Rehabilitation after elective total hip replacement

Abstract

Primary total hip replacement surgery was performed on over 40,000 Australians in 2013. While THR is tremendously successful in terms of pain relief for patients, outcome studies report some residual impairment and functional limitations in these patients post operatively. Despite the rising number of hip replacements performed, the optimum rehabilitation after total hip replacement lacks consensus throughout the literature and no evidence based guidelines exist worldwide on this topic. Physiotherapy exercises and protocols within rehabilitation programs are largely based on level 4 evidence. There is little evidence to support the effectiveness of physiotherapy post total hip replacement, and little to support physiotherapy supervised exercise programs in favour of home exercise programs. This thesis aimed to inform best practice in rehabilitation following hip replacement. First, by systematically reviewing the current evidence for total hip replacement rehabilitation. Secondly by a prospective study to determine the benefit of supervised and unsupervised rehabilitation interventions on patient outcomes, namely functional and quality of life measures (WOMAC and SF-36 scores); post total hip replacement surgery in the adult population. Finally, to contribute to the evidence supporting clinical decisions in Australia for total hip replacement rehabilitation. Our systematic review aimed to synthesise the current literature for rehabilitative exercise effectiveness on strength, gait, function and quality of life after a total hip replacement including comparison in a home based or supervised setting. Five randomised controlled trials were included comprising 234 participants. Meta-analysis showed that physiotherapy can improve abductor muscle strength of the operated leg, as well as gait speed and cadence. Function and quality of life measures were unable to be measured due to the broad variation in outcome measures used in the studies. There was no difference between supervised and unsupervised exercise programs. Further well designed research is needed to compare the efficacy of home based to supervised programs. A randomised controlled trial was performed to investigate the efficacy of two rehabilitation programs; a supervised (centre based) and an independent (home-based) program in the early phase of rehabilitation (<8weeks) after THR in the adult population. The SF-36 and the WOMAC questionnaires were used to measure quality of life and functional outcomes. 98 patients were followed 6 months post-surgery. The results demonstrated that outcomes in response to rehabilitation post THR in the early weeks following discharge are similar clinically and statistically whether the program was supervised or not. No differences in QOL or function were detected between groups. This result is supported by previous works on the same topic. Future research should further evaluate the relative importance of components of the home exercise program, including progressive resistance training, gait re-education and treadmill training in this patient group. Finally development of an evidence based guideline into THR rehabilitation is needed. The clinical implication of the research of this thesis would suggest that patients after THR without complications may be sent home to manage independently with a home exercise program including gait advice and ongoing physiotherapy contact initiated by the patient if required. Show more