identifies the patient’s current complaint such as stiffness, weakness, pain, or an inability to walk a certain distance is an important starting place. Further history on the current complaint can be sought to gauge how long the patient had pain and/or limited motion of the hip prior to having the THA. This information can affect the prognosis on return to functional mobility, with longer durations of hip pathology often resulting in greater reductions in strength and flexibility with compensatory patterns. A full knowledge of the patient’s medical history is also important so that comorbidities such as other surgeries, cardiac limitations, or other medical conditions can be considered when designing a rehabilitation program. A patient’s current medication intake can often provide additional insights into comorbidities that the patient fails to mention. The patient’s living environment, such as the home layout and need to complete steps and stairs, should be considered in the social history, as should the patient’s intentions to return to hobbies or leisure activities. In concluding the history, this is a good time to recap with the patient the pertinent information provided and ask the patient for his or her goals from PT (Fruth, 2014). Physical examination The physical examination will be guided by the subjective history. An assessment of walking ability is often informally completed as the patient walks back from the waiting room. The patient is often unaware at this time that he or she is being observed and will walk with a gait pattern similar to his or her habitual pattern. Once back in the treatment room or gym, observation of standing posture barefoot can provide insight into the presence of a leg length difference. With a leg length difference, the patient can on the shorter limb supinate the foot and externally rotate the tibia and femur in order to compensate for the difference. A difference in the crease height in the popliteal area of the knees can also be observed. An examination of active range of motion (AROM) of the hip is frequently completed in supine where the nonsurgical limb is assessed first. When the patient presents to outpatient PT, that patient may still be bound to the hip precautions, so this should be kept in mind when assessing hip flexion and internal rotation with patients who had a posterior or posterolateral approach. If no precautions are in place the patient should demonstrate full AROM available. At this time the flexibility of the hip flexors can be assessed using the Thomas test. Care does need to be taken completing this when examining a patient who has undergone a THA using an anterior surgical approach because the hip is extended to end-range extension with this test. Communication with that patient’s surgeon should provide clarification regarding when it is appropriate to take the hip into extension. Additionally, hamstring length can be assessed again keeping in mind any hip precautions with the patient who has undergone a posterior or posterolateral surgical approach. The examination of strength can be completed with the patient supine where hip flexors and internal and external rotators are assessed. Hip abductor strength is best assessed in a side lying posture, and hip extensor strength is optimally tested in a prone position when possible. An element of the physical examination is balance. This provides information on the patient’s ability to hold a single limb posture, which is a key element of the gait cycle. Balance can be assessed as duration to hold single limb stance (while considering the gait cycle only requires a hold of less than 1 second in the single limb position before the next foot fall occurs). The evaluation of the patient stems from combining the findings of the patient history and the physical examination, and from here the prognosis for the patient will be established, along with an individualized rehabilitation plan for the patient’s care. Intervention In the outpatient clinic, the elements of the rehabilitation plan may include range of motion exercises, strength exercises, stretching, and dynamic balance activities. There is little
consensus on what exercises are most effective after THA (Artz et al., 2013; Monaco & Castiglioni, 2013; Okoro et al., 2013). A systematic review by Monaco and Castiglioni (2013) which sought answers to the following questions regarding “which type and/or timing of exercise therapy is effective following THA,” concluded that after the review of four databases and 11 qualified papers that there was insufficient evidence existing to build a detailed evidence-based exercise protocol. It has been identified in the United Kingdom that there is a paucity of guidance in the provision of post-acute PT services (Artz et al., 2013). In 2014 a Delphi study was published which outlined expert consensus in the United States and Canada on best practices for post-acute rehabilitation after total hip and total knee arthroplasty. Expert panels of clinicians, researchers, and patients participated in the Delphi study, and consensus was reached on 22 THA best-practice statements. Areas of consensus were the need for supervised rehabilitation interventions provided by trained health professionals early (within 1 week) after discharge from the acute care setting. Additionally, agreement occurred on the importance of tracking outcomes and for short-term follow up of patients up until 2 years after surgery. Consensus was not reached by the THA expert panel on the following elements: rehabilitation format of individual versus group treatment, rehabilitation setting such as outpatient or home, and rehabilitation dosage (Westby et al., 2014). In light of the lack of consensus in certain components of post-acute rehabilitation for the patient who has undergone a THA, a recent study sheds light on the impact of a physical therapist-led functional exercise program provided between 12 to 18 weeks post THA (Monaghan et al., 2016). In this study 63 subjects were randomized to either the usual care group or to the functional exercise and usual care group. Those in the usual care group received an educational booklet and an exercise regime (ankle pumps, static quadriceps, isometric contractions, static gluteal contractions, active hip flexion, and active hip abduction). These patients were encouraged to walk daily with an assistive device until seen by the orthopedic surgeon at 6 weeks following surgery. Those patients who were randomized to the functional exercise group also underwent the elements of the usual care program but in addition attended a class where they were instructed in 12 additional exercises. Those exercises were the following: sit to stand, toe raises, knee raises, side leg raises, back leg raises, single knee bends, abduction in side lying, step ups, lateral step ups, one legged balance, and pelvic raising. The primary outcome measure used in this study was the WOMAC and secondary outcomes included walking speed, hip abduction dynamometry, the Short Form 12 physical and mental health scores, and the visual analog pain scale score. At 18 weeks postsurgery, WOMAC function and walking speed improved significantly more in the functional exercise group than the control group, but there was no significant difference in the hip abductor strength. Additional studies of this nature are necessary to better understand the role of PT in the post-acute recovery phase. Another recent randomized controlled trial studied whether an early home-based progressive resistance training program (PRT) would be as beneficial in improving patients’ muscle strength and function compared to a standardized clinic-based program (Okoro et al., 2016). In this study 49 subjects participated in either home-based PRT rehabilitation or in standard outpatient rehabilitation. The participants in the home-based PRT program completed the following exercises: sit to stand, block stepping, stair climbing, walking, sitting knee extension against resistance, and lateral weight transfer exercises. Foam blocks and ankle weights were used as inexpensive and adjustable forms of equipment to increase resistance for stepping exercises and knee extension exercises, respectively. The number of repetitions prescribed per individual participant was based on the initial assessment and was tailored to that participant’s needs. The primary outcome measure was the maximum voluntary contraction of the quadriceps on the surgical limb
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Book Code: PTNY3622B
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