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Total Hip Replacement (THR) Post-operative Physiotherapy/Hydrotherapy Pre-operative guidelines Restore Hip range of movement as follows: Flexion 90°, abduction 40°, extension 10-15° Strengthen the Quads, hamstrings and glutes to promote recovery. Gait re-education Educate Patient on post-op compliance to ensure the best functional outcome Home advice: avoid bending your hip more than 90° (a right angle) during any activity avoid twisting your hip do not swivel on the ball of your foot when you turn around, take small steps do not apply pressure to the wound in the early stages (so try to avoid lying on your side) do not cross your legs over each other do not force the hip or do anything that makes your hip feel uncomfortable avoid low chairs and toilet seats (raised toilet seats are available) Precautions/Contraindications: Will depend upon type of surgical approach: If anterior approach, contraindicated motions are simultaneous hip extension and external rotation. For lateral approach, motions to be avoided are simultaneous hip flexion/adduction and internal rotation. For posterolateral approach, contraindicated motions are simultaneous hip flexion/adduction and internal rotation. Phase 1: (Post Op Days 1-7) Frequency: 1-2 times per week Duration: 6-12 weeks depending on physiotherapy findings Goals: To complete a full assessment in clinic including goals i.e.: returning to work and hobbies to promote specificity of rehab. To ensure sufficient pain management. To ensure that patient is free from DVT or infection. Demonstrate safe and independent transfers from the bed to chair. Demonstrate safe and independent ambulation with assistive devise. To demonstrate safe use of stairs to mimic their home environment. To attain the following ranges of movement by day 7: Flexion 90°, Abduction 25° and Extension 5° To demonstrate a safe home exercise program. To orientate to pool and treadmill program and given information pack. To address secondary problems at the knee, lumbar spine and ankle to promote realignment of the musculoskeletal system. * All Post Op programmes have been carefully formulated to facilitate and promote the normality of tissue to repair throughout the stages of healing: Inflammatory phase – Essential component of healing. Starts in first few hours post injury and peaks at 1-3 days, gradually resolving after 2 weeks. Proliferation phase – Production of scar (collagen) material. Rapid onset of 24-48 hours and peaks at around 2-3 weeks post injury. (The more vascular the tissue the shorter the time it takes to reach its peak). This phase continues for several months post trauma. Remodelling Phase- Results in an organised quality and functional scar which will behave in a similar way. Starts around 1-2 weeks and continues for several months. Water component (1-2 weeks) Underwater Treadmill Water level at 1000- 1200m to reduce weight bearing by 50%-75% Walking slowly encouraging a normal gait. Re-education phase, i.e. heel to toe To increase speed of belt to encourage larger stride lengths and full knee extension/ VMO activation. Walking slowly with knees to 90° to encourage mobility in hips and knees. Hydrotherapy Pool (Limit ROM dependent upon surgical approach) Walking forward and backwards Marching/clap unders Walking heel to buttocks Walking lunges in comfortable range Kickboard hip flexion/extension (not exceeding 90°) Step lunges Step ups Semi squats in pain-free range Knee flexion/extension with buoyancy aid to promote further range Cycling legs under water Hip abduction exercises (straight plane) Single leg balance with eyes open/closed Core stability exercises Hamstring/hip flexor/ gastrocnemius stretches in open area/bench/steps Cryotherapy 15 mins cryotherapy to be done at the end of each session. Land component Strengthening exercises for Quads/Hamstrings/Glutes/Core Stretching exercises for Quads/Hamstrings/Glutes/Core Scar massage Ice for reducing swelling Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation. Post-operative 2-4 weeks GOALS Reduce pain and swelling Restore mobility to Flexion 90°, Abduction 20°-30° and Extension 5° Independent with transfers Weight bearing as tolerated with appropriate assistive devices (weight bearing status determined by physician) Demonstrates good understanding of Total Hip Arthroplasty Precautions Fair/good recruitment of gluteus medius Water component (2-4 weeks) Underwater Treadmill Reduce water level at 900-1000m to increase weight bearing To increase speed of belt to encourage increase stride length. Hydrotherapy Pool REPEAT OTHER EXERCISES FROM WEEK 1-2 Sit to stand with weight (don’t exceed 90° hip flexion) Lunge with weight Single leg squat Step ups with weight Cryotherapy 15 mins cryotherapy to be done at the end of each session. Land Based Continue with mobilisations techniques Stationary bike Manual stretching Balance and Proprioception exercises. Encourage home exercises – Add stair Quad stretch and Partial squats Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation. Post-Op Weeks 5-6 Goals Minimal effusion Hip active range of movement as follows: Flexion 90°, abduction 40°, extension 10-15° No incisional adherence/hypersensitivity Normal reciprocal stair negotiation with/without rail Meet Self- management criteria at the end of this phase Water Component Underwater Treadmill Reduce water level at 600-900 to increase weight bearing depending on progress To increase speed of belt to encourage increase stride length To start jogging and incorporating interval training for CV fitness and plyometrics Hydrotherapy Pool REPEAT OTHER EXERCISES FROM WEEK 2-4 Walking Lunges with weight or medicine ball with rotations Kickboarding exercises with hip flexion/extension (don’t exceed 90° hip flexion) Lateral Lunges with weight (be guided by surgeons protocol, surgical approach dependent) Heel to butt Increase height of step ups Increase depth of step downs Single leg squats Challenge balance Land Based Continue strengthening program: Leg Press, Leg extensions, Leg Curls, Shoulder Bridge, Lateral step ups, Step Downs, Continue Balance/Proprioception exercises: Rocker board, Walking Lunges Cardiovascular exercises: Treadmill walking with an incline and increasing resistance on stationary bike. Hands on Physio including SSTM’s, PNF, Joint mobilisations, Taping, Acupuncture, Electrotherapy and Muscle Stimulation. Post op weeks 7-8 Goals Meet self-management criteria Precautions/contraindications: Dependent upon surgical approach and/or physician Land/Water Components: Continue with treatment as indicated in post-operative weeks 5-6 Begin sports specific exercises if appropriate with consideration of precautions set by surgeon. Continue with home exercise program progression Continue with swim/swim program dependent upon physician recommendations and physiotherapy re-evaluation Orient patient to program and equipment selection at a local health club Discharge Criteria Symmetrical knee/ankle active range of movement Hip active range of movement as follows: Flexion 90°, abduction 40°, extension 10-15° No scar sensitivity Normal gait pattern 4/5 to 5/5 glute and quad strength A good understanding and performance of their home exercise program Failure to Progress Failure to Comply See attachment for illustrations of exercises