with secondary measures of the sit to stand score, the timed up and go test, stair climb, and the 6-minute walk test. Only 26 participants (13 from each group) completed the follow up at 1 year, but they all demonstrated marked progressive improvements from baseline indicating that the home-based exercise program was potentially as effective as the center-based program. Despite the variation in rehabilitation programs, there has been consensus on which muscles need to be strengthened. In a study by Okoro et al. (2013), focus group interviews and a survey of practicing physical therapists identified that the most important muscles to be targeted following THA were the hip abductors (62.2%), quadriceps (16.9%), and other muscles (21%). However, in this study consensus was not achieved on the exercise type prescribed, with 42% of clinicians recommending weight-bearing exercises, 45% making a recommendation for functional exercise, and 13% favoring bed-based/bridging/ postural exercise. Interestingly, of those surveyed over 83% were able to define the basis of progressive resistance training for strengthening but only 33% prescribed it. In the prescription of exercise, a clinician may decide to start with an open chain exercise for a muscle group that has been identified as being weak. The preference of an open chain over a closed chain exercise is that it allows for an isolated contraction of the target muscle. With a closed chain exercise it is harder to enforce contraction of the weaker muscle and often substitutions from alternate muscles will occur. For example when weakness of the hip abductors is identified, it may be necessary to start to strengthen these muscles in a gravity assisted position such as a supine clamshell exercise. This exercise can then be progressed to a side lying clamshell with the operative limb uppermost where the shortened lever works against gravity. A continued progression from this exercise would be to a side lying hip abduction exercise where the abductors are required to lift the entire lower limb against gravity. If the patient is still bound to posterior hip precautions, then the placement of a pillow or two between the lower limbs may be needed during the clamshell and side lying hip abduction exercise. When the patient can control without substitution the motion of the entire limb into 30º to 40º of abduction from a resting neutral position, that patient should progress to closed chain exercises. Exercises such as a single limb stance exercise with the contralateral limb against a wall in 90º of hip and knee flexion is a way to engage the hip abductors in the control of the pelvis in a weight-bearing position. A variety of resistance band exercises can be employed where the surgical limb is either the moving limb or the stationary limb with the band. Eventual progression to forward and lateral step ups allow for functional stability of the pelvis using the hip abductors. For younger, more active patients who wish to return to recreational activities, such as golf or doubles tennis, a variety of lateral motions should be employed, such as lateral walking against the resistance of the resistance band or cable column. For all the exercises overload of the muscle is required for strengthening, and therefore attention to correct form and muscle overloading are key factors that maximize the outcome of the exercises. In general, prescribing an exact number of repetitions may or may not overload the muscle and what is preferable is for the patient to learn how to gauge the strain feeling that comes from challenging the muscle. The key to progressive strengthening is to continually challenge the muscle or muscles in question. In addition to strengthening the muscles around the hip joint, it may be appropriate to address any lumbar or pelvic muscle weaknesses because of the integral nature of how multiple muscles in this region of the body work simultaneously. As a rule, regardless of whether the patient has had THA or a hip resurfacing surgery, it is important to perform only low-impact activities so as not to repeatedly load the new joint with high forces that may wear the prosthesis out faster. However, there are a variety of opinions regarding what exact level of activity is appropriate. Activities that cause high-impact stresses to the new
hip, those that have a high potential risk of contact injury, or those that may result in a fall are contraindicated. Such types of activity may lead to damage, wear and tear, dislocation, or loosening of the implant, all pathways to revision surgery. Activities that are not recommended following THA are those such as long-distance running, singles tennis, and other higher impact sports. Any form of low-impact aerobic exercise is preferable, and it is important to introduce these forms of exercise, as many patients become deconditioned due to limited mobility both prior to and following surgery. Outcomes measures In order to be able to identify changes that occur as a result of surgery or rehabilitation, a number of patient self-reported outcome measures and physical performance measures are now being used with patients who have undergone THA. Several of the measures are used more exclusively in the research setting and other measures are applicable to be used in the clinic on a The 12-Item Short Form Health Survey is an example of a general patient self-reported outcome measure that is used to assess health related quality of life domains and is frequently used in research studies to provide a global sense of a patient’s change without being specific to the hip joint (Choi, Geller, Yoon, Wang, & Macaulay, 2012). Examples of hip specific patient daily basis to identify change. Patient-reported outcomes self-reported measures are the Harris Hip Scale (HHS), the Hip Disability and Osteoarthritis Outcome Score (HOOS), the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire (WOMAC; (Berliner, Brodke, Chan, SooHoo, & Bozic, 2016; Choi et al., 2012; Heiberg, Ekeland, Bruun-Olsen, & Mengshoel, 2013; Kennedy, Stratford, Robarts, & Gollish, 2011; Slaven, 2012). The HHS covers the topics of pain, functions of daily living and gait using a rating scale of 0 (worst) to 100 points (best; (Heiberg et al., 2013). The questions on this questionnaire are straightforward for the patient to understand, and it does not take long for the patient to complete, so it can be easily used in the clinical setting. Additionally there is no cost for the use of this outcome measure. However, it does contain a question about getting on and off public transportation (the survey was developed in the 1960s in Boston) which can be difficult for patients to answer because many individuals in the United States outside of large cities do not frequently take public transportation. In addition to this there is a section in the HHS that must be completed by the medical practitioner related to joint range of motion and whether there are joint contractors of the hip. In contrast to the three subscales on the HHS, the HOOS consists of five subscales: pain, other symptoms, activities of daily living, functions of sport and recreation, and hip-related quality of life. The scores on the HOOS range from 0 (worst) to 100 points (best; (Heiberg et al., 2013). The minimum clinically important difference (MCID) for the HOOS was calculated to be 9.1. With the scales relating to physical activity, it can be more useful than the HHS or the WOMAC to capture the activities of the patient undergoing THA who is younger or more physically active. There is no cost with administering the HOOS, and it can take 10 to 15 minutes to complete compared to the HHS which can take 5 minutes (Nilsdotter & Bremander, 2011). The WOMAC is a tool specific to individuals who have undergone either a THA or TKA, and it is used frequently in the research setting. It consists of 24 items subdivided into three categories: pain, stiffness, and physical function. It does take longer to complete than the HHS but is comparable in length to the HOOS and has a cost associated with its use. An additional patient self-reported measure not specific to the hip but to lower limb function is the Lower Extremity Functional Scale (LEFS; (Kennedy et al., 2011; Slaven, 2012). The LEFS measures the perceived difficulty with a variety of activities. There are 20 items with each item score on a five-point scale (0 to 4)
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