Originally published in Massage Bodywork magazine, November/December 2010. Copyright 2010. Associated Bodywork and Massage Professionals. All rights reserved.
Close to 800,000 people in the United States will have a joint replaced this year. Osteoarthritis is the main--but not the only--reason. Joint replacements have become so common that most massage therapists can expect to see clients who are in various stages of recovery from this procedure. But just because it's common doesn't mean it's risk-free, and a person who has had a joint repaired has a significant chance of complications that impact bodywork choices in both the near and long-term."I have a friend in her 60s who had hip surgery. She seemed to do fine, but two weeks later she had blood clots in her legs. They caught them early, but she ended up spending a long time in the hospital to treat them. Of course, that interrupted her physical therapy. Now her scar is all puckered, and she never really fully recovered the use of her hip."What Is Arthroplasty?
Joint replacement surgery, also called arthroplasty, is a procedure designed to repair articulating surfaces within a synovial joint. The precipitating factors are chronic and progressively worsening pain and loss of function. The goal of the surgery is to restore pain-free (or at least pain-reduced) movement. Why Joint Replacement?
Osteoarthritis is the condition behind most joint replacements. This form of inflammation is specifically related to wear and tear of synovial joints, especially the weight-bearing joints. As the baby-boomer generation abandons the Age of Aquarius for the Age of Arthritis, the interest in this condition has grown, and the health-care industry's investment in preventing and treating arthritis is at an all-time high. This article will focus on what happens after the joint has been irretrievably damaged, but it is worth looking at the factors that lead up to joint replacement and what role massage might have in that context as well.
Osteoarthritis, or wear-and-tear arthritis, develops when the articular cartilage in synovial joints begins to degrade. Articular cartilage is structured differently, depending on its proximity to the attached bone, and each cartilage zone has the capacity to absorb either compressive or shearing mechanical forces. Articular cartilage is invested with chondroblasts--cells that can produce new material to repair damage. However, these cells are limited in their activities. Unlike other connective tissue fibroblasts, chondroblasts don't migrate or reproduce in areas where damage has occurred. In other words, cumulative damage related to overuse, trauma, dehydration, or inadequate nutrition can simply overwhelm the chondroblasts' ability to repair tissue. It appears that once cartilage injury has accrued to a certain level, it is for all intents and purposes stable and irreversible.
Joint replacements restore a new, smooth surface to rough cartilage, but they usually have a proscribed lifespan. That is to say, a replaced knee or hip is expected to last about 10-15 years, depending on the weight and physical activity of the recipient. For this reason, younger patients are often counseled to delay a joint replacement surgery as long as possible, especially because each successive surgery has a greater chance for a poor outcome. At this point, massage may be particularly useful: skillfully administered massage can address osteoarthritis symptoms and help in the strategy to prolong the time a person can get along without undergoing surgery. "A business acquaintance shredded his anterior cruciate ligament, medial collateral ligament, lateral collateral ligament, and meniscus in a series of falls and accidents. They've cleaned out his knee and told him to live with it for five more years and then get the knee replacement surgery. Ugh."
Other reasons for joint replacement surgery include rheumatoid arthritis, avascular necrosis, or serious trauma. Older people who have osteoporosis may be candidates for hip repair (to insert a stabilizing rod into the femur) simultaneously with a hip replacement. No matter what the underlying condition is, surgery is only conducted when all other options, including exercise, braces, anti-inflammatory medication, cortisone and synovial fluid replacement injections, and less invasive surgeries are no longer adequate interventions. The X-rays of a good candidate for joint replacement surgery typically show a loss of space in the joint cavity, bony remodeling, bone spurs, and the possibility of debris inside the joint cavity.Types Of Joint Replacements
The implants used in arthroplastic surgery are called prostheses. Historically, these have been made of various materials ranging from ceramic to titanium, but today they are most likely to include a highly polished ball made of cobalt chrome on one surface and a polyethylene cup or socket on the other.Shoulders
Arthroplasty of the glenohumeral joint is a relatively new surgical procedure, but it is becoming increasingly common. This is done when the joint is no longer competent: trauma, ongoing and irreversible damage to the rotator cuff, or bone spurs have made the head of the humerus and the glenoid fossa incompatible in shape. Shoulder joint repairs can take two forms. The most common version replaces the ball of the humerus and the cup of the glenoid. Some patients are candidates for a "reverse" shoulder replacement, in which a ball is attached to the scapula, and the head of the humerus is replaced with a shallow cup, thus reversing the typical relationship between the bones.Hips
Hip joints are frequently replaced, either as a consequence of arthritis that wears away at this huge weight-bearing joint, or as a result of femoral trauma with osteoporosis or avascular necrosis (a condition in which the blood supply to the femoral head is impaired and the bone degenerates).Knees
Knees are unique in that they combine a large range of motion with strict limitation in direction--that is, they only flex and extend (unless the knee is bent, in which position it can slightly rotate). Consequently, knees are vulnerable to shearing forces that can injure their stabilizing ligaments and put the internal cartilage at risk for permanent damage. Small repairs can be made with arthroscopic surgery, but eventually the joint may be reduced to bone-on-bone contact. Knee joint replacements can sometimes involve resurfacing only one part of the joint, or they can involve replacing the ends of the tibia, femur, and the contacting surface of the patella. Cruciate ligaments may be replaced with polyethylene posts to help stabilize the new mechanism."My client tore her ACL by jumping off the back of a truck. She had it repaired and did fine. Then, about two years later, she tore her meniscus and had it scraped out. She knew she'd have to have a replacement eventually. She got massage regularly, specifically, on her knee, which helped her live with it for two years before her surgery. Now, she's very active--bikes and walks. She has stiffness and some pain at the end of the day. A hot tub helps the aches."Other Joints
Arthroplasty can be conducted on ankles, various carpal-metacarpal and interphalangeal joints, the saddle joint of the thumb, and the temporomandibular joint. These procedures are relatively rare compared to replacements of knees, hips, and shoulders.Will It Be Successful?
Several variables influence exactly how an arthroplasty is conducted. Older and less physically active patients may have their implants simply glued or cemented to their existing bone: this allows for a speedier recovery, but the joints tend to be less stable (they may loosen or dislocate easily). Younger or more active patients are better candidates for prostheses that have tiny pores where new bone tissue can grow to blend with the synthetic material. This takes a longer time, but the strength of the joint tends to be much better than with the cemented type.
The surgical approach through the soft tissues is another important variable in the predication for how quickly or successfully a joint replacement surgery will heal. Longitudinal approaches are less damaging to the muscles, but they may require a much longer incision than a lateral approach. The angle at which the socket is secured and the size of the prosthesis are other important factors. Women obviously have differently sized and angled joints than men. These differences have been recognized by surgeons and manufacturers, so prostheses are available in a range of sizes and can be tailored to the individual.
Perhaps the most important variable in whether a joint replacement surgery will be successful is the commitment of the patient to manage the rehabilitation process. Not surprisingly, patients who follow well-designed physical therapy programs and exercise appropriately, have the most consistently successful outcomes. Massage therapy can be a useful adjunct in this phase as well, as it can help to reduce pain and provide incentive for rigorous training. "I had total hip replacement in October 2009. I hosted Thanksgiving dinner the next month, and traveled 1,000 miles for Christmas. The secret to my success was two-fold: I had the new 'anterior approach' to hip replacement, where no muscles are cut, and I rehabbed like it was a job. I am a poster child for successful joint replacement surgery!"Short-Term and Long-Term Repercussions of Arthroplasty
The possible complications that accompany any major surgery are daunting. They include a reaction to anesthesia, arrhythmia, and blood clots, which may lead to deep vein thrombosis, pulmonary embolism, and circulatory shock. Hospital-borne pathogens may lead to an infection in the joint, urinary tract infection, or pneumonia.
Complications related specifically to arthroplasty include inadvertent fracture of the articulating bones, excessive scarring, and a loss of range of motion that is far beyond what was expected. Later complications can arise relating to a poorly seated prosthesis or failure to bond correctly with bone tissue: these require additional surgery with all the accompanying risks.
Longer-term risks are related to a permanently limited range of motion. Depending on which joint is replaced, and what type of surgery is used, arthroplasty patients may need to limit hip and knee flexion and rotation, or risk dislocation and failure of the implant. These limitations will be different for each individual, so it is important to have clear guidelines about which movements and positions are safe.Massage?
Massage has some significant benefits to offer clients who are dealing with the prospect or the consequences of arthroplastic surgery. If a person is trying to delay surgery for a few years, massage can help improve arthritis symptoms. Understand that osteoarthritis impacts multiple joints, so it is useful to address postural compensation patterns that may cause pain and interfere with the most pain-free and efficient function possible.
After surgery, massage can reduce postsurgical pain and inflammation, and it can improve the quality of scar tissue for better mobility. For clients with older surgeries and no other complications, massage that respects their limited range of motion has all the benefits it does for the rest of the population. "I have had a knee replacement since 1992. I've done tae kwon do, swam, and worked out at the gym. I LOVE my new knee!" Ruth Werner is the president of the Massage Therapy Foundation. She is a writer and NCBTMB-approved provider of continuing education. She wrote
A Massage Therapist's Guide to Pathology (Lippincott Williams Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Her latest book,
Disease Handbook for Massage Therapists (Lippincott Williams Wilkins, 2009), is also available at www.lww.com. Werner can be reached at www.rutherwerner.com or firstname.lastname@example.org.Author Note: The author wishes to thank all the people who graciously contributed their joint replacement experiences to this piece: your generosity enriches us all.