Stabilizes knee

Iliopsoas Transverse

Processes

Lesser

Trochanter

Flexes Hip Joint

Sartorius ASIS Medial Tibial

Tubercle

Lateral Hip

Rotation

Rectus Femoris Iliac Spine Tibial

Tuberosity

Flexion Hip Joint

Vastus Lateralis Linea Aspera

Posterior Femur

Tibial

Tuberosity

Knee Extension

Vastus

Intermedius

Anterior

Femoral Shaft

Tibial

Tuberosity

Knee Extension

Vastus Medialis Linea Aspera

Femur

Tibial

Tuberosity

Knee Extension

Adductor Brevis Iliopectineal

Eminence

Femur Adduction

Adductor Longus Iliopectineal

Eminence

Femur Adduction

Adductor Magnus Iliopectineal

Eminence

Femur Adduction

Gracillis Pubic Tubercle Tibia Hip Flexion

Pectineus Superior Ramus Femur Adduction/Flexion

42



6.1 ANATOMY OF THE HIP JOINT CONTINUED

43



6.2 TOTAL HIP REPLACEMENT AND HIP RESURFACING SURGERY

There are two surgical procedures to replace the hip. One is a total hip

replacement and the other is called hip resurfacing; the latter is still quite a

new procedure. In a total hip replacement, the acetabulum is replaced with a

plastic and metal socket implant that is placed directly into the pelvic bone.

The femoral head component of the prosthetic is a metal ball that is attached

to a metal rod that extends down into the center of the femur bone.

Conversely, hip resurfacing only affects the surfaces of the head of the femur

and the acetabulum. The resurfacing procedure involves cleaning of

damaged cartilage, tissue, and bone just at the end of the femur and the

edges of the acetabulum which are then resurfaced with the metal alloy

prosthesis.

Surgical Procedure Summary

The surgical procedure for a total hip replacement and hip resurfacing

actually involves dislocating the hip joint. The incision is usually 10 to

12 inches long although progressions have been made and some

patients may be candidates for the minimally invasive incision of 3 to 5

inches.

There are a few surgical incision approaches which include the

anterior approach or the lateral approach which includes anterolateral,

direct lateral, and posterolateral in relation to the gluteus muscles.

The lateral approach is the most commonly used by surgeons. The

glutei are at least partially detached in the anterolateral and direct

lateral incisions and therefore may produce prolonged abductor

weakness post surgery, but have minimal tendency to dislocate.

Although the posterolateral approach produces minimal impact to the

glutei muscles, it may produce a higher risk for dislocation post-op.

The anterior approach is an incision placed between the Sartorius and

the Tensor Fascia Lata muscles.

The surgeon dislocates the hip either by internally or externally

rotating the hip and then the femoral head is removed by cutting

through the femoral neck with a power saw. The socket is cleaned out

by using a power drill and special tool called a reamer that removes

damaged cartilage. The acetabular prosthetic is held in place by

having a good, solid fit or by applying screws to hold it in place. Then,

the femoral shaft implant is inserted into the femur once the femur has

been hollowed by special rasps (filling tools) to the shape of the stem.

The surgery usually lasts 2-3 hours followed by a 2-5 day hospital stay.

44



6.2 TOTAL HIP REPLACEMENT AND HIP RESURFACING SURGERY CONTINUED

45



6.3 TYPES OF HIP REPLACEMENTS

Total Hip Replacement (THR)

A total hip replacement refers to hip surgery that replaces both the

ball (femoral head), and socket (acetabulum) joints with prosthetic

components including a femoral shaft. One portion of the prosthesis is

the acetabular component (or the socket) which is made up of a metal

shell with a plastic inner liner that provides for the bearing surface.

The other portion is the femoral component (or the stem and ball) and

it is usually metal. There are numerous materials used for hip

implants including metal, plastic, and ceramic. Any combination of

these materials can be used for all parts of the prosthetic and the

surgeon will decide what to use based on their own preference and also

on their patient’s medical history.

Hip Resurfacing – This is a relatively new procedure being used on

mainly young, active patients who have good bone health. It involves

resurfacing the end of the femur with a metal shell to replace the

damaged bone without having to remove or replace the femoral head.

The acetabulum or socket joint is replaced as it would be in the

traditional hip replacement with a metal cup that has a porous inner

lining and it is cementless. Both prosthetic implants are made of cobalt

and chrome alloys.

The great result from this surgery is that there will be no leg length

discrepancy which can occur in a THR. Also, patients who receive this

treatment are gaining great results where they have terrific range of

motion and can return to their sports with ease. There are fewer

restrictions and contraindications for the hip resurfacing patient as

compared to the THR patient. Hip resurfacing is thought to restore

normal anatomy quicker than THR, have increased proprioception,

lower incidence of dislocation, and provides the option for THA if

needed, but no long term data is available.

The only risk with this type of surgery is risk of fracture of the femoral

neck, but so far very few cases have been reported. They will only

perform this surgery on individuals who have good bone health and so

risk of fracture of the femoral neck should be limited.

46



Minimally Invasive Hip Replacement

The minimally invasive or mini-incision hip surgery (MIH) uses a less

invasive surgical procedure by reducing the incision to 2-4 inches

rather than the traditional 12 inch incision. This type of surgery

causes less damage to the surrounding tissue which ultimately speeds

up the recovery process and may cause less bleeding, less post

operative pain, and less scar tissue. This procedure may include one

incision usually about 3 to 4 inches in length (referred to as the mini incision approach) or two 2 inch incisions (the two incision approach).

The mini incision to the hip joint may be made anterior, posterior, or

lateral to the joint and is usually dependent on the surgeon’s

experience and the patient’s physical condition and lifestyle. The two

incision approach is usually performed with an anterior and a posterior

incision. One of the incisions is made to insert the acetabular implant

and the other incision is performed to insert the femoral implant.

There is no long term data supporting the survivorship of these

implants or if they produce greater function or require less

rehabilitation.

This procedure may or may not involve having to cut muscles. If

muscles are cut, the muscles affected are dependent on where the

incision is made and could be the gluteus medius, gluteus maximus, or

the hip flexors. This specific surgery spares the tensor fascia latae

which will provide greater hip stability post surgery and possibly less

pain around the greater trochanter. The same implants that are used

in the minimally invasive technique are used in the traditional total

hip replacement surgery. There may be some limitations to the

implants the surgeon chooses due to the restrictions made by the

smaller incision.

The surgeon will decide the right candidate for this type of surgery and

his/her decision may depend on multiple factors including how

advanced the arthritic condition of the joint is and the patient’s bone

type, body size, and body shape. Also, a good candidate must have

healthy bone quality, normal hip anatomy, weigh less than 200

pounds, and not have had previous surgery. Often these two mini

incision techniques are reserved for the younger, more active patients

who need to return to work quickly. The other limiting factor for older

patients with the mini incision approach is that it may require a

cementless implant which may not be safe and/or compatible with the

bone density of the older patient.

47



6.4 HIP IMPLANTS: the following chart outlines the combination of

materials used in hip replacements and may be helpful just to know what is available

Type of

Implant

Properties of Implant Benefits(+)/Drawbacks(-)

Metal and Plastic Implant

-both the ball and socket are

replaced with metal and a

plastic spacer is placed in

between the two implants

-the metals may be titanium,

stainless steel, and cobalt

chrome

-the implants here can be

secured to the bone by ‘press

fit’ or cement

-wear at a rate of 0.1

millimeters each year

-do not wear as well as the

metal on metal

Metal on Metal Implant

-there is no plastic piece

inserted between the two

implants

+ they do not wear out as

quickly as the metal and plastic

implants

- concerns about the wear debris

caused by the metal on metal

implant

- metal ions released into the

blood stream and the body can

detect these

-the concentration of these ions

increases over time

-no data to show risk of cancer

or other diseases

Ceramic on Ceramic Implant

- both the acetabular and the

femoral component of the

prosthesis are made of ceramic

+ most resistant to wear of all

the implants

+ more scratch resistant and

smoother

- no long term data available on

longevity

- concern these ceramic

materials can break inside the

body

Metal and Highly Crosslinked Polyethylene *most

common*

-newer plastic designed to be

more resistant to wear

- made of highly cross linked

polyethylene

- only available in the last few

years; therefore there is no long

term evidence to prove they last

longer

48


SECTION 7: HIP ASSESSMENT & CONSULTATION PROCEDURE

HIP ASSESSMENT CHECK LIST

1. Hip Flexibility Assess Hip Flexor Tightness _______________________

Hip Extension Flexibility _______________________

2. Leg Length Discrepancy Yes _______ No _______ Amount ______________

3. Strength / Function Assessment

Exercise Observation

1. Clam Shell (Abductors)

2. Hip Extension Prone

3. Sit to Stand

4. Step Up Platform / 1 Riser

5. Adductors

6. Core

4. Shoe tying ability/socks/pants ___________________________________________

Getting in and out of car/chair ___________________________________________

5. Swelling Yes ______ No ______ Amount/Area _____________

6. Level of Current Pain __________________________________________________

7. Gait (Use Gait Checklist)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

8. Postural Observations

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

9. Balance Ability

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

10. Other / Comments

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

49


SECTION 8: PROGRAM DESIGN PRE & POST OP THR OR RESURFACING

8.1 PRE AND POST OPERATIVE HIP STRENGTH EXERCISES

If the surgery will be done using a lateral incision, the most important

muscles to maintain or strengthen prior to surgery are the gluteus medius

and minimus. The lateral incision hip replacement is usually the most

common incision clients will receive. It is also important to make the gluteus

maximus stronger to support the joint and help with hip extension, which can

become limited prior to surgery. If a posterior incision approach is used the

gluteus maximus muscle would become the priority; however, the gluteus

medius would continue to be extremely important due to its stabilizing role.

Muscle Exercise

Gluteus

Medius

1) Clam Shell with or without band (foam between legs may be

needed)

*If there is no ROM or pain is present, then try clam shell supine.

2) Side leg raise (option of ankle weight)

Gluteus

Maximus

1) Glut squeezes on ball and hold

2) Bridges from floor/ bench

3) Bent knee hip extension prone

4) Prone hip extension from mat / bench

5) Hip extension (cables/band as progression)

Hamstring

Group

1) Bridge with ball (option of curl in if ability permits)

2) Leg curl machine single and double leg

3) Chair band or cable leg curl

4) Prone hip extensions (option to be done standing with band or

cable if no pain and if good core stability is present)

5) Bent knee hip extension prone

Quadricep

Group

1) Leg Press or Shuttle single leg press

2) Sit to Stand

3) Ball Squat (if no pain)

4) Step ups and downs (if no pain)

5) Straight leg lifts supine or seated

6) Knee extension over circle foam or on chair/ball with hold 5 sec

(option to do with small ball between knees)

Hip Flexor Leg lift and hold on chair or ball (usually tight, assess first)

Adductors

1) Small ball squeeze and hold on ball

2) Flex ring squeeze and hold

3) Side lying adduction straight leg lift

4) Adduction machine (must be careful with setting distance from

midline)

50



8.2 POST-OP HOSPITAL/HOME EXERCISE PROGRAM FOR THR

It is really beneficial to know what types of exercises the client has been

given at the hospital, how long they have been doing them, and how much

they are actually keeping up with at home. Usually the local hospital

physiotherapy department will have handouts of the post-operative exercises

for knee and hip replacements that the patients can take home with them

and follow. It is helpful to know which exercises they have been doing and the

challenge they provide to each client. It is important to educate the client on

which of the new exercises they are now doing in the gym duplicate ones they

may still be doing at home.

Some clients will keep up all their home physio exercises on the alternate

days to the classes and they may find themselves getting stiff and sore from

over training. These clients will need to be informed and educated on the

importance of rest for recovery and healing. The following exercises outline

the variety of post-operative exercises patients are given at the hospital:

1. Ankle Dorsi Flexion, Plantar Flexion, and Circumduction (lying

supine)

2. Static Quadricep Contraction (supine with surgical leg straight)

3. Static Gluteals (supine glut contractions and hold)

4. Static TVA and pelvic floor recruitment and hold

5. Knee extension over roll lying supine

6. Hip Abduction lying supine toes and knee cap pointed to ceiling with

TVA contracted

7. Hip and Knee Flexion lying supine (set TVA, bending the knee by

sliding the heel towards the buttocks and then lifting the foot until the

thigh is vertical and hip 90 degrees

8. Hip Flexor Stretch

9. Prone Hip Extension focusing on the gluteal muscles; position the

pelvis over two pillows to neutralize the pelvis

10. Clam Shell or Side lying straight leg life with pillow between legs

11. Isometric hip adduction squeezing a pillow

12. Seated hamstring curl with band

13. Standing hip extension standing only on non-surgical leg

14. Standing hip abduction standing only on non-surgical leg

15. Step ups and lateral step ups

16. Walking with gradual increase in distance

17. Stationary Cycling, Treadmill Walking

51



8.3 POST OP ADVANCED HIP REPLACEMENT EXERCISES

Post operation exercise selections for hip replacement or hip resurfacing

should focus on strengthening of the gluteus medius and maximus. After a

client has mastered the exercises in 8.1 he or she will be able to advance to

more weight bearing options as outlined below.

Muscle Exercise

Gluteus Medius

1) Cable side leg raise on platform, foam

2) Side Step with exertube bands (intermediate)

3) 1 leg balance post 3 months

4) Side leg abduction into body ball

Gluteus Maximus

1) Standing hip extension at cables on platform or ½

foam

Note: See Section 10, pages 61 to 62: Specific and Appropriate Exercise

Progressions for Joint Rehabilitation Clients and Section 11, pages 63 to 64:

Contraindications and Precautions for more post operative hip replacement

exercises.

52



8.4 PRE OP PROGRAM DESIGN

Hip Pre-Op Assessment, Goals and Exercise Guidelines

Strength

Gluteus Medius and Maximus Strengthening

Limit atrophy and build strength in all the muscles of the pre-

op leg

Build and maintain as much strength as possible in ADL

Flexibility

Hip flexibility – stretching hip flexors and optimizing hip

extension

Hip flexibility – hamstring, adductor, and hip external rotators

stretching

Cardiovascular Maintain and build cardiovascular endurance

Core Core training and pelvic stability

Educate Educate client on the most important aspects of their training

for pre-op prep

Pain Management Minimize pain and wear and tear

Gait Gait biomechanics education

The 5 Components of Exercise Prescription for the Pre-op Hip:

1. Cardiovascular

2. Strength

3. Flexibility

4. Transverse Abdominals

5. Balance

1. Cardiovascular:

Upright Bike is the best option as it is non weight bearing and less hip flexion

than the recumbent bike

Recumbent Bike is another great option that may suit some clients depending on

their hip flexion limitations

Treadmill and

Elliptical

weight bearing may cause pain and therefore both the Elliptical and

Treadmill should be chosen only if there is no pain during use or

post work out

Treadmill

is best for gait training if the client can use it without experiencing

any pain ;it is best to focus on proper, efficient biomechanics of gait

first before increasing the speed

Elliptical (no

research to support

it is O.K..)

is a great cardiovascular workout that pushes the hip through more

range of motion both in flexion and extension by going both

forward and backward and can be used if no pain is felt

Arm Ergometer is a great option if all the other machines cause pain

53


SECTION 8: PROGRAM DESIGN PRE & POST-OP THR OR RESURFACING


Gluteus Medius Clam Shell Side lying (advance by adding band)

Clam Shell Supine with band if unable to do side lying

Side leg raise (add in as advancement from clam shell)

Advanced standing side leg raise with band / cable

Gluteus Maximus Gluteal squeezes and hold seated on chair or ball facing mirror

Bridge lift and hold Supine ( option with small ball between

knees or band around thighs)

Hip Extension prone on bench or floor (option: assess whether

they need a pillow under their pelvis)

Prone Bent knee ankle ball squeeze with glut contraction and

hold

Hip Extension over ball or from hands and knees

Advanced – Ball walk out Glut squeeze bridge lift and hold

Advanced – standing hip extension with band / cable

Quadricep Sit to Stands (with foam blocks dependent on form /height)

Advanced – Ball Squat (only do if this exercise can be performed

with equal weight distribution between both legs – no favouring)

Almost Sit – Free Squat with chair behind

Wall Sits and hold

Unilateral Leg Press / Shuttle through full pain free range

Adductors Adductor small ball squeezes and hold seated on ball / chair

Transverse

Abdominals &

Bracing

TVA setting training in 4 point stance or supine knees bent

Advanced Core – Hip flexion knee lifts seated on ball facing

mirror with neutral spine, TVA engaged, and even pelvis

The following may

be tight, but assess

for strength

Hamstrings

Hip Flexors

Calves

Step Ups an excellent, functional exercise selection, but should only be

implemented if they can be performed pain free

Stationary Lunges A functional exercise if they need to be able to get up and down

off of the floor, but should only be implemented if their hip

flexibility allows for proper technique and pain free execution

Drop Squats Are advanced and should only be done if no pain is felt and only

if good form can be executed

54



3. Flexibility:

Muscle Seated / Chair Lying Down

Hip Flexor

The hip flexor is

usually the most

important muscle to

stretch pre and post-op

Sit sideways on a chair with

the pre-op hip leg off the

chair and positioned with the

knee under the hip supported

by foam blocks

Lying supine leg drop off the

side or end of bench holding

opposite knee tucked to chest

and supporting the stretched leg

with foam blocks under the foot

Quadricep Sit sideways on chair with 1

leg off the side of the chair

knee aligned under the hip;

Foam blocks can be

positioned under the knee

and gently pull the ankle

Side lying or prone heel to bum

stretch / knee in line with hip

Hamstring

(the hamstring is

extremely important to

stretch & keep

flexible)

Sit forward on the edge of

the chair with 1 leg extended

straight and one bent, point

toes gently up and lean

forward with a straight back

Wall / Towel / Band supine

hamstring stretch

Gluts / Piriformis

(these muscles may

shorten pre-op and

stretching post-op will

be limited. Therefore,

it is very important to

stretch them pre-op)

Cross leg on chair if

flexibility permits and only

lean forward if needed to feel

a stretch

The bent knee, cross leg and

lift up toward chest in supine

The 1 leg bent knee pull to

opposite shoulder lying supine

for the Piriformis

Single leg knee tuck to chest

Adductor Seated on the floor on a foam

block with back up against

the wall

Supine lying knee fall out bent

knee and bring soles of the feet

together only if pain free

Low back (the hips

and low back may

become very stiff

pre-op)

Single knee tuck to chest

Seated Chest to thigh leg

hug

Seated on ball, Ball circles,

side to side, pelvic roll, and

alphabets

Bench seated ball forward

lean stretch with hands up

on the ball, arms stretched

and lower chest to the bench

All of the following are options

dependent on hip range of

motion and pain:

Child’s pose

Cat and Dog stretch

Bent Knee double leg drop to

side

Knee tuck to chest

Illiotibial Band

(can often become

very tight)

Lying Supine legs straight

crossing one over other and

shifting both legs laterally

Calf Straight & bent knee

55



4. Transverse Abdominals:

The Transverse abdominals (TVA) play an important role in pelvic stability

and spinal stabilization. Clients who have hip osteoarthritis experience

changes in gait, posture, and musculoskeletal tightness due to pain. These

specific changes can alter pelvic alignment and affect the normal firing of the

transverse abdominals. Educating and giving clients exercises on their

transverse abdominals is crucial to help retrain proper posture and assist

neutral pelvic alignment thereby improving their gait and overall function.

1) Neutral pelvis position can be taught on a ball or lying supine

2) Teach TVA engagement with visualization and/or tactile cuing

3) Emphasize low intensity as they are low grade endurance muscles

4) Add in limb movements when they can maintain the TVA setting

5. Balance:

1) Selecting balance exercises pre-op will usually include

standing on both feet on the rocker board, sit fit, Bosu, or ½

foam, but 1 leg balancing may be too painful

2) 1 leg balancing can be incorporated as long as the glutes can

fire properly along with the transverse holding the pelvis

level

3) Seated 1 leg lift on the ball facing mirror and maintaining a

level pelvis

56



8.5 POST OP PROGRAM DESIGN

Hip Post-Op Assessment, Exercise Contraindications & Precautions:

Hip range of motion should not exceed 90 degrees of hip flexion

No hip external rotation or internal rotation

No hip adduction crossing the midline of the body

No 1 leg balancing prior to the 3 month mark post-op and usually longer

Advise clients to avoid being seated and bending forward into trunk flexion


Strength

Rebuild gluteus medius strength

Rebuild gluteus maximus strength

Work on gaining back overall strength in the operated

leg to equal the strength in the opposing leg (quadriceps,

adductors, hip flexors, hamstring, calf)

Flexibility

Flexibility into hip extension, stretching the hip flexors

Stretching IT Band, Quads, Hip Flexor, Hamstrings,

pelvic mobility

Cardiovascular Increase cardiovascular endurance

Gait Encourage good Gait mechanics

Function Work on building strength and flexibility for function in

ADL (getting out of a chair, climbing stairs, getting in

and out of a car, putting their socks and shoes on)

Core / Bracing Core Stability training

Balance / Agility Retrain Balance, Agility, and Body Awareness

The 6 Components of Exercise Prescription for the Post-op Hip:

1) Cardiovascular

2) Strength (focus on function)

3) Flexibility

4) Transverse Abdominals

5) Balance

6) Gait

1. Cardiovascular:

Upright Bike The upright bike is preferable over the recumbent bike as the

recumbent bike may require too much hip flexion

Treadmill Start at a slower controllable speed where the client can focus on

good gait mechanics

Elliptical Use in both forward and backward, low ramp to begin

57



2. Strength: Gluteus Medius and Minimus strength are most affected

Gluteus Medius Clam Shells (option with bands for progression)

Side lying or Supine dependent on strength and flexibility

Side leg raises (advance with ankle weights)

Advanced Band Side Stepping

Advanced Cable Side Leg Raise

Gluteus Maximus Seated C Chair or Ball glute squeezes unilateral and contralateral

facing mirror and holding 5 seconds

Prone Ankle Ball Squeezes activating glutes and holding 5 sec

Bridge lifts with glut squeeze and hold 5 sec, even pelvis

Prone Hip Extension (pillow option under pelvis, core set)

Advanced Ball Walk Out glute squeeze bridge lifts and hold

Quadricep

Unilateral Leg Press / Shuttle

Step Ups Platform only to begin, add risers as challenge

needed

Sit to Sit to Stand (foam blocks can be used dependent on the

client’s height and their strength)

Ball Sq Ball Squat (for the advanced, stable client) begin with ¼ squat

and then progress as strength, flexibility, and ability permits

Advance Stationary Lunge being careful of 90 hip flexion (non operated

leg forward initially post-op until restrictions lifted and the

client must demonstrate sufficient strength)

Adductor Adductor Seated Small Ball Squeeze and hold 5 sec

Side Lying Adductor Straight Leg Lift up and hold

Hamstring Single leg on Leg Curl Machine if hamstring is weak

Bridge lift on Ball with or without curl in, even weight both

legs

Transverse / Brace TVA training in 4 point stance or lying supine (progressions)

Superman on floor or over ball

Hip Flexors Hip Flexors are usually tight, but should be assessed for

strength

3. Flexibility:

Hip Flexor Stretch Important as usually tight – Seated sideways, leg drop off chair

Hamstring Important–seated at edge of chair, 1 leg extended & lean forward

IT Band It will need to be stretched or loosened by massage

Quadricep Will need stretching and should be done prior to the hip flexor

Calf Should be assessed for tightness and stretched pre hamstring

Glutes Need to be stretched without external rotation of the hip

and so gentle knee tucks to the chest are good

Low Back / Pelvis Seated ball pelvis circles, side to side, tilting, and alphabet

58



4. Transverse Abdominals:

The Transverse abdominals (TVA) play an important role in pelvic stability

and spinal stabilization. Clients who have hip osteoarthritis experience

changes in gait, posture, and musculoskeletal tightness due to pain. These

specific changes can alter pelvic alignment and affect the normal firing of the

transverse abdominals. Educating and giving clients exercises on their

transverse abdominals is crucial to help retrain proper posture and assist

neutral pelvic alignment thereby improving their gait and overall function.

1) Neutral pelvis position can be taught on a ball or lying supine

2) Teach TVA engagement with visualization and/or tactile cuing

3) Emphasize low intensity as they are low grade endurance muscles

4) Add in limb movements when they can maintain the TVA setting

5. Balance:

1) Rocker Board balance both directions

2) Bosu, Sit Fit, ½ foam 2 leg balance with core and posture set

3) 1 leg balance at the earliest 3 months post-op and only if gluteus

medius, maximus, TVA, and pelvic stability is strong

4) Mini trampoline marching

5) Backward walking on the floor by a railing / progress to treadmill

6) Agility dot or fabric agility ladder step up and over or side step up and

over

6. Gait:

1) Heel toe emphasis is extremely important

2) Advise clients who have poor gait mechanics to make an appointment

with a physiotherapist to assess their gait and determine what is

causing the gait abnormalities. The Gait check list included in the

appendix can be given to the client to relay to the physiotherapists

some of the observations you have seen. Educate the client on how

important this could be to helping them walk more efficiently and

prevent them from tiring so quickly when they are walking; thereby

decreasing pain and fatigue and increasing the distance they may be

able to walk before the get tired.

59


SECTION 9: TRAINING PRINCIPLES PRE & POST- OP HIP & KNEE REPLACEMENT

HOW IS TRAINING THE OSTEOARTHRITIC CLIENT DIFFERENT FROM OUR

OTHER CLIENTS?

Two very Important Training Principles:

1. Isometric Contractions

2. Functional Training / Activities of Daily Living (ADL)

1. Isometric Contractions

When the body has been experiencing pain in a specific area, it will

automatically and unconsciously begin compensation techniques to avoid

pain. This usually will result in limiting use of the limb affected and

therefore, the body will rely more heavily on the use of the good limb. The

results of lack of use of a limb or joint will result in corresponding muscle

atrophy, joint stiffening or decreased range of motion, and decreased joint

stability. It is also important to be aware that motor unit recruitment (brain

to muscle connection) and motor unit patterns will be weakened all due to

lack of use. In addition, often osteoarthritic sufferers will experience pain as

they move their joint through full range which can make trying to strengthen

the joint difficult. For all of the above reasons, isometric contractions can be

a very useful training technique to implement both pre-op and post-op. An

isometric contraction will strengthen the muscle without having to force the

joint through a painful range of motion. Also, isometric contractions can

teach the client to be more mindful when recruiting their muscles and focus

their attention on the strength of contraction.

Use isometric contraction training when:

i) There is considerable muscle atrophy

ii) There is a minimal or weak muscular contraction

iii) Strengthening exercises through range of motion are too painful

iv) Post-op to re-establish muscular contraction after surgery

v) The client is brand new to exercise with little body awareness

vi) The opposing muscle is extremely tight and possibly causing an

inhibitory response

vii) The client is just starting exercises either pre-op or post-op

Isometric Contractions for the Knee will focus on the Quadriceps Muscles

Isometric Contractions for the Hip will focus on the Gluteus Maximus,

Medius, and Quadriceps Muscles

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SECTION 9: TRAINING PRINCIPLES PRE & POST- OP HIP & KNEE

2. Functional Training / ADL

Most clients you will see whether it be pre-operatively or post-op will

complain of loss of function in what we take for granted as simple activities of

daily living such as getting out of a chair or car, sitting down and getting up

off of the toilet seat, going up and down stairs, or just walking without a limp.

It is crucial that as fitness professionals, we assess our clients’ abilities in

functional movements and ADL’s as well as prescribe exercises to address

these specific concerns. Functional training exercises will foster gross motor

movement patterns strengthening your client’s coordination and confidence

in his/her physical ability. It may be hard to implement functional training

exercises pre-op depending on the individual’s pain response to each exercise,

but if any functional exercise can be performed pre-op without pain, then it

should be prescribed. Post-op, the client should most definitely be performing

as many functional exercises as possible to restore their independence,

strength and stamina.

Examples of Functional Exercises:

i) Sit to Stand

ii) Step Ups & Step Up and Over and Down

iii) Ball Squats

iv) Gait training (obstacle course) and Balance exercises

v) Getting up and down off the floor (when restrictions

permit)

vi) Activities that mimic getting in and out of a car and

bathtub

vii) Balance to get pants on standing on 1 leg

CLOSED CHAIN VS. OPEN CHAIN EXERCISES

Closed Chain exercises are considered more functional and therefore

better for rehabilitation purposes and are defined as exercises where

the foot is in contact with a surface such as the floor in a squat or the

plate of a leg press. Closed chain exercises involve co-contraction of

two or more muscle groups and greater joint stability.

Open Chain exercises are defined as where the limb, in this case the

feet, are not planted on a surface and therefore leave an open chain.

Examples of open chain exercises include the leg curl machine and the

knee extension machine. Open chain exercises can cause significant

shearing across the unstable knee joint which is damaging to cartilage

and strains ligaments.

61


SECTION 10: EXERCISE PROGRESSIONS

THE DEFINITION OF EXERCISE PROGRESSIONS

The overload principle relates to human performance and states that

beneficial adaptations occur in response to demands applied to the body at

levels beyond a certain threshold (overload), but within the limits of

tolerance and safety.

The term progression used here refers to the above definition where the

muscle needs to be overloaded and it is also used in the context of

advancing or providing more challenging exercise selections.

HOW DOES THIS PRINCIPLE RELATE TO JOINT REPLACEMENT POST

REHABILITATION?

a) You can assign a new more advanced exercise to a client after he or she

has performed their initial exercise for at least eight weeks. The

exercise may need to be progressed sooner if the difficulty level is not

sufficient to challenge your client

b) Usually exercise design pre and post operation will start with body

weight exercises that can be done pain free through a joint’s full range

of motion with good technique

c) The next step after body weight training would be to add external

resistance with therabands, ankle weights, resistance from machines

or any other means for increasing the resistance of the exercise

d) Increasing the weight on machines should be done gradually. For the

single leg exercises, the increment should be no more than two to five

pounds at a time

62



SPECIFIC AND APPROPRIATE EXERCISE PROGRESSIONS FOR JOINT

REHABILITATION CLIENTS

1) Sit to Stand - Most clients will need one to three foam cushions on the

chair when they begin this exercise to be able to perform it correctly. The

progressions will occur as they are able to execute the sit to stand with fewer

cushions or no cushions and by adding weight to the exercise in the form of a

plyoball, body bar or other weighted resistance.

*Clients with a THR should not bend their hip past 90 degrees for 3 months

post-op

2) Ball Squat - Both hip and knee post-op participants should start with only

a one quarter squat. As they get stronger and further along in their

rehabilitation, progress them to a full range squat. The next progression,

once they are able to do full range of motion to 90 degrees, is adding weight

by using dumbbells or a plyoball.

3) Step Ups - Most post-operative hip and knee clients will only be able to do

the platform or one riser with good form. The progression will be by adding

risers and possibly weight depending on the client’s ability level. It is

important for the client to be able to maintain good pelvic alignment during

the step up exercise.

The step up is usually performed incorrectly by the participant using their

calf muscles of the back leg to push them up and on to the step. They usually

perform this exercise quickly as well. Cuing the correct technique on this

exercise is crucial for proper biomechanics that will strengthen the hip

musculature and prevent overuse of the calf muscles.

Cuing of the Step Up:

transfer body weight to front leg

push through the heel of that leg

contracting gluteus maximus muscle

perform the exercise slowly

keep pelvis level

63



4) Abduction / Gluteus Medius - When the client first starts this exercise

make sure their gluteus medius is firing and that they can initiate the muscle

before adding any progressions. Watch that they are not cheating by pushing

up through their feet or rolling their hips open. Once they demonstrate good

form and initiate from the gluteus medius muscle, then the following

progressions could be added in order of difficulty:

a) holding the leg up in clam shell position for 5 seconds

b) add a band to the clam shell

c) side leg raise body weight only

d) side leg raise with ankle weights

e) cables abduction on platform

f) advanced cable abduction on ½ foam roller

g) side step with exertube band

h) hip abduction into a body ball standing sideways balancing on one

leg (the outer leg balances while the inner leg abducts into the body

ball)

5) Hip Extension / Gluteus Maximus – Often post surgery, clients may find

that their gluteus maximus muscle has become lazy and does not fire well or

at all. Start these clients with simple glut squeezes sitting on the ball or lying

supine and holding the contraction for 5 seconds. Once firing of the gluteus

maximus muscle is efficient, then you could try the following exercises:

a) Prone bent knee / ankle ball squeezes with concurrent gluteus

squeeze

b) bridge on a bench/floor (this can begin with both legs and progress

to one leg and/or the option with a ball)

c) hip extension prone on bench (this can be done bent knee or

straight leg and can be advanced by using ankle weights)

d) standing hip extension with band or cable for resistance

Sometimes hip extension can be so limited for a specific individual that

performing it prone from a bench or the floor is too difficult for them and they

are unable to lift their leg. One option to give to these clients is to have them

lie over a ball or at the end of a bench with only their pelvis supported and

their legs off the end of the bench or ball. This will allow for some hip

extension to occur without pelvis rotation or other mechanical compensations

occurring.

64


SECTION 11: CONTRAINDICATIONS AND PRECAUTIONS

CONTRAINDICATIONS AND PRECAUTIONS

Some of the specific signs that may be present if progressions are

implemented too quickly are listed below:

Increased swelling

Increased pain

Increased or abnormal fatigue

Change in performance / abnormal technique

Muscle soreness lasting more than 48-72 hours

Client feedback of perceived intensity of muscle soreness

A new source of discomfort or pain felt

Client unable to sustain level of repetitions or sets

The charts below are an extremely important source of information that

should be used as a reference in designing programs and advising clients of

what they are able to do and what they should avoid. Review this chart often

and make sure clients are aware of their limitations and the risks associated

with specific movements.

TKR and UKR Contraindications and Precautions

Medial or Lateral

Rotation of the

knee

-avoid in unicompartmental

and total knee replacement

-always avoid

Kneeling -avoid for knee replacement

clients both pre and post-op

- always avoid (some

clients will kneel, but it

is not advised and should

be for brief moments)

Deep Bends -avoid for total knee

replacement pre and post-op

- always avoid

Sitting and

Standing for long

periods

-avoid long term in both knee

and hip pre and post-op

clients

- always avoid to prevent

stiffness

65


SECTION 11: CONTRAINDICATIONS AND PRECAUTIONS

THR and Hip Resurfacing Contraindications and Precautions

Movement Hip Replacement Hip Resurfacing Risk for

how long?

External Rotation

of the Hip

avoid this movement

with post-op hip

clients in the first 3

months and longer if

dislocations have

occurred or weak

-avoid for first 2-3

months

-thereafter would

be okay if no pain

External Rotation of

the hip is restricted in

the first 3 months

post-op and can be

gently implemented

thereafter on an

individual basis

Internal Rotation

of the hip

- Avoid in first 3

months and longer if

joint is weak, has

dislocated, or is at

risk for dislocating

-avoid for first 2-3

months

-after 3 months

okay if no pain

Internal Rotation of

the hip is restricted

for 3 months in THR

Flexion of Hip

past 90 degrees

-for first 3 months or

longer in post-op

THR clients

(dependent on pain,

dislocation risk, and

muscle strength)

-there is no proven

recommendation

here, but it is best

to follow this rule

for the first 2 -3

months

-3 months + in THR

- hip resurfacing

clients can usually do

more than 90 degrees

sooner, but should

follow advice of their

physiotherapist and

use pain as a guide

Forward Trunk

Flexion in

seated position

for THR

-hip patients

should avoid this

movement post-op

long term to avoid

dislocation

-not a risk for hip

resurfacing

clients; however

ask their physio

as to their

progress and

risks

-avoid long term for

THR patients

-may not cause

dislocation if good

bone growth and

muscle development

but is best to avoid

One Leg

Balance

-avoid in THR

until 3 months

post-op and

possibly longer

dependent on

patient

-avoid for at least

first 2 months

post-op or as per

advice given by

physio

-3 months for THR

-2 to 3 months for

hip resurfacing

clients

Hip Adduction

(do not allow the

leg to cross the

midline of the

body)

-avoid in THR

-this position puts

the hip socket at

risk for dislocation

-avoid for first 2-

3 months or as

advised by

physio

-always avoid in

THR patients

-avoid for 2 to 3

months in hip

resurfacing

66


SECTION 12: CARDIOVASCULAR PROGRAM DESIGN

Although flexibility and strength take center stage in the rehabilitation

process, it is still paramount that we assess and program time for every

individual to rebuild their aerobic capacity. Take a minute to think about

how someone’s life changes when they experience pain in their joints upon

weight bearing. Imagine how long a joint replacement candidate may suffer

with this pain before they have surgery and how that length of time in a

debilitated state impacts their overall cardiovascular capacity.

How would their daily routine change? They most likely have obtained a

handicap parking pass so they do not have to walk too far. Also, they

probably strategically plan to bring everything downstairs with them at one

time so they have very few trips to make up and down their staircase. All of

their recreation activities have probably been dropped or reduced

significantly and in addition it is possible that they interact less socially due

to the pain they experience walking too far or sitting and standing too long.

All of these and even more life patterns have changed for these individuals

because of the advancing deterioration in their joint. This means they have

significantly reduced their cardiac function and will need to gradually

increase their cardiovascular capacity to an optimal level.

The extremely important fact to realize here is that a large percentage of the

individuals you will see have compounding health concerns including

cardiovascular disease, diabetes, high blood pressure, elevated cholesterol

levels, and other health concerns. The great benefit these individuals have

gained by having surgery is that they can now begin to do more aerobically

because they are not suffering from as much pain or may even be pain free.

Being able to increase their aerobic capacity is an exhilarating feeling for

these joint replacement clients because it makes them feel they are really on

the road to recovery.

12.1 CARDIOVASCULAR EXERCISE – WHERE TO START?

The first step in designing the cardiovascular exercise program for

individuals, either pre or post-operative, is to have a good understanding of

what their current activity level is. It is best to liaise with their

physiotherapist to obtain information on how much they have been doing or

just ask the individual directly to quantify their current exercise regime.

Assess the client’s aerobic functioning first hand during the consultation by

personally observing the rate of perceived exertion and monitoring their

heart rate. Generally five minutes of cardiovascular exercise on either the

bike and/or treadmill will be a good starting place as that is usually what

they have been doing during their physiotherapy at the hospital.

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12.2 CARDIO MACHINE RECOMMENDATIONS

Pre-Op Knee Reclining bike or Upright bike

Pre-Op Hip

Upright bike best, Recumbent O.K. if back rest needed or if it

feels better

Pre-Op

Hip/Knee

Treadmill is O.K. only if no pain is felt during or after exercise

The Elliptical has not been researched for safety or

effectiveness in total joint replacements (TJR) or for

individuals living with advanced osteoarthritis.

Post-Op Hip Upright Bike, Treadmill, Elliptical forward and backward

Post-Op Knee Recumbent and Upright Bike, Treadmill

Always use pain as the guide

to the selection of which machine is best for the client

Note: The Rowing machine may be a choice for the pre-op knee clients as

there is no weight bearing involved and it works the knee through a good

ROM; however this choice would depend upon how much range your client

has and if they can perform the row with good form. It may not be a good

selection choice post-op as your client may not have the appropriate range of

motion to execute with good form.

The rower is usually not a good option for the hip client pre or post-op

because of their limited range of motion and the restriction post-op of not

bending past 90 degrees. It is too low and awkward for most clients both pre

and post-op. Also, it is a contraindicated selection choice for the hip patient

because they are usually tight in their hip flexors and should not be given

any exercises that contribute to their tightness there.

12.3 APPROPRIATE CARDIOVASCULAR TRAINING TIMES

The time allocation for cardio varies greatly between clients and therefore

cardiovascular exercise programming should be tailored to each individual’s

ability.

The clients with heart disease, high blood pressure (HBP), diabetes, high

cholesterol, or who are overweight will all need to focus and build up to at

least 30 minutes of cardiovascular training.

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It is best to start clients who are pre or post-op and relatively inactive at 3 to

5 minutes of aerobic training with 1 to 2 minute increases each week. The

cardiovascular endurance will vary greatly between clients. Therefore, it is

imperative to modify each participant’s cardiovascular training to their

capability and support, motivate, and educate them on this goal. Clients

with heart disease, high blood pressure, diabetes, and high cholesterol must

have exercise programs that focus on at least 20 to 30 minutes of

cardiovascular training depending on their personal abilities.

Scheduling Cardiovascular Training

It may be beneficial to have clients begin their cardiovascular training

prior to the start of class for two reasons. If there is limited equipment

and/or if they have difficulty completing their whole routine during

class time this will give them the extra time they need.

It is important for the trainer to have sufficient time to monitor each

client and know they are capable of performing their cardio correctly

and safely on their own and within their target heart rate. Therefore,

if clients can come early to do their aerobic training, and the instructor

is available, they will benefit by receiving more guidance on the more

complex resistance exercises and find that the technique cuing is very

helpful. It will also provide a smooth flow to the class if the class size is

large because it will allow for a somewhat staggered format where you

can focus on a small group of clients at one time.

12.4 HEART RATE TRAINING ZONES

Although the participants may appear healthy, vibrant, and eager to

progress, it is important to remember that these individuals are most likely

beginners or have been relatively inactive leading up to their surgery due to

their pain. The ACSM heart rate training guidelines for a beginner, inactive

client should be followed. Calculate their target heart rate at 40-60% of their

heart rate maximum using the Karvonen formula or take 50-65% of the heart

rate maximum 220-age calculation. A large percentage of clients, especially

if they are seniors, may be on beta blockers and therefore the rate of

perceived exertion Borg Scale and the talk test will be needed with these

individuals. It is extremely valuable to use all three measurements for heart

rate when supervising clients including the heart rate reading, rate of

perceived exertion, and the talk test.

69



12.5 THE IMPORTANCE OF THE WARM-UP AND COOL-DOWN

One of the most basic, simple components we learn as fitness professionals in

the first course we ever take is the importance of warm-up and cool-down. It

is surprising how many newcomers to fitness and seniors have no

comprehension of the concept of warm-up and cool down. These two groups

need the rule enforced the most.

This is actually a very serious topic that will need to be addressed with the

class; they will need to be educated on the reasons it is crucial that they

follow the warm-up and cool-down procedure. The group discussion is the

best forum to relay this information as the clients can ask questions and will

then have a good overall understanding of the logistics behind the rule.

70


SECTION 13: GAIT ANALYSIS

In the initial consultation with your client, it is extremely beneficial to watch

how they walk. Many of the individuals you will be seeing will not walk with

normal gait due to compensations they have learned to avoid pain. It is our

goal as instructors to help retrain these individuals with the proper

biomechanics of normal gait to increase their efficiency. It will be hard to

alter the gait of the individuals you are training prior to their operation, but

there is hope for your post-operative clients. It may not be realistic to aim for

normal gait, but improvements can be made towards the normal gait ideal.

13.1 BIOMECHANICS OF NORMAL GAIT

Hip Flexion > Knee Flexion > Knee Extension > Ankle Dorsi Flexion > Heel

Plant > Heel/Toe transfer > Plantar Flexion > Toe Off > Hip Extension

Observe the diagrams below to visually demonstrate the proper biomechanics

of walking.

Take a moment to watch someone’s gait and think about each movement, the

joints participating, and the muscles involved. Watch the individual as they

walk away from you and toward you and note any abnormalities.

Refer to Appendix A for the Gait Analysis Observation Checklist

71



13.2 GAIT ABNORMALITIES

1) Heel / Toe Transfer

Does the subject land flat footed or walk on their toes? Encourage clients

to heel strike and then transfer through to the toe off phase. When people

are in pain or feel unstable in terms of their balance they begin to walk

flat footed on their soles because it feels more stable for them. Educate

them on how important it is to practice heel/toe walking to prevent

further injuries and to keep their body functioning in its correct

movement patterns. The heel (calcaneus bone) is designed to absorb a lot

more shock than the balls of our feet and if we begin walking on the balls

of our feet more, this may cause undue stress to the bones and muscles of

our feet as well as tighten our calf muscles.

2) Circumduction presenting as a leg swing laterally

Does the subject move their leg out laterally in a swooping arc as they

take a step? Teach the individuals with this concern to flex their hip and

swing their leg directly in front of their body. This may indicate a

weakness in their hip flexor and/or adductor muscles and so they will need

to strengthen those muscles.

72



3) Hip Hiking / Hip Elevation (Trendelenburg Gait / Reverse

Trendelenberg)

Clients may lift their pelvis up as they go to swing their leg forward. This

may indicate a problem with knee flexion for clients who have had a knee

replacement and now are experiencing limited knee range of motion in

flexion. Also, it would be important to assess the strength of their hip

flexor muscles, weakness in their abductors, and tightness in the

quadratus lumborum.

4) Hip Extension

Sometimes a client may appear to have a shortened stride length that

does not look normal for them. The first step to take if this is happening

is to educate the client and see if they are able to take a longer stride that

will still feel natural and comfortable for them. They may have shortened

their stride due to pain or lack of balance and if they are post surgery,

they may now be able to correct their stride length through awareness,

stretching, and practice. If they are unable to correct this, then there may

be structural obstacles limiting their movement. This is an indication

that hip extension is limited by tight hip flexor muscles and/or a possible

weakness in the hip extension musculature. Assess and implement hip

flexor and quadricep muscle stretching along with hip extension

strengthening. Have the client walk backwards with a good long stride

and toe/heel plant to aid in their hip extension flexibility.

It is important to be aware of your observations and use this information

within your scope of practice. Be careful that you are not diagnosing what

is causing the gait abnormalities as this is beyond our scope of practice.

73


SECTION 14: BALANCE

14.1 BALANCE TRAINING FOR JOINT REPLACEMENT PATIENTS Benefits

Retrain body’s propriocepters post surgery

Expand ability to balance

Prevent falls / injury

Increase confidence level

Work stabilizing muscles

Improve core strengthening

Build body awareness

Altered and reduced proprioception has been observed in people with hip and

knee replacements for many months following surgery.

As a fitness professional working with this special population, it is important

to include at least one to two balance exercises for each client. The balance

exercises you select should be able to be executed by the individual safely and

effectively.

Identify with Clients’ Challenges

In order to help us understand as professionals, the difficulties clients

experience, we need to put ourselves in their shoes by replicating their

structural changes on our own body.

Try placing a tennis ball behind your knee with your knee flexed up to a 20

degree angle and secure it in place with a towel or band. This will mimic a

client who has had a knee replacement and now has either limited range of

extension or restricted movement in knee flexion.

Now, try walking, sitting, getting out of a chair, off the toilet, in and out of a

car, and up and down stairs. What is your assessment of the changes it

creates? You will find it is very difficult to maneuver in these activities of

daily living with limited range of motion.

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SECTION 14: BALANCE

Balance affects both knee and hip replacement clients

Using canes, crutches, and walkers post surgery, has made these patients

rely on their device for balance assistance. Also, a cane and the other aids

change their center of gravity thereby affecting balance because of the

forward thrust movement required to ambulate with the cane.

Whether your client has received a new knee or hip, their balance is greatly

affected by all of the following:

a) the new foreign object

b) swelling

c) tissue damage

d) scar tissue development

e) structural changes / removal of proprioceptive tissue (capsule,

ligaments)

f) leg length discrepancies

g) muscle atrophy or weakness and decreased protective

neuromuscular reflexes.

The balance exercises chosen will depend on how much time has past since

the operation and both your client’s ability and comfort level.

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SECTION 14: BALANCE

14.2 BALANCE EXERCISES

Knee, THR,

Hip Resurfacing Pre-Op Post- Op

Rocker Board (Square

Wobble Board

-Side to Side option

-Front to Back option

O.K. if no pain Good

1 Leg Balance

Usually too painful pre-

op depending how

advanced the

osteoarthritis is

Clients with either knee or

hip replacement should be 3

months post-op

-check with physio

Sitting on Ball (near bar

to hold); progress to knee

lift and hold if possible

with core set in neutral

and posture tall

O.K. if the client is

comfortable and stable

(if you are not confident

with your client’s ability

to balance and you feel

there is a risk to their

safety, then avoid this

exercise)

Good for your clients who

feel confident and are stable

on it. Always set them

where they could grab and

hold on to something

Best to do after 3 months

post-op

Sit Fit Cushions Standing

(start with both feet on

the sit fit).


(only an extremely advanced

client who is strong with

good balance should attempt

1 leg on the sit fit; reserve

for clients who are at least 6

– 12 months post-op)

Bosu Standing

- 2 leg balance

- Advanced: 1 leg balance


One Half Foam Roller

- 2 leg balance

- Advanced: 1 leg

Avoid pre-op

-this is usually too

unstable for pre-op

clients

Good

-reserve this option for at

least 3 month post-op clients

who have good strength,

core stability, and who are

confident with their balance

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SECTION 15: POSTURE ASSESSMENT

WHY IS IT IMPORTANT TO DO A POSTURE ASSESSMENT PRIOR TO DESIGNING

AN EXERCISE PROGRAM?

1) Information obtained from the posture assessment will guide the exercise

prescription

2) The posture assessment can be used as an educational tool to make each

client aware of their posture and the role exercise plays in posture

3) Often clients will list posture as one of their goals and therefore doing a

posture assessment directly addresses their goal with feedback given

immediately

4) Having an initial posture assessment to compare to a later posture

assessment can be an excellent referral source to demonstrate

improvement. It is a good idea to take a picture at the initial consultation,

and then another months later; this will provide the client with visual

evidence of the progress he/she has made.

5) Taking the time to do a thorough postural assessment may provide

additional pertinent information about the client’s body that they may not

be aware of or have just neglected to report on their health form. It is a

fantastic tool to help the exercise specialist become familiar with their

new client’s body and the areas they will need to help them work on.

HOW SHOULD A POSTURAL ASSESSMENT BE COMPLETED?

A postural assessment can be an extremely technical procedure. The scope of

this manual will not cover in great detail the specifics of postural assessment.

However, a summary of what you will need and what to look for is provided

below. It is beneficial to use a postural table or chart and a diagram of a

human body to mark your findings on. A sample of each is included for your

reference.

Equipment required:

Plum line

Camera

Posture Chart & Diagram

Private Room

Stickers to mark the body for correct plum alignment

77


SECTION 15: POSTURE ASSESSMENT

Postural landmarks to assess include the following:

Poke chin

Round shoulders

Winged shoulders

Pronated arms

Arm placement

Thoracic back

Flat back

Lordosis

Scoliosis

Leg length discrepancy

Locked knees

Feet pronation/supination

External/Internal rotation of feet

Pelvic alignment

Refer to Appendix B for Posture Graph

78


SECTION 16: POINTS OF INTEREST

LEG LENGTH DISCREPANCY IN HIP REPLACEMENT PATIENTS

After hip replacement surgery the client may present with a leg length

discrepancy. There are two types of leg length discrepancies and they are

referred to as true or anatomical shortening and functional or apparent

shortening. The true leg length discrepancy represents an actual length

variation in the bones of the leg whether it be the limbs of the lower leg or the

femur; whereas an apparent leg length discrepancy can be caused by pelvic

misalignment or from a flexion or adduction deformity.

The measurement for a true leg length discrepancy is taken from the anterior

superior iliac spine to the inferior tip of the lateral maleoli. The functional

measurement is taken from the umbilicus to the medial maleoli of each

ankle. These measurements can be performed by a physiotherapist and

require training to do accurately.

Clinical findings suggest that leg length discrepancies post hip replacements

are usually due to apparent or functional discrepancies caused by pelvic

obliquities originating in muscular imbalances. It is not recommended to use

a shoe lift for at least 6 months post-op to see if some of these muscular and

soft tissue imbalances may resolve. An x-ray is the most valid measurement

tool.

Although, the leg length difference cannot always be rectified, it is important

for the fitness professional to be aware of it and assess the effects it may be

having on the body. Being aware of the difference could lead to the

discussion of building their shoe up on the affected leg in order to improve

their gait and prevent stress to the back and pelvis. This would be done

under the supervision of an occupational therapist or physiotherapist. It may

also explain their gait biomechanics or other ailments they are experiencing.

79



SCAR TISSUE

What can the patient do to facilitate scar tissue healing and why is it

important to address this concern?

Scar tissue is less viable than normal tissue. It is firm, fibrous, inelastic, and

devoid of capillary action. Scar tissue around a joint can therefore limit

range of motion or cause restriction in movement. The first 3-6 weeks post

surgery demonstrates increased production of scar tissue and the strength of

scar tissue continues to increase from 3 months to a year following surgery.

Some individuals will have a genetic predisposition to easily produce scar

tissue which is called hypertrophic scarring and it may limit their healing

and range of motion possibly affecting the return of functional movement.

Age, nutrition, some medications, and metabolic disorders such as diabetes

will all affect the healing process of tissues post surgery.

The first goal to prevent the damaging effects of scar tissue is to mobilize the

joint through its pain free range of motion early on in post surgery recovery.

Early mobilization can assist in making the joint more viable; whereas too

long a period of immobilization would delay healing. Gentle, dynamic range

of motion exercises and low intensity static stretches will foster flexibility

and elasticity in the new scar tissue. All efforts should be made to avoid

painful or forced stretching as it will only keep the joint and surrounding

tissue in an inflammatory response which will prolong healing.

Physiotherapists use a variety of hands-on massage and stretching

techniques to keep the scar mobile and free of adhesions.

The goal of the post rehab instructor should be to maintain and implement

pain free gentle stretches and range of motion exercises to restore normal

function and ease of movement. There are alternative therapies available to

individuals experiencing complications due to heavy scar tissue build up.

They can pursue treatment in massage therapy, micro stretching, and active

release therapy. For some people, gently heating the scar and surrounding

skin will make the tissue more pliable and reduce discomfort.

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THE STRETCHING INTENSITY DEBATE

It has been extremely interesting to observe and experience the varying

methods and opinions of health professionals surrounding stretching

principles. Some health practitioners obtain results in range of motion from

forcing the knee joint even into the pain threshold for the patient. Other

health professionals have adopted the stretching philosophy of working range

of motion only through a pain free range and receive positive results that

way.

There was one specific scenario where a client only had about 45 degrees in

her right knee and had tried massage and forced stretching for about two

years with little improvement. She finally tried an alternative therapy called

Micro Stretching. It is a gentle form of stretching where the body is

completely supported by cushions or the practitioner so that all the muscles

can relax and the intensity of the stretch falls around a 2 or 3 on a scale of 10.

It has been amazing to see how positively she has responded to this

treatment. The swelling and heat in her joint has dissipated and she is

gaining more range of motion in small increments, but enough to improve her

gait and restore her somewhat back to normal function.

The research is still developing surrounding this debate and it will be up to

the fitness professional to stay well informed and use their best judgment

from the evidence and facts available to us. Until studies confirm proper

procedures in stretching post-op for the knee replacement client, the general

rule of thumb is that you can stretch a joint through its pain free range of

motion. Be extremely cautious with the intensity of the stretch keeping it at

a level 2 or 3 on a scale of 10 and try to support the limb with cushions. The

most effective stretches are when the client’s body is at rest and supported so

that their muscles do not have to assist or work at the stretch and also when

the muscles and surrounding tissues are warm.

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SECTION 17: HOW TO BUILD A JOINT REPLACEMENT PROGRAM

17.1 KEY COMPONENTS

Excellent Community Program

Community Links

Communicate with

hospital partners,

physiotherapists,

medical practitioners,

and resource centers

Staff

Educated,

well trained,

caring staff

Organized System

Organized class

structure

and a detailed,

comprehensive

consultation

Facility

A well equipped, clean,

and accessible facility

with safe and

well maintained

equipment

Client Perks

Provide Certificates,

Parties, Graduation and

Report Cards

Pre-Planning

Well planned budget,

scheduling, marketing,

and progression system

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SECTION 17: HOW TO BUILD A SUCCESSFUL JOINT REPLACEMENT

PROGRAM

17.2 DESIGNING A SUCCESSFUL JOINT REPLACEMENT CLASS

There are important elements to consider when you are creating a joint

replacement post rehabilitation or pre-operation class. The following are a

few guidelines to ensure the operation of a well managed class.

Facility: How many participants can be registered with the space and

equipment available? Is the appropriate equipment available that is

required for this type of class? How will this class impact the other gym

members? It is proactive to forecast any possible conflicts that may occur

here.

Staff : What instructor-to-participant ratio will the class operate with and

will there be a lead and assistant instructor with corresponding

responsibilities? How will the instructors of this program be supported?

(meetings, round table etc.)

Pre-Plan: What time of day will the class run? How long will each session

be and how often each week? There are participants who join on an

ongoing basis year round. Therefore the length of the break between each

session is important and needs to be considered as well as options for

progressions for those who graduate from the initial program?

Consults: Will there be a consultation and what will the fee be for this

service?

System: Does there need to be a specific class design with a breakdown of

the time for cardio, strength, balance, and flexibility to ensure consistency

or will that be left to the responsibility of each instructor?

It will be important to plan and anticipate growth.

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17.3 PROGRAM FRAMEWORK

Class Size

The class size is actually a very important factor contributing to the

success of your program. There are two main determinants of class

size that need to be assessed; one is the size of the training space

available and the other is the number of available instructors to teach

the class. Unforeseen conflicts can arise due to participant numbers

and space availability. If cardiovascular equipment is limited, but

space availability can accommodate a larger class size, then you can

have the participants split their cardio. There is also the option of

offering a staggered start time or just simply having some clients come

early. Creative problem solving skills will help you resolve any

concerns.

Instructor-to-Participant Ratio

The instructor-to-participant ratio is of great significance for two

reasons. The most important contribution that must be considered

when deciding the instructor-to-participant ratio is safety. The age,

frailty, and balance of the individuals will vary impacting the risk

factor for falls and therefore possibly the ratio required. A 1:4 ratio of

instructor-to-participant is best. This ratio allows for both safety and

personalized, effective training. At the beginning, this ratio may

appear to make for a hectic class since all the participants are new and

just learning their program. Later on, when the clients become

familiar with and understand their program, this ratio will seem more

efficient and maybe even generous.

Ideal Personality for Instructors

This class requires a special person as an instructor as they are

constantly dealing with people who are in pain, frustrated and needing

a great deal of supervision. In a class format, it is a very fast paced,

hands-on environment that requires an individual who can multitask,

move quickly, and still give each participant the care they require. The

reason this niche group demands a special type of instructor is because

of all the physical, mental, and emotional challenges they are facing.

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Ideal Personality for Instructors continued

Extremely patient, sympathetic, caring personal trainers are a must as

clients may experience all of the following challenges:

they may have never been in a weight room or exercised in their life

the majority are older than 65 years with possible loss of hearing,

eyesight, coordination, balance, and in some cases early stages of

dementia/memory loss

most are afraid or uncertain of what to do and are there for your

guidance and leadership

many will need to be educated on or reminded of the basic exercise

fundamentals such as warm-up, cool-down, the difference between

repetitions and sets, breathing, hydration, core stability, body

alignment, and how to hold a stretch

often they will have been taught something numerous times and

yet will still ask the same question over and over or they will just

simply need to be told repeatedly how to do something

Risk Assessment for the Space Allocated

1) Is all the equipment maintained to high safety standards?

2) Is the weight room kept clean, orderly, and free of clutter?

3) Is the weight room accessible for individuals with walkers?

4) Is there enough space for people who need to get around with

crutches or a cane?

Emergency Planning / Evacuation

All instructors should be aware of the emergency procedures and how

to evacuate the participants who have special concerns. For instance,

if the program is operated on the second floor of a building and the

elevator is shut down, you will need to have a system describing how

the participants who cannot use the stairs will be assisted. Meet with

the facility managers or bring this topic to the safety committee to gain

clarity and procedural guidelines. Once guidelines are set, it is

important to make sure every instructor receives emergency

evacuation plan training.

85



Equipment Checklist: What will you need?

An elevated bench as most participants cannot get on to the floor (1 - 2)

Therabands of varying resistance (number dependent on class size)

One-half foam roller and circle foam (1 to 2 each)

Foam blocks (6 to 8)

Hard chairs with no arms (1 to 2) / 1 raised chair for THR prior to 3

months

Body Balls in varying sizes (number dependent on class size)

Small, squishy balls to put between knees

Ankle weights of 2 to 5 pounds each (1 to 2 sets)

Exertubes - tubing with handles in varying resistance (2 to 3)

Balance Boards-mainly the rocker board (1 to 2), Circle Board, Sit Fit

Cable or Pulley system -best starting at 2 pounds

Seated Leg Curl Machine-1 and 2 leg option (controversial: open chain)

Leg Press-low weight option

Shuttle

Step Platform with at least two riser option (2)

Wall Space

Long Portable Mirror to provide biofeedback to client on

posture/alignment

Recumbent Bikes

Upright Bikes

Treadmills with safety clips and low speed option

Elliptical (no evidence supporting benefit for THA)

APT (Active/Passive Trainer)

Calf Incline Board

Towels, cleaner, tissues, accessible water and washroom

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17.4 DESIGNING SPECIFIC CLASS DETAILS

Throughout the past six years of this program we have received input from

participants, staff, the hospital, and gym members. Many options have been

tested in the following areas: class length, frequency per week, session

length, class progressions, and special class options. The most efficient class

design has evolved from these findings and is listed below. Tailor the

program specifics to meet your individual clients’ needs.

Recommendations for the Most Efficient Class Design

Class Length An hour to an hour and fifteen minutes is best for this class as it

will allow your clients enough time for cardiovascular training, and

a series of 6 to10 exercises including strength, balance, and core

exercises. The last 10 minutes of the class can be reserved for the

group stretch on balls, chairs, or on the floor. The amount of cardio

for each client is optimally 30 minutes; restrictions on time will

necessitate emphasis on the importance of cardio and muscular

strengthening for each client individually. This will make sure they

are receiving the full overall benefit they need from exercise

Frequency

Per Week

A 3 times a week class option yields the best results in terms of

progress for the participant; however the 2 day a week option is also

extremely popular due to time constraints, travel, and energy level

Session

Length

The 3 month session gives the participant the ideal time

commitment required to see good results and gives the instructor an

opportunity to really learn about and work with the specific

concerns of each individual.

Class

Progressions

There will be clients that continue on an ongoing basis year round

and so having a session break of no more than 10 days is important

as they may not continue on their own and the set back physically

frustrates them

Special Class

Options

- It works well to have an advanced class where independent, faster

paced clients can work at their speed rather than being limited by

the slower, more demanding clients who require a lot of attention.

- A class option at an earlier time of day for the younger clients who

are still working has been extremely popular.

- It is a great idea to clarify that the program accommodates

pre-op patients or even design a specific class for this group as it is

crucial that these individuals strengthen as much as they can prior

to surgery.

- Combine pre-op clients with post-op clients as this has proven to

be a really beneficial, supportive environment whereby the former

can benefit from the latter’s first hand experience with joint

replacement.

87



17.5 PHYSIOTHERAPISTS The Fitness Professional’s Link to the Medical Community

An important step to take when creating a post rehabilitative program for

joint replacement patients is to call the senior or practice leader

physiotherapist at your local hospital and advise them of the dates and times.

Keep in mind that the physiotherapists at hospitals are extremely busy and

may or may not have time to reply. Once the physiotherapist is informed as

to the purpose of the call, ask them if a meeting to set up a referral network

is possible. It is very important to be respectful of their time and understand

they are operating in a hectic environment and may not be receptive or able

to respond due to time constraints.

If the physiotherapists agree to meeting and corresponding, it is important to

realize hospitals must abide by confidentiality laws and regulations;

therefore, the physiotherapy staff will know best what information they can

provide and in the format of their choice. The patient may need to sign an

information release form to allow any of their medical history to be disclosed.

If it is difficult to liaise directly with the physiotherapist, then it is helpful to

have the client request feedback on areas they need to improve upon, either

verbally or on a written form, from their physiotherapist,. This system can

work efficiently because often the client returns to his/her physiotherapist for

a check up approximately one month after they have finished their

rehabilitation at the hospital. Therefore a form with any questions or

concerns the exercise specialist has can be given to the client and passed on

to their physiotherapist. The form can then be sent back with the client. This

helps to establish a professional relationship with the physiotherapist and

demonstrates your interest in providing a safe and effective exercise program

for the client.

Refer to Appendix C for the Physio Referral Form

Refer to Appendix D for the Information Release Form

Physiotherapists will have different approaches that work best for them and

their team. Build a successful rapport with the medical community, be

respectful of their requests and foster a partnership to best support the

health of our mutual clients. Physiotherapists are extremely important in

helping us understand each client’s individual concerns, diagnosis, and

specific exercise needs. Clients are put at ease knowing they have a team of

health and fitness professionals working together to help them. Therefore,

this strong partnership can increase the level of improvement, satisfaction,

and success for every client.

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17.5 PHYSIOTHERAPISTS CONTINUED

The Fitness Professional’s Link to the Medical Community

Physiotherapists are an excellent networking / educational and referral

resource; Taking the time to link with a physiotherapist is a professional,

proactive step that will accomplish all of the following:

1) It will increase community awareness about your program among health

professionals

2) It will create good trustworthy working relationships with the medical

community

3) It will build increased professional knowledge, insight and direction to

create the best post rehabilitative exercise regime for each client

4) It shows a genuine concern for the client, and attention to detail

5) It demonstrates a strong commitment and builds respect for the

program/services, and level of instructor dedication

89



17.6 SCOPE OF PRACTICE

One of the most important lessons to learn as a health and fitness

professional is the scope of practice for personal trainers. Physiotherapists

have extensive years of anatomical training, functional body mechanics

testing, exercise physiology, diagnostic testing, and understanding of

pathophysiology of musculoskeletal and neurological conditions. The

personal trainer’s role is never to diagnose or treat an acute or chronic injury,

but rather to refer clients to the appropriate health professionals. Exercise

specialists can only train clients in their post rehabilitative stage once the

clients are ready to leave physiotherapy treatment and continue within a

community setting.

Post rehabilitation refers to physical training and exercise prescription

beyond the rehabilitative phase conducted by physiotherapists. It is

important to be aware that exercise specialists can only be involved in the

post rehabilitative phase if they are working in collaboration with or

communicating with a physiotherapist. Be respectful of the difference. Using

the term post rehabilitation in marketing is ethical and within the liability

protocols for fitness professionals. Abiding by the ethical guidelines outlined

above, will achieve the following goals:

1) It will abide by all the regulations and liability concerns for fitness

professionals

2) It will ensure the safety and effective treatment for each client

3) It will foster respect and good working relations with the medical

community

Who should you refer to a physiotherapist or other health professional?

Any client less than 6-8 weeks post surgery

A client experiencing any of the following abnormal or suspicious

changes: increase in swelling, increase in pain, or color change in their

skin, discharge from incision or marked decrease in joint ROM

Anyone who is having compounding body pain that requires a medical

diagnosis including sacroiliac pain, Illiotibial band pain, heart or

breathing concerns, persistent limp or compensatory gait pattern

Anyone describing instability or sensation of “giving way” in the

replaced joint

90


Anyone experiencing altered sensation (numbness, tingling, referred

pain)

91



It is okay and professional to explain to the participant that their medical

concerns are out of the scope of practice for an exercise specialist. Educate

your clients on the scope of practice a trainer must abide by. It is important

to respect and protect your liability and stay within the parameters of your

knowledge and expertise.

17.7 RECORD KEEPING

S.O.A.P.

It may be helpful to have a SOAP report form for each class and each

participant. On this document the subjective and objective findings are

recorded as well as the action and plan taken. This information can be very

helpful to investigate and correlate positive and negative feedback from your

clients in order to tailor their programs. The class may be so hectic some

days that there is no time during or after class to perform the S.O.A.P.

analysis. If this is the case, then make notes directly on the client’s card with

a date so that every instructor who teaches the class can be kept up to date

and informed of any changes. This is a useful, efficient system that can be

completed quickly. Recognizing the importance of accurate, detailed report

taking will benefit the client and even the trainer, in respect to possible

liability concerns.

Refer to Appendix G for the S.O.A.P. Form

17.8 PROGRAM EVALUATION & FEEDBACK

The customer survey/feedback forms can contribute greatly to the success of

the program. It gives the client an opportunity to have a voice and it

provides the instructors and programmers valuable feedback. The feedback

may provide information that will make changes to increase customer

satisfaction and/or class efficiency. Also, the feedback can be a rewarding

experience for the instructors providing positive reinforcement and

motivation for them.

Refer to Appendix H for the Joint Rehab Evaluation Review

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17.9 CREATING A POSITIVE ATMOSPHERE FOR HEALING

This program will be an amazing life long learning experience for any

instructor who chooses to teach it. In this type of program, the typical

participant is enrolling with a lot of pain. Each knows that they will have to

work through their pain and exercise to get better and maximize the results

of their surgery. Most people find it hard to motivate themselves to exercise

without even a hint of pain. However, these individuals persevere through

the pain hoping it will enable them to achieve better health. The instructor

has a special role to play to keep them positive when the progress is slower

than they thought it would be. The following ingredients will create a

positive atmosphere for the clients:

Create a supportive, non judgmental environment

Use Instructors who are overloaded with patience

Have a fun, uplifting, light hearted approach

Introduce participants to each other and help them to find things in

common

Select music well; it has a huge impact on the tone and atmosphere of the

class

See every client the same: someone trying their best to improve their

health

Believe in your participants, even when they cannot

Listen intently to your participants’ concerns and document important

notes

Remember important details about your participants from one class to

another

Celebrate small, large and personal milestones that the participants reach

Develop a cohesive, friendly team of instructors who all get along and

work well together and present a united front at all times

Be fair and respectful to each participant

Encourage, motivate, and acknowledge every client’s goals

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17.10 SOCIAL FUNCTIONS

Organizing a group wrap up party at the end of a session supports the

participants’ success and creates a close group connection. These parties

allow for the group to mingle outside of the structure of the gym environment

and it gives them a chance to get to know the instructors a little better too.

These parties can be used as a forum to congratulate the participants and to

honor all their hard work and dedication. The party also gives the

instructors an opportunity to thank all their staff and acknowledge the effort

and commitment they have put into the program. Often this class is

sometimes the highlight of the day for some of these seniors and it may be

their only outlet for socializing. These parties have been such a huge success

that the year round participants keep asking when the next one will be. For

individuals who are finishing the program and going out on their own, the

party offers a wonderful finale to their experience and a feeling of

accomplishment. Handing out graduation certificates and/or report cards is a

really great touch! It may take extra time and money to organize, but

creating a system where each participant pays $2 to $3 works well to cover

the costs of any food and beverages. There is also the option of everyone

bringing something; however there is usually too much food leftover and

client feedback has shown they prefer to pay a nominal amount and have it

all arranged by the instructors.

Refer to Appendix I for the Certificate of Graduation

Refer to Appendix J for the Report Card

17.11 PERSONAL INSTRUCTORS HAVE A UNIQUE ROLE

This class requires a special person who will be committed to excellence,

professionalism, and who is sincerely interested in both the people and their

profession. The instructors who succeed and are in demand in these classes

are the individuals who really care and want to help these clients.

Individuals will continue to exercise if they receive physical benefits, if they

have a positive experience, and if they like and believe in their trainer. The

effort and care you display as an instructor is farther reaching then may be

expected. News about a phenomenal instructor will travel fast throughout

the community. Our program has become well known and promoted more

through word of mouth and referrals from the medical community than by

our community leisure guide. The participants who have benefited from the

class and believe in the instructors become ambassadors of the program

promoting the class to their friends. Instructors play a huge role in creating

a positive atmosphere for their clients and are often the reason the

participants continue.

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Going the Distance

What are those small actions that make a world of difference and set you

or your program apart from others?

Listen and act on the clients’ concerns, goals, and difficulties

Recognize their achievements with verbal praise or a certificate

Link with the clients’ medical practitioners if applicable and possible

Help to guide the client to pursue their health concerns

Provide graduation options to help them continue their exercises on

their own

Acknowledge Birthdays, Anniversaries; send Christmas, and Get Well

cards

Organize end of the season parties

Make follow-up phone calls for classes missed

95


APPENDIX A GAIT ANALYSIS OBSERVATION CHECK LIST

NAME:

________________________________________________________

DATE:

________________________________________________________

Gait Component

Good

Needs Attention

Comments/Notes

1. Heel Plant

2. Toe off

3. Knee Flexion

4. Knee Extension

5. Hip Sway

6. Hip Extension

7. Hip Flexion

8. Upright Posture

9. Hip Hiking

10. Ankle External

Rotation

11. Pronation

12. Supination

13. Limp

14. Width of Foot

Placement

15. Posture

Analysis and Plan for Progression:

Assessment done by: ______________________

Follow up review date: ______________________

96


APPENDIX B POSTURE GRAPH

97


APPENDIX C PHYSIO REFERRAL FORM

Date: ______________________

Client Name: ______________________ Telephone: ________________________

Physiotherapist: ____________________

Surgical Status

Surgery Date ______________ Right Leg ________ Left Leg __________

Type of Surgery: TKR ______ UKR ______ THR _______ Hip Resurfacing ____

Incision Approach: ____________________________________________________

ROM for TKR/UKR: Flexion ______________ Extension ________________

Weight Bearing Status: FWB _______________ PWB ____________________

Restrictions:

________________________________________________________________________

________________________________________________________________________

Complications: (Dislocations, Manipulations)

________________________________________________________________________

________________________________________________________________________

Post Rehabilitation Exercise Recommendations

Stretching:

Hamstring ___ Quadriceps ___ IT Band ___ Calves ___ Hip Flexor ___

Gluteals ___ Back ___ Chest ____ Neck ___

Strengthen:

VMO ____ Quadriceps ____ Adductors ___ Glut Med ____ Glut Max ____

Hamstring _____ Tibialis Anterior _____ Calves _____ Hip Flexor ____

Cardio:

Recumbent Bike ___ Upright Bike ____ Treadmill ____ Elliptical ____ APT ____

Balance:

Restrictions on 1 leg _______ Restrictions for how long? __________________

Other Relevant Medical History:

________________________________________________________________________

________________________________________________________________________

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APPENDIX D INFORMATION RELEASE FORM

INFORMATION RELEASE FORM This form is to verify that I, (print name) ________________________________ give permission for (Name of hospital, or Physiotherapist) _______________________ to release any pertinent medical information about myself to ____________________. I understand that my medical history impacts my physical health and that this information needs to be shared in order to create the best exercise program possible for my recovery. (initial required) __________________ By signing this release, I am fully aware that my personal health history may be discussed or documented in writing from (hospital name, physiotherapist, doctor’s name) _______________________________to (exercise specialist, personal trainer) _____________________________________.

____________________________________

Patient / Client Name (Print Please)

____________________________________

Patient / Client Signature

____________________________________

Date

____________________________________

Witness Name (Print Please)

____________________________________

Witness Signature

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APPENDIX E SAMPLE PAR-Q

PAR-Q

PAR-Q Physical Activity Readiness Questionnaire

For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them Common sense is your best guide in answering these few questions. Please read them carefully and check the yes or no opposite the question if it applies to you.

NO YES

NO

Question

1.

Has your doctor ever said you have heart trouble?

2.

Do you frequently have pains in your heart and chest?

3.

Do you often feel faint or have spells of severe dizziness?

4.

Has a doctor ever said your blood pressure was too high?

5.

Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?

6.

Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?

7.

Are you over age 65 and not accustomed to vigorous exercise?

If you answered YES to one or more questions... If you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.

If you answered NO to all questions... If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for exercise.

Please be advised that anyone who has the following health status will need to have physician clearance with documented approval before beginning an

exercise program.

High Blood Pressure History Heart/Cardiovascular Disease Diabetes Mellitus Family History of Heart Disease

High Cholesterol Smoker Physcial Inactivity Obesity

Stroke Pulmonary Disease (COPD) Immune Disorder Cancer

Thank you for your cooperation in attaining physician clearance!

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APPENDIX F SAMPLE OF HEALTH QUESTIONNAIRE

Do you have a history of any of the following health concerns?

Health Condition

Yes No Explain / Details

Heart Problems

Blood Pressure

Stroke / TIA

Cholesterol

Diabetes

Respiratory/Asthma

Hypoglycaemia

Dizziness

Seizures

Osteoporosis

Arthritis

Back Pain

Neck Concerns

Other Joint Problems

Broken Bones/Sprains

Whiplash

Surgery

Pregnant

Menopause Status

Neurological Concerns

Other

Hearing

Vision

Memory

Lifestyle Questions:

1. Are you a smoker? Yes ___ No ___ Quantity _________________

2. What is your alcohol consumption? Drinks per week ____________ 3. Rate your stress level on a scale of 1 to 10 (10 is high) _________

4. List your three biggest sources of stress: i) ______________________________________________

ii) ______________________________________________ iii) ______________________________________________ 5. Rate your nutrition level and areas you would like to improve

Nutrition on Scale of 1-10 (10 is great) __________________

Areas for improvement: ______________________________

__________________________________________________ 6. How many hours of sleep do you get per night? ______________

101


APPENDIX G MEDICAL RELEASE FORM

102


APPENDIX H S.O.A.P. CLIENT ANALYSIS

Client Name

________________________________________

Date: ________________________________________

Instructor:

________________________________________

Medical Concern/ Area of Interest: ________________________________________________

________________________________________________

Subjective

Objective

Assessment Action

Plan

Comments:

________________________________________________ ________________________________________________

________________________________________________

________________________________________________

103


Client Initial _______

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APPENDIX I JOINT REHAB EVALUATION REVIEW

Help us to expand the Joint Rehab Program. We welcome your feedback. Please take some time to answer these questions so that we can continue to improve and create the best possible Joint Rehab Programs for you and future knees and hips!

1. What was the most valuable part of this program for you and why?

2. Did the overall program outline meet your expectations?

3. Do you want to suggest any changes and/or additions to this program?

4. Please comment on the knowledge, organization, pace, and overall level of instruction you received.

5. What aspects of the program do you think could be strengthened and how?

6. Do you have any further comments, suggestions or recommendations for us?

Thank you!

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APPENDIX J CERTIFICATE OF GRADUATION

Date Signature

Date Signature

Healthy Joints

Name of Community Centre presents

CERTIFICATE OF GRADUATION

JOINT REPLACEMENT CLASS

OF CLASS of MONTH 2005

FOR OUTSTANDING STRENGTH, STAMINA, AND MIGHTY GLUTS

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APPENDIX K REPORT CARD

JOINT REPLACEMENT POST REHABILITATION CLASS OF ________

Graduate Name: ________________________________________ Instructor: ________________________________________ Congratulations on completing the joint replacement rehabilitation class! You have made progress and achievements in the following areas: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ The physical components we would like you to continue to focus on developing include: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Your greatest accomplishment was __________________________ Wishing you continued health and happiness! We hope you keep active and pursue lifelong fitness!

CONGRATULATIONS!!!

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APPENDIX L NUTRITION GUIDELINES FOR HEALTHY JOINTS

Include cold water fish in your diet. Fish oils are beneficial to the joints and

act as a natural anti-inflammatory. Eat wild fish rather than farmed

whenever possible.

Cod liver oil is a common remedy for joint pain and an excellent source of

vitamin D. Vitamin D is essential for strong bones. Take at least one

teaspoon of high quality cod liver oil daily.

Include essential fatty acids (EFA’s) such as raw nuts, legumes, primrose

oil, grape seed oil, fish oil, salmon oil, flax seeds or flax seed oil

Reduce or eliminate alcohol, caffeine, and refined sugar.

Maximize your intake of fresh fruits and vegetables as a source of vitamins,

minerals, and fibre.

Plants of the nightshade family may aggravate osteoarthritis in some

people. If all other changes do not bring sufficient improvement, then do

a trail elimination of tomatoes, white potatoes, eggplant, and peppers.

Some people find they can eat cooked tomatoes if the skin and seeds

are removed.

Eat more sulphur-containing foods, such as eggs, garlic, onions, and

asparagus. Sulphur is needed for the repair and rebuilding of bone,

cartilage, and connective tissue and aids in the absorption of calcium.

Get plenty of fresh air and sunshine. Sunshine is needed for the synthesis of

vitamin D and in turn promotes proper bone formation.

While non-steroidal anti-inflammatory drugs (NSAIDS) offer symptomatic

relief, they may actually promote the disease by inhibiting cartilage

repair. They also have significant negative side effects. Try natural anti-

inflammatory alternatives such as bromelain, tumeric, and devils claw.

Fresh pineapple is an excellent source of the enzyme bromelain.

Bromelain is commonly used for reducing inflammation. Cooking or

canning will destroy enzymes.

Good quality fat is essential to the absorption of minerals including

calcium and magnesium. Use butter in moderation and include whole fat

yogurt in your diet. Cultured dairy products are less likely to cause

digestive problems.

Check for possible food allergies. Wheat and dairy are particularly

implicated in osteoarthritis and rheumatoid arthritis.

For more information email Nick McDonnell, RHN, RNCP,

Registered Nutritional Consultant, BCRPA Personal Trainer

108


APPENDIX M SHOE SELECTION BIOMECHANIC DESIGN

Individuals with knee or hip related pain find some respite when fitted properly in a good

supportive “running” shoe. Though running a 10 k is not necessarily part of their exercise routine, this type of footwear is a shoe fitter’s first choice for the joint sufferer because of its unique combination of support, cushion, and fit.

Some “running” or “training” shoes are made for feet that pronate too much or roll in. This is

the most problematic and dominant gait deviation that negatively influences the knee and hip. Excessive pronation, if not properly controlled, is a prime contributor to numerous foot, leg, and back-related syndromes. Knees that internally rotate, or “pronate” too much, cause undue stress on the medial or inside aspect of the knee. This hyperpronation allows too much hip rotation, causing torque on a variety of tendons, ligaments, and muscles that support the hip region. Many running shoe styles are specifically profiled for this mechanical tendency of over-pronation! Combining the supportive shoe with arch supports or custom orthotics represents a strong front line attack on this significant contributor to knee and hip instability. The strategy of support from the ground up is the same whether the knee/hip is in pain or the patient is adjusting to a replacement joint. Stability, structure, and support will aid in creating superior alignment with less joint wear and better balance. Replacement joints will mean new, and hopefully improved, mechanics; therefore, it is always a good strategy to have the correct shoes that do not allow the foot to “revert to old foot habits”. The shoe fitter and the health care professional should watch the client walk and be able to assess whether the foot, arch, knee, and hip are all working together in a mechanically efficient manner. Making sure that any excessive pronation or under pronation is being managed is key to any rehabilitation program. The shoe needs to fit well and feel stable while walking or exercising.

Some walking shoes have excellent support and/or cushioning, but, on average, are guilty of sacrificing one or both of these qualities for a casual look and easy to clean material. So those who are not blessed with perfect mechanics and have joint issues may find the runner a more sound choice. If the rehabilitation program and exercise involves pool aerobics, there are aqua shoes, which protect the bottom of the feet and help with stability. As one is buoyant while in the water, the primary purpose of aqua shoes is to protect the foot from scraping against an abrasive pool floor.

Remember with each foot strike, a chain of events begins; the impact and resultant torque affects every joint in the body. Therefore start with a good foundation…..supportive, good fitting shoes………your joints will thank you as you speed to a strong and healthy future.

Phil Moore BA-BPHE, Queens ‘81

Co-owner LadySport Ltd.

Telephone: 604-733-1173

3545 W. 4th

Ave Vancouver BC V6R 1N9

109


GLOSSARY

Avascular necrosis – this term describes the loss of or lack of blood flow to

a joint causing death to the surrounding tissue and bone

Bilateral Hip Replacements – This refers to when both hips are replaced

simultaneously. This surgery has a long recovery period and is only

performed on individuals with a high fitness level pre operation.

Biological Fixation – the process where the bone grows into the metal

prosthesis and secures the joint *(Interestingly, only about 30% of the

prosthetic surface becomes ingrown with bone tissue. Also, the bone

ingrowth occurs increasingly for the first 12 weeks post operation and then

slows to minimal growth after that point.)*

Hemiarthroplasty – is a partial or ½ of a hip replacement where only the

femoral head is replaced due to damage such as occurs with femoral

head necrosis

Hybrid is a type of hip replacement which describes a prosthesis that has

a combination of cemented and uncemented components.

Inflammatory Arthritis: is a group of arthritic conditions involving significant

inflammation (pain, swelling, redness) in the joints and/or other tissues and

examples include: Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic

Arthritis.

Manipulation – a manipulation procedure occurs when a patient is not

gaining the range of motion they should have post surgery and so the

surgeon applies extreme forces to the knee joint while the patient is under

general anesthetic

Minimally Invasive Knee Surgery (MIS) describes a knee replacement

procedure where smaller incisions are made with the result of a smaller

scar and less tissue damage; the surgeon decides whether this procedure

is appropriate depending on the patient’s joint size, severity of their

arthritis, and ROM.

Osteonecrosis – this term refers to the death of bone by various means

Post traumatic Arthritis: Injury induced arthritis, induced immediately or

shortly after a trauma or injury

110


GLOSSARY

Primary Knee Replacement – is the first knee replacement surgery on a

knee joint

Revision Surgery – refers to the second surgery or any further surgery

performed on a joint replacement when loosening or other complications

occur

Resurfacing Arthroplasty – Is a term used for a type of hip surgery where

only the surfaces of the femur and acetabulum are cleaned up and

resurfaced rather than the whole head of the femur being cut off and

hollowed as would happen in a THR. In a TKR, only the patella has the

option for resurfacing.

Revision of Hip Replacement – A second operation on a previous hip

operation which has failed or loosened. The revision may include only

part or all of the previous implants being replaced with new ones.

Total Hip Arthroplasty – this is another term used for THR

Total Knee Replacement (TKR) – (also referred to as total knee

arthroplasty) is when both the medial and lateral components of the knee

joint require replacement including the femoral condyles and the tibial

plateau. A total knee replacement does not always involve replacement

or resurfacing of the patella; it will only be altered in surgery if required.

Unicompartmental Knee Replacement (UKR) describes a partial knee

replacement where only the medial or lateral aspect of the knee joint is

replaced.

111


WORKS CITED

Access to the Minds of Medicine. 23 April, 2005 www.emedicine.com/pmr/topic222.htm

Brander V., Stulberg SD. Rehabilitation after hip and knee joint

replacement: An experienced and Evidence Based Approach to Care. American Journal of Physical Medicine and Rehabilitation.

Vol 85, No. 11. pp S98-S118

Cluett, Jonathon M.D. “Minimally Invasive Knee Surgery.” About Orthopedics. 21 Jun, 2003. Orthopedics. 23 April, 2005.

http://othopedics.about.com/cs/kneereplacement/a/kneeuni_2.htm

Cluett, Jonathon M.D. “Unicompartmental Knee Replacement”.

About Orthopedics. 21 Jun, 2003. Orthopedics. 23 April, 2005 http://orthopedics.about.com/cs/kneereplacement/a/kneeuni.ht

m

Jones Dina L., Westby Marie D., Greidanus Nelson, Johanson Norman A., Krebs David E., Robbins Laura, Rooks Daniel S.,

Brander Victoria. Update on Hip and Knee Arthroplasty: Current State of Evidence. Arthritis and Rheumatism. Vol. 53 No.5

October 15, 2005,pp 772-780

Mayo Clinic Staff. “Knee replacement: Surgery can relieve pain”. MayoClinic.com 17 Jun, 2004. The Mayo Clinic. 23 April, 2005

http://www.mayoclinic.com

Mayo Clinic Staff. “Total hip replacement: Relieve pain, improve

mobility”. MayoClinic.com 18 Apr, 2005. The Mayo Clinic.

23 April, 2005. http://www.mayoclinic.com

Nichols, Jack, Dr. Joint Replacement Surgery. 23 April, 2005

North Valley Orthopedic Medical Group http://www.drjacknichols.com/news-joint-replacement-

surgery.htm

Rasul, Abraham T Jr MD, Wright, Jeffrey. “Total Joint Replacement Rehabilitation”. Emedicine.com. 13 July, 2004.

Emedicine Instant

“Total Joint Replacement”. Your Orthopedic Connection. 2000. American Academy of Orthopedic Surgeons. 08 May, 2005

http://orthoinfo.aaos.org

http://www.emedicine.com/pmr/topic222.htm



http://orthopedics.about.com/cs/kneereplacement/a/kneeuni.htm

http://orthopedics.about.com/cs/kneereplacement/a/kneeuni.htm

http://www.mayoclinic.com/

http://www.mayoclinic.com/

http://www.drjacknichols.com/news-joint-replacement-surgery.htm

http://www.drjacknichols.com/news-joint-replacement-surgery.htm

http://orthoinfo.aaos.org/

Documents

“The World of Joint Replacements”“The World of Joint Replacements” ... these individuals to keep up their exercise regime in the hopes of returning back to a pain free functional