Knee Replacement “Prehabilitation”

Let me tell you about Lilly. Lilly is 81 years old and holds a position on the board of a large hospital. She routinely works 10-hour days, five days per week, which includes giving lectures and running board meetings. Due to all of her work, Lilly is on her feet for hours per day.

This is not only impressive when considering Lilly’s age, but also because she had a total knee replacement (TKR) six months ago. Despite the close proximity to her surgery, Lilly has no knee pain, caregiver, or gait issues. How? Lilly attributes her quick recovery to the strength she built during three months of “prehabilitation,” where she strength trained twice per week prior to her surgery.

Lilly is not a fluke. A 2009 study at

the University of Louisville demonstrated that strength training prior to a TKR led to greater improvements in strength of the operated leg, standing from a chair, and with walking up and down stairs [1]. In addition, quadriceps strength prior to surgery is associated with greater dynamic balance a year after surgery [2].

TKRs are as popular as ever. More than 381,000 TKRs take place every year, and researchers expect that number to grow six-fold in the next 20 years [1]. The surgery can be very helpful as it enables people with severe knee osteoarthritis to decrease or eliminate their pain while improving their functional ability.

However, a TKR also leads to a period of inactivity during recovery, and that inactivity has drawbacks. People lose about 60% of their quadriceps strength within the first month following surgery. Considering that information, it’s no surprise that people with TKRs have demonstrated slower walking and stair-climbing speeds when compared to their peers.

Researchers at the University of Louisville conducted a study comparing people who “prehabbed” against those who did not (control group) for the five months prior to surgery. Like Lilly, the individuals who strength trained fared very well. Before the surgery, strength training prevented knee pain from increasing and improved the participants’ functional abilities (getting up from a chair, walking speed, and stair-climbing speed).

One month after the surgery, the control group experienced losses in quadriceps strength and walking speed, whereas the exercise group did not (when compared to baseline tests). Three months later, functional ability and strength in the operated leg were greater in the exercise group.

The exercise group trained three times per week prior to the surgery, including exercises such as the leg curl and leg extension. Following the surgery, both groups received the same physical therapy.

Overall, the study found quadriceps strength was associated with greater functional ability and less knee pain. Researchers in a study out of the University of Delaware found the same connections when monitoring quadriceps strength days before and one year after a TKR [2]. They also noticed that quadriceps strength before surgery also predicts dynamic balance a year after surgery. Dynamic balance is tested by seeing how quickly a person can stand from a chair, walk around a sharp turn, and then return to the chair.

If a TKR is in your future, you might wonder how long you should train for prior to the procedure. As mentioned, the study included five months of prehabilitation, although Lilly trained for only three. Obviously, the earlier you start, the more strength you will build prior to surgery.

As a whole, the studies and Lilly’s experience make sense: joints are healthier when their surrounding muscles are stronger. Strength training before a TKR allows you the opportunity to build healthier joints and muscles that you will simply work to maintain after surgery, instead of having to build them for the first time.

By Matt Hedman, President of The Perfect Workout


  1. Topp, R., Swank, A. M., Quesada, P. M., Nyland, J., & Malkani, A. (2009). The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. PM&R, 1(8), 729-735.
  2. Mizner, R. L., Petterson, S. C., Stevens, J. E., Axe, M. J., & Snyder-Mackler, L. (2005). Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. The Journal of rheumatology, 32(8), 1533-1539.
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Don’t Skip This Part! – Exercise’s Most Productive Time

If I could pick just one issue that would have the biggest impact on most peoples’ exercise results, it would be to increase their effort level when an exercise gets hardest and most challenging. This means increasing the effort right at the end of a set of repetitions on each exercise. This certainly would be my #1 recommendation to people who exercise on their own either at a regular gym or at home. And even for our company’s own personal training clients, I find that although on the whole our clients work much harder during their workouts than most other people who exercise, many of our clients could achieve even better fitness results if they gave even more effort at the most productive time.

What “even more effort at the most productive time” means in practical terms is to carry every set of strength training repetitions to the point of “muscle success.” Muscle success is the point on an exercise at which after several repetitions your muscles become so fatigued that completing another repetition is not just difficult, it’s actually impossible. You’re pushing or pulling as hard as you can, and the weight refuses to budge even a fraction of an inch because your muscles have become so fatigued. You’re attempting to make the weight move, but it’s momentarily impossible for you to do so. If you continue maximally pushing or pulling for several more seconds to make sure you’re really at this point of muscle success, you’ll have achieved deep momentary fatigue in the targeted muscles.

Deep fatigue in the muscle sends a strong signal to your body that it needs to get stronger, improve muscle tone, and increase your metabolism. Within certain limits, the deeper you momentarily fatigue your muscles, the greater the changes you stimulate in your body.

Although this next point may sound counterintuitive, in a lot of ways long workouts are easier than briefer “high-intensity” workouts. How can a long workout be easier than a (properly performed) brief workout? Because in order to exercise for a long period of time, you can’t push yourself really hard on each of the exercises you’re performing. You have to pace yourself at a lower intensity to workout for a long period of time.

I’ve experienced this firsthand. Prior to stumbling upon slow-motion strength training in 1992, I was doing resistance training for 2 hours a day, 6 days a week – 12 total hours of exercise per week. I would rarely (if ever) fatigue to the point of muscle success on any of my exercises (lengthy workouts require pacing yourself with a lower level of effort, which reduces how intensely you’re able to train). When I tried slow-motion strength training, I learned to fatigue all the way to muscle success on every set of each workout, and my results improved significantly (I added 10 pounds of lean muscle tissue during the first 9 days). Plus, the amount of time I spent exercising was FAR less (reduced from 12 hours a week to about an hour a

week). My dramatically improved results weren’t because I was working out less, though. It was because I’d learned to make my muscles work harder. The higher intensity (pushing harder at the end of each exercise) stimulated better improvements in my body. And because my effort and intensity were much higher than before, I couldn’t sustain that high effort level for very long. So the extra intensity didn’t just significantly improve my results, it also necessitated briefer workouts.

It’s certainly a lot easier to terminate each set of repetitions before you reach “muscle success” and do a much longer workout than it is to “gut it out” and take each set you perform to a deep level of muscular fatigue. But stopping short of muscle success will make your workouts less productive.

Taking a set of repetitions to this muscle success point is not fun while you’re doing it. It’s uncomfortable. Your muscles often vibrate and burn. But it’s the best thing you can do to generate results from your training. The fun part is the results you get afterward in stronger muscles, enhanced cardiovascular efficiency, faster metabolism, stronger bones, and added body-shaping lean muscle tissue.

A fair amount of people have a lot of difficulty pushing themselves to work hard enough to achieve “muscle success” as described above. If pushing every set to this muscle success point is more challenging than you’re able to do on each exercise, at least make sure to fatigue the muscles as deeply as you can on each set. The deeper you fatigue the muscles, the more effective the stimulus is, and it will require more significant adaptations from your body.

So, when your repetitions start to get challenging, try to cultivate a mindset of looking forward to the burning and shaking sensations you’re experiencing. That’s where it’s beginning to get really productive!

By Matt Hedman, President of The Perfect Workout

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Meet Aja Bradley Personal Trainer at The Perfect Workout’s Anaheim Hills and Newport Beach Studios

personal-trainer-aja As a mother of three, Aja values the time efficiency of The Perfect Workout for her own workouts. As a trainer, she values how effective slow-motion strength training is at getting her clients their desired results.

For a busy mom with three kids, an hour in the gym is not realistic. That’s why Aja Bradley not only loves training her clients at The Perfect Workout, she’s also completely devoted to the 20-minute slow-motion strength training workouts herself. Growing up with three brothers, she played all the sports they played, and has always been interested in fitness. She’s done her share of weight lifting, even hiring a personal trainer at one point, but never quite like this. Since coming on board as a trainer in October of 2013 and starting this workout, she has more definition in her abs, arms, and everywhere, in a much shorter amount of time.

Once she went through The Perfect Workout’s rigorous training and certification program, Aja quickly started helping her clients get great results, too. “The thing I like most about training is the relationships with clients,” she says. “We’re going so slow that I have time to actually coach. I take the time to understand each person’s goals. That’s very important.” Clients regularly make comments like, “My clothes are fitting better,” “I’m getting stronger and can pick up my grandkids now,” and her favorite, “I arm wrestled my husband and he was surprised by how strong I was!” Aja’s style is a good mix of getting to know her clients on a very personal level, pushing them to full capacity during the workout, and maintaining a very upbeat, optimistic attitude.

Besides her work as a personal trainer, Aja writes for Independent films, and just produced her first one as well. She’s been acting and modeling since she was five, and you may have seen her in a Mad TV skit or in a commercial. There’s not a lot of spare time in the Bradley household, but if she had more she’d enjoy spending more time with her husband and working out with him since they work opposite schedules. For now, Aja’s goals are to stay in shape, keep setting an example for her kids, and for her first movie that she produced to do well. She’s excited to be part of The Perfect Workout team, and says, “I really like how everyone in the company looks out for one another. I love my clients and the people I work with.”

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Judy Lost 2 Sizes and 26 Pounds!

judy-lost-two-sizesStrength training helped Judy, 66, lose 26 pounds and drop from a size 12 down to an 8. She says her clothes fit better, she has more energy, she sleeps better, her shoulder and neck pain is gone, and she has a more muscular, toned body.

When your husband is a foodie and a chef who makes amazing meals, it can be a challenge to stay in good shape, especially at age 66. For Judy Schons, it wasn’t for lack of trying. She did the obligatory one-hour block at her health club, whether that was a spinning class, on the treadmill, or some other aerobic exercise. She got good results, but Judy describes that kind of exercise as being “a rat in a cage,” and thinks exercising inside for an hour is ridiculous and abhorrent for anyone who lives in beautiful San Diego. “I did not look forward to it,” she says. “At 20 minutes I was tired, 30 minutes I was bored silly, and 45 minutes I accepted it and just tried to finish.” Making it to 60 minutes was gratifying but simply took too long.

Suffice it to say, The Perfect Workout’s two workouts per week of only 20 minutes each were a big draw. She also wanted to increase her bone strength and density and change the way she looked. “All my life I’ve had chubby thighs and hips. It ran in my family. I always felt like I wasn’t wearing clothes well. I didn’t look good in pants.”

The slow-motion workouts fit perfectly into Judy’s schedule, and trainer Sarah Speers at the Mission Valley studio made sure she got the most out of every session. “Sarah pushes me to exhaustion, and constantly encourages me. She’s a very interesting person, and the 20 minutes flies by. I wouldn’t do this on my own,” says Judy. The key with slow-motion strength training is the emphasis on working toward “muscle success” on every exercise. That’s the point at which you can’t possibly move the weights even a fraction of an inch further, after doing several repetitions for 10 seconds out and 10 seconds back. If you continue maximally pushing or pulling for a few more seconds, you achieve this deep muscle fatigue, and that’s what brings results. Judy started seeing the effects within weeks. Her pants started fitting better, she had more energy, she slept better, and she lost inches. She also noticed her shoulder and neck pain from sitting at her desk was gone. While gaining muscle everywhere (she leg presses 400 pounds now!), Judy lost 16 pounds while going from a size 12 to an 8.

Judy still had another goal, though – to get into a dress that her husband had gotten her. “I tried it on and it had a lot of lumps and was stretched to the max,” she says. During a recent challenge at The Perfect Workout, she lost another 10 pounds, just in time for her 15th anniversary, where she debuted her new svelte look. “I got a lot of compliments on the dress!” While Judy would like to lose another five pounds or so, the increased strength and new look is paying huge dividends. She’s able to hoist those heavy bags of soil from Home Depot, hits the golf ball a good 30 yards further than the women she plays with, and isn’t huffing and puffing after pushing her cart for four or five hours at The Vineyard or Admiral Baker North. Even better, she’s now wearing whatever she wants – skinny jeans, skirts, sundresses, shorts, and sleeveless tops. Her next objective is to wear a bathing suit on a cruise she and her husband are taking in July from Montreal down to Boston. “I’m delighted! I don’t have the ‘wiggle wobble’ in my arms. I enjoy The Perfect Workout, and I really look forward to going to this gym. I’m very happy with what it’s done for my body.”

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