Managing Knee Pain: Article 3 of 5

Prehab Paves the Way for Knee Replacement

Private: Wolfgang Fitz, MD
Contributor Wolfgang Fitz, MD
Private: Jean Flanagan Jay, PT, DPT, CLT
Contributor Jean Flanagan Jay, PT, DPT, CLT

After enduring the pain of osteoarthritis and making the decision to undergo knee replacement surgery, some people worry that post-surgery rehabilitation will be yet one more challenge. A new focus on “prehab” is helping some patients prepare physically and mentally for the road ahead.

At Brigham and Women’s Hospital, orthopaedic surgeons and physical therapists collaborated to create a program of brief, daily exercises leading up to surgery. By strengthening muscles in advance of surgery, patients get a head start on the rehabilitation that occurs afterward. Patients can access the exercises on an app that they begin using before surgery.

“Doing the exercises made me realize how much I was compensating due to osteoarthritis — I couldn’t stand on my right leg and my agility and strength had decreased,” said patient Peg Curro, describing the prehab work before her knee replacement (called arthroplasty). “The app was so easy to follow and the videos especially were wonderful. It helped me keep my eye on the goal of what I was aiming for: better function. It motivated me.”

Prehab has been gaining acceptance around the country, with patients typically conditioning through physical therapy sessions. Rather than send patients to physical therapy sessions each week, Wolfgang Fitz, MD, an orthopaedic surgeon in the Department of Orthopaedic Surgery and colleagues found that short, daily sessions could be as effective and possibly easier on arthritic knees.

He also knew that people approach surgery with a broad range of function and may do better with customized exercise plans.

“Some patients are active. Others are severely deconditioned. It would be difficult for them all to have one exercise plan,” Fitz said. He and Jean Flanagan Jay, PT, DPT, director of rehabilitation services, developed an exercise program through an app (with the company Force Therapeutics) that patients use through a desktop computer, tablet or phone.

At the time of surgery, patients say to us, ‘I could never believe that exercise could make such a big difference.’

All patients who are planning arthroplasty begin prehab roughly 10 weeks before surgery. During an initial patient visit with the surgeon, a physical therapist assesses balance, strength, range of motion and functional level. Then a patient receives an exercise plan customized to his or her needs and fitness level. It is all available on the app, which enables patients to monitor their progress and communicate with their doctor. If a patient reports a high pain level, the doctor is alerted. Each patient’s progress is followed remotely. If a patient is struggling, the exercise regimen is adjusted.

“These patients come in feeling confident and prepared for surgery,” says Jay. “They have improved their functional level. Some even may delay surgery because they are doing well.”

More than 1,000 Brigham patients have now used the app and 240 have completed the entire sequence of prehab, surgery and follow-up rehab.

“At the time of surgery, patients say to us, ‘I could never believe that exercise could make such a big difference,’” Dr. Fitz says, adding that patients also feel like they are part of the process and that their specific issues and weaknesses are being addressed.

The app began as a way to customize exercises for post-surgery rehab. Now it focuses on preparation before surgery. Exercises recently were added for proprioception, a difficulty with spatial perception that inhibits some patients’ ability to stand or balance.

“The whole concept is to prepare people for the idea that they aren’t sick,” Jay says. “If someone has expectations that they will be up and walking the first night and that they’ll be in the hospital typically just one night, they do better. Telling people what to expect is very reassuring to them.” Early research shows that patients who undergo the prehab exercise program are back on their feet faster and recover more quickly.

Just 7 weeks after surgery, Curro, a recently retired college administrator, is still working hard at physical therapy. But she expects to resume travelling soon and enjoying activities that osteoarthritis had made difficult before surgery.

For others facing knee replacement surgery, Curro offers this advice: “Absolutely do the prehab, to start thinking about functioning better. Osteoarthritis doesn’t get better on its own. You need to work at it and make the right decisions to keep your life active. The prehab was a wake-up call for me to take action so I could do what I want to do in retirement. I’m not going to sit home.”

Private: Wolfgang Fitz, MD
Wolfgang Fitz, MD

Wolfgang Fitz, MD, is an Orthopaedic Surgeon at Brigham and Women's Hospital and an Assistant Professor at Harvard Medical School.

Private: Jean Flanagan Jay, PT, DPT, CLT
Jean Flanagan Jay, PT, DPT, CLT

Jean Flanagan Jay, PT, DPT, CLT is the Director of Rehabilitation Services at Brigham and Women's Faulkner Hospital.

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Learn how to cope with all kinds of joint pain, from pain caused by sports injuries to joint pain linked to aging and osteoarthritis. Our experts can help you find out when your pain requires medical care. Read more articles about joint pain.