Journey to Wellness Series: Real Patient Journey #1

Total Hip Replacement Rehabilitation – Part 1

My name is Daniel Snider, I am a Certified Athletic Therapist, Registered Kinesiologist, and in the final stages of my Osteopathic Manual Therapist designation. My focus in on rehabilitation after injury and/or surgery.

I am currently doing in-home rehabilitation with a 54-year-old patient who had a posterior total hip replacement (THR) surgery in August of 2020. Ari, a very active, healthy male was diagnosed with bilateral hip osteoarthritis requiring total replacements. He chose to do his right side first. After many preparatory appointments it was decided that he would proceed as an out-patient THR surgery at St. Michael’s hospital. Some patients may need to spend 1-3 nights in the hospital to monitor for post-op swelling, blot clots, etc. - always at the discretion of the surgeon. Ari, evaluated by his surgeon Dr. Atrey, met the criteria for same-day surgery.

Post-op - it will take patients, in general, a few weeks to get into the rehab mindset and starting initiating therapy to rehabilitate their body. Apart from the initial swelling and stiffness, the discomfort is typically minimal. Pain is controlled with medication and weaned off very quickly. Ari used a GameReady device for 2 weeks to help manage post-op swelling. Weight bearing can be tough at the start. Walking and navigating stairs starts on day 1 while using a walking aid. Ari is using his cane around the house and taking daily walks (20-30minutes) outside using walking sticks. The initial exercises were provided by his surgeon’s office, to be self-directed at home - under his own volition and capability.

I met Ari towards the end of his second week post-op. I assessed his progress to date, his strength, stamina, and of course reviewed what exercises he was doing and how well he was executing them. It is always much more difficult to execute an exercise with no-one guiding you, iterating with you, giving you feedback, and adapting them to your specific needs. Some patients who have had THR try in the beginning but burnout without outside supports - leaving their recovery less than ideal. It is quite common to see patients relax an exercise into a pattern that feels comfortable for them, rather than continue to push their upper limits.

After an initial evaluation it was clear that Ari would benefit from a continuous engagement model, meaning therapeutic and manual therapy sessions on a regular basis - to continually evaluate his progress, execution quality, as well as customize and elevate the exercises to ensure continuous improvement, as well as release tight muscles. The exercises we focused on are;

1. Standing Supported Hip ROM – flexion, extension, abduction

2. Standing Supported Hamstring curls

3. Quads activation

4. Mini-squats

5. Sideways stepping

6. Calf raises

7. Gait training – fine tuning his process daily

8. Stair climbing – he’s a champ

In the initial appointment, I evaluated Ari’s self-progress in executing some of the surgeon prescribed exercise. As an expert in rehabilitation and manual therapy, part of my job is to make sure Ari moves through the expected ROM, and he is not cheating or contorting to something comfortable. I watched Ari execute his understanding of the movements, while evaluating quality of the movement. Focusing on a few key exercises, I have Ari demonstrate them for quality and technique. I measured his hip ROM, both statically and dynamically. I also check his muscle activation to ensure he is recruiting his muscles properly and not cheating by engaging other areas of the body for help.

My clinical observations and measurements were key inputs in effectively setting a progressive therapeutic approach for Ari. Starting with his Set of 8 exercises the following summarizes some of the challenges and progress we made in the first few weeks;

1. Standing Hip Range of Motion (ROM) - Flexion, Abduction, Extension. At times, Ari would move his leg too quickly. Establishing a proper tempo with each repetition helps improve the benefit of the exercise. Abduction and extension can be difficult in the beginning. Support in the proper execution has resulted in both flexion and abduction being full - with a continued need to progress extension.

2. Standing Hamstring Curls – At first, Ari required feedback to ensure knee flexion to 90 degrees and greater as well as preventing excessive pelvic tilt and lumbar extension. Following these interventions, Ari progressed significantly to full range and can curl with proper posture.

3. Quads Activation - Ari started with short arc, and has quickly progressed to long arc quickly. This is typical with someone who had strong quads pre-op.

4. Mini-squats - The challenge here initially was to maintain level pelvis, and avoid weight shift to left hip when bending the knees. Over the course of our sessions, he has progressed to execute ½ depth with ease.

5. Calf-Raises – Ari had great strength from the beginning. Progression will occur in the next phase to single leg.

6. Gait Training - I assess that a focus on hip flexion, heel-to-toe walking, prevent circumlocution would be needed. Ari has progressed, using ambulatory aid at all times, which we will be weening off as per protocol

7. Stair Climbing - Ari was preforming as expected, leading with left leg and using rails to help. Currently, Ari is able to traverse one stair at a time, has improved strength, and does not get tired as initially.

8. Sideways Stepping - This requires a dynamic use of hip abduction. I have monitored Ari for proper weight transfer onto the affected hip. In this 5th week, Ari is able to transfer weight better with each step and less reliance on the wall for support.

Over the last three weeks, Ari has progressed significantly, has more energy, and more confidence. As he requires less feedback for his current exercises, we have been able to focus more on gait, including establishing a solid heel strike and weight transfer to the toe-off phase. It is very common for patients in post-op to want to walk with the leg turned out due to the tightness in the glute muscles. Active attention has to be given to Ari prevent this, and to focus on weighted steps

After 4 weeks of working with Ari, he is walking more comfortably and with more confidence every day. He is managing stairs well and he continues to make gains and progress with his exercises. Ari still gets tired and needs rest (he knows never to sit in low chairs that cause his hip to exceed 90 degrees of flexion).

In addition to exercise, guidance, assessment, I am using manual therapy techniques to reduce the tightness in his glutes, upper and lower leg. I am continuously monitoring his exercises to ensure execution quality and proper technique (It’s easy to cheat some times).

As a therapist it is also key that I continuously reinforce and remind Ari, the importance of these exercises, including maintaining a level pelvis when standing - to avoid developing a problematic gait.

The combination of hands-on exercise guidance, execution assessment, coaching, feedback, elevating exercises as strength returns, and manual therapy - Ari is progressing strongly. Our next stage of rehabilitation will include resistance bands, balance training, cardio, and more core. Eventually, exercises will become more global and more sport-specific. Ari’s goals are to return to his previous active lifestyle - which includes waterskiing and jujitsu. We are well on our way to achieving his goals.

Total Hip Replacement (THR) surgery is a very common procedure in Canada and is in high demand. In 2018-19, 62,016 hip replacement surgeries were preformed. This number represents a 20% increase from 5 years earlier (1). Anyone that is living with hip osteoarthritis, knows the discomfort that comes with it. If you are thinking of THR surgery, you may want to do a pre-op rehab routine to help build strength, which can make the post-op routine easier. Post-op rehab can be done in clinic and at home with a home exercise program. To learn more about how Athletic Therapy can help you, connect with Daniel Snider through the LiveWell website or send him an email on the ContactUs – Email a Therapist sub-page.  References:

1. Canadian Institute for Health Information. Hip and Knee Replacements in Canada: CJRR Annual Statistics Summary, 2018–2019. Ottawa, ON: CIHI; 2020.