Written By Susan James

Background:

In the United States, there are approximately, 175,000 hip replacements performed annually. According to a 2006 study by the American Academy of Orthopedic Surgeons, hip replacements are expected to increase by 174% in the next 20 years.

Two thirds of those requiring this surgery are over 65 years of age. Women need hip replacements more often than men because of the greater risk of osteoporosis and fracture. Most hip replacements occur because of severe osteoarthritis. One considers hip replacement because ordinary activities of daily living have become limited, the joint is very stiff, and pain cannot be relieved by more conservative methods.

According to WebMd, hip replacement surgery is a surgical procedure in which the diseased parts of the hip joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. The goals of hip replacement surgery are to improve mobility by relieving pain and improve function of the hip joint.

The causes of the disease from a Medical Practitioner’s point of view can be osteoarthritis. Other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), avascular necrosis (loss of bone caused by insufficient blood supply), injury, and bone tumors also may lead to breakdown of the hip joint.

Louise Hay in her internationally recognized book, Heal Your Body,
says that the “Hip: Carries body in Perfect Balance. Major thrust in moving forward.” Hip problems reflect the person’s “ Fear of moving forward in major decisions. Nothing to move Forward to.”

The joints in general “symbolize changes in direction in life and the ease with which one moves towards these changes.”

Arthritis is “the manifestation of feeling unloved, harboring criticism, and resentment.”

Depending on your point of view, each of the above can be correct. The person who is experiencing pain may opt for hip replacement surgery when the pain is excessive and their movement is compromised.

What happens during Hip Replacement surgery:

During standard hip replacement surgery, you are given general anesthesia to relax your muscles and put you into a temporary deep sleep. This will prevent you from feeling any pain during the surgery. A spinal anesthetic also may be given to help prevent pain.

The doctor will then make a cut along the side of the hip and move the muscles connected to the top of the thighbone to expose the hip joint. Next, the ball portion of the joint is removed by cutting the thighbone with a saw. Then an artificial joint is attached to the thighbone using either cement or a special material that allows the remaining bone to attach to the new joint.

The doctor then prepares the surface of the hipbone — removing any damaged cartilage — and attaches the replacement socket part to the hipbone. The new ball part of the thighbone is then inserted into the socket part of the hip. A drain may be put in to help drain any fluid. The doctor then reattaches the muscles and closes the incision.

Recuperation:

Physical therapy usually begins the day after surgery and within days you can walk with a walker, crutches, or a cane. You will continue physical therapy for weeks to months following the surgery.

When the patient’s physical therapist and Surgeon sees that the patient is ready which is anywhere from six to twelve months of physical therapy, the patient can be released to practice yoga.

Yoga After Hip Replacement Surgery:

It is important that the yoga teacher has the experience and knowledge to modify the yoga asanas to fit the student’s needs. It is important for the student to keep his range of motion. Keeping mind that the student’s range of motion will not be the same as it was with the natural joint.

According to Dr. Rowena Nicholson, Director of the The Center for Balanced Medicine, if the student has recently had a joint replaced, they may have been ‘favoring’ their other side for some time, so posture and alignment are very important to consider. Many people who have had a hip replacement take some time to get down onto the floor and up again, and this should be taken into account when planning their class, to avoid too many position changes.

For some students, it may be preferable to give some chair alternatives rather than them getting onto the floor. Prolonged standing may not be comfortable, but a well balanced class should in any case avoid this.

It is important to note that the student must avoid the internal rotation of the hip. Internal hip rotation could result in a risk of dislocation.

General Guidelines For the Yoga Teacher and the student with a Hip Replacement:

First of all, yoga should be enjoyed and the student should not be afraid to move his body. The practice of yoga includes many benefits from the social aspects to the deeper spiritual aspects. Yoga can help shorten the recovery period, stabilize and strengthen the hip joint, and aid in regaining and maintaining freedom of movement. It is very beneficial for the student to be in class and to be included in class keeping in mind what movements should be avoided:

1. Moving the leg across the mid line of the body as in hip circles, the eagle, the spinal twist, Revolved Triangle, Half Lord of the Fishes
2. Sitting between the feet, Hero
3. Standing with feet turned in
4. Sitting in any “hurdle position”( foot next to the hip )
5. Any extreme movement of the hip including flexion beyond 90 degrees

Before the first class:

Interview the student and see that they have their physical therapist’s and surgeon’s approval to be in the Yoga class. Ask the student if either health practitioner gave him any specific movements, postures to avoid. Ask the student if the surgery was Anterior(Side) Hip Replacement or Posterior Hip Replacement.

Posterior Hip Replacement ( from the rear)

Asanas to avoid ( potential for dislocation)
Eagle
Cow Face Pose
Child’s Pose

Anterior ( side/front ) Hip Replacement

Asanas to avoid:
Triangle Pose
Warrior II
Warrior I
Bound Angle
Most backbends
Lotus Pose

Roger Cole, Ph.D.., Research Scientist specializing in physiology recommends that students who have had anterior hip replacement avoid the following postures for one year:
Warrior I
Backbends
Lotus
Warrior II
Bound angle

Measure the student’s range of motion:

External hip rotation should be 45 degrees; internal hip rotation 35. The safest way to assess the range of motion is with client lying prone (on belly) and knees bent feet in the air ask them to widen the feet towards wall (internal hip rotation) and assess angles then reverse so feet are crossed with knees wider than hips width (external hip rotation).

Determining the functional range of motion will guide the yoga teacher in determining modifications that will avoid dislocation or damaging the joint.

Make certain that the student can do the tests without pain. You do need to ask them if they experience pain. They may not tell you otherwise.

Asanas for the Hip Replacement Student:

The important thing to keep in mind is that it is crucial to stabilize the hip joint by strengthening the muscles that cross it.

All Standing Postures are good for stabilization

Posterior Hip Replacement:
Backbends
Bridge
Tree Pose

Anterior Hip Replacement:
Boat Pose ( using a block between the thighs )
Any asana that strengthens the hip flexors, adductors and medial rotators.

Asanas that strengthen the hip and knee muscles are:
Bridge
Mountain
Warrior I ( NOT beyond 90 degree hip flexion)
Warrior II ( NOT beyond 90 degree hip flexion)
Cobra
Boat

In all of the above asanas caution your student to stop when they since resistance. To listen to their bodies and let their body be the guide.

The following asanas are from an article by Libby Ribold and Patty Bauer, “Yoga and Hip Replacement Surgery”, in the International Journal of Yoga Therapy.

1. Supported shavasana: Rest in the corpse pose and release tension in the body by observing the rhythm of the breath. Soften areas that may be tense.

2. Reclining extension or tadasana on your back: Activate the legs and flex the ankles.
Extend the arms into the air in line with the shoulders or overhead in line with the ears.
Keep the hips and legs muscularly activated. While in this pose, take 3-5 breaths.

3. Open the Gate: On your back with the arms in a T position (or lower), extend the right leg. Then on an inhalation, flex the left knee and open the left leg, using a small external rotation in the hip. On the exhalation return the leg to tadasana. Do this 6 times on each side.

4. Pendulum Swing: Lying on the back in semi-supine (knees bent at 45 degrees), create a pendulum movement in the pelvis. Slide the left iliac crest(hip bone) towards the left shoulder;then slide the right iliac crest(hip bone) towards the right shoulder. The back stays on the floor,maintaining its natural curves. Press the feet into the floor.

5. Diaphragmatic breath in makarasana (crocodile pose): Lying prone on the stomach cup the elbows the hands and rest your forehead on the top forearm. Slightly rotate the thighs externally by turning your feet outward. Notice the flow of the breath and feel the pressure on the navel center. This pressure is calming. This position allows the diaphragm to work more efficiently and the breath to fill the thoracic cavity more fully.

6. Extension from the front side of the belly. While on the stomach, be aware of your breath as you stretch through the arms and legs. Do this 3-5 times.

7. Cat/Cow pose: While on all fours, exhale and round the spine (cat); then allow the spine to relax into a neutral pose on the inhalation (cow). Do this 6-8 times.

8. Leg Extension: While on all fours extend the right leg back, pressing through the heel. This may be done with the leg extended and the foot on the floor. The ankle is still in a strong dorsiflexion, toes curled under, while the foot is on the floor.

9. Standing, move into tadasana (mountain pose): While standing with a block between the upper thighs, stand in tadasana and extend the spine. With the upper thighs draw the block back and the tailbone towards the block.

10. Standing ardha-canddrasana (half moon pose): Stand in tadasana with the block between the upper thighs. Move the arms overhead and cup the elbows. While bending from the top of the hip, move sideways to the right. Face forward and keep the chest and left armpit open. Extending is more important than the sideways bend. After 3-5 breaths, repeat on the other side.

11. Forward facing trikonasana: Stand with your back to a wall and separate the feet. The buttocks touch the wall, and the feet are facing forward. On the exhalation, bend to the right. The right arm moves down the right leg, and the left arm reaches overhead.Try to keep the upper body in the same plane as the legs. Take 3-5 breaths, and then repeat on the left side.

12. Upright dog pose: Facing a wall, stand 5-6 inches away from it. Move the arms up the wall, while pulling the tail away from the wall. Stretch for 3-5 breaths.

13. Natarajasana (dancer’ pose): Face a wall and stand a foot away from it in tadasana. Bend right knee so that you can hold the right foot (behind you) in your hand. Put your left hand on the wall for stability. Move the right foot towards the buttocks on the exhalation. Release on the inhalation. Exhale and repeat. Do 6 times on each side.

14. Modified virabhadrasana I (warrior I): Stand in tadasana and face a wall. Press both hands into the wall as you step back with the right foot into warrior I pose. Extend the spine through the chest, yet allow the tailbone to release down. Press back with the right thigh and take 3-5 breaths. Repeat on the other side.

15. Virasana (hero pose): While sitting on the heels or a block, place hands on thighs. Palms are open and heart lifted. Do this for 5-8 breaths.

16. Hip sling: Sit in dandasana with a block on either side. Press onto the block and lengthen the spine, lift the heart, and allow the hips to relax towards the floor. Release any tension in the lower back. Extend through the legs. Hold for several breaths. Repeat twice more.

17. Baddhakonasana (bound angle pose): Sit against a wall with several blankets under buttocks and hips. Place the soles of the feet together and put a blanket or other support under the knees to limit range of motion. Hold the toes or ankles if that is comfortable.
Lengthen the spine. Omit this one if external rotation is not desired.

18. Upavishtakonasana (seated wide angle pose): Seated against a wall, open the legs to about a 45 degree angle. Make certain that the feet are centered on the heels, feet squared with the little toe drawing back towards the head to keep the little toe in line with the big toe. Press through the legs and lengthen the spine. If desired, place a belt around the ball of either foot or around both feet at the same time. Press through the legs and out the feet.
Hold for 3-5 breaths.

19. Bhujangasana (cobra pose) variation: Lie in prone position with the balls of the feet on the wall. Arms are alongside the body. Extend the spine and press the balls of the feet into the wall, inhale, and lift the upper arms towards the ceiling. In a variation the sphinx pose may be used for a less intense pose. Think about moving the skin of the stomach towards the sternum. At the same time press the forearms into the floor and back towards
the body. Continue for 3-5 breaths.

20. Modified ardha-salabhasana (half locust pose): In prone position place the arms alongside the body, palms down. While pressing the hands in the floor and feet into the wall behind, lift the right leg on the exhalation. Hold for 3-5 breaths. Repeat on the other side.

21. Cat/Cow pose: Repeat no. 7 here.

22. Suptabaddhakonasana (reclining bound angle pose): Use a strap around the top of the hips and around the feet. Rest on blankets and support all joints. Use a small lift under the wrists and arms, blocks under the knees and a pillow under the head. Rest and breathe for 3-5 minutes.

23. Shavasana: Use support under the head and the knees.

The following are general principles from the International Journal of Yoga Therapy for yoga students with a hip replacement:

Learn to regulate the breath and the body.

Feel the rhythm of your breathing; relax, and be still.

Become aware of excess muscle tension around the hip joint; try to release it.

Practice sensing the body as a whole, noticing the hip in relation to the whole.

Support the hip with the wall or props when exercising the non-injured areas, so that those areas can still move with balance.

Use restorative poses to balance internal energy.

Exercise the muscles around the prosthesis.

Breathing practices steady the mind, relax the body, and make it more receptive to therapy.

A regular meditation practice enhances awareness which will help with the detection of any shift in the body’ balance. Then one can become aware of unhealthy movement patterns before they become habits.

Summary:

As a yoga instructor, welcome students who have had hip replacement surgery. The student will bring a valuable ingredient to your class as someone who is not giving up living a fully expressed life in the face of surgery and the recovery that hip replacement surgery requires.

In your initial interview with the student, ask him if he has been released either by his surgeon or physical therapist to participate in yoga practice. Find out when the student had the surgery and if it was anterior or posterior surgery. Ask if the surgeon or physical therapist has provided him with a list of movements, he should avoid. Review the list with the student or if he doesn’t have a list of movements seek permission to speak personally to the health practitioner about the treatment plan and postures that they want the student to avoid.

Before you begin to create the asanas plan, check the student’s range of motion. Consult with your mentor teacher or another yoga instructor who has successfully instructed students with hip replacements. Create your teaching plan and review it with the student before he comes to the first class. Let him know that you will be adjusting him and cueing him in a way that allow him to practice without causing further harm to his new hip. Give him permission to take the class at his own pace and encourage him to practice self-care. Have him be your partner in benefiting from a rewarding yoga practice.

Resource List

Cole, Roger, Ph.D, certified Iyengar Yoga teacher, Research Scientist in the physiology of relaxation, sleep, and biological rhythms
North County Yoga Center, Solana Beach, California
“ Practicing Safely with Bilaterial Hip Replacements”, Yoga Journal

Hay, Louise: Heal Your Body , Publisher: Hay House, Date of Publication: 1984

Lerner, Dan, Certified Advanced Iyengar instructor
Co-Director: Center for Well Being, Lemont, Pennsylvania
“Hip Tips”, Yoga Journal

Nicholson, Rowena, Dr.,MB, BS, MRCGP, DRCOG, Dip PCouns, Dip NSpH, Dip THY&R.
Director:The Center for Balanced Medicine: United Kingdom

O’Hara, Sara, BS., MS of Education, University of Virginia, Certification in Integral Yoga and Structural Yoga: Yoga Therapy Center, Boulder, Colorado: Hip Replacement, Research Paper, Date of Publication: February, 2006

Stiles, Mukunda, Structural Yoga Therapy, Yoga Sutras of Patanjali, Ayurvidic Yoga Therapy
Director : Yoga Therapy Center , Holyoke, MA

WebMD.com (http://www.webmd.com)

WWW.YogaForums.com (http://www.yogaforums.com)

Drawings of hip replacement surgery can be found at WebMD.com

About The Author: Susan James is a “soon to be” certified Yoga teacher, who resides in Bahias de Huatulco, Oaxaca, Mexico.