ORIGINAL ARTICLES
EUR J PHYS REHABIL MED 2009;45:303-17
Rehabilitation after total hip arthroplasty: a systematic
review of controlled trials on physical exercise programs
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M. DI MONACO 1, F. VALLERO 1, R. TAPPERO 2, A. CAVANNA 1
Total hip arthroplasty (THA) has revolutionized the care
of patients with end-stage joint disease, leading to pain
relief, functional recovery, and substantial improvement in quality of life. However, long-term studies indicate persistence of impairment and functional limitation after THA, and the optimal rehabilitation protocols
are largely unknown. The aim of this paper was to systematically review the controlled trials published on
the effectiveness of physical exercise programs after
THA. Nine studies were retrieved from MEDLINE and
reviewed. Results show that the physical exercise protocols most frequently used after THA in the early postoperative phase are neither supported nor denied by
clinical controlled trials. Convincing evidence for the
effectiveness of single interventions in addition to usual exercise programs exists for each of the three following options: treadmill training with partial bodyweight support, unilateral resistance training of the
quadriceps muscle (operated side), and arm-interval
exercises with an arm ergometer. In the late postoperative phase (operation interval > 8 weeks) exercise programs consistently improve both impairment and ability to function. Weight-bearing exercises with hip-abductor eccentric strengthening may be the crucial component of the late-phase protocols. Substantial limitations
were found in the nine studies, including small sample
size, patient selection, heterogeneity of outcome assessments, and potential sources of variability not investigated. Despite limitations, we conclude that three main
suggestions emerge from controlled trials on physical
exercise after THA: early postoperative protocols should
Received on September 03, 2008.
Accepted for publication on January 30, 2009.
Epub ahead of print on February 23, 2009.
Corresponding author: M. Di Monaco, Osteoporosis Research
Center, San Camillo Hospital, Strada Santa Margherita 136, 10131
Turin, Italy. E-mail medici@h-sancamillo.to.it
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1Osteoporosis
Research Center, San Camillo Hospital
Turin, Italy
2Division of Physical Medicine and Rehabilitation
San Camillo Hospital, Turin, Italy
include additive interventions whose effectiveness has
been shown. Late postoperative programs are useful
and should comprise weight-bearing exercises with hipabductor eccentric strengthening.
KEY WORDS: Arthroplasty, replacement, hip - Osteoarthritis Exercise - Prosthesis implantation - Rehabilitation.
otal hip arthroplasty (THA) is among the most
widely performed procedures in orthopedic practice and with the aging of the population, the number
of persons who require THA is on the rise.1 Furthermore, THA is now performed in several persons who
previously would not have been considered candidates for the surgery, including younger individuals,
the very elderly, and those with multiple comorbidities.2, 3 As the number of primary surgical interventions
grows, the number of revisions is expected to expand
as well.4 THA has revolutionized the care of patients
with end-stage joint disease, leading to pain relief,
functional recovery and substantial improvement in
quality of life.5-8 Outcome studies consistently showed
an overall satisfaction by both patients and physicians.9, 10 However, long-term studies indicate the persistence of impairment and functional limitation after
THA, even in the absence of pain.11-16 Long-lasting
impairments include reduced muscle strength, reduced
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REHABILITATION AFTER TOTAL HIP ARTHROPLASTY
postural stability, and limited flexibility. Functional
limitations include reduced walking speed, and lower ratings on various assessment tools used to measure
ability to function. Notably, muscle weakness and
functional deterioration were reported in THA patients
who developed loosening of the hip components,
and a causal role of persistent impairment and poor
function in affecting implant longevity was hypothesized, although it cannot be definitively established by
observational studies.15, 16 Rehabilitation after THA is
expected to avoid impairment persistence and to optimize functional recovery. Consequently, people with
THA largely attend rehabilitation services.17-19 A very
recent review showed that following THA, early multidisciplinary rehabilitation improved outcomes at the
level both of activity and participation when compared with routine rehabilitation.20 The authors
showed a significant advantage due to early multidisciplinary intervention for both inpatient and homebased rehabilitation. However, no evidence-based
guidelines on rehabilitation after THA are available
worldwide, and detailed rehabilitation protocols,
including exercise type, duration of each session, time
interval between sessions, and specific equipment
required, strictly based on the hierarchy of evidence,
have not been published. In everyday practice it is
common to find different rehabilitation protocols,
either from physiatrist to physiatrist or from surgeon
to surgeon, even within the same geographic area or
the same institution. We wondered what evidence
supports postoperative exercise programs usually performed in clinical practice, and what exercise programs are supported by strong evidence from controlled trials. We tried to address this issue by systematically reviewing all the controlled trials published on the effectiveness of specific physical exercise programs versus control exercise programs after
total hip replacement surgery.
cise type, duration of each session, time interval
between sessions, and specific equipment required
and should allow the reader to repeat the exercise
program as described by the authors. Alternatively,
intensity may be the only variable described in detail,
provided that exercise types were the same in intervention groups and controls and that exercise protocol was the only (or the main) variable discriminating
intervention groups and controls; 4) outcome measures included at least one among impairment, activity, health-related quality of life, or length of stay in
hospital; 5) language was English; 6) all patients underwent THA, or data from the subgroup with THA were
analyzed separately.
We did not select studies on the basis of their
methodological quality, although we judged each
study using the Physiotherapy Evidence Database
(PEDro) scale. This is a reliable scale developed to
rate the quality of randomized controlled trials (RCTs)
evaluating physical therapist interventions.21, 22 The
PEDro score is determined by counting the number
of checklist criteria that are satisfied in the trial report.
Overall, PEDro score derives from 10 criteria (out of
the 11 criteria of the checklist): random allocation,
concealed allocation, comparability of groups at baseline, subject blinding, therapist blinding, assessor
blinding, >85% of the patients evaluated at follow-up,
intention-to-treat analysis, between-group statistical
comparisons, point estimates and measure of variability provided. No limitations were applied as for
date of publication. All potentially eligible studies
were evaluated for inclusion by one reviewer, without prior consideration of the results. Selected studies where then evaluated by all the authors of this
review. Conflicts on eligibility were resolved by discussion.
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Materials and methods
Criteria for considering studies for this review
Studies were eligible for review if they met the following criteria: 1) clinical trials with a control group;
2) interventions regarded type and/or intensity of
physical exercises; 3) descriptions of physical exercise
protocols used both for intervention groups and controls were available. Descriptions should include exer-
304
Search strategy for identification of studies
We conducted a MEDLINE search of articles published in the English language literature by using the
following key words: “hip, arthroplasty, rehabilitation”. Further searches were performed by substituting either “prosthesis” or “replacement” for “arthroplasty” and “exercise” for “rehabilitation”. To expand
our search for additional articles of interest, we also
hand-searched the bibliography of all studies included in this review. Furthermore, we evaluated the
“related articles” (by using Pubmed) for each study
included in this review.
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Description of included studies and of 3 studies excluded after discussion
On the whole, our searches led to 1 102 articles.
Twelve studies were selected for this review at the first
step by adopting our inclusion criteria. Three of these
12 were excluded from this review after discussion
among the authors of this article.23-25
Finally, 9 studies that met our inclusion criteria
were identified. Five of these 9 studies dealt with early-phase exercises (operation interval <8 weeks),
whereas the other 4 regarded late-phase exercises
(operation interval >8 weeks).
We summarized the main characteristics of the 9
studies in a single structured table (Table I). This compilation allowed us to examine the variation in patient
characteristics, study quality, intervention, and outcome measure assessed.
DI MONACO
bosis and pulmonary embolism. The Authors were
aware of a possible pro-thrombotic risk and excluded from their study the patients at highest risk, i.e.,
those with a history of deep vein thrombosis in the
previous 6 months. The patient who died suffered
from a deep vein thrombosis one year before study
onset. Also, a possible beneficial effect of treadmill
training was suggested as for arthroplasty stability,
because loosening of the prosthesis was found in 4
patients from the control group, whereas none of the
patients from the intervention group developed loosening at the one-year follow-up.
Suetta et al.27 showed that unilateral resistance training of the quadriceps muscle (operated side) exerted several beneficial effects when started just after
surgery and performed over a 12-week period.
Hospital stay length was significantly shorter, with a
relevant reduction (10±2.4 days versus 16±7.2 days in
the control group, mean ± SE; P<0.05). Functional
performance significantly increased by about 30%
(within group comparison), whereas it did not change
in the controls. Among functional performance tests,
a significant between group difference was observed
for the sit-to-stand test (P=0.02). Quadriceps muscle
cross-sectional area significantly increased versus
baseline (12%; P<0.05), whereas it significantly
decreased by 9% in the controls (P<0.05). A significant between-group difference was observed
(P<0.001). Peak quadriceps muscle torque significantly increased versus baseline, whereas it did not
change in the controls. A significant between-group
difference was observed (P=0.001). Notably, all the
outcome measures assessed by Suetta et al. significantly improved in the group of patients treated with
unilateral resistance training. No training-related complications were observed. In the RCT by Suetta et
al., a further group was included: they were treated
with neuromuscular electrical stimulation (NES). This
group showed a significant increase by about 20% in
functional performance versus baseline (P<0.05). The
change in the sit-to-stand test was significantly greater
than in the control group (P=0.03). However they
did not show significant improvements in the legth of
stay in hospital, cross sectional muscle area, and
quadricpes muscle peak torque versus baseline (within group comparison). Furthermore, NES group
showed a significantly lower increase in muscle peak
torque than the resistance training group (P=0.001)
and a significantly lower increase in cross-sectional
muscle area (P<0.001).
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Results
Interventions performed in the early postoperative
phase (operation interval <8 weeks)
Hesse et al.26 showed that treadmill training with
partial body-weight support significantly improved
the Harris hip score assessed at the end of a ten-day
training. The difference in favor of the treatment group
persisted at the 3- and 12-month follow-up. The Harris
hip score consists of 6 weighted categories: pain,
limping, use of technical aids for daily mobility, maximum walking distance, competence in some daily
activities, and passive hip range of motion. Within
the Harris hip score, the pain and maximum walking
distance categories revealed the largest differences
in favor of the treadmill group. Hip extension deficit,
gait symmetry, hip-abductor strength, and the amplitude of gluteus medius activity assessed by electromyography were all better in the treatment group,
with significant differences that persisted during the
follow-up period. Furthermore, patients in the treatment group abandoned their crutches far sooner than
controls (mean operation intervals were 3.2 and 7.9
weeks, respectively). Among the outcome measures,
only gait speed did not significantly differ between the
two groups. A safety concern raised, because one
patient in the treatment group died of pulmonary
embolism during the treatment phase: the firm pressure of the harness around patient’s thighs possibly
played a causal role in the genesis of deep vein throm-
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TABLE I.—Characteristics of the nine controlled trials included in this review.
Study
Hesse 2003 26
Participants
Intervention
Outcome
PEDro score
and dropouts
RCT
Duration: 1 year.
Blinding: assessor.
80 patients from 1 center,
age <75 years, first time
unilateral fully-loadable
THA for osteoarthritis or
hip fracture, ability to
walk reciprocally with
2 crutches, gait symmetry < 0.85, no further
orthopedic or neurologic diseases affecting
gait, no history of deep
vein thrombosis or
symptomatic heart disease in the previous 6
months.
Operation
interval
about 3 weeks.
Mean age: 64.7 years in
the intervention group
and 65.5 years in the
controls.
Two groups.
Intervention
group:
treadmill training with
partial body-weight support by a harness suspended by a set of pulleys for 25 to 35 minutes
a day for 10 working
days + 20 to 10 minutes
of passive joint mobilization.
Control group: 45 minutes a day of passive
joint
mobilization,
strengthening of hip
abductor and extensor
muscles and gait retraining.
Additionally,
both
groups received 30
minute-sessions
of
occupational therapy
and passive physical
therapy + 25-minute
sessions of group therapy in the swimming
pool daily.
Primary: Harris hip
score.
Secondary: hip extension deficit (from Harris
hip score), gait velocity, gait symmetry, hip
abductor
muscle
strength (by using the
Medical
Research
Council Scale grade),
hip abductor mean electromyographic activation, interval from
surgery to abandoning
crutches.
PEDro score: 7
Dropouts: at two weeks,
3 months and 12
months they were 1, 5,
and 14, respectively in
the intervention group
(0, 5, and 16 in the control group).
RCT
Duration:
12
weeks
Blinding: assessor for muscle
cross-sectional
area.
36 patients from 1 center,
aged 60 years and older,
first time unilateral THA
for osteoarthrosis, no
cardiological, neurological or cognitive problems. No comorbidity or
comorbidity without
systemic affection.
Operation
interval:
about 1 day.
Mean age: 69 years in
both the intervention
groups, 68 years in the
control group.
Three groups.
Intervention
group:
standard rehabilitation
+ unilateral progressive
training for the quadriceps muscle of the
operated leg. First
week: daily knee extension exercises in seated
position with sandbags
strapped to the ankle.
Weeks 2 to 12: leg-press
and knee-extension
machines 3 times per
week; training intensity
from 20 repetition maximum to 8 repetition
maximum. During each
session patients performed 3 to 5 sets of 8
to 10 repetitions.
Neuromuscular Electrical Stimulation (NES)
group: standard rehabilitation + NES for
1h daily (pulse rate
40Hz, pulse width
0.25 ms, stimulations
Hospital length of stay,
quadriceps
muscle
cross-sectional area (by
computed tomography),
speed in 3 functional
performances
(gait,
stair-climbing, rising
from a chair), isokinetic
maximal knee extension
moment
PEDro score: 5
Dropouts: 3 from the
controls, 1 from the
electrical stimulation
group, and 2 from the
resistance
training
group.
Methods
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Suetta 2004 27
(To be continued)
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DI MONACO
TABLE I.—Characteristics of the nine controlled trials included in this review (continues).
Study
Methods
Participants
Intervention
Outcome
PEDro score
and dropouts
for 10s followed by 20s
of rest).
Controls = standard rehabilitation (active exercises without resistance
+ stretching exercises
for 1h daily. Training in
transfer situations and
ambulation).
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Maire 2004 28
RCT. Duration: 2
months.
Blinding: none.
14 patients from 1 center, aged 65 years and
older, first time unilateral THA for primary
osteoarthritis, no medications that could interfere with exercise testing and training, no diseases
other
than
osteoarthritis.
Operation interval: 1
week.
Mean age: 75.1 years.
Two groups.
Intervention
group:
standard rehabilitation
+ arm-interval exercise
program with an arm
ergometer. The program
started one week after
surgery. It consisted of a
30-minute session, 3
times per week, for 6
weeks. One session
consisted of 6 consecutive periods of 5 minutes, including 4 minutes of rather low work,
and 1 minute of peak
work. The loads were
progressively increased
during the training period.
Control group: standard
rehabilitation (muscle
strength, range of
motion, aquatics, walking), 2 hours per day.
Western Ontario and
McMaster Universities
(WOMAC) osteoarthritis index.
Six-minute-walk test.
Incremental exercise
test on an arm crank
ergometer.
PEDro score: 4.
Dropouts: none declared.
Jesudason
2002 30
RCT.
Duration 4 days.
Blinding: assessors
42 patients from 1 center, first time unilateral
elective THA, able to
undertand English language, able to co-operate, able to walk prior
to admission, full
weight-bearing status
post-operatively.
Operation interval 3 to 4
days.
Mean age: 69.1 years in
the intervention group
and 69.3 years in the
control group.
Two groups.
Intervention
group:
standard mobilization +
bed exercises aimed at
increasing strength and
range of motion. The
exercises were performed in supine position and comprised hip
and knee flexion, hip
and knee extension to
neutral, hip abduction,
hip adduction to neutral, ankle dorsiflexion
and plantar flexion, static quadriceps contraction, inner range quadriceps exercises over a
rolled up towel. Each
exercise was repeated
Severity of resting pain
by using a visual analogue scale. Range of
hip flexion and abduction in the supine position. Functional status
by using the Iowa Level
of Assistance Scale.
Length of stay in hospital.
PEDro score: 7.
Dropouts: 2 for each
group.
(To be continued)
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TABLE I.—Characteristics of the nine controlled trials included in this review (Continues).
Study
Methods
Participants
Intervention
Outcome
PEDro score
and dropouts
from 5 to 10 times, 2 to
3 times per day from
day 3-4 to day 7-8.
Control group: standard
mobilization.
Sitting/perching on the
edge of the bed, attempt
at standing and walking,
mobilization for the purposes of showering and
toileting.
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Munin 1998 31
RCT
Duration
16
weeks.
Blinding: none.
35 patients from 1 center, elective THA, 70
years of age or older
and living alone (or 70
years of age or older
with 2 or more comorbid conditions, or any
age with 3 or more
comorbid conditions),
no medical or surgical
complications occurring
post-operatively and
precluding scheduled
rehabilitation programs.
Operation interval 3
days.
Mean age: 75.7 years in
the intervention group
and 74 years in the control group.
Two groups.
Intervention
group
began intensive rehabilitation on post-operative day 3.
Intensive rehabilitation
consisted of 2 sixtyminute physical therapy and 2 sixty- minute
occupational therapy
sessions daily (weekdays only), and a single
30-minute physical therapy
session
on
Saturdays.
Control group began
intensive rehabilitation
on post-operative day 7.
From day 3 to 7 the
controls received two
30-minute physical therapy sessions + a single
30-minute occupational
therapy session during
weekdays only, and a
single 30-minute physical therapy session on
Saturdays.
Length of stay in hospital. Hospitalization cost.
General health status by
using the RAND 36-item
health survey I (at the
16-week follow-up).
Functional score by
using the functional status index (at the 16week follow-up) and a
subset of the functional
independence measure
(at day 6 to 10 postoperatively).
PEDro score: 6
Dropouts: 5 from the
intervention group and
4 from the control
group.
Jan 2004 32
RCT
Duration
12
weeks.
Blinding: none
58 patients from 1 center, primary THA by the
same surgeon using the
anterolateral approach,
no prosthesis failures,
no revisions, being able
to walk independently
without
assistive
devices, no major
comorbidities
(cardiopulmonary, neurologic or cognitive).
Operation interval at
least 1.5 years.
Mean age: 59.5 years in
Two groups.
Intervention
group
underwent a 12-week
daily home exercise
program. It consisted of
hip flexion range of
motion exercises for
both hips (2 sets by 10
repetitions/set), isotonic exercise for bilateral
hip flexors, extensors
and abductors with constant low-resistance
weight tied on the ankle
(2 sets by 10 repeti-
Isometric
muscle
strength of bilateral hip
extensors, flexors, and
abductors. Functional
status by using the functional activity part of the
Harris hip score. Free
and fast walking speed
over 3 different terrains.
PEDro score: 6.
Dropouts: 3 from the
intervention group and
2 from the controls.
(To be continued)
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DI MONACO
TABLE I.—Characteristics of the nine controlled trials included in this review (continues).
Study
Methods
Participants
Intervention
the intervention group
and 57.0 years in the
control group.
tions/set),
1-legged
stance on each leg (2
sets
by
10
repetitions/set, holding
for 5s each repetition),
and a 30-minute walk at
comfortable speed.
Control group: no training.
Outcome
PEDro score
and dropouts
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TrudelleJackson 2004 33
RCT
Duration
8 weeks.
Blinding:
patients.
34 patients from 1 center, THA, no revisions,
no pain at weight bearing, no low back pain
at the time of the study,
no diagnosed vestibular
problems, no central or
peripherial nervous system diseases, no cognitive impairment
Operation interval: 4 to
12 months.
Mean age: 59.4 years in
the intervention group
and 59.6 years in the
control group.
Two groups.
Both groups underwent
a 8-week home exercise
program. Subjects were
instructed to 15 repetitions of each exercise 3
to 4 times a week. The
number of repetitions
progressively increased,
reaching 2 sets of 20
repetitions by the end
of the 8-week program.
Good form and slow,
controlled movement
were emphasized for
both groups.
In the intervention
group the exercise program consisted of 7
weight bearing exercises: sit to stand, unilateral heel raises, partial
knee bends, 1-legged
standing balance, kneeraises with alternating
arm raises, side and
back leg raises in standing and unilateral pelvic
raising and lowering in
standing.
The control group followed an exercise program of 7 basic isometric and range of movement exercises, including gluteal muscles sets,
qudriceps sets, hamstring
sets,
ankle
pumps, heel slides, hip
abduction in supine,
and hip rotations in
supine.
Self assessed physical
function by using the
12-item
Hp
Questionnaire. Postural
stability by using a lightweight force platform
that tracks changes in
the center of pressure
over time as the subjects
stand erect over 1 feet.
Maximal
isometric
strength produced by
hip flexors, abductors,
and extensors, and knee
extensors. Fear of falling
by asking 2 simple
questions.
PEDro
score:
5.
Dropouts: 4 from the
intervention group and
2 from the controls.
Sashika 1996 34
Nonrandomized
CT
Duration
6
23 patients from 1 center. THA for hip
osteoarthritis, no pros-
Three groups.
Intervention groups (A
and B) underwent a 6-
Hip range of movement, gait quality , pain,
activities of daily living
PEDro score: 4.
Dropouts:
declared.
none
(To be continued)
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TABLE I.—Characteristics of the nine controlled trials included in this review (continues).
Study
Methods
weeks.
Blinding: none.
Participants
Intervention
Outcome
thesis failures, no major
comorbidities
(cardiopulmonary, neurologic or cognitive).
Operation interval at
least 6 months.
Mean age: 66.0 years in
the intervention group
A, 64.8 years in the
intervention group B,
and 66.2 years in the
control group.
week daily home exercise program. For group
A the program consisted
of range of movement
exercises of hip flexion,
isometric exercise for
bilateral hip flexors,
extensors and abductors
with
low-resistance
weight tied on the ankle
(2 sets by 20 repetitions/set). For group B
the program was the
same as for group A +
eccentric muscle contractile exercises of hip
abductors in the standing position on one leg
(2 different exercises,
each for 6 seconds, 2
sets
by
10
repetitions/set).
Control group: no training.
(by using the Japanese
Orthopaedic Association hip score).
Walking speed and
cadence.
Isometric muscle torque
for hip abductors.
26 patients from 1 center.
THA for hip osteorthritis, no cognitive impairment, no neurologic diseases, no severe metabolic diseases, no early
post-operative complications, no revisions, no
joint problems causing
difficulty in ambulation.
Operation interval: 1224 months.
Mean age: 45.4 years in
intervention group A,
57.7 years in intervention group B, and 52.5
years in the controls (a
significant difference
among groups was
found as for age).
Three groups.
Intervention groups (A
and B) underwent a 6week exercise program.
It consisted of two sessions daily with the program used by Sashika et
al.33: range of movement exercises of hip
flexion, isometric exercise for bilateral hip
flexors, extensors and
abductors, eccentric
muscle contractile exercises of hip abductors
in the standing position
on one leg. Patients in
group A followed a
home program, without
supervision; patients in
group B followed the
same program in hospital, under direct physioterapist supervision.
Control group: only
walking.
Primary: maximum isometric hip abduction
torque. Secondary: gait
speed (in 1 minute) and
cadence (in 1 minute).
PEDro score
and dropouts
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Unlu 2007 35
RCT
Duration
6
weeks.
Blinding: assessor.
Maire et al.28 investigated the efficacy of an arminterval exercise program with an arm ergometer in
a small RCT. At a 2-month follow-up patients from the
310
PEDro score: 6
Dropouts: none.
intervention group showed a significantly higher VO2
peak value than controls, and covered a significantly longer distance in the 6-minute-walk test (mean dis-
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REHABILITATION AFTER TOTAL HIP ARTHROPLASTY
tance was 405 m and 259 m, respectively, P<0.05).
No significant differences in the Western Ontario and
McMaster Universities (WOMAC) osteoarthritis index
were shown between the two groups, whereas both
groups significantly improved in WOMAC score. Also,
the WOMAC subscores (pain, stiffness, and physical
function) did not significantly differ between the two
groups. Results of a one-year follow-up of the same
study have been published afterwards: a confirmation of the improvement at the 6-minute-walk-test
was obtained.29
Jesudason et al.30 investigated the efficacy of bed
exercises begun 3 to 4 days postoperatively and performed for a very short period (till day VII or VIII
postoperatively). The Authors emphasized the absence
of beneficial effects due to bed exercises and early
mobilization compared with early mobilization alone.
Indeed, no differences in length of stay in hospital,
pain severity and functional score were shown.
However, 2 of the 6 categories of the functional score
(i.e., walk 15 feet and climbing stairs) were significantly better in the treatment group (between group
comparison) and a trend toward an overall better
functional score (that also includes supine to sitting,
sitting on the edge of the bed to standing and walking speed over 13.4 meters) was observed (P=0.07).
Data from the assessment of hip range of motion
showed a non-significant trend toward a better outcome in the treatment group for hip flexion.
Munin et al.31 addressed the role of early intensive
rehabilitation in a sample of patients at high risk.
Although the patients included in the study underwent either hip or knee arthroplasty, data for people
with hip replacement were analyzed separately and
looked similar to those of the patients with knee
arthroplasty. The group performing early intensive
rehabilitation showed a shorter length of stay in hospital (the mean was 12.2 days versus 14.8 days in the
control group) and a lower total cost for surgery and
rehabilitation. Patients from the intervention group
exhibited more rapid attainment of short-term functional milestones between days 6 and 10 postoperatively, but these differences were not significant when
data were stratified for surgery type. Both functional
self-assessment and general health status did not differ between the two groups at the 16-week follow-up.
No concern for complications due to early intensive
treatment was reported. Droputs were similar in the
two groups, and early intensive treatment was overall well tollerated.
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Interventions performed in the late postoperative phase
(operation interval > 8 weeks)
Jan et al.32 showed that a 12-week home exercise
program increased hip muscle strength, fast walking
speed, and functional score (functional subscore of the
Harris hip score). The effects were significant in the
subgroup of patients from the intervention group who
were highly compliant (practice ratio >50%), whereas the subgroup with low compliance and the controls
exhibited no significant improvements (within group
comparison). The highly-compliant group showed a
significant improvement in muscle strength, walking
speed, and function versus both low-compliant patients
and controls (between group comparison). Patients
from the low-compliance group showed a significant
improvement in ability to function versus controls
(between group comparison). Overall, compliance
was modest: among the 26 patients from the intervention group who completed the study, 13 showed
a practice ratio <50%. Notably, the exercise program
took about 60 minutes daily, for 12 weeks.
Trudelle-Jackson et al.33 showed that a 8-week home
exercise program including weight bearing exercises
aimed at increasing strength and balance (intervention) but not on range of movement and isometric
exercises (control) significantly increased self-perceived
function (within group comparisons). No significant
differences in self-perceived function were shown
between the two groups. Muscle strength (at all the
sites assessed) and postural balance significantly
increased in the intervention group but not in the control group (within group comparisons). Also, differences between the two groups in muscle strength and
postural balance were significant at the end of the
study (between group comparison). Fear of falling was
not significantly changed in both groups. All the patients
included in this study were surgically operated on by
using an anterolateral approach (although a specific
surgical approach was not an inclusion criterion).
Sashika et al.34 showed in a nonrandomized controlled trial that a 6-week home exercise program
including hip range of motion exercises, isometric
and eccentric strengthening exercises increased
strength of hip abductors, fast walking speed and
cadence (within group comparisons). In the intervention group without eccentric strengthening exercises, improvements were seen in walking speed and
cadence, whereas muscle strength increase was seen
in the operated side only. Notably, muscle strength in
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the operated side increased in the control group, too.
The hip score of the Japanese Orthopedic Association
(a weighted sum of subscores from evaluations of
pain, hip range of motion, gait quality, and activities
of daily living) assessed at the end of the study was not
shown in the paper (despite it was included among the
outcome measures assessed). None of the groups
improved as for range of motion of hip flexion.
Unlu et al.35 evaluated the same exercise program
used by Sashika et al.,34 including eccentric strengthening exercise, with two differences versus the previous trial: the study by Unlu et al. was randomized
(while Sashika’s one was non randomized), and there
were two settings for the intervention group (a subgroup followed a home-exercise program as in the
previous study, another one performed the same exercises in hospital, under direct physioterapist supervision). Both intervention groups showed a significant
increase in hip abductor muscle torque (within group
and versus controls). The increase was significantly
higher in the group with physioterapist supervision
than in the home exercise group (between group
comparison). Gait speed and cadence significantly
increased in both the intervention groups (within
group and versus controls) whereas no significant differences where shown between the group with physioterapist supervision and the home exercise group.
Unfortunately, a substantial difference in age was
seen among the three groups at baseline.
including transfer training (bed-to-standing and toilet
transfer), gait training with proper devices, instructions and training in activities of daily living.17, 18, 36-40
None of the 5 studies we reviewed addressed the
issue of the effectiveness of the most frequently used
protocols as briefly described above, because no control groups without rehabilitation were adopted in
the 5 studies. This likely reflects the general belief
that rehabilitation is useful in the early postoperative
phase, although there are no evidence-based studies
proving rehabilitation usefulness and defining the
best interventions. Jesudason et al.30 evaluated the
effectiveness of a single component of the usual exercise protocol, i.e., bed exercises performed in supine
position without resistance between days 3-4 and 78 post-surgery. The authors emphasized the absence
of beneficial effects due to bed exercises and early
mobilization compared with early mobilization alone.
It may be concluded that early mobilization is the
gold standard for achieving functional recovery after
THA, and that bed exercises are not required.35
However, the study by Jesudason et al. seems not to
provide adequate evidence to support the conclusions driven by the authors. According to the authors’
scope, their bed exercise program was aimed at
increasing range of movement and/or muscle strength.
Indeed, active range of movement exercises were
performed for hip, knee and ankle. However, the bed
exercises without resistance seemed not designed to
increase muscle strength. Unfortunately, strength measurements were performed neither before nor after the
intervention. This is a relevant limitation, because
strengthening exercises may be a pivotal component
of the exercise programs after THA.17, 18, 29, 36-40
Furthermore, study design was characterized by several limitations, listed below. Study duration was very
short (4 days). Statistical power seemed not adequate
for negative conclusions, given small sample size,
variability of the outcome measures, and dropouts.
Power calculation was provided for 40 patients (but
data were available only for 38 of them) and for a
type I error of 0.05 (but a more stringent level of significance was chosen by the authors, given multiple
comparisons). A trend toward a better outcome in
favor of the group performing bed exercises clearly
emerged from the study. Overall, we conclude that the
rehabilitation protocols most frequently used after
THA are neither supported nor denied by clinical
controlled trials.
Three of the 5 trials we reviewed evaluated the
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Discussion
Interventions performed during the early postoperative
phase (operation interval <8 weeks)
Comments on the exercise programs tested in the
controlled studies we reviewed should take into
account the lack of a standard protocol agreed upon
for rehabilitation after THA. Although several authors
called “standard” the protocol performed by their controls, they simply described the exercises usually performed in their own institution. Given the lack of a
standard protocol, it is challenging to compare different studies and to judge whether the results were
weakened (or invalidated) by a not proper exercise
program performed by control subjects. Most frequently, early postoperative exercise protocols include
ankle pumps, quadriceps and gluteal sets, active exercises for hip range of motion, early mobilization
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effectiveness of single additive components of the
early-phase rehabilitation protocols. Each of these
three studies provided convincing evidence for the
effectiveness of the single additive intervention evaluated. Hesse et al., showed that treadmill training
with partial body-weight support significantly
improved both impairment and function 26. Some limitations of this study, including high number of
dropouts and limited assessment of potential confounders, have been emphasized.17 However, the
comprehensive quality score of the study was high.
Impressively, beneficial effects due to a ten-day intervention performed in the early postoperative phase
persisted at a one-year follow-up. Changes were clinically relevant and regarded all the outcome measures assessed, but walking speed. Despite people
in the control group but not those from the intervention group performed an exercise program based on
strengthening exercises for both hip extensors and
abductors, patients in the intervention group developed stronger hip abductors and greater hip extension
than controls. So, treadmill training with partial body
weight support seems to be a tool to maximize
strength and movement recovery, without performing
specific exercises. This result may lead to move
beyond the usual programs based both on “non-functional” exercises for muscle strength and hip range of
movement and “functional” activities, including gait
training. This study suggests that a task-specific, repetitive approach consisting of numerous complex gait
cycles optimizes recovery of strength, range of movement and function. However, two relevant limitations
make this conclusion weak. Firstly, the authors do
not describe in detail the strengthening exercises performed by their control subjects and the reader cannot generalize the results to every strengthening program. Secondly, the study does not include a control
group with intensive gait training without partial body
weight support. So, the beneficial effect observed in
the intervention group may simply depend on gait,
irrespectively of the use of harnesses and pulleys.
The safety concern on deep vein thrombosis and pulmonary embolism imposes an accurate selection of
low-risk patients for this treatment option. Suetta et al.
showed that unilateral resistance training of the quadriceps muscle improved both impairment and function
and shortened the length of stay in hospital.27 This is
the only paper included in this review that clearly
indicated exercise intensity and its progressive increase
by using repetition maximum units, thus reassuring the
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readers on optimal exercise intensity and generalizability of the results. Because controls performed
exercises without resistance, this study suggests that
resistance training is a crucial component of the exercise program after THA. Resistance training was performed unilaterally (operated side, only). This may be
proper, because the operated side is characterized by
a greater strength reduction than the contralateral
side. However, it is not possible to predict whether
bilateral training could lead to a further improvement
in function and reduction in the length of stay in hospital. In the same study, the group treated with NES
showed a modest improvement in functional ability
versus controls, but a worse outcome than the group
treated with resistance training. NES is expected to
increase muscle mass, whereas its effects on voluntary
muscle strength may be questionable.27 Unfortunately,
NES did not significantly increase muscle mass in this
study, whereas resistance training did. It is possible
that NES protocol (1 h daily, pulse rate 40 Hz, pulse
width 0.25 ms, stimulations for 10 s followed by 20 s
of rest), was not optimized in this study (unfortunately, a dose-finding preliminary study was not performed). Maire et al. showed an improvement in
impairment and function due to an arm-interval exercise program with an arm ergometer.28 Notably, lower limbs were not involved in this exercise program,
thus avoiding any potential adverse events at the
operated hip, and the patients were able to obtain a
relevant change in VO2 peak value just exercising
with an arm ergometer for 30-minute sessions three
times a week. Again, it is impressive that beneficial
effects persisted at a 1-year follow-up.29 Overall, data
from these three RCTs supported the role of treadmill training with partial body weight support, resistance training of the quadriceps muscle, and the use
of an arm ergometer. Neurumuscular electrical stimulation may be used in those patients who cannot
perform resistance training. Notably, all three interventions were evaluated in addition to “standard”
rehabilitation, although “standard” rehabilitation itself
varied across studies, as it varies in clinical practice
from institution to institution and even within the
same center. It is surprising that these three interventions, i.e., the only ones supported by RCTs, seem
not to be routinely included in the most frequently
used rehabilitation protocols.
The fifth study we reviewed showed that early
intensive rehabilitation accelerated the attainment of
functional milestones leading to shorter length of stay
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in hospital and reduced economic burden.31 Notably,
early intensive treatment begun on day III postoperatively was well tolerated and patients, who were at
high risk, exhibited no complications and a good
compliance. The message from this study is relevant.
However, generalizability of the results is questionable
because setting change (patients in the intervention
group were early transferred to the rehabilitation
ward) may be a crucial confounder. Furthermore, the
authors did not fully describe the exercise protocols.
Duration and frequency of treatment sessions were the
only variables described in detail, provided that exercise types were the same in intervention groups and
controls. The last limitation further reduces generalizability of the conclusions.
tion group also performed walking exercise (30 minutes daily at a comfortable speed). This possibly contributed to both strength increase and functional
improvement, but the absence of a group performing
only walking exercise makes impossible to drive definitive conclusions on walking role which is further
confounded by spontaneous walking by patients
belonging to both groups. Moreover, it is unlikely
that walking itself exerted a relevant effect, because
of two observations. Firstly, in the study by Unlu et al.
controls were invited to walk (although intensity,
duration and frequency were not defined) and they
showed an outcome significantly worse than patients
in the intervention group who performed a combination of active range of motion exercises, low resistance strengthening exercises, and weight-bearing
exercises with hip-abductor eccentric strengthening.
Secondly, patients in the intervention group in the
studies by Jan et al, and Sashika et al, obtained significant improvements in strength and function without including walking in their exercise programs. In
the study by Unlu et al.35 difference in age among
the groups at baseline may be a potent confounder.
However, the oldest patients were those who performed the exercise under physioterapist supervision,
whose outcome results were the best. So, a relevant
role of age as a confounder in this study seems unlikely. The fourth study was based on the comparison
between two “active” groups. Trudelle-Jackson et al.
showed the superior effect of weight bearing exercises
versus active range of motion and low-resistance training exercises.33 Benefits included increases in muscle
strength and postural balance. Self-perceived functional ability significantly increased in the weight bearing group only, although difference between the two
groups did not achieve statistical significance. The
authors concluded that weight bearing exercise was
the effective treatment. Unfortunately, the exercise
program performed by the controls did not increase
muscle strength, as shown by the authors. So, this
study simply confirms that changes in function mirrored changes in muscle strength (strength did not
increase in the controls who did not improve functionally, whereas it significantly increased in the treatment group that obtained a significant functional
gain). We conclude that the specific exercise regimen
adopted by the control group was not effective as for
muscle strength. This may depend on the lack of
weight-bearing exercises, as suggested by the authors,
but it may also depend on inadequate exercise dosage.
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Interventions performed during the late postoperative
phase (operation interval > 8 weeks)
Two of the 4 studies we reviewed adopted a control group with no training.32, 34 In one further study,
patients in the control group were only invited to
walk.35 The absence of an “active” treatment in the
control group seems to reflect the lack of a general
belief on the usefulness of rehabilitation during the late
post-operative phase. This is consistent with the lack
of definite exercise protocols specifically designed
for the late phase. All the three studies showed beneficial effects due to the combination of active range
of motion exercises, low resistance strengthening
exercises, and weight-bearing exercises with hipabductor eccentric strengthening. Benefits included
improvements in muscle strength,32, 34, 35 walking
speed,32, 34, 35 walking cadence,34, 35 and function as
measured by an ordinal scale.32 Functional gains seem
to depend on muscle strength augmentation, because
improvements in function mirrored strength increases.32, 34, 35 Jan et al. showed that the exercise program
performed in the intervention group actually increased
muscle strength of hip flexors, extensors and abductors. Sashika et al. and Unlu et al. showed a significant
increase in the strength of hip abductors. Notably,
patients in all the three studies performed low-resistance exercises without progressive resistance increase.
We can hypothesize that higher intensity and progressive resistance enhancement could generate
greater strengthening effects in these subjects and
greater functional gains, but data on effectiveness
(and safety) is not available to support our hypothesis. In the study by Jan et al, patients in the interven-
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In agreement with a putative crucial role exerted by
weight bearing exercises, in the oldest study by
Sashika et al.34 the addiction of weight bearing exercises to range of motion and low-resistance strengthening exercises showed a trend toward a greater
increase in muscle strength.
Overall data from late-phase postoperative studies
support the usefulness of rehabilitation, in agreement
with the well known persistence of both impairment
and functional limitations 11-16, and with the effectiveness of physical exercise in the management of hip
osteoarthritis in chronic patients who do not undergo
surgery.41, 42 Furthermore, they emphasize the importance of weight-bearing exercises that may be the
crucial component of the exercise programs.
Compliance is expected to play a crucial role in affecting the results of each exercise program, as suggested in the study by Jan et al.32
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body level of the International Classification of
Functioning, Disability and Health.44, 45 Furthermore,
outcome assessments were not homogeneous across
studies. In future research, outcome measures should
include indexes of both activity and participation, and
an effort should be made to use the same validated
scales. “Standard” rehabilitation varied across studies. These differences mirror discrepancies among
rehabilitation protocols from various institutions
throughout the world. Efforts should be made to minimize differences in standard rehabilitation by preferring interventions whose effectiveness was supported by previous controlled trials.
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Limitations of the studies reviewed and recommendations for further research
Overall, a limited number of controlled studies was
found. Sample size was modest (it ranged from 14 to
80 subjects). No multicenter studies were found. These
three limitations are quite surprising, given the huge
number of patients who undergo THA, the high
request for rehabilitation and the economic burden of
both rehabilitation and long-lasting disability. It is
mandatory that multicenter clinical trials with large
sample sizes become available to optimize physical
exercise programs after THA. Patients included in the
controlled trials were selected, mainly to avoid comorbidities and/or postsurgery complications. This may
limit generalizability of the results (indeed, this is a
general problem for clinical trials).43 Specific trials
should be performed for homogeneous subgroups
of patients with relevant comorbidities (such as neurologic diseases, rheumatoid arthritis, diabetes, arterial diseases) or complications (such as nerve injuries,
length difference between lower limbs, recurrent dislocations) that may affect the effectiveness of rehabilitation and need specific interventions. Further
potential sources of variability not investigated were
arthroplasty type and surgical approach. New studies
should take into account these sources of variability
by either selecting homogeneous patients as for type
of prosthesis and surgical operation, or stratifying participants for these variables in adequately powered trials. In most cases, the outcomes were measured at the
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Limitations of the study
Articles from journals not indexed in Medline were
not searched for, so as articles written in a language
other than English. A single reviewer performed the
first-line analysis of the literature. We focused on postoperative exercise programmes, i.e., a single component of rehabilitation in patients with THA. To build
an evidence-based rehabilitation protocol, several
other issues should be addressed, including pre- and
post-operative education, preoperative exercises, optimal setting to perform rehabilitation, weight-bearing
and range-of-motion restrictions, sport activity, treatment both of comorbidities and complications, and
pain management.17-19, 36-40, 46-52
Conclusions
Three main suggestions emerge from this review of
controlled trials on the effectiveness of physical exercise programs after THA: early postoperative protocols
should include additive interventions whose effectiveness has been shown (i.e., treadmill training with
partial body-weight support, unilateral resistance training of the quadriceps muscle, and arm-interval exercise program with an arm ergometer). Late postoperative programs are useful and should comprise weightbearing exercises with hip-abductor eccentric strengthening.
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