New Participant With an Unreported Mobility Limitation
First session of a 12-week shallow-water arthritis-friendly class, 10 participants, water 33 °C, depth 1.0 m. A new participant, a 70-year-old woman, completed a health screening that lists 'knee replacement 8 months ago' and 'uses a cane on land' but no physician restrictions. During the first set of standing knee lifts she grimaces, holds the pool wall, and shifts weight to her other leg. When you ask, she says the knee is 'a little stiff' and that she 'didn't want to be the one who holds everyone up.' She wants to keep going with the group. The class plan includes 20 minutes of continuous standing marching and lateral steps.
1. How do you respond in the moment, and what movement substitutions do you make?
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Stop the continuous standing work for her and offer an immediate substitute that reduces load and shear on the replaced knee: seated or wall-supported knee extension/flexion through a comfortable range, hip abduction with support, and water walking at her own pace rather than timed marching. Normalize the modification out loud to the whole class ('support options are always available') so she isn't singled out. Check in briefly, confirm the discomfort is manageable and not sharp/swelling, and let her choose the supported track. Do not push her to 'keep up.'
2. What does her comment 'didn't want to hold everyone up' tell you about your class design, and what would you change?
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It signals that the session was structured so that only one pace existed, making modification feel like failure. Redesign for layered options: every exercise gets a supported/seated regression and a progression, and continuous blocks are broken with rest and choice points. Build in a short orientation before week one that explains that modifications are standard, not remedial. This is a program-design judgment, not just an in-class fix.
3. What documentation and follow-up are warranted, and what should you not do?
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Record the observed signs, the substitution provided, and her response in the session log. Follow up after class to ask about pain during and after, and encourage her to mention the stiffness to her surgeon/physiotherapist if it persists. Do not diagnose the cause, promise the class will 'fix' the knee, or clear her for activities beyond what the screening allows; refer to her clinician for restrictions.