SENIORS USING PILATES FOR A BETTER QUALITY OF LIFE WITH KNEE OSTEOARTHRITIS & AFTER KNEE ARTHROPLASTIES

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1 SENIORS USING PILATES FOR A BETTER QUALITY OF LIFE WITH KNEE OSTEOARTHRITIS & AFTER KNEE ARTHROPLASTIES Katina Weaver Walker Basi CTTC Spring 2013

2 Table of Contents Abstract... 3 Anatomical Description: Healthy/Unhealthy Knee... 4 Picture of Healthy/UnhealthyKnee.5 Picture of Post Arthroplasty (Knee replacement)... 5 List of Muscles and Movements of Knee... 6 Osteoarthritis of the Knee (KOA)... 7 Case Study... 8 Basi Block 3 months Postoperative Conclusion Bibliography

3 A B S T R A C T Osteoarthritis is a chronic and progressive disease which involves the breakdown of cartilage, the material which cushions the joints. This breakdown of cartilage causes the joint to rub together which causes severe pain, stiffness and the loss of joint mobility. Osteoarthritis of the hip and knee is responsible for a million office visits to an orthopedic surgeon each year and is one of the leading syndromes ultimately leading to joint replacement. And the total number of knee and hip replacements in the US each year is steadily increasing. In this research paper, I will demonstrate through a balance of strengthening and stretching exercises, Pilates is conducive for knee osteoarthritis and knee arthroplasty, pre and post-operative because it puts less stress on the knee joint and works and strengthens several muscles around the joint at a time. 3

4 A N A T O M I C A L D E S C R I P T I O N : H E A L T H Y / U N H E A L T H Y K N E E The knee is the joint where the upper and lower leg meets and is the largest joint in the body. It gives you the support to stand, walk, sit or jump. This hinge joint endures considerable stress from weight bearing impact of gravity, walking, running and dancing. While sports injuries are common which leads to acute, chronic pain and disability. The knee joint depends more on the adjacent ligaments, tendons and muscles and less on the configuration of the body anatomy for its strength and stability. (Magee 2008) There are four bones which make up the knee complex: 1. The femur: The distal end of the thigh 2. The proximal end (Plateau) of the tibia 3. The kneecap (patella) 4. The fibula, which is the thinner bone that accompanies The distal femur, proximal tibia and the patella are the only three bones which make up the knee joint. Please note that the fibula does not work in articulation with the knee joint and is not typically involved in common knee conditions or in replacement surgery. The end of the bones are covered with a layer of cartilage, a slick, cushiony elastic material which absorbs shock and allows the bones to glide easily as they rub against each other. Between the tibia and the femur are two crescent shaped pads of connective tissue, the lateral meniscus and the medial meniscus. These connective tissues reduce friction and evenly disperse the weight of the body across the joint. The bones are held together by a joint capsule, two layers, an outer layer of connective tissue and an inner membrane. This is called synovium, which secretes fluid to lubricate the joints. The outer layer of the capsule is attached to the end of the bones and is connected to tendons and ligaments. The ligaments are primary stabilizers and guide the movement of the bones. There are four principal ligamentous stabilizers of the knee and tendons. 1. Medial collateral ligament (MCL)-provides stability for the inner part of the knee 2. Lateral collateral ligament (LCL)-stabilizers the outer part of the knee 3. Anterior cruciate ligament (ACL)-located in the center part of the knee and responsible for the front to back stability of the knee and prevents excessive forward movement of the tibia 4. Quadriceps tendon-connects the patella and quadriceps 4

5 P I C T U R E O F P O S T A R T H R O P L A S T Y ( K N E E R E P L A C E M E N T ) After Knee Arthroplasty Surgery 5

6 L I S T O F M U S C L E S A N D M O V E M E N T S O F K N E E The two major muscles that support the knee are quadriceps and hamstrings, which aid in flexion and extension of the knee. The following lists movements of the knee with the muscles that direct those motions. Flexion Bicep femoris Semimembranosus Semitendinosus Gracilis Sartorius Popliteus Gastrocnemius Tensor fasciae latae (in degree of flexion) Plantaris Extension Rectus femoris Vastus medialis Vastus intermedius Vastus lateralis Tensor fasciae latae Medial Rotation of Flexed Leg (Non Weight Bearing leg) Semimembranosus Semitendinosus Sartorius Gracilis Popliteus Lateral Rotation of Flexed Leg (Non-Weight-Bearing Leg) Biceps femoris 6

7 O S T E O A R T H R I T I S O F T H E K N E E ( K O A ) Osteoarthritis is a degenerative disease of the joints and is the most common chronic condition of the joints affecting between 27 and 40 million. It can occur in people of all ages, but the more mature population, ages 65 and older are more susceptible to this disease. The knee is the most commonly affected peripheral joint, and the occurrence of KOA greatly increases as we age. Risk factors for Osteoarthritis are both systemic and local. Some systemic factors include age, gender, race, dietary factors, smoking and estrogen deficiency. Local risk factors include obesity, joint mechanics, muscle weakness, occupational stress, physical activity and injury. According to Kaplanek, patients experience pain that may be more localized or diffused throughout the entire knee joint. The pain may start out as a dull sensation and gradually progress to a sharp and more constant ache. Knee stiffness first thing in the morning is common, but as the day progresses the joint tends to improve as it become more active. Recurrent swelling and the increase in the size of the knee, bowing at the knees, and the increase in the size of the knee is seen as the KOA advances. A decrease in range of motion is also another effect of Osteoarthritis, which patients are unable to straighten their knee to a full extension. As the disease persist, walking normal without any assistance becomes unbearable. Typically when the pain continues with daily activities and sleep is disrupted due to severity of the pain, the patient will seek an orthopedic specialist. The average age of knee replacement participant is decreasing and is now in their 60 s. Times have changed and Americans are living longer and want to stay active. Knee Arthroscopy and Knee Arthroplasty are two knee surgical procedures for knee syndromes; however I will be focusing on knee arthroplasty because of my case study. After knee arthroplasty, getting used to a new artificial joint takes time and doesn t happen overnight due to postural imbalances as a result bodily compensations. An example of compensations would be one using all of the weight on one leg while walking to alleviate pain on the right which in most cases causes structural imbalances. This pain created compensation strategies in their bodies that won t be fixed by simply replacing the joint. Even though the pain is gone now, the body is still used to moving as if it were protecting the painful area. Plus the limited range of motion in the joint as well as the unnatural sensation experienced by some of the post-replacement population makes regular daily activities as well as traditional exercise more challenging and sometimes even dangerous (pilatesbridge.org). 7

8 C A S E S T U D Y Pauline Lemire has knee arthritis in her right knee. She is 83 years old. Pauline has never done Pilates before, but has strength trained with me for over six years. When her knee was in good condition, she often played tennis twice a week with friends, not to mention her love of gardening. And I must say Pauline grows the best tomatoes I ve ever tasted! Pauline knew that it would only be a matter of time before she would have to have knee arthroplasty, but after the loss of her husband and the doctors being cautious because of her age, surgery was put off until she could no longer bear the pain. When she received the go ahead from an orthopedic surgeon, Pauline was optimistic. She new that the pain post-surgery wouldn t compare to the quality of life she would have once she began to heal. So after getting her estate and financials in order, Pauline had knee arthroplasty. We began pre-operative exercises at least two months before the surgery. This was my way of gradually introducing Pauline to Pilates and to break those poor compensation habits due to the knee pain. In some cases, students have developed poor muscular and compensation habits that have contributed to the need for the knee replacement. We can begin to undo some of these problems prior to surgery and then retrain the muscles after surgery to work in the proper manner, says Julie Erickson of Endurance Pilates. Pauline had always been fascinated with Pilates, but a little nervous to try something new. I knew I had to seize the moment because I knew Pilates would be beneficial to her before and after the surgery. Once she saw the studio and recognized familiar looking assists, hip high mats and a reformer from past Physical therapy sessions, she quickly relaxed. Focusing on her breathing was the first thing we did. She lay supine on the mat, legs straight, and we first concentrated on inhalation, exhalation and lateral breathing. She pointed and flexed each foot at least times slowly with her breath. I introduced her to a pelvic curl. I placed a ball between her knees to keep them from abducting. We did a modified hundred prep (feet on the floor legs bent), leg changes and chest lifts, and I also modified the single leg kick by placing her hands under her forehead and had her lift one bent leg at a time. I felt it best to focus on correct form and that her abdominals were drawn in and hamstrings were engaged during this exercise. Six weeks after the surgery, Pauline had gotten the authorization from her doctor that it was okay to start Pilates. She d just finished her PT and was ready to go. I was relieved that we did the preoperative Pilates exercises. She later told me that her doctor was surprised at her ROM of the knee and how well she was doing considering her age. According to Heike Yates of HEYlifetraining Pilates & Wellness, Due to the no- to low-impact form of Pilates joints can be exercised very gently and surrounding tissue is strengthened even when range of motion is diminished, for instance, the lack of cartilage in the knee or deterioration of the femur in the hip. Pauline later bragged that according to her doctor, she d done better than some of the 50 and 60year-olds that had the same surgery. We basically did mat workouts for a couple weeks when she returned and continued to do some of the preoperative exercises and added modified criss cross, modified spine stretch and modified saw with her sitting on a small box. A modified double leg stretch with a barrel under her feet was also added to the repertoire. 8

9 Three months post-surgery Pauline was feeling stronger and confident and ready to advance. She started back driving and her bi-monthly shopping at Costco wasn t such an arduous task since she was able to get around better. On the next page are Basi block exercises we did 3 months post-surgery, including balancing exercises I do with all of my senior clients, such as tandem stance with eyes closed for 15 seconds (both leg), gait exercises such as standing on toes and heels and sideway walks. 9

10 B A S I B L O C K 3 M O N T H S P O S T O P E R A T I V E NAME Warm up Foot work Abdominal Hip Work Stretches Spinal Articulation Full Body Int 1 Arm work Full Body Int 2 Legs Lateral Back DESCRIPTION Pelvic Curl, chest lift, chest lift with rotation (used a small barrel under feet as an assist) on Mat Parallel Heels, parallel toes, v pos. toes, open V heels, open V toes, calf raises and prances on Reformer Hundred prep feet on foot bar on Reformer Frog, down and up circles, openings on Reformer Side stretch (pole series ), shoulder stretch (pole series), overhead stretch (pole series) Bottom Lift (modified) on Reformer Chest expansions, hug a tree, bicep curls, salute on Avalon Side left lift, forward and lift, forward with drops, adductor squeeze Side lifts Back Extension on mat I chose to modify the bottom lift with her heels on the bar instead of her toes because she was uncomfortable with her toes on the bar as she lifted her pelvic region. I also placed a ball between her knees to keep them from abducting. Regarding full body integration, I chose not to incorporate that block into Pauline s repertoire as of yet. We did balance and gait exercises as I mentioned earlier instead. 10

11 C O N C L U S I O N Pilates is the perfect conditioning program to accelerate recovery after knee replacement surgery. According to Kaplanek the stability of the knee is not due to its bony structure but to the arrangement of the adjacent ligaments and muscles and reviewing the pertinent anatomy should clarify why specific Pilates exercises are chosen to treat various knee syndromes. The knee encounters daily wear and tear and weight bearing activities such as normal daily living, walking, running and sports. Improving the muscles around the joint is imperative for functionality and longevity of the bony structure. This is evident in both knee syndromes such as knee OA or after knee replacement surgery. The saying muscle has memory rings true because a Pilates pre-operative exercise routine helps build the muscle memory and aids in the rehabilitation and provides comfort for the client after the surgery. 11

12 B I B L I O G R A P H Y Arthritis Today Data. Balance Body Data. Basi Movement Analysis Workbook-Reformer, Mat and Avalon Basi Pilates, Comprehensive Course Study Guide, Rael Isacowitz, copyright; ; pages Ideafit Data. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis: Saunders, 2008: Pilates for Hip and Knee Syndromes and Arthroplasties, Beth Kaplanek, Brett Levine and William L Jaffe, copyright 2011 pages 15-25, Pilates Bridge. 12