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Before Joint Replacement Surgery, Go Into 'Pre-Hab'

Patients can sharply improve post-op rehabilitation with pre-surgical physical therapy

By Eileen Beal | July 31, 2013

If your knee, hip, elbow, shoulder or ankle pain has progressed to the point that it's drastically interfering with daily activities, sleep and work, and you have exhausted all other options, you're probably facing joint replacement surgery.

The key now is to approach the operation with as much knowledge, preparation and confidence as possible.
 
(MORE: How Do You Know It's Time for Joint Replacement?)

More than a million Americans undergo a total or partial joint replacement every year, according to the National Institute of Arthritis, Musculoskeletal and Skin Diseases. About 60 percent of all joint replacements — the most common: knee and hip — are performed on women. "They tend to live longer and have more arthritis, the main reason for surgery," says Dr. Steven Fitzgerald, an orthopedic surgeon at University Hospitals Case Medical Center in Cleveland.
 
Joint replacement is a major operation, but it's not emergency surgery. In most cases, you can plan it around your schedule, enabling you to spend the weeks leading up to the procedure doing the crucial physical conditioning, or "pre-hab," that can get you in the best possible condition for surgery and give you the best chance of a quick recovery.

Done properly, pre-hab can shorten your post-op hospital stay. But that's not all: According to a study published in the Journal Arthritis Care and Research, patients who participated in a presurgical exercise intervention reduced their odds of requiring post-surgical discharge to an in-patient rehabilitation facility by 73 percent, regardless of which joint was replaced.

What to Expect From Pre-Hab
 
Like rehab, pre-hab is an individualized physical conditioning program designed to strengthen and tone muscles, enhance stamina and increase flexibility and range of motion. It's a team effort involving the patient, surgeon and physical therapist aimed at maximizing the benefits and minimizing the challenges that come with a new joint. 

While the exercises will likely be similar to those a patient can expect to do in rehab, in pre-hab there's no fear of tearing a surgical wound, wrangling a swollen, painful new joint or dealing with side effects of antibiotics or pain medications, like lethargy, dizziness or constipation.

By training and preparing your muscles in advance for the exercises you'll need to do in rehab, you can make that exercise more efficient and effective. In pre-hab, "you are learning how to do rehab and make the most of it," says Dr. Santiago Toledo, medical director of the Orthopedic Rehabilitation Program at the Rehabilitation Institute of Chicago.

For most people, two to six weeks of pre-hab is enough to prepare for surgery and rehab, although patients with co-existing conditions — like obesity, a sedentary lifestyle, multiple joint problems and cardiovascular disease — will probably require a longer program. "Having co-existing medical conditions doesn't exclude you from pre-hab," Toledo says, "but it limits how much conditioning can be done." (Anyone with high blood pressure or cardiovascular disease should consult his or her doctor before starting pre-hab.)

The best programs are "teaching-learning processes customized to the specific goals and needs of the patient," says Leslie Hoyer, supervisor of outpatient physical therapy at Emory University Hospital in Atlanta. Pre-hab often includes: 

  • Coordination and monitoring by a physical therapist who specializes in joint rehab.
  • A variety of structured, progressively more complex activities – and rest breaks.
  • A setting where patients can talk with others who have already had the surgery – and see their progress.
  • At least two supervised, one-on-one sessions a week – and guidance for follow-up exercises to do on your own at home.

Programs usually begin with isometric exercises, like low-impact muscle toning, tensing and stretching. Whether done standing, seated or lying down, these movements are designed to strengthen the muscles, tendons and ligaments surrounding and supporting the joint that will be replaced. The goal is to have as little pain as possible, but there will likely still be some discomfort. Pain can be addressed by therapists through ultrasound, electrical stimulation, hot packs or cold packs, Hoyer says.
 
(MORE: Speed Up Your Recovery by Relaxing)

Initial sessions will detail how your joint's support system works, explore its range of motion and lay the groundwork for later, more complex workouts that may employ resistance bands, weights, gym equipment and, often, a pool. "Pool workouts work for just about everyone," Toledo says, "and because they are very forgiving environments — you are never going to fall out of a pool — they are great confidence builders, too."
 
Is Pre-Hab for You?
 
Almost every joint-replacement patient can benefit from pre-hab, Toledo says, although the best candidates tend to exercise regularly or have experience with a personal trainer. Such patients are already familiar with the payoff that physical conditioning can deliver. People who have had to curtail their regular daily activities because of joint pain, he says, also tend to be particularly motivated pre-hab participants.

Patients who typically gain less from pre-hab are those who haven't come to terms with their need for surgery or who have unrealistic expectations of what pre-hab can accomplish or how easy it will be. But even then, pre-hab can deliver benefits, like changing negative attitudes and providing some of the mental and emotional confidence needed to succeed in post-surgical programs.

(MORE: Replacing Old Joints Can Improve Your Love Life)

Pre-hab is increasingly being covered by insurance and HMO plans, but there are usually limits to the number of one-on-one sessions that will be paid for. Some plans also place a cap on the total allowed pre-hab and rehab appointments. There may also be some out-of-pocket expenses, for personal trainers or gear, like stretch bands.

Every surgeon may not routinely advise pre-hab, so you may need to speak up and ask him or her to suggest a program or put you in touch with a qualified physical therapist or rehab-savvy personal trainer. The professional overseeing your hospital's pre-surgery orientation class, or the rehab clinic's director, may also have suggestions or references.

Doing both pre-hab and rehab with the same staffer can create a seamless, more efficient program and get you back on your feet sooner, stronger and with more confidence.

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