Total Hip Replacement Rehabilitation: Progression and Restrictions

The success of total hip replacement (THR) is a result of predictable pain relief, improvements in quality of life, and restoration of normal function. Postoperative rehabilitation is one of the factors that can affect outcomes after THR. The main goal of postoperative rehabilitation protocols is achieving maximal functional performance by focusing on reducing pain, increasing ROM, and strengthening the hip muscles.

PREOPERATIVE MANAGEMENT Patient education regarding postoperative pain management, restrictions, independent walking, and proper rehabilitation is an important first step in achieving satisfactory results after THR. Patients who both performed the postoperative exercises and received preoperative education demonstrated the ability to perform functional activities significantly earlier.

These functional activities included being able to walk up and down stairs earlier, use the toilet and chair sooner, transfer independently and ambulate independently. Patient education also has been shown to be directly related to faster postoperative ambulation, reductions in hospital length of stay, and less use of narcotic pain medications.

For patients planning to undergo total hip replacement, many surgeons will require a course of preoperative physical therapy prior to proceeding with the replacement. Preoperative strengthening exercises may have a significant correlation with longer postoperative walking distance and may improve early return to ambulatory function after THR.

MULTIMODAL PAIN MANAGEMENT Optimal pain control promotes earlier ambulation and faster return to normal gait Decreased postoperative range of motion due to pain commonly contributes to inferior results.

POSTOPERATIVE TOTAL HIP ARTHROPLASTY REHABILITATION PROGRAMS Most protocols, include quadriceps sets, gluteal sets, ankle pumps, and active hip flexion exercises. Progressive hip abductor strengthening is also advocated because the abductors maintain the pelvis level during the stance phase and prevent tilting of the contralateral hip during the swing phase.

Most exercise programs address this issue initially by concentric hip abduction in a supine position and later through isometric hip abduction against resistance. The straight-leg raising exercise has been shown to apply a force of 1.5 to 1.8 times body weight and should be allowed only when partial or full weight bearing is permitted.

If pain occurs, hip flexion and knee extension exercises can be done separately with placement of a bolster under the knee to minimize hip stress.

Functional tasks of daily living targeted in the rehabilitation program include weight transfer to the nonoperated hip, gait training on both level and uneven surfaces, stair climbing, and lower extremity dressing.

Transferring of weight to the uninvolved side is initiated by leading with the nonoperated limb both into and out of bed and then is progressed to both sides of the bed. This method is also used with stair climbing: Patients are instructed to lead with the uninvolved hip while ascending and lead with the operated hip while descending the stairs to optimize control of body weight through the uninvolved leg.

WEIGHT BEARING Weightbearing restrictions after hip replacement, such as toe-touch weight bearing (TTWB) or partial weight bearing (PWB), directly affect the level of functional independence after surgery. PWB refers to 30% to 50% of the body weight

In TTWB, no more than 10% of body weight should be applied. TTWB is preferred over nonweight bearing (NWB) because the latter may actually create greater pressures over the hip joint as a result of muscle forces maintaining the correct pelvic positioning.

Full weight bearing (FWB) has been shown to promote faster recovery and shorter hospital stays. This is a result of reduced reliance on the upper extremities for weight bearing, resulting in earlier strengthening of the operative hip abductors and improved functional outcomes.

Assistive devices such as walkers, crutches, and canes are used to unload the operated joint and provide support and balance. Progression from one to another is dependent on several factors such as age, comorbidities, and weightbearing restrictions. Walkers are usually the first choice after THR and provide the greatest stability by increasing the patient s base of support and unloading the affected leg.

Using Crutches: Up and Down Steps When climbing up and down steps, remember this rule: Up with the good (unaffected leg) and down with the bad (affected leg).

Most patients advance easily from gait training with a walker to crutches or a cane.

A potential complication of axillary crutches is axillary nerve compression injuries from incorrect use.

Canes are usually used on the contralateral side of the hip replacement and can transfer 10% to 20% of body weight by decreasing vertical hip contact forces.

The basic function of a cane is to extend the base of support and to provide stability. Canes should be used only for patients who are fully weight bearing. Canes are inexpensive, can be used on stairs, and can be sized according to the patients height.

Different rehabilitation settings include acute hospital care, inpatient rehabilitation and home or outpatient rehabilitation centers. In acute hospital care, postoperative physical therapy is usually started on the same day of surgery or the next morning.

The goals for the first physical therapy session are to assess the patient s mobility status and to initiate therapeutic activities. Physical therapist, assess and record the ROM and strength of the uninvolved leg.

Initial training includes strength assessments, sit-to-stand transfers, and gait and balance teaching. Transfers from bed to chair are usually done twice a day for half an hour at a time. Patient education further involves lower extremity dressing, bathing, and toilet transfers using appropriate equipment to maintain hip precautions.

Transfers and gait training exercises are advanced depending on the patients weightbearing status, preoperative level of ambulation, age, and amount of improvement, progressing from simple walking to attempting curbs and ramps based on the patient s needs.

Therapeutic exercises initiated during the initial visit may consist of lower extremity isometrics (quadriceps, hamstring, gluteal sets) and ankle pumps.

Ankle Pump: flex, both feet. Doing this 10 to 30 times each hour

Quadriceps Set: Lie in bed with your legs straight. Tighten the front thigh muscle of your operated leg while pressing the back of your knee down into the bed.

Gluteal sets: Squeeze your buttocks together tightly. Your hips will rise slightly off the bed. Hold for 5 seconds, then release.

Heel Slide

Sitting Heel Rise

Squat Exercises

Initially, a patient may be able to tolerate only passive ROM; however, he or she should be able to demonstrate increased active ROM tolerance over the course of the inpatient stay. Therapeutic exercises frequently are added daily to the patient s routine.

POSTOPERATIVE PROTOCOL AFTER PRIMARY TOTAL HIP REPLACEMENT P.O. protocol after primary THR includes progression of quad sets and calf raises, each twice a day, up to 20 lifts each time. Recommend walking as far as possible every day with the physical therapist and with an assistive device (walker), stationary bicycling with no resistance for 15 to 20 minutes each day, and eventually swimming as tolerated.

Calf Raise

Stationary Bicycling

Management of Common Problems after Total Hip Replacement 1. Trendelenburg gait (weak hip abductors): - Concentrate on hip abduction exercises to strengthen abductors. - Evaluate leg-length discrepancy - Have patient stand on involved leg while flexing opposite (uninvolved) knee 30 degrees. If opposite hip drops, have patient try to lift and hold in an effort to re-educate and work gluteus medius muscle (hip abductor).

Hip Abductor Strenghtening

In a walk stance position patient should shift weight forward over the involved hip. the hip abductor strength improves when the patient performs full weight bearing on involved limb.

2. Flexion contracture of the hip: - AVOID placing pillows under the knee after surgery. - Walking backward helps stretch flexion contracture. - Perform a Thomas stretch of 30 stretches a day (five stretches six times per day). - Pull the uninvolved knee to the chest while supine - Push the involved (postoperative) leg into extension against the bed. This stretches the anterior capsule and hip flexors of the involved leg.

Thomas Stretch

Gait Faults Gait faults should be watched for and corrected. Most gait faults either are caused by or contribute to flexion deformities at the hip. These faults generally are attributable to the patient s attempts to avoid extension of the involved hip, because such extension causes an uncomfortable stretching sensation in the groin.

Hip Extension Exercises

Outpatient Total Hip Arthroplasty Physical Therapy Protocol Typically, a patient should be either able to demonstrate or be working toward the following clinical goals:

Achieving full, allowed active ROM at the hip by the end of the sixth postoperative week. For example: hip flexion 90 degrees, hip abduction 40 degrees for the patient who has had a posterior approach surgery. Additional ROM may be restored through stretching exercises once the physician s postoperative precautions have been lifted.

Balance Exercises Progress functional strengthening; including balance exercises.

Independent ambulation by week 12 (and without the use of an assistive device for those who did not require their utilization preoperatively). Patient able to drive by the end of the sixth postoperative week. Patient able to assume side-lying on operative hip by the end of the sixth postoperative week.

Return to most recreational/sports pursuits by the end of the twelfth week postoperative

Exercises to increase muscle strength include the following: Isometrics Open kinetic chain exercises Closed kinetic chain exercises Balance exercises

Kinetic Chain Exercises: Open and Closed A healthy body is often described as a well-oiled machine. Like a machine, it s made up of otherwise fixed segments made mobile by joints. A kinetic chain is the motion that these joints and segments have an effect on one another during movement. When one is in motion, it creates a chain of events that affects the movement of neighboring joints and segments.

There are two kinds of kinetic chain exercises: open and closed. In open kinetic chain exercises, the segment furthest away from the body known as the distal aspect, usually the hand or foot is free and not fixed to an object. In a closed chain exercise, it is fixed, or stationary.

Open kinetic chain exercises

Closed kinetic chain exercises

Balance Exercises

Therapeutic Exercises Frequently Prescribed in the Outpatient Orthopedic Physical Therapy Setting

Sports Participation Recommendations for Patients With a Total Hip Replacement