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The Role of Physical Therapy in Joint Replacement
The providers at the University of Maryland Joint Network believe that the better prepared patients are, the better the outcome of the joint replacement or joint surgery will be. Dahlia Joseph, Orthopaedic Nurse Practitioner at UM BWMC, recommends that patients do physical therapy, including pre-habilitation and rehabilitation, whenever possible. Learn what pre-hab and rehab are, who is eligible and how they can affect the outcome of surgery and shorten recovery.
Featured Speaker:
Dahlia Joseph, MS, CRNP, ACNP-BC, NLI Fellow
Dahlia Joseph, Orthopaedic Nurse Practitioner at the University of Maryland Baltimore Washington Medical Center, is board certified by the American Nurses Credentialing Center as an Acute Care Nurse Practitioner. Mrs. Joseph graduated with her Bachelor’s of Science degree in Nursing in 1998, from Coppin State University in Baltimore, Maryland. She then went on to earn a Master’s of Science degree in Acute Care Nurse Practitioner and Clinical Nurse Specialist in Trauma, Critical Care, and Emergency Nursing at the University of Maryland, Baltimore (UMB). She has earned the designation of Fellow from the University of Maryland Nurses Leadership Institute. With over 23 years of practice in various facets of nursing, Mrs. Joseph currently functions as the lead Nurse Practitioner for the Inpatient Orthopedic Nurse Practitioner Hospitalist group - for the Total Joint Replacement Program, as well as for the Spine Surgery Program. She is a Clinical Faculty Associate at the University of Maryland School of Nursing, and is past Adjunct Faculty at Coppin State University Helene Fuld School of Nursing. She has served as preceptor to over 30 Acute Care Nurse Practitioner students, and continues to do so today. She maintains her knowledge of the latest advances in her field through memberships in various professional organizations, such as the Nurse Practitioner Association of Maryland (NPAM), Maryland Nurses Association (MNA) and the American Nurses Association (ANA). She continues to serve on various committees and workgroups within the UM BWMC institution. Transcription:
The Role of Physical Therapy in Joint Replacement
Amanda Wilde (Host): Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This podcast is brought to you by the University of Maryland Joint Network. I'm Amanda Wilde.
Joint replacement is a reality for almost 1 million people in the US this year. And joint replacement can be a life-changer if you remember that physical therapy is the key. Orthopedic nurse practitioner, Dahlia Joseph is here to talk about that essential piece of rehabilitation. And actually, Dahlia, for joint surgery, there is actually prehabilitation before surgery. What is it? Why do you recommend it for your patients?
Dahlia Joseph: Thank you for having me, Amanda. I'm happy to be here. Prehabilitation, like you mentioned, is physical therapy that is done before a surgical procedure. It can usually be started within one week to four weeks before a surgery, but that is dependent on the needs of each individual patient. The goal of prehabilitation in joint replacement is to prepare muscles, soft tissues and joints of the body for the stresses that will be involved with the recovery process after surgery. It is usually individualized to the patient and the specific procedure, which the patient is expected to follow.
Studies have shown that a stronger supporting muscle group around a joint preoperatively will facilitate a faster recovery of the joint postoperatively. So in other words, a prehabilitation program will shorten the postoperative rehabilitation process.
Amanda Wilde (Host): Perfect. And who doesn't want a shorter rehab process after surgery? So you were talking about strengthening the muscles, I mean, what happens during a prehab session then?
Dahlia Joseph: During the prehab session, the physical therapist will perform a thorough assessment of the joint, focusing on symptoms, such as swelling, pain loss of motion and, like you mentioned, muscle weakness. Focus will also be placed on the current functional status of that patient, as well as the anticipated functional expectations that the patient will have after surgery.
So the therapist will then perform interventions, such as range of motion exercises to keep the joint mobile and to reduce pain from stiffness; soft tissue massages to decrease swelling and targeted exercise regimens that will strengthen specific muscle groups. The therapist is also going to provide education on the proper use of assistive devices, such as walkers, canes, or crutches that may be used for mobility in the immediate postoperative rehab phase.
Amanda Wilde (Host): It's really good to know that we'll get training on those pieces of equipment, the walkers, crutches, those kinds of things, because that can be intimidating when you haven't used those before. Is everyone a candidate for prehab?
Dahlia Joseph: No, not everyone is a candidate for prehab. And although most patients would benefit from prehabilitation, it is most beneficial for patients who have significant weaknesses, contractures or muscle atrophy.
Amanda Wilde (Host): So whether or not you've had the prehab, of course, everyone gets the surgery, then your doctor recommends rehabilitation. So what is that post joint surgery?
Dahlia Joseph: So the word rehabilitation is another way of describing physical therapy. So at this point, after surgery, the physical therapist is going to perform an initial post-operative evaluation. And this is often referred to as an eval. The eval is usually comprised of extensive assessments of the affected extremity, the patient's functional status and the lifestyle to which the patient is expected to return.
This process is going to include measurements of that affected joint for girth, which would be the degree of swelling that's present; motion, muscle strength, balance or coordination; gait, which refers to how the patient is walking and the pain level. So based on the findings from the eval, the therapist is going to then work with the patient to set some goals and will develop a treatment plan to advance the patient towards achieving these goals. And this is done all within an identified timeframe, so the patient can progress to getting back to their normal status.
Amanda Wilde (Host): What activities do we do during rehab? What are the range of activities people do during joint rehabilitation?
Dahlia Joseph: Because physical therapy is a professional skill, there is a vast range of activities that can happen in order to return a patient to their functional status prior to surgery. And these activities can include manual therapies, such as soft tissue massage to reduce swelling, promote healing and mobility of the tissues. This of course is done with great care to avoid massaging the actual incision just around the incision.
Therapeutic exercise programs are also done, and these will focus on range of motion exercises for joint mobilization. This can be done through passive stretches of the quadricep and the hamstrings initially, and then the use of stationary bikes later on in the process.
Neuromuscular reeducation is also one of the therapies that's done for muscle strengthening. And this type of therapy uses electrodes to facilitate quicker muscle activation for those patients who need it. Then, we move on to weight-bearing exercises, and this will train the muscles of the effective limb to support the body through incremental weight, distribution, weight shifting and balancing.
Then we move on to gait training or training the patient how to walk. And gait training is for normalized movement, which is done through proper body biomechanics and kinetics while the patient is walking.
There is also functional training based on the patient's profession. And this one is really important, and I'll give you some examples. So if we have a male carrier who has a joint replacement, we can anticipate that this person will be doing sustained walking and will require more endurance training. And a second example would be an Amazon worker who is constantly squatting, twisting, and reaching. And in some instances, this worker might need some modified alternatives to performing their job duties based on the identified limitation that they might have following the surgery.
Amanda Wilde (Host): So this is very individual and you're monitoring every step of the way. I'm sure that makes patients feel secure. How long do we get to go to rehab? And do you continue to do rehabilitation exercises after you've left physical therapy?
Dahlia Joseph: That's a very good question. And lots of people will have this question for us. Not all courses of postoperative physical therapy are the same. On average, usually for a knee or hip replacement, we can anticipate four to six weeks. And this of course depends on the condition of that individual patient. We do most definitely recommend continuing the exercises after the rehab period is complete. We specifically recommend maintenance stretching and a walking program. And the goal is to prevent re-injury and improve function because if activity is not maintained, there is the risk of joint stiffness, muscle weakness and compensation, which can all create additional issues with other joints of the body.
Amanda Wilde (Host): So it's really important to keep up with this. Is it a lifetime enterprise?
Dahlia Joseph: I would say yes, because as we know, habits take about three months to form. So if you are continuing with this maintenance stretching and walking programs, and you continue that for a period of about three months, then you will make it a habit and you will continue with it, and it will become a lifestyle change.
Amanda Wilde (Host): And I think the physical therapy really gets you off to a good start. Are there any final thoughts you'd like to share for those getting joint replacement surgery and looking at physical therapy?
Dahlia Joseph: Yes, most definitely. Some patients will have the expectation that a surgery itself will fix the problem. And they tend to get a little discouraged when this is not the case. The reality is that surgery is only the first step in fixing the problem. Rehabilitation or physical therapy is the next step. And then maintenance exercises is the last step. It is a long process, of course, and the patients will need encouragement and support as they navigate through this process.
The second thought I have that I'd like to leave with the audience is pain management is an important part of the rehab process. And if it's not done properly, it will impact recovery. It is very important for patients to follow the recommendations of their surgeon, nurse practitioners, physician assistants or just the care team regarding the plan of care for pain control in order for them to recover successfully.
And the last thing I'll leave with you is that it is very important to complete the rehabilitation process. Exercises are very important for patients, or they can fall into abnormal movement patterns unknowingly, and then that will lead to them compensating when they move. This abnormal movement can result in undue stress on other joints. This can also lead to back pain. So trained therapists are there during that postoperative rehab process who can readily identify these issues in real time, and they'll be able to correct them and prevent this compensation and the potential future problem.
Amanda Wilde (Host): Well, I must say anyone who comes to you is in excellent hands. Thank you, Dahlia, for teaching us how to prepare and then have long-term successful joint replacement results.
Dahlia Joseph: Thank you for having me.
Amanda Wilde (Host): This episode is sponsored by the University of Maryland Joint Network. UM Joint Network surgeons are experts in total hip and knee replacements. Held to the highest standard of care, UM Joint Network surgeons produce better outcomes for patients compared to national averages, including lower infection rates and faster recovery times. The UM Joint Network, home to Maryland's leading joint replacement surgeons.
For more shows just like this one, go to umms.org/podcast. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.
The Role of Physical Therapy in Joint Replacement
Amanda Wilde (Host): Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This podcast is brought to you by the University of Maryland Joint Network. I'm Amanda Wilde.
Joint replacement is a reality for almost 1 million people in the US this year. And joint replacement can be a life-changer if you remember that physical therapy is the key. Orthopedic nurse practitioner, Dahlia Joseph is here to talk about that essential piece of rehabilitation. And actually, Dahlia, for joint surgery, there is actually prehabilitation before surgery. What is it? Why do you recommend it for your patients?
Dahlia Joseph: Thank you for having me, Amanda. I'm happy to be here. Prehabilitation, like you mentioned, is physical therapy that is done before a surgical procedure. It can usually be started within one week to four weeks before a surgery, but that is dependent on the needs of each individual patient. The goal of prehabilitation in joint replacement is to prepare muscles, soft tissues and joints of the body for the stresses that will be involved with the recovery process after surgery. It is usually individualized to the patient and the specific procedure, which the patient is expected to follow.
Studies have shown that a stronger supporting muscle group around a joint preoperatively will facilitate a faster recovery of the joint postoperatively. So in other words, a prehabilitation program will shorten the postoperative rehabilitation process.
Amanda Wilde (Host): Perfect. And who doesn't want a shorter rehab process after surgery? So you were talking about strengthening the muscles, I mean, what happens during a prehab session then?
Dahlia Joseph: During the prehab session, the physical therapist will perform a thorough assessment of the joint, focusing on symptoms, such as swelling, pain loss of motion and, like you mentioned, muscle weakness. Focus will also be placed on the current functional status of that patient, as well as the anticipated functional expectations that the patient will have after surgery.
So the therapist will then perform interventions, such as range of motion exercises to keep the joint mobile and to reduce pain from stiffness; soft tissue massages to decrease swelling and targeted exercise regimens that will strengthen specific muscle groups. The therapist is also going to provide education on the proper use of assistive devices, such as walkers, canes, or crutches that may be used for mobility in the immediate postoperative rehab phase.
Amanda Wilde (Host): It's really good to know that we'll get training on those pieces of equipment, the walkers, crutches, those kinds of things, because that can be intimidating when you haven't used those before. Is everyone a candidate for prehab?
Dahlia Joseph: No, not everyone is a candidate for prehab. And although most patients would benefit from prehabilitation, it is most beneficial for patients who have significant weaknesses, contractures or muscle atrophy.
Amanda Wilde (Host): So whether or not you've had the prehab, of course, everyone gets the surgery, then your doctor recommends rehabilitation. So what is that post joint surgery?
Dahlia Joseph: So the word rehabilitation is another way of describing physical therapy. So at this point, after surgery, the physical therapist is going to perform an initial post-operative evaluation. And this is often referred to as an eval. The eval is usually comprised of extensive assessments of the affected extremity, the patient's functional status and the lifestyle to which the patient is expected to return.
This process is going to include measurements of that affected joint for girth, which would be the degree of swelling that's present; motion, muscle strength, balance or coordination; gait, which refers to how the patient is walking and the pain level. So based on the findings from the eval, the therapist is going to then work with the patient to set some goals and will develop a treatment plan to advance the patient towards achieving these goals. And this is done all within an identified timeframe, so the patient can progress to getting back to their normal status.
Amanda Wilde (Host): What activities do we do during rehab? What are the range of activities people do during joint rehabilitation?
Dahlia Joseph: Because physical therapy is a professional skill, there is a vast range of activities that can happen in order to return a patient to their functional status prior to surgery. And these activities can include manual therapies, such as soft tissue massage to reduce swelling, promote healing and mobility of the tissues. This of course is done with great care to avoid massaging the actual incision just around the incision.
Therapeutic exercise programs are also done, and these will focus on range of motion exercises for joint mobilization. This can be done through passive stretches of the quadricep and the hamstrings initially, and then the use of stationary bikes later on in the process.
Neuromuscular reeducation is also one of the therapies that's done for muscle strengthening. And this type of therapy uses electrodes to facilitate quicker muscle activation for those patients who need it. Then, we move on to weight-bearing exercises, and this will train the muscles of the effective limb to support the body through incremental weight, distribution, weight shifting and balancing.
Then we move on to gait training or training the patient how to walk. And gait training is for normalized movement, which is done through proper body biomechanics and kinetics while the patient is walking.
There is also functional training based on the patient's profession. And this one is really important, and I'll give you some examples. So if we have a male carrier who has a joint replacement, we can anticipate that this person will be doing sustained walking and will require more endurance training. And a second example would be an Amazon worker who is constantly squatting, twisting, and reaching. And in some instances, this worker might need some modified alternatives to performing their job duties based on the identified limitation that they might have following the surgery.
Amanda Wilde (Host): So this is very individual and you're monitoring every step of the way. I'm sure that makes patients feel secure. How long do we get to go to rehab? And do you continue to do rehabilitation exercises after you've left physical therapy?
Dahlia Joseph: That's a very good question. And lots of people will have this question for us. Not all courses of postoperative physical therapy are the same. On average, usually for a knee or hip replacement, we can anticipate four to six weeks. And this of course depends on the condition of that individual patient. We do most definitely recommend continuing the exercises after the rehab period is complete. We specifically recommend maintenance stretching and a walking program. And the goal is to prevent re-injury and improve function because if activity is not maintained, there is the risk of joint stiffness, muscle weakness and compensation, which can all create additional issues with other joints of the body.
Amanda Wilde (Host): So it's really important to keep up with this. Is it a lifetime enterprise?
Dahlia Joseph: I would say yes, because as we know, habits take about three months to form. So if you are continuing with this maintenance stretching and walking programs, and you continue that for a period of about three months, then you will make it a habit and you will continue with it, and it will become a lifestyle change.
Amanda Wilde (Host): And I think the physical therapy really gets you off to a good start. Are there any final thoughts you'd like to share for those getting joint replacement surgery and looking at physical therapy?
Dahlia Joseph: Yes, most definitely. Some patients will have the expectation that a surgery itself will fix the problem. And they tend to get a little discouraged when this is not the case. The reality is that surgery is only the first step in fixing the problem. Rehabilitation or physical therapy is the next step. And then maintenance exercises is the last step. It is a long process, of course, and the patients will need encouragement and support as they navigate through this process.
The second thought I have that I'd like to leave with the audience is pain management is an important part of the rehab process. And if it's not done properly, it will impact recovery. It is very important for patients to follow the recommendations of their surgeon, nurse practitioners, physician assistants or just the care team regarding the plan of care for pain control in order for them to recover successfully.
And the last thing I'll leave with you is that it is very important to complete the rehabilitation process. Exercises are very important for patients, or they can fall into abnormal movement patterns unknowingly, and then that will lead to them compensating when they move. This abnormal movement can result in undue stress on other joints. This can also lead to back pain. So trained therapists are there during that postoperative rehab process who can readily identify these issues in real time, and they'll be able to correct them and prevent this compensation and the potential future problem.
Amanda Wilde (Host): Well, I must say anyone who comes to you is in excellent hands. Thank you, Dahlia, for teaching us how to prepare and then have long-term successful joint replacement results.
Dahlia Joseph: Thank you for having me.
Amanda Wilde (Host): This episode is sponsored by the University of Maryland Joint Network. UM Joint Network surgeons are experts in total hip and knee replacements. Held to the highest standard of care, UM Joint Network surgeons produce better outcomes for patients compared to national averages, including lower infection rates and faster recovery times. The UM Joint Network, home to Maryland's leading joint replacement surgeons.
For more shows just like this one, go to umms.org/podcast. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.