How to Build Strength and Flexibility Pre and Post-Op Hip Replacement Surgery due to Acetabular Dysplasia Ulrika Egner December 2017 CTTC 2017 Pretoria South Africa
Abstract This paper examines how one can build strength and flexibility pre and post-op for a client that is scheduled to have hip replacement surgery due to acetabular (hip) dysplasia. Hip replacement surgery is a procedure in which a doctor surgically removes a painful hip joint with osteoarthritis and replaces it with an artificial joint often made from metal and plastic components. This paper gives an overview of the function of the hip joint, acetabular dysplasia, osteoarthritis and a case study of myself who has had two hip replacements and undergone the below Pilates strengthening programmes. 2
Table of Contents Abstract... 2 Table of Contents... 3 Anatomical Description... 4 The Pelvic Girdle... 4 The Hip Joint... 4 Muscles Supporting the Hip Joint... 5 The Gluteal Group... 5 The Adductor Group... 5 The Iliopsoas Group... 5 Lateral Rotator Group... 6 Other Hip Muscles... 6 Dysplasia... 7 Symptoms of Hip Dysplasia... 8 Osteoarthritis... 8 Case Study... 9 Strengthening Pre Operative Programme... 11 Reasons for the above programme:... 12 Post Second Operation... 13 Strengthening Post Operative Programme... 13 Reasons for the above programme:... 15 Conclusion... 16 Bibliography... 17 3
Anatomical Description The Pelvic Girdle The three bones of the pelvis come together to become the Acetabulum that is the socket. These three bones are ischium (lower and side boundary 2/5 of structure), ilium (upper boundary 2/5 of structure) and the pubis, which is near the midline. The Hip Joint The hip joint is one of the body s largest joints. It is a tri-axial joint that allows flexion, extension, abduction, adduction, internal and external rotation and a combination of these movements called circumduction. It is a ball and socket joint where the ball is the femoral head, which is the upper end of the femur/thighbone. It has an angled neck and a round head (the ball). The bone surfaces of the ball and socket are covered with articular cartilage, a rubbery, lubricated, low friction-bearing surface that allows for smooth and painless joint motion. Around the rim of the acetabulum, there is a ring of dense fibrocartilage that forms a suction seal around the joint; this ring is called the labrum. 4
Muscles Supporting the Hip Joint There are numerous muscles supporting the hip joint and they cause the movement of the joint. The movement occurs when multiple muscles activate at once and most muscles execute more than one movement. The muscles that support the hip joint can be grouped into five according to their orientation around the hip joint: The Gluteal Group The gluteal muscles include the gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae. The gluteus maximus is the main hip extensor, but the inferior portion of the adductor magnus also plays a role. The Adductor Group The adductor brevis, adductor longus, adductor magnus, pectineus, and gracilis make up the adductor group. The adductor group is responsible for hip adduction. Abduction primarily occurs via the gluteus medius as well as the gluteus minimus. The Iliopsoas Group The iliacus and psoas major comprise the iliopsoas group. The psoas is the primary hip flexor, assisted by the iliacus. The pectineus, the adductors longus, brevis, and magnus, as well as the tensor fasciae latae are also involved in flexion. 5
Lateral Rotator Group This group consists of the externus and internus obturators, the piriformis, the superior and inferior gemelli, and the quadratus femoris. Each muscle of the lateral rotator group causes lateral rotation of the thigh. The gluteus maximus and the inferior portion of the adductor magnus aid these muscles. Medial rotation is performed by the gluteus medius and gluteus minimus, as well as the tensor fasciae latae and assisted by the adductors brevis and longus and the superior portion of the adductor magnus. Other Hip Muscles Additional muscles, such as the rectus femoris and the sartorius, can cause some movement in the hip joint. However these muscles primarily move the knee and aid in some flexion. The hamstring muscles, which originate mostly from the ischial tuberosity (sit bones) inserting on the tibia/fibula, have a large impact on assisting with hip extension. Hip muscles also play a role in maintaining the standing posture. These muscles work in an integrated system with muscles of the shoulder, neck, core, lower leg, and supporting muscles of the spine, to provide the ability to stand and move with good posture. 6
Dysplasia Hip Dysplasia is a fairly common condition in both adolescents and adults. It ranges from being barely detectable to a severe malformation that causes extreme pain and disruption to daily life. It is a condition where the hip joint is abnormally formed in early development. The condition can affect the thighbone, however the most common complications in hip dysplasia are those to the socket. Abnormally shallow sockets characterize Dysplastic hips. Hip joints with shallow sockets With time the contact and space between the acetabulum and the femoral head is decreased and it causes an increase in pressure on the articular cartilage of the joint. Over time, this can lead to pain and more damage to the labrum and articular cartilage. Ultimately, if left untreated, significant dysplasia is formed with the 7
development of osteoarthritis at an unusually young age. Symptoms of Hip Dysplasia In adults and adolescence dysplasia is most commonly noticed as an activity-related hip pain and occasionally, a limp. The causes of pain in the dysplastic hip include: Muscle fatigue: The muscles around the hip joint work very hard at keeping the hip stable and the hip firmly set in the hip socket at all times. Muscles that fatigue and shorten due to the body compensating are the Gluteus Muscles, Hip flexors, Adductors and Abductors. Labral injury: The labrum can become damaged from stress at the rim of the socket and might pull away from the socket. This causes pain in the groin and can lead to a hypermobile hip joint. Articular cartilage damage: The increased pressure on the articular cartilage over time can lead to damage to the cartilage and eventually osteoarthritis will form. Osteoarthritis Osteoarthritis is a degenerative type of arthritis that occurs most often in people 50 years of age and older. It is caused by mechanical wear and tear on joints. In osteoarthritis of the hip, the cartilage in the hip joint gradually wears away over time with use. As the cartilage wears away, it becomes frayed and rough and the protective joint space between the bones decreases. This can result in bone rubbing on bone. To make up for the lost cartilage, the damaged bones may start to grow outward and form bone spurs (osteophytes). Osteoarthritis develops slowly and the pain it causes worsens over time. 8
Case Study I am doing this case study on myself as I have undergone two hip replacements surgeries, one in 2013 and one in 2016 due to Acetabular Dysplasia. I am focusing this case study on the pre and post-operative programme that I developed together with my Pilates instructor for my second surgery i.e. the left hip. I recommend that before undertaking any exercise programme pre and post hip replacement surgery professional medical and physiotherapist advice should be sought. This programme was developed for a physically fit athlete that has been working with weight training, stretching, cardio vascular exercise for years thereof the intensity. 9
I had been living with severe hip pain for many years and as a very active sports person I did not want to undergo surgery until I absolutely had to. Painkillers and anti-inflammatory medication got me through each day. The day the doctor told me that I should consider hip replacement surgery was devastating but I had no choice, I could not live with the pain any longer. The right socket was particularly bad with osteoarthritis, bone spurs and the articular cartilage was completely worn down. The first hip replacement took place 2013 and I recovered well without much physiotherapy and did the recovery on my own with many sessions in the gym and on the treadmill focusing on my gait. Although I was very active, fit and fully functional in my daily life I still could not eliminate the lower back stiffness and the feeling that my core was still weak. I found it difficult to pick up things from the floor and lifting things without putting my hands on my knees and walking my hands up against my legs to get back to an upright position. I discovered Pilates in 2015 where I started with one on one mat exercises focusing on core strength and increasing the mobility of the lumbar spine. We also started with the reformer the same year that gave great results and my core began to get stronger and the lumbar spine flexible and mobile again. I continued with my regular gym sessions and Pilates on the reformer twice a week to keep up the core strength and mobility. In 2016 my left hip joint had become worse with osteoarthritis and the articular cartilage had worn down and it was time to book the surgery for my left hip. We had eight weeks (16 sessions) to prepare and since I was already fit and had been exercising for the past few years we continued with our regular routine. We added specific exercises to strengthen the muscles surrounding the hip joint and incorporating flexibility and stability of the same. Muscles that become very weak and shortened after years of pain and the body compensating due to hip dysplasia are the Gluteus Muscles, Hip Flexor, Adductors and Abductors. A weakening of the Core Muscles is also seen and with this comes an instable pelvis. The strengthening Pre Op Programme below focuses on 10
strengthening and elongating the above muscles and to prepare the body as a whole for a hip replacement and the weeks following of walking with crutches. Strengthening Pre Operative Programme Block Sessions 1-10 Sessions 11-20 Warm-up Pelvic Curl, Spine Twist Roll Up, Spine Twist, Supine, Chest Lift, Chest Supine Double Leg, Lift with Rotation Stretch Single Leg Stretch, Criss Cross Foot Work Reformer: Parallel Heels, Chair: Parallel Heels, Parallel Toes, V Position Parallel Toes, V Position Toes, Open V Heels, Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Single Leg Heel, Single Leg Toe Open V Toes, Calf Raises, Prances, Single Leg Heel, Single Leg Toes Abdominal Work Reformer: Double Leg, Double Leg with Rotation Hip Work Reformer: Frog, Circles (Down, Up), Openings Spinal Articulation Reformer: Bottom Lift, Bottom Lift with Extension, Short Spine Long Spine Reformer: Short Box Series; Round Back, Flat Back, Tilt, Twist, Round About, Climb-A-Tree Reformer: Extended Frog, Extended Frog Reverse Chair: Pelvic Curl, Jack Knife Reformer: Bottom Lift with Extension, Semi-Circle Stretch Reformer: Kneeling Lunge Reformer: Standing Lunge, Full Lunge Full Body Integration (F/I) Reformer: Elephant, Reformer: Reverse Knee Scooter, Up Stretch 2, Stretch, Up Stretch 2, Up Long Stretch, Down Stretch 3 Stretch Arm Work Reformer: Arms Kneeling Series Reformer: Shoulder Push, Side Arms Kneeling Series 11
Full Body Integration (A/M) Leg Work Reformer: Single Leg Skating, Hamstring Curl Chair: Hip Opener Reformer: Long Back Stretch Chair: Tendon Stretch Chair: Forward Lunge, Backward Step Down, Chair: Hip Opener Reformer: Single Leg Skating Lateral Flexion/Rotation Chair: Side Stretch, Kneeling Back Extension Chair: Swan Basic, Back Extension Single Arm Reformer: Side Over on Box Reformer: Breaststroke, Pulling Straps 2 Reasons for the above programme: We had 8 weeks (16 sessions) which is the reason being for sessions 21-30 not being incorporated. I trained Pilates twice per week with added gym sessions and stationary bike. Since I am a fit individual and at that time had been working with a BASI trained Pilates instructor twice weekly for over 12 months and been training with weights in the gym we decided to build on the fitness and flexibility that we already had. If the programme was designed for a client with no prior Pilates knowledge and with only basic fitness I would for the first 10 Sessions change the following in the above programme: Abdominals: Omit the above and add 100 prep and Coordination Spinal Articulation: Omit the Bottom Lift with Extension, Long Spine and Short Spine Stretch: Omit Kneeling Lunge and add Standing Lunge Full Body Integration: Omit Up Stretch 2 and Long Stretch Arm Work: Omit the Kneeling Arm Series and add the Supine Arm Series Leg Work: Omit Hamstring Curl Back Extension: Omit Back Extension Single Arm 12
For the 11-20 Sessions I would change the following: Abdominals: Omit Twist And Round-A-Bout Spinal Articulation: Omit Jack Knife (Chair) and Semi Circle Stretch: Omit Full Lunge and add Kneeling Lunge Full Body Integration (F/I): Omit Up Stretch 3 Arms: Omit Side Arms Kneeling Series and add Arms Kneeling Series Full Body Integration (A/M): I would Omit FBI (A/M) completely Leg Work: Omit Backward Step Down and on the Forward Lunge the client was to start with holding on to the handles of the Chair, add Hamstring Curl (Reformer) Post Second Operation After the operation basic strengthening exercises were given to me by the Physiotherapist to execute whilst I was still bedridden and walking a few times per day aided by crutches. At about 3-4 weeks I found that for my mental and physical health I needed to get out of the house and walk around the block with the crutches to feel normal. I started training in the gym again at five weeks twice per week focusing on upper body strengthening and practicing my gait very carefully and slowly on the Treadmill. At seven weeks I got back into the Pilates studio and worked on the Reformer and the Wundachair again. It was now very important to fire up the muscles again although not to damage anything or challenge the muscles too much with the resistance. My Pilates trainer and I worked according to the below training programme keeping the resistance on the springs on very light to start with. Strengthening Post Operative Programme Block Sessions 1-10 Sessions 11-20 Sessions 21-30 Warm-up Pelvic Curl, Roll Up, Roll Up, Spine Twist Spine Twist Spine Twist Supine, Chest Lift, Supine, Double Supine, Double Chest Lift with Leg Stretch, Single Leg Stretch, Single Rotation Leg Stretch, Criss Cross Leg Stretch, Criss Cross 13
Foot Work Reformer: Parallel Reformer: Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances Omitted: Single Leg Heel, Single Leg Toe Abdominal Work Reformer: 100 Prep, Coordination Hip Work Reformer: Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Single Leg Heel, Single Leg Toe Reformer: Hundred, Teaser Prep Reformer: Frog, Circles Frog, Circles (Down, Up) (Down, Up) Openings Openings (Very light (Light to Medium resistance and Resistance) small ranges) Spinal Articulation Chair: Pelvic Curl Reformer: Bottom Lift, Long Spine Stretch Reformer: Standing Lunge Reformer: Kneeling Lunge Full Body Reformer: Scooter Reformer: Scooter Integration (F/I) (light resistance), (medium to heavy Reverse Knee resistance), Up Stretch Stretch 1, Elephant, Down Stretch Arm Work Reformer: Arms Reformer: Arms Supine Series Sitting Series Chair: Parallel Heels, Parallel Toes, V Position Toes, Open V Heels, Open V Toes, Calf Raises, Prances, Single Leg Heel, Single Leg Toes Reformer: Double Leg Double Leg with Rotation, Backstroke Reformer: Extended Frog, Extended Frog Reverse Reformer: Bottom Lift with Extension, Semi Circle, Chair: Jack Knife Reformer: Full Lunge Reformer: Up Stretch 2, Long Stretch, Down Stretch Reformer: Arms Kneeling Series 14
Full Body Reformer: Balance Integration (A/M) Control Front, Balance Control Back Prep Leg Work Mat: Gluteal Side Reformer Side Chair: Forward Laying Series: Side Split, Single Leg Lunge, Backward Leg Lift Skating (very light Step Down, Forward and Lift resistance) Hamstring Curl, Forward with Chair: Leg Press Hip Opener Drops, Adductor Standing, Hip squeeze Opener Lateral Chair: Side Flexion/Rotation Stretch, Side Kneeling Stretch Back Extension Reformer: Breast Stroke Prep Chair: Swan Basic Chair: Side Stretch Reformer: Mermaid Chair: Swan Basic, Back Extension Single Arm Reformer: Side Over on Box Chair: Side Pike, Side Stretch Reformer: Breast Stroke, Pulling Straps 1 & 2 Reasons for the above programme: Foot Work: In the first 10 sessions Single Leg Heel and Single Leg Toe was omitted. Hip Work: In the first 10 sessions the Hip Work was executed with a very light resistance, small and limited ranges and with a short resting period between each exercise to let the hip adductors and hip flexors relax. Full Body Integration: In the first 10 sessions Scooter was executed with light resistance to focus on hip disassociation and pelvic lumbar stabilization. In the next 11-20 sessions Scooter was executed with a medium to heavy load to focus on hip and knee extensor strength. Leg Work: In the first 10 sessions we used light to medium resistance to give the hip the correct support both when abducting and adducting. In the next 11-20 sessions the resistance was set to very light to light so that the hip abductors and adductors were more challenged. 15
Conclusion Daniel S. Rooks, Sc.D., of Beth Israel Deaconess Medical Center, New England Baptist Hospital, in Boston has found that exercise significantly improves pre-op muscle strength and a that the patient has a 73% lower-risk of needing post-op care at a rehab facility. Patients who had engaged in a pre-op programme were also more likely to walk more than 50 feet in the early post-op period. (https://www.ncbi.nlm.nih.gov/pubmed/17013852) I firmly agree with the above finding and that the above eight week pre-op Pilates regime helps and speeds up the recovery process after a hip replacement. I have experienced it and am living proof that one can recover fast and get back to daily life without any necessary post-op rehab facilities. I was already a fit person but had weaknesses and muscle fatigue due to pain in my un-operated hip. I persevered with the pre-op programme even with pain and limited mobility of the hip joint. The day after the operation I got up aided by the crutches confidently and managed to walk further than the distance that the physiotherapist required. A few weeks after the operation I was back in the Pilates studio and managed to keep up with the post-op strengthening programme with ease twice per week. The flexibility, strength and stability that I have acquired after my two hip replacements and overall body strength with the aid of Pilates is outstanding. I recommend Pilates to anybody who is having or has undergone hip replacement surgery. Pilates is a vital part in the preparation for and recovery from hip replacement surgery. 16
Bibliography http://www.wosm.com/blog/understanding-and-treating-hip-dysplasia/ http://hipjointsurgery.co.uk/hips/hip-dysplasia/ https://www.medpagetoday.com/surgery/orthopedics/4209 http://orthoinfo.aaos.org/topic.cfm?topic=a00213 https://en.wikipedia.org/wiki/muscles_of_the_hip https://www.ncbi.nlm.nih.gov/pubmed/17013852 https://ballsbridgephysio.ie/news/the-benefits-of-doing-pilates-before-and-after-a-hipor-knee-replacement/ BASI Study Guide Comprehensive Course 17