Working with Pre and Post-operative Orthopaedic Clients

Learning Objectives:

1. The fitness professional will be introduced to the guiding concepts of working with the pre-and post-operative population so that they can develop the skills to confidently serve the client.
2. The fitness professional will discover how the three principles of the Integrative Movement System™ can help the pre- and post-operative client achieve their functional goals.
3. The fitness professional will be able to marry the guiding concepts with the principles of the Integrative Movement System™ so that they can administer a successful corrective exercise program with their clientele.
4. The fitness professional will understand how to modify and progress a client’s exercise pattern, from the most basic to more advanced versions, using the pre-operative client undergoing knee surgery as an example.

As individual’s move through various challenges in life, whether they are natural occurrences (e.g., pregnancy, aging, the result of injuries, surgeries), or from the development of disease processes (e.g., diabetes, metabolic syndrome, Parkinson’s disease), there is an increasing need for qualified fitness professionals to serve the unique needs of these special populations.

To effectively work with these populations and to become a viable part of a client’s health care team, the fitness professional must understand the unique needs and wants of these populations. They must also possess the knowledge and skill set required to work with this population so that they are not only successful in helping their clients achieve their health and fitness goals, but are also instrumental in helping these individuals accomplish their goals in a safe and effective manner.

This article will focus on the pre- and post-operative orthopaedic clientele and identify some of their unique needs and wants. Additionally, the fitness professional will be introduced to the guiding concepts and the three principles that are required to successfully work with the pre- and post-operative client. Finally, the fitness professional will be guided through modifications and adaptions of an exercise progression so they understand how to apply the concepts and principles to working with the pre- and post-operative client, regardless of the individual’s current level of ability or functional goals.

If you work with the general population, one group of special populations that you will likely encounter is the pre- or post-operative orthopaedic clientele. These are the clients that are experiencing either a joint or soft tissue (muscle, tendon, ligament, joint capsule, or cartilage) injury as a result of a traumatic and/or repetitive use (degenerative) injury. As insurance companies develop stricter guidelines regarding therapy and on-going care, more individuals are being released early from physical therapy. This results in an increasing need for qualified fitness professionals to work with these clients and help progress them towards performing their activities of daily living and accomplishing their health and fitness goals. While it can be challenging to work with clients that currently have orthopaedic problems – pain, degeneration, inflammation, or soft tissue injuries, such as a tears – if you do your due diligence and accumulate the knowledge and the skills, you can help your client approach surgery in a condition that allows them to recuperate quickly. Similarly, if you are working with the post-surgical client, this information can help you progress your client after they have been released from therapy and have been cleared to participate in an on-going exercise program.

Guidelines of Working with the Pre- and Post-operative Client

When working with the pre- or post-operative orthopaedic client, it is important that your client obtain a letter of clearance to participate in physical activity from their medical professional (Bryant & Greene, 2003). Because you are ultimately responsible for knowing what you should or shouldn’t do with your client, you will want and need to directly communicate with this professional so that you can both establish a professional working relationship, as well as determine any indications (things your client should do) and contraindications (things your client absolutely should not do) to working with them.

What are the unique requirements and needs of the pre and post-operative orthopaedic client? Pre-operatively, the client needs to maintain strength, mobility, range of motion, endurance, and stability. As fitness professionals, we can also help these clients develop optimal postural and movement habits that can be built upon after their surgery. Through appropriate corrective exercise patterns and programs, we can help avoid further injuries or compensations until they have their surgery. With the post-operative client, we can pick up where the physical therapist left off and help the client develop symmetry in range of motion, as well as aid them in improving their strength, endurance, and efficiency of movement. Finally, we can be instrumental in continuing to progress our client towards achieving their health and fitness goals.

There are five distinct guidelines that should be adhered when helping these clients accomplish their health and fitness goals either before or after surgery:

1. Become the expert in your special population niche. While basic knowledge can get you by if you are working with a generally healthy clientele without any obvious challenges, you must become an expert at working with the pre- and post-operative populations. Begin by studying everything you can about their injury, their surgical procedure, as well as the rehabilitation process. Your research can include reading any information you can find about your client’s procedure, accompanying them to their doctors and/or physical therapy appointments, as well as studying current information about working with clients either before or after surgery so that you have as much information as possible and are in the best position to be of service to them.
2. It is important to realize that there isn’t one set of rules or a specific program that applies to all pre- or post-operative clients. As evident as the physical and emotional differences are between individuals when you are working with the general population, these variations become even more evident when you start working with pre- and post-operative populations. For example, two clients can present to you having just finished physical therapy following a hip joint replacement. Even though both clients may have had the same surgeon and surgical procedure, been through equal amounts of therapy, and be of the same age, one individual may be ready to progress into a functional training program and will be back to playing tennis in 8 weeks, while the other client may struggle just to walk without compensations after the same period of training. Be sure that your approach reflects the individuality of your client.
3. Establish a working relationship with your client’s health care professional. You are a vital part of your clients’ health care team and at times and in certain situations you may be the most important part of their team. While a parent may be invested in working with their post-surgical youth athlete, many seniors in particular, may not have the same support network. For example, a client of mine recently underwent a hip replacement. She lives alone and has no one to rely upon to help her with her day-to-day tasks or for daily encouragement. Therefore, it is imperative with clients such as this that you not only support them through the work that you do, but that you also remain present during your sessions and provide them with positive emotional support. This often makes all the difference in how quickly these individuals recover. With the post-surgical client, it is imperative that you speak with their physical therapist about where they left off with their rehabilitation and find out if there are any strength, mobility, endurance or other functional deficits so that you can address them as you begin working with your client.
4. Understand the common side-effects of all surgeries including adhesion/scar tissue formation, muscle inhibition, and pain. All surgery results in the formation of scar tissue. In fact, it has been reported that between 85-95% of patients undergoing even relatively ‘routine’ laparoscopic surgical procedures develop adhesions secondary to these procedures (Diamond et al., 1993 & Schleip et al., 2012). Anecdotally, I have had several clients that have undergone surgical procedures to remove significant adhesions/scar tissue following trauma or surgery of the abdomen. If you are working with clients that have postural alterations, myofascial restrictions, or muscle inhibition and aren't responding to the normal program of corrective exercise, consider working with a therapist who specializes in scar tissue therapy. I have had many clients who struggled to progress forward, or fully regain their ability to perform their activity levels, until they combined scar tissue release work with the corrective exercise I was doing with them. For more information on this type of work or to find a therapist that specializes in this kind of work in your area, visit http://www.barralinstitute.com.
   
   Similar to acute joint or soft tissue injuries, inflammation is a normal protective and self-healing response in chronic injuries. The inflammatory response is also a normal occurrence following surgery. Inflammation has been shown to inhibit muscles – generally the smaller muscles – around the regions of the surgery. This also suggests that if there was significant and/or prolonged swelling, either pre- or post-surgically, it is often necessary to help your clients preferentially recruit these deeper, smaller muscles to help restore or regain function.
   
   Pain, either pre- or post-operative pain, is a common part of the injury-healing process. Pain can also affect the ability to produce smooth efficient motion as it tends to inhibit the deep, local stabilizers. For example, low back pain has been shown to lead to inhibition (timing delays and/or atrophy) of the transversus abdominus and multifidus in individuals with low back pain (Richardson et al., 2004). Research has also demonstrated that the deep stabilizers muscles, such as the multifidi, don’t spontaneously regain function even once the painful stimulus is removed (Richardson et al., 2004). Therefore, these individuals require a specific corrective exercise intervention to help restore the balance between the deep and superficial muscle systems as they are progressed through their exercise programs.
   
   
5. Constantly evaluate your corrective exercises and programs, as well as any recommendations given to your client, on a risk to reward basis. This means that when choosing and/or evaluating the effectiveness of a certain exercise pattern or program, consider the risk of the exercise versus the reward of performing the exercise. In other words, you want to be doing exercises and designing programs that have a high benefit for accomplishing your client’s goals with a low risk for developing poor patterns or reinjuring the client. For example, I once had a client returning from low back fusion surgery and he had been cleared by his neurosurgeon to do any core exercise he wanted including crunches. Since he really felt like crunches were good for his abdominals, I had to explain to my client that although the surgeon gave him the carte blanche to do this exercise, it was not an exercise that would help him establish better core stability and would potentially put him at risk for further back injury at the disc levels above and below the fusion. The risk of him doing crunches wasn’t worth the limited benefits of the exercises. Conversely, teaching this client how to find and control neutral spine posture and combining this with leg drops has a much better risk-reward relationship – there is very minimal risk of injury to his spine and there is a lot of benefit or reward from him knowing how to control his neutral spine posture and breathing. Be sure you know what your client wants to do or has been recommended they do so you can assess both their ability to efficiently perform the exercise and/or activity while assessing the risk-reward relationship.

Principles of Working with the Pre- and Post-operative Client

In addition to adhering to the five aforementioned guidelines, helping clients achieve their health and fitness goals either before or after surgery requires a strict adherence to the principles that govern human movement. There are three principles that should be incorporated when working with all clients and especially the pre- and post-operative client.

1. Respiration – Unless there is a specific contraindication, improving respiration will enhance your clients’ ability to perform virtually every functional movement pattern. In addition to the obvious benefits of improved circulation, improved oxygenation and decrease in resting blood pressure, pulse, and stress improving respiratory function of the diaphragm and the deep muscle system, has been shown to improve stabilization of the trunk and spine and hence function of the lower extremity (Osar, 2012).
2. Centration – Similar to respiration, virtually every client will benefit from improved joint centration. Centration is achieving an optimal positioning and control of a joint or series of joints. Centration enables our clients to achieve optimal alignment of their body. Centration requires both stability (the ability to control the position of the joints) and dissociation (the ability to control our joints as we move segments independently from each other). Improving centration can be challenging, especially when there is associated joint or soft tissue injury. An example of how to optimally centrate the hip and lower extremity is demonstrated in the exercise progression described below.
3. Integration – Once we have taught our clients how to optimally breathe and centrate their joints, to restore function we must teach them how to coordinate these activities into the fundamental movement patterns. All movement can be broken down into a combination of seven basic patterns: pushing, pulling, squatting, lunging, bending, rotating, and gait. While the pre-operative client may not be able to perform each pattern in its entirety, we can break down many of these patterns so that they can develop improved alignment, breathing, and control prior to their surgery. Similarly, we can use modifications of these patterns to progress our post-operative clients towards achieving their functional health and fitness goals.

Exercise Progressions for the Pre and Post-operative Client

To improve their functional capacity and/or return to activity, each client in a pre- or post-operative condition will require a certain level of acuity in the following components: alignment, breathing, and control. Regardless of their level of ability, our goal as fitness professionals is to find ways to help our clients be successful in improving their ability to maintain posture, alignment, breathing, and integrating these components into their corrective exercise program.

If you work with the general population, you will likely either be working with a client that has had a knee procedure or you will have a client that will be going for a knee procedure in the future. Knee surgery is the most common orthopaedic surgery and not so ironically, approximately one-third of all orthopaedic surgeons focus in this region of the body (Kim et al., 2011). In fact, there are approximately 719,000 total knee replacements (Kim et al., 2011) and over 900,000 arthroscopic knee procedures (Centers for Disease Control) every year in the United States. For purposes of providing a practical example of using these concepts in an exercise progression, consider that you are working with a client that has a moderate to significant level of knee discomfort and is scheduled for surgery in three months.

On assessment you note limited range of motion of her hip and knee, postural compensations of her pelvis and spine, and atrophy of her hip and thigh muscles on the side of her painful knee. However, you also note that this client can barely load through her lower extremity without significant discomfort. How do you structure an effective corrective exercise program to help your client when she presents with the recommendation by her orthopaedic surgeon to strengthen her leg prior to surgery?

First, you will want to find a position in which your client can achieve the best postural alignment, while placing the least amount of stress on her knee. Let’s assume she can sit fairly comfortable without knee discomfort. You can teach her how to sit with a neutral pelvis position and position her spine in neutral posture. In this posture, you can challenge her to isometrically hold this posture or you could challenge her with a combination of pushing and pulling patterns. For many clients, you may be able to push laterally on their thighs or knees to challenge their ability to hold neutral alignment of their hip, knee, ankle and foot. (See video below for example of how to utilize this isometric postural challenge).

To further challenge the lower extremity without placing any relative load through the knee, the modified side bridge pattern, a modification of the reflex roll patterns taught in Kolar’s Dynamic Neuromuscular System, is a great way to begin activating the muscles of the entire hip complex (Kolar, 2009; Osar, 2012). Since loss of hip alignment is a primary contributor to knee problems, this pattern is an effective way to centrate the hip without placing any additional stress upon the knee. It is also a great pattern to re-establish hip and knee stability and return your client to a high level of function following their surgery. Remember, whether your client is pre- or post-operative, use the level of pattern that is appropriate for your client and either modify or discontinue the movement if there is any associated joint or myofascial pain as the client performs the exercise.

Level 1

The client lies on his side so that his shoulders and hips are stacked and parallel to each other. The elbow and shoulder are flexed to 90° and the hip is flexed to approximately 45-90° so that the client’s spine and pelvis remain neutral. Although not noted in the image below, the client’s head and top knee should be supported on a rolled up towel or bolster so that his spine and pelvis remain neutral. He activates his core and pushes both his elbow and knee down towards the floor, holding this contraction for 5 seconds. This will not be a strong contraction, so be sure the client holds the isometric position and doesn't compensate by rotating away from the starting position. You can challenge the client’s ability to maintain this position by lightly pulling back on their pelvis and/or by having the client rotate their pelvis over top their bottom hip. (See the video at the end of this article for an example of these challenges).

Level 2

In level 2 of this progression, the client will support himself on his ipsilateral forearm and leg. As in level 1, he will push his knee into the floor activating the muscles of his hip complex and retain a neutral spine and pelvis position, parallel alignment of the shoulders and hips, and while continuing to breathe. He holds this position for 2 – 5 breathe cycles and then relaxes. As in the level 1 progression, you can challenge him to hold this position by pulling back on his pelvis or by having him resist pushing or pulling with his non-supporting arm. He repeats the pattern for 2-5 sets depending on the number of repetitions and amount of rest he is taking in between reps.

Level 3

While level 3 is a higher-level progression, if the knee is resting on a soft surface such as a folded up towel and they have optimal core stability, many of pre-operative clients with the appropriate shoulder and core control can perform this version. Just be sure to use caution and discontinue it immediately if there is any pain or inability to maintain the optimal alignment as described below. The client assumes the position from the previous progressions and lifts himself up so that he is supported on both his elbow and knee with his back leg on the floor (images 3a-b). He holds for 2 seconds and returns to the starting position. He repeats for 5-10 repetitions and for 2-5 sets depending upon the number of reps and amount of rest he is taking. It is important that he eccentrically controls the descent and sits back in his hip to improve centration and control of the hip.

Level 4

It is not imperative that a client progress to the level four progression of the modified side bridge, however for the higher level client, this pattern will challenge the lateral stabilization chain and develop the stability required for returning to running, racquet sports, and other high level activities. The client assumes the position and activation from the previous levels. He then lifts himself up so that he is supported on both his elbow and knee while his back leg is off the floor (images 4a-b). The client holds for 2 seconds and returns to the starting position. He repeats for 5-10 repetitions for 2 sets as long as there is no loss of spinal control or shoulder/hip stability throughout the pattern.

To view video examples of these patterns, view the video below:

Conclusion

As our population ages, as certain individuals become more active and sustain injuries, and as more individuals are being released early from physical therapy, there is an increasing demand for qualified fitness professionals to work with the pre- and post-operative client. By increasing your knowledge and skill set, by following the guidelines and principles discussed in this article, and by remaining flexible and empathetic in your approach, you will quickly become known as the go-to expert in this niche so that you continue to passionately serve the population that requires your specific skill set to help them accomplish their health and fitness goals. Working with a special population such as the pre- and post-operative client is the easiest way to differentiate yourself in the industry so that you are not only providing a valuable and needed service, but that you remain in-demand and earn the income deserved of an expert.

References

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3. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. Journal of Bone and Joint Surgery (American Volume); June 2011; 1-93(11).
4. Kolar, P. (2009). Dynamic Neuromuscular Stabilization: A Developmental Kinesiology Approach. Course Handouts. Chicago, IL.
5. Osar, E. (2012). Corrective Exercise Solutions to Common Movement Dysfunction of the Hip and Shoulder. Chinchester, UK: Lotus Publishing.
6. Richardson, C, Hodges, PW, Hides, J. (2004). Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain. Second Edition. Churchill Livingston-Elsevier; NYC, NY
7. Schleip, R, Findley, TW, Chaitow, L, Huijing, PA. (2012). Fascia: The Tensional Network of the Human Body. Churchill Livingston-Elsevier; NYC, NY.
8. Centers for Disease Control. http://www.cdc.gov/nchs/fastats/insurg.htm. Downloaded May 24, 2013.