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In Motion April 2014

Exercise to Prep Your Joints for Surgery

By Michael Bloomfield, MD and Scott Euype, DPT

What to do now for easier recovery later

Replacing worn body parts has become pretty common today. If you’re facing major joint surgery like hip or knee replacement or reconstruction, you may be concerned about what happens after the surgery.

In thinking about what to expect from the recovery process, you may wonder how quick your recovery will be or how much pain you’ll experience. Research has shown that the speed and success of your recovery has a lot to do with your activity level before surgery.

“Stay as active as you can before surgery,” says orthopaedic surgeon Michael Bloomfield, MD. “It will speed along your recovery and prepare you to deal with therapy afterwards.”

Cleveland Clinic physical therapist Scott Euype, DPT, stresses being active, too. “Many times people who are having a joint replacement will be weak and deconditioned, and they may have chronic osteoarthritis,” he says. “It really helps in the recovery process if patients work on improving their range of motion and muscle strength before surgery.”

‘Let pain be your guide’

Dr. Bloomfield acknowledges that it can be tough to convince patients who are awaiting joint surgery — and are already experiencing a lot of pain — to exercise beforehand. “Let pain be your guide,” he says. “Be as active as you can within the limits of your pain.”

Dr. Bloomfield and Euype recommend the following:

  • Pre-surgical exercises – These strengthen muscles that support the knee and hip, including short arc quad exercises and straight leg raises.
  • Abdominal exercises – A strong core is the foundation of everything. It is important for general conditioning, posture and balance.
  • Low impact exercises – Stay low-impact with joint-friendly swimming, cycling or elliptical conditioning. You will want to stay away from jumping and high impact exercise and instead work on cardiovascular capacity and range of motion. High-impact activities like running, basketball or tennis subject your joints to five times your body weight in force.
  • Pre-op education with a physical therapist – During the pre-operative visit, patients meet with a physical therapist (PT) to get instructions on the way the exercises and a frame of reference of what therapy will be like after surgery.
  • Post-op expectations – The goal is to get you up and moving as soon as possible after surgery so you can be home and rehabilitating within a day or two of the procedure.

Euype explains that in the standard education session before surgery, you will talk to different healthcare staff, from nursing to nutrition. The physical therapist will be the one to help prepare you for rehabilitation after surgery.

PTs can also help you if you are overcompensating when you walk. He explains that if you have hip pain and you’re compensating for this pain, you will often develop other pains such as pain in the back. A PT can educate you on the proper posture and provide an assist device such as a cane.

Studies confirm ‘prehabilitation’ benefit

Numerous studies have documented the benefit of preconditioning or “prehabilitation” before joint surgery.

  • One 2011 study from the University of Louisville showed that four to eight weeks of exercise before knee reconstruction helped people return to normal activities faster after surgery and experience less pain during recovery.
  • A 2006 study by the American College of Rheumatology showed that six weeks of pre-surgical exercise reduced the chances that inpatient rehabilitation would be needed.
  • A 2007 study conducted at Thomas Jefferson University found that preconditioning before minimally invasive hip reconstruction was beneficial to recovery time and pain levels, regardless of the size of the surgical incision.

Michael Bloomfield, MD, is an orthopaedic surgeon who specializes in hip and knee replacements and reconstruction. He sees patients at Cleveland Clinic main campus and Hillcrest Hospital. To schedule an appointment with Dr. Bloomfield or any of our hip and knee surgeons, please call 440.312.6242.

Scott Euype, DPT, is a physical therapist who sees patients at the Independence Family Health Center. To schedule an appointment with Scott or any of our physical therapists, please call 216.444.6262.

Partial Shoulder Resurfacing: An Innovative New Way to Treat Shoulder Instability

By Lionel Gottschalk IV, MD; Morgan Jones, MD, MPH; Anthony Miniaci, MD, FRCSC

Shoulder dislocation is painful and incapacitating, and it is one of the most common injuries in the human body. It happens most commonly during athletic activities, and severe and/or repetitive dislocations can lead to a condition called shoulder instability. This happens when there is enough damage to the shoulder joint that it is predisposed to dislocation – sometimes from nothing more than simple every day activities.

Instability is most commonly due to repeated shoulder dislocations, and younger patients are more likely to have them than patients who suffer their first dislocation at an older age. An unwelcome consequence of shoulder instability is the risk of developing osteoarthritis.

The goal of treatment for instability is to make the shoulder stable again to prevent future dislocations and to decrease the risk of developing arthritis down the road.

Despite many advances in surgery over the years, shoulder instability continues to be a challenging condition. Partial shoulder cap resurfacing, called a HemiCAP®, is a promising treatment for many patients with chronic shoulder instability. It has been in use at Cleveland Clinic in select patients for nearly seven years, and results are encouraging.

The shoulder is a ball (humeral head) and socket joint (glenoid) that includes a “protective bumper” (the labrum) to help keep the ball in the socket. Shoulder dislocation can involve the tearing off of the labrum from the joint, a joint fracture or a humeral head fracture.

Treatment options

When instability happens because of labral damage or a small amount of bone loss, it can often be treated non-surgically or with arthroscopic surgery. However, in shoulders with large bone defects, open surgery is often required.

A partial humeral head resurfacing implant (the HemiCAP®) is a relatively new treatment for managing shoulder instability due to large humeral head defects. This metallic resurfacing implant is available in multiple sizes and can help to preserve much of the patient’s own bone.

In an early series of 20 patients at Cleveland Clinic who were treated with partial cap resurfacing, there were no episodes of dislocation following HemiCAP implantation. Additionally, patients reported an overall improvement to their shoulders and increased quality of life. And greater than 80 percent of patients were able to return to activities they did before their shoulder injuries.

While shoulder instability remains a challenging condition to treat successfully, partial resurfacing appears to be a promising technique.

Lionel Gottschalk, MD, is a senior resident in the Department of Orthopaedic Surgery.

Morgan Jones, MD, is a staff surgeon in the Department of Orthopaedic Surgery and the Center for Sports Health. He specializes in sports medicine surgery and arthroscopy of the shoulder, knee, foot and ankle. He sees patients at the Sports Health Center and Willoughby Hills Family Health Center.

Anthony Miniaci, MD, is a staff surgeon in the Department of Orthopaedic Surgery and the Center for Sports Health. He specializes in shoulder reconstruction, knee reconstruction and cartilage resurfacing. He sees patients at Cleveland Clinic main campus and the Sports Health Center.

To make an appointment with these physicians or another Sports Health surgeon, please call 440.312.6242.

Nutrients and Supplements that Promote Bone and Joint Health

By Shailey Desai, MD

As people lead active daily lives, many look to vitamins and supplements to aid in bone health. With hundreds of vitamins and supplements available on the market today, it can be overwhelming to determine which are proven to strengthen bone and help in the prevention of bone diseases such as osteoporosis. Osteoporosis is a major health disorder in which there is decreased density of the bone, which can lead to an increased risk for fracture. The two nutrients that work together to keep your bones healthy are:

  • Calcium: This mineral is part of the basic building block of bone.
  • Vitamin D: This vitamin is required to absorb calcium effectively.

Calcium and vitamin D play important roles in maintaining or improving bone mineral density and reducing your risk of fracture. For strong bones throughout your life, you need to obtain an adequate amount of calcium and vitamin D in your diet and through over-the counter supplements as needed.

The best way to get calcium in your diet is from dairy products such as milk, cheese and yogurt. Other foods that are high in calcium include spinach, kale, soy and white beans and some fish (including salmon, perch and sardines). Many foods are also fortified with calcium. Vitamin D on the other hand is only found in a few foods, including cheese, egg yolks and some fatty fish (tuna, salmon and mackerel). Your body can make vitamin D on its own when it is exposed to sunlight.

The exact recommended amount of supplements will vary depending on your diet and how thin your bones are. It is important to talk to your doctor to determine the proper amounts for you. Your doctor will most likely do a blood test to determine the proper dosage, but in general, daily dietary recommendations for calcium and vitamin D supplements are as follows (according to the Institute of Medicine, 2011):

Premenopausal women and younger men Postmenopausal women and older men
Calcium ≥1000 mg daily ≥1200 mg daily
Vitamin D 600 units daily ≥800 units daily
Chondroitin and glucosamine

Osteoarthritis is another common condition affecting the joints in which there is degradation of cartilage that can lead to joint pain. Chondroitin and glucosamine are two supplements that have been advertised to help treat osteoarthritis. The evidence for their use is limited and based on large randomized trials in patients with osteoarthritis of the hips or knees. These trials have compared chondroitin, glucosamine, the combination of both, and placebo.

Overall, these studies have demonstrated that there is no clinically significant improvement in pain. Therefore, these medications are generally not recommended to treat osteoarthritis. There are relatively few side effects from the medications so patients may still opt to try this strategy. However, glucosamine should not be taken by those with a shellfish allergy as it is often made from the shells of lobster, shrimp and crab.

Along with a healthy diet and the right amount of vitamins and supplements for you, regular exercise is always recommended for optimal bone health. In addition, it is important to understand that smoking accelerates bone loss—another reason for you to stop smoking if you do.

Shailey Desai, MD, is a rheumatologist who specializes in arthritis, osteoporosis, lupus and general rheumatology. She sees patients at Cleveland Clinic main campus and Strongsville Family Health and Surgery Center. To make an appointment with her or another rheumatologist, call 440.312.6242.

Yoga Helps Us Age Gracefully…Things to Consider When Starting Yoga

By Judi Bar, E-RYT 500, and Dawn Lorring, PT, MEd, MPT, CSCS, SCS

Yoga can be tremendously beneficial for people as they age. Physically it improves overall mobility, flexibility, posture, balance and strength. Mentally it is a great tool for stress management. You may be surprised to learn that it can also help improve memory and energy levels as it lowers blood pressure and eases arthritis and other forms of pain.

For anyone suffering with mood swings or depression, yoga has been proven to help. For one thing, being in a class setting and getting to know other students fosters a sense of community and can be a distraction from pain and negativity. Participants often come out of class with a sense of well-being and a feeling of light-heartedness. From a preventive stand point, yoga can aid in weight management and reduce the effects of stress.

But, yoga classes are not one size fits all. If you are thinking about starting yoga, there are some important things to consider. It is recommended that you research yoga offerings and the instructors prior to attending a class. Some classes focus mostly on the physical body, while others focus more on the mind, emotions and spirituality. Every instructor is different in his or her approach and training, so you may have to test the waters with a few different classes and teachers to find out what works for you.

Many community and fitness centers offer beginner classes. These classes take into account health challenges common to many, such as cardiac issues, osteoporosis, back and bone conditions or joint replacements. A good beginner class will also modify the postures with gentler variations and props (such as a chair) as well as limit or eliminate bending activities, so that those who are starting out with less physical ability and restrictions can lean on the prop and gradually build their strength and endurance. Conscious deep breathing, meditation and relaxation are usually included, which are perhaps the most beneficial components for stress and anxiety management.

If you are looking more for stress relief and relaxation, a gentle class such as chair yoga, hatha yoga or restorative yoga, which includes more relaxation and meditation, might be the way to go. You will still create strength and flexibility in the body with these gentler movements.

If you are looking for more physical fitness and cardio, and yoga is the only exercise in which you are engaging, you may choose a class with more movement such as a vinyasa or flowing class. A main component in vinyasa style is the blending of movement with breath.

Yoga is a process of meeting your body as it is, and working from that place. There should be NO PAIN in yoga, and more vigorous classes definitely increase the potential for injury, especially if you are not familiar with the proper body mechanics of the postures.

Learn how to do postures slowly and deliberately first before you attempt to flow through them quickly. It may be beneficial to observe a class prior to participation to familiarize yourself with the poses and make sure that the class is at an appropriate level for you. And remember, even a more powerful class should still have plenty of time for relaxation at the end, because the body needs time to rest and repair.

Finally, it is essential to make sure the instructor is aware of any conditions or limitations that you have, and that he or she has a valid certification and can help you work within your ability level.

Judi Bar, E-RYT 500, is a yoga therapist and Yoga Program Manager for Cleveland Clinic. To make an appointment with her or another yoga specialist, call 877.331.9355.

Dawn Lorring, PT, MEd, is the Clinical Rehabilitation Manager in Cleveland Clinic’s Department of Rehabilitation and Sports Therapy. To make an appointment with her or another physical therapist, please call 216.444.6262.

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