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On the Floor: Responsive Teaching for Extraordinary Participants: Hip and Knee Replacements

Sanders, Mary E. M.S.

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ACSM's Health & Fitness Journal: July-August 2004 - Volume 8 - Issue 4 - p 31-34
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In Brief

A quick show of hands during my Monday morning class at the YMCA revealed that almost everyone had some kind of arthritis and had undergone joint replacement surgery. Some people raised two hands indicating double replacements or multiple surgeries on the same joint! Other people were challenged with low-back pain, diabetes, fibromyalgia, and heart conditions. Hopefully this trend toward physical activity for health will increase; however, health/fitness instructors will want to be prepared to teach participants how to take charge of their own experiences.

One Size Fits All?

The increased prevalence of obesity and related conditions along with an aging population is resulting in larger populations of special needs students who attend activity programs. The U.S. Centers for Disease Control and Prevention (2003) indicates that 1 in 4 Americans engage in little or no regular physical activity. Some of these people may belong to the group of the 34 to 43 million people in the United States who have chronic conditions or disabilities (1). As more people understand the benefits of exercise and its role in achieving a healthy lifestyle while managing a chronic condition, a wider variety will be turning to health/fitness professionals for guidance. Learning how to perform safe, comfortable, and effective exercise progressions can help people cope with health challenges while improving the quality of their lives and preserving functional capacity, freedom, and independence (2).

People Soup

Blending a diverse group of people successfully into your exercise program is not easy and requires knowledge about a variety of conditions along with the challenges to exercise. People who are apparently healthy and those with special conditions benefit from developing an ability to exercise purposefully. However, the challenges for special needs students require specific skills that empower them to take charge of their own activities using modifications.

This column provides some responsive teaching tips and special skills that can help students take charge of their workouts so they comfortably achieve personal success.

What Is Responsive Teaching?

A responsive teaching method requires instructors to understand the health objectives of participants and their individual challenges. Trainers who are responsive to individual client needs, both in group exercise and during personal training, can provide instruction that addresses individual health/fitness goals by teaching participants how to modify exercises for their own special conditions. By teaching skills or tips that clients can then use as needed during an exercise session, the instructor allows students to be responsible for their own success. Responsive teaching might include showing participants how to adjust the intensity at which they perform exercises, encouraging them to work at their own level, and providing positive corrective feedback (3, 4).

The next few columns will focus on some general screening guidelines and exercise modifications, along with abnormal responses to exercise and suggestions about when to refer to a health-care provider. When students with special needs attend your class, you may consider spending time to determine if the class is appropriate based upon the individual's special need, followed by a screening to determine readiness to exercise. You and your client may want to briefly discuss the objectives of the program and why he or she is attending.

Personal trainers have an opportunity to target individual needs after examining their client's health history along with one-on-one discussions and feedback. Group exercise instructors, however, have a much greater challenge. If you are faced with the challenge of budgeting time for communicating specifically with students who may have special needs, consider the following ideas:


  • Begin class by stating the objectives. "Today we'll be focusing on resistance exercise to build muscular endurance, which is important for lifting your kids or grandkids and going up and down stairs."
  • Briefly explain the game plan. "We'll be working on muscular endurance today, and that may include lifting some equipment."
  • Give students choices. "During the class we'll work each exercise through a progression. Go at your own pace. You may choose to work some exercises using only your own body weight, or the weight bar only, or you might want to add some weights."

During Class

  • During group exercise, you might want to "call out" modifications based upon common conditions in the population. For example, many adults suffer from low-back pain, so a general "call out" cue might be "belly button in and up" or have everyone practice a modification together so they'll understand how to change the exercise if necessary, for example, for individuals who have had knee replacement surgery, they may want to reduce the size of the movement during a squat progression.

After Class

  • Make yourself available after class for participants to ask you questions, discuss responses to exercise, or to review modification skills. Remember, some clients may have more than one condition that needs to be considered.

These guidelines are not exhaustive; be sure to monitor your participants' ability to help themselves. Follow the recommendations of your client's health care providers and consult with them as needed. As a health/fitness professional, your role is to increase your clients' ability to perform activities of daily living and help them keep themselves healthy.

Orthopedic Conditions: Total Hip and Knee Replacements

Common conditions such as obesity and osteoarthritis are associated with total hip and knee replacements, typically associated with older adults. In 1999, 168,000 total hip replacements were performed on patients who are on average 66 years old (57% women). Knee replacements in 1999 accounted for 98% of all joint procedures with 267,000 reported for 1999 (average age of patients, 68 years; 61% women) (5).

However, according to the American Academy of Orthopaedic Surgeons, as reported by T. Agonvino (6), baby boomers, aged 38 to 56 years had 35,000 hip replacements (21% of the procedures) in 2001. Knee replacements for the same group were 48,000 (15% of the total) in 2001. Hip and knee placements increased 16% and 12% respectively for boomers compared to 1997 procedures for the same group. One reason why there seems to be an increased incidence in arthritis at a younger age could be the result of more active lifestyles including jogging, aerobics, and other vigorous activities. Many boomers enjoy playing hard and refuse to enter older age "quietly," wanting to keep up with kids and grandkids. Patients who don't want to live with the symptoms are more eager to seek treatment to "fix" the joints, and they now have options of new prostheses and medications (6). Your exercise program may include both young and older adults who have hip and knee replacements and are ready for physical activity as part of their return to functional performance.


The following section co-authored with my colleague, Cathy Maloney-Hills, PT (3, 4), presents a sample of responsive teaching tips and modifications appropriate for both land and water exercise. Remember, the role of the instructor is to help students help themselves by developing new skills in response to their challenges.

Hip: Total Hip Replacement

A total hip replacement (THR) is the surgical removal of the head and neck of the femur and the acetabulum. These structures are replaced with artificial metal or plastic implants. A THR is usually performed because of a fracture to the femoral neck, loss of blood supply to the femoral head, or arthritis. Severe pain and loss of function are the primary criteria for performing a THR on someone with arthritis.

Medical clearance and guidelines are required for any exercise participant who has had a THR. Students should follow the guidelines for all exercises and functional activities such as dressing, using equipment, and getting in or out of the pool. Cardiovascular conditioning exercises, lower extremity strengthening (especially gluteals), and functional activities are essential elements for individuals who have had a THR who are participating in a community-based fitness program.


  • Observe level of difficulty and independence in entering/exiting the studio or pool.
  • Have the participant wait until the wound is healed and there is minimal swelling of the involved lower extremity.
  • Ask about any previous or current low back injury or pain.
  • The participant should have medical clearance for exercise.
  • For a water exercise program, the participant should wait approximately 12 weeks after surgery before participating (or follow the guidelines of their health care provider). Water exercise may be helpful if the patient has swelling because of the hydrostatic pressure.

Safety Tips and Suggested Exercise Modifications

It is critical to teach the student these guidelines for proper self-care.

  • Follow the surgeon's guidelines carefully because there are some newer, less invasive THRs being performed that don't require as much restriction or others that have different restrictions.
  • Avoid combination of hip flexion, adduction, and internal rotation (check surgeon's guidelines).
  • Avoid pivoting on the involved leg.
  • Avoid hip flexion greater than or equal to 90 degrees.
  • Avoid having the participant cross the leg midline in front or behind.
  • Decrease lower body range of motion and intensity.
  • Include exercises that strengthen hip extensors and abductors.
  • Monitor the participant when he or she enters or exits the class or pool. Watch the individual for hip range of motion when using ladders in the pool or stairs on land.
  • Wear shoes to prevent jarring and avoid falls.

Abnormal Response to Exercise

  • moderate or greater pain during or after exercise
  • lower-back pain
  • excessive fatigue

Recommendations after Abnormal Response

  • Decrease range of motion and speed of the lower extremities.
  • Cue the participant to find and maintain the low back in neutral position. If necessary, eliminate kicking to the rear to prevent hyperextension of the low back.
  • Decrease overall intensity.

Refer the Participant Back to His or Her Health-Care Provider if Any of the Following Occurs:

  • Sudden leg swelling or pain
  • Fever
  • Severe pain in hip
  • Sign of hip dislocation, which can include severe pain, sudden inability to move the leg, or sudden shortening of the leg.
  • Increased pain in the groin or thigh (not just the lateral hip) may be a contraindication to continuing exercise because the hip may refer pain.

Knee: Total Knee Replacement

A total knee replacement (TKR) is performed when all conservative measures to treat arthritis of the knee have failed. Pain and loss of function are the main criteria for performing a total knee replacement. A TKR involves resurfacing the ends of the bones of the knee joint with a metal or metal-backed plastic insert. The distal end of the femur, proximal end of the tibia, and the patella are replaced in a TKR. Some receive a hemiarthroplasty (one half of a knee replacement) if only one end of the joint is arthritic (7).

Benefits of a TKR include relief of pain, increased ability to perform daily tasks, increased knee range of motion, and improved alignment of the leg. Infection, blood clots, and mechanical loosening of the prosthesis (implants) are some of the potential risks associated with a TKR. The most important precautions after knee replacement surgery are to avoid activities that increase rotational force or impact loading to the knee. Vigorous activities that involve running or jumping are not advised after a knee replacement. Swimming, biking, and golfing (if done carefully) are safe activities to perform (7).


  • Observe the available range of motion of the involved knee as compared with the other knee.
  • The participant should not exercise if there are significant signs of inflammation, including moderate or greater swelling or pain.
  • Follow post-surgical guidelines from the health-care provider and remind the participant to do so as well.
  • Have the participant wait until the wound is healed and there is minimal swelling of the involved lower extremity.
  • Medical clearance should be obtained for both land and water exercise.

Safety Tips and Suggested Exercises Modifications

  • Check that the participant performs movement and works within the available knee range of motion only.
  • Decrease size or intensity of movement.
  • Include strengthening exercises for the lower extremities (especially quadriceps and hamstrings) and trunk, which are essential for improving functional activities.
  • Avoid rotational stress and minimize impact loading of the knee.
  • Practice functional activities such as sit-to-stand, balancing, going up and down steps, and dressing.

Abnormal Response to Exercise

  • moderate or greater pain during or after exercise
  • moderate knee joint swelling
  • loss of range of motion
  • loss of function
  • increase in local temperature of the knee

Recommendations after Abnormal Response

  • Tell the participant to ice and rest the injured knee.
  • Avoid end-of-range knee movements.
  • In the pool: increase water depth or use a buoyancy belt in shallow water to decrease impact.

Warning: Referral back to Health-Care Provider

  • Persistent increase in pain and swelling.
  • Loss of movement because of pain.
  • Development of a limp.
  • Instructors should be aware of the signs and symptoms of a blood clot because this is not all that uncommon in a TKA: redness, edema, and tenderness in the calf, worsened pain with weight-bearing that is relieved by rest/elevation along with signs of an infection, including increased swelling of the joint, warmth, irregular margin of redness, fever, and chills.

Extraordinary Participants Take Charge!

As people become more engaged in physical activity for managing health and fitness, health/fitness professionals will be working with a broader mixed population of participants, sometimes together in the same class. Responsive teaching takes into consideration the client's special needs in front of you and the exercise environment surrounding you. By teaching specific skills for special conditions, participants will be better prepared to take charge of their own physical activity more successfully. The next column will address responsive teaching for participants with lower-back pain.


Special thanks to Mary Curry, College of St. Catherine, St. Paul, Minnesota, and to Melanie Youngquist, P.T., and Jessica Solberg, P.T.A, OSI-Physical Therapy, White Bear Lake, Minnesota, for technical review and editorial assistance.


1. Centers for Disease Control, National Center for Health Statistics. HHSIssuesnewreportonAmericans'overallphysicalactivitylevels. Available at Accessed March 16, 2004.
2. ACSM. ACSM's Exercise Management for Persons with Chronic Disease and Disabilities. Champaign, IL: Human Kinetics, 2003.
3. Sanders, M., and C. Maloney-Hills. The Golden Waves Functional Water Training for Health Program and The Golden Waves, Functional Water Training for Health, Leadership Program. Sanford Center for Aging: University of Nevada, Reno, 1998.
4. Sanders, M. YMCA, Water Fitness for Health. Champaign, IL: Human Kinetics, 2000.
5. American Academy of Orthopaedic Surgeons. National Center for health Statistics, 1999 National Hospital Discharge Survey. Available at Accessed March 16, 2004.
6. Agonvino, T. More boomers have hip and knee replacements. Eldercare Directory. Available at Accessed March 16, 2004.
7. Torrey, D. Current Concepts in Knee Rehabilitation Seminar. Folsom Physical Therapy, Folsom, California, 1996.
© 2004 American College of Sports Medicine