Knee Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s previous post Arthritis of the Knee and Yoga about what the next step might be when your own self-care management techniques are not as effective and your quality of life is severely impacted. So I thought I would you give some background about the elective procedure total knee replacement and why you might elect to have it done. Professionally, I see a lot of total knee replacements in my work as a home health physical therapist, and I also have yoga students who come to my class either after the procedure or beforehand as they are preparing themselves for the surgery.

Although many people will never need surgery for arthritis of the knee, if you have severe joint damage, extreme pain that isn’t helped by other treatments, or very limited motion as a result of the condition, knee replacement surgery may be necessary. So if the arthritis pain in your knee worsens, and the exercise that once helped you feel better has become unbearable, your doctor may recommend a total knee replacement (TKR). Surgery for osteoarthritis can provide several benefits, including :

• improved movement
• pain relief
• improved joint alignment

When you research the procedure, you will discover there are gender-specific knees, which are knee replacement models designed for women, and dozens of other options, too, including different materials, sizes and models from a variety of manufacturers. How do you choose? Generally, you don’t. Surgeons typically determine which implant they’ll use when they are in the operating room and actually looking at the structure and size of your bones.

X-Rays of Knee Replacements (from Wikimedia)

Prior to surgery, however, you should have an informed conversation with the doctor about your options so you can ask good questions about why a particular model might be chosen, and determine if you’re comfortable with the doctor’s approach and experience or whether you’d like a second opinion.

When only a portion of your knee has severe arthritic wear and tear symptoms, as confirmed by diagnostic testing as well as subjective complaints, you may be recommended to undergo a “partial or unicompartmental knee replacement.” This may be recommended because it helps to straighten up the joint, which has changed its position as a result of osteoarthritis. Partial knee replacement can be more effective and durable if appropriate and are less invasive. Recovery time is less because there is less surgical trauma.When the entire knee joint is replaced that is called a total knee replacement, and the ends of the femur, top of the tibia and often the patella (knee cap) are fully replaced.

When you are ready to return to your yoga class, you should take time to talk with your teacher about your knee replacement. I will routinely ask these students a series of questions:

1.    How long ago was the surgery?
2.    Are you still in pain?
3.    Are you still in physical therapy?
4.    Do you have any hip or back pain (either before or after the knee replacement)?
5.    How much mobility do you currently have? Can you get up and down from the floor?
6.    Do you have arthritis in any other joints?

So be prepared to provide your teacher with this information. Knee range of motion will vary widely both in a recent post-operative knee as well as a knee replacement that is over one year old. A lot depends on how much motion you lost prior to the surgery and how hard you worked postoperatively. The answer to the question “Can you get up and down from the floor?” is important because it tells the teacher a lot about a student’s flexibility and strength. Knee flexion will vary considerably, but I have never seen a knee replacement with 155 degrees flexion nor have I ever seen someone able to do a deep squat. Whether this just happens to be my student demographic or not, I don’t know.

When resuming yoga practice, alignment is a big deal with knee replacements because post operatively you want to avoid torque forces through the joint because that affects cement in the joint. “Closed chain activities,” where your weight is shifted with your foot remaining on the floor,” where your foot is lifted off of the floor with subsequent weight bearing will affect the joint differently. For standing poses, I teach students with recent knee replacements to pick their feet up and then replace and position as opposed to pivoting to change directions. Down the road, you can introduce pivoting if it doesn’t cause pain or discomfort. Liberal usage of props; walls, chairs, blocks will assist the student in not over-doing too quickly.

Strengthening all of the muscles that cross the knee joint as well as secondary stabilizers is also important. This means front, back and side leg muscles. Attention to hip alignment and strength also translates to protection of the knee replacement. Kneeling is problematic but not necessarily injurious to the new knee. Finally, pay attention to the feet—where is the weight on the foot? A lot of individuals who suffer from arthritic hips and knees have feet that need some tender loving attention. Baxter in his prior posts talked about feet (see Your Feet on My Mind), and I agree that where the body meets the ground and how we stack up from there is crucial in protecting our joints for longevity, especially when we become bionic.

I would like to add that lot depends on your pre-surgical state of health. If you have been active up till the day of the surgery then your recovery time will take about three months till you feel like you have integrated the new knee into your body. This is a rough estimate, but it seems about right for a traditional total knee replacement. Minimally invasive and partial knee replacements have less trauma, so healing and function comes more quickly. For those individuals who have lost a lot of mobility and have developed severe range of motion loss and significant loss of muscle strength, the recovery time will be more arduous because of all the structural as well as cardiac changes.

Finally I want to emphasize this: talk to your surgeon before and after surgery to know what your particular limitations and precautions may be, and remember to share them with your yoga teacher. Remember this is an invasive surgical procedure and everyone heals in a different manner. Be kind to yourself and remember that with a lot of hard work you will regain function and improve the quality of your life. This the reason why you decided to undergo this surgical option in the first place.

Arthritis of the Knee and Yoga

by Baxter

While in Montreal for a weekend workshop, I found myself attending a modern dance performance.  I’d say the average age of the performers was about 30, and all looked very fit and flexible.  As part of their performance, they did a move in which they leapt forward while spinning and landed on the floor in a Pigeon-pose like stance.  The first time they did this, I found myself wincing, as I imagined the impact on their knees on the firm, uncarpeted dance floor.  I’d have to guess they did this at least five more times, and usually always landing on the same knee.  My host and I spoke about this after the show, and we were both of the opinion that no good could come of this for the future health of these dancers’ knees. 

Trauma to the knee is one of several risk factors for the development of arthritis of the knees later in life.  It was no coincidence that one of the attendees at my weekend Anatomy and Yoga workshop has arthritis in his knees at the ripe age of 40, as he had been dancing for over 20 years and had suffered numerous injuries to both knees over that time.  But since starting his yoga a few years back, his knee pain had improved to the point that after a hiatus of almost 10 years, he was gradually returning to some dance.

In addition to trauma, other risk factors for developing osteoarthritis (the most common form of arthritis) of the knee include:;

• weight, as in more body weight, more stress on the knee joint
• sedentary lifestyle, as it seems that some activity is better for the knee joint than no activity
• work or hobbies that involve repetitive demands on the knees, such as horseback riding, which encourages a bowing outward at the knee joint and places unusual stress on the knee joint
• bone abnormalities, which some people are born with and could include skeletal issues such as bow legs or knock knees
• other diseases like hypothyroidism and Paget’s disease, which could lead to arthritis over time advancing age
• gender, that is, women, for reasons that are not yet clear, have a higher incidence of arthritis than men

Typically, in a healthy knee joint, just as in the hips, the surfaces of the top bone, the femur, and the bottom bone, the tibia, are covered in a layer of protective connective tissue known as cartilage. The cartilage acts as both a shock absorber when the bones move close to one another, as when you are walking or running, and also as a smooth, slick surface for the bones to slide over one another when you are doing any knee bending activities.

If any or several of the risk factors are present, the usually smooth surfaces can become rough, like sandpaper, which may or may not produce pain, but could produce some grinding sounds from the knees. Eventually, the cartilage could wear through and expose the underlying bone, which is even rougher. When bone on bone contact starts to occur, it usually results in inflammation in the joint, which then swells, can become hot to touch and limited in movement and painful. Since the condition usually worsens over time, especially if you don’t seek help for it, it could eventually lead to significant immobility and pain. I am going to assume you have had the common sense to see you family MD to get an accurate diagnosis and have tried some of the western treatment options, such as medications, physical therapy, and braces, and such and are looking for alternative ways to work with the knees to avoid worsening of your situation and surgery.

Yoga is both helpful in addressing the acute problems of swelling and pain, and the longer-term issues of improving mobility, strength and stability of the knee joints. 

In acute situations, restorative practices or reclining sequences can allow for you to maintain some gentle movement of the knee while reducing the effects of gravity on the knee that occurs when you stand. A regular favorite when the knee is swollen is any reclining posture that elevates the leg higher than the chest. My personal favorite is Legs Up the Wall pose (Vipariti Karani). Another is the door jam version of Reclined Leg Stretch (Supta Padangustasana_, where you lie down on the floor on your back at a doorway, your hips lined up with the doorway, and take the affected leg up in the air and rest the heel on the door jam.  This allows for a more passive approach to this pose that we usually do with a strap on the foot of the lifted leg.

In addition, a whole slew of other reclining poses can be performed that are safe for the knee and allow you to get some of the stress-reducing benefits of a regular home practice (see Timothy’s post from yesterday Home Practice: The Best Way to Improve Your Health and Well-Being).  On top of helping to quiet down an inflamed knee, you can use your practice to strengthen the muscular/tendonous support around the knee. Engaging the muscles that surround the knees simultaneously has been shown to benefit the joints, as Shari noted in a post a while back on hips.  So I recommend starting with poses in which the knees are extended or straight, as this reduces sheering actions on the cartilage. This includes Mountain pose (Tadasana), Triangle pose (Utthita Trikonasana), Pyramid pose (Parsvottanasana), Wide-Spread Standing Forward Bend (Prasarita Padottanasana), and such.  If these are done successfully, without aggravating your knees, and are hopefully bringing some gradual improvement in your symptoms, you can add in standing poses with knees bent.  This will require that you pay special attention to the trajectory of the knee as you flex it.  Ideally, you will want to bend the knee directly in line with your mid-foot, so the knee is tracking in the most anatomically correct way.  You may want to have your local yoga teacher help you to figure this out, as it is a bit difficult to sense on your own at first.

Another potential way to modify seated poses to allow you to do them pain free is to use some sort of a spacer tucked into the back of your knees before you deeply flex (bend) the knees. You can use a rolled up washcloth, or a thinly folded yoga blanket.  Once you place the spacer in the fold of the back of the knee, mindfully bend the knee and see how it feels.  There should be no pain.  If you have a history of ACL repair (anterior cruciate ligament), then never use a spacer, as it could loosen this precious repaired tear. 

Since every arthritic knee is going to be a bit different, these suggestions are offered to get you thinking about ways yoga could be helpful for you. As I always say, it would be a good idea to do some one-on-one work with an experienced teacher to guide you safely on your way.

And skip the Flying Twist Dropping Pigeon from your repertoire until next lifetime!

Arthritis of the Hip Joint

In past posts, we have shared with you poses that can open tight hips, as well as discussed hips in a few specialized settings, but we have not addressed perhaps the most common aging concern for hips: the development of arthritis in the hip joint. The hip joint is a synovial joint, meaning the pelvic bone and the femur, or upper leg bone, connect with one another via a closed system. A sock-like sleeve of connective tissue holds the two bones relatively close together via what is called the joint capsule. The inner lining of this structure is lined with a specialized tissue called the synovial membrane, which secretes a special liquid, not unlike a lubricant such as oil in you car engine, to allow the bones to move over each other more smoothly. In addition, the ends of the bones are coated in a layer of cartilage—also a kind of connective tissue—that acts as a tough barrier over the bone for shock absorption, and is smooth and slick, so the bones again can glide over each other more smoothly. Finally, the inner surface of the acetabulum, the hollowed out part of the pelvic bone that the head of the femur bone fits into, has an additional cushion of cartilage lining it called the labrum. This provides a better fit for the two bones and a lot more shock absorbing potential.

Now that you have some idea of what makes up the hip joint, we can talk a bit about arthritis of the hip. As with arthritis anywhere in the body, there are two broad types. The wear and tear type of arthritis, which could be a result of repeated movements over a long time, or complicated by some old trauma, infection or injury to the joint, is called osteoarthritis (OA). In this, the most common form of arthritis, the cartilage covering on the ends of the bones is worn away gradually, exposing sensitive raw bone, which, when rubbing against another raw bone, leads to inflammation inside that closed synovial joint described above. This results in swelling, stiffness, tightness, decreased movement and pain.

The other main type of arthritis, rheumatoid arthritis (RA), in an auto-immune disease, meaning your body mistakes itself (in this case, the joint lining) as a foreign invader and mounts an immune response to fight it off. This response is an inflammatory one, resulting in damage to the ends of the bones, sometimes even at a young age. It is quite a bit less common than osteoarthritis, but still seen enough to be aware of it. 

It almost goes without saying that this condition can be painful. What other symptoms would you look for? Because of the damage to the cartilage, people with arthritis may feel as though their hip is stiff and their motion is limited. Sometimes people feel a catching or clicking within the hip. The pain usually gets worse when the hip joint is strained by walking long distances, standing for a long time or climbing stairs. The pain is usually felt in the groin, but also may be felt on the side of the hip, the buttock and sometimes into the knee.

Here in the US, we start to diagnose the condition via the history and physical exam, with the aid of X-rays, which often reveal diminished space between the bones. If surgery is being considered, an MRI of the joint will also likely be ordered. Treatment offered by your family MD or arthritis specialist could include medications for pain and inflammation, recommendations to change activities to reduce the stress on the joint, a plan for weight loss which also reduces joint stress, assistive devices like a cane if needed, and surgery to clean out the joint or to replace the joint. 

At the start of any treatment regimen, conservative recommendations are made, which include rest and avoiding any repetitive activity that may have strained the joint or muscle, as well as working with a physical therapist who can help increase your range of motion or strengthen muscles to increase stability on the joint. Here is where yoga can fit into your healing regimen. But first, you want to take a good look at what you are already doing in your yoga practice to see if any of the poses or vinyasa practices you do now could be contributing to your pain and dysfunction. Do you get pain while doing certain poses, like the front leg hip joint in a Lunge pose? Do you have a flare of pain in the hip after class or the next morning? Yes to any of these questions requires you consider suspending the offending practice, at least temporarily.

On the other hand, it is not uncommon for a student to start yoga because they have heard it could help their condition. In this setting, you will want to begin at the beginning, with a gentle practice as your entry into yoga. A one-on-one session would also be a good way to start. If you are having chronic, persistent pain, start out by lying on the floor and moving through our Dynamic Reclined Hip Stretches, in which you take the joint through many of the movements it is capable of. Add to this Snow Angel Legs, where you are lying supine (on your back) and you spread your legs wide on the floor, without rolling your thighs in or out, and then bring them back to center. Follow this with by Dynamic Locust pose, which is done on your belly, lifting one leg up off the floor without bending your knee. Lift up on your inhale and lower down on your exhale. These three explorations will give you a better sense of the range of motion of your hips, right and left, as well as movements that cause immediate pain. This is very useful information as you explore other poses in different positions. 

It is considered important in arthritis care to keep the joint as mobile as you can and keep the supporting muscles as strong as they can be in order to keep you functional and prolong the time before surgery has to be considered (surgery is not inevitable, by the way).  Since you can do many yoga poses without bearing direct weight on the joint, either prone or supine poses, seated poses and inversions, yoga provides lots of opportunity to work on range of motion and some strengthening of the joint. The pose Reclined Leg Stretch (Supta Padangusthasana) and its variations are good example of both goals being met.  Each time you lift your leg straight up to begin the pose, you are strengthening the quad muscles and the psoas, for instance. And even the standing poses can be done in a fairly weight free manner if your do them with your pelvis supported on a chair. Poses like Lunge, Warrior 1 and 2, and Extended Side Angle, all have chair variations that could be helpful when full weight on the joint needs to be avoided. And as always, breath work and meditation can be helpful with pain management, as well as yoga nidra.  I understand that yoga is even being taught in swimming pool settings, where weightlessness is beneficial for arthritic hip joints.  Sounds potentially helpful, but I’d skip the inversions class!

When your symptoms are milder, movement practices like Sun and Moon Salutations done slowly, mindfully and with the idea of soft foot landings might be safely added to your home practice. If your yoga practice can diminish your pain, improve your mobility and delay any invasive treatments, you’ll be getting your moneys worth! And the mental equanimity that is a result of a balanced yoga practice can hopefully guide any difficult decisions you may need to make about your hip toward the best outcome.   

Yoga and Arthritis of the Hands

by Baxter

Every time I get a call from a student or patient about arthritis of the hands, it brings to mind an image of my beloved Grandma Lopresto, at her towering height of 4’11”, who lived to be 93 with the clearest mind you can imagine. She had arthritis in her hands. Yet I never recall her complaining about it. In fact, I never heard her complain about her body at all, even though she also suffered from post-herpetic neuralgia, a chronic painful condition that is an aftermath of getting shingles. 

But back to Grandma’s hands—when you looked at her hands, she had obvious swelling around the knuckles of almost every finger on both hands. And although I would see her working the fingers by rubbing and bending them, it did not seem to slow her down, as she lived on her own for 29 years after her husband died when she was 64. I can recall her even doing some simple sewing projects to replace a button and such.

Ah, if this were the case for others with arthritis of the hands! For many, there is chronic pain that is disruptive to daily activities, sometimes requiring pain medication, anti-inflammatories, injections and more invasive measures to deal with it. Grandma certainly had classic osteoarthritis of the fingers, which affects the last joint of the finger, the DIP joint, and involves small nodular swelling around the joint known as Heberden’s nodes, and the closer knuckle, the PIP joint, with Bouchard's nodes. The most common site affected by arthritis in the hands, however, is the thumb. It is usually a form of osteoarthritis, the common wear and tear arthritis that affects millions of Americans annually. It affects the joint between the carpal (wrist bones) bones and the metacarpal of the thumb (which resides in the palm of the hand). On its worst days, basal joint arthritis (its other name) can cause pain, swelling, stiffness, weakness or immobility. In addition to what I have mentioned already, treatment by your family doc or rheumatologist can also include self-care recommendations and splints. These splints can help decrease pain, re-align the bones, and permit the joint to rest. Obviously, if you have to wear a splint, you’ll need to modify your hand use in yoga.

One thing to keep in mind is that osteoarthritis often results from trauma or injury to the thumb at some point in the past, and that over time the protective coating of cartilage on the ends of the bones wears away, exposing sensitive bone to bone.  One way to address this via yoga or visualization is to lengthen the thumbs or fingers, depending on which joints are affected, from palm to fingertips, specifically focusing on the affected joint. The encouragement you get from your teacher to spread and lengthen the fingers in poses like Downward-Facing Dog pose is pretty good advice. Although, as you might imagine, you may need to avoid putting full body weight onto your hands if you are experiencing a full-blown joint flare.  In such situations, non-weight bearing asana would be more appropriate, of which there are many.  Ones in which the arms are overhead, such as Warrior 1 and Tree pose, can be particularly helpful to enlist the aid of gravity in pulling swelling away from the hands and back toward the heart. 

Often the pain and stiffness of osteoarthritis in the hands is most noticeable in the morning when you first get up. Warming your joints in the shower and gentle movements of your hands and fingers for 15 to 20 minutes can result in less stiffness and decrease in pain.  If you have not seen a physical therapist for specific range of motion exercises, consider asking to do so. In the meantime, you can use your yoga sessions to put your hands and thumbs through their paces, maximizing the range of motions in the most pain free way you can. 

Other patterns of finger arthritis include the less common condition of rheumatoid arthritis, which affects the hands at the wrist joint and at the joint between the palm bone and the finger bone, the metacarpal-phalageal joint.  Often, more than one joint is involved. Rheumatoid arthritis is an autoimmune illness, and it can cause much worse and more persistent symptoms than osteoarthritis so even gentler approach may be needed.

If you are at risk for developing arthritis in the hands, via age (over 40), sex (female), family history of osteoarthritis or rheumatoid arthritis, or history of trauma to your hands, a balanced yoga practice, with a careful, stepwise approach to yoga poses that involve bearing weight on the hands (such Cat/Cow pose, Downward-Facing Dog pose, Upward-Facing Dog pose, and all arm balances), may be helpful in maintaining a good range of motion in your hand joints over time. Adding a variety of hasta mudras, or hand seals, could exercise and strengthen your fingers in a non-weight bearing fashion.

And for those who have already developed arthritis, less weight-bearing asana is likely the way to go. There are also a number of props coming out that could assist in more pain-free exploration of the asana in which your hands are on the floor.  Specialized gloves with a rubber cushion for the heel of the hand, as well as wedges, rounded blocks, and weird circular cushions called Yoga Jellies are all possible aids to permit careful inclusion of weight-bearing asana in your practice.  And surely, as you must know by now if you are a frequent reader, enlist the help of an experienced teacher who has worked with others who have arthritis!

Delaying Joint Replacement

by Nina

Did any of you read Jane Brody’s latest article on arthritis Relief for Joints Besieged by Arthritis in the New York Times last week? Well, I did. And as someone who had an orthopedist say to me, “You are heading for a joint replacement. It could be months or it could be years, but there is nothing you can do about it,” I was very struck by her discussion of joint replacement, especially the following quote:

 “People with osteoarthritis are relying more and more heavily on surgery,” Dr. David T. Felson, a rheumatologist and epidemiologist at Boston University School of Medicine, told me. “The rate of knee replacement is just skyrocketing, out of proportion to increases in arthritic changes seen on X-rays, and replacement surgery is contributing greatly to the rising costs of Medicare..”

She also quoted Dr. Felson saying that although hip replacement is “dynamite,” knee replacement may be far less helpful. “For 10 to 30 percent of patients, the improvement never comes.” Brody goes on to recommend to people, the same way we at Yoga for Healthy Aging do, that people try to postpone joint replacement if possible and states, ever so clearly and concisely, the reasons why:  

Artificial joints usually last 10 to 15 years. Delaying surgery is helpful because the earlier in life a joint is replaced, the more likely a subsequent replacement will be needed. And both devices and surgical techniques are constantly being improved; by delaying a joint replacement, you may end up with a simpler operation or more durable device.

Snails and a Bee on the Same Flower by Michele Macartney-Filgate

That’s it in a nutshell! So how exactly can you delay surgery if you’re having pain in your joints? Why yoga, of course. Although Brody doesn’t specifically recommend yoga, she does quote Dr. Felson again when talking about the importance of exercise for arthritic joints:

“The severity of pain is directly correlated with the degree of muscle weakness."

Well, that’s pretty clear, isn’t it? In fact, I’ve never seen it put that bluntly before. And the yoga standing poses, because they are weight bearing, are excellent for building strength in your knees and hips. For your knees, the poses where one or both bent knees are particularly beneficial (Warrior 1 and 2, Extended Side Angle pose, Powerful Pose, and so on). Although we have not yet addressed arthritis of the hip (note to self: good idea for future topic), most, if not all, of the standing poses would be beneficial for your hips. For arthritis of the shoulder joint, yoga provides a number of simple poses where you bear weight on your arms, including Downward and Upward-Facing Dog, Upward Plank pose (Purvottansana), and Side Plank pose (Vasithasana), so don’t think that if you can’t do Handstand yet, you can’t work on your arm strength (note to self: another good idea for future topic).  

Sometimes being slow is a good thing. 

P.S. Thank you Michele for this perfect photograph (isn't it amazing everyone?) as well as the rest of the other ones you've shared with us in the past and plan to share in the future. I can't wait for the next batch!