An appraisal of rehabilitation regimes used for improving functional outcome after total hip replacement surgery

The Impact of Early Rehabilitation and the Acceptance of the Disease on the Quality of Life of Patients after Hip Arthroplasty: An Observational Study

Background: The early introduction of physiotherapy significantly shortens the time required for a patient to regain full mobility after hip arthroplasty. Obtaining the expected result is determined by cooperation with a physiotherapist and the patient's involvement in the rehabilitation process. The aim of this study was to assess the quality of life, life satisfaction, and motor ability of patients after hip arthroplasty. Methods: This study included 147 patients who underwent hip arthroplasty at the Orthopedic and Trauma Department. The research material was collected using questionnaires, and the study used the Barthel Index (BI), Harris Hip Score (HHS), Visual Analogue Scale (VAS), Acceptance of Illness Scale (AIS), and Quality of Life Assessment Questionnaire (WHOQOL-BREF). In the studied group of patients, the Excia cementless endoprosthesis was primarily used (69.39%), as well as the Metha Short Hip prosthesis (15.65%), AM hip prosthesis (10.20%), and bipolar hip prosthesis (4.76%). Results: The analyzed group of patients included 95 women (64.63%) and 52 men (35.37%); the average age was 67 years. Six weeks after hip arthroplasty, mild disability occurred in 53.74% of the patients, while the remaining 46.26% had no disability, and 95.24% of the patients achieved a high level of acceptance of the disease and quality of life. Conclusions: Early improvement after hip replacement surgery contributes to eliminating the disability of the hip joint in the following areas: pain sensation, functionality, lack of deformation, and range of motion. Each subsequent stage of treatment increased the level of acceptance of the disease in the study group. The applied surgical treatment increased satisfaction with overall health and quality of life.

Functional Ability, Psychological Factors, and Rehabilitation Outcomes After Elective Total Hip Replacement

Background. The role of positive psychological factors in acute rehabilitation after total hip replacement (THR) is unclear. Purpose. (a) Examine the trajectory of functional ability among older adults after THR from presurgery to discharge from acute rehabilitation and (b) determine which physical and psychological factors at admission would predict functional ability at discharge and length of stay in rehabilitation. Methods. This prospective cohort study included 30 participants (age M = 76.20 years) from an inpatient geriatric rehabilitation center. They completed the Geriatric Depression Scale and Positive Affect questionnaire. The FIM® Motor domain of Functional Independent Measure (mFIM) was recorded presurgery, at admission, and upon discharge. Findings. Functional ability improved at discharge; however, the presurgery functional ability was not regained. Positive affect explained the length of stay in rehabilitation above and beyond the presurgery mFIM. Implications. Occupational therapists should improve ways to enhance self-care and positive affect in acute rehabilitation.

Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty

The prevalence of total hip arthroplasty (THA) for advanced hip osteoarthritis (OA) is both increasing and shifting toward a younger average age. However, THA alone does not typically normalize function in these patients. Postoperative rehabilitation is often recommended to optimize joint motion, strength, and function. To date, there are no peer-reviewed clinical practice guidelines for postoperative rehabilitation following THA. Thus, optimal postoperative rehabilitation requires consideration of the existing literature and clinical expertise. This review article summarizes current recommendations for postoperative management of THA, including phases of rehabilitation, postoperative hip precautions, the effect of rehabilitation setting and mode of delivery on postoperative outcomes, and gait mechanics.

[Effects of joint replacement on spinal movement]

Although studies after joint replacement show significant improvements in important gait parameters during rehabilitation, the gait pattern at the end of rehabilitation is still clearly deficient. Patients show compensation strategies that also suggest changes in spinal movement. The aim of the present study was to analyse the spinal movement in dynamics in patients after total hip and knee replacement and to identify abnormalities in comparison to a reference group. 3D gait analyses and 4D spinal analyses were performed with the subjects at the beginning and at the end of rehabilitation. The analysis of the movement patterns showed abnormalities in all three movement dimensions, which manifested themselves in increased trunk forward tilt and lordosis, lateral tilt on the operative side and altered pelvic rotation. In consequence therapeutic measures after total hip and knee replacement should, therefore, include neighbouring joints such as the spine in order to avoid consequential complications.

Feasibility of a preoperative strengthening exercise program on postoperative function in patients undergoing hip or knee arthroplasty: a pilot randomized controlled trial

BACKGROUND

There are conflicting results on the effect of preoperative exercise programs on long-term function and little evidence on short-term function. The aim is to assess the feasibility of a preoperative strengthening exercise program in patients undergoing hip or knee joint arthroplasty in terms of trial design, recruitment, and follow-up rates.

METHODS

A randomized controlled feasibility study with patients undergoing hip or knee joint arthroplasty. Patients were randomized to a preoperative strengthening exercise program or standard of care. Feasibility outcome measures were recruitment rate (≥ 50%) and loss to follow-up (≤ 15%).

RESULTS

Of the 129 eligible participants, 63 participants consented to participate in the study (49%), and 27 were successfully randomized prior to surgery (43%). All 27 participants completed the baseline assessment. Of these, 6 (22%) had surgery during the exercise period. Of the remaining 21 participants, 20 (95%) completed the pre-surgery assessment. The study was terminated before five participants could be eligible for the 6-month assessment. Sixteen (76%) participants completed the 6-week post-surgery assessment. Twelve participants completed the 6-month assessment (75%).

CONCLUSION

Given the recruitment rate, randomization barriers, and study participant loss to follow-up, the study was discontinued since it was not considered feasible in this current form at our clinical site despite modifications made to the protocol. Future investigations into a modified intervention via telerehabilitation should be explored.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03483519 . Retrospectively registered in March 2018.

In vivo loading on the hip joint in patients with total hip replacement performing gymnastics and aerobics exercises

A further increase in the number of total hip arthroplasty (THA) is predicted, in particular the number of young THA patients has raised and with it their demands. There is no standardized evidence-based rehabilitation program and no reliable guidelines for sports activities after THA. Stretching and strengthening gymnastics are routinely performed in rehabilitation and aerobics as a sport after THA. The aim of the investigation was to determine the in vivo force and moments acting on the hip prosthesis during gymnastics and aerobic exercises to provide a source for evidence-based recommendations. Hip joint loads were measured in six patients with instrumented hip implants. The resulting force F_Res, bending moment M_Bend at the neck and torsional moment M_Tors at the stem were examined during seven strengthening (with two different resistance bands) and four stretching gymnastic exercises and seven aerobic exercises with and without an aerobic step board compared to the loads during the reference activity walking. The stretching and strengthening gymnastics exercises and the aerobic exercises with and without a board demonstrated in their median peak force and moments mostly lower or similar values compared to walking. Significantly increased loads were recorded for the flexor stretching exercise in monopod stand (F_res and M_Bend), the strengthening abduction exercise on the chair (M_Tors) and the strengthening flexion exercise with the stronger resistance band (M_Tors). We also found a significant increase in median peak values in aerobic exercises with a board for the "Basic Step" (ipsilateral started F_res and M_Tors; contralateral started M_Tors), "Kickstep ipsilateral started" (F_res and M_Tors) and "Over the Top contralateral started" (F_res). The in vivo loads in THA patients during frequently performed stretching, strengthening and aerobic exercises were demonstrated for the first time. It was proved that stretching gymnastic exercises are safe in terms of resulting force, bending and torque moments for THA patients, although an external assistance for stabilization may be considered. Strengthening gymnastics exercises are reliable in terms of F_res, M_Bend and M_Tors, but, based on our data, we recommend to adhere to the communicated specific postoperative restrictions and select the resistance bands with lower tension. Aerobic exercises without an aerobic board can be considered as reliable activity in terms of force and moments for THA patients. Aerobic exercises with a board are not recommended for the early postoperative period and in our opinion need to be adapted to the individual muscular and coordinative resources.

Effects of progressive resistance training for early postoperative fast-track total hip or knee arthroplasty: A systematic review and meta-analysis

Progressive resistance training (PRT) is one of the most commonly used exercise methods after joint replacement, while its effectiveness and safety are still controversial. Therefore, it's vital to investigate the effect of PRT on muscle strength and functional capacity early postoperative total hip arthroplasty (THA) or total knee arthroplasty (TKA). Relevant studies were identified via a search of Medline, Web of science and Cochrane Library from 2002 to 12 May 2020. Fifteen of 704 studies which comprised 6 THAs and 8 TKAs, involving 1021 adult patients were eligible for inclusion in the meta-analysis. There were no significant differences between the two groups after TKA in the 6-min walk test (6-WMT) within 1 month (95% CI = -0.41, 1.53), within 3 months (95% CI = -0.27, 0.76), within 12 months (95% CI = -0.29, 0.66); climb performance in seconds (s) (SCP), leg extension power, timed up and go test in seconds (s) (TUG) within 1 month (95% CI = -1.75, 0.77), within 3 months (95% CI = -0.48, 0.33), within 12 months (95% CI = -0.44, 0.35), sit to stand, number of repetitions in 30s (ST). There was no difference in the incidence of adverse events (95% CI = -0.01, 0.10). Similarly, two groups were also no obvious distinction after THA in the 6-WMT, SCP, Leg extension power, ST. PRT early after THA or TKA did not differ significantly from SR in terms of functional capacity, muscle strength recovery and incidence of adverse events. PRT is one of the options for rapid rehabilitation after joint replacement.

Digital Versus Conventional Rehabilitation After Total Hip Arthroplasty: A Single-Center, Parallel-Group Pilot Study

Background

The demand for total hip arthroplasty (THA) is rising. In the face of rapidly increasing health care costs, ensuring widespread, cost-effective rehabilitation is a priority. Technologies allowing independent home-based rehabilitation may be the key to facilitate access, improve effectiveness, and lower costs of care.

Objective

The aim of this study was to assess the feasibility of a novel artificial intelligence–powered digital biofeedback system following THA and compare the clinical outcomes against supervised conventional rehabilitation.

Methods

This was a single-center, parallel-group pilot study, with an 8-week intervention program. Patients were assessed at baseline, during the program (at 4 and 8 weeks), and 3 and 6 months after surgery. The primary outcome was the Timed Up and Go (TUG) score and secondary outcomes were the Hip dysfunction and Osteoarthritis Outcome Scale (HOOS; a patient-reported outcome) and hip range of motion (ROM).

Results

A total of 66 patients were included: 35 digital physiotherapy (PT) versus 31 conventional. There were no differences at baseline between groups except for lower HOOS quality of life (QoL) subscale scores in the digital PT group. Clinically relevant improvements were noted in both groups at all time points. The digital PT group showed a retention rate of 86% (30/35). Per-protocol analysis revealed a superiority of the digital PT group for all outcome measures. Intention-to-treat analysis revealed the superiority of the digital PT group at all time points for TUG (change between baseline and 4 and 8 weeks: P<.001; change between baseline and 3 and 6 months: P=.001 and P=.005, respectively), with a difference between median changes of −4.79 seconds (95% CI −7.24 to −1.71) at 6 months post-THA. Between baseline and month 6, results were also superior in the digital PT group for the HOOS sports and QoL subscales and all ROM except for standing flexion.

Conclusions

This study demonstrates this novel solution holds promise in rehabilitation after THA, ensuring better clinical outcomes than conventional rehabilitation while reducing dependence on human resources.

Trial Registration

ClinicalTrials.gov NCT03045549; https://clinicaltrials.gov/ct2/show/NCT03045549

Total Hip Arthroplasty in the Outpatient Setting: What You Need to Know (Part 2)

The intra- and postoperative phases of outpatient total hip arthroplasty (THA) vary by institution and surgeon. An understanding of an evidence-based approach to enhancing the intra- and postoperative phases of the care continuum is warranted to offer high-value care to outpatient candidates. This article will discuss methods for implementing successful outpatient THA protocols. Specifically it reviews information regarding anesthesia and analgesia modalities, intraoperative considerations, and postoperative rehabilitation amenable to outpatient THA.

Rehabilitation of revision total hip replacement: A multi-centre survey of current practice

BACKGROUND

Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation.

AIMS AND OBJECTIVES

To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery.

METHODS

An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically.

RESULTS

There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably.

CONCLUSIONS

This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.

The effectiveness of supplementary arm and upper body exercises following total hip arthroplasty for osteoarthritis in the elderly: a randomized controlled trial

OBJECTIVE

To determine whether arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes after hip arthroplasty.

DESIGN

Prospective, parallel, randomized, controlled trial.

SETTING

Orthopaedic and rehabilitation departments.

SUBJECTS

A total of 70 patients >60 years of age, who underwent hip replacement, out of 98 eligible candidates after exclusion criteria were implemented.

INTERVENTIONS

The study group took part in the supplementary arm and upper body exercise programme to be compared with the standard rehabilitation programme group.

MAIN OUTCOME

The primary outcome was a Harris Hip Score. Secondary outcomes were: Hand grip strength and Medical Outcomes Study 36-Item Short-Form Health Survey. Outcomes were assessed preoperatively, two weeks after surgery and at 12 weeks follow-up.

RESULTS

In the intervention group, significant improvements were found: in functional ability - Harris Hip Score after two (mean difference = 4.7 points) and 12 (mean difference = 5.85 points) weeks; in muscle strength - handgrip for both hands (mean difference for dominant hand = 4.16 and for the other hand = 2.8) after 12 weeks; and in role-physical dimension SF-36 Health Survey (mean difference = 6.42 points) after 12 weeks.

CONCLUSION

Results of this study indicate that arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes 12 weeks after hip arthroplasty.

Rehabilitation following total hip arthroplasty evaluation over short follow-up time: randomized clinical trial

Hip osteoarthritis (OA) is a degenerative disease, and total hip arthroplasty (THA) is one of the surgical procedures of choice to improve the OA patient's quality of life. Without a rehabilitation program, THA patients will develop functional limitations. A randomized double-blind trial was performed between July 2009 and October 2011 to compare in a short follow-up time two groups of patients who underwent THA for OA. The THA protocol (THAP) group received verbal instructions and physiotherapy exercise demonstrations, and the THA physiotherapy care protocol (THAPCP) group received the same verbal instructions and demonstrations associated with daily exercise practice guided by a physiotherapist. The outcomes that were assessed preoperatively and 15 d postoperatively in 106 patients were muscle strength force, goniometry, Medical Outcomes Study 36-Item Short Form Health Survey, and Merle d'Aubigné and Postel score. Higher muscle strength force scores and degrees in range of motion were found in the THAPCP group. Higher improvements were also observed for the THAPCP group compared with the THAP group in the Merle d'Aubigné and Postel score. At the end of the follow-up period, the intervention in the THAPCP group improved functional capacity, quality of life, mobility, muscle strength, goniometry, and pain. It appears to be a safe tool for accelerating recovery in THA patients.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT01491048.

A feasibility randomised controlled trial of pre-operative occupational therapy to optimise recovery for patients undergoing primary total hip replacement for osteoarthritis (PROOF-THR)

Objective:

To assess the feasibility of a pre-operative occupational therapy intervention for patients undergoing primary total hip replacement.

Design:

Single blinded feasibility randomised controlled trial, with data collection prior to the intervention, and at 4, 12, and 26 weeks following surgery.

Setting:

Recruitment from two NHS orthopaedic outpatient centres in the West Midlands, UK.

Subjects:

Patients awaiting primary total hip replacement due to osteoarthritis were recruited. Following pre-operative assessment, patients were individually randomised to intervention or control by a computer-generated block randomisation algorithm stratified by age and centre.

Interventions:

The intervention group received a pre-surgery home visit by an occupational therapist who discussed expectations, assessed home safety, and provided appropriate adaptive equipment. The control group received treatment as usual.

Outcomes:

The study assessed the feasibility of recruitment procedures, delivery of the intervention, appropriateness of outcome measures and data collection methods. Health related quality of life and resource use were recorded at 4, 12 and 26 weeks.

Results:

Forty-four participants were recruited, 21 were randomised to the occupational therapy intervention and 23 to usual care. Analysis of 26 week data included 18 participants in the intervention group and 21 in the control. The intervention was delivered successfully with no withdrawals or crossovers; 5/44 were lost to follow-up with further missing data for participation and resource use.

Conclusions:

The feasibility study provided the information required to conduct a definitive trial. Burden of assessment would need to be addressed. A total of 219 patients would be required in an efficacy trial.

Test-retest reliability of Common Mental Disorders Questionnaire (CMDQ) in patients with total hip replacement (THR)

Background

The Common Mental Disorders Questionnaire (CMDQ) is used to assess patients’ mental health. It has previously been shown to provide a sensitive and specific instrument for general practitioner setting but has so far not been tested in hospital setting or for changes over time (test-retest). The aim of this study is, by means of a test-retest method, to investigate the reliability of the instrument over time with total hip replacement (THR) patients.

Methods

Forty-nine hip osteoarthritis patients who had undergone THR answered the questionnaire twelve months after their operation. Fourteen days later they completed it again. Covering emotional disorder, anxiety, depression, concern, somatoform disorder and alcohol abuse, the questionnaire consists of 38 items with six subscales, each of which has between 4 to 12 items. A five-point Likert scale (from 0–4) is used.

Results

For each of the 38 questions, a quadratic-weighted Kappa coefficient of 0.42 (0.68 – 0.16) to 0.98 (1.00 – 0.70) was found. A Cronbach’s alpha of 0.94 for all the questions indicated high internal consistency.

Conclusion

The results showed a moderate to almost perfect reliability of CMDQ of this specific population.

Trial registration

Current Controlled Trials: NCT01205295

Does physiotherapy contribute to the improvement of functional results and of quality of life after primary total hip arthroplasty?

INTRODUCTION

This paper aims to determine whether physiotherapy succeeds in improving the functional results (expressed by the Harris hip score) and the quality of life after primary total hip arthroplasty, especially in very elderly persons.

MATERIAL AND METHOD

A prospective study has followed up 100 patients with coxarthrosis, who underwent a primary total hip arthroplasty and who were subject to an early initiation of a recovery treatment, adapted to each individual, focused on regaining functionality and independence and continued at home after discharge from hospital. After 3 months, the Harris hip score was compared with the preoperative one and the quality of life was assessed according to a simplified questionnaire derived from SF-36.

RESULTS

The average preoperative Harris hip score was significantly lower in patients aged over 75 years, as compared to the other 3 age groups (under 40 years, between 41 and 60 years and between 61 and 75 years). After 3 months, the average Harris hip score was significantly improved, in comparison to the preoperative one (85.89 as compared to 40.06) and there were no statistically significant differences between the average Harris hip score in all 4 age groups. The quality of life was regarded by patients as being good on average, in all 4 age groups.

CONCLUSION

Very elderly people benefit equally with the other age groups from a functional recovery after primary total hip arthroplasty, even if this recovery is initially more difficult and more cautious.

What does standard rehabilitation practice after total hip replacement in the UK entail? Results of a mixed methods study

Background

There is evidence of prolonged poor function in patients following total hip replacement (THR). Studies of progressive resistance training (PRT) interventions to improve function are often compared to ‘standard’ practice which is not well defined. This study aimed to investigate ‘standard’ rehabilitation care in the UK after total hip replacement (THR) as well as determine whether PRT was part of ‘standard’ care.

Methods

After ethical approval, questionnaire item development about rehabilitation practice was guided by a focus group interview (after informed consent) with physiotherapists (n = 4; >5 years post-qualification) who regularly treated THR patients. An online questionnaire investigating the exercises prescribed and rehabilitation practice following THR was developed and sent to physiotherapists working in hospitals in the UK. The survey was performed from January to May 2011. The survey results were analysed (frequency (%) of responses) focusing on the exercises the physiotherapists considered important, as well as their use of PRT in prescribed regimes.

Results

106 responses were obtained from physiotherapists in the UK. The survey respondents considered that the most important muscles to target in all phases of rehabilitation were the hip abductors (62.2%), followed by the quadriceps (16.9%), and other muscles (21%). Exercise type prescribed revealed no consensus, with weight bearing (42%), functional (45%) and Bed-based/Bridging/Postural exercises (13%) favoured. 83.7% were able to define the basis of progressive resistance training (PRT), but only 33% prescribed it.

Conclusions

Standard physiotherapy rehabilitation in the UK after THR is variable, and appears to rarely include PRT. This may be a factor in prolonged poor function in some patients after this common operation.