A multidisciplinary program is normally initiated in the hospital on the first postoperative day, and in some hospitals this program is actually initiated later in the day on the day of surgery (Pelt et al., 2016). The movement to starting earlier therapy has been highlighted in many hospitals that have streamlined the postoperative inpatient process using programs often referred to as “fast-track hip arthroplasty,” “enhanced recovery program,” or “rapid recovery protocols” (Jorgensen et al., 2013; Man Sun, Bailey, & Pearce, 2014; Stambough et al., 2015). The multidisciplinary program requires the combined efforts of physical therapists, occupational therapists, and nurses to begin the task of restoring patient mobility. Nursing staff provide skilled services to ensure that the wound is well cared for, that the amount of surgical drainage is within normal parameters, that the patient is well oxygenated, and that pain levels are adequately controlled. All team members also monitor for signs of infection, DVT, and pressure sores that could delay participation in therapy and slow down the recovery process. Pain management is of special importance to successful rehabilitation because patients who do not have adequate pain control may not be willing or able to fully participate in therapy. Therapists should expect that patients who have undergone THA may experience moderate levels of pain, and therapists need to coordinate the timing of PT sessions with nursing to maximize patient comfort and participation. An element of the streamlined inpatient care programs that appear to be gathering momentum is the element of pain control. There has been a movement away from general anesthesia and patient controlled analgesic (PCA) delivery to spinal anesthesia and multimodal pain management protocols (Jorgensen et al., 2013; Stambough et al., 2015). Regardless of the method of pain control, therapists must stay alert to patient pain levels and their ability to tolerate therapeutic intervention on an ongoing basis. Hip precautions Traditionally, because the posterior or posterolateral surgical approaches were the mainstay of THAs performed, hip precautions for the majority of patients included no hip flexion beyond 90°, no internal hip rotation beyond neutral (0°), and no hip adduction beyond the midline. These positions can place the posterior hip joint capsule and the reattached deep hip rotators in a position for disruption of the surgical repair. These precautions were adopted to limit the stress on the reattached capsular and muscular structures. However, now with more patients having THA through an anterior approach, fewer patients are bound to these well-known precautions because the frequency of dislocations is much lower where a larger femoral head component is used which reduces the risk of dislocation (Chen et al., 2013). Being aware of the surgical approach used and the preferences of the individual surgeon should be the first information that the therapist should identify when working with a patient who has undergone a THA. Developing open channels of communication where additional information such as bone health and soft-tissue attachment concerns are clearly communicated is another crucial element in the team approach to caring for the patient who has undergone THA. There can be substantial variation between individual surgeons even in the same hospital on whether precautions are given and how long those precautions are in place. Inpatient care The goal of physical and occupational therapy in the hospital is to get patients back on their feet as quickly and safely as possible. As indicated in the previous paragraph, it is essential for therapists to check the physician orders for any postsurgical precautions and weight-bearing recommendations and to know what type of hip implant and which method of fixation was used, as these factors may affect weight-bearing status. Usually, patients with cemented THA are allowed to be weight bearing as tolerated, and traditionally those with uncemented THA were either toe touch weight bearing or partial weight bearing for approximately 4 to 12 weeks according to the surgeon’s discretion (Markmiller et al., 2011). The rationale behind this
weight-bearing restriction is to ensure that the implants do not subside into the surrounding bone, potentially causing stress fractures and impaired bony integration. There has been a movement toward immediate postoperative weight bearing as tolerated for those with uncemented THAs where the findings of research have shown no adverse issues being noted from this change (Markmiller et al., 2011; Wolf, Mattsson, Milbrink, Larsson, & Mallmin, 2012). In addition to no evidence of a negative effect of early weight bearing as tolerated, researchers in a recent study found that compliance with limits on weight bearing were poor (Schaefer, Hotfiel, Pauser, Swoboda, & Carl, 2015). In this study, peak pressures in foot loading were assessed using sensor-loaded insoles with 14 patients who had undergone an uncemented THA. Each of these patients had been taught by an experienced physical therapist to bear 10% body weight using a bathroom scale to indicate what 10% felt underfoot. The results of the study found that patients were placing up to 88% of full weight on the surgical limb. The authors of the study concluded that patients do not comply with the limited weight- bearing instructions at least when trained using the biofeedback of a bathroom scale. Where instructions do remain for any level of reduced weight bearing in the first few weeks after THA, the physical therapist needs to initially assess the patient’s balance and, prior to discharge from hospital, assess what is the optimal assistive device for that patient to use either at home or in a rehabilitative setting. Comprehensive inpatient rehabilitation programs are designed to address multiple elements that influence both immediate postoperative mobility and long-term discharge planning. Key elements of this program are patient education on limb positioning in the bed, safety during transfers in and out of bed, gait and assistive device training including education on weight- bearing status, and range of motion and functional strength training (K Enseki & Berliner, 2013). Examination The first contact that a physical therapist has with a patient is normally preceded by the review of the patient’s medical chart, which is now more frequently in electronic form. The medical chart can be a good source of information about pertinent medical comorbidities, details of the surgical procedure, including any additional information about precautions, and then the social care team’s assessment of the patient’s long-term needs as they relate to the patient’s home environment and available support system. Having the chance to interview the patient, the therapist can clarify any details from the review of the medical chart and, with the patient in the bed, can assess the patient’s willingness for limb motion and strength levels along with bed mobility such as scooting in bed and repositioning. Intervention The initial priority with patients either in postoperative day zero or postoperative day one will be in education in bed mobility and transfers in and out of bed and on and off the toilet. It is not uncommon for a patient’s family to be involved in these educational sessions because frequently the family members will be overseeing the patient’s mobility when the patient has been discharged home. At this early stage postoperatively, it is appropriate to review the precautions when applicable. Following the functional mobility training, it is common to start with simple bed exercises immediately after surgery. These exercises may consist of ankle pumps (ankle dorsi and plantarflexion), isometric exercises for the quadriceps and gluteal muscles, heel slide exercises for hip and knee flexion, and abduction slides (K Enseki & Berliner, 2013). The role of the ankle pumps in particular is to increase lower leg circulation and reduce the risk of a DVT occurring. Frequently the actual order of exercises, number of repetitions, and frequency during the day is protocol driven by the surgeon or that hospital’s group of surgeons. Bed exercises are valuable as a means to establishing a relationship and trust between therapist and patient during the early hours of rehabilitation
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Book Code: PTNY3622B
EliteLearning.com/Physical-Therapy
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