Exercising with a Hip Replacement
Rehabilitation after a hip replacement is usually straightforward but it is important to be aware of the priorities at each stage of the operation and recovery for the best outcome. Because an osteoarthritic hip is painful this has a series of knock-on effects. A painful joint means the musculature which controls that joint cannot work properly so tends to lose some of its strength and support for the joint. The joint may also become tight as the natural movements are not performed and the person may adopt an abnormal gait which becomes an ingrained habit.
Physiotherapists start with rehabilitation and education of patients pre-operatively so they are well prepared for the operation and understand what they need to do. Joint restriction is assessed with strengthening and mobilising exercises given for the hip and the gait checked and corrected as necessary. If the gait is poor then the physiotherapist will consider a walking aid such as a crutch or stick, in the hand opposite to the affected joint. If a good walking pattern is not established with this a second stick or crutch may be necessary to attain a suitable gait with pain relief.
After the operation patients are routinely reviewed by a physiotherapist the day following the procedure. Initial instruction will be in regular contraction of the buttock and quadriceps muscles to reactivate their use and restore some joint movement. Range of motion exercises of the hip might include gentle hip flexion, sliding the heel towards the body as the knee rises. This is a functional movement patients need to be able to perform to move themselves around the bed. Ankle movements are also encouraged to aid circulation, although this effect may be small.
The ability to move the operated leg about is produced by instruction to perform muscle contractions and joint range of movements hourly in the bed. The physiotherapist and an assistant will get the patient out of bed and walking with a frame or crutches. Early sitting in a moderately high seat for the patient is routine, to prevent hip flexion attaining too great a level. The lateral incision up the side of thigh can inhibit patients from stretching that area when they bend their knees in sitting so they need to be encouraged to slide their feet towards themselves regularly while they are sitting.
Initially mobilisation should produce a safe and acceptable walking pattern and after the initial period the physiotherapist will progress to teaching as close to a normal gait as possible. Once the patient has achieved a step-through gait and are walking well their gait pattern should be very close to normal with the addition of a pair of crutches the only clue they have had an operation. Muscle activation is normalised by the natural rhythm of an automatic activity such as walking and a correct sequence of muscle activity lowers the energy requirements for walking and increases muscle strength.
Specific exercises can be added to the patient’s regime if a significant weakness in one or more muscles is identified. Standing and holding on to a firm object in front is the best position to start with from a balance and safety point of view. The exercises consists of three movements: raising the knee up in front so the thigh eventually is close to horizontal; abducting the leg to the side whilst kept straight; maintaining an upright posture whilst moving the straight leg behind the body. These exercises strengthen the major moving and stabilising muscles around the hip and pelvis and can easily be performed even by elderly and less strong patients.
In some cases these exercises will need to be supplemented by harder ones or by prescribing hydrotherapy. Pool therapy is very useful for patients after their joint replacement as they feel supported and in control of the leg but the water gives significant resistance to muscular activity. Resistance can be increased by using floats attached to the foot and the water resists the practice of the gait pattern, resisting the whole process. Care must be taken not to exercise hip replacements unduly or this can loosen the cement-bone interface and reduce the life expectancy of the replacement.
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