Article: How to help my client who is having or had a total knee replacement

As Pilates practitioners, we occasionally have clients who have had a total knee replacement or are going to have a total knee replacement surgery.  A total knee replacement is an elective surgery that is only considered once all other conservative treatments have been exhausted.  The main purpose of the surgery is to replace the weight bearing surfaces of the knee joint to relieve pain and disability caused most commonly by osteoarthritis.  There are three stages of a knee replacement; pre-operative preparation, the surgery and post-operative rehabilitation.

As a Pilates practitioner we can help the client manage two of the three stages – pre-operatively and post-operatively and what we do with the client in both of these stages is different.

Pre-operative preparation or ‘pre-hab’ begins as soon as the surgeon has agreed to the surgery.  Unlike an injury which is either acutely suffered or chronically ongoing, surgery is a planned intervention and produces all the same healing mechanisms of an acute injury. However, preparation is done to speed up and improve the post-operative recovery phase.  The client will need to be taught strengthening exercises for the hips, knees and ankles.  These exercises serve a few purposes in preparing the body for surgery by moving the joint through pain free range and strengthening the muscles around the knee, especially the quadriceps, glutes, hamstrings and calves.  We as Pilates practitioners must be careful not to load the knees with springs that are too heavy, or have the client irritate the joint by standing unsupported on one leg.  Rather we should keep spring tension for footwork at a moderate tension and only do simple single leg balance work with them such as standing leg pumps on the Wunda Chair.  Standing on the affected leg on an unstable surface such as a rotator disc, foam block or OOV is contraindicated at this point due to the potential risk of twisting the knee and causing further injury.

Post-operative rehabilitation of the replaced knee is done after the client has medical clearance from their doctor and has usually completed six weeks of outpatient physiotherapy care in the hospital or rehabilitation centre.  At this stage, the goal of the Pilates instructor is to strengthen the muscles of the lower limb, increase the range of movement in the knee, improve standing balance and proprioception.  Footwork on the reformer is a fantastic exercise at this stage, we can start to increase the spring tension, change the position of the stopper to allow more range of movement, explore different foot placement and start to work on single leg variations.  Side lying glutes on the reformer with one foot on the foot bar and a light spring is fantastic for getting the glutes firing with the knee moving through a gradually increased range of movement.  Slowly starting to introduce legs in springs or straps is great to maintain range and strength in the hip joints, however be mindful that frogs and bicycles may twist the knee and irritate the new joint if not controlled well.  At this stage, some clients will be able to kneel and some will have difficulty kneeling, so placing a foam pad under the knees and limiting the amount of time spent kneeling is recommended.  Knee stretches on the reformer can often be too painful, but scooter is a good alternative.

Knee replacements will rarely function as well as a non-replaced knee, so we always need to bear that in mind when working with a client following knee replacement surgery.  Any unexplained pain, swelling or bruising should be referred   for proper assessment by a clinician.

Recommended exercises for clients following total knee replacement aim to:

  • strengthen the quadriceps, glutes and calves
  • improve movement quality of the lower limb
  • strengthen the VMO
  • increase knee flexion and extension with guidance of health practitioner
  • strengthen the standing postural muscles
  • improve standing balance
  • improve client’s ability to stand on one leg

Common exercises for clients post total knee replacement include:

  • footwork on the reformer
  • side lying glutes on the reformer
  • legs in springs or straps
  • side lying legwork in springs
  • standing leg pumps on Wunda Chair
  • seated footwork on Wunda Chair
  • bridges on most pieces of equipment and mat

Here are some articles you can read for further information:

Knee replacement surgery

Total knee arthroplasty

 

Jeremy Hunt
MPhty, BScAPP(HMS)
PAA Treasurer
Studio Manager Polestar

 

image credit: J. Edward Ferguson

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