Presurgical conditioning pays big postsurgical dividends

By Eileen Beal, MA

If the arthritic joint pain you are having is constant, excruciating and so disabling it’s drastically interfering with work, everyday activities and sleep, you are probably contemplating joint replacement surgery.

You’re not alone.  Over a million joint replacements – partial and total – are done every year.  Knee replacements top the list, but hip, shoulder, ankle and elbow surgeries are common, too, says Dr. Laurence Bilfield, FABOS, an orthopaedic surgeon at Lutheran Hospital.

And, adds Janet Babinyecz, RN, CNS, the coordinator of Parma Community General Hospital’s “Joint Camp,” women outnumber men when it comes to joint replacements.  “They live longer,” she explains, “and the wear and tear on joints due to obesity may play a role, too.”

Surgery you can plan for

Joint surgery is major surgery.  But it’s not emergency surgery, so you can plan it around your schedule.  And you can spend the weeks leading up to it doing pre-hab – physical conditioning – to get ready for it and post-surgical rehab.

Most of the research published in the leading rehab and physiotherapy journals indicates that pre-hab, especially for knee replacement, pays big postsurgery dividends in terms of increased upper leg strength, better balance and walking speed, and endurance.

“The kind of preparation and education the patient gets [in pre-hab] … doesn’t just get them in the best possible condition for surgery and rehab, it shapes expectations and, because they know what’s coming, enables patients to have some modicum of control over the situation,” explains Dr. Michael J. Salata, director of the Joint Preservation and Cartilage Restoration Center at University Hospitals Case Medical Center.

And because you also learn how to “do” rehab, he adds, you gain the mental and emotional confidence needed to get the most out of rehab – whether it’s done in a skilled nursing facility, outpatient clinic or at home.

Pre-hab vs. rehab

Like rehab, pre-hab is:

• a comprehensive, progressive physical conditioning program focused on building and strengthening muscle and improving coordination
• personalized and individualized to the patient’s needs, abilities and goals
• a team effort  involving the surgeon, physical therapist and patient

Unlike rehab, however, pre-hab is done when you aren’t:

• worried about tearing open a surgical wound
• figuring out how to use a new, swollen joint
• dealing with the side effects of pain medications that may make you lethargic, dizzy or constipated
• struggling to figure out how to use equipment or assistive devices – that are supposed to make getting around easier – without falling

For most people, four to six weeks of pre-hab is sufficient preparation for surgery and rehab, Babinyecz says.

However, those who are frail and/or extremely reconditioned due to their joint pain or who have co-existing conditions – obesity, multiple joint problems, cardiovascular disease, etc. – may require a longer or specially tailored program. Noting that neuromuscular stimulation can provide significant gains in strength and muscle function, Bilfield stresses that “If patients aren’t able to do even simple exercises, there are other options.”

Whether you are participating in a hospital-sponsored class, working with a physical therapist or personal trainer (an out-of-pocket expense), or using the materials – hand-outs, DVDs, etc. – at home that are provided by the surgeon who’ll be doing your surgery, you need to ensure your program:

• begins with at least one session with a physical therapist (PT) “to make sure you are doing everything the right way,” stresses Salata.
• isn’t too strenuous.  “Aim for sessions three times a week and make sure to take breaks,” advises Salata.
• provides a variety of structured and progressively more complex activities because, admits Babinyecz, “you can get bored in re-hab.”

In pre-hab you will usually be doing what are called “conditioning” exercises.  These kinds of exercises don’t just strengthen main muscle groups, they improve circulation and cardiovascular fitness; improve balance, flexibility and range of motion; increase stamina and coordination; and increase the physical reserves you take into surgery and rehab, says Bilfield.

Start off slowly and gently

Most programs begin with exercises that strengthen muscles and muscle groups without putting stress on the affected joint.  “Everything is gentle and slow at the start,” says Salata.

These early exercises put you in touch with how the affected joint’s support system – muscles, tendons, ligaments, etc. – works.  And they lay the groundwork for increasingly more complex workouts, perhaps with resistance bands, equipment … or the pool.

In a pool, explains Bilfield, gravity is your friend.  “It takes the stress off the patient’s joints – including the pain in the spine and back pain that’s often associated with hip or knee pain – so there’s minimum pain during workouts.”

Since the body is buoyed, there’s better balance, too, adds Salata.

Is pre-hab for you?

Almost everyone is a candidate for pre-hab.  The best candidates, however, are those who are undergoing knee replacement (which tends to respond very well to pre-hab); athletes and sports buffs; and, surprisingly, those who have become very reconditioned due to pain and joint immobility. “They aren’t just motivated,” says Bilfield, “they are committed to a program that will benefit their long-term outcome.”

Who pays for pre-hab?

A growing number of hospitals now offer pre-hab programs (such as Parma Community General Hospital’s Joint Camp) and pre-hab sessions are increasingly covered by insurance and HMO plans.  However, insurance usually covers only a set number of pre-hab/rehab sessions. If you feel you need more, or want to work on your own with a physical therapist, that’s a cost you’ll be covering on your own.  In addition, if you decide on a home-based program, there may be out-of-pocket expenses for DVDs or equipment.

Is the time-energy-money investment in pre-hab worth it?

“Absolutely!” says Bilfield.  “Studies show faster recovery and that function comes back more quickly, too.”

“Definitely!” says Babinyecz.  “We get really good feedback on Joint Camp.”

Salata is a bit more cautious.  “For the right patient, yes.  And it’s just a matter of determining who that patient is.”

The following sites provide excellent information about pre-hab, surgical procedures and postsurgical recovery and rehabilitation:

Joint Replacement Surgery and You

The publication can also be ordered, free of charge, by calling:  877-22-NIAMS (877-226-4267)

OrthoInfo

Arthritis Foundation