Post Operative Physiotherapy for Hip Replacement



Posted: Thursday, May 28, 2009

by Jonathan Blood Smyth

Total hip replacement has matured into a routine operation for the relief of hip pain and disability due to hip arthritis, giving some of the greatest quality of life increases of all medical procedures. Typically performed in older people, many get a good result from their hip replacement surgery but many do not reach their greatest potential due to lack of follow up rehabilitation in the post-operative period.

Before a person has a total hip replacement they are likely to have had some years of hip pain and disability from the joint. This has consequences for the remainder of the tissues around the joints, which can be important post-operatively. The pain and the arthritic process in the joint can make the person limit the range of motion they put the joint through each day, a limitation which can cause a gradual loss of joint movement. Joints respond to pain and limited movement by a process of adaptive shortening as the ligaments respond to the actual joint movement which is typically performed daily.

Weakness of a muscle or muscle group is the consequence of stiffness and pain interfering with the normal function of a joint. Weight bearing while the body is in motion is the function of the hip joints and they allow us to perform functional activities such as climbing the stairs, getting up from a chair, walking and running. To do these activities against the weight of the body and the force of gravity they are provided with the largest and most powerful muscles in the body. Weakness which develops in this muscle group can be disabling and compromise independence.

Another important group of muscles are the hip abductors which control the lateral balance of the pelvis in walking and without which gait is compromised significantly. Standing on one leg during walking, the abductor muscles on the supporting side must work hard to hold the pelvis in line crosswise, with some raise of the non-supported side to allow that leg to come through for the next step. If these muscles do not work well the unsupported side of the pelvis tends to drop, throwing the weight over to that side and forcing the person to shift their trunk over to the opposite side to compensate. This is known as a Trendelenberg gait.

The hip joint is exposed to abnormal forces in the Trendelenberg gait and the spine has to make repeated sideways movements each step to prevent overbalancing. In this kind of gait there is no strengthening of the hip abductor muscles so the abnormality remains. The pain and the weakness of the hip extensor muscles means that the person does not fully extend their leg behind them in each walking step, leading to a shortened and less efficient gait. Maintaining mobility becomes more and more of a challenge and can, in the absence of physiotherapy rehabilitation, lead to their hip replacement doing less well than hoped.

Patients typically have impaired balance and coordination even before they have their joint replacement operation, with some improvement occurring as the hip's function moves more towards normal after the joint has been replaced and the mechanical function of the hip is restored towards normal. Other impairments usually include the sense of joint position sense, an important ability the lack of which compromises balance and makes falling more likely.

Physiotherapists assess a patient's hip function and ability to get through their normal daily work, looking at the deficiencies in the joint so they can plan the rehabilitation. Noting the gait of the patient will be the first thing in the assessment, moving on to checking movements of the hip, knee and spine to check for any restrictions due to joint stiffness. An abnormal gait can be habitual and the physiotherapist will analyse and correct the gait pattern towards normal.

Excessive range is not encouraged in hip replacements due to the risk of dislocation. Next the muscle power in all the surrounding muscles will be tested and then the person's balance reactions and joint position sense. Once the assessment is complete the physiotherapist will give the patient a programme including joint mobility, strengthening, and balance and gait correction. Many with hip arthroplasty do not reach their best potential due to a lack of rehabilitation care after the operation.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about  Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and  physiotherapists in Edinburgh. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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