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Rehabilitation Exercise Prescription Program

Group #1Carlos Leon-Carlyle #0317752

Loriana Costanzo #0308293Bruce Monkman #

Michael Bois #

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Henry Hiploss Henry is an ex athlete triple jumper who fractured

his left hip in an automobile accident ten years ago and has never really recovered from the accident. Although the fracture healed he developed osteoarthritis which has since caused the joint surfaces to deteriorate and the acetabulum collapsed therefore requiring a hip transplant.

The surgery was a success and he is ready to receive an exercise prescription to get his hip back to normal and correct his gait pattern. He was weight bearing using crutches within 24 hours but has little muscle tone in the hip and leg musculature

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Henry Hiploss (Con’t) Henry is 6 ft 2 inches and 190 lbs and his activity

level has dropped since his car accident so that he is sedentary and works 12 hour days while commuting in his car for 2 hours each way. He sits at a desk all day when he works as a computer statistical analyst and experiences high psychological stress to meet deadlines. Henry is separated from his wife and is currently single so he has time available when he is not with his children every second week.

After the surgery Henry has been attending rehab with a physiotherapist and is now ready to strengthen the musculature around his hip and start to fully weight bare without crutches.

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Range of Motion Measurement

The leg is capable of moving in many different planes and along many axes at the hip joint.

These motions include:FlexionExtensionAbductionAdduction Internal and External Rotation

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Active Range of Motion Patient lies supine with their legs in the

anatomical position. They then bring their heel toward the

contralateral hip. The therapist observes the AROM of hip flexion,

abduction, external rotation, and knee flexion. Next the patient extends the knee, adducts,

internally rotates, and extends the hip to move the great toe toward the corner of the table.

The therapist observes the AROM of hip extension, adduction, internal rotation, and knee extension.

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Flexion PROM Patient lies supine with the knee on the test

side in a neutral position. The therapist stabilizes the pelvis. The

trunk is stabilized through body positioning. While maintaining pelvic stabilization, the

therapist applies slight traction to move the femur anteriorly to the limit of hip flexion.

End feel should be soft. Possible tricks include posterior pelvic tilt

and flexion of the lumbar spine.

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Flexion Measurement The patient is supine, with the hip and knee on the

test table in a neutral position. The contralateral hip may be flexed or extended. The trunk is stabilized through body positioning, and the therapist stabilizes the pelvis.

The axis of rotation is the greater trochanter of the femur

The stationary arm should be parallel to the midaxillary line of the trunk.

The movable arm should be parallel to the femur, pointing toward the lateral epicondyle.

The end position should have the hip flexed to the limit of motion (120 degrees) while flexing the knee.

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Extension PROM

The patient should lie prone with both hips and knees in neutral positions. The feet should lie over the end of the table. The therapist stabilizes the pelvis.

The therapist grasps the anterior aspect of the distal femur and applies slight traction to and moves the femur posteriorly to the limit of hip extension.

There should be a firm end feel to the motion. Common tricks/substitutions include anterior

pelvic tilt and extension of the lumbar spine. Common tricks/substitutions include external

rotation and flexion of the hip.

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Extension Measurement The patient lies prone with the hips and knees in a

neutral position and the feet overhanging the edge of the table.

The pelvis is stabilized through strapping. The axis of rotation is the greater trochanter of the

femur. The stationary arm should be parallel to the midaxillary

line of the trunk. The movable arm should be parallel to the longitudinal

axis of the femur, pointing toward the lateral epicondyle.

The patient’s knee is maintained in extension. The hip is extended to the limit of motion (30 degrees).

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Abduction PROM

The patient lies supine with the pelvis level and the lower extremities in the anatomical position.

The therapist stabilizes the pelvis. If additional stabilization of the trunk and pelvis is required, the contralateral lower extremity may be positioned in hip abduction with the knee flexed over the edge of the table with the foot supported on a stool.

The therapist grasps the medial aspect of the distal femur and applies slight traction to and moves the femur to the limit of hip abduction motion.

There should be a firm end feel to the motion.

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Abduction Measurement The patient lies supine with the lower extremities in the

anatomical position with the pelvis level. The axis is placed over the ASIS on the side being

measured. The stationary arm should be placed along a line

between the two ASISs. The movable arm should be parallel to the longitudinal

axis of the femur. The goniometer should indicate 90 degrees in the start position described. The PROM should be 30 degrees with an end reading of 60 degrees on the goniometer.

The hip is abducted to the limit of the motion (45 degrees).

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Adduction PROM The patient lies supine with the pelvis level and

the lower extremity in the anatomical position. The hip on the nontest side is abducted to allow full ROM in adduction on the test side.

The therapist stabilizes the pelvis. The therapist grasps the distal femur and

applies slight traction and moves the femur to the limit of hip adduction ROM (30 degrees).

The end feel of the motion should be soft or firm.

Common tricks/substitutions include internal rotation and hiking of the contralateral pelvis.

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Adduction Measurement

The patient lies supine with the lower extremity in the anatomical position. The hip on the nontest side is abducted to allow full range of hip adduction on the test side. The pelvis should be level.

The axis is placed over the ASIS on the side being measured.

The goniometer is aligned the same as for hip abduction ROM measurement.

The hip is adducted to the limit of motion (30 degrees).

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Internal and External Rotation PROM

This test can be performed sitting or supine with the hip and knee flexed to 90 degrees.

The pelvis is stabilized through body positioning. The therapist maintains the position of the femur, without restricting movement.

The therapist grasps the distal tibia and fibula and applies slight traction to the distal femur, then moves the tibia and fibula in a lateral direction to the limit of hip internal rotation and in medial direction the limit of hip external rotation.

The end feel of internal and external rotation is firm.

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Muscle Testing

Testing for True Leg Length Discrepancy

Place the patients in a supine position with the legs in outstretched in a coomparable position. Next, measure the distance from the anterior superior iliac spines to the medial malleoli of the ankles. Unequal distances between these fixation points would verify that one lower extremity is shorter than another. Finnaly, if a leg length descrepancy is appearent, the physition needs to establish where the descrepancy lies. Ask the patient to lie in supine and knees flexed at 90 degrees. If one knee is higher than the other, then the descrepancy is asscociated with one tibia being longer than the other. If one knee projects further than the other, than the descrepancy is associated with different femur lenghts. These length descrepancy’s are often treated with orthotics and muscle thearapy.

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Appearent Leg Length Discrepancy

After establishing a negitive result for a true leg length discrepancy, it is time to determine if the appearent shortning is due to a deformity with the pelvis. Appearent shortning often results from pelvic obliquity, or from either adduction or flexion deformity of the hip joint.

Have the patient stand and palpate the patient posteriorly. Inspect for any uneven heights of either the anterior or posterior superior iliac spine. Next have the pateint lie supine and measure from the umbilicus (belly button) to the medial mallioli. Unequal distances signify an apparent leg length discrepancy.

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Ober Test for Contraction of the Iliotibial Band

Have the patient lie on their side with the involved leg uppermost. Abduct the leg as far as possible and flex the knee to 90 degrees while keeping the hip joint in a neutral position to relax the iliotibial tract. Release the the abducted leg and look for it to adduct towards the other leg. An inability to adduct results in a positive ober test. This indicates there may be a contracture of the fascia lata or iliotibial band.

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Thomas Test for Flexion Contracture

The patient lies supine with the pelvis level and square to the trunk. Stabilikze the pelvis by placing a hand under the patients lumbar spine. Flex the patients hip joint by bringing their leg towards the trunk. As you flex the hip take note of when the lumbar lordosis touches your hand. Normal flexion limits allow the anterior portion of the thigh to rest against the trunk. Make sure to repeat with the other leg. Next, have the patient raise both legs towrd the chest. Have the patient hold on leg next to the trunk and extend the other leg at the knee and hip joints. If the hip does not extend fully, then this is an indication of a fixed flexion contracture. Also look for the patient to lift thoracic spine and rock forward as it is also an indication of a fixed flexion contracture.

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Telescoping Test for Congenitally Dislocated Hip

Have the patient lie on their side with the involved leg on towards the celling. With one hand apply tration to the femur at the level of the knee. With the other hand, stabilize the pelvis and place your thumb on the greater trochanter. Feel for the greater trochanter to move distally when a force is applied to the femur. Allow for the femur to return to its original position upon the release of traction. This abnormal to and fro motion of the greater trcochanter is called telescoping.

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Ortolani Click Test for Congenital Dislocation of the

Hip Have patient flex thigh. With the thigh flexed abduct and externally rotate the thigh listen and palpate for a click or watch for the thigh to jerk as the femoral head leaves the acetabulum. Congenital dislocated hips limit abduction on the involved side.

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Exercise PrescriptionFlexibility

All of the following exercise should be done after the body is warmed up. A proper warm-up consist of any activity that elevates the heart rate. Perform the activity until a light sweat is achieved.

Each exercise should be performed at 2-4 times Each exercise should be held for 20-30 seconds It is recommended to perform the flexibility

portion of the program before performing the strengthening portion.

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Tensor Fascia Lata Stretch Can be done in a standing or sitting position In standing, the patient places the affected side closest to a wall

about an arm’s length away from the wall. The feet are crossed, with the affected extremity behind the uninvolved extremity. Placing the hand on the wall, the patient pushes the hips toward the wall, keeping both feet on the ground as the hand on the wall provides a push force. The patient should not rotate the body or bend the elbow. The stretch should be felt on the outside of the thigh.

In sitting the patient has the uninvolved extremity out straight and the involved extremity flexed at the knee and hip; the foot f the involved extremity is placed flat on the floor on the ground on the outside of the uninvolved knee. The patient uses the hands to pull the uninvolved knee across the body towards the opposite shoulder

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Hip Flexors (Iliopsoas & Rectus Femoris) stretch

Can be done standing or kneeling. In kneeling, the involved leg is the kneeling leg and the opposite

leg bears weight on the front foot. The patient transfers weight from the back knee to the front foot so the center of mass moves in front of the back knee. The back should remain erect. An additional stretch can be applied by attempting to flex the knee. A pad can be placed under the knee for comfort.

In standing, the patient grasp the ankle of the involved leg from behind to bring the heel to the buttock while keeping the knee pointing to the floor. The back must remain erect during the stretch. The patient can apply an additional stretch by pushing the hip forward.

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Adductors Stretch The adductors should be done with the knee bend and extended

since the short adductors do not cross the knee, while the long adductors cross the knee.

In a sitting position, the patient flexes and abducts the hips and knees to place the bottom of the feet together, and pulls the feet towards the buttocks. In this position the hands are placed on the feet and the forearms are placed along the inner legs.a stretch force is applied along the forearms to lower the knees. The back should remain upright.

An alternative to position is sitting with the knees extended, and the hips abducted the patient flexes at forward from the hips, keeping the back straight, and placing the hands on the floor to support the body weight in order the keep to the adductors relaxed. An additional stretch can be applied by rotating towards the affected leg, and reaching for the toes.

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Hip Extensor (Hamstrings & Gluteus Maximus) Stretch

Both stretches can be done in the supine position To stretch the hamstrings lay in the supine position with the

uninvolved leg in full hip and knees extension. With the involved knee the patient places their hands around the posterior thigh and pulls the leg towards the chest. The back should not arch and the uninvolved leg should not come off of the ground. The knee is extended until the stretch is felt.

The gluteus maximus is stretched in a position similar to the hamstring stretch, with the difference being that the involved extremity’s knee is flexed and the force pulls the knee towards the chest. The pelvis should not roll posteriorly, and the opposite thigh should not lift off of the ground

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Piriformis Stretch The piriformis can be stretched effectively in the supine

or quadruped position. In the supine position, the patient lies with the knees

crossed, the involved extremity on top of the uninvolved extremity. the knees are brought to the chest, and the patient pulls on them with the involved extremity’s knee directed towards the opposite shoulder.

In a quadruped position, the patient crosses the involved extremity under the uninvolved extremity and leans the hips backward, keeping the uninvolved extremity’s knee off of the floor, allowing it to move back. This position adducts, flexes, and medially rotates the hip.

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Strengthening Exercises

The exercises should be performed in a smooth, controlled motion of the hip through a full range of motion. Substitution of other muscles occur easily in the hip, the patient must be careful to avoid trick movements while the hip is weak. It is recommended to perform the exercises at a low intensity with a high volume of sets.

Body weight exercises will be used until the patient can complete the workout pain-free, with full range of motion. If the patient is unable to lift the extremity against gravity, flexing the knee to perform the exercise can shorten the resistance level-arm length resulting in a reduced workload.

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Hip Abduction

With the patient lying on their side of the uninvolved extremity, with the uninvolved extremity flexed at hip and the knee for stability. The patient’s involved leg will remain extended, while lifting the leg against gravity.

To insure proper form do not allow the patient to roll onto their back, and lift leg using the hip flexors. Try to prevent the patient from rotating the limb. This exercise should isolated the hip abductors

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Hip Adduction

Have the patient lay on the involved extremity with the uninvolved extremity flexed at the hip and the knee, with the foot placed in front of the bottom knee. Keeping the involved extremity’s knee and hip full extended, raise the leg against gravity.

To insure proper form do not allow the patient to roll onto their back, and lift leg using the hip flexors.

If the patient lacks the core strength to keep the body stabile during exercise, you can place the patient’s uninvolved leg on a supportive object such as a chair.

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Hip Extension The patient lies in prone with the extremity either supported

in extension or positioned in flexion. Have the patient extend the leg against gravity. Since hip hyperextension is limited to about 15o, any movements that appear to be past 15o will indicate hip and or trunk rotation.

Hip extension can also be done using a bridging exercise. The patient lies supine with the hips and knees flexed with the feet flat on the floor. The hips are raised so that the hips and trunk form a straight line. Hold this position for a several second, then return to the starting position.

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Hip Flexion

The patient lies in the supine position, with the uninvolved leg flexed at the hip and knee with the foot flat on the supporting surface. The patient tightens the abdominals to prevent the back from arching, tightens the quadriceps to maintain knee extension, and lifts the involved extremity upward toward the ceiling.

Do not allow the patient to rotate or abduct the hip during this exercise.

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Functional tests

To test Henry’s functional ability, he should perform a walking and/or running test, to make sure his gait pattern is corrected, and to watch for any irregular patterns. Since he is also a triple jumper, Henry can attempt at breaking down the skill and performing each action seperately. (run up, hop, skip, jump)

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Pool Workouts

To maintain fitness, range of motion, and aid in healing Henry’s osteoarthritis, it is useful for Henry to perform aquatic therapeutic exercises. Cardiovascular and strength exercises in the pool will increase Henry’s ability to perform exercises for longer periods of time without adding stress from weight bearing on the joints. Henry may also perform many of his stretching exercises while he is in the pool.

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Pool Exercises

Inner tube exercises: performed in the shallow end using a flotation tube, the patient maintains a vertical position in the water. The hips and knees are flexed, and the patient rotates the hips first in one direction, and then the opposite side. The exercise is more demanding if the knees are fully extended.

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Pool Exercises

Inner tube lateral flexion: performed in the shallow end, using a flotation tube, the patient flexes the hips and knees to 90 degrees. He should maintain this position while lifting both hips laterally toward the left ribs and then lifting both hips laterally toward the right ribs.

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Pool Exercises

Jumping jacks: performed in the deep end, with a flotation device around the waist, the elbows and knees are kept straight, and the spine is in neutral. The arms begin in an abducted position. As the hips are abducted, the arms are adducted and vice versa. In addition to staying afloat, the patient must also work to maintain an upright posture and stable trunk.