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Corrective Exercise Strategies for Training the Older Adult with Hip and/or Knee Replacements


Increasing numbers of older adults will undergo orthopedic procedures such as total hip and knee replacements. While hip and knee replacements will improve overall quality of life, a significant proportion of these individuals will require ongoing exercise to combat post-operative changes in strength, endurance, and balance. As part of a comprehensive training program, corrective exercise is a viable strategy for helping these individuals restore function and move towards successfully accomplishing their health and fitness goals. This article will outline how to implement corrective exercise into an overall training program designed to help older adults thrive and achieve their functional goals after hip or knee replacement.

Learning Objectives:

Introduction

A significant number of individuals are undergoing orthopedic surgeries to help them restore quality of life. In fact, a recent survey revealed that there are nearly 7.2 million Americans living with total hip and knee replacements including 4.7 million knee and 2.5 million hip procedures (Kremers et al., 2015; Dotinga, 2015; “Mayo Clinic,” n.d.).

The rate of hip replacements has more than doubled in the previous ten years and the age of individuals having total reconstructive hip or knee surgery has decreased within that time (Kremers et al., 2015; “American Association,” n.d.; “Mayo Clinic,” n.d.). Over half a million individuals have had both hip and knee replacement (Kremers et al., 2015).

It’s been suggested that the increased incidence of individuals experiencing degenerative joint disease, also known as osteoarthritis, has likely contributed to the increased frequency in joint replacement (Dotinga, 2015; Osar, 2015; Osar, 2017).

Once released from post-operative therapy, many individuals that have had a hip or knee replacement will seek out the services of a fitness professional to help them improve strength, balance, and mobility. Secondary to post-operative issues such as scar tissue, muscle imbalances, and altered proprioception, these individuals require a specific approach for helping them achieve their health and fitness goals. As part of a comprehensive training program, corrective exercise is an effective strategy for improving function following a total hip or knee replacement.

This article will discuss what corrective exercise is and how it can be seamlessly integrated into an overall training program designed to help older clients work towards successfully accomplishing their functional goals.

Improving Post-surgical Function with Corrective Exercise

Following joint replacement surgery, many older individuals will present with deficits in strength and mobility in addition to a general loss of optimal movement strategies related to both the surgery itself in addition to compensatory patterning acquired in the years preceding their procedure. Post-surgical physical therapy protocols as well as general strength training programs are effective for restoring function in many people that have undergone these procedures. However, a significant portion of individuals will continue to experience decreased mobility related to scar tissue related restrictions and over-active muscles secondary to proprioceptive deficits and muscle weakness (Mattek & Fisher, 2017; Osar, 2015; Osar, 2017). Additionally, because of the changing landscape of the health care and insurance industries, many individuals are being released from therapy before fully achieving optimal function (Osar, 2017). These individuals are best served by working with a qualified fitness professional who can work with them on developing an integrated strength and conditioning program so that they can achieve their functional goals (activities they need, want, and/or love to do) and simultaneously improve their quality of life.

Corrective exercise is one of the best approaches to addressing post-surgical changes such as mobility, strength, and balance issues that are contributing to one’s chronic tightness, discomfort, or inability to perform their functional goals. In the Integrative Movement System Corrective Exercise Approach´âö (IMS-CEA), corrective exercise is defined as an exercise-based strategy aimed at addressing the underlying cause(s) of chronic tightness, discomfort, and/or an inability to perform at the level one would like or expect (Osar 2015; Osar, 2017). Rather than a substitute for traditional strength training or mobility exercises, corrective exercise should be considered an integral part of an overall training program. Thereby, corrective exercise should enhance and never inhibit an individual’s ability to improve strength, speed, endurance, flexibility or whatever one’s functional goal(s) may be.

Prior to instituting a corrective exercise strategy, performing a thorough assessment is key in uncovering the underlying driving or contributing factors to the client’s issues and/or decreased performance. While it is beyond the scope of this article to discuss all the nuances, a thorough assessment would include posture, range of motion, and more dynamic or movement-based evaluations. If it is within the fitness professional’s scope of practice, muscle testing can also be a valuable tool to help evaluate for muscle inhibition and substitution strategies. While there’s a multitude of assessments that can be performed, the fitness professional will choose the ones that are within their scope of practice and the ones from which they can gather the most information. Recognize that the information gained from the assessment process is more important than the actual group of assessments one is using. This information will guide the fitness professional in choosing the most appropriate and specific corrective and functional exercises.

In the IMS-CEA, there are three specific components to helping individuals work towards their goals once they have been assessed: release, activation, and integration (Osar, 2015; Osar, 2017). As noted, the information gained during the assessment process will then direct the fitness professional to where the individual has deficits in range of motion, proprioception, balance, mobility, and/or strength. The first step of the corrective exercise process is to release the structures that are inhibiting the individual from achieving a range of motion and next, activate the inhibited muscles to help them stabilize a specific position or movement pattern.

Finally, the fitness professional must integrate the concepts from the corrective exercise strategy into the fundamental movement patterns; squatting, lunging, bending, rotating, pushing, pulling, and gait. A successful training program designed for post-surgical clients that are experiencing the loss of performance or chronic posture/movement issues is predicated upon how effectively the individual can incorporate the information from the corrective exercise strategy into both their fundamental movement patterns as well as their functional goals (Osar, 2015; Osar, 2017).

Incorporating Corrective Exercise into a Program

Below is an example of how to integrate corrective exercise into an overall strength program for an older adult client with hip and/or knee replacement. While there will be obvious individual variability, there are common findings with individuals that have undergone hip and/or knee replacements. These include: poor ability to use their posterior hip complex with a decreased ability to rotate their pelvis over their femoral heads (hip hinge), non-optimal alignment and control while standing on one leg, myofascial restrictions in the posterior hip complex, poor respiratory patterns (non-optimal use of the diaphragm and other deep core muscles) and thereby non-optimal core stabilization, over-gripping with the low back erectors and posterior hip complex to compensate for balance deficits (Osar, 2012; Osar, 2015; Osar, 2017).

To address common range of motion, stabilization, and movement issues following hip or knee replacement, there are three primary steps within IMS-CEA: release, activate, integrate (Osar 2015; Osar, 2017).

  1. Release myofascial gripping (over-active muscles and/or fascial restrictions) around the trunk, spine, pelvis and hips to restore range of motion.
  2. Activate the inhibited muscles around the core and hips (generally the diaphragm and other deep hip and core stabilizers including the pelvic floor, psoas, transversusabdominus and deeper glutes) to improve general stability as well as to stabilize the newly acquired range of motion.
  3. Integrate the acquired range of motion and stability into the fundamental movement patterns necessary to help the individual progress towards achieving their health and fitness goals.

Osar on a foam rollerRelease

First, the client will release regions of myofascial (muscles and their investing fascia) restrictions and/or gripping (over-contracted muscles). The foam roll is an effective tool to release posterior myofascial restrictions and/or gripping related to post-surgical compensations (image on right). If it is within one’s scope of practice, manual therapy is also an effective strategy for releasing chronic myofascial tone or gripping that is inhibiting optimal range of motion or joint mobility.

Activate

older adult laying on back stretchNext, the client will perform a pattern such as Supported Happy Baby Breathing with Leg Lift to address three-dimensional breathing while improving overall alignment as well as core and hip stability (image on right). Coordinating three-dimensional breathing with a leg lift from the supine position is important to hip and knee function for several reasons:

older adult squatThe alignment and control developed in the Supported Happy Baby Breathing with Leg Lift pattern is coordinated into the upright position using the Supported Squat pattern. This pattern helps the individual focus on anterior pelvic rotation so they can optimally load their glutes and posterior hip complex without the fear of losing their balance (image on right). It is also a great pattern for developing optimal alignment of the hip, knee, and ankle-foot complex while reducing stress upon the knees and low back that frequently occurs when walking up and down stairs, squatting, lunging, walking, or other activities of daily living. The Supported Squat pattern also helps the individual integrate the overall alignment of their trunk, spine, and pelvis that was developed through the Supported Happy Baby position.

Man standing with arms upIntegration

Finally, the fitness professional will help their client integrate the alignment, breathing, and control developed through their corrective exercise strategy into the fundamental movement patterns. For example, the Split Squat pattern (image on left) is an excellent progression for those clients that have demonstrated optimal alignment and control in the Supported Squat pattern. This is a prerequisite pattern prior to performing lunges, step ups, and single leg balance patterns because it helps clients establish the optimal alignment and control of the core and lower extremities while developing the endurance required for higher-level progressions. The remainder of the client’s program should continue to reinforce and integrate alignment, breathing, and control into the most appropriate movement patterns that help the client work towards their functional goal(s).

Conclusion

Increasing numbers of older adults experiencing degenerative joint disease are undergoing total hip and knee replacements to improve their quality of life. Fitness professionals are in the best position to help individuals who continue to experience chronic tightness, loss of function, and/or the inability to perform at the level they want or need following total hip or knee replacement. This article has discussed how corrective exercise is an integral component of an overall strategy for improving strength, stability, and endurance in individuals that have had hip and/or knee replacements.

Following a thorough assessment to determine the individual’s specific needs, releasing the myofascial restrictions helps to restore range of motion and compensatory gripping strategies. Activation of inhibited muscles facilitates optimal use of the deep core and hip stabilizers required for stabilizing the newly acquired range of motion while reinforcing optimal alignment and control. By integrating alignment, breathing, and control into the fundamental movement patterns, the individual has a strategy for seamlessly integrating the key concepts from the corrective exercise strategy into the exercise patterns that will best help them improve posture and movement efficiency. Corrective exercise as part of an overall conditioning program is an effective strategy for helping older adults remain active and productive in their advancing years while safely helping them work towards achieving their health and fitness goals.

References:

American Association of Hip and Knee Surgeons. NCHS Releases Hip Replacement Data. Retrieved from:
http://www.aahks.org/nchs-releases-hip-replacement-data/

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

Kremers, H. M., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., Jiranek, W. A., Berry, D. J. (2015). Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone and Joint Surgery; 97:1386-1397.

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

Mattek, J. and Fisher, S. 2017. What Lies Beneath: The under-realized effects of breast, abdominal, and pelvic surgeries. St. Bernardino, CA: Niche Pressworks.

Osar, E. (2012). Corrective Exercise Solutions for Common Hip and Knee Dysfunction. Chinchester, UK: Lotus Publishing.

Osar, E. (2017). Integrative Corrective Exercise Instructor: Training the Older Client. Chicago, IL: Institute for Integrative Health and Fitness Education course handouts.

Osar, E. (2015). The Integrative Corrective Exercise Approach. Video retrieved from Fitness Revolution:
http://integrativecorrectiveexercisespecialist.com/