NSCA's Essentials of Personal Training

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

Total Knee Arthroplasty

Years of repetitive loading to the human knee can result in degeneration and degradation of the joint surfaces of the distal femur and proximal tibia. Often the degeneration is specifically located on either the medial or the lateral side of the knee joint, based on wear patterns and more specifically the individual's lower extremity alignment. People who are excessively bow-legged (genu varum) or knock-kneed (genu valgum), or who have had serious injury to the knee (such as extensive fractures through the joint, meniscal pathology, or instability of the knee due to unrepaired or failed repair of ligamentous structures), are often candidates for a total knee replacement.

Total knee arthroplasty (TKA) requires extensive exposure of the joint with a large central incision. Prosthetic components are selected and inserted to cover the worn areas at the ends of both the femur and tibia. Rehabilitation begins immediately with a ROM focus. Individuals perform open and closed kinetic chain exercises initially in the hospital and at home prior to formal outpatient rehabilitation.

Movement and Exercise Guidelines

Following discharge from formal rehabilitation, clients often have 100° to 120° of knee flexion and nearly complete knee extension. Indications for exercise include cycling, swimming, and endurance-based activities that minimize joint impact loading and improve muscular and cardiovascular function and fitness levels. Specific exercises such as leg press, multidirection hip strengthening, calf raises, and knee flexion and extension exercises using a low resistance and high repetition format are recommended. As an example, lunges onto a BOSU ball (figure 21.16) are not only a strategy for strengthening; they also benefit balance and proprioception for the entire kinetic chain.

Again, closed kinetic chain exercises that place the knee in greater than 100° of flexion are risky and impose added stresses on the knee. Further, because kneeling is generally contraindicated during the first few weeks following TKA, it is necessary for clients to avoid exercises requiring that position (e.g., kneeling lat pulldown, bent-over dumbbell row using a bench) or exercises that may cause them to kneel inadvertently (e.g., lunges performed too deeply). Exercises using less than 90° knee flexion postures are recommended in both open and closed kinetic chain exercises.

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).