Summary of condition
Brigham and Women’s Hospital Department of Rehabilitation Services reports common post surgical impairments may include[1]:
- Edema
- Pain
- Decreased range of motion
- Impaired muscle control and strength
- Impaired balance
- Decreased proprioception
These impairments along with any other patient specific impairments should be included in the initial problem list developed by the physical therapist. Goals should be developed to address each impairment to work to improve the patient’s optimal level of independence and quality of life.
Guide to Physical Therapy Practice
Image taken from http://guidetoptpractice.apta.org/local/img/home_cover.gif
The Guide to Physical Therapy Practice provides a general outline for potential treatments for patients that fall within the broad diagnosis. This Guide provides the physical therapist with an expansive list of possible impairments and suggested treatment options. It is up to the physical therapist to use his/her clinical decision making to collect information through test and measures to develop a comprehensive problem list and a treatment plan to match.[2]
A patient recovering from a total hip arthroplasty can be included in the two following patterns:
Pattern 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Joint Arthroplasty
Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery
According to pattern 4H, the expected range of visits is between12 to 60. The guide states that approximately 80% of the patients included in this pattern will reach all anticipated goals within the 60 visit limit. The 60 visits are over a continuous treatment period with the frequency and duration being decided by the physical therapist.[2]
Therapeutic exercise interventions include:
- Aerobic capacity and endurance conditioning
- Balance and coordination training
- Gait training
- Flexibility exercises
- Body mechanics and postural stabilization
- Strength training
Manual therapy interventions include:
- Massage
- Passive range of motion
- Mobilization/ manipulation of soft tissue
Other therapeutic modalities include:
- Cryotherapy
- Hydrotherapy
- Thermotherapy
- Sound therapy
- Electrotherapeutic modalities
Management of total hip arthroplasty
Acute Phase
A patient that experiences an uncomplicated hip arthroplasty will stay in the hospital for 2-3 days. Most hospitals have an established clinical pathway for joint arthroplasties. Below is an example of a 72 hour clinical pathway initiated day of surgery and followed until discharge. In a study completed by Juliano et al, patients that participated in therapy day of surgery in comparison to post op day one had a decreased length of stay in hospital, showed more independence on activity upon discharge, and attempted the use of a minimal assistance device, such as a cane instead of a walker. The clinical pathway established for this study is provided below.[3]
| 4 day length of stay THA clinical pathway | 72-h clinical pathway | |
| DOS | No physical therapy | Treatment occurs bedside, Evaluation, dangle, stand or ambulate as tolerated, Bedside exercises, THA precautions instructed, |
| POD 1 | Treatment occurs bedside, Evaluation, dangle, stand or ambulate as tolerated, Bedside exercises, THA precautions instructed | Treatment occurs bedside, Transfer training, Progress ambulation distance as tolerated with walker, Review exercises and precautions, High chair sitting and privileges |
| POD 2 | Treatment occurs bedside, Transfer training, Progress ambulation distance as tolerated with walker, Review exercises and precautions, High chair sitting and bathroom privileges | Continue transfer training, Attempt gait progression to cane or crutches and stair training*, Treatment session in PT gym, Progression of exercise program, Review Precautions, High chair sitting and bathroom privileges |
| POD 3 | Continue transfer training, Attempt gait progression to cane or crutches and stair training*, Treatment session in PT gym, Progression of exercise program, Review Precautions, High chair sitting and bathroom privileges | Continue transfer training, Continue gait progression and stairs*, Treatment session in PT gym, Review home exercise program and ADL technique, Discharge if appropriate |
| POD 4 | Continue transfer training, Continue gait progression and stairs*, Treatment session in PT gym, Review home exercise program and ADL technique, Discharge if appropriate |
* The stairs are negotiated with one rail and a cane or two rails, depending on the patient’s need to negotiate stairs and the home environment.
Post Operation Precautions
Surgeons instruct patients on three common precautions following surgery. Patients are also instructed in proper weight bearing. The surgeon might remove or add different precautions based on each individual surgery. The three main precautions for a posteriolateral approach are as follows:
- Do not flex hip past 90 degrees
- Do not Internally rotate the hip; keep toes straight forward
- Do not adduct the hip; do not cross midline
Management of Total Hip Arthroplasty
The protocol listed below is adopted from a protocol developed by The Brigham and Women's Hospital Department of Rehabilitation Services. This protocol is broken down into 4 phases, Acute, Motion, Intermediate, and Advanced strengthening and higher level function stage.[1] Each protocol should be molded to fit the needs of the individual patient to comply with all precautions.
Acute phase (1-4 days)
This phase corresponds with the acute phase described above.
Goals for this phase include:
- Educate on dislocation precautions
- Increase independence with function
- Prevent or reduce post operative impairments.
Motion Phase (week 1-6)
This phase includes therapeutic exercise and modalities as needed.
Goals of this phase include:
- Muscle strengthening of the hip girdle of the operative extremity
- Proprioceptive training to improve body awareness for functional training
- Endurance to increase cardiovascular fitness
- Gait training; discontinue assistive device approx. 4-6 weeks when there are no signs of an antalgic gait, or trendelenburg sign.
- Increase ROM
- Increase Strength
- Return to functional activities
Therapeutic Exercises:
- Weeks 1-4
image retrieved from http://www.poolcenter.com/blog-pool-workout-exercises.gif
- AA/A/ PROM for all hip motions
- Isometric quadriceps, hamstrings, and gluteal exercises
- Heel slides
- Balance training : weight shifting activities and closed kinetic chain activites
- Gait training
- Stationary bike, weeks 3-4 as advised by MD
- Weeks 4-6
- Continue above exercises
- Front and lateral step up and down
- 4 way straight leg raise; if not contraindicated by precautions
- ¼ lunge
- Sit to stand exercises
- Pushing and pulling exercises
- Aquatic program
Criteria for progression:
- AROM 0-110 degrees
- Voluntary quadriceps control
- Independent ambulation of 800ft without an assistive device, antalgia, or deviations
- Minimal complaints of pain and inflammation
Intermediate Phase (week 7-12)
Goals for this phase include:
- Good Strength for all lower extremity musculature
- Return to most functional activity and participation in light recreational activities
Therapeutic Exercises:
image retrieved from : http://www.inkity.com/catalog/img/4/5990.jpg
- Progress exercises in Movement phase by adding resistance and repititions.
- Assess lower extremity and trunk stability, provide open and closed chain exercises as necessary to fit the needs of the individual patient
- Initiate endurance program ( pool or walking)
- Initiate age appropriate balance and proprioception training
Criteria for progression:
- 4+/5 mmt on all lower extremity musculature
- Minimal to no complaint of pain and swelling
Advanced strengthening and higher level function stage (week 12-16)
Goals for this phase include:
- Return fully to appropriate recreational activities
- Enhance strength, endurance, and proprioception
Therapeutic Exercises:
image retrieved from http://youcastcorp.com/acesplace/images/Deuce_-_Cartoon.jpg
- Continue to progress previous exercises
- Increase duration of endurance activities
- Carrying, pushing, pulling activities
- Return to specific recreational activities ( golf, tennis, walking, biking)
- Return to work tasks
Criteria for discharge:
- Non-antalgic independent gait
- Independent step over step stair climbing
- Pain free AROM
- 4+/5 MMT on all lower extremities
- Independent with home exercise program
- Age appropriate balance and proprioception
Modalities supported by research
Cryotherapy
- Cryotherapy is defined as the removal of heat from the body. It can provide local and systemic effects. The application of cold therapy can decrease the temperature of the skin 2 to 4 cm in depth.[4]
- Continuous cryotherapy is effective in decreasing post-operative pain of total hip arthroplasty (THA). The hip joint is considered too deep to be effected by cooling agents. Saito et al demonstrates the effectiveness of continuous cryotherapy on post op THA for the first 4 days after surgery. The effectiveness can be related to decreasing the pain of the superficial soft tissue damage caused by the surgery and not the joint itself.[5]
Thermotherapy
- Thermotherapy is defined as the application of any substance that increases the temperature of the affected body area.[4] Moist heat is the most common form of thermotherapy used in the treatment of THA.
- Thermotherapy is used to decrease pain and muscular spasms. Thermotherapy is contraindicated in any patient in an acute phase of inflammation.[4]
Electrical Muscle Stimulation
- Electrical muscle stimulation is being applied in clinical settings to decrease pain and improve strength and functional independence. Research is ongoing in this field to further study the effectiveness in adjunct with therapeutic exercise.
- Gremeaux et al completed a study investigating the application of low frequency electrical muscle stimulation in combination with physical therapy on elderly patients following THA. The results of the study demonstrate an improvement in strength in the surgical leg and higher scores on the Functional Independence Measure (FIM) questionnaire. The study concludes that it is appropriate and effective to use low frequency electric muscle stimulation to work on maintaining or increasing strength of the operated leg to achieve balance between lower extremities and promote functional independence.[6]
- Alghamry conducted a study investigating the effectiveness of electrical stimulation of quadriceps and hamstrings in adjunct with therapeutic exercise. Alghamry concludes that electrical stimulation is effective in decreasing pain, and increasing strength, range of motion, and quality of life.[7]
Exercise
- Exercise is the most common modality used to treat THA. The section above lists a clinical pathway to treat the acute in hospital post operative phase of rehab and a rehab protocol that addresses recovery up to week 12.
- • Trudelle –Jackson and Smith report that a late phase rehab program covering months 4 to 12 post surgery is beneficial to the patient to increase muscle strength, postural stability, and self perceived function.[8]
