Reha hab f b following t ng total h hip r p repl placem emen - - PowerPoint PPT Presentation

Reha hab f b following t ng total h hip r p repl placem emen ent:

AVOID COMPLICATIONS AND RETURN TO SPORT/ADL

Ashley Campbell, PT, DPT, SCS, CSCS

I have no personal financial conflicts to disclose. (And even if I did, Vegas has it all now…)

A speci cial t thank y k you to both Dr. B Byrd and Dr. F Fer erguson for

• r allowing m

ng me to

• grow w

with Na Nashville Hip I Institute

Anatomy and surgical procedure

• There remains a wide variety of
• pinions and standards for total hip

arthroplasty approach and selection of prosthesis

• No significant scientific evidence

exists with regards to long term

• utcomes that favors one particular

approach over another

• Most decisions are based on

the surgeon’s training and preferences

An argument for the anterior approach

• The dynamic stabilizers for the posterior hip are

not disrupted

• Anteriorly musculature is retracted but not cut

from the hip or pelvis

• Supine position allows for the use of fluoroscopy

for implant placement such that precise acetabular component position can be obtained as well as anatomical restoration of leg length and femoral offset which are both critical to stability

• Due to the inherently more stable aTHA as

compared to traditional posterior approach, the surgeon is able to use a smaller head size component without concern for dislocation

Benefits of smaller head in return to function and return to play

• Decreased risk of

polyethylene wear and/or not needing to use metal surface therefore decreased risk of metallosis

Prehab and Pre-op Visits – What’s the point?

• Education regarding post-op

mobility – gait, stair navigation, bed mobility, etc.

• HEP education
• Modifiable risk factors for

poor outcome?

Establish patient goals pre-op

POST-OP REHAB CONSDERATIONS

• From 2001 to 2007 there was a

50% increase in the incidence rate

• f THA in patients between 50-59
• From a physician standpoint

recommendations on return to higher level/higher impact activity are based on their clinical experience and preference

• From a patient standpoint studies

performed by both Delasotta et al. and Abe et al. Patients report that when they have not returned to prior activity level the most common reason is fear, followed by physician recommendation.

A shift in goals…

• Utilization of the anterior approach allows physical

therapists to stop focusing post op rehab on what not to do and treatment plan based on restoring full mobility, strength, and function

• Initial concerns or limitations with the anterior approach

are typically limited to incision protection and avoidance

• f early loaded rotation to allow bone surrounding the

prosthesis to heal

• In addition to decreasing pain and effusion, normalizing

ROM and normalizing gait, factors related to fear of movement should be of primary importance with all patients especially those with goals to return to sports

GET MOVING!!!

Hip focused rehab phase

• Early soft tissue mobilization
• Early scar mobilization when superficial

healing complete

• Anterior chain mobility
• Rectus femoris
• Iliopsoas
• TFL
• Capsular mobilization – as indicated by surgical

approach as well as objective findings

The theoretical role of IASTM in rehab

• Because the fascia is embedded with mechanoreceptors, the stimulus of these

non-nociceptive receptors allows gate control to occur facilitating decreased pain and guarding

• The introduction of controlled micro-trauma results in increased fibroblast

production and conversion of the collagen produced from low-quality type III to high-quality type I collagen.

• Use of instruments to break up immature collagen tissue, followed by exercise

used to:

• Stimulate new fiber production
• Re-align fibers in direction of force

• Fluid movement needed for tissue health
• Cross-links can limit fluid mobility
• Hypertonicity of muscle can limit blood flow

**IASTM does not work by one single mechanism. Likely there are multiple potential effects that may vary depending on the injury and the dysfunction – it is important that the clinician have a firm grasp on what tissues they are targeting and the desired treatment effect.**

Establish functional/foundational strength

• Patients looking to restore ADLs and general activity level

as well as high level athletes must both establish a baseline of core stability to build off of.

• In the aTHA patient, this commonly includes

restoration of quad and hip flexor activation and function secondary to prior weakness due to pain as well as weakness and/or inhibition due to the retraction of the musculature during the anterior approach.

• The other key stabilizer(s) are the posterior hip

complex, specifically the gluteus maximus, medius and minimus.

A neurodevelopmental approach

• The benefits of positions such as quadruped and tall or

half kneeling are significant:

• Ability to increase the core and hip stability

demands in more functional positions with out moving straight to standing

• These positions, when coached and performed

properly take away several of the common compensations such as:

• over use of the foot and ankle musculature

to create stability

• “hanging” on the anterior hip
• Trunk leaning/compensations in the frontal

plane

• The half kneel position especially can be used to

safely progress balance training without moving directly into standing and again avoiding compensations from the foot and ankle

Transitional postures

Return to sport

• Meira and Zeni – clinical commentary Nov

2014 issue of IJSPT

• The athletes demands of the sport as it relates

to position, load, planes of movement, equipment, and endurance should all be considered when establishing goals and POC for return to sport

• At this stage normal mobility and strength

should be achieved

• Pain should not be present with activity

Establishing neuromuscular control

The mechanoreceptors in and around the respective joints offer information about the change of position, motion, and loading of the joint to the CNS, which, in turn, stimulates the muscles around the joint to function. If a time lag exists in the neuromuscular reaction, injury may occur. The main objective of the rehabilitation program for neuromuscular control is to develop

• r reestablish the afferent and

efferent characteristics about the joint that are essential for dynamic restraint.

Reactive Neuromuscular Training (RNT)

• Muscle receptors (GTO and muscle spindles)

play a crucial role in signaling joint position

• This system processes stimulus at 80 to 100

m/s vs 1 m/s with regards to pain transmission

• Therefore, we must stimulate these

receptors in a multitude of ways to create a somatosensory image within the CNS, ultimately protecting the joint and surrounding structures

• We can create anterior/posterior,

medial/lateral, and multiplanar challenges in a variety of ways

Activities should be goal oriented and relevant to the tasks expected of the athlete

Slow to fast speed activities Low to high force activities Controlled to uncontrolled activities

Ultimately, this results in subconcious control of the joints and body position at a variety of speeds, loads, and environments.

Advanced technology and equipment

• Use of motion capture systems such as

the TRAZER allows us to identify asymmetries and functional deficits

• bjectively down to one 100th of a second

and then build training around those deficits

• Unstable or unpredictable environments

like ActiveMotion Bar and the Cortex can be used for basic gait progressions to sport specific drills

• These types of activities assist in

eliminating the fear component in return to sport progression and create a variable environment for better learning

Summary and conclusions

• Utilize a team approach and understand the

surgeon’s point of view and/or any potential concerns they may have

• Address non-joint related issues pre-op when

possible, or make an appropriate plan to address them post-operatively

• Have clear and realistic plan that you have

discussed with the patient regarding return to activity

• Take advantage of all the tools in your

toolbox…just becuase it’s a joint replacement doesn’t mean it shouldn’t or can’t be treated like you would an arthroscopy

Summary and conclusions continued

• When it comes to return to sport we really don’t have a

lot of consistent research to go off of, however an understanding of the surgical procedure is important – along with some common sense!

• Restore full , pain free movement and strength then

INTEGRATE into function ASAP!

• Utilize principles of neuromuscular control
• And above all…

MAKE TOTAL HIP REHAB FUN!

THA HANK Y YOU! OU!