weight bearing), and the strengthening - as tolerated - of both the affected and non-affected sides. These patients may be on bed rest; PT management will then focus on the prevention of issues associated with bed rest, such as blood clots, weakness, and ulcers.
educating caregivers about turning, positioning and transferring the patient with the least amount of pain, as well as for positioning the patient to reduce the risk of pressure ulcers. A surgeon will rarely decide that surgery is not indicated when a hip fracture is nondisplaced. In these cases, PT will focus on mobility, following weight bearing precautions (most likely non- PT after surgery The physical therapy type and treatment will vary somewhat, de - pending on the type of surgery (or lack of surgery) that was per- formed to correct the hip fracture. A variation of an ORIF (open reduction internal fixation) surgery is most common; however, as discussed in an earlier section, a total hip replacement may be completed to prevent arthritis due to avascular necrosis. Total hip replacements may be completed with cement, without cement, and also from an anterior approach or from a posterior approach. While each of these variations presents different precautions and challenges for the treating therapist, the goal of each is to re- turn every patient to his/her prior level of function. This has been found to be most successful by incorporating early ambulation into treatment plans. Patients who ambulate within the first 48 hours after surgery (postoperative day one or two ) are statistically more likely to discharge directly to home from acute care, as well as not require a higher level of care than patients whose ambula- tion is delayed to postoperative days three or four (Oldmeadow et al., 2006) . The challenge for the treating therapist is how to consistently incorporate ambulation into an acute care program with each individual patient’s weight bearing precautions, move- ment precautions, and comorbidities. One study found that using neurostimulation of the quadriceps beginning one week after surgery drastically improved the ability of patients to return to their prior level of function. Although no statistical difference was detected within the first seven weeks, notable gains were made in the test group between weeks seven and thirteen. Nine out of the twelve patients in the test group re- ported to be at their indoor prior level of functioning, compared to only three of the 12 in the control group (Lamb, Oldham, Morse & Evans, 2002). Another study compared hip fracture patients in an inpatient rehab facility. One group received 60 minutes of higher intensity exercise every day with a focus on weight bearing activities - the other group Open Reduction and Internal Fixation (ORIF) A large number of patients sustaining a hip fracture will have some form of an Open Reduction and Internal Fixation (ORIF) to stabilize and promote healing of the fracture. Typically, a patient will be “weight-bearing as tolerated” (WBAT) after surgery with no hip precautions. This will make returning to the prior level of function easier for the patient than when hip precautions are in place. There are still challenges to the physical therapist, how- ever, as many patients may have had poor balance prior to the hip fracture, may be obese, may be dealing with depression and be poorly motivated, or may have high pain levels after surgery. It becomes the job of the treating therapist to overcome these challenges and enable the patient to obtain the best result from surgery. Consider the following example: An 82 year old woman has been admitted to the hospital after fall- ing at home while trying to reach into her lower kitchen cabinets. An X-ray showed a subtrochanteric fracture on the left femur. The doctor performed an ORIF yesterday, and has sent orders down to the physical therapy department to evaluate and treat s/p ORIF to the left hip with WBAT. The chart review reveals that the patient has osteoporosis, a-fib, and a history of frequent falls. During the subjective portion of the exam, the patient reveals that she lives alone in a senior apartment. The patient reports that she was able to ambulate with a straight cane by herself and completed all her self-care independently. The patient is anxious about returning home, but is adamant about not going to a nurs- ing home. She reports pain being 7/10 after pain medication has
received only 30 minutes a day of lower intensity exercises with the focus on non-weight bearing (or sitting) activities. No statisti- cal difference was found between the two groups regarding knee extensor muscle strength in the affected leg or in walking speed, the exceptions being patients that also had cognitive impairments (Mosely et al., 2009). This would suggest that for patients with cog- nitive impairments, physical therapy should put an increased em - phasis on weight bearing activities. Therapists should also attempt to increase the time spent with these patients for the best results. An additional study on this subject found that weight bearing exer- cises in PT contributed to statistical improvements in both balance and functional activities (but not in strength) four months after a hip fracture (Sherrington, Lord & Herbert, 2004). A fascinating study compared an extended 60 minutes of daily supervised PT in the acute hospital, compared with 30 minutes of daily supervised therapy , in addition to vitamin D supplements given at 2000 - versus 800 - units a day. The study found that the extended therapy reduced falls risk by 25 percent, but had no effect on readmission rates; the vitamin D supplements given at 2000 units decreased readmission rates by 39 percent, with no effect on falls risk. This study concluded that a two pronged ap- proach that included increasing PT to 60 minutes a day and also supplementing patients with 2000 units of vitamin D would be an effective way to reduce both fall risks and readmission rates of patients with hip fractures (Bischoff-Ferrari et al., 2010). With these studies in mind, a comprehensive physical therapy program should include: Ambulation within the first 48 hours after surgery, 60 minutes of supervised therapy a day (espe- cially when working with patients who are cognitively impaired), strength training (with an emphasis on quadriceps strength and hip strength), weight bearing activities to improve balance and functional activities, and neurostimulation to the quadriceps start- ing one week after surgery. been administered. Objectively, she has ROM in the right LE that is within functional limits, and 4+/5 strength in the right LE. On the left side, ROM is within functional limits in the knee and ankle, but there are moderate limitations in ROM at the hip - primarily secondary to pain and inflammation. Strength testing on the left LE shows 5/5 strength at the ankle, 3/5 strength at the knee, and 2/5 strength at the hip. The patient requires moderate assist to transfer supine to sit, maximum assist of one to stand, and was unable to ambulate secondary to pain. Sitting balance was good, but standing balance was not assessed. With this information, what should the treating therapist focus treatment on? Knowing how important ambulation is within the first 48 hours, ambulation would be of the highest priority; however, ambulation is limited by pain. Therefore, adequate pain control should be the first issue addressed by the therapist. Because the patient reports pain that is 7/10 - even after pain medication - the therapist may need to first speak with the doctor about pain control: A differ- ent medication or administering a stronger dose. If those are not options, or if the doctor does not want to change the medica- tions for other reasons, the therapist can coordinate treatment times with the nurse, so that the patient receives the most pain relief possible from the medications during therapy. Ice is often effective in the management of pain. It can be helpful to ensure that the patient has an ice pack in place 15 minutes prior to treat- ment. There is also evidence to support instructing patients about relaxation techniques to relax painful muscles to decrease pain
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Book Code: PTCA2624
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