March 2017: Total Joint Replacement



Patients who eventually undergo total joint replacements come to the rehab department with completely different backstories. While the original causes of arthritis can be different (genetics, activity level, weight, occupation, trauma), the eventual result is the breakdown of cartilage, leading to painful “bone on bone” weight bearing. By the time that patients reach an orthopedic surgeon’s office, many have exhausted therapy options. Pain, deformity, and lack of use have led to a poor quality of life. The patient presents to the surgeon with the desire to reduce pain and improve quality of life. For those individuals, the only true solution becomes the total joint replacement.

The water offers a unique therapeutic environment which can be harnessed by a skilled therapist to permit treatments unachievable on land. This environment is created because of water’s properties such as buoyancy, viscosity, hydrostatic pressure and neutral warmth. Although aquatic therapy is useful for many conditions, there are certain circumstances which make immersed exercise a better choice than its land-based cousin. If the patient:

  • Is on any weight-bearing restriction;
  • Is unable to support his weight to initiate ambulation due to obesity, weakness or other factors;
  • Has an abnormal gait pattern or makes excessive use of an assistive device;
  • Is in too much pain to treat on land;
  • Has lower-extremity edema

then the therapist should begin to “think water”. Everyone of these conditions is present immediately after total joint replacement and that is why the therapy pool is now considered a treatment of choice for post-surgical patients.

Recent Publications: Systematic reviews and meta-analysis

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.

Ciolac, E. G., & Greve, J. M. D. (2011). Muscle strength and exercise intensity adaptation to resistance training in older women with knee osteoarthritis and total knee arthroplasty. Clinics (São Paulo, Brazil), 66(12), 2079–84.

Giaquinto, S., Ciotola, E., Dall’armi, V., & Margutti, F. (2010). Hydrotherapy after total hip arthroplasty: a follow-up study. Archives of Gerontology and Geriatrics, 50(1), 92–95. article.

Kochar, R. D. (2011). Effect of AquaStretch on Range of Motion at Knee Joint in Total Knee Arthroplasty Patients. ProQuest Dissertations and Theses, 56. Retrieved from

Kwok, I., Paton, B., & Haddad, F. (2015). Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty?—A Systematic Review. The Journal of Arthroplasty.

Lahav, I. W., Hutzler, Y., Roth, D., & Hadar-Frumer, M. (2007). Physical and Psychological Effects of Aquatic Therapy in Participants After Hip-Joint Replacement : A Pilot Study. Internation Journal of Aquatic Research and Education, 1(4), 311–321.

Liebs, T. R., Herzberg, W., Rüther, W., Haasters, J. J. J., Russlies, M., Hassenpflug, J., … J., H. H. H. H. (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. article.

Łyp, M., Kaczor, R., Cabak, A., Tederko, P., Włostowska, E., Stanisławska, I., … Tomaszewski, W. (2016). A Water Rehabilitation Program in Patients with Hip Osteoarthritis Before and After Total Hip Replacement. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, 22, 2635–42. Retrieved from

Mortenson, K. (2015). Effect of an Aquatic Therapy Program with Progression to Land Program for Adult Following Three Total Hip. Florida Gulf Coast University. Retrieved from

Piva, S. R., Gil, A. B., Almeida, G. J. M., DiGioia  III, A. M., Levison, T. J., & Fitzgerald, G. K. (2010). A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther, 90(6), 880–894 15p.

Pozzi, F. (2015). Optimizing functional and biomechanical outcomes following total joint arthroplasty. University of Delaware. Retrieved from

Valkenet, K., van de Port, I. G. L., Dronkers, J. J., de Vries, W. R., Lindeman, E., & Backx, F. J. G. (2011). The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clinical Rehabilitation, 25(2), 99–111.

Valtonen, A., Pöyhönen, T., Sipilä, S., Heinonen, A., Poyhonen, T., Sipila, S., … Sipilä, S. (2010). Effects of aquatic resistance training on mobility limitation and lower-limb impairments after knee replacement. Archives of Physical Medicine and Rehabilitation, 91(6), 833–839. article.

Valtonen, A., Pöyhönen, T., Sipilä, S., Heinonen, A., Sipil, S., & Heinonen, A. (2011). Maintenance of aquatic training-induced benefits on mobility and lower-extremity muscles among persons with unilateral knee replacement. Archives of Physical Medicine and Rehabilitation, 92(12), 1944–1950. article.

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. article.

Zech, A., Hendrich, S., & Pfeifer, K. (2015). Association between exercise therapy dose and functional improvements in the early postoperative phase after hip and knee arthroplasty. An observational study. PM & R : The Journal of Injury, Function, and Rehabilitation.