© Polish Orthopedics and Traumatology, 2013; 78: 33-39 www. POLORTHOPTRAUMATOL.

com
Review Article

Received: 2012.08.23
Accepted: 2012.11.28 Algorithm of physical therapy exercises following total
Published: 2013.01.09
hip arthroplasty
Wanda Stryła1, Adam M. Pogorzała1, Piotr Rogala2, Andrzej Nowakowski2
1
Chair and Department of Rehabilitation of the Poznań University of Medical Sciences, Poznań, Poland
2
Department of Spinal Surgery, Oncological Orthopedics and Traumatology of the Poznań University of Medical
Sciences, Poznań, Poland

Summary
Authors present a set of exercises for patients after total hip replacement (THR) treated due to id-
iopathic hip joint osteoarthritis. Outcome of surgical treatment depends largely on physical thera-
py conducted after the procedure. Physical therapy following total hip arthroplasty involves restora-
tion of proper physical function. Exercises increase the strength of hip girdle muscles and stabilize
the involved hip joint. Total postoperative rehabilitation improves the gait esthetics. Restoring pa-
tient’s full independence in everyday and professional life after total hip arthroplasty is the best
test for properly conducted rehabilitation.
A rehabilitation algorithm following hip arthroplasty was established based on the data acquired
from literature and authors’ own studies. Methods of rehabilitation following total arthroplasty was
unified with regard to the type of endoprosthesis (cemented and non-cemented). Rehabilitation
after revision and cancer arthroplasties were not taken into consideration.
Exercises were divided into those performed in supine and standing positions as well as resistance
training (using an elastic TheraBand® tape). At a later stage of rehabilitation, marching and walk-
ing as well as cycloergometer training were included. Patient’s position during the day and in the
sleep for two months following THR was taken into account, including some types of exercises that
are contraindicated and pose a threat of endoprosthesis luxation.

key words: total hip replacement • algorithm of physical therapy after total hip replacement • sets of
exercises for patients after total hip replacement • quality of life after total hip replacement

Full-text PDF: http://www.polorthoptraumatol.com/fulltxt.php?ICID=883729

Word count: 2885
Tables: —
Figures: 3
References: 39

Author’s address: Wanda Stryła, Katedra i Klinika Rehabilitacji Uniwersytetu Medycznego w Poznaniu,
28 czerwca 1956 r. 135/147 St., 61-545 Poznań, Poland, e-mail: [email protected]

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Polish Orthopedics and Traumatology, 2013; 78: 33-39

Background On the third day after THR surgery patient begins to walk
around the hospital room and the corridor. During walk-
Postoperative exercises in patients after total hip replace- ing, we assess the length of lower limbs and weightbearing
ment (THR) are the basis of physical therapy. The present- symmetry. Patient begins to walk with pelvis in a proper po-
ed sets of exercises should be individually matched to each sition regardless of shortening or relative lengthening of
patient. Type of procedure, postoperative management and the operated leg [19,20]. Degree of independence increas-
possible complications should be taken into account when es and patient life activity gradually return.
determining the optimal training solutions [1]. Medical
history and co-morbidities as well as severity of pain deter- Learning to walk and early return of movement and life
mine the level of activity and frequency of performed ex- activity as an another goal of physical therapy
ercises [2–5].
Full or partial weightbearing?
Exercises included in the established physical therapy algo-
rithm following THR may be divided into those performed Walking should be a smooth motion. Patient should comfort-
in a supine and erect position [6], as well as resistance train- ably stand up straight, with a uniform transfer of body weight
ing using the TheraBand® tape [7]. onto the walker or both crutches. In the supporting stage,
the foot of the operated limb is the first to touch the floor,
The goal of this work is to present the algorithm of reha- beginning with the heel. Knee and ankle joints of both limbs
bilitation of patients following THR on the basis of our participate in subsequent phases of walking. Subsequently,
own clinical experience and current literature data [8–15]. patient should move elbow crutches or a walker and prepare
for the next stride. As joint function and lower limb mus-
In the program of rehabilitation of patients after total cle strength return, patient is able to walk longer distances.
hip arthroplasty, regular exercises lead to restoring prop-
er range of movement and muscle strength of lower limb According to previous reports on learning to walk after THR,
joints. Every physical activity exerts positive influence on no weight should be put on the operated limb for a period
human organism. Gradual return to everyday activity up to of 2–3 months [21] due to the necessity of bone remode-
complete healing is attained on average 4–5 months after ling between an implant and the bone. Adhesion between
the surgery. Physical activity reflects susceptibility or capa- the prosthesis and the bone behaves differently in the so-
bility to take on various initiatives and participate in vari- called non-cemented prostheses than in the cement pros-
ous enterprises. According to clinical observations, patient theses, where bone cement (bone glue) is the adhesive. The
after THR attains activity after 3–4 months, although ac- concept of inserting a cemented hip prosthesis in the old-
cording to the literature, it takes about 5–6 months [14,16]. er age ensued from osteoporotic disorders and bone loss
as well as decreased bone-remodeling capability (reduced
Set of exercises recommended after hip arthroplasty number of stem cells) [22,23].

Orthopedic surgeon and a physiotherapist recommend re- The most recent studies indicate that weight bearing imme-
habilitation exercises according to patient’s general state diately after THR depends more on the porosity of implant-
and degree of fitness after THR. Exercises taking up 20–30 bone adhesion. Due to the significance of weight bearing
minutes, performed 2 or 3 times a day ensure early recov- as an impulse for faster bone remodeling around the im-
ery. Below, we present a physical therapy algorithm in pa- plant, load should be put on the lower limb, gradually in-
tients after THR. creasing load percentage. These observations are corrobo-
rated by literature data [24–26].
Exercises in the early postoperative period
When should we use walkers?
On the first day after the surgery, one should pay particu-
lar attention to breathing exercises and postural lower limb A walker is often used for the first few days as an aid in main-
exercises. They are performed on the operated side. They taining balance and preventing falls. Depending on patient’s
include isometric exercises of gluteal muscles, quadriceps general condition and co-morbidities (e.g. rheumatoid ar-
femoris and triceps surae. The exercises maintain optimal thritis, neurological disorders) the walker may have to be
circulation in the lower limbs and play a role in restoration used for a longer period. The disabled, elderly people of-
of muscle strength. Exercises also play an important function ten require a walker because of psychological or function-
for anti-thrombotic prophylaxis. Patient performs exercises al maladaptation to elbow crutches [21,27].
immediately after the surgery in the post-op room (Intensive
Care Unit) despite some kind of discomfort following wak- Learning to walk with a walker is analogous to learning to
ing up or dwindling extradural anesthesia [17]. On the first walk using elbow crutches. It ensures greater sense of secu-
day following THR, exercises are performed in a supine po- rity, with weight distributed onto a greater surface. Patient’s
sition, with lower limbs in a horizontal position [18]. When state determines the time of putting away the walker and re-
patient’s state is good, he can be placed in an erect position. placing it with elbow crutches [10,18,25,28].

On the second day patient is put in an upright position fol- On the fourth day following THR patient begins to learn
lowing a control x-ray picture and consultation with the sur- how to climb stairs.
geon. Patient is still performing respiratory exercises and
isometric lower limb training together with functional an- Climbing stairs is an excellent exercise increasing muscle
ti-thrombotic prophylaxis [17,18]. strength and endurance.

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 Stryła W. et al. – Algorithm of physical therapy exercises following total hip…

Learning how to climb up and down the stairs is improve, it is indicated to walk for 20–30-minutes two or
important for the process of physical therapy after total three times a day. Regaining full fitness allows for making
hip replacement longer, over 30-minute walks every day.

Climbing up and down the stairs following THR requires Proposed rehabilitation techniques for a patient after
both agility and strength. At the beginning, one should walk THR with respect to home and work environment
with the help of handrails.
When patient is ready to be discharged from the ward, it
Climbing up and down is limited to walking step by step is important to deliver several basic rules he should abide
(split step). One should not try to step onto the steps of by. Independent of regular exercises, one should pay atten-
above-standard height (about 15 cm) and should always tion to activities, which are forbidden. Firstly, they involve
use a handrail for balance. adduction in the involved hip joint as well as external rota-
tion. Forbidden motions in the hip joint can lead to luxa-
Patient begins the climbing movement with the non-oper- tion of hip joint endoprosthesis. Crossing lower extremities
ated limb and the elbow crutch is subsequently advanced. (a “cabinet position”) is also contraindicated. One should
The operated lower limb is then placed next to the non-op- not flex hip joints more than 90 degrees or kneel down for
erated one located on the upper step. 4 months following THR. It is also not allowed to bend over
or perform forward body drops. Patient must not lift items
Patient begins walking down the stairs by moving the crutch located below his waistline. When traveling by car, it is rec-
onto the lower step. He transfers the operated lower extrem- ommended to stop every two hours in order to prevent the
ity to the step below. In the last phase, the non-operated leg adverse influence of staying in a forced position, i.e. local
joins the operated one. tissue ischemia, venous and lymphatic stasis in the lower
limbs. A break, which should last for 20 minutes, involves
Remember: “The healthy leg goes up” and “the sick leg changing position and should be connected with exercis-
goes down” es improving overall condition in order to prevent possible
thrombotic complications. When entering a car, one should
On average, patient stays at an orthopedic ward up to 14 make sure that the vehicle is not placed too low (getting
days. The length of hospitalization on the ward depends into a car from a sidewalk or an elevation should be avoid-
on his general state. ed). Patient is positioned perpendicular to the car, he steps
forward with the operated limb, grasps the seatback with
Walking with a single cane or elbow crutch. Patient is ready one hand and the seat with the other. He sits and, with the
for a single cane or single elbow crutch when he is able to help of another person, moves his limbs into the car cab-
stand and balance the body without a walker, weightbears in. It is important to place the operated extremity forward
uniformly on both feet and does not support himself with and avoid making the forbidden movements (i.e. adduction
his hands while using a walker. It should be held on the side and external rotation) while transferring it. When leaving
contralateral to the operated lower extremity. A cane or el- the car, one should proceed in the reverse order – the op-
bow crutch is useful for the following weeks until full mus- erated limb should be extended forward, making sure not
cle strength and balance is regained. to perform the forbidden motions.

Riding a cycloergometer or/and a bicycle – Riding a bicycle Height of steps should be also considered (about 15 cm).
is an excellent physical activity. It aids muscles regain their Ergonomic conditions and adjustment of home applianc-
strength and increases the range of movement in the hip es to patient’s condition are very important. All low arm-
joints. Introducing cyclic motions, i.e. riding a bike, to the chairs and chairs should be replaced with higher seats and
rehabilitation process depends on surgeon’s decision fol- headrests. Adjusting the bathroom to meet patient’s needs
lowing a control x-ray of the operated joint. Riding a bike requires placing anti-slip mats, raised toilet seat overlays,
is usually allowed 6–8 weeks after THR. The seat of the er- stand-up showers, bath adapters and handles. It is recom-
gometer should be set on a level allowing the soles of the mended to use a shower for a period of 4 months. However,
feet to touch the pedals when knee joint is extended. if the shower is not available, patient may use a bath pro-
vided that it is equipped with a board that enables climb-
Physical activity influencing the entire musculoskeletal ing into it and a stool at the bottom of it. While climbing
system is crucial for the physical therapy process into the bath, patient should first transfer the non-operat-
ed lower extremity, followed by the operated one (the op-
In the first phase, patient performs backward cycling mo- erated limb should be extended).
tions. Cycling forward may begin only when cycling back-
wards poses no difficulties. After 4–6 weeks, with improved Patient should be made aware of body position during sleep.
muscle strength, one may slowly increase the training load. For the first two months patient should lie in a supine posi-
Cycling should be performed twice daily for 10–15 min- tion during sleep with extremities abducted (a pillow or a
utes, increasing the time to 20–30 minutes three or four triangular sponge should be placed between lower limbs).
times a week. Such body position during sleep prevents possible luxation
of endoprosthesis when a secondary fibrous joint capsule
Walking – walking is an important element of returning to forms around the THR and prevents contracture of lower
normal everyday life. Patient’s ability to maintain balance limb muscles. Before leaving the orthopedic ward, each pa-
and begin to walk with a cane opens the possibility of in- tient should receive a detailed list of indications and con-
creasingly longer walks. As patient’s strength and endurance traindications concerning late rehabilitation following THR.

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Polish Orthopedics and Traumatology, 2013; 78: 33-39

One should follow these recommendations in order to en-

sure proper function of hip endoprosthesis.

Proper lifting of the involved limb after THR is particular-

ly important from a physiotherapist’s point of view, partic-
ularly in the first postoperative phase when muscles are not
strong enough to properly protect the operated joint. Every
improper move of the operated extremity may evoke pain
or even contribute to endoprosthesis luxation. When stand-
ing the patient up, he should be instructed how to behave
to safely leave the bed and not expose him to unnecessary
complications. Initially, supporting the operated leg is indi-
cated in every case of transferring it beyond the bed, which
subsequently should be gently placed on the ground. Lower
extremity is held up at the level of ankle joint with one hand
and above the knee joint with the other. As muscle strength Figure 1A. Dorsal and plantar flexion of the foot – patient slowly
and joint mobility improves, patient alone begins to transfer flexes the foot dorsally and in the plantar direction.
the lower limb outside the bed. Particular attention should He performs these exercises several times every 5–10
be paid to the forbidden rotation and adduction motions. minutes. Exercises are commenced following THR. Patient
Adduction of the operated limb is contraindicated regard- is taught to perform these exercises several times a day:
less of the type of surgical access. External rotation move- e.g. 5 minutes of exercise every hour.
ments are not recommended in postoperative rehabilitation
of patients treated with THR from lateral access according
to Bauer-Hardinge method [29–31]. The situation is oppo-
site in case of posterior access [32,33] – in such cases pa-
tient is not allowed to perform internal rotation.

A leveling pad eliminating possible differences in relative

length of both extremities is also an important factor, which
should be taken into consideration. Restoration of proper
gait is not possible when iliac spines are not appropriately
positioned at the same level.

A set of exercises for a patient after total hip

replacement surgery

The first group of presented exercise set includes exercis-

es performed in supine position (Figure 1A,B) Figure 1B. Circular foot movements – patient performs pronation
and supination motions. He repeats this exercises 5 times
Subsequent exercises performed in a supine position. a day, as early following THR surgery as possible. Exercises
Exercises are performed in 10 cycles and repeated three or strengthen lower limb stability in the calcaneotibial joint.
four times a day. They are introduced on the second day fol- They prepare for proper weightbearing.
lowing THR as preparation for maintaining erect posture
and learning to walk (Figure 1C–G).

Another group of exercises includes exercises performed

in an erect position – On the second or third day following
THR patient stands up from bed. It may be associated with
dizziness due to orthostatic disturbances. Therefore, dur-
ing first attempts at standing the patient up he should be
fully secured by the assistant personnel and medical pro-
tection equipment in case of fainting. Gradually assuming
erect position and regaining muscle strength enables pa-
tient’s independent mobilization. Additional items (walk-
er, elbow crutches, bed frame, wall) are initially used in or-
der to maintain balance disrupted after THR.

Exercises performed in a standing position. Patient performs

it in 10 cycles, 3–4 times a day (Figure 2A–C). Figure 1C. Knee flexion without lifting the foot – patient moves the
foot toward the buttocks, flexes the knee, while moving
Resistance exercises using TheraBand® elastic tape the foot along the surface of the bed. There is no inward
knee motion.
Full recovery following THR requires several months of exer-
cise. During postoperative management of THR we consider

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 Stryła W. et al. – Algorithm of physical therapy exercises following total hip…

Figure 1D. Tightening of the buttocks – patient presses the buttocks Figure 1F. Pressing the knees against the ground – patient tightens
against the bed and maintains gluteal muscle tension for the quadriceps femoris muscles. Knee joints are extended.
5 seconds. Patient maintains muscle tension while staying still
(isometric exercises) for 5–10 seconds. Exercise is
performed 10 times with 10-minute breaks.

Figure 1E. Lower limb abduction – patient abducts the lower limb
until meeting the first resistance and returns to the
intermediate position. Figure 1G. Lifting extended lower limbs – patient tightens the lower
extremity, extended in the knee joint, on the bed. He
changes in the locomotor system acquired before the sur- lifts it few centimeters above the bed, maintaining this
gery. Pain in the sick joints could cause lower limb weakness position for 5–10 seconds. He slowly puts it down.
and fixed muscle contractures may lead to muscle wasting.
Multi-joint degenerative changes other than those treated [16,36,37]. Each motion learned before THR is easier to
with THR additionally increased muscle weakness in adja- perform after the procedure, as proper motion pattern is
cent joint. Resistance exercises with an elastic tape restore encoded by the patient [12,36,38]. Overcoming psycholog-
lower limb muscle strength. They are performed in cycles of ical barriers in a patient following THR also determines pa-
10, four times a day. One end of the tape is attached to the tient’s return to full activity [6,15]. Both before and after
ankle of the operated lower limb and the other to station- THR exercises exert a great influence on faster return of
ary objects such as doorframe or heavy furniture. Patient mobility and muscle strength [37,39].
supports himself on a chair or a handrail in order to main-
tain balance (Figure 3A–C). Presented model of exercises and rehabilitation scheme for
people before and after THR is similar to the one cited in
Discussion the literature [8,9,11–15,28]. Rehabilitation model is only
to indicate the direction and aid in the choice of exercises.
When educating a patient after total hip replacement (THR) The types of exercises and their duration depend on individ-
it is important to encourage active lifestyle in the early post- ual patient capabilities. The moment of introducing train-
operative phase. Optimal range of movement in the low- ing modification depends on patient’s general condition. It
er limb joints and general physical fitness should be taken is important that all processes accompanying patient reha-
care of [14–16]. It was proven that people in good physical bilitation in the pre- and postoperative period constitute a
condition better tolerate THR surgeries [13,16]. Literature series of logically considered decisions. Improperly select-
data shows that postoperative complications more often con- ed exercises and/or training introduced too early may im-
cern people who do not exercise [34,35]. pede the process of improvement. Physical activity together
with prophylactic rehabilitation reduces the risk of post-
Appropriate preparation is indicated in patients before THR operative THR complications. Postoperative pain subsides
surgery in order to improve general and functional fitness earlier and the risk of lower limb thrombotic complications

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Polish Orthopedics and Traumatology, 2013; 78: 33-39

Figure 2A. Hip abduction in a standing position – patient extends Figure 3A. Hip flexion against resistance – patient stands with his
the lower limb at the hip, knee and calcaneotibial joint. legs spread hips width apart. He performs a forward
In a fully extended position, he abducts the operated movement with his operated leg (knee joint is extended)
extremity and slowly lowers it to central position. and slowly returns to central position.

Figure 3B. Hip abduction against resistance – patient stands

sideways to the direction of the exercise. He moves the
Figure 2B. Lifting the knee in a standing position – patient lifts the extended lower limb to the side and slowly returns to
operated lower extremity forward and upward, while central position.
flexing it simultaneously in the knee joint. Knee does not
rise above the waist. Limb is held in this position for 3
seconds and slowly lowered down.

Figure 3C. Extending the operated hip joint against resistance – patient
stands facing the end of the tape. He overextends the hip
joint to stretch the tape and slowly returns to the center.

decreases [17]. Regular exercises indirectly influences a

Figure 2C. Extending the hip in a standing position – patient slowly reduction in the risk of inflammation (early and late), im-
transfers the operated extremity backward. He tries to proving patient’s general immunity. They ensure favorable
maintain erect body posture. He holds this position for 3 course of postoperative management of THR and reduce
seconds and brings the limb to central position. the risk of complications.

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 Stryła W. et al. – Algorithm of physical therapy exercises following total hip…

Conclusions 2. General condition, age, comorbidities and patient’s in-

dividual predispositions determine individual choice of
1. Based on the literature and authors’ own observations, exercise sets in the postoperative period.
the presented algorithm of patient management follow- 3. The course of postoperative rehabilitation and meth-
ing total hip arthroplasty may initiate unification of post- od of weightbearing on the involved lower limb may be
operative rehabilitation process. similar in both non-cement as well as cement total hip
arthroplasty.

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