hip resurfacing and arthroscopy rehabilitation. role of the physiotherapist pre-operative guidance...

Hip Resurfacing and Arthroscopy Rehabilitation

Role of the Physiotherapist

Pre-operative guidance and information Guide rehabilitation Motivation Support Facilitate Discharge

Stages of Rehabilitation

Stage 1

Day 1 – Day 5/7 Post op Initial contact and explanation of rehabilitation Safe transfers from bed-chair-walking Increasing mobility and exercise tolerance Stairs Gait re-education (walking aids) Teaching of home exercise programme

Home Exercises

Circulation exercises Range of motion exercises in supine and

standing Extension – Gluteus Maximus Flexion – Iliopsoas Hip Abduction – Gluteus Medius Teach basic core stability HEP – TA and

Psoas

Stages of Rehabilitation

Stage 2

2 weeks– 4 weeks Re-evaluation of ROM exercises Improve ROM Muscle strength testing Improve muscle strength and control and

personalise the exercise programme to the patient Gait Education/Walking Aids Exercise tolerance

Stages of Rehabilitation

Stage 3

4 weeks – 6 weeks Fine tune dynamic

stability – specific muscle improvement.

Proprioception Core Stability Exercise Tolerance

Aims of the Rehabilitation Programme

1. Restore normal range of active and passive movement

2. Restore dynamic stability of the muscles in the lumbar/pelvic/hip region

3. Restore balance and proprioception

4. To regain normal functional ability for the individual patient

1. Restore Normal ROM

Mobilising exercises Manual Mobilisations Muscle lengthening techniques (sustained

stretch) Muscle energy techniques

2. Restore Dynamic Stability

Facilitate muscles that act as local stabilisers and those that act as global stabilisers of the pelvis on the weight bearing leg

Failure causes gait abnormalities-Antalgic-Trendellenburg (glut medius)-Glut maximus gait

3. Balance and Proprioception

Impulses originating from joints, muscles, tendons and deep tissue

Processed by the CNS to provide information about joint position, motion, vibration and pressure

This is the process by which the body can vary muscle contraction in immediate response to incoming information regarding external forces.

3.Balance and Proprioception

Wobble-boards

PNF stretches and exercises

Swiss Balls – Core stability

Strength and ROM Exercises

Hip Abduction

Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius.

Proximal stability and control

Pelvis control

Strength and ROM Exercises

Hip Abduction

Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius.

Proximal stability and control

Pelvis control

Strength and ROM Exercises

Hip Abduction

Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius.

Proximal stability and control

Pelvis control

Strength and ROM Exercises

Hip Flexion

Improve functional range of motion and strengthen Ilio Psoas

Control of Trunk on Pelvis movement

Strength and ROM Exercises

Hip Flexion

Improve functional range of motion and strengthen Ilio Psoas

Control of Trunk on Pelvis movement

Strength and ROM Exercises

Hip Extension

Strengthen the gluteus maximus muscles and improve gait

Dynamic stability

Strength and ROM Exercises

Hip Extension

Strengthen the gluteus maximus muscles and improve gait

Dynamic stability

Strength and ROM Exercises

Hip Extension

Strengthen the gluteus maximus muscles and improve gait

Dynamic stability

Strength and ROM Exercises

Hip Extension

Strengthen the gluteus maximus muscles and improve gait

Dynamic stability

Discharge Criteria

Full weight-bearing gait without walking aids Good hip stability/control – absence of Gait

disturbances. Good proximal stability and muscle strength Full/Functional Pain free ROM Advise patient to continue with exercise programme

for up to 6 months. 6 weeks of physiotherapy prior to discharge,

may require more if returning to a specific sport

Resurfacing vs THR

Ease of movement - ROM Confidence in the prosthesis Less pain Mobility progress No precautions Dynamic Stability Return to activity quicker

Limited ROM – slower progress

Initially apprehensive More painful Mobility takes longer Combined movement

limitations Less Stability Slow return

Hip Arthroscopy Rehabilitation

Aims of Physiotherapy

Address pattern of recruitment of muscles involved in hip movement

Restore normal range of movement and gait pattern

Increase core stability and proprioception (balance reactions)

Return patient to previous lifestyle/sport

Stage 1 (immediate Rehabilitation)

This should be followed whilst the patient is using walking aids, and may last 2 days -> 6 weeks dependent on the level of surgical intervention.

Exercises during Stage 1 aim to:

Restore range of movement Maintain muscle function Allow tissue healing and pain to settle

Exercises (Stage 1)

Range of movement (flex, ext abd) Begin core stability HEP:

1. TA setting

2. Pelvis tilting with TA control Gentle stretches ( quads, hams, piriformis) Bent knee fallout with theraband Static Quads, Hams, Gluts etc.

Precautions

Do not push through hip flexor pain May need to keep to specific range of

movement restrictions May need to keep to specific weight bearing

restrictions

Criteria for progression to stage 2

Minimal pain with stage 1 exercises ROM (85% of uninvolved side) Correct muscle recruitment patterns for initial

exercises Do not progress until patient is fully weight

bearing

Stage 2 (Intermediate Rehabilitation)

Exercises taught at this stage are aimed at:

restoring and maintaining movement promoting normal walking patterns strengthening muscles improving balance reactions There is a strong focus on core stability work at this

stage.

Exercises (stage 2)

Cycling (stationary bike) low resistance Swimming (no breast stroke)

-front crawl

-kicking with float Progression of core stability HEP

-Bridging

-Heel slides Proprioception Work

Exercises (Stage 2)

Strengthening with theraband

-Flex, ext, abd, add, int/ext rot, PNF patterns Side stepping Stretches (Piriformis, ITB, Quads, Hams etc) Passive Stretches/ Joint mobilisations Gait Reeducation

Precautions

No forced stretching No treadmill use Avoid inflammation of anterior structures of

hip

Criteria for progression to stage 3

Full ROM Pain free / normal gait pattern Hip strength 70% of uninvolved side

Stage 3 (Advanced Exercises)

The goals at this stage are the restoration of muscular and cardiovascular endurance, and the improvement of balance reactions.

Return to social sport should be possible at

this stage.

Exercises (stage 3)

Gradually build up gym routine to pre-injury level

-Cross trainer-Stepper-Cycling

Introduce gentle jog and gradually build up time and intensity

Exercises (Stage 3)

Introduce Ball work, Starting with a light ball and gradually introduce full size ball with drills

Lunges

Criteria for progression to stage 4

Cardiovascular fitness equal to pre-injury level

Demonstrates no faulty muscle recruitment patterns during stage 3 exercises

Hip strength 80% of uninvolved side

Stage 4 (sport specific training)

Not all patients require rehabilitation to this level. Those who take part in competetive sport will

certainly benefit from further strengthening and more sport specific exercises.

Training regimens should be developed in conjunction with sports club physio /personal trainer.

Stage 4 (Sports specific Training)

Speed Endurance Plyometrics Advanced proprioception exercises Multidirectional Full sport specific training can begin

Criteria for return to full competition

Full, painfree range of movement Hip strength >90% of the uninvolved side Ability to perform sport specific drills at full

speed without pain

Conclusion

Physiotherapy is an integral part of the process of recovery for patients undergoing any hip surgery in order to restore:-Movement-Strength-Core stability -Proprioception-Function