Below is a Total Hip Protocol and some excellent current
references on controversial topics related to Total Hip Arthroplasty.
VANDERBILT MEDICAL CENTER
DEPARTMENT OF PHYSICAL THERAPYTOTAL HIP ARTHROPLASTY REHABILITATION
Purpose:To
guide patients through the pre-operative, acute, and sub-acute phases of rehabilitation
associated with Total Hip Arthroplasty (THA), in an effort to assist the patient
in becoming functionally independent following surgery.
Indication: Patients
who are considering or who have undergone Total Hip Arthroplasty.
Contraindications:Any
medical, surgical, or post-operative complication as stated by the attending
physician.
Physical Therapy Goals:Pre-Operative
- Explanation of the role of physical therapy in THA rehabilitation.
- Discussion/Agreement on physical therapy goals following THA.
- Instruction and demonstration of post-operative physical therapy procedure/treatment
(i.e., dislocation precautions, gait training with assistive devices,
exercise regiment, Activity of Daily Living restrictions).
- Establish home exercise program to prepare for surgery/hospital admission.
Acute (In Hospital)
- Early cardinal plane motion of the operative hip with progression as
rapidly as possible toward full anatomical range of motion, limited only
by the prosthetic design and the patient’s potential.
- Muscle strengthening primarily of the hip abductor and extensor muscle
groups.
- Gait training: Assistive devices are used to enable the patient to achieve
the proper weight bearing status on the operative extremity. These devices
are discontinued at the discretion of the Orthopedic Surgeon.
Sub-Acute (Post Discharge)
- Achieve maximal hip range of motion, within cardinal planes of movement.
- Muscle strengthening of the entire hip girdle of the operative extremity
with emphasis on hip abductor and extensor muscle groups. Attention should
also be directed toward any weakness present in the operative extremity
as well as any generalized weakness in the upper extremities, trunk or
contralateral lower extremity.
- Proprioceptive training to improve body/spatial awareness of the operative
extremity in functional activities.
- Endurance training to increase cardiovascular fitness.
- Functional training to promote independence in activities of dialing
living and mobility.
- Gait training: Assistive devices are discontinued when the patient is
able to ambulate without a positive Trendelendberg test based upon the
ambulation guidelines.
PHYSICAL THERAPY REHABILITATION GUIDELINESPrecautions/Restrictions
- Avoid SIMULTANEOUS/COMBINATION movements of the operative hip.
- Patients are allowed to flex, extend, abduct, adduct, or rotate their
operative hip in cardinal planes of motion with NO restriction to movement.
Any combination of motion during the initial three (3) months, post operative
period should be avoided.
- No straight leg raises (SLR) as a repetitive exercises for 6 weeks-as
a functional activity, leg lifting is permissible.
- No sleeping on the operative hip for 6 weeks post-operative.
- Low, soft, contour-type furniture should be avoided.
- Sexual activity may be resumed when comfortable. Specific handouts on
this subject are available upon request.
- Patients may return to work at the discretion of their physician.
- Patients are allowed to resume driving as outlined below:
- Operative left lower extremity-6 weeks post-operative.
- Operative right lower extremity-10 weeks post-operative.
- Ambulation Guidelines:
- Cemented Prosthesis: Weight bearing as tolerated (WBAT) ambulation.
Patients are required to initially use a walker/crutches for a period
of time, then are progressed to cane ambulation. The cane is discontinued
when the patient is ambulating without a positive Trendelenberg test.
- Uncemented Prosthesis: Patients are required to ambulate using a walker/crutches
with either bearing as tolerated or touch down weight bearing (TDWB) status
for the initial six (6) post-operative weeks. If touch down weight bearing
at six (6) post operative, a progressive weight bearing program is initiated-
1/3 body weight on the operative extremity at (6) weeks post-operative;
at eight (8) weeks post operative, progress to 2/3 body weight on the
operative extremity; at ten (10) weeks progress to full body weigh on
the operative extremity, continuing to use the walker/crutches for two
(2) more weeks; at twelve (12) weeks post operative, patients are progressed
to cane ambulation; when the patient is able to ambulate without a positive
Tredenlenberg, the cane is discontinued and the patient is encouraged
to ambulate without any assistive devices.
- No running or involvement in sporting activities requiring running and/or
jumping.
Treatment Parameters:Pre-Operative
- Participation in educational class on Hip Arthroplasty. Material covered
in this class included discussion of normal and abnormal hip joint anatomy,
components of hip prosthesis, intra-operative sequence of events, identification
of post operative complications and preventive measures, admission procedures
for Vanderbilt University Medical Center, post operative rehabilitation
and discharge needs.
- Pre-operative physical therapy assessment at the time of the THA class.
This session included a baseline assessment of joint range of motion,
muscle strength, mobility, and discussion of dislocation precautions/rehab
guidelines following surgery.
Acute Care (Vanderbilt University Medical Center)
- Treatment protocol instituted day of surgery with efforts to achieve
discharge 2-3 days after surgery.
Days of Surgery:
- Begin to lower extremity isometric exercises and ankle pumps. Encourage
the patient to perform these exercises every two hours while awake.
- Begin assisted bed-to-chair transfers using an assistive device to a
chair of appropriate height. Weight bearing status is dependent upon the
type of prosthesis implanted. Patients are not required to “slouch”
sit but may sit in an upright position if comfortable.
- Discuss post-operative dislocation precautions/restrictions.
Post-Operative Day 1:
- Continue lower extremity isometrics and ankle pumps.
- Initiate upper extremity and contralateral limb strengthening exercises.
- Begin assisted ambulation on level surfaces using an assistive device,
weight bearing status dependent upon prosthesis used.
- Begin discharge planning and home needs assessment.
- Review dislocation precautions/restrictions.
Post Operative Day 2:
- Review lower extremity isometric and ankle pumping exercises.
- Begin supine lower extremity active assisted range of motion exercises
to the operative extremity. Motions are to the patient’s tolerance
and in cardinal planes.
- Continue assisted ambulation on level surfaces.
- Reinforce hip dislocation precautions/restrictions.
Post Operative Day 3-Discharge:
- Continue comprehensive exercise program with emphasis on increasing
hip range of motion and general muscle strength in the operative extremity.
- Begin sitting exercises.
- Refine gait pattern and instruct in stair climbing.
- Review home instructions/exercise program with emphasis on hip dislocation/precautions.
- Finalize discharge plans. All patients require an assistive device for
ambulation, an elevated toilet seat, and follow-up physical therapy.
Sub Acute Care
- Patients who have acutely undergone Total Hip Arthroplasty require
physical therapy services post-discharge. Based upon each individual’s
needs, the multidisciplinary team will, prior to discharge from the acute
care setting, make arrangements for the patient to receive physical therapy
services. Criteria for each setting is listed below:
1. Home Health Physical Therapy-Patients with transportation difficulties,
functional limitations restricting mobility (difficulty with transfers,
etc.).
2. Extended Care Facility Physical Therapy-Patients who live alone or
have limited support services to assist with home care activities (i.e.,
no family members or friend able to help with homemaker activities and
transportation to/from therapy) and whose overall endurance level is diminished
and would interfere with their participation in a comprehensive rehabilitation
program.
3. Inpatient Rehabilitation Center-Patients who pre-operatively lived
alone and were independently functioning in that environment and will
be returning to that living arrangement at the conclusion of their rehabilitation;
also there general medical status and cardiovascular endurance is sufficient
to participate in an intensive rehabilitation program.
4. Outpatient Physical Therapy-Patients with transportation into an outpatient
clinic; any patient having difficulty achieving hip abductor and extensor
muscle strength will be strongly be strongly encouraged to attend outpatient
physical therapy.
5. Dayani Center/Wellness Center-Younger and physically active patient
who have achieved functional range of motion and muscle strength in their
operative hip may be referred to the Dayani Center for instruction and/or
supervision in general conditioning program; this may be on one of the
later phases of rehabilitation following THA, involving a limited number
of patients.
Within each of these setting, a comprehensive treatment program should be
implemented based upon each individual patient’s needs and within established
therapy restrictions. Suggested physical therapy treatments/activities are
listed below: Modalities for Pain Control and Edema Reduction:
- Moist Heat
- Interferential
- Ice
- Tens
- FES
Therapeutic Exercise:
- Passive, Active-Assisted, and active lower extremity range of motion
- Closed Kinetic Chain Activities
- Stationary Biking-No resistance to motion
- Lower Extremtiy Strengthening Exercises using Theraband
- Nordic Track
- Stair-Step Machine
- Aquatic Therapy/Activities
- Iliotibial Band Stretches-Supine stretches may be initiated at two (2)
weeks post operatively, standing at twelve (12) weeks post-operatively
- Scar Massage/Mobility-May be instituted after suture removal when the
incision is clean and dry.
Endurance Training:
- UBE
- Upper and/or Lower Extremity Restorator
- Ambulation Activities
- One-Leg Cycling –Using non-operative leg, with resistance to motion
- Aquatic Therapy
Balance/Proprioception Training:
- Tandem Walking
- Lateral Stepping over/around objects
- Obstacle Course
- Weight-Shifting Activities
- Closed Kinetic Chain Activities
Gait Training:
- Level Surface
- Forward Walking
- Sidestepping
- Retro Walking
- Uneven Surfaces
Functional Training:
- Standing Activities
- Transfer Activities
- Lifting
- Carrying
- Pushing or Pulling
- Squatting or Crouching