REHABILITATION EXERCISE PROTOCOLS
A number of exercise protocols are used by various institutions; however, the functional goals of these protocols are the same.
TOTAL HIP REPLACEMENT PROTOCOL
v Preoperative (1-2 weeks prior to surgery)
§ Preoperative education about the surgical process and its outcomes
§ Instruction on a postoperative exercise program
§ Instruction on total hip precautions - The following instruction points apply to the posterior surgical approach to the hip. With the anterior hip approach, the patient can cross his or her legs and internally rotate the hip, although positions that involve extreme hip extension and external rotation will dislocate the hip.
§ No hip flexion beyond 90°
§ No crossing of the legs (hip adduction beyond neutral)
§ No hip internal rotation past neutral
v Assessment of the home environment
v Postoperative (day 1)
§ Initiation of bedside exercises - Such as ankle pumps, quadriceps sets, and gluteal sets
§ Review of hip precautions and weight-bearing status
§ Initiation of bed mobility and transfer training - Bed to/from chair
v Postoperative (day 2)
§ Initiation of gait training with the use of assistive devices, such as crutches and a walker
§ Continuation of functional transfer training
v Postoperative (days 3-5 or on discharge to the rehabilitation unit)
§ Progression of ROM and strengthening exercises to the patient's tolerance
§ Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device
§ Progression of ADL training
§ Rahmann et al found that aquatic physiotherapy can promote early recovery of hip strength in patients who have undergone hip or knee arthroplasty. In a randomized, controlled trial that compared the results of supplementary inpatient physiotherapies — aquatic physiotherapy, nonspecific water exercise, and additional ward physiotherapy — in 65 patients, a specific inpatient aquatic physiotherapy program, begun on day 4, was associated with significantly greater hip abductor strength by day 14.
v Postoperative (day 5 to 4 weeks)
§ Strengthening exercises - For example, seated leg extensions, side-lying/standing hip abduction, standing hip extension and hip abduction, knee bends, bridging
§ Stretching exercises to increase the flexibility of hip muscles
§ Progression of ambulation distance
§ Progression of independence with ADL
MEASUREMENT OF LEG LENGTHS
Leg lengths are measured meticulously during the preoperative phase to prevent postoperative leg-length discrepancy. Measurement is performed radiologically and clinically by measuring the actual leg lengths.
However, during the operative process, leg lengths can change, depending on how the prosthesis is fixed or stabilized or on how much bone needs to be removed, among other surgical considerations. Therefore, it is important in the postoperative phase to correct any leg-length discrepancy by using appropriate orthoses or heel lifts. The correction of any discrepancies has a direct impact on the patient's gait pattern, as well as on the development of low back pain (LBP).
TOTAL KNEE REPLACEMENT EXERCISE PROTOCOL
Preoperative (1-2 weeks prior to surgery)
Ø Education on the surgical process and outcomes
Ø Instruction on a postoperative exercise program
Ø Assessment of the home environment
Postoperative (day 1)
Ø Bedside exercises - For example, ankle pumps, quadriceps sets, and gluteal sets
Ø Review of weight-bearing status
Ø Bed mobility and transfer training - Bed to/from chair
Postoperative (day 2)
Ø Exercises for active ROM, active-assistive ROM (AAROM), and terminal knee extension
Ø Strengthening exercises - For instance, ankle pumps, quadriceps sets, gluteal sets, heel slides, straight leg raises, and isometric hip adduction
Ø Gait training with an assistive device and functional transfer training - Such as sit to/from stand, toilet transfers, bed mobility)
Postoperative (days 3-5 or on discharge to the rehabilitation unit)
Ø Progression of ROM and strengthening exercises to the patient's tolerance
Ø Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device
Ø Progression of ADL training
Postoperative (day 5 to 4 weeks)
Ø Strengthening exercises (seated leg extensions, standing hip abduction and extension, knee bends, short arc quads)
Ø Stretching of quadriceps and hamstring muscles
Ø Progression of ambulation distance
Ø Progression of independence with ADL