The

The effects
effects of
of short-term
short-term
preoperative
preoperative physical
physical therapy
therapy and
and
education
education on
on early
early functional
functional
recovery
recovery of
of patients
patients younger
younger than
than 70
70
undergoing
undergoing total
total hip
hip arthroplasty
arthroplasty
Vukomanovic A, Popovic Z, Djurovic A, Krstic Lj
Military Medical Academy, Belgrade, Serbia
[email protected]

Vojnosanit Pregl 2008; 65(4): 291-7

 The role of physical therapy and education
after hip arthroplasty was recognized1, but
the importance of pre-operative physical
therapy and education is still to be judged2-4.
• 1. Bitar AA, Kaplan RJ, Stitik TP, Shih VC, Vo AN, Kamen BK. Rehabilitation of orthropedic and
rheumatological disorders. 3. Total hip arthroplasty rehabilitation. Arch Phys Med Rehabil 2005; 86
(suppl 1): S56 – 60.
• 2. Ackerman IN, Bennell KL. Does pre-operative physiotherapy improve outcomes from lower limb joint
replacement surgery? A systematic rewiew. Australian Journal of Physiotherapy 2004; 50: 25-30.
• 3. Mc Donald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. The Cochrane
Database of Systematic Reviews 2004 Issue 1.
• 4. Johansson K, Liisamaija N, Heli V, Jouko K, Salanterä S. Preoperative education for orthopaedic
patients: systematic review. Journal of Advanced Nursing 2005; 50 (2): 212-23.
 Pre-operative physical therapy?
• Wijgman AJ, Dekkers GH, Waltje E, Krekels T, Arsens H. No
no positive effects of preoperative exercise therapy and teaching in
patients to be subjected to hip arthroplasty. Ned Tijdschr
Geneeskd 1994; 138: 949-52. (In Dutch).
• Gilbey HJ, Ackland TR Wang AW, Morton AR, Tapper J. Exercise
yes improves early functional recovery after total hip arthroplasty.
Clin Orthop 2003; 408: 193-200.
• Gocen Z, Sen A, Unver B, Karatosun V, Gunal I. The effect of
preoperative physiotherapy and education on the outcome of total
no hip replacement: a prospective randomized controlled trial. Clin
Rehabil 2004 Jun; 18 (4): 353-8.
• Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE,
Alpert S, Iverson MD, Katz JN. Effect of preoperative exercise
yes on measures of functional status in men and women undergoing
total hip and knee arthroplasty. Arthritis Rheum 2006 Oct 15;
55(5): 700-8.

There is not strong evidence that continuous

pre-operative physical therapy alone brings
significant benefits to patients’ functional
recovery immediately after operation.
 Pre-operative education?
Pre-operative programs of education appear to have
been effective in reducing pre-operative anxiety,
pain1 and shortening the hospital stay2-6. A
considerable reduction in length of hospital stay
results in a significant cost saving1,7.
1. Giraudet – Le Quintrec JS, Coste J, Vastel L, Pacault V, Jeanne L, Lamas JP, Kerboull L, Fougeray M, Conseiller C, Kohan A,
Courpied JP. Positive effect of of patient education for hip surgery: a randomized trail. Clin Orthop 2003; 414: 112-120.
2. Mc Gregor AH, Rylands H, Owen A, Dore CJ, Hughes SPF. Does preoperative advice improve recovery and patient
satisfaction? J Arthroplasty 2004; 19: 464-8.
3. Siggeirsdottir K, Olafsson O, Jonsson H, Iwarsson S, Gudnason V, Jonsson BY. Short hospital stay augmented with education
and home-based rehabilitation improves function and quality of life after hip replacement. Acta Orthopaedica 2005; 76 (4): 555
– 62.
4. Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Can J Occup Ther 2003; 70 (2):
88 – 96.
5. Weingarten S, Riedinger MS, Sandhu M, Browers C, Elldort G, Nunn C, Hobson P, Greengold N. Can practice guidelines safely
reduce hospital stay? Results from a multicenter interventional study. Am J Med 1998; 105: 33 – 40.
6. Fisher DA, Trimble S, Clapp B, Dorsett K. Effect of a patient management system on outcomes of total hip and knee
arthroplasty. Clin Orthop 1997; 345: 155 – 60.
7. Brunenberg DE, van Steyn MJ, Sluimer JC, Bekebrede LL, Bulstra SK, Joore MA. Joint Recovery Programme versus usual care:
An economic evaluation of a clinical pathway for joint replacement surgery. Medical Care 2005; 43(10):1018 – 26.

But we still don’t know much about effects of

education pre-operative programs on patients’
ability to perform basic activities of daily
living safely and independently on the
discharge from the orthopedic unit.
In clinical practice, we observed that patients
mostly benefited from pre-operative program of
education and physical therapy immediately after
operation. But not a single study investigates the
acceleration of patients’ functional recovery in
that period.

AIM
The aim of this study was to examine
effects of short-term preoperative
program of education and physical
therapy on patients’ early functional
recovery immediately after hip
arthroplasty.
 Eligible patients were:
• (1) with primary and secondary osteoarthritis,
• (2) aged 70 and younger,
• (3) who gave informed consent to participate in investigation.
Additional eligibility criteria included:
• (4) ability to walk up and down stairs,
• (5) no need for using crutches while walking,
• (6) no experience in walking whit crutches (because of opposite hip arthroplasty or
some other reasons) and
• (7) no coexisting morbidity such as a history of severe cardiovascular, respiratory,
neuromuscular, rheumatic disease or mentally confusion.
Reasons for exclusion patients through the trail were appearance of:
• (1) intraoperative (femoral or acetabular fracture) or
• (2) postoperative complications (postoperative disorientation, anemia, circulatory
collapse, orthostatic hypotension, chest pain, sustained hypertension, deep venous
thrombosis, pulmonary embolism, hip dislocation) which compromised or delayed
beginning of physical therapy after operation.

METHODS SUBJECTS

Forty-five patients admitted to Department

of orthopedics scheduled to undergo primary
total hip replacement who satisfied our
eligibility criteria were recruited into this
study at the authors’ institution.
• The patients were randomly divided into two groups.
• Study group received short-term intensive preoperative
preparation which consisted of education and elements of
physical therapy. Patients from the study group were
informed about operation, caution measures and rehabilitation
after arthroplasty through conversation with physiatrist and
brochure. They were instructed by physiotherapist to
perform exercises and basic activities from the postoperative
rehabilitation program, such as bed mobility, getting out and
in bed, standing and walking with crutches, use of toilet,
sitting on chair, walking up and down stairs with aids. The
study group had 1 appointment with physiatrist and 2
practical classes with physiotherapist.
• Control group didn’t receive preoperative education and
physical therapy, but
• both groups had the same program of rehabilitation after
arthroplasty. Program of rehabilitation for patients of both
groups started on the first day after operation.

METHODS
INTERVENTIONS
• Visual analog scale (VAS), 0 – 100 mm, was used for the
assessment of pain while moving and in the rest.
• Range of motion (flexion of the hip with flexed knee, flexion of
the hip with extended knee, abduction) was measured with
goniometry.
• Harris hip score, hip score of the Japanese Orthopaedic
Association (JOA) and Oxford hip score were used for the
assessment of functional status.
• All patients were evaluated at admission, discharge and 15 months
after operation (Oxford hip score).

METHODS OUTCOMES MEASURES

Patient’s ability to perform nine basic

activities and endurance were evaluated at the
end of every day of rehabilitation program
during hospital stay on Department of
orthopedics.
 Marks showing ability to
perform activity were:
0• 0 – if patient didn’t perform
activity,
1• 1 – if patient was absolutely
dependent of therapist help,
2• 2 – if patient performed Marks showing endurance
activity with little therapist were:
help, 0• 0 – didn’t walk,
3• 3 – patient needed therapist’
1• 1 – walked 5 meters (in bed
verbal suggestion while room),
performing activity, 2• 2 – walked 15 meters,
4• 4 – patient performed activity 3•
independently but insecurely 3 – walked 50 meters,
(needed presence of another 4• 4 – walked 100 meters,
person, member of family for 5• 5 – walked more than 100
example), meters.
5• 5 – patient performed activity
independently and securely.

METHODS
OUTCOMES MEASURES
Protocol for assessment patient’s ability to perform basic activities
from program of rehabilitation after total hip arhroplasty

DAY OF PHYSICAL THERAPY 1st 2nd 3rd 4th 5th

1. FROM SUPINE TO SIDE LYING 4 5 5

2. FROM SUPINE TO SITTING 3 5 5
3. FROM SITTING TO STANDING 2 4 5
4. STANDING 2 4 5
5. BACK TO BED 2 4 5
6. WALKING WITH CRUCHES 2 4 5
7. USE OF TOALET 1 4 5
8. SITTING ON CHAIR 1 4 5
9. WALKING UP AND DOWN STAIRS 0 2 5
10. ENDURANCE WHILE WALKING 2 4 5
SUME
19 40 50

METHODS OUTCOMES MEASURES

All analyses were performed using SPSS
software, version 10.0.
• Fisher Exact Test,
• Pearson Chi-squared Test,
• Mann Whitney Exact Test
were used for comparison between groups.
Distribution of variables was shown as mean,
standard deviation, medians, range, p – values less
than 0.05 were accepted as significant.

METHODS
STATISTICAL ANALYSIS
 45 patients undergoing total hip arthroplasty

Study group N = 23 Control group N = 22

Assessment on the admission: pain, range Assessment on the admission: pain, range
of motion, Oxford, Harris, JOA hip score of motion, Oxford, Harris, JOA hip score
N = 23 N = 22

Exclusion because Exclusion because

of intra et postop. of intra et postop.
complications N = 3 complications N = 2

Assessment of basic activities Assessment of basic activities

1st-3rd day after operation and 1st-3rd day after operation and
on the discharge N = 20 on the discharge N = 20

Assessment on the discharge: pain, range Assessment on the discharge: pain, range
of motion, Harris, JOA hip score of motion, Harris, JOA hip score
N = 20 N = 20

Drop-out N = 2

Assessment 15 months after operation: Assessment 15 months after operation :

Oxford hip score N = 18 Oxford hip score N = 18
Preoperative characteristics of study participants
Study group Control group p – value

Age, years 60.05 ± 11.01 56.2 ± 18.45 0.77

62.5 (30 – 70) 66.5 (19 – 70)
Female, No (%) 14 (70%) 16 (80%)

Years past since first 8.05 ± 5.89 6.33 ±7.53 0.06

disorder has started 6 (1 – 25) 4 (1 – 27)
Months with intensive pain 20.1 ± 14.34 16.35 ± 14.34 0.73
12 (6 – 60) 12 (1 – 36)
Use of analgetics, No (%):
Doesn’t use 6 (30%) 4 (20%) 0.48
Occasionally
9 (45%) 7 (35%)
Permanently
5 (25%) 9 (45%)
No of other medications 2.55 ± 2.39 2.25 ± 2 0.80
2.5 (0 – 6) 2.5 (0 – 6)

Values are mean ± standard deviation,

median (range) unless otherwise indicated. RESULTS
Pain on the admission
(VAS)
p=0.70

100
mm
90
p=0.66
80 69.9 71.95
70
60
STUDY 50
37.45 33.5
40
CONTROL
30
20
10
0
in rest while move

RESULTS Mann Whitney Exact Test

Abduction and flexion of the hip
with flexed and extended knee on
the admission, degrees
p=0.37 p=0.30 P=0.19
n.s. n.s. n.s.
100
91.5
90 84.5
79
80
69
70
60
STUDY 50
CONTROL 40
28 31
30
20
degrees
10
0
abduction hip flexion fl. knee hip flexion ex. knee

RESULTS Mann Whitney Exact Test

 Haris, JOA, Oxford
RESULTS on the admission
60
54.75
50
50
44 45.75 44.75
40 38.85

30 STUDY
CONTROL
20

10

0
Harris JOA Oxford

p=0.55 p=0.17 p=0.03

n.s. n.s. p < 0.05
Participants from the study group had statistically higher Oxford hip score before
operation. That result suggested worse functional status of the study group at the
baseline. But, for the assessment of the functional status we also used Harris and
JOA hip scores and then there were no differences between groups at baseline.
 The first days of activities
Study Control p – value
group group
Walking 1.4 ± 0.5 1.75 ± 0.55 0.08
1 (1 – 2) 2 (1 – 3)
Use of toilet 2.3 ± 0.92 3.2 ± 1.24 0.02*
2 (1 – 4) 3 (1 – 6)
Use of chair 2.2 ± 1.01 3.25 ± 1.21 0.006*
2 (1 – 4) 3 (1 – 6)
Walking up and down 3.7 ± 1.66 5.37 ± 1.46 0.002*
stairs 3.5 (1 – 7) 6 (3 – 8)
Values are mean ± standard deviation,
median (range).
* Significant values The first daypatients could stand, walk, climb a stair was one of
the parameters which could be compared. Gocen et al. found that
patients in the study group performed transfer activities earlier
than the control group, but that was not case in Wijgmans study.
Results of our trail showed that both groups started walking at
the same time, but the study group used toilet and chair, walked up
and down stairs earlier than the control group.
 RESULTS
Comment
• It is important when the patient starts doing these activities, but
it is more important when that patient becomes independent and
secure in performing these activities. Those data were not
available in other studies. In our study, every day during hospital
stay, a physiotherapist assessed patients’ ability to perform some
basic activities using marks from 0 to 5. Mark 4 meaned the first
degree of independence; patient could do activity alone, without
help or verbal suggestion of physiotherapist. Already from the
third day after operation, the study group had mean mark higher
than 4 for changing position in bed, getting out and in bed,
standing and walking. They trained all basic activities until
discharge and went home absolutely independently and mostly
securely. Some patients from the control group were insecure on
the discharge, and, for some activities, they depended from the
help of physiotherapist. So, mean marks of the control group were
significantly worse at the moment of discharge.
 1. FROM SUPINE
TO SIDE LYING

mark 5 5
4.55 4.6
4 3.9
3.6
3 2.9 STUDY
2.75
2.25 CONTROL
2

1
Day of
0 physical
1st 2nd 3rd discharge therapy

p=0.08 p < 0.01 p < 0.01 p < 0.05

Mann Whitney Exact Test

 2. FROM SUPINE
TO SITTING
mark

5 5
4.45 4.55
4 3.85
3.55 p < 0.05
3 2.85 2.9 STUDY

2 p < 0.01 CONTROL

1.95

1 p < 0.05
p < 0.01
0
1st 2nd 3rd discharge

Day of physical
therapy

Mann Whitney Exact Test

5 5 p < 0.05
4.45 4.55
p < 0.01
4
3.65
3.4
3 STUDY
2.6
2.4
2 p < 0.01 CONTROL

1 p < 0.01
0.9
Mann Whitney
0
Exact Test
1st 2nd 3rd discharge

Day of
physical
therapy
mark
3.
FROM SITTING
TO STANDING
 4. STANDING

5 5
4.4 4.55
p < 0.01 p < 0.05
4
3.7
3.3
3 STUDY
2.55 p < 0.01
2.3 CONTROL
2
p < 0.01
1 0.8

0
1st 2nd 3rd discharge
Day of physical
mark therapy

Mann Whitney Exact Test

 5.
BACK TO BED FROM
THE STANDING
POSITION
5 5
4.4 4.55
4
p < 0.05 3.7
p < 0.05
3.25
3 STUDY
2.6
p < 0.01
2 1.95 CONTROL
p < 0.01
1 0.8
mark
0
1st 2nd 3rd discharge Day of physical
therapy

Mann Whitney Exact Test

 6.WALKING
WITH CRUCHES
mark

5 5 p < 0.05
4.5
4.2
4
p < 0.05
3.5
3 3.05
STUDY
2.45
2 p < 0.01 CONTROL
1.85
p < 0.01
1 0.8

0
1st 2nd 3rd discharge Day of physical
therapy

Mann Whitney Exact Test

 mark
5 5
p < 0.05
4 n.s. 4
3.7
3

7.
STUDY
n.s.
USE OF 2
2.2
1.8
CONTROL

TOALET 1 1
0.8
p < 0.01
0 0.2
1st 2nd 3rd discharge

Day of physical
therapy

Mann Whitney Exact Test

 p < 0.01 p < 0.01
5 5

4 p < 0.01
3.65 3.75
3 n.s. STUDY
2.5
2 CONTROL
1.75
1 0.9 0.95
Mann Whitney
0 0.2 Exact Test
1st 2nd 3rd discharge
Day of physical
therapy
mark

8. SITTING ON
CHAIR
 Walking up and down stairs was the heaviest activity from the
program of the physical therapy. We calculated that on the way
from hospital to patient’s home, patient had to climb up average
12 – 13 steps. So, it’s important for them to overcome stairs
during hospital stay. Patients from the study group could do it
without any problems but patients from the control group mainly
still needed help and suggestions from the physiotherapist.

5 4.85

9. WALKING
4

p < 0.05
p < 0.01 p < 0.001

UP AND DOWN 3 3 STUDY

STAIRS 2
n.s. 2.2 CONTROL
1.4
mark 1
0.25 0.4
0 0 0
Day of
1st 2nd 3rd discharge
physical
therapy
Mann Whitney Exact Test
 10. ENDURANCE WHILE
WALKING
mark

5 4.9
p < 0.01
4 3.9
3.55
p < 0.05 3.25
3 STUDY
2.55
2 1.95 CONTROL
1.55 p < 0.01
1 p < 0.01
0.6
0
1st 2nd 3rd discharge

Day of
physical
therapy
Mann Whitney Exact Test
 Haris, JOA on the discharge,
Oxford 15 months after operation
n.s.
70 n.s. 64 62.6
60
51.2550.1
50
40
n.s. STUDY
30
CONTROL
20 17 17.6
10
0
Harris JOA Oxford
Mann Whitney Exact Test

Harris and JOA hip score can successfully measure

remote effects of hip arthroplasty but maybe they are
not sensitive enough to measure effects of preoperative
physical therapy and education at the time of discharge
from the orthopedic unit. Of course, this state needs to
be investigated in another study.
 Pain on the discharge
(VAS)

mm 100
90
80
70
60 p=0.66 p=0.66
50 n.s. STUDY
40 n.s.
CONTROL
30
20 10 12
10 4 6
0
Mann Whitney
in rest while moving
Exact Test
Giraudet – Le Quintrec et al. found that patient education
decreased preoperative anxiety and pain in patients having hip
surgery. Unfortunately we can’t confirm those results. Before
the operation, participants from both groups had intensive pain
while moving which diminished in the rest but not completely.
On discharge, we can notice that mean of pain assessed by
VAS decreased in both groups. But there were no differences
between groups neither before nor after the operation.
 Length of hospital stay and physical
day therapy after operation
n.s.
11 10.2
9.8
10 p < 0.01
9
8 6.85
7
6 5.2 STUDY
5
4 CONTROL
3
2
1
0 Mann Whitney
hospital stay physical therapy
Exact Test
The study group achieved goals of early postoperative
physical therapy earlier and they needed fewer classes
with physiotherapist. Length of hospital stay didn’t differ
between the groups because the moment of discharge is
mostly planned according to wound healing (10 or 11 day
after operation) and functional recovery didn’t influence
that.
 Comment
• In view of world’s growing tendency for reducing health
care costs and unconvincing effects of continuous
preoperative physical therapy we created a short-term pre-
operative program of education with elements of physical
therapy. This preoperative program helped patient
scheduled for arthroplasty to overcome basic activities of
daily living with minimum practical classes of physical
therapy after operation.
• These results were gained from 1 appointment with
physiatrist, 2 practical classes with physiotherapist and
from reading brochure with information about arthroplasty
and recovery after operation. We practiced this
preoperative program after admission on orthopedic unit,
but it can be perform like an outpatient activity.
 CONCLUSION
• The short-term preoperative program of education with
elements of physical therapy, presented in this issue,
accelerated early functional recovery of patients (younger than
70) immediately after total hip arthroplasty. On the third day
after operation, they were able to change position in bed, get
out and in bed, stand up and walk independently. On the
discharge they could use toilet and sit on chair, walk up and
down stair without help of physiotherapist. Their endurance
while walking was significantly better than the control group.
• Patients, who were educated and instructed postoperatively,
achieved better functional outcome on discharge with
significantly less classes with therapist during hospital stay.
Their functional level on discharge didn’t require further
engagement of physiotherapist.
• The short-term preoperative program of education with
elements of physical therapy is useful for patients undergoing
total hip arthroplasty and we recommend it for routine use.