Total Hip Replacement (THR)

Total Hip Replacement (THR)

Post-operative Physiotherapy/Hydrotherapy

Pre-operative guidelines

·  Restore Hip range of movement as follows: Flexion 90°, abduction 40°, extension 10-15°

·  Strengthen the Quads, hamstrings and glutes to promote recovery.

·  Gait re-education

·  Educate Patient on post-op compliance to ensure the best functional outcome

·  Home advice:

·  avoid bending your hip more than 90° (a right angle) during any activity

·  avoid twisting your hip

·  do not swivel on the ball of your foot

·  when you turn around, take small steps

·  do not apply pressure to the wound in the early stages (so try to avoid lying on your side)

·  do not cross your legs over each other

·  do not force the hip or do anything that makes your hip feel uncomfortable

·  avoid low chairs and toilet seats (raised toilet seats are available)

Precautions/Contraindications:

Will depend upon type of surgical approach: If anterior approach, contraindicated motions are simultaneous hip extension and external rotation. For lateral approach, motions to be avoided are simultaneous hip flexion/adduction and internal rotation. For posterolateral approach, contraindicated motions are simultaneous hip flexion/adduction and internal rotation.

Phase 1: (Post Op Days 1-7)

Frequency: 1-2 times per week

Duration: 6-12 weeks depending on physiotherapy findings

Goals:

·  To complete a full assessment in clinic including goals i.e.: returning to work and hobbies to promote specificity of rehab.

·  To ensure sufficient pain management.

·  To ensure that patient is free from DVT or infection.

·  Demonstrate safe and independent transfers from the bed to chair.

·  Demonstrate safe and independent ambulation with assistive devise.

·  To demonstrate safe use of stairs to mimic their home environment.

·  To attain the following ranges of movement by day 7: Flexion 90°, Abduction 25° and Extension 5°

·  To demonstrate a safe home exercise program.

·  To orientate to pool and treadmill program and given information pack.

·  To address secondary problems at the knee, lumbar spine and ankle to promote re-alignment of the musculoskeletal system.

* All Post Op programmes have been carefully formulated to facilitate and promote the normality of tissue to repair throughout the stages of healing:

·  Inflammatory phase – Essential component of healing. Starts in first few hours post injury and peaks at 1-3 days, gradually resolving after 2 weeks.

·  Proliferation phase – Production of scar (collagen) material. Rapid onset of 24-48 hours and peaks at around 2-3 weeks post injury. (The more vascular the tissue the shorter the time it takes to reach its peak). This phase continues for several months post trauma.

·  Remodelling Phase- Results in an organised quality and functional scar which will behave in a similar way. Starts around 1-2 weeks and continues for several months.

Water component (1-2 weeks)

Underwater Treadmill

·  Water level at 1000- 1200m to reduce weight bearing by 50%-75%

·  Walking slowly encouraging a normal gait. Re-education phase, i.e. heel to toe

·  To increase speed of belt to encourage larger stride lengths and full knee extension/ VMO activation.

·  Walking slowly with knees to 90° to encourage mobility in hips and knees.

Hydrotherapy Pool (Limit ROM dependent upon surgical approach)

·  Walking forward and backwards

·  Marching/clap unders

·  Walking heel to buttocks

·  Walking lunges in comfortable range

·  Kickboard hip flexion/extension (not exceeding 90°)

·  Step lunges

·  Step ups

·  Semi squats in pain-free range

·  Knee flexion/extension with buoyancy aid to promote further range

·  Cycling legs under water

·  Hip abduction exercises (straight plane)

·  Single leg balance with eyes open/closed

·  Core stability exercises

·  Hamstring/hip flexor/ gastrocnemius stretches in open area/bench/steps

Cryotherapy

·  15 mins cryotherapy to be done at the end of each session.

Land component

·  Strengthening exercises for Quads/Hamstrings/Glutes/Core

·  Stretching exercises for Quads/Hamstrings/Glutes/Core

·  Scar massage

·  Ice for reducing swelling

·  Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.

Post-operative 2-4 weeks

GOALS

·  Reduce pain and swelling

·  Restore mobility to Flexion 90°, Abduction 20°-30° and Extension 5°

·  Independent with transfers

·  Weight bearing as tolerated with appropriate assistive devices (weight bearing status determined by physician)

·  Demonstrates good understanding of Total Hip Arthroplasty Precautions

·  Fair/good recruitment of gluteus medius

Water component (2-4 weeks)

Underwater Treadmill

·  Reduce water level at 900-1000m to increase weight bearing

·  To increase speed of belt to encourage increase stride length.

Hydrotherapy Pool

REPEAT OTHER EXERCISES FROM WEEK 1-2

·  Sit to stand with weight (don’t exceed 90° hip flexion)

·  Lunge with weight

·  Single leg squat

·  Step ups with weight

Cryotherapy

·  15 mins cryotherapy to be done at the end of each session.

Land Based

·  Continue with mobilisations techniques

·  Stationary bike

·  Manual stretching

·  Balance and Proprioception exercises.

·  Encourage home exercises – Add stair Quad stretch and Partial squats

·  Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.

Post-Op Weeks 5-6

Goals

·  Minimal effusion

·  Hip active range of movement as follows: Flexion 90°, abduction 40°, extension 10-15°

·  No incisional adherence/hypersensitivity

·  Normal reciprocal stair negotiation with/without rail

·  Meet Self- management criteria at the end of this phase

Water Component

Underwater Treadmill

·  Reduce water level at 600-900 to increase weight bearing depending on progress

·  To increase speed of belt to encourage increase stride length

·  To start jogging and incorporating interval training for CV fitness and plyometrics

Hydrotherapy Pool

REPEAT OTHER EXERCISES FROM WEEK 2-4

·  Walking Lunges with weight or medicine ball with rotations

·  Kickboarding exercises with hip flexion/extension (don’t exceed 90° hip flexion)

·  Lateral Lunges with weight (be guided by surgeons protocol, surgical approach dependent)

·  Heel to butt

·  Increase height of step ups

·  Increase depth of step downs

·  Single leg squats

·  Challenge balance

Land Based

·  Continue strengthening program: Leg Press, Leg extensions, Leg Curls, Shoulder Bridge, Lateral step ups, Step Downs,

·  Continue Balance/Proprioception exercises: Rocker board, Walking Lunges

·  Cardiovascular exercises: Treadmill walking with an incline and increasing resistance on stationary bike.

·  Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation.

Post op weeks 7-8

Goals

·  Meet self-management criteria

Precautions/contraindications:

Dependent upon surgical approach and/or physician

Land/Water Components:

·  Continue with treatment as indicated in post-operative weeks 5-6

·  Begin sports specific exercises if appropriate with consideration of precautions set by surgeon.

·  Continue with home exercise program progression

·  Continue with swim/swim program dependent upon physician recommendations and physiotherapy re-evaluation

·  Orient patient to program and equipment selection at a local health club

Discharge Criteria

·  Symmetrical knee/ankle active range of movement

·  Hip active range of movement as follows: Flexion 90°, abduction 40°, extension 10-15°

·  No scar sensitivity

·  Normal gait pattern

·  4/5 to 5/5 glute and quad strength

·  A good understanding and performance of their home exercise program

·  Failure to Progress

·  Failure to Comply

See attachment for illustrations of exercises