Post Surgery Phase 3

So welcome to phase three of our status post hip reconstruction, or total hip replacement protocol. And we're gonna go right into our exercises on the plaudits reformer. These exercises again, are designed for that span of time, six to 12 weeks post-op assuming that they've done well with the exercises pre. And everybody has their own timeframe. And again, remember that every surgeon has a different protocol that they want as far as how active they want their clients.

Again, I use this part of my interviewing process as well to know what kind of surgeon I wanna work with that embodies re-education therapy and really getting strong again and getting back to function. So at this stage of the game we have a few objectives, right? And we're looking at, are we able to start doing activities like pushing and pulling? So thinking of, can you get things in and out of the back of the car? Can you get children out of their car seats?

Can you push a grocery cart? Or, can you pull maybe a heavy door or those kind of things? Do you have that strength to pull or to push something? We're also looking at being able to have flexibility to actually put your shoes and socks on. Do you have that mobility?

We're looking at the ability to squat down. Can we get down to the ground now and come back up? So those are gonna be some major goals of ours as we move into this phase six to 12 weeks. And then lastly, just being able to start some cardio exercise. So I want them to be able to know that they can be on a bike and start really doing something or walking.

Not time to run yet, but walking and being able to hike. And maybe even do some different inclinations of terrain as they go for their daily walks. So we're really trying to get in the sense by the end of this 12-week period, that's three months, they should really be feeling healthy and like they're participating, their pain should really be gone. And if anything, we're putting the reins on them trying to get them to hold back a little bit and not be too aggressive. We still have our precautions at this stage of the game where we're just starting to introduce some hip flexion activity that I'm gonna show you in the mat work and also on the apparatus.

And again, we're trying to be careful, no long levers against gravity or unnecessary resistance. So let's get started with the reformer. And we're gonna start with a seated knee extension on the foot bar. So right now I have a red and a blue spring on and I'm just gonna sit up on top of the foot bar and hook my heels. And again, this activity is really, they already should have 120 degrees of hip flexion by this time.

They should have at least zero degrees of hip extension. So this should be a fairly easy exercise. If anything, they might be a little sensitive of actually sitting on their sit bones, especially if they had a posterior approach surgery. But for the most part, this is very appropriate. And again, you have all the same precautions and safety measures of making sure that they're stable seated on the bar.

I like to have my sit bones just a smidge in front of the foot bar wedging me into the foot bar as I do the exercise. And again, just starting, maybe they have their hands down to the side and they're just doing some seated knee extension. Again, this is similar to doing the seated leg press on the chair, right? And the nice thing here now is we're working on balance. So they now have to maintain the upper body nice and vertical as they allow the disassociation to happen in their hips.

And we can play with the strength on here. And again, this is preparatory to what we're gonna introduce in phase four of going into the gymnast where they actually now start coming off of the bar. So always be thinking of where you're going and where you came from. So the pre would be the seated on the chair then seated knee extension on the reformer. And then we can go into advanced exercise like tendon stretch in gymnast in phase four and after.

So, I love this exercise. Again, you can change the orientation. So remember we said, if they're in a little bit of external rotation with their legs, it's gonna be a little easier on their hips. And as they come into parallel, it's going to be a little more challenging. They might feel a little bit of resistance.

And the work that's actually happening as you know is holding the body up into a nice vertical position. The next exercise I wanna go into is gonna be the quadruped series. And I'm gonna leave it around the same to start. I wanna have a little bit of resistance on the carriage. I'm gonna sit back until my arms are at a 45 degree angle to the floor.

And I think it's important in this exercise from it's design, 45 degrees to the floor can be 90 degrees to my body. And I wanna maintain the 90 degrees to my body. So as I press the carriage out, I now have that load coming to the front of the body. By using the red and the blue spring, it's not too much work on the anterior hip flexors. I'm still doing more hip extension work than I am hip flexion work.

When I get comfortable with this in the quadruped or the knee stretch position, I can then start playing with some of the variations. So one of the first variation is to go into a round back knee stretch and now I can actually play maybe with a rhythm or a tempo coming in and start creating that load on the posterior fibers of the hip to start getting that strong as if I was jumping, or if I was going downstairs real fast, or hiking, or even preparing to run. I can also go into extension. And we'll go through this in a little bit, just the down stretch. Right now in the knee stretch, I could also take off a spring, and now that lightness is gonna create more load on the anterior body.

I can also bring my hands down onto the platform and create that. So in the quadruped exercise, different from the knee stretch, we can also now add the flexion of the shoulders. Again starting to load the anterior wall, which we said up until now we have avoided, right? So we're just starting to introduce that. So I love the quadruped series as a way to introduce hip flexion load and abdominal load that's not against gravity.

I can completely control it in the quadruped position. And again, we control it by the springs. The lighter the springs, the heavier the load is on the anterior. The heavier the springs, the heavier the load is on the posterior. Next up I wanna go into some box work, so I have my box here with me.

And I'm gonna start out with some short box work, and I'm gonna set it up where we're gonna go with all the springs on for safety. I'm gonna remove my foot plate and make sure that I have my safety strap for the feet. And in this exercise series, I don't wanna go too far into the extension motion. So I'm gonna put my feet in a safe place. Scoot back and make sure the box is adjusted appropriately for the length of their body.

And from here what I wanna start doing is creating some abdominal work and some anterior load work without putting too much stress on the hip. So I'll start just by having hands across the chest with the image of the head reaching to the ceiling. And also as if I was just keeping it still in space start by moving the pelvis forward and back without the head dropping down. So it's sort of a preparation. I often think of it, if I use the image, is that I had rollers underneath my sit bones and I was just rolling the pelvis back.

And I'm just rolling it back enough to where the lumbar curve actually goes into a little bit of flexion and becomes straight. The pelvis, as it rolls back, actually increases in height. So the low back increases height and with that combination, nothing changes on the head. It almost creates a nice length in position now for us to start going back and working on the beginning of the short box work. So here we can introduce a little bit of rotation, working on the obliques, same idea, pelvis initiates side to side.

And we can even do a little bit of around the world. So we can rotate to the side, come back in the center, just not going too far. So you're doing maybe 50, 25% of that range of motion on the box. We can also now introduce side bending work. Again, we don't have to go very far.

Sometimes I just like to get them out there so they're actually weight bearing on the hip. And that often becomes a little bit of a shocker for them and just have them come back up into sitting. So they're literally just going out to a straight position and coming back up. And so we're starting to load the lateral tissues of the body doing side bending on the short box. And that's probably enough to start in the short box.

When we go into the long box now, in the area that you know... If you know me very well, you know I'm a fanatic about extension. And so I love to introduce the sort of pre-Swan work that we can do with the long box. So I'm gonna take the springs down to just a red, keep it really simple. It's not about strength or power at this stage of the game, it's about giving people a sense of successful movement experiences, giving them places that they can move that can distribute that force that we talked about often felt in the hip joint that we want to remove.

So getting on top of the box, I always mount putting my hands onto the box to get on, not onto the foot bar. So I get onto the box. And I want the chest to be just at the edge of the box, then the hands go onto the box, and we do just simple overhead press, okay? Now from here, I can do a couple things. I love just doing an overhead press, but if I want to go into the Swan, I might drop the foot bar down another notch depending on how much movement I have, press out, leave the arm straight, and just come up into that upper thoracic extension.

So again, getting them ready to go into some of the mat exercises we're gonna add in this level of exercise. And again, getting them used to getting onto the long box, laying on their tummy, getting some back extension work, things that also can be with hip extension. So one of the things I'm a stickler about, a lot of times people just leave their legs relaxed here. No, I don't want them relaxed, I want them reaching out. So they're gonna have a little bit of that engagement in the hip extension.

Just like that. Coming off again, hands on the box. The last thing you need is somebody to have a slip, or have the carriage go flying out, or not have the spring set heavy enough for them to be able to move. The last thing I want to do is to go into some more standing variations that I think we can move into at this stage of the game. So I'm gonna remove the box and we're gonna put the standing platform back here.

And I'm gonna start with just a red spring like we did the other day. And now moving into here, always again, mounting up onto the frame first then onto the carriage. Then now we can start playing with some different variations. So what we've done already has been straight leg, bent leg, and then doing single leg off of the frame. Now we're gonna move into single leg on the carriage.

And what I mean by that single leg on the carriage is that I'm squatting down in my position and I'm gonna keep this side on the carriage in its place and skate out the frame leg. So if you think you are a roller skater or ice skater, it's that idea. And what this is doing now is this is creating a lot of proprioception in this standing leg, not the gesture leg pushing off. And it's a lot of work. And remember we had a home exercise that was the Tai Chi exercise.

That's sort of what it feels like on here to me as I do that. The next variation in standing, is for us to go into a front split. So now they're trying to get their pelvis to square off a little bit and pushing out and back in. Again, we have our same gestures. We can go down into a squat and just gesture the front leg.

We can stay on the front leg and gesture the back leg. And we can do the same thing facing the foot, so we can do reaching the back. So what I love about this exercise in particular is that this is my right hip that I had the replacement on. And facing this direction I feel relatively safe, and I love that anterior stretch that I'm getting now across the surgical site. So I love this feeling in this direction.

And there's always a little bit of fear in the beginning. I remember the first time that I did this, you're sort of thinking of like, what happens, will my hip pop out of socket kind of thing? That kind of fear. And again, we hope that it never does. And it certainly has no intention of doing that.

This is just, you go to where you feel that little stretch. If you push too hard or it's too light of a spring, it could give that sense. So here I'm very careful. It is delicious to me and hopefully you or your client feels the same way, but it builds a lot of confidence. And the reason why this is so important is because in walking, I need to be able to have that toe off with the hip going into extension.

One of the first things with the anterior approach is we shorten that toe off because we're afraid to go into extension. So this might be the first time in their walking that they start feeling like, wow, I could actually really go into a toe off. So sometimes I'll do just the foot itself and ankle on that toe off. They end up going like, that's where I should be pushing off from in my walking, in my gait, all right? So that concludes some of the new exercises that we're looking at for the reformer in this phase.

Again, you're doing a whole body workout. So at this stage of the game, there's really very few restrictions. You're listening to your client's body, what they feel, what they observe. These are just some exercise suggestions that take them to that next level. One of the things I'm a real stickler about as well is leaving somebody in the same exercises at the two to six-week margin for too long, where they're just doing the same things that are really simple and being afraid to do things that are very natural.

We want them squatting at this stage of the game, we want them to be able to push and pull and to have rotation forces going through their body. So be thinking of that as you go through your exercise protocol on the reformer. And I'll be right back as we move into the next apparatus. So next I wanna continue with the chair and making some advancements. In phase two, we did some single leg presses and we changed the orientation to it.

I wanna move into the lunge now. And I'm gonna use a heavy spring. So right now I have two black springs on or two heavy springs on the chair to be able to assist because we're starting to work on them being able to go up and down stairs, to do some incline climbing, to have that nice deep glute strength that we're looking for, and also being able to go into squatting activities that we talked about. Do they have the strength to go down into a squat and come back up so they can pick things off the ground or get up and down off the ground independent. There is something magical about this phase of six to 12 weeks.

If we can get somebody that has had a hip replacement to be able to get down to the ground and back off the ground independently without assistance, it is a huge confidence builder. And that's why I love this exercise. So what we'll basically do is get up on top of here. And I like to start on the up. And so I'm just gonna have them coming down, they can use their hands if they need to, but really coming down into that hip.

And when we think of the bone rhythms that Eric Franklin talks about and that we teach in Polestar as you're going down, you wanna think of the sit bones widening. And it's that widening of the sit bones that really puts the emphasis on the posterior muscles of the hip. And then eventually going to where they no longer need their hands, and then eventually going to where they can come all the way up and then switch sides with hands, without hands, and then all the way transferring into the stance. So great exercise. When we go into phase four, we'll take that another step further by adding some more complex variations to it.

Next, I wanna go into the hamstring series. So I'm gonna take one of the heavy springs off, and I just have one black spring on. And I'm gonna start with hamstring one. So standing in front. And the key here, as much as possible, is keeping the legs vertical, right?

So we don't want the strategy to be sending the butt back on this one, we wanna keep it nice and straight. So from here, hands come down onto the pedal and pushing down. So again, I get a chance to load the abdominal tissues, that anterior wall, without loading the hip flexors. Great exercise. I can also start working into some rotation.

And remember, our purpose here is, can we get them to where they can reach down, put socks on, put shoes on. And this tries to make a lot of sense as they acquire this ability. And then from here, we can walk around the back of the machine, get the legs nice and close to the box or the chair. And we can come down, and again, a little more advanced, pulling up through the abdominal and doing a hamstring two. And again, remember how I talked about our objectives of pushing and pulling.

We're definitely getting that orientation of how the trunk and the legs work together to push and pull things around. As we move into hamstring three, and again, remember, this is a progression over these weeks. So you don't start out with hamstring three. If they're successful with hamstring one and two and they wanna do a little more advanced work, then we go to hamstring three. Trick here is, add the spring back, make it nice and strong like we did for the lunges.

So here again, we can start just with a simple sagittal plane, hook the toes nicely on to the pedal and then working on again that strength of lifting up. And this is a great way to get the core to work without the load so much on the hip flexors against gravity. More variations could obviously be added to go side to side or to go with the single leg or what we call the Thomas flare. So that's it for the chair. Again, thinking of all the other chair exercises that are fine at this level, those are some key ones to help with our objectives of pushing and pulling exercises.

I next wanna go over to the barrel and the ladder barrel. And we already showed on the chair the importance of doing Swan or a pre-extension of the thoracic spine on the long box. And so this is a continuation of that. I want to really start focusing on that thoracic extension. And the beauty of the barrel...

Let me see. I'm gonna... The beauty of the barrel is the ability to block the pelvis into the barrel. So I can be very safe here. This is the same thing we use with our patients that have lumbar pathologies or lumbar stenosis.

We can block them here and we can just work on the extension in the thoracic spine and very safely keep the lumbar in that little bit of flexion without creating any compromise into those tissues. Now, again, from here we can start increasing that and coming up and starting to use the hip extensors. So it's a very safe progression. Teach them how to organize that. And a lot of times, one of the other comorbidities that accompanies a hip replacement and hip arthritis is lumbar arthritis, people that have stenosis.

And so we have to be careful of extension in the lumbar spine. So if we can get extension in the upper spine, extension in the hips, we can avoid secondary problems that we often see with our elderly population or aging population of a lumbar stenosis. Another nice movement exercise that we can do here. And again, I'll move the barrel back to give me some space. I love the new balance body barrel.

And I can do just some passive extension. So I'm just getting ready to just let gravity open up the chest to practice breathing. And then I can also slide my legs out, just getting some opening across the front of the hips. And I'm not doing anything other than just a passive move here. If it's too stiff, you can bring it back in.

I can also bring my legs back a little bit and increase the stretch across the front of the hips. And then coming back up here, I can also just work on some partial sit-ups or roll-ups again without loading the front of the hips but loading the abdominal wall and also focusing on segmental mobility. And I can increase that range of motion and then I'm gonna stand up. So that concludes the things that I want to add for the chair and the barrel during phase three, post-op. And we're now gonna move into the trapeze table.

So now with the trapeze table we're gonna add a few variations. One of the ones that I'm adding back in from the pre-surgery or pre-op is the assisted squat, which I'm not gonna demonstrate right now but you could go back into the pre-op. And again, we're just introducing the ability for them to squat, remembering that our goal or objective during this particular phase is for them to be able to squat down or to get down and up off the ground independently. So the practical exercise of squatting is really important. Another exercise I wanna show on the trapeze table is the parakeet.

I really like the parakeet, it does have some safety precautions. So you notice we've wrapped a theraband around here so that when I push into it, it's not gonna let the bar go too far and go through the other side where I would fall off. Typically if that happens, it doesn't do anything but scare everybody in the gym. Or if somebody's standing down the other side, they could get whacked with a bar and that could be pretty dangerous. So always have a safety precaution.

And if you're teaching somebody for the first time, by all means, you're standing to the side, hand over the foot and the bar as you guide them through on the parakeet exercise. So let's give that a shot and then we're gonna move into a few more exercises that are really fun on trapeze table. So we can start just with a simple, again, remember we went from doing the foot work or the leg press here in phase two, and now in phase three we can start making it a little more challenging combining the bridge with it, and we could just start with almost like a breathing exercise where they roll up and reach through rolling back down through their spine, crossing the legs. And what we're trying to do here is connect that whole posterior chain, and then from here going into the more advanced variation of the parakeet, bringing it up, really working on that hip extension as they push through and then rolling back down through the spine. The next exercise you wanna do is the push through.

And I love the push through and circumduction mainly because it's starting to give them the power to put shoes and socks on. So giving them the guidance and sort of teaching them how to use their body in a way to be able to not just collapse into the hip. Like let the flexion of the thoracic spine be part of their flexion getting down to their feet and to their toes. And again, the other thing in this particular series, our goal is to have the ability to push and to pull. So now they can put bags over their head, they can travel, they can reach their cabinets, they can squat down, they can put shoes and socks on.

And then we can move into circumduction. So now being able to reach back, come around, and in particular, being able to start rotating, get that movement to happen more up in the thoracic spine when they're gonna go reach for their foot. So we're gonna come around sort of like the saw, now they're coming into that foot. It's not coming from the motion of the hip as much as it is from my thoracic spine that allows me to put socks or shoes on. And then again, just always thinking of the practical application of the exercise.

And besides being just absolutely delicious, circumduction is a great exercise to functionally get them back into touching their feet. And from here sometimes what I'll do is I'll even bring the foot up now that they have that movement and let them see that they can put their shoes and socks on now with her hip motion. They can bring it up across just like they used to prior to the hip arthritis, all right? The last variation I wanna show on the trapeze table is long spring series. And I wanna move into, we've already done it in supine, I wanna move into sidelines.

So I wanna start working in the abduction, adduction, some circumduction and also a little bit of rotation. So I have the spring set in the middle of the crossbar up on top, laying on their side now. And again, sort of doing that hold on their head, or they can hold onto the bar here, just start with something simple. I'm using a purple spring. You could definitely go with the yellow spring, my leg is probably a lot heavier than most.

So you got to grade it at the right level for the client, but just working on some adduction. I can also work adduction from below. And I can work on some circles. And if you happen to be working with a dancer, you can certainly start introducing things like passe, developpe work in that hip. Being able to start restoring some movement.

If there were thinking of going back to take an adult dance class that maybe they haven't done for 10, 15 years due to the hip arthritis. So this is a very nice area. Again, even here's a nice place to start sidekick. So they can start with the relaxed side kick laying on their side, or you could bring them up onto their forearm and have them sort of preparing to have the balance of sidekick. And that's why I had the spring in the center so it lines.

So right through here. So a great way to start reeducating the hip, especially for some of the mat exercises or getting ready to go back into more advanced movements. Next we're gonna move into the mat and also the Home Exercise Program, and we'll incorporate that Oov with that as well. So now we're ready to move into some mat exercises. And I think it's very important to acknowledge here that the ultimate goal is that all of our clients are able to perform mat exercises.

This is what Joseph Pilates talked about with the theory of contrology is that everybody should be able to perform these exercises every day in their home. And then we'd go to the studio to refine them, to work on some of our weaknesses, use equipment to advance our mat practice. So I think this applies to all of our patients and clients as well. There's no exception to it. So we've already done a little bit of sidekick work on the trapeze table with the spring assistance.

So now we can introduce sidekick into the mat and also for them to do at home. We can start sidekick laying down on their side so there's minimal effort. And from here, just even keeping the knees bent they can just lift the leg up and they can start to move it through a range of motion that they're comfortable with. And over three weeks of this phase, actually six weeks of this phase, we can really start advancing that, right? So they can go to a straight leg and then we can come up into our prop position of traditional with a hand in front for balance, we can make it sway with a choreography, a double pump, double pump, we can add the breath with it.

(breathing heavily) And we can then take the hand away looking for balance. And right now I have my surgical side up. And it's important to know, just as it is to have this leg up, it's also important to start desensitizing the surgical side and have them actually laying on that hip as well as they work on the other side. So again, sidekick is a great exercise for them to progress into. And as we go into more advanced work, we'll start doing the side lifts and things that really strengthen the abductors.

But it's just a nice way preparatory for phase four. The next series that I wanna go through here is preparing for roll-up. So we did push through on the trapeze table. You certainly could do a spring-assisted roll down on the trapeze table or a spring or strap-assisted roll down on the reformer. And now we're preparing them to be able to do the roll down on the mat.

So I like to start roll down in what we call the modified roll down in a seated position. So again, just like we did on the box work, the short box, is just have them initiate the beginning of going back and down. And I love the image of the feet being heavy onto the mat. And that we're really almost pushing the feet into the mat as we're rolling back. So we're trying to get rid of all that anterior grabbing that a lot of people do, and also to let the arms lengthen.

And it's almost like at any point in time, they could stop or start the flow of the roll down and just rolling through. So I often play a game called red light, green light, where at any time I could call red light, they have to stop there, green light, they would continue through. So I'd liked them to get to that level before we would advance them into something like the full roll-up. And I also like to work on breathing at this stage of the game, really getting them confident with movement in their spine, really learn how to use that thoracic spine in their daily activities. The next round is gonna be seated long sit exercises.

And usually I find that after surgery, most people don't have enough hamstring length. So I have a small box, a moon box, with me to be able to do this exercise. And you can adjust it base on your client. The key is, can they get the sacrum at least vertical in this position? If they can't get it vertical, they could do this in a chair, they could do this on a big box, and you just have to adjust it accordingly.

So from here we can start with the legs together, going into spine stretch, walking the fingers out, floating the arms up, hug that imaginary tree in front of you, reach over. And again, we're looking, just like the push through, we're looking for that round and articulating spine. I wanna see that distribution of motion in the thoracic spine through the shoulder girdle, through the back of the neck as they come forward. And I do it a little bit differently, I like the hands to drop down to the floor and I like them to think of the pubic bone zipping up as they stack the vertebra up into the natural spine posture. If I say natural spine, it means the lumbar has a lordotic curve and the thoracic has a kyphotic curve.

I'm not pulling back in deflection as much as I am stacking back up into a nice, tall seated position. And then repeat it until they feel comfortable. And don't be satisfied with the idea of using the box all the time. They should be, with their exercises, hamstrings and feet in straps. They should be getting more range of motion and being able to get closer and closer to the floor with less prompts.

And that's true for all of our clients to be able to progress them to where they don't need so much modification, okay? The next one is going to spine twist. And I like to take the emphasis out of the arms. A lot of people do spine twist from their arms. And I want the spine twist to come from the thoracic spine.

So I'll bring the arms across sort of like I love genie and rotate without the sit bone coming off of the box or the ground, and then come back to center. And so the idea to really emphasize the sternum rolling around the center, I always often say like a lighthouse. The light here is shining around the ocean telling everybody where you are. Now, once they understand that, they can now add the arms to it. And the arms are just merely an extension of the thoracic spine.

Now, why is this important? Remember that distribution of movement equals distribution of force. I can't emphasize that enough to you. As we're getting them ready to push, pull, reach, squat, lift, put shoes and socks on, if we have 50 or 30% of the rotation coming from their thoracic spine and some of the flexion coming from the thoracic spine, it's much easier for them then to get to their shoes and socks. So often what I'll do is, from the seated exercises, I prove to them that they can put their own shoes and socks on safely.

Really important, right? So from here, spine twist. We combine spine twist and spine stretch to create saw. And saw is putting your shoes and socks on. Saw is picking things up off the ground.

Saw is cutting your toenails. All of those functional things that they've lost either because of the hip arthritis beforehand or post-surgery, they haven't had the ability to get back to those toes now for six, 10, 12 weeks. And we're gradually bringing them back into that range. Now, going into spine saw or the saw exercise, again, getting them to feel that fluidity. And then we can also bring their feet in and give them the sense that now that same motion they now can get shoes and socks on their feet, they can put their pant leg in, they can bathe and toilet and all of those things with complete independence and confidence if they can do spine stretch, twist and saw, The last med exercise that I wanna do with you in phase three is going to be the Swan.

And I think again, we've already practiced it on the barrel And we've practice it on the reformer with a long box. And now we're ready to move into the Swan on the mat. And so when we do our pre-Swan, pre-Swan just coming up to the bottom of the rib cage is the preparation for the upper body. The other thing that I like is preparing the lower body which now becomes more important, right? So cocking the toes underneath and sending the heels back until the knees come off.

And if they can just hover the legs at that level this is a great achievement post hip surgery. You might just spend some time here with a hip extension doing this for a little while before you even adventure into Swan one, right? But it's this here combined with pre Swan that allows you to come up into a nice strong Swan. When I come back down notice that my legs come back up, they stay connected through the entire Swan and through that motion, okay? And again, you might just spend time doing the pre and also the prep with the legs for a month, giving them that sound hip extension.

All right. So moving into their Home Exercise Program, again using our mat to help us out with that, we're now ready to start introducing things like swimming, right? So we wanna be able to start them having that whole extension strengthening, not just like we did in the Swan, but now that reciprocal motion that's necessary for walking, climbing, a lot of the activities we do in sports or playing if they wanna go back and play tennis, if they want play golf, any of these activities require reciprocal motion and rotation. So starting off with swimming, same preparation we did with that pre-Swan and now adding the arms and just being happy at this level of them being able to move their legs into extension and to have a pulse or a pace, and to be able to breathe and have that reciprocal load in motion through their body. We also have already taught the quadruped mainly to get movement in the hips.

Now I wanna go quadruped to get a little more strength. So we're all familiar with the opposite arm and leg, right? And to me, the most important thing here is not how high you lift your leg, it's how quiet you keep the body when you reach, right? So I'm not interested in how high the leg goes yet. I just wanna know that they can start gradually getting that nice reciprocal load to the back that we do in our quadruped exercise.

From there, I like to advance it where we might take the arm and the leg up and come back in a diagonal to load through that hip. Diagonal load through the hip. It's a little more advanced variation. And again, you might have some comorbidities that don't allow them to do that. So they might have a knee arthritis or something.

So you just have to be sensitive to other things that they might be dealing with. So it's not like, well you're in the third phase, you should be able to do these advanced quadruped exercises. So be sensitive to the comorbidities which we'll talk about at the very end of the program. The other things we wanna do in the Home Exercise Program is our squats. So when we're looking at the squats now, we can do a couple different things.

Probably one of the best is looking at what we call our marriage proposal or the lunge, right? So from here, we can start working with them Cock toes, quadruped here, and working on being able to come up and to come down, getting that strength in the hip extension which will help them greatly as they go into now the half squat. And the half squat, I do this every morning in the shower. I go down to my squat and I hold it for 30 seconds, 50 seconds, however long I can hold it. And I keep trying to go down lower and lower.

Not rounding the back, just trying to go down where I can load and feel that load getting strong into the buttocks. So that's a great home exercise for them to do. Now, if that's too difficult for them, you can always put a ball behind their back and they can do the half squat with a ball behind their back. And they don't have to go all the way down to a half squat. Remember we said, they might have a limitation due to their ankles that doesn't let them go down.

So a way to adjust that is if you roll the mat up or you put a foam roller underneath their heels, that might be enough to allow them to have a good mechanical squats. So very important for them. Last thing I like in this section is single leg balance. So you can imagine you have an artificial hip, there's no proprioception fibers in that hip, there's nothing telling your body where you are in space, so we really have to rely on the connective tissue around it. So balance can just be holding for five, 10, 15 seconds.

And then they switch legs, do the same thing. Then we can start moving the other leg to create different loads of single leg. How long can they hold that position? Can they reach the leg out and bring it front to back? Can they move the arms around as they do these exercises?

So anything to have single leg balance. When they get up to about 15 seconds, that's more than enough for almost any activity, including things like having them imaginarily put on their pants. Can they put the pants on their leg with control, bringing the knees up towards the center line? Can they get dressed independently without having to hold on to things or to sit down to put their pant legs on? And again, moving towards complete autonomy with all of their daily activities.

This concludes the section on phase three, six to 12 weeks post-op that we're referring to as your Lab Four. I hope that you take away some good pointers with it. Again, I reiterate, everything we do always is a very whole-body comprehensive workout for our clients. And I've just given you some tidbits of some ideas of the level that your clients should be working at at this time period post-op if we've done everything else. We do not progress if they're not able to successfully do the exercises from the previous phase, but we should be always trying to modify or progress our clients into those more advanced phases that represent normal daily activities.

And so a lot of times that is done by us overcoming the fear of movement, the fear of falling, the fear of the hip dislocating. As we remove those fears with successful movement experiences inside the Pilates environment, we establish a confidence that allows them to progress and to live a much more full life than maybe they even expected with the total hip replacement. And we'll see you on the next phase.