In the early postoperative phase of rehabilitation, therapists must focus on restoring functional muscle length and strength. This might start during the immediate postoperative phase and is frequently a key component during the post-acute phase or when outpatient PT services are provided. Due to the underlying pathology that necessitated the THA, many patients were preoperatively forced to rely on compensatory gait patterns and ways of transferring due to long periods of pain with resultant muscle weakness (Bennell & Hinman, 2011; Loureiro, Mills, & Barrett, 2013). While relying on the compensatory gait pattern, their bodies adjusted accordingly by producing dysfunctional movement patterns in the effort to maintain functional mobility. Dysfunctional movement patterns include Trendelenburg gait patterns, antalgic gait patterns exhibiting decreased stance time or increased limb circumduction during the swing phase of the affected limb, or flexed postures. Therapist input is integral in helping patients undo those learned, habitual compensatory movement patterns with neuromuscular reeducation, strengthening exercises, and stretching tight muscles. During the initial days following surgery when the patient is frequently in the hospital, it is important that the physical therapist observes the patient’s motion patterns and provides verbal, and if necessary, tactile feedback in order to start to correct the learned asymmetrical gait patterns. During this time, the patient may be using an assistive device which will allow for the use of the upper extremities which can facilitate improved motion of the lower limbs where unloading can occur. One of the most important areas to stretch is the anteromedial hip structures – the hip flexors and adductors – to help normalize step length and facilitate a normal gait pattern (Lenaerts, Mulier, Spaepen, Van der Perre, & Jonkers, 2009). Stretching activities must be performed cautiously, however, especially if the patient has undergone a hip resurfacing procedure, and the surgeon should be consulted if the therapist wishes to stretch the hip flexors where an anterior approach has been used for the surgery because stretching into extension creates an anterior glide of the femoral head and can stress the surgical site. Where strength is concerned, it is well documented that patients with hip OA present with muscle weakness (Bennell & Hinman, 2011; Loureiro et al., 2013). The main findings of a systematic review on muscle weakness in hip OA which incorporated evidence from 13 cross-sectional studies found that there was strong evidence for large muscle weakness and moderate evidence for small muscle weakness of the affected limb compared to the contralateral lower limb. In addition the authors identified that the greatest reductions in strength were in the hip flexors and extensors of the affected limb relative to the contralateral limb. The reduction in muscle strength in the hip abductors and adductors was less consistent (Loureiro et al., 2013). Muscle weakness can be addressed in the acute postoperative time period with a variety of isometric and isotonic exercises. However, strengthening at this time can be limited by the patient’s recovery from surgery and adaptations to a different mobility level. The specifics of a progressive strength program will be discussed in more detail in the outpatient section later in this module. As inpatient rehabilitation proceeds, strengthening exercises and gait training activities are progressed according to the patient’s tolerance. Concurrently, occupational therapists begin instructing patients in techniques for performing activities of daily living, which include patient education in the use of adaptive equipment such as reachers, limb enablers, grab bars, dressing sticks, and sock aids. Occupational therapists also show patients strategies for independent dressing, toileting, bathing, and eating that reinforce the correct application of hip precautions, when necessary, in anticipation of going home. Whereas therapists anecdotally report that functional mobility improves and that patients are pleased with streamlining the discharge process via functional education, exercise, and gait training, more research is needed to ascertain whether such intervention speeds recovery and improves functional outcomes. Inpatient
rehabilitation protocols continue to vary according to the individual facility and the experiences of the treating therapist. During the inpatient rehabilitation stay a clear understanding of the patient’s home situation, such as the layout of the house, support available at the house, and expectations for physical activity, is determined. This allows the therapist to individualize the care given to enhance the patient’s ability to return home successfully. In a select patient population where the surgical procedure is completed as an outpatient procedure, a patient may be discharged home later in the day following surgery (Aynardi et al., 2014). This is not uncommon in particular where minimally invasive operative procedures are employed. In the case where the patient is discharged the same day of surgery the preoperative education in the postoperative exercises and use of an assistive device becomes paramount. In the hours following surgery, the patient is assessed with his or her use of assistive device, weight-bearing instructions are reviewed as are any dislocation precautions if indicated. Many patients who do undergo outpatient THA receive home health PT and/or outpatient PT. Outpatient care In general, patients who undergo THA are frequently satisfied with the decrease in pain and the immediate improvements with basic functional activities compared to pain and functional levels preoperatively, but many patients do not feel that they regain full strength and optimal function, specifically walking ability, during the postoperative time period (Judd et al., 2014). Several studies have examined walking ability – in particular, symmetry of motion – following THA and have identified that this does not automatically return even at 1 year following surgery and even when pain is no longer the issue that it was prior to surgery (Agostini et al., 2014; Foucher & Wimmer, 2012). These asymmetries can present as reduced stance time on the surgical limb or as a Trendelenburg pattern. These studies have suggested that with targeted interventions this asymmetry could be improved. It is important therefore during the postoperative outpatient rehabilitative phase that attention is paid to providing individualized care to address each patient’s unique limitations whether the limitations are with strength, flexibility or balance, which are all important factors in normal gait. With a trend toward rapid hospital discharges and an early return home after joint replacement surgeries, patients are utilizing therapy services in their own homes more, but the use of the home health (HH) physical therapist will vary considerably (Freburger et al., 2011). A study examining disparities in post- acute rehabilitation care for joint replacement found that both race and state of residence influenced the provision of HH services. In addition women, older individuals, and individuals receiving Medicaid or those without insurance were less likely to receive HH services. Finally those living in metropolitan areas were more likely to receive HH than those living in rural areas (Freburger et al., 2011). Fortunately, this trend towards shorter hospital stays does not seem to be associated with an increase in adverse events, such as higher dislocation rates or increased numbers of DVT events; instead, early home discharge actually demonstrates decreased rates of wound infection compared to patients who stay longer in the hospital (Mahomed et al., 2008). Examination The purpose of the outpatient therapy program is to restore functional range of motion, improve strength and balance, normalize ambulation, and adjust lifestyle parameters to embrace a new, lower impact, way of life. In order to identify limitations in range of motion, flexibility, strength, balance, or gait, an individualized and thorough PT examination and evaluation must be completed. Patient history The focus of the physical examination is frequently driven by the findings of the subjective history. Therefore, a history that
EliteLearning.com/Physical-Therapy
Book Code: PTNY3622B
Page 149
Powered by FlippingBook