Resistance Training after Knee Replacements (trying to help my mom lose fat)

[Kenny537]

Hello,

I have briefly mentioned my mom in my diet/training thread here, but I want to make a new thread for her. She has recently begun to be more serious about her diet and I want to make sure that I am doing the right things in helping her. I have posted this thread in the training section because that is the area I feel I need the most assistance in, but I will talk about her diet as well to start off with.

Background Info: Age: 47 | Height: 5???4??? | Weight: 155lbs (40+%BF? 90lb LBM?)
??? Sedentary lifestyle but works A LOT
??? Lacto-Ovo Vegetarian (although I do have her on fish oil pills)
??? Partial knee replacement on both knees one year ago. This means she has Osteoarthritis.

The type of knee replacement is non-constrained I believe. The major location in her knee that she has osteoarthritis is in the medial compartment (medial condyles - bilaterally). They replaced the medial condyle cartilage with an artificial material, due to the major degeneration that was seen in that particular location of the joint.

Goal: Her goal is to lose fat.
She is not obese by any means, and has been skinny most of her life. But in the past few years, she has put on some weight (I am guessing as a result of aging/menopause). I am guessing she is about 40% bodyfat , but I could be very wrong.

Diet: 1400 calories, 140g protein, 80g carb, 55g fat (assuming she is counting calories correctly, I believe this is about a 600 (30%) calorie deficit, assuming a 2000 calorie maintenance (13 x 155)).
Am I right in thinking that the 30% deficit is too much? Especially when her maintenance is just an estimate. She has begun to eat ???healthier??? overall as a result of seeing me count my calories meticulously over the past few months. During the past few weeks, I have also gotten her to count calories and measure her food (and record it online). She???s not perfect about it though ??? and still eats some Indian junk food out of habit and social obligations. I don???t have her on any supplements yet besides the protein powder, vitamins, and fish oil (10g).
??? My main concern is her adherence to her diet. Right now, the way I designed it, her primary protein sources include tofu, fat-free milk/cheese/cottage cheese/greek yogurt, liquid egg whites (very minimal.. she makes a small omelet), and protein powder
??? Another concern of mine is consistency. For one thing, we will always have relative get-togethers or some event every weekend which will force her to eat like crap due to social obligations. I will just try to make her be smart about it

I am more concerned with her training though than her diet. I am sure she will lose weight with her current diet, but I want her to lose fat while minimizing muscle loss as much as possible. It???s been a few weeks now and she says she has a lost a few pounds ??? although she does not weigh herself consistently and at the same time with the same level of hydration.

Training: I really need help in this area. I don???t have any experience designing workouts since I am a newbie myself. The knee replacements compound this difficulty. I asked her last week how her knees feel now after 1 year of having the replacement surgeries - are they still bothering her? She said ???1 percent??? - which means she???s pretty much fine for the most part now. But keep in mind she isn't really doing any sort of regular exercise, let alone resistance training.

My problem, more specifically, is how to create the high tension stimulus that is needed to retain muscle mass while in a calorie deficit.
How can I have her lift heavy with the limitations in her knees? How can I have her incorporate resistance training in the lower body at all? As she is a complete newbie, I realize this is not as vital of an issue right now. But I guess I am just thinking ahead. Any recommendations would be appreciated. I am trying to do research on my own. Before more on that, please keep in mind that I do not have much practice reading scientific studies, so my ability to interpret them may be limited

According to UpToDate, the only evidence that exists supports low to moderate intensity exercise. The concern I have is that I think that this type of exercise will not help in preserving her muscle, and could even aid in burning muscle (please correct me if I???m wrong).
Here is the exact quote from my source:

Long-term, patients may be encouraged to pursue low to moderate intensity, low impact exercises, as patients who are more active do not appear to increase their risk of needing revision arthroplasty [55]. The limited evidence available suggests that remaining active may actually be associated with a reduced risk of requiring subsequent replacement of the operated knee.

The reference cited is this study: Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study.
Physical activity and risk of revision total knee ... [J Rheumatol. 2004] - PubMed result

Can anyone find any other relevant studies? There does not seem to be much research in this area.

I found a pilot study:
???Reversing Muscle and Mobility Defects 1-4 Years after TKA
Reversing muscle and mobility deficits 1 to 4 year... [Clin Orthop Relat Res. 2009] - PubMed result
In terms of muscle gain in TKA patients, this study seems to favor ???eccentric lower extremity resistance??? as opposed to traditional resistance exercise for the lower body (with machine exercises like leg press, leg extension, leg extension, calf raise)
So this study favors this eccentric type of training, but I guess it makes the big assumption that the participant should be fine doing resistance training in the first place. And that is an assumption that I am hesitant to make - because I don???t want her to damage her knees further -- or even worse, need revisionary surgery

Here are more studies that may or may be relevant:
Improved function from progressive strengthening interventions after total knee arthroplasty: A randomized clinical trial with an imbedded prospective cohort - Petterson - 2009 - Arthritis Care & Research - Wiley Online Library - I did not understand this study too well, but I believe it seems to reiterate the importance of strength training following a TKA.

???Our data suggest that individuals who do not undertake an intensive rehabilitation program following TKA are clearly at a disadvantage.???

Physical activity and risk of revision total knee ... [J Rheumatol. 2004] - PubMed result - This seems to echo the above conclusion as well, but I don???t have access to the full text

Regarding aquatic training - I found this study - Effects of aquatic resistance training on mobility... [Arch Phys Med Rehabil. 2010] - PubMed result - I can???t find access for the full text, but the conclusion says:

???Progressive aquatic resistance training had favorable effects on mobility limitation by increasing walking speed and decreasing stair ascending time. In addition, training increased lower limb muscle power and muscle CSA. Resistance training in water is a feasible mode of rehabilitation that has wide-ranging positive effects on patients after knee replacement surgery.???

Although I am still unsure if this is something I should consider (even though I doubt its something practical any way).
I found a statement from Lyle McDonald that is sort of relevant here:

"I would suggest that swimming, by dint of low impact, might be workable. Or water exercise. But it turns out to have some major limitations not the least of which is that a lack of impact/weight bearing can lead to decreased bone density. So while it might allow activity and work the muscles of the knee, it will cause/not solve other issues."

I don't know if it's fair to single out that statement, but it was in a thread about someone who had knee problems that was consider surgery.

Here is another statement by Lyle from that thread that may be helpful to me:

"As a generality, closed chain leg exercises (leg press/squats) tend to cause less knee stress than open chain (leg extensions), deadlifts are usually less knee stressful than squats since there is less bending at the knee"

Lastly, Whole-body-vibration training increases knee-exten... [J Am Geriatr Soc. 2004] - PubMed result - I don???t have access to the full text for that study - but WBV training seems to be interesting.

So anyway, to reiterate my dilemma: I really want her to diet correctly and lose the fat while maintaining muscle - but I also don't want to risk damaging her knees with resistance training

What do you guys think? Am I in over my head? Should I just go to some exercise physiologist or something?

ANY advice at all would be appreciated.

Thanks!

 

[Built]

By far, the diet is her biggest concern. I think you've put forward some fairly reasonable estimates about her lean mass and intake. I'm her age and I was in about the same state (minus the knee problems) at 39 when I started this. I'm not vegetarian, which does make my life easier. I'd avoid soy as much as possible. Is she on any medications and/or hormones?

 

[Kenny537]

I'm pretty sure she is not on any sort of medication/hormones. But I will find out for sure tomorrow.
You mentioned avoiding soy in my thread as well. But I think you said the studies are mixed. I don't eat much, just 40g a day. I think she may be eating a little more - but I kind of just assumed that since she is female - it wouldn't be bad for her. Could you please elaborate on why she (and I) should avoid soy?

Thanks Built!

 

[Built]

I actually think for women it's worse - especially for overweight women. Soy competes with the thyroid for iodine, and can slow metabolism. It also promotes estrogen, and if her estrogen is anything like mine (we're the same age), MORE estrogen right now is the LAST thing she wants.

 

[Kenny537]

Yeah it's confirmed. She says she isn't on any medication/hormones.

I'll try to get her off the tofu (and me). So you don't think the 30% deficit is too much?

Any suggestions on how I should go about designing a workout routine for her?

Thanks!

 

[Built]

30% deficit at her level of bodyfat is fine if she can manage it. Let her have one or two one-hour free meals weekly.

What has her doctor said is okay for her to do given her knees? Is she comfortable on a bicycle? Is she able to walk for say 10+ minutes without pain?

 

[Kenny537]

Built,

She said she is comfortable walking without pain, as long as it is not walking on a treadmill. She doesn't have any pain on the bike or elliptical. However, she says she has not tried the treadmill for three years.

She did do physical therapy for a few months following the surgery. Now she has a follow up appointment for July 2012.
She says her contact person regarding her knees is still the person that did the surgery. I will give him a call and see if he can help me with any of this.

Thanks.

 

[Built]

Good. See if you can get a referral to a Sports Medicine doc. In the meantime, have her learn upper body stuff three times a week - dumbbell bench press, one-arm dumbbell rows, lat pulldowns, olympic bar corner presses are excellent, and have her walk, cycle or elliptical train for up to an hour at least five days a week.

Oh, she can probably do RDLs too - very little knee involvement. In fact, hamstring work will only help her knees.

Because she's out of shape, you probably want to spend ten or 15 minutes each time doing planks and other core work. I skip this part with healthy young novices, but with older, fatter adults with injuries, it's not a bad idea. I think Patrick Ward's got some stuff on this on his blog.

 

[Kenny537]

My mom and I just had the visit with the doctor that did the surgery. The guy was not helpful at all. We got some updated x-rays and the replacements seem to be fine right now, no loss of cartilage anywhere.

But he was literally in the room for like 2 minutes - and I got the impression that he recommends that I shouldn't even do anything at all with her knees. My mom told the guy that I have been really into fitness lately and I had some questions for him for her training. Then he asks me if I've tried p90x (for me, not her). I really was hoping he was joking but I don't think he was. And I don't think he really understod what I was saying when I tried to explain that I have her in a caloric deficit and I need to know what I can and cannot do with her knees in terms of high tension exercises. He just said not to put pressure on it. Obviously he's very knowledgeable in his field, but I don't think he really told me much. After he left, his assistant said stick to isometric exercises, yoga and stuff like that. The assistant then wrote down some info about this one mom&pop gym that he used to personal train at, and said that he recommends trying HIIT. I don't think he meant cardio HIIT though. He gave me an example of this with leg extensions. Where he said the concentric motion is 4-5 seconds and so is the eccentric, and 10-12 sets of that.

Overall, I don't think either of them really helped me much, besides saying do isometric exercises if you must. The only part that really helped in any significant way was them doing the x-ray again and making sure everything was fine. I am thinking I will have to look for help elsewhere.

My mom says she has lost a few more pounds and she is down to 149 - but when I ask her if she sees a difference in the mirror, her answer is no. Maybe it's still too soon.

 

[Built]

Sports med, or regular doc?

 

[Kenny537]

No it was the orthopedic surgeon that performed the knee replacements.

 

[Built]

That explains everything. Get her to sports med.

 

[Kenny537]

Okay. I'll see if I can get a referral from them like you mentioned earlier, thanks!

 

[Kenny537]

I called the doctor's assistant and he said that they don't refer anyone to sports medicine doctors. And he also thought it was the wrong thing for me to look for because he said it sounded like it was more geared towards athletes and the sports medicine doctor would not take into account the arthritis, which should take precedence in terms of importance. He said I should look for physical therapists or personal trainers instead.

Anyway, he said they wouldn't mind writing a referral if it is required to see a sports medicine doctor, and they could also write a prescription for a physical therapist. So I guess they cannot write prescriptions for sports medicine doctors? But the point is that I'll pretty much just be looking for one on my own.