Physiotherapy Rehab After Total Hip Replacement

Physiotherapy Rehab After Total Hip Replacement

1. PHYSIOTHERAPY MANAGEMENT PROTOCOL Pre and Post Operative Total Hip Replacement Presenter – MD. Mozammal (BPT) Physiotherapist Orthopedic Surgery Department ( SSMCMH )

2. Pre operative Management

3. It contains Examination and Evaluation Patient Education

4. Examination and Evaluation Pain ROM Muscle Strength Balance Ambulatory status and Gait Leg lengths Use of assistive devices General level of function Perceived level of disability

5. Patient Education Information for patient about joint disease and operative procedure in non medical term. Postoperative precautions for hip dislocation. Rationale including positioning and weight bearing. Transfer instructions- In and out of the bed. Chair (avoid deep chair) to minimize trunk flexion Ambulation – Instruct on use of anticipated assistive device (walker). Mentally prepare the patient for the painful active stage ahead.

6. Post Operative Management

7. It’s divided into four phases Immobilization Phase Maximum Protection Phase Moderate Protection Phase Minimum Protection Phase and Resumption of Full Activity

8. Immobilization Phase Position of the patient is supine in the bed and the operated limb may need to remain in a slight abduction and neutral rotation. Abduction pillow or wedge typically used to maintain this position To prevent a flexion contracture of the operated hip, avoid use of pillow under the knee.

9. Maximum Protection Phase Usually the day or the day after surgery Prevent vascular and pulmonary complication Ankle pumping exercise to prevent venous stasis, thrombosis formation and potential for pulmonary embolism Deep Breathing exercise and bronchial hygiene to prevent postoperative atelectasis , pneumonia Prevent post op dislocation or subluxation of operated hip

10. Diaphragmatic breathing exercise Costal breathing exercise

11. Achieve independent functional mobility prior to discharge Emphasize proper trunk and lower extremity alignment Ambulation with assisted device (initially a walker or two crutches) Maintain a functional level of strength and muscular endurance in the upper extremities and non operative lower extremity

12. Prevent reflex inhibition and atrophy of musculature in the operated limb Quadriceps Hip extensors Hip abductor Just enough to elicit contraction Quad Set Inner Range Quad exercise

13. Early post op ROM precaution after THR Posterior/ posterolateral approaches Avoid hip flex >90 deg, add & int. rot beyond neutral. Anterior/ anterolateral & direct lateral approaches Avoid hip flex >90 deg & combined motion of hip flex, abduc & ext. rot. Transgluteal / Trochanteric osteotomy approach No active, antigravity hip abduction for at least 6-8 weeks or until approved by the surgeon

14. Do and Don’ts

15. Weight Bearing Considerations It depends on Method of fixation Surgical approach Other factors

16. Cemented total hip : weight bearing to tolerance (WBTT) with walker immediately after surgery and carry on at least 3-6 weeks, then use a cane in the contralateral hand for 4-6 months. Cement less total hip : touch down weight bearing with walker for 6-8 weeks (some author recommended 12 weeks), then use a cane in the contra lateral hand for 4-6 months

17. Traditional verses minimally invasive : More restriction after standard (Traditional) than minimally approach Trochanteric osteotomy : Restricted weight bearing at least 6-8 weeks or 12-16 weeks for bone healing Other factors include : use of bone graft Poor quality of patients bone

18. Criteria to progress Weak healed incision, no sign of wound drainage or infection Independent level ground ambulation with one crutch or cane Ability to bear full weight on the operated site with full knee extension Muscle strength of operated hip at least 3/5

19. Moderate Protection Phase Phase of rehab begins at about 4 to 6 weeks Goals and interventions Regain strength of hip abductors and extensors

20. Improve cardiopulmonary endurance: Progressive stationary cycling, swimming, water aerobics Restore ROM while adhering to precaution: Thomas test position in supine Passive stretch of hip flexor muscles Stretching anterior capsule while the patient is in standing position. Improve postural stability, balance and gait

21. Thomas stretch: pt trying to stretch his right hip anterior capsule by pushing down hard in the bed with his right lower extremity G Medius strengthening in side lying

22. Criteria to progress Pain free ambulation with or without a cane and previous exercises Functional ROM and strength of operated hip Independence in ADL

23. Minimum Protection Phase and Resumption of Full Activity Usually occurs around 12 weeks post op Extended rehab & modification of activities Return to sport activities

24. Instruction for home Continue previous exercises and ambulation activities Continue to observe hip precautions Install elevated toilet seat in home Avoidance of trunk flexion Avoidance of driving for 6 weeks

25. Common Gait faults after THR Trendelenburg gait (weak hip abductor) Flexion contracture of hip Avoidance extension of involved leg

26. Outcomes Pain relief Patient satisfaction Quality of life Physical functioning