How Prehabilitation Prepares Patients for Total Joint Replacement

Prehabilitation — optimizing a patient’s condition before surgery to help optimize their outcomes after it — is especially important in total joint replacement, says Gary Calabrese, DPT, Senior Director of Rehabilitation and Sports Therapy at Cleveland Clinic.

Patients needing total joint replacement typically have adapted to reduced joint function and increased pain over time. Prehabilitation can help them begin to undo these adaptations by optimizing tissues and modifying behaviors, preparing their body for restoration after surgery.

“The goal of prehabilitation is to help patients reduce complications and length of stay postoperatively, as well as enhance overall quality of life and function,” says Dr. Calabrese. “This involves gathering baseline information and designing a program to maximize their functional capabilities and strength and prepare them mentally for what to expect regarding their pain level, function and stages of recovery.”

Prehabilitation is offered to all patients preparing for total replacement of any joint at Cleveland Clinic.

Systematic preoperative assessment

“When someone tears their ACL, the repair and recovery process is usually a lot like what others go through with the same injury,” says Dr. Calabrese. “For a total joint replacement, however, no patient is the same. Every starting point is different. Every trajectory is different. To plan a patient’s return to function and prepare the patient for what to expect in the short-, mid- and long-term, we must conduct an individual assessment.”

Cleveland Clinic uses a systematic approach to assess patients. For example, this battery of tests is used for patients planning a hip or knee replacement:

• Balance assessment. Physical therapists conduct a single-leg and double-leg balance test to assess a patient’s fall risk.
• Strength assessment. Using handheld electronic dynamometry, therapists measure foot-pounds of force that a patient can generate with their quadriceps, hamstrings, hip abductors and dorsiflexion of the ankle.
• Timed Up and Go (TUG) test. This functional test assesses a patient’s ability to move from sitting to standing, walking a distance, turning, walking back and returning to sitting.
• Stair-climb test. This assesses a patient’s ability to navigate a 6-inch step.
• Six-minute walk test. Done on a treadmill, this test assesses how far a patient can walk on a flat surface.

Physical therapists also review patient-reported outcome scores to assess health-related quality of life.

The combination of these data helps physical therapists customize a patient’s prehabilitation regimen.

“Our goals are to evaluate each patient’s preoperative pain, fitness level and impairments that might affect their functional outcome of total joint replacement,” says Dr. Calabrese. “Then, to offset these, we design a custom physical therapy program, including type, intensity and duration of exercise.”

Customized exercise regimen

While interventions are always individualized, there are some standards.

For knee replacement, programs typically include:

• Strength optimization, especially standing, sitting and supine exercises for the quadriceps
• Hamstring stretching, since patients often don’t have full extension because they’ve been walking on a flexed knee for some time
• Balancing, to mitigate falls
• Gait training, to help correct stride patterns and improve walking ability, balance and coordination
• General conditioning (e.g., cycling, aquatic therapy), to improve aerobic capacity

For hip replacement, programs usually add strengthening exercises for hip abductors and adductors, as well as stretching to improve lower back flexibility.

For shoulder replacement, depending on the type of surgery and plan for recovery, prehabilitation can include postural and scapular exercises as well as isometric rotator cuff exercises as tolerated.

“Patients may see us for only one or two prehabilitation visits, but then we follow them through electronic health record messaging, wearable technologies and apps where they can input metrics as they complete the program on their own,” Dr. Calabrese says.

Addressing pain and mobility limitations

Patients with preoperative pain or mobility limitations still can complete a prehabilitation program.

In addition to advising use of cold therapy and nonsteroidal anti-inflammatory medications, physical therapists teach patients isometric exercises, which can reduce perceived pain in a joint. They also advise patients to move within their pain-free range of motion (e.g., knee flexion within a range of 30-60 degrees).

Manual distraction of a joint also can help relieve pain by creating space between articular surfaces. Patients can be taught self-mobilization of a painful joint, using a roller, ball or other tools.

Engaging the patient is key

“The success of a prehabilitation program depends on engaging the patient,” Dr. Calabrese says. “We can set a recovery plan and explain to a patient how we’ll help them, but the patient needs to accept their role in the process. A well-educated patient who follows through on the plan is key.”