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Yoga after Joint Replacement
Information for teachers and students
by Dr Rowena Nicholson
MB, BS, MRCGP, DRCOG, Dip PCouns, Dip NSpH, Dip THY&R.
Hip, knee and shoulder replacements are becoming ever more commonplace, and many people are keen to start or continue yoga after their surgery. There is no reason why this should not be so, provided the teacher has the experience and knowledge to allow the yoga to be modified to their student’s unique needs. In general, it is important for people with arthritis to preserve their range of movement. I have often told my arthritic patients to ‘use it or loose it’!
There is only one reason why a joint replacement is carried out: to relieve pain. It is not done to correct deformity or improve function in itself, though the reduction in pain often allows the person to be more mobile. It is important to be aware that an artificial joint will never have the range of movement of a natural one. I remember as a medical student watching a consultation with a man whose knees were so badly deformed by arthritis that they had a severe degree of angulation, such that I couldn’t imagine him being able to walk. When the surgeon discovered that the man still played tennis, he advised him against the surgery, saying “you won’t be allowed to run when you’ve got one of my knees”!
It is important that the student gets the permission of either their surgeon or their physiotherapist to attend yoga classes. I wouldn’t usually expect someone to start yoga until they have been discharged by their physiotherapist, although individual yoga therapy focusing on the rest of the body may well be possible before this. Generally I would expect a student to do stage 1, not stage 2, after any major joint replacement, the exception being possibly after hip resurfacing. Many people who have had one joint replaced have arthritis in other joints as well, and may even be waiting for another new joint, so their needs with respect to their other arthritic joints must also be taken into account. Depending on the number of ‘problem’ joints and mobility, a chair yoga class or individual yoga therapy may be appropriate. If the student has recently had a joint replaced, they may have been ‘favouring’ their other side for some time, so posture and alignment are very important to consider. Many people who have had a knee or hip replacement take some time to get down onto the floor and up again, and this should be taken into account when planning their class, to avoid too many position changes. For some students, it may be preferable to give some chair alternatives rather than them getting onto the floor. Prolonged standing may not be comfortable, but a well balanced class should in any case avoid this.
You should also bear in mind the student’s medication, as some pain killers and other drugs for nerve pain and depression can cause drowsiness, so it is important to specifically ask about this.
Make sure that any arthritic joints are well warmed up, with particular attention given to the joint circles. (However, use the hip roll rather than a single leg hip circle after hip replacement).
The following sections give some general advice on particular joint replacements. However, a teacher should only teach students who have artificial joints if their own teacher training has given them competency in this area. Also, it is very important that the advice given here is not used as a do-it-yourself guide. Always seek out a suitably qualified and experienced teacher.
Above all, however, yoga should be enjoyed, and you should not fear to move the body at all. Knowledge makes for safe yoga.
The Hip Replacement.
There are two main options for patients: either the traditional hip replacement (where both the ball and socket are replaced), or a newer technique called resurfacing.
The full replacement is smaller than the natural hip joint and is potentially vulnerable to dislocating posteriorly. It is helpful for both students and teachers to look at a model of a hip joint to understand this; it then becomes easy to work out which movements or asanas would be inappropriate. Surgeons usually tell their patients they are not to cross their legs ever again. This is because they need to avoid internal rotation of the hip, which leads to a risk of dislocation. However, from a yoga point of view there are a number of movements or asanas which cause internal rotation of the hip, without classically crossing the legs. It is important that both the student and teacher understand which movements these are before starting in the class. No list can ever fully cover this; it is much better to understand the principle and then apply it. But as a general guide, the following should be avoided:
i/ Taking the leg across the midline of the body. eg. hip cross, hip circle (warm up), the eagle, the spinal twist, hip swivel, the cow, water carrier.
ii/ Sitting between the feet, e.g. the hero.
iii/ standing with the feet turned in.
iv/ sitting in any hurdle type position (i.e. foot next to hip), e.g. hurdle sitting, hurdle switch, hurdle stretch. (These movements can have a degree of internal rotation if not correctly and fully done).
In addition, after a hip replacement, external rotation, though not dangerous like internal rotation, is reduced. Therefore, the knee bend may be fine, but the full squat position is unlikely to be achieved (and may be considered inadvisable- see later). All movements of the hip will be reduced to a varying degree. Most people will also find that they cannot kneel down fully, but may be able to kneel upright with the thighs in a vertical position.
Some yoga publications have suggested that the hip should not be flexed more than 90 degrees, as this can also involve some internal rotation of the hip. Personally, I believe that any such effect would be very minimal, and I have never yet heard an orthopaedic doctor advising their patients on this. However, in these days of litigation, it is prudent to avoid any extreme movement of the hip, including flexion beyond 90 degrees. This means that a student should only do a forward bend type movement to 90 degrees, and may sit on the floor, legs out straight, but no further forwards. In practice however, I have not had to concern myself with this technicality, as I have found that most students are unable to achieve this degree of flexion and usually need to be given alternatives to sitting on the floor.
Hip resurfacing is a relatively new technique used on younger patients, with the aim of delaying their need for a full hip replacement (as an artificial hip is only expected to last 10-15 years and revision surgery is more complex). The top of the ‘ball’ of the hip joint only is replaced, so most of the hip is the patient’s own and the size of the joint is the natural one. There is therefore not the same risk of dislocation as with the full joint replacement, and such patients are not usually advised of any movements they must avoid. However, there may still be some general reduction in the range of movement. If the patient is not certain that they have only had resurfacing, assume they have had a full joint replacement and avoid internal rotation until the patient has definate confirmation from their doctor. It is not enough to ask the patient if they have been told to avoid any specific movements (though you should always avoid giving them the movements they have been advised to avoid); some people may have forgotten, particularly if the reasons why were not explained to them. Interestingly, some surgeons are now veering away from resurfacing, as they have found it makes subsequent hip replacement more difficult, but opinion is currently divided.
Knee replacements.
The artificial knee is a straightforward hinge joint, without some of the more subtle give (or rotation) of a natural knee.
i/ Replaced knees should not be knelt on.
ii/ The student will not be able to sit between their knees, and won’t be able to go into a hurdle type sitting position or achieve the full spinal twist position.
iii/ Getting up and down from the floor can take a while, and some students may need chair alternatives.
iv/ People usually achieve at least 90 degrees of flexion in the new knee, but it will be reduced compared to a natural healthy knee (i.e. will not be able to do the heron, bow, or other asanas involving holding the foot near the buttocks).
v/ The student may not be very comfortable sitting crossed legged, and may be uncomfortable sitting on the floor in any position.
vi/ Movements where there is a degree of rotation may need to be modified, e.g. the warrior, fencing.
Shoulder replacement.
The shoulder is a complex joint, in terms of both the range and types of movement it is capable of. Following joint replacement, there will be a considerable loss of range of movement compared to a natural healthy joint. Post surgery, people will not usually be able to lift their elbow to above shoulder height, and will require asanas involving this to be modified. No movements are specifically ‘banned’, but it is important to take time to ask the student which movements they can comfortably do, and how their movement is restricted. It may be worthwhile to have a one to one session before joining a class to assess this. It would also be wise to avoid taking any body weight through the arms. E.g. the Cat asanas, supported camel, cobra, up and over etc.