Rehabilitation after a hip replacement is usually straightforward but it is important to be aware of the priorities at each stage of the operation and recovery for the best outcome. Because an osteoarthritic hip is painful this has a series of knock-on effects. A painful joint means the musculature which controls that joint cannot work properly so tends to lose some of its strength and support for the joint. The joint may also become tight as the natural movements are not performed and the person may adopt an abnormal gait which becomes an ingrained habit.
Pre-operative education and rehabilitation is important so the person knows what they are trying to achieve with their exercises and gait practice. Range of motion and strengthening exercises can be given along with gait correction. If the gait cannot be easily corrected by instruction, consideration should be given to using a walking aid. Either a stick or a crutch can be used depending on the degree of support needed, held in the opposite hand to the arthritic joint. If the patient walks with a good pattern this is sufficient, but if they still walk poorly they may need two sticks or crutches to achieve a reasonable gait pattern.
On the first post-operative day the physiotherapist assesses and treats the patient both in the bed and up mobilizing. Quadriceps and buttock muscle contractions performed hourly allow the leg to regain muscle control to enable movement. Repeated gentle hip flexions by sliding the heel up and down in the bed can help the patient regain control of the leg and restore this functional activity which they need to master bed mobility. Circulatory improvement is also encouraged by pumping movements of the ankles routinely but the size of this effect may not be very great.
Hourly contractions and gentle movements of the hip will get the joint moving and restore some confidence in the patient that they can independently move their leg around, which initially feels very heavy. The physiotherapist and an assistant will mobilize the patient as their condition allows, using crutches or a frame. Early sitting out in a chair is encouraged with a seat high enough to prevent too much hip flexion. As the side of the thigh has been operated this can limit the amount of knee bend so patients are encouraged to regularly slide their feet back towards themselves in sitting.
Giving the patient confidence to independently perform a safe and relatively normal gait pattern is the initial goal of mobilization. This progresses into teaching a walking technique which approximates as closely as possible to normal walking. Once this has been well learned the patient should walk with a pattern very close to a natural gait, with an observer only understanding they have a restriction by the presence of crutches. The natural sequence of muscle activation is promoted by an involuntary and repetitive function such as walking and this reduces the energy cost of walking and facilitates return of muscle power.
The physiotherapist may prescribe an exercise regime for the patient if he or she identifies a particular weakness in the hip musculature. The upright position with the patient holding onto a solid object is the safest starting position and promotes stability and confidence. Three movements can be used to start with: bringing the thigh up towards horizontal in front of the body; making a sideways movement of the leg outwards whilst keeping it straight; pushing the leg behind the body whilst keeping the body upright and the leg straight. The main hip and pelvic muscles which control hip stability are worked by these movements.
Hydrotherapy or more strongly resisted exercises may be necessary in some cases. Joint replacement treatment is very effectively managed in a pool due to both the resistance and the support of the water. Floats attached to the feet increase the forces needed to perform muscle activity in water and the entire walking pattern can be practiced by walking against the water resistance up and down the pool. Hip surgeons are not very keen on significant exercises for total hip replacements, except gait, due to possible implant loosening and reduction in the survival of the implant.
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