This document provides an overview of a physical therapy course on total hip rehabilitation. The course objectives are to understand hip surgery and exercises, describe hip biomechanics, and effectively progress patients through rehabilitation. The schedule covers topics like evidence-based practice, anatomy, exercises, and outcome measures. Recent advances in hip rehabilitation include smaller incisions, reduced hospital stays, and early mobilization leading to better short-term outcomes. Assessment tools for hip function include the Lower Extremity Function Scale and Harris Hip Score.

1. Total Hip Rehabilitation:The latest advances

2. Bridgit Finley, PT, DPT, M.Ed., OCSBoard Certified in Orthopaedicsbfinley@ptcentral.orgwww.ptcentral.orgFacebook

3. Physical Therapy Central Choctaw Chickasha Newcastle Norman OKC Pauls Valley Stillwater

4. Objectives Course Objective: The course participants will be able to: Understand the surgical procedures and contraindications with specific exercises. Describe normal biomechanics for the hip joint. Implement the use of outcome measures for patient’s that have had hip surgery. Utilize the internet to access information in regards to evidence based practice. Effectively progress patients through the rehabilitation protocol.

5. Course Schedule Evidence Based Practice Anatomy Biomechanics Hip O-A & Surgery Manual Therapy Therapeutic Exercises Outcome Measures

6. Vision 2020 The first, best choice in musculoskeletal care. Resources APTA JOSPT Physiopedia Evidence in Motion AAOMPT PEDro NAIOMT Life Long Learners Patient Access Autonomous Experts Take our game to the next level Specialty Certifications Manual Therapy Certifications DPT

7. Evidence Based Practice Integration of the best research evidence with clinical expertise and patient values. Levels of Evidence Systematic Reviews Case Series Expert Opinion

8. American Physical Therapy Association Consumers Professional Development Advocacy Reimbursement Learning Center Hooked on Evidence Database current research Earn CEU’s

9. JOSPT Journal of Orthopaedic & Sports Physical Therapy Searched Hip Arthritis 20 Abstracts Full Text Articles

10. NAJSPT Sports Physical Therapy Section Hip Arthritis North American Journal of Sports Physical Therapy

11. Overview of the Hip

12. OSTEOARTHRITIS In US, 100 Billion Health Care $ by 2020 Progressive loss of articular cartilage with variable subchondral bone loss. Prevalence – 10 to 25% in adults age 55 and older. 43 Million people in US Standard of care is THA

13. Total Hip Arthroplasty The most common surgical procedure for end-stage hip osteoarthritis. Primary reason for surgery is pain which interferes with ambulation.

14. American College of Rheumatology Classification Hip OA Cluster 1 Pain in the hip < 115 hip flexion < 15 IR Cluster 2 Pain with IR < 60 minutes morning stiffness > 50 yrs. old Current guidelines focus on pharmacological and surgical management

15. X-Ray Demonstrate loss of joint space, osteophytes and sclerosis. Dysplasia tears are more common in individuals with acetabular dysplasia.

16. In US, between 1990 and 2002, THA rose from 119,000 to 193,000 annually. 62% increase 600,000 THA Procedures Performed Annually

17. Total Hip Arthroplasty The first joint replacement, a total hip arthroplasty, was performed in 1936. Most widely performed orthopedic procedure performed on adults. In 2008, the average hospital and physician charge for a THA totaled $ 45,000.

18. Prosthesis Materials Glass Pyrex Ivory Plastics Dr. Charnley in 1960 developed a low friction All new designs are adapted from his design.

19. Artificial Joint Titanium hip prosthesis Ceramic head Polyethylene acetabular cup

20. Zimmer

21. Health Care Costs Physical Therapy 12 visits Manual Therapy and exercise $1,200 THR $45,000 Surgery, hospitalization and rehabilitation

22. Risks and Complications Medical Risks Heart Attack Stroke Venous Thromboembolism 1% Pneumonia UTI Infection 0.2 – 1% Intra-operative Mal-positioning Short/Long 1% Instability Loss of ROM Fracture 2-5% Nerve Damage 1% Dislocation 4-10%

23. Long Term Risks Osteolysis Loosening of the components Cement breaks down Wear debris Inflammatory Pain Polyethylene wear rate is 0.3mm year Wear debris Body will absorb the metal

24. Osteolysis Cascade starts from particles The body creates an inflammatory response. Re-absorbs the bone. 12 months

25. A Squeaking hip ? Stryker Highly durable ceramic hips in 2003. 7% of patients from 2003-2005 developed squeaking Squeaky Walk

26. Trendelenburg (+) for weakness in Abductor muscles Tendinous avulsion Sonography used to diagnosis Test Gait

27. Glut Medius controls Adductor Moment Hip Abductor function in closed chain is to maintain a level pelvis.

28. Trendelenburg Gait Have patient stand on one leg and assess if the pelvis drops. (+) Trendelenburg Sign

29. Subjective History DJD (> 50) Usually no specific mechanism of injury Groin pain; behind greater trochanter, anterior thigh to knee Stiffness in the morning Loss of ROM (Flexion, IR) Increased pain with WB (bony)

30. Functional Limitations Walking Stair climbing Putting on shoes Shaving legs Rising from a chair

31. Causes of Hip OA Congenital Dysplasia Genetics Disease Process Trauma Compensation Leg length, lumbar pathology

32. X-Ray Gold Standard Joint Space Narrowing Osteophytes Subchondral Bony Change

33. Femoroacetabular Impingement (FAI) Contact between the femoral head-neck junction and the acetabular rim. Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.

34. Precursor to early hip O-A Acetabular labral pathology secondary to femoroacetabular impingement (FAI) Acetabular labral pathology is frequently present in highly active individuals 20-40 yo. Gradual on-set with repetitive microtrauma.

35. Diagnosis of FAI Scour Test FADIR – anterior-superior labrum EABDER – posterior-inferior labrum Log Roll Test

36. Scour Test The examiner moves the patient’s hip through a range of motion from hip flexion and adduction to hip extension and abduction, while adding a compressive force through the hip joint as well as movement into hip internal and external rotation. The test is considered positive if there is a reproduction in hip pain and/or intraarticular joint clicking.

37. Log Roll Test The examiner passively moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B). Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity

38. Impingement Test The examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation. A positive test is reflected by increased hip or groin pain.

39. FABER Test The examiner passively positions the testing limb in a position of hip flexion, abduction, and external rotation. The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table. A decrease in this distance or pain, when compared to the uninvolved side, is suggestive of intra-articular hip pathology.

40. Hip Impingement

41. Hip Special Tests Martin et al JOSPT July 2006 Intra-articular Tests FABER Test Scour Test Resisted SLR Log Roll Test Distraction FAI

42. Hip Arthroscopy

43. Recent Developments

44. Clinical Prediction RuleChilds September 2008 Loss of IR < 15 degrees Loss of Flexion < 115 degrees (+) Scour Test (+) FABER Test (+) Hip Flexion Test Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 95% confidence interval: 4.4-142.1, increasing the probability of hip OA to 91%.

45. Diagnosis Hip O-A Made with certainty on the basis of history and physical exam. X-ray is definitive CPR – Child’s et al. Hip Guidelines – Cibukla Physiopedia

46. 1975 Management THA Phase I – immobilization. If unstable will use hip spica cast x 3 weeks. (2-5 days) Phase II – mobilization. Isometric, isotonic (AAROM, AROM). Trochanter detached and transplanted distally. 2-3 week and D/C to home. Crutches x 8 weeks. Walk day 7 - WBAT ROM goals Flexion 90, ER 15, Abd 15, IR 0, Add 0

47. 2010 THA Management Hospital 1-3 days/Out-patient Ambulate day 1 – FWB AROM day 1 Isotonic week 1 C-V by day 10 ROM goals Flexion 125, Add. 30, ER 50, IR 30 by week 12

49. Muscles

50. Gluteus Medius Gluteus Medius – main hip abductor Primary stabilizer of hip and pelvis Trendelenburg sign

51. Gluteus Maximus TFL envelops the muscles of the thigh Counteracts the backward pull of the gluteus maximums of the ITB. Hip extensors are 3 times as strong as the flexors

52. Psoas Iliopsoas bursa – present in 98% of adults. Lies under the psoas tendon Overuse and impingement syndromes

53. SLR Exercises Must have excellent core strength This is a core exercise, If neutral pelvis is not maintained

54. Hip External Rotators Hip capsule is cut and the ER are retracted so that the joint can be exposed. THA – now most repair the capsule

55. Surgical Incisions

56. Journal of Orthopedic Surgery Chung, et al. Smaller incision Operating time Blood loss Narcotic use Length of Stay Assistive device Harris Hip Score 2004 9.2 20 49 55 136 200 2.2 2.64 4.4 5.4 21 25 95 93

57. Metal-on-Metal Hip Resurfacing Arthroplasty

58. Resurfacing Main advantage is bone conservation for younger patients Early resurfacing failed because of polyethylene 5 year follow-up excellent results Complication Femoral neck fracture Osteonecrosis

59. High Failure Rate 1970, materials available at the time had insufficient wear resistance Incorrect patient selection 1999, re-introduced Same revision rate as THA at 4 years Women 2 x than men 1-3%

60. Design Metal on Metal Cause release of inflammatory cytokines Metal allergy Large ball – decrease wear rate Cemented THA - Cementless acetabular fixation – bony in growth

61. Patient Selection Young and active Isolated hip disease Excellent bone quality Normal kidney function Contra-indicated Severe acetabular dysplasia Obesity

62. Surgery High learning curve Posterior approach Capsulotomy – preserve lateral muscles but sacrifice medial circumflex artery Implant positioning Limited candidates

63. Outcomes 94-99% survival rates at 5 years 446 hips, patients < 55 yrs old Primary diagnosis of OA No difference in ROM Gait analysis – no difference THA Hip impingement

64. Birmingham Hip Resurfacing

65. Traditional THA

66. Floyd Landis Won the Tour de France in 2006 Stripped of his title Road with Lance 2002-2004 Osteonecrosis – crash in 2002 Sept 2006 Surgery

67. Tour de France

68. Birmingham Hip Resurfacing Part 1 Part 2 Part 3 Part 4 Part 5

69. Rehabilitation Considerations Surgical Approach Selection of appropriate hip precautions Cemented vs. non-cemented Weight bearing precautions Early mobilization (prevent DVT) Early rehab can improve short term outcomes.

70. Bioengineering

71. Viscosupplementation Injection of artificial lubricants into the joint. Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymaltem cells.

72. Biomechanics

73. Hip Dysplasia Displacement of femoral head in acetabulum Left hip is more often involved 80 % Females Breech birth First born

74. Hip Dysplasia Less degress of femoral head coverage Decreased joint surface area Normal 30-40% Angle of inclination >125 degrees Increased femoral anterversion Acetabular retroversion McCarthy & Lee found 72% of patients with dysplasia had labral tears

75. Ball and Socket Joint Flexion to 110-120 Extension 10-15 Abduction 30-50 Adduction 25-30 ER 30-45 IR 20-35 Rolls anterior glides posterior Rolls posterior glides anterior Rolls laterally Rolls medially Spins anteriorly and laterally Spins posteriorly and medially

76. Mobilization Flexion Extension Adduction Internal Rotation Posterior / Inferior Glide Anterior Glide Lateral Glide Lateral Glide

77. Distraction General joint mobility Can be diagnostic Gentle let off Place in open packed position Don’t grab ankle

78. Posterior Gain Flexion Adduction Be careful not to create impingement

79. Exercise Posterior Mobilization Psoas & TFL Release Follow with psoas stretch

80. Psoas Stretch Avoid lumbar extension Have patient posterior pelvic tile Can flex or extend the knee

81. Lateral Mobilization Gain Adduction Internal Rotation

82. Lateral Mobilization To gain adduction Can also work on ER

83. Lateral Mobilization Patient self mob Must stretch lateral structures ITB Don’t let hip IR

84. Inferior Mobilization Excellent technique to use with hip impingement Test – re-test

85. Caudal/Inferior Mobilization Mulligan technique – mobilization with movement. Measure flexion or IR and mobilize and re-measure

86. Anterior Mobilization Assess gait Pelvic wink To gain extension and external rotation Stress the anterior labrum If had labral repair

87. Anterior Mobilization Mobilize anterior capsule Self stretch and exercises – army crawl

88. Anterior Self Stretch Kneeling Mobilization Psoas and TFL stretching

89. Cyriax Capsular pattern – specific and proportional loss of movement Most common cause of capsular pattern is arthritis

90. Capsular Pattern Cyriax IR Flexion Abduction If capsular pattern of restriction; joint is arthritic. If non capsular pattern; not joint. Cyriax listed in ascending order Loss of internal rotation More than flexion More than abduction

91. Noncapsular Restrictions Fractures Osteomiylitis Labral tears Cancer Bursitis Capsular Irritation Synovitis Impingement

92. Resting Closed Packed Flexion 30 degrees Abduction 30 degrees External Rotation 10-15 degrees Extension Adduction Internal Rotation Stable position of the joint Tighten capsule

93. Muscle Imbalances Tightness Psoas Adductors Quadratus Lumborum TFL Piriformis Weakness Glut Maximus Glut Medius Quads Hip ER Core Muslces Abs Errector spinae

94. FACILITATED MUSCLES Iliopsoas Rectus Femoris TFL QL Hip Adductors Piriformis Hamstring Lumbar Erector Spinae

95. Medial Hip Mobilization Makofsky, et al. Journal of Manual and Manipulative Therapy 2007 Increase in abductor muscle force Prior to exercise

96. Abductor Strength

97. Outcome Measures

98. Lower Extremity Function Scale Ordinal Scale 0 “extreme difficulty” to 4 “no difficulty” Patient rate ability to perform 20 different activities 0 to 80 scale, 80 no limitations. Minimum detectable change 9 scale points

99. Harris Hip Score Scores on 10 different variables Pain ROM Gait ADLs Score range from 0 “worst” to 100 “best”. Harris Hip Score

100. Hip Outcomes Measures Validity Reliability Includes Pain ROM Function Surgeon & Patient disagree on outcomes Harris Hip Score Charnley Score Oxford Hip Score The Hip Disability and Osteoarthritis Outcome Score

101. Patient Based Scales Site Specific Oxford Hip Scale Health Status Designed for RA 20 Tasks SF-12 Disease-Specific Hip & Knee OA WOMAC Oxford 12 item questionnaire THR Validated against SF-36 Short, practical and valid

102. Activity Limitation 6 Minute Walk Test How far a person can walk in 6 minutes. Can use walking aids. Treadmill is good. Stair Measure Patients are instructed to ascend and descend 9 stairs (step height 20cm) Timed measure in seconds

103. Rehabilitation Protocol Age Health Status Control pain and swelling Body Weight Body Build -

104. Week 2-3 Goals Patient Education Decrease Edema Incision Healing Independent HEP ROM: flexion 90, abduction 35, ER 35, IR 20, adduction 20

105. Treatment Modalities MFR/ Massage PROM Transfer and gait training Rhythmic Stabilization MET / Manual Stretching

106. Modalities US At incision and piriformis/ITB NMS Glut Medius with isometric ABD. IFC & CP Control swelling and pain At the end of treatment

107. Manual Therapy MFR ITB Piriformis Psoas

108. Hip PROM Watch for compensation at the pelvis. Capsular pattern? End-feel? Pain?

109. PROM

110. Hip Rotation PROM of left hip Loss of IR > loss of hip ER End-feel usually empty and painful.

111. MET – manual stretching Soft tissue and capsular tightness Have not moved hip though this motion in years

112. Gait Hip extension 15-20 degrees Pelvic Rotation Side bending Most patients will have LBP

113. Rhythmic Stabilization Neutral Position Manual resistance in ER and IR

114. Muscle Energy Technique Hamstrings Psoas Lumbar Spine

115. Hamstring Stretch Lumabr spine is protected Increase stretch with APT Contract quads will inhibit hamstrings

116. Exercises Exercise Pro Handout Week 2-3

117. Week 5-6 Hip Flexion 100-110, add. 40, ER 40, IR 30 Quad/Ham strength 70% (-) Trendelenburg Initiate Hip PRE Neutral alignment lumbar spine

118. Treatment Myofascial Release Psoas Posterior Hip Capsule PROM/Jt. Mobilization Core Stabilization

119. Thomas Test Psoas Stretch Thigh off the table Tight iliopsoas and rectus femoris muscle (knee flexion)

120. Mobilization Leg traction – inferior glide Distraction – inferior or caudal glide. Mobilization with movement Belt MET to restore IR/ER or hip flexion

121. Joint Mobilization

122. Whitman & ClelandSeptember 2007 Hip OA when treated with manual therapy (mobilization) 5 PT sessions Total PROM increases 82 degrees Harris Hip Score 25 points

123. Case Report JOSPT Dec. 2007Vol. 37, Num. 12 73 yo female with THA revision 2 yrs s/p revision admitted to hospital 10/10 hip pain after lifting her foot to put on her shoe X-ray normal d/c PT – manual therapy – 4 PT visits 4 year follow up

124. Proprioception Arthritic hips lose input secondary to loss of articular cartilage. THR – no input from the hip joint. Must retrain neuromuscular system. Balance activities.

125. Airplane Balance Hip Strength Functional

126. Therapeutic Exercise THA Protocol Exercise Pro Handout Week 5-6

127. Week 6-12 Walk 1 mile C-V Endurance 20-40 minutes Pain Free Equal strength between legs Flexion 130, ER 45, IR 35

128. S.E.R.F. Strap Pulls the hip into ER JOSPT September 2008 Vol 38, N 9 50% self report decrease pain Decreases hip impingement

129. Treatment D/C all modalities Manual techniques if necessary Exercise Pro Week 6-12

130. 10 days S/P 12 Weeks

132. SLR