Hip international : the journal of clinical and experimental research on hip pathology and therapy. JMIR rehabilitation and assistive technologies. Effectiveness of delayed rehabilitation programmes in patients following total hip replacement. Effect of cycle ergometer and conventional exercises on rehabilitation of older patients with total hip arthroplasty: study protocol for randomized controlled trial.
View 3 excerpts, cites background. Physical training in rehabilitation programs before and after total hip and knee arthroplasty. Annales de readaptation et de medecine physique : revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de medecine physique.
Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis and rheumatism. Outcomes of total hip arthroplasty: a study of patients one year postsurgery. The Journal of orthopaedic and sports physical therapy. Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial. Archives of physical medicine and rehabilitation. Are bed exercises necessary following hip arthroplasty?
The Australian journal of physiotherapy. Home program of physical therapy: effect on disabilities of patients with total hip arthroplasty. Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? On the PSFS, patient's list activities that are important to them, and quantify their current ability to complete those activities.
Some examples of sports and activities in this group of patients included basketball, running, golf, hiking, and curling. Training for return to basketball included drop jumps from a low height Figure 1 and dynamic single leg balance exercises, such as single leg stance on foam while bouncing a weighted ball off of a trampoline Figure 2. Agility training was also used and included grape vines, cone weaving Figure 3 , and high knees.
Those returning to running performed single leg stability and strengthening exercises while also completing a structured running progression program. This program started with walking, progressed to fast walking, alternate walk-jogs, and slow jogging up to one mile on a treadmill. Those returning to golf practiced repeated stroking on uneven surfaces outside and swung a medicine ball like a club while on two foam balance mats Figure 4.
The full protocol can be found in Appendix 3. Intervention Patient Rehabilitation Goals that guided the focus of the second half of the intervention during the last four weeks. Change scores were calculated for each variable of interest. Descriptive measures of means and direction of change were also reported. To assess differences in patient satisfaction 16 weeks after THA compared to individuals who underwent usual care, an independent t-test was used to compare self-reported satisfaction between the groups at the week time point.
To assess feasibility and safety, descriptive data were reported. Safety was measured by assessing the number and type of adverse events during the experimental treatment. Feasibility was assessed by calculating the number of patients who attended all 16 visits, as well as reviewing the reasons for missed visits. A comparison of total visits between the control and intervention group was assessed using an independent t-test. One patient dropped from the control group prior to the start of rehabilitation.
The intervention group had a greater change in 6MWT distance by There were no other differences in change score between groups for other performance-based tests of function. There was also a statistically significant difference in satisfaction after treatment.
The intervention group had an average satisfaction of 96 out of while the control group average satisfaction was 84 out of Similar to the functional measures both groups had greater scores at week follow-up for the remaining self-reported measures. Clinical Measures Pre- and Post-Intervention , presented as mean scores, change values, and confidence intervals.
Values in indicate the number of subjects that completed a measure at both pre- and post- testing sessions. All values can be found in Table 2.
There were significant differences of average vertical ground reaction force symmetry during sit-to-stand in which the intervention group became more symmetrical at follow-up, while the control group became more asymmetrical. All values can be found in Table 3. The first and second peak vertical ground reaction force during stance are indicated by two black arrows on the graph. Figure 7 A shows the control groups and Figure 7 B shows the intervention group. The graph shows the average symmetry in the intervention group 8A and in the control group 8B during sit to stand before and after surgery.
In this table, the post intervention symmetry is closer to the symmetrical cut off then before surgery. Biomechanical Measures Pre- and Post-Intervention , presented as mean scores, change values, and confidence intervals.
The intervention group completed an average of 15 visits with a range of 14 to 18 visits. The control group completed an average of 19 visits, but the number of visits ranged from 11 to This physical therapy protocol, which focused on reducing supervised visits early after THA and retraining higher level activities later in the course of recovery, had a positive effect on outcomes without compromising safety.
Although it needs to be substantiated in larger, randomized clinical studies, the progressive intervention may produce better outcomes across multiple domains recovery as compared to usual care. The TUG was originally developed as a test for individuals with neurological dysfunction and may not be substantially challenging for patients after THA.
In reviewing the outcomes for this test, many patients in both groups preoperative scores would already be considered normal for their age and remained so after surgery as well. The experimental group had a large mean improvement in the SCT 10 seconds compared to the control group 2 seconds , even though there was no statistical difference between these scores.
It is likely that the study was underpowered to detect a difference given the large variability of patients in both groups. Even though there was no statistical difference between groups for change in surgical side hip abductor strength, the intervention group demonstrated a mean increase in strength while the control group decreased on average.
Previous work in this lab 29 and others 30 , 31 demonstrated that individuals after THA have residual weakness in the operated limb that does not improve with rehabilitation, even when measured one year post-surgery. It is possible that the progressive and higher-level training in the experimental group produced strength gains greater than what is typically seen in this patient population.
Given the clinically meaningful improvement in strength on surgical side, and statistically significant improvement in strength on the non-surgical side, it is not surprising that there the intervention group had better outcomes with the 6MWT which exceeded the clinically minimal significant difference of 85m. The experimental protocol specifically targeted activities and goals most pertinent to the patient as were measured using the Patient Specific Functional Scale.
For example, one patient was starting his own company for which he would be welding. This vocation involved getting underneath trucks and climbing into large vehicles. The outcomes of his recovery would directly affect his livelihood. Another patient sought out a surgeon that would allow him to return to running, and his rehabilitation program was tailored to include a progressive return to running protocol. By the end of treatment, he was able to run a mile without pain or noticeable deviation.
Often successful outcomes from this musculoskeletal surgery is measured in terms of range of motion, strength, or scales that measure the ability to complete activities of daily living. Future research should explore measuring and training individuals in tasks that are most relevant to their overall goals.
Although there were no significant differences in discrete measures of gait biomechanics, between-limb force symmetry improved in the intervention group during a sit-to-stand task. This is a meaningful result, as asymmetrical movement patterns that continually overload the non-operated limb are common after primary THA. It is important that the integrity of the operated limb, as well as the non-operated limb is maintained, particularly in a demographic that is getting younger and will have a longer post-operative life expectancy.
Patients in the experimental group after THA had a first and second peak vGRF that were closer to established norms for gait as compared to both their pre-operative time point and the post-operative time point in the control group. While some of these improvements may be solely related to the surgery and lower pain, the trend towards a difference between groups in this small sample may warrant future investigation.
While the tenets of this program would seem to be of benefit to most individuals with THA, this rehabilitation approach may be most appropriate for a select group of patients. This study was envisioned with timing and content of this protocol to best suit younger, active patients who are substantially motivated to return to high level physical activity or participation in a more demanding recreational and vocational activities.
Because the initial phase required that patients perform and progress exercises independently outside of the clinic, it may not be suitable for patients who do not completely comprehend instructions for exercise and progression, individuals who have low-functional levels and poor mobility, or patients who are not motivated to perform exercises in their home environment.
For successful outcomes communication with the surgeon is critical for patients enrolled in this type of intervention. Clearance from the surgeon was recieved before performing any dynamic training component with patients in this study that may be considered outside the scope of traditional rehabilitation after THA.
All patients in the experimental group routinely followed-up with their surgeons to ensure stability of the prosthesis and to obtain a prescription for continued enrollment in the rehabilitation program.
A set of soreness rules 35 were followed for all patients to make sure that exercise and training progression was not having negative consequences on the prosthesis or surrounding soft tissue. Even with these safety precautions, there are still potential risk associated with greater joint loading, from higher level activites, after THA include aseptic loosening, fractures, polyethylene wear, or joint revision. Previous work has found that while perceived outcomes may be better in those who participate in higher-level activities, the rate of revision may be greater.
In order to make better informed decisions, future long-term outcome studies on prosthetic survivorship and activity-level are needed as the goals, needs, and activities evolve in this patient demographic.
Study enrollment was not randomized and patients had a choice in where they received treatment, which may have affected outcomes. Future studies evaluating this protocol should randomly allocate patient grouping to avoid bias in the patient sample or in the delivery of the intervention.
The researcher was also not blinded to the groups and was the intervening therapist. Functional measures decline with advancing age and younger patients may have a better rehabilitation potential. Additionally, other studies have shown that age is not a major contributing factor to functional recovery after joint arthroplasty. Baseline differences may partially explain the difference between groups in change scores for this measure.
Future studies that randomize treatment allocation would be beneficial to overcome this potential confounding factor.
Since this study evaluated feasibility and preliminary effectiveness, the sample size was small to allow for safe and direct evaluation of the novel protocol. Also, a pilot study in nature usually has a low sample size, therefore it is possible this study was underpowered to detect statistically significant differences in the biomechanics during gait.
A larger sample size may find differences between groups for the first and second peak vGRF during stance phase. Also, there was a difference in groups with a greater number of males, however although raw clinical data is sometimes higher for males a study by Kostamo et al, 45 found there was no effect for gender when assessing change scores after THA, along with survivorship and revision rates.
Thus, the differences in gender distribution between the two groups both with larger male counterpart should not have had an impact when assessing change scores, however in a larger trial if raw clinic scores are assessed equal distribution of gender in groups would be needed.
This feasibly study supports the notion that a progressive rehabilitation protocol that includes a period of home-based exercises, followed by supervised movement training may benefit individuals after THA.
A larger sample size with randomization and a matched cohort would allow for a more robust analysis of this protocol to identify the strengths and weakness of the protocol as well as success in returning patients to higher-level goals. The results of this study indicate that a delayed treatment timing and focus on return to high level activity results in improvements in function and biomechanics after THA, and is feasible and safe to complete.
This novel therapy protocol may be more appropriate and provide better clinical outcomes than traditional rehabilitation for younger and more active patients. It accounts for a variety of patient goals ranging in different levels and types of activity and sports. Use of this protocol could allow therapists a unique approach to patients, particularly those who have an interest in higher level activities or return to sports.
Therapist Instructions :. The following is a guideline for home exercises for subjects enrolled in the total hip arthroplasty THA rehabilitation study. Please bear in mind that the subject population for THA is very heterogeneous and the exercises given in this guide may not all be appropriate for your subject. We recommend using clinical judgment to provide an individualized home exercise plan that best matches your subject's impairments and goals.
On the table below, the exercises are broken down into categories to target muscle groups and ADLs rows within the table. Within these rows, the exercise and activities are listed from least challenging to most challenging. The columns represent the three phases of rehabilitation and exercises should be selected from the appropriate column.
Choose five exercises for the subject. We ask you to use the exercises given, but you are free to mix and match these home exercises depending on the subject's goals and deficits.
More than one exercise can be taken from a category depending on the subject's deficits. Print out the exercises from the computer and add any additional instructions specific to the subject.
Pre-written instructions on how to progress strengthening exercises with respect to number of repetitions and resistance should be provided to the subject. Soreness rules should also be printed and provided to the subject. Exercises will be prescribed starting at 3 sets of 8 reps so that the last rep is difficult to complete.
Prescribe either a theraband resistance or cuff weight if appropriate. Usually the subjects will start with limb weight against gravity, then progress to a theraband or cuff weight. The cuff weights are adjustable up to 10lbs and you can remove or add the individual weights to the cuff as necessary. Each subject will receive a cuff to have at home for exercises.
At the end of this document is a copy of subject instructions on how to progress their exercises between in-clinic therapy sessions. If the subject can complete 12 reps with no difficulty before the next visit they can increase the resistance if the exercises allows. Discuss soreness rules and how they will affect the frequency and progression of home exercises. If subjects experience soreness greater than two days with an increase in resistance or repetitions, they should decrease to original reps of 8.
If they experience hip or groin pain after or during one set of exercises they should reduce resistance or rep count. You will advance to the next phase based on the time since THA. However, if the subject has moved through the levels of difficulty for Phase 1 exercises able to complete the hardest exercises with 12 reps with green theraband or 8lbs of resistance , exercises from the subsequent phase can be introduced if appropriate.
The phases in the protocol see Protocol Document correlate to the phases on this sheet, but it is not necessary to achieve the milestones on the protocol before progressing the subject to the next level of home exercises.
Some subjects may advance quickly due to the large time between sessions in the early and mid-phase of treatment. At the end of therapy the goal is for the subject to 1 return to their activity of choice as measured on the PSFS and 2 continue physical activity and independent exercise on a daily basis.
PT should also educate subject on what activities they are capable and should be doing, given their fitness level, balance, strength, etc. This is the time to discuss access to gyms or weights to encourage continued strength and functional gains.
If they have access to a gym, discuss the machines and best exercises to do independently. If they will be at home encourage continued bodyweight exercises squats, side steps, bridges with single leg lift as well as use of the theraband use of higher resistances in side steps, 4 way hips, side lying hip. If you find it is easy to complete eight consecutive repetitions of the exercise your therapist gave you, add one more repetition to the exercise until the last one feels difficult to complete.
If the next day your muscles feel sore like you had a tough work out that is okay. If this lasts for greater than two days, decrease your number of repetitions back to 8.
She was a nonsmoker with seasonal allergies and no known drug allergies. On her physical examination, her gait was antalgic with a reduced stance phase on the right side. There was leg length discrepancy and no exaggeration of lumbar lordosis. There was no lymphadenopathy and no superficial tenderness. Deep palpation revealed the right anterior joint line tenderness.
There was an absence of any trochanteric tenderness. The range of motion was restricted in abduction and external rotation with pain at end movements. The left hip, bilateral ankles, and knees were normal. She denied any long term steroid or alcohol abuse. Radiographs of the pelvis revealed osteoarthritic changes in the right hip. Considering her comorbidities and lifestyle limiting hip pain, she was advised a total hip replacement surgery.
She was made aware of the added risk of the surgery owing to atrial fibrillation and hypertension. Preoperative X-ray images showing AP and frog-leg lateral view of the right hip. Risks, benefits, and alternatives including nonoperative and operative management were discussed in detail with the patient and her husband. She agreed to go ahead with the right total hip replacement. She was advised to get medical and cardiac clearance. She stopped Xarelto 3 days before the surgery.
The risks, benefits, and alternatives were extensively discussed with the patient prior to the procedure. The patient was then definitively positioned in the lateral position after anesthesia and the right hip up was then draped and prepped in the usual sterile manner.
A curved incision centered over the greater trochanter was used for the arthrotomy. Skin and subcutaneous tissues were incised. The fascia was then divided. The hip was then placed into internal rotation and the posterior soft tissue structures were then taken down and then tagged for future repair. The hip was then dislocated. Lesser trochanter to the center measurement was taken. Neck resection was made at the correct level.
Attention was then turned towards the acetabulum. The remainder of the labrum was then debrided. The acetabulum was then sequentially reamed. The final shell was then placed into position in the correct abduction and anteversion. A screw was used for additional fixation. A poly was then placed over the shell and attention was then turned towards the femur.
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