January 2016: Joint Replacements



Content courtesy of the National Swimming Pool Foundation

Aquatic therapy (also known as pool therapy or hydrotherapy) is a viable treatment option which can be used by rehabilitation providers working with patients after knee and hip replacements (Gibson & Shields 2015). Aquatic therapy can safely be initiated as early as the 5th day post-operatively for many patients (Leibs 2012); more importantly, a recent systematic review has shown that there is no increase in risk of infection with immersion after orthopedic surgeries (Villalta 2013). Aquatic therapy is often prescribed and performed early in rehabilitation to control and prevent the negative consequences associated with surgery (Noack 2015). Therapists believe that aquatic therapy provides greater benefits compared to land exercises for the following reasons:

  • The hydrostatic pressure gradient present during immersion can reduce distal edema and effusion and permit greater ROM, especially for closed systems like the knee;
  • The buoyancy effect of immersion offsets body weight and reduces compression forces on the new joint, permitting greater movement freedom;
  • The buoyancy effect reduces the need for an assistive device and allows for “normalization” of gait almost immediately after surgery;
  • The thermal properties of water can reduce post-operative muscle spasm and pain and the “normal” social atmosphere of the pool can produce a feeling of immediate success.

In short, exercise in a therapeutic pool environment provides a safe and gentle means of easing post-surgical patients into rehabilitation and recent publications, such as those provided below, can help us better understand the role aquatics can play.


ART ET Al 2015
This systematic review posed a very important question: Is physical therapy even effective after total knee surgery? The authors compared studies which examined the effects of different kinds of PT treatments including: physiotherapy exercise versus no therapy; home versus outpatient therapy; pool versus gym-based therapy; walking skills versus more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. As always seems to happen in the physical medicine literature, the authors concluded that the evidence was too weak to make much of a global statement about the effectiveness of therapy, including aquatic therapy. However, this review is a great place to find interesting studies on this topic as the authors included 18 clinical trials, including aquatic trials. Read more here: http://www.ncbi.nlm.nih.gov/pubmed/25886975

Cadenas-Sánchez et al 2016
Ever wondered if post-operative patients should be encouraged to walk both directions in water after surgery? And if so, at what speeds? This study asked this very question and found that walking forward and walking backwards were very different biomechanical events. Therapists looking to make their sessions the most beneficial for post-op ROM and gait training can benefit from reading their findings, including the fact that the ankle, knee and hip flex more during forward walking than they do retro-walking.  Read more here: http://www.ncbi.nlm.nih.gov/pubmed/26047156

Gibson & Shields 2015
This systematic review asks the question: Is it beneficial to add aquatics to a land-based program for the post-operative patient. It is a review process that needs to be repeated every year or two. Why? Insurers keep asking therapists why they should pay for aquatic therapy on top of traditional land-based therapy. The authors of this systematic review and meta-analysis asked whether the addition of aquatics to a traditional post-operative rehabilitation program made a difference in outcomes for patients who had undergone a total knee or total hip surgery. The authors only found 3 studies which met their criteria, but it’s a start. These three studies showed moderate-quality evidence that aquatic therapy in combination with land-based therapy improves functional outcomes, knee range of motion, and edema when compared with land-based therapy alone. Read more here: http://www.ncbi.nlm.nih.gov/pubmed/25931664

Leibs 2012
There have been many aquatic therapy studies published since 2012, but few that have generated the amount of attention that this huge, multi-center study did. These authors asked a set of compelling questions including: 1.How early should aquatic therapy be started after total knee replacement surgery? and 2. How early should it be started after total hip replacement surgery? They found that knee replacement patients who began aquatics earlier (meaning during the first week post-op) did better than their counterparts who did not start for 2 weeks or more after surgery. Total hip patients did not show this same need for a week 1 start to aquatics; they did just as well if aquatic therapy was delayed until 14 days post-op. This study really rocked the aquatic therapy world by showing the difference a single week could make in outcomes. Read more here: http://www.ncbi.nlm.nih.gov/pubmed/22196125

Noack et al 2015
The question is often asked: Is aquatic therapy even safe for patients who are diagnosed with a deep vein thrombosis? This is especially relevant immediately after surgery as patients remain at an elevated risk both due to the surgery itself and due to the short-term immobilization afterwards. This research study went a step further and examined which therapies can be recommended as rehabilitation after patients suffered not just a DVT, but a subsequent pulmonary embolism. Aquatic exercise made the cut! This publication shows, for the first time, that aquatic exercise/swimming after a pulmonary embolism appears to be safe. Read more here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508081/

Villalta & Peiris 2013
Yes, this is the landmark study which was heralded by therapists around the world. The researchers asked 2 questions: 1.Is aquatic therapy safe to perform immediately after surgery? and 2. Is it effective? The answers delivered by the study were clear. Orthopedic surgery does NOT increase the risk of infection or other wound-related adverse events. It is more effective at improving function than its land-based counterpart and it is at least as effective as more traditional therapy in addressing edema, strength pain and range of motion in the early post-operative period. Read more here: http://www.ncbi.nlm.nih.gov/pubmed/22878230


Artz, N., Elvers, K. T., Lowe, C. M., Sackley, C., Jepson, P., & Beswick, A. D. (2015). Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskeletal Disorders, 16(1), 15. doi:10.1186/s12891-015-0469-6

Cadenas-Sánchez, C., Arellano, R., Taladriz, S., & López-Contreras, G. (2016). Biomechanical characteristics of adults walking forward and backward in water at different stride frequencies. Journal of sports sciences, 34(3), 224-231. 

Gibson, A. J., & Shields, N. (2015). Effects of aquatic therapy and land-based therapy versus land-based therapy alone on range of motion edema and function after hip or knee replacement: A systematic review and meta-analysis. Physiotherapy Canada. 67(2):133-41.

Liebs, T. R., Herzberg, W., Rüther, W., Haasters, J., Russlies, M., Hassenpflug, J., & Project, M. A. A. (2012). Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Archives of physical medicine and rehabilitation, 93(2), 192-199.

Noack, F., Schmidt, B., Amoury, M., Stoevesandt, D., Gielen, S., Pflaumbaum, B., … Schlitt, A. (2015). Feasibility and safety of rehabilitation after venous thromboembolism. Vascular Health and Risk Management, 11, 397–401. doi:10.2147/VHRM.S81411

Villalta, E. M., & Peiris, C. L. (2013). Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults post orthopedic surgery: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 94(1), 138–148. doi:10.1016/j.apmr.2012.07.020