Total Hip Replacement – Exercising
Posted on June 4, 2009
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Total hip replacement rehabilitation is not a complex process but it is useful for a skilled eye to be kept on the progress of the patient if the outcome is going to be optimal. The muscles around a painful joint weaken due to lack of use and this reduces the support of the joint given by them. Tightness may develop in the joints due to the restrictions in the movements which are limited by the pain and so the patient may develop an abnormality of gait to cope with the pain and tightness.
Physiotherapists start with rehabilitation and education of patients pre-operatively so they are well prepared for the operation and understand what they need to do. Joint restriction is assessed with strengthening and mobilising exercises given for the hip and the gait checked and corrected as necessary. If the gait is poor then the physiotherapist will consider a walking aid such as a crutch or stick, in the hand opposite to the affected joint. If a good walking pattern is not established with this a second stick or crutch may be necessary to attain a suitable gait with pain relief.
Physiotherapy assessment and treatment of the patient begins on the first day after the operation with encouragement to perform hourly contractions of the major quadriceps and buttock muscles. This aids restoration of the patient’s leg control and enables joint movement to be performed. Sliding the knee and heel up and down the bed allows practice of repeated hip flexion and joint control which improves the ability to mobilise both around the bed for self care and in and out of bed. Routine ankle pumping exercises are traditionally taught for the same reason and to improve circulation but the effect of this may be small.
As the operated leg often feels very heavy and difficult to control, the repeated movements and contractions improve the patient’s ability and confidence in moving their leg with good control. Mobilisation of the patient into standing will be performed by the physiotherapist and an assistant, with walking a short or longer distance achieved depending on the patient’s ability. A relatively high sitting position is advised to limit extremes of hip flexion. The operative site on the outside of the upper thigh can limit the bend of the knee due to pain. Routine practice knee flexion is important to restore movement, by sliding the foot back towards and under the chair as able in sitting.
Initially mobilisation should produce a safe and acceptable walking pattern and after the initial period the physiotherapist will progress to teaching as close to a normal gait as possible. Once the patient has achieved a step-through gait and are walking well their gait pattern should be very close to normal with the addition of a pair of crutches the only clue they have had an operation. Muscle activation is normalised by the natural rhythm of an automatic activity such as walking and a correct sequence of muscle activity lowers the energy requirements for walking and increases muscle strength.
Specific exercises can be added to the patient’s regime if a significant weakness in one or more muscles is identified. Standing and holding on to a firm object in front is the best position to start with from a balance and safety point of view. The exercises consists of three movements: raising the knee up in front so the thigh eventually is close to horizontal; abducting the leg to the side whilst kept straight; maintaining an upright posture whilst moving the straight leg behind the body. These exercises strengthen the major moving and stabilising muscles around the hip and pelvis and can easily be performed even by elderly and less strong patients.
In some cases these exercises will need to be supplemented by harder ones or by prescribing hydrotherapy. Pool therapy is very useful for patients after their joint replacement as they feel supported and in control of the leg but the water gives significant resistance to muscular activity. Resistance can be increased by using floats attached to the foot and the water resists the practice of the gait pattern, resisting the whole process. Care must be taken not to exercise hip replacements unduly or this can loosen the cement-bone interface and reduce the life expectancy of the replacement.
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