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Doctor Examining Male Patient With Knee Pain

Restoring Movement and Mobility: The fitness professional’s role in total joint replacement care

According to the American Joint Replacement Registry, there are 860,000 total knee and hip replacements done in the United States per year. This number is projected to double in the next ten years. There are more knees than hips done per year and more females have these joint replacements than males.

According to Mike Carberry of Advanced Medical Integration, “Regenerative medicine is one of the most talked about subject healthcare has ever known; and for good reason. It could hold the solution to the puzzle of America’s failed healthcare system.”

This is wonderful news for the personal training industry. Insurance is paying for less and less, costing more while the number of consumers seeking optimal health is increasing. A perfect storm in the making!

A personal training certificate, however, is not enough to appropriately deal with the typical client with total joint needs. Specialization in anatomy, joint physiology, biomechanics and therapeutic exercise are necessary in order to adequately and appropriately manage total joint conditions. These skills and techniques in conjunction with medical communication skills will give physicians confidence to send these patients to the appropriately skilled personal trainer. Spending time with a physical therapist and surgeon specializing in these areas will go a long way in establishing confidence, trust and credibility in handling the client with total joint conditions.

Most individuals with true joint pain have some level of osteoarthritis. Approximately 27 million Americans suffer from degenerative joint disease (also known as degenerative arthritis or osteoarthritis). Degenerative joint disease is the most common chronic condition of the joints and occurs most often in knees, hips, lower back and neck, small joints of the fingers, and the bases of the thumb and big toe.

Osteoarthritis is the most common form of arthritis that causes a breakdown of joint cartilage, and it affects mostly middle-aged and older adults.

Although there is no cure for osteoarthritis, the good news is that it can be helped, and quality of life maintained by implementing and maintaining some simple changes in daily life. Regardless of the intervention, from routine steroid injections to platelet rich plasma/stem cell treatments to total joint replacement, here are a few areas where the personal trainer can intervene with great success.

Exercise

Exercise is key component of arthritis care, exercise strengthens the muscles, lessens joint pain and stiffness and improves overall health. Types of recommended exercises may include strengthening, aerobic activity (aquatic activity is wonderful), range of motion or stretching activities and balance exercises.

Joint protection

Protect the joints to ease pain and avoid further damage. Make sure to balance rest with activity as well as know when to stop. A good rule of thumb is to adjust down the frequency, intensity and duration by 50% of what a “normal” client can do or what the client thinks they can do. Remember these clients are typically deconditioned relative to strength and cardiovascular fitness. They will not handle the all-too-popular high-intensity interval training (HIIT). This population will succumb to overload and may be injured.

Pain control

Pain control routinely treated with prescription or over-the-counter medications can be replaced or augmented by relaxation techniques (yoga, Tai Chi, meditation and massage) along with application of heat, cold and/or vibration.

Post-procedure care

If the client has had regenerative therapy or a total joint replacement, they will need a specific post-procedure plan to allow for healing/protection, early intervention and return to activity function. Hopefully, they had pre-intervention care inclusive of appropriate exercise, nutritional counseling and insight on what to expect with the procedure and post-procedure care. Appropriate nutrition for optimal health and healing along with hydration techniques and insights are a must during these sessions.

Phase 1: Post-procedure care

Typical post-procedure care is in three to four phases. Phase one is protect/rest, restore and control pain. During this phase the focus is on mediating pain, restoring range of motion, controlling swelling and protecting the joint. This is typically fourteen to twenty-one days in duration. Stitches or staples are usually removed at this time and scar management can commence around the twenty-first day.

Phase 2: Post-procedure care

Phase two is the restore and regenerate phase. The

wound is healing (healed), the joint and soft tissue healing continues, and remodeling of tissue has begun. This phase is typically three to six weeks in duration. Techniques to restore range of motion and other soft tissue techniques to facilitate healing according to tissue physiology and the client’s general health are initiated (conditions such as diabetes, obesity, cardiovascular disease and others will alter the healing and remediation phases). Techniques for ambulation, gait and balance are initiated along with appropriate cardiovascular conditioning.

Phase 3: Post-procedure care

Phase three typically commences when the client has gained full range of motion, has good balance and gait mechanics and is able to tolerate closed-chain activities for both upper and lower extremity movement patterns. This phase is the final phase and progresses to full functional activity and return to sport or recreational activities of choice (these activities may be placed into a fourth phase). During this phase it is incumbent upon the personal trainer to load appropriately and have working knowledge of the mechanics of the sport or recreational activity. There are some tremendous resources available for this purpose.

Complications

Complications to be aware of when working with these patients include but are not limited to infection, blood loss, dislocation, blood clots and fatigue. The personal trainer should also be in contact with the client’s physician and physical therapist if one has been engaged. These are medical conditions requiring communication and conservative care.

Most physicians like to know who is working with their patients and appreciate the communication for optimal outcomes. The insightful and knowledgeable personal trainer with the right training can be an invaluable member of the total joint care team. The future is bright!

This information is provided as an overview and in no way should be interpreted as a protocol for treatment or otherwise. Our goal is to inform the reader on opportunities in the profession and stimulate further investigation.

This article was featured in MedFit Professional Magazine fall 2019 issue.

Subscribe to MedFit Professional Magazine to read more great content like this!


Dr. Stephen A. Black is a sports medicine specialist, author and clinician. His doctoral degree is in sports medicine and he holds degrees in physical therapy, athletic training and certification through the National Strength and Conditioning Association. Dr. Black has over forty years’ experience in patient care and practice management. He lectures frequently on topics in sports medicine, works with professional, Olympic and youth athletes and holds several academic appointments. Visit his website, rockymountainhpc.com

trainer-and-senior-woman-gym

Specialize and Thrive: Working with Individuals with Osteoarthritis and Joint Replacements

Arthritis is the most common cause of disability in the world.3 Osteoarthritis, the most common form of arthritis, has led to a dramatic increase in the incidence of hip and knee replacements in recent years. The rate of total hip replacements has almost doubled between the years 2000-20101 and approximately 7.2 million Americans are now living with hip and/or knee replacements. 6 While these rates have nearly doubled in recent years, the number of younger individuals (ages 45-54) having these replacement surgeries is increasing.5

The rapid and dramatic increase in individuals living with osteoarthritis and/or joint replacements has created a massive void between the number of people living with these issues and the number of qualified individuals to help them safely and effectively accomplish their functional goals. This void, however, has created an incredible opportunity for fitness professionals to align themselves with allied health professionals to become part of the solution. This article will discuss some recent changes in the thought process about how osteoarthritis develops, how fitness professionals are an important part of the solution, and why this is the most opportune time for fitness professionals to specialize and align themselves with health professionals.

Why do so many individuals experience osteoarthritis and what can be done about it?

While injury, overuse, age, obesity, genetics, and race have been given as possible causes, there has been a lack of solid evidence to explain why the incidence rate of osteoarthritis continues to skyrocket. 2,3,5 However, recently there have been suggestions that osteoarthritis is not as previously suggested, due only to old age or genetics. Dr. Ian Wallace, a postdoctoral researcher who has studied more than 2,000 skeletons, believes the recent dramatic increase in osteoarthritis isn’t an inevitable consequence of living longer. He believes it is more attributable to the modern decline of physical activity and is quoted as follows: “Dr. Wallace thinks the most obvious candidate to explain the increase in knee osteoarthritis is the modern decline in physical activity.” 8

Nevertheless, it is not just about people needing more quantity of activity; it’s also about the quality of the exercise.10,11 If exercise is performed without optimal joint alignment and control, the individual is at risk for developing degenerative joint changes.10,11 Therefore, it’s imperative that fitness professionals specializing in working with individuals that have osteoarthritis or joint replacements are able to properly assess for non-optimal and inefficient posture and movement habits and from these results, develop an appropriate exercise program. Additionally, fitness professions specializing in this niche must also be able to instruct proper exercise form and understand what exercises or activities are contraindicated with these populations. 10,11

A well-designed exercise program that includes flexibility, strength, and cardiovascular exercise is required to appropriately address the postural and movement habits that contributed to the development of osteoarthritis. Likewise, many individuals will have developed compensatory patterns as a result of joint pain or loss of mobility and subsequently developed non-optimal posture and movement habits that need to be addressed.

Several organizations including the Arthritis Foundation, Center for Disease Control, and American College of Sports Medicine have created guidelines for working with individuals that present with arthritis. General recommendations include improving joint mobility/flexibility, aerobic conditioning, resistance training, maintaining a healthy weight, and consulting with a medical doctor.2,3,13

Helping individuals develop a more optimal and efficient posture and movement strategy is one of the most effective strategies for safely working with individuals with osteoarthritis and joint replacements.9,10,11 An approach that includes using the most appropriate soft tissue release, mobilization, stretching, neuromuscular activation strategies, and appropriately progressing the individual through the fundamental movement patterns has been shown to improve joint mobility and strength in individuals with osteoarthritis as well as joint replacements. 9,10,11 Additional strategies that have been shown to be helpful in improving strength and mobility and managing the symptoms of osteoarthritis include three-dimensional breathing7,9,10,11, proper nutrition featuring a whole-foods, plant-based diet4, and meditation.14

The future

The great news is that there is a growing need for qualified fitness professionals to work with the increasing numbers of individuals that have osteoarthritis and/or joint replacements. However, this requires that the fitness professional have both the right education and the appropriate skillset as many of these individuals will require a thorough approach to address their specific needs and to provide them with the best functional outcomes. Organizations such as the MedFit Network, The Institute for Integrative Health and Fitness Education, and the Functional Aging Institute are helping to create the education necessary for health and fitness professionals to develop specializations in working with special populations including the older adult populations experiencing osteoarthritis and joint replacements. Additionally, through their educational platforms and live course work, they provide fitness professionals with strategies for aligning and working with allied health professionals.

For many individuals experiencing pain or loss of function secondary to osteoarthritic changes, seamless integration between medical procedures, rehabilitation, and functional fitness is becoming a viable and necessary alternative to narcotics and surgery. Hence, the birth of the medical fitness space where fitness professionals work either in collaboration with or in the actual physical location of medical doctors, physical therapists, chiropractic physicians, and massage therapists. Clinics such as Rejuv Medical have provided a model for how to improve patient outcomes by combining the benefits of regenerative medicine procedures (Plasma Rich Protein and Stem Cell Therapy), physical therapy, and personal/group training.

Specialization in working with individuals that have osteoarthritis and/or joint replacements and working in the medical fitness space is the future. The fitness professional that acquires the appropriate education and develops a working relationship with allied health professionals will be able to attract more individuals that need, want, and will pay for their expertise. By providing a more integrated and effective approach to helping individuals accomplish their health and fitness goals, these fitness professionals will continue to thrive in the coming years.

This article was featured in MedFit Professional Magazine summer 2019 issue.

Subscribe to MedFit Professional Magazine to read more great content like this!


Dr. Evan Osar is an internationally recognized speaker, author, and expert on assessment, corrective exercise, and functional movement. Dr. Osar is committed to educating and empowering fitness professionals while helping them develop relationships with allied health professionals. He is author of the Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction and has developed the industry’s most complete training certification, the Integrative Movement Specialist™. With his wife Jenice Mattek, he created the on-line educational resource www.IIHFE.com

 

References:

  1. American Association of Hip and Knee Surgeons. NCHS Releases Hip Replacement Data. Retrieved from http://www.aahks.org/nchs-releases-hip-replacement-data/
  2. Arthritis Foundation. Osteoarthritis Treatment. Retrieved from http://www.arthritis.org/about-arthritis/types/osteoarthritis/
  3. Centers for Disease Control and Prevention. Osteoarthritis. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
  4. Clinton, C., O’Brien, S., Law, J., Reiner, C., Wendt, M.R. (2015). Whole-Foods, Plant-Based Diet Alleviates the Symptoms of Osteoarthritis. Arthritis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359818/
  5. Dotinga, R. (2015). Number of Hip Replacements Has Skyrocketed, U.S. Report Shows. Retrieved from https://consumer.healthday.com/senior-citizen-information-31/demographic-arthritis-news-37/number-of-hip-replacements-has-skyrocketed-u-s-report-shows-696419.html
  6. Mayo Clinic. First nationwide prevalence study of hip and knee arthroplasty shows 7.2 million Americans living with implants. Retrieved from http://www.mayoclinic.org/medical-professionals/clinical-updates/orthopedic-surgery/study-hip-knee-arthroplasty-shows-7-2-million-americans-living-with-implants
  7. Mattek, J. and Fisher, S. (2017). What Lies Beneath: The under-realized effects of breast, abdominal, and pelvic surgeries. St. Bernardino, CA: Niche Pressworks.
  8. McDonald, B. (2017). Skeletons say arthritis isn’t about aging – it’s about activity. Retrieved from http://www.cbc.ca/radio/quirks/august-19-2017-1.4252722/skeletons-say-arthritis-isn-t-about-aging-it-s-about-activity-1.4252755
  9. Osar, E. (2012). Corrective Exercise Solutions for Common Hip and Shoulder Dysfunction. Chinchester, UK: Lotus Publishing.
  10. Osar, E. (2017). Integrative Corrective Exercise Instructor Certification Program: Training the Older Client. Chicago, IL: Institute for Integrative Health and Fitness Education course handouts.
  11. Osar, E. (2018). The Fundamentals for Training the Older Client with Osteoarthritis. Retrieved from https://www.ptonthenet.com/remote-learning
  12. Pagnano, M., Wolfort, M., Berovitz, A. 2015. U.S. National Center for Health Statistics. Data brief; National Center for Health Statistics.
  13. Riebe, D., Ehrman, J., Liguori, G., Magal, M. ACSM’s Guidelines for Exercise Testing and Prescription. 10th Philadelphia, PA: Wolters Kluwer.
  14. Selfe, TK., Innes, KE. 2013. Effects of Meditation on Symptoms of Knee Osteoarthritis. Alternative Complementary Therapies; 19(3): 139-146.

 

ORTHOPEDICS CONSULTATION WOMAN

If You Can’t Beat It, Use It: An Exercise Guide to Post-Joint Replacement Wellness

It all started over 40 years ago, when I chose as my sport – some would say, my life – the Korean martial art of Tae Kwon Do. I was young, fit, pretty strong and, unbeknownst to me, very flexible – perfect for the art of kicking high and hard. Once I got hooked on it, I was in the gym a few hours a day, 6-7 days a week…for the next almost 20 years. That did not include the running I did to get my cardiovascular conditioning primed for the art and sport I was practicing at high levels of both skill and competition. I knew then, at age 19, that I was going to pay for the training and abuse I was putting my body through, but not until I was older, say, 40 or so.

ORTHOPEDICS CONSULTATION WOMAN

Rebuilding and Regenerating Damaged Knees: The Future Has Arrived!

If you grew up in the 1970s, you may remember the Six Million Dollar Man TV show with Steve Austin. The show began with a futuristic-type regeneration of an injured Steve Austin, and they would say, “we have the technology, we can rebuild him.” It was a great one-liner, but seem so far-fetched. Fast forward 30 years, or just one generation. The future is now. We have the technology!

Baby Boomers and Joint Replacement Surgery

Close to 800,000 people in the United States will have a joint replaced this year. Osteoarthritis is the main—but not the only—reason. Joint replacements have become so common that most massage therapists can expect to see clients who are in various stages of recovery from this procedure. But just because it’s common doesn’t mean it’s risk-free, and a person who has had a joint repaired has a significant chance of complications that impact bodywork choices in both the near and long-term.