Exploring Advances In THA

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Rehabilitation of Total Hip Arthroplasty and Arthroscopy patients.

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  • We are in private practice, we are not owned by a hospital or any physicians. I want to try and take back our profession – when you work for yourself you have to become a better clinician. Look at the work that has come from Austrailia – Diane Lee, Maitland, McConnell, Jim MeadowsIt is my goal today to make you a better clinician, and I challenge you to use that knowledge to reclaim our profession.
  • The health care bill just passed. I got up the next morning and log on to APTA web site to gain more information. I also get emails from the OPTA listserve. APTA members – this is my other soap box today, if you are not a member you need to join. The APTA is fighting for our rights. You need to get active in the OPTA, the PAC. Things are changing and you can either get involved and fight for your profession or your profession may drastically change.
  • Research – read your journals. CE courses – Clinical Expertise – clinical skill and formulated educationWhen I graduated, we tried to selective isolate the VMO for improving patellar mechanics – the literature has proven this ineffective.
  • Increaseing at a rate of 10% a year.
  • Sensitivity was 86% and specificity was 75% with a LR+ of 3.44
  • This was a low friction arthroplasty. Smaller femoral head 7/8 inch which has a decreased wear rate. However, it had a poor stability. This prosetesis used cement.Stems are typically made of titanium alloys or chrome cobalt – very strong and most biocompatible. New heads are ceramic or cobalt-chromium alloy.
  • FDA issued a warning. Recalled ceramic hip parts.
  • Most patients are diagnosed with snapping hip or psoas muscle strain or bursitis
  • This is a non-specific test – internal hip pathology (intra-capsular).
  • Feel end-feel. Should be capsular, not empty or painful.
  • Used to assess FAI – exactally like the shoulder impingement test. Same ball and socket joint. Always test this prior to having a patient stretch the piriformis muscle
  • Mitchell et all reported that the presence of hip pain during the FABER test was 88% sensitive for intra-articular hip pathology.
  • JOSPT July 2006
  • College of Rheumatology has criteria – so why did Childs develop a CPR?
  • X-ray will show joint space narrowing, osteophytes.
  • Do the exercise. How to correctly stretch the psoas.
  • Surgical approach used is one of the main determinates to rehabilitation. The posterior lateral approach is the most common, although as new techniques of minimally invasive THA are evolving, the anterior-lateral approach is becoming more common for younger, active patients.Posterior lateral approach – cuts posterior capsule and gluteus maximus – posterior dislocation.Anterior-lateral approach involves take-down of the gluteus medius, which can limit post-op weight bearing.
  • Surgery done in Europe for over 17 years. Birmingham Hip Resurfacing device was approved by the FDA in May 2006
  • Fracture rate at about 4% compared to 1% in THA. Have preserved the bone in the femur.
  • 2009 returned to cycling after his ban and finished 17th overall in the Tour of New Zeland.
  • FDA approved in 1997 – hyaluronan acid – extracellular matrix, contributes to cell proliferation.Molicular goo. Syovial fluid – increase the viscosity. Lubrication. Using in wound healing.
  • Exploring Advances In THA

    1. 1. Total Hip Rehabilitation:The latest advances<br />
    2. 2. Bridgit Finley, PT, DPT, M.Ed., OCSBoard Certified in Orthopaedicsbfinley@ptcentral.orgwww.ptcentral.orgFacebook<br />
    3. 3. Physical Therapy Central<br />Choctaw Chickasha Newcastle Norman<br />OKC Pauls Valley Stillwater <br />
    4. 4. Objectives<br />Course Objective:<br />The course participants will be able to:<br />Understand the surgical procedures and contraindications with specific exercises.<br />Describe normal biomechanics for the hip joint.<br />Implement the use of outcome measures for patient’s that have had hip surgery.<br />Utilize the internet to access information in regards to evidence based practice.<br />Effectively progress patients through the rehabilitation protocol.<br />
    5. 5. Course Schedule<br />Evidence Based Practice<br />Anatomy<br />Biomechanics<br />Hip O-A & Surgery<br />Manual Therapy<br />Therapeutic Exercises<br />Outcome Measures<br />
    6. 6. Vision 2020 The first, best choice in musculoskeletal care.<br />Resources<br />APTA<br />JOSPT<br />Physiopedia<br />Evidence in Motion<br />AAOMPT<br />PEDro<br />NAIOMT<br />Life Long Learners<br />Patient Access<br />Autonomous <br />Experts<br />Take our game to the next level<br />Specialty Certifications<br />Manual Therapy Certifications<br />DPT<br />
    7. 7. Evidence Based Practice<br />Integration of the best research evidence with clinical expertise and patient values.<br />Levels of Evidence<br />Systematic Reviews<br />Case Series<br />Expert Opinion<br />
    8. 8. American Physical Therapy Association<br />Consumers<br />Professional Development<br />Advocacy<br />Reimbursement<br />Learning Center<br />Hooked on Evidence<br />Database current research<br />Earn CEU’s<br />
    9. 9. JOSPT<br />Journal of Orthopaedic & Sports Physical Therapy<br />Searched<br />Hip Arthritis<br />20 Abstracts<br />Full Text Articles<br />
    10. 10. NAJSPT<br />Sports Physical Therapy Section<br />Hip Arthritis<br />North American Journal of Sports Physical Therapy<br />
    11. 11. Overview of the Hip<br />
    12. 12. OSTEOARTHRITIS<br />In US, 100 Billion Health Care $ by 2020<br />Progressive loss of articular cartilage with variable subchondral bone loss.<br />Prevalence – 10 to 25% in adults age 55 and older.<br />43 Million people in US<br />Standard of care is THA<br />
    13. 13. Total Hip Arthroplasty<br />The most common surgical procedure for end-stage hip osteoarthritis.<br />Primary reason for surgery is pain which interferes with ambulation.<br />
    14. 14. American College of Rheumatology<br />Classification Hip OA<br />Cluster 1<br />Pain in the hip<br />< 115 hip flexion<br />< 15 IR<br />Cluster 2<br />Pain with IR<br />< 60 minutes morning stiffness<br />> 50 yrs. old<br />Current guidelines focus on pharmacological and surgical management<br />
    15. 15. X-Ray<br />Demonstrate loss of joint space, osteophytes and sclerosis.<br />Dysplasia<br />tears are more common in individuals with acetabular dysplasia.<br />
    16. 16. In US, between 1990 and 2002, THA rose from 119,000 to 193,000 annually.<br />62% increase<br />600,000 <br />THA Procedures Performed Annually<br />
    17. 17. Total Hip Arthroplasty<br />The first joint replacement, a total hip arthroplasty, was performed in 1936.<br />Most widely performed orthopedic procedure performed on adults.<br />In 2008, the average hospital and physician charge for a THA totaled $ 45,000.<br />
    18. 18. Prosthesis<br />Materials<br />Glass<br />Pyrex<br />Ivory<br />Plastics<br />Dr. Charnley in 1960 developed a low friction<br />All new designs are adapted from his design.<br />
    19. 19. Artificial Joint<br />Titanium hip prosthesis<br />Ceramic head<br />Polyethylene acetabular cup<br />
    20. 20. Zimmer<br />
    21. 21. Health Care Costs<br />Physical Therapy<br />12 visits<br />Manual Therapy and exercise<br />$1,200<br />THR<br />$45,000<br />Surgery, hospitalization and rehabilitation<br />
    22. 22. Risks and Complications<br />Medical Risks <br />Heart Attack<br />Stroke<br />Venous Thromboembolism 1%<br />Pneumonia<br />UTI<br />Infection 0.2 – 1%<br />Intra-operative<br />Mal-positioning<br />Short/Long 1%<br />Instability<br />Loss of ROM<br />Fracture 2-5%<br />Nerve Damage 1%<br />Dislocation 4-10%<br />
    23. 23. Long Term Risks<br />Osteolysis<br />Loosening of the components<br />Cement breaks down<br />Wear debris<br />Inflammatory<br />Pain<br />Polyethylene wear rate is 0.3mm year<br />Wear debris<br />Body will absorb the metal<br />
    24. 24. Osteolysis<br />Cascade starts from particles<br />The body creates an inflammatory response.<br />Re-absorbs the bone. <br />12 months<br />
    25. 25. A Squeaking hip ?<br />Stryker<br />Highly durable ceramic hips in 2003.<br />7% of patients from 2003-2005 developed squeaking<br />Squeaky Walk<br />
    26. 26. Trendelenburg <br />(+) for weakness in Abductor muscles<br />Tendinous avulsion<br />Sonography used to diagnosis<br />Test<br />Gait<br />
    27. 27. Glut Medius controls Adductor Moment<br />Hip Abductor function in closed chain is to maintain a level pelvis.<br />
    28. 28. Trendelenburg Gait<br />Have patient stand on one leg and assess if the pelvis drops.<br />(+) Trendelenburg Sign<br />
    29. 29. Subjective History<br />DJD (> 50)<br />Usually no specific mechanism of injury<br />Groin pain; behind greater trochanter, anterior thigh to knee<br />Stiffness in the morning<br />Loss of ROM (Flexion, IR)<br />Increased pain with WB (bony)<br />
    30. 30. Functional Limitations<br />Walking<br />Stair climbing<br />Putting on shoes<br />Shaving legs<br />Rising from a chair<br />
    31. 31. Causes of Hip OA<br /> Congenital Dysplasia<br />Genetics<br /> Disease Process<br /> Trauma<br /> Compensation<br />Leg length, lumbar pathology<br />
    32. 32. X-Ray<br />Gold Standard<br />Joint Space Narrowing<br />Osteophytes<br />Subchondral Bony Change<br />
    33. 33. Femoroacetabular Impingement (FAI)<br />Contact between the femoral head-neck junction and the acetabular rim.<br />Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.<br />
    34. 34. Precursor to early hip O-A<br />Acetabular labral pathology secondary to femoroacetabular impingement (FAI)<br />Acetabular labral pathology is frequently present in highly active individuals 20-40 yo.<br />Gradual on-set with repetitive microtrauma.<br />
    35. 35. Diagnosis of FAI<br />Scour Test<br />FADIR – anterior-superior labrum<br />EABDER – posterior-inferior labrum<br />Log Roll Test<br />
    36. 36. Scour Test<br />The examiner moves the patient’s hip through a range of motion from hip flexion and adduction to hip extension and abduction, while adding a compressive force through the hip joint as well as movement into hip internal and external rotation. The test is considered positive if there is a reproduction in hip pain and/or intraarticular joint clicking.<br />
    37. 37. Log Roll Test<br />The examiner passively moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B).<br />Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity<br />
    38. 38. Impingement Test<br />The examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation. <br />A positive test is reflected by increased hip or groin pain.<br />
    39. 39. FABER Test<br />The examiner passively positions the testing limb in a position of hip flexion, abduction, and external rotation. <br />The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table. <br />A decrease in this distance or pain, when compared to the uninvolved side, is<br />suggestive of intra-articular hip pathology.<br />
    40. 40. Hip Impingement<br />
    41. 41. Hip Special Tests<br />Martin et al<br />JOSPT July 2006<br />Intra-articular Tests<br />FABER Test<br />Scour Test<br />Resisted SLR<br />Log Roll Test<br />Distraction<br />FAI<br />
    42. 42. Hip Arthroscopy<br />
    43. 43. Recent Developments<br />
    44. 44. Clinical Prediction RuleChilds September 2008<br />Loss of IR<br />< 15 degrees <br />Loss of Flexion<br />< 115 degrees<br />(+) Scour Test<br />(+) FABER Test<br />(+) Hip Flexion Test<br /> Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. <br />A clinical prediction rule consisting of 5 examination variables was identified. <br />If at least 4 of 5 variables were present, the positive LR was equal to 24.3<br />95% confidence interval: 4.4-142.1, increasing the probability of hip OA to 91%.<br />
    45. 45. Diagnosis Hip O-A<br />Made with certainty on the basis of history and physical exam.<br />X-ray is definitive <br />CPR – Child’s et al.<br />Hip Guidelines – Cibukla<br />Physiopedia<br />
    46. 46. 1975 Management THA<br />Phase I – immobilization. If unstable will use hip spica cast x 3 weeks. (2-5 days)<br />Phase II – mobilization. Isometric, isotonic (AAROM, AROM). Trochanter detached and transplanted distally. 2-3 week and D/C to home. Crutches x 8 weeks. Walk day 7 - WBAT<br />ROM goals<br />Flexion 90, ER 15, Abd 15, IR 0, Add 0<br />
    47. 47. 2010 THA Management<br />Hospital 1-3 days/Out-patient<br />Ambulate day 1 – FWB<br />AROM day 1<br />Isotonic week 1<br />C-V by day 10<br />ROM goals<br />Flexion 125, Add. 30, ER 50, IR 30 by week 12 <br />
    48. 48.
    49. 49. Muscles<br />
    50. 50. Gluteus Medius<br />Gluteus Medius – main hip abductor<br />Primary stabilizer of hip and pelvis<br />Trendelenburg sign<br />
    51. 51. Gluteus Maximus<br />TFL envelops the muscles of the thigh<br />Counteracts the backward pull of the gluteus maximums of the ITB.<br />Hip extensors are 3 times as strong as the flexors<br />
    52. 52. Psoas<br />Iliopsoas bursa – present in 98% of adults.<br />Lies under the psoas tendon<br />Overuse and impingement syndromes<br />
    53. 53. SLR Exercises<br />Must have excellent core strength<br />This is a core exercise, <br />If neutral pelvis is not maintained<br />
    54. 54. Hip External Rotators<br />Hip capsule is cut and the ER are retracted so that the joint can be exposed.<br />THA – now most repair the capsule<br />
    55. 55. Surgical Incisions<br />
    56. 56. Journal of Orthopedic Surgery <br />Chung, et al. <br />Smaller incision<br />Operating time<br />Blood loss<br />Narcotic use<br />Length of Stay<br />Assistive device<br />Harris Hip Score<br />2004<br />9.2 20<br />49 55<br />136 200<br />2.2 2.64<br />4.4 5.4<br />21 25<br />95 93<br />
    57. 57. Metal-on-Metal Hip Resurfacing Arthroplasty<br />
    58. 58. Resurfacing<br />Main advantage is bone conservation for younger patients<br />Early resurfacing failed because of polyethylene<br />5 year follow-up excellent results<br />Complication<br />Femoral neck fracture<br />Osteonecrosis<br />
    59. 59. High Failure Rate<br />1970, materials available at the time had insufficient wear resistance<br />Incorrect patient selection<br />1999, re-introduced <br />Same revision rate as THA at 4 years<br />Women 2 x than men<br />1-3% <br />
    60. 60. Design<br />Metal on Metal<br />Cause release of inflammatory cytokines<br />Metal allergy<br />Large ball – decrease wear rate<br />Cemented<br />THA - Cementless acetabular fixation – bony in growth<br />
    61. 61. Patient Selection<br />Young and active<br />Isolated hip disease<br />Excellent bone quality<br />Normal kidney function<br />Contra-indicated<br />Severe acetabular dysplasia<br />Obesity<br />
    62. 62. Surgery<br />High learning curve<br />Posterior approach <br />Capsulotomy – preserve lateral muscles but sacrifice medial circumflex artery<br />Implant positioning<br />Limited candidates <br />
    63. 63. Outcomes<br />94-99% survival rates at 5 years<br />446 hips, patients < 55 yrs old<br />Primary diagnosis of OA<br />No difference in ROM<br />Gait analysis – no difference THA<br />Hip impingement<br />
    64. 64. Birmingham Hip Resurfacing<br />
    65. 65. Traditional THA<br />
    66. 66. Floyd Landis<br />Won the Tour de France in 2006<br />Stripped of his title<br />Road with Lance 2002-2004<br />Osteonecrosis – crash in 2002<br />Sept 2006 Surgery<br />
    67. 67. Tour de France<br />
    68. 68. Birmingham Hip Resurfacing<br />Part 1<br />Part 2<br />Part 3<br />Part 4<br />Part 5<br />
    69. 69. Rehabilitation Considerations<br />Surgical Approach<br />Selection of appropriate hip precautions<br />Cemented vs. non-cemented<br />Weight bearing precautions<br />Early mobilization (prevent DVT)<br />Early rehab can improve short term outcomes.<br />
    70. 70. Bioengineering<br />
    71. 71. Viscosupplementation<br />Injection of artificial lubricants into the joint.<br />Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymaltem cells.<br />
    72. 72. Biomechanics<br />
    73. 73. Hip Dysplasia<br />Displacement of femoral head in acetabulum<br />Left hip is more often involved<br />80 % Females<br />Breech birth<br />First born<br />
    74. 74. Hip Dysplasia<br />Less degress of femoral head coverage<br />Decreased joint surface area<br />Normal 30-40%<br />Angle of inclination >125 degrees<br />Increased femoral anterversion<br />Acetabular retroversion<br />McCarthy & Lee found 72% of patients with dysplasia had labral tears<br />
    75. 75. Ball and Socket Joint<br />Flexion to 110-120<br />Extension 10-15<br />Abduction 30-50<br />Adduction 25-30<br />ER 30-45<br />IR 20-35<br />Rolls anterior glides posterior<br />Rolls posterior glides anterior<br />Rolls laterally<br />Rolls medially<br />Spins anteriorly and laterally<br />Spins posteriorly and medially<br />
    76. 76. Mobilization<br />Flexion<br />Extension<br />Adduction<br />Internal Rotation<br />Posterior / Inferior Glide<br />Anterior Glide<br />Lateral Glide<br />Lateral Glide<br />
    77. 77. Distraction<br />General joint mobility<br />Can be diagnostic<br />Gentle let off<br />Place in open packed position<br />Don’t grab ankle<br />
    78. 78. Posterior<br />Gain <br />Flexion<br />Adduction<br />Be careful not to create impingement<br />
    79. 79. Exercise <br />Posterior Mobilization<br />Psoas & TFL Release<br />Follow with psoas stretch<br />
    80. 80. Psoas Stretch<br />Avoid lumbar extension<br />Have patient posterior pelvic tile<br />Can flex or extend the knee<br />
    81. 81. Lateral Mobilization<br />Gain<br />Adduction<br />Internal Rotation<br />
    82. 82. Lateral Mobilization<br />To gain adduction <br />Can also work on ER<br />
    83. 83. Lateral Mobilization<br />Patient self mob<br />Must stretch lateral structures<br />ITB<br />Don’t let hip IR<br />
    84. 84. Inferior Mobilization<br />Excellent technique to use with hip impingement<br />Test – re-test<br />
    85. 85. Caudal/Inferior Mobilization<br />Mulligan technique – mobilization with movement.<br />Measure flexion or IR and mobilize and re-measure<br />
    86. 86. Anterior Mobilization<br />Assess gait<br />Pelvic wink<br />To gain extension and external rotation<br />Stress the anterior labrum<br />If had labral repair<br />
    87. 87. Anterior Mobilization<br />Mobilize anterior capsule<br />Self stretch and exercises – army crawl<br />
    88. 88. Anterior Self Stretch<br />Kneeling Mobilization<br />Psoas and TFL stretching<br />
    89. 89. Cyriax<br />Capsular pattern – specific and proportional loss of movement<br />Most common cause of capsular pattern is arthritis<br />
    90. 90. Capsular Pattern<br />Cyriax<br />IR<br />Flexion<br />Abduction<br />If capsular pattern of restriction; joint is arthritic.<br />If non capsular pattern; not joint.<br />Cyriax listed in ascending order<br />Loss of internal rotation<br />More than flexion<br />More than abduction<br />
    91. 91. Noncapsular Restrictions<br />Fractures<br />Osteomiylitis<br />Labral tears<br />Cancer<br />Bursitis<br />Capsular Irritation<br />Synovitis<br />Impingement<br />
    92. 92. Resting Closed Packed<br />Flexion 30 degrees<br />Abduction 30 degrees<br />External Rotation 10-15 degrees<br />Extension<br />Adduction<br />Internal Rotation<br />Stable position of the joint<br />Tighten capsule<br />
    93. 93. Muscle Imbalances<br />Tightness<br />Psoas<br />Adductors<br />Quadratus Lumborum<br />TFL<br />Piriformis<br />Weakness<br />Glut Maximus<br />Glut Medius<br />Quads<br />Hip ER<br />Core Muslces<br />Abs<br />Errector spinae<br />
    94. 94. FACILITATED MUSCLES<br />Iliopsoas<br />Rectus Femoris<br />TFL<br />QL<br />Hip Adductors<br />Piriformis<br />Hamstring<br />Lumbar Erector Spinae<br />
    95. 95. Medial Hip Mobilization<br />Makofsky, et al. <br />Journal of Manual and Manipulative Therapy 2007<br />Increase in abductor muscle force<br />Prior to exercise <br />
    96. 96. Abductor Strength<br />
    97. 97. Outcome<br />Measures<br />
    98. 98. Lower Extremity Function Scale<br />Ordinal Scale 0 “extreme difficulty” to 4 “no difficulty”<br />Patient rate ability to perform 20 different activities<br />0 to 80 scale, 80 no limitations.<br />Minimum detectable change 9 scale points<br />
    99. 99. Harris Hip Score<br />Scores on 10 different variables<br />Pain<br />ROM<br />Gait<br />ADLs<br />Score range from 0 “worst” to 100 “best”.<br />Harris Hip Score<br />
    100. 100. Hip Outcomes Measures<br />Validity<br />Reliability<br />Includes<br />Pain<br />ROM<br />Function<br />Surgeon & Patient disagree on outcomes<br />Harris Hip Score<br />Charnley Score<br />Oxford Hip Score<br />The Hip Disability and Osteoarthritis Outcome Score<br />
    101. 101. Patient Based Scales<br />Site Specific<br />Oxford Hip Scale<br />Health Status<br />Designed for RA<br />20 Tasks<br />SF-12<br />Disease-Specific<br />Hip & Knee OA<br />WOMAC<br />Oxford<br />12 item questionnaire<br />THR<br />Validated against SF-36<br />Short, practical and valid<br />
    102. 102. Activity Limitation<br />6 Minute Walk Test<br />How far a person can walk in 6 minutes. <br />Can use walking aids.<br />Treadmill is good.<br />Stair Measure<br />Patients are instructed to ascend and descend 9 stairs (step height 20cm) <br />Timed measure in seconds<br />
    103. 103. Rehabilitation Protocol<br />Age<br />Health Status<br />Control pain and swelling<br />Body Weight<br />Body Build - <br />
    104. 104. Week 2-3<br />Goals<br />Patient Education<br />Decrease Edema<br />Incision Healing<br />Independent HEP<br />ROM: flexion 90, abduction 35, ER 35, IR 20, adduction 20<br />
    105. 105. Treatment<br />Modalities<br />MFR/ Massage<br />PROM<br />Transfer and gait training<br />Rhythmic Stabilization<br />MET / Manual Stretching<br />
    106. 106. Modalities<br />US<br />At incision and piriformis/ITB<br />NMS<br />Glut Medius with isometric ABD.<br />IFC & CP<br />Control swelling and pain<br />At the end of treatment<br />
    107. 107. Manual Therapy<br />MFR<br />ITB<br />Piriformis<br />Psoas<br />
    108. 108. Hip PROM<br />Watch for compensation at the pelvis.<br />Capsular pattern?<br />End-feel?<br />Pain?<br />
    109. 109. PROM<br />
    110. 110. Hip Rotation<br />PROM of left hip<br />Loss of IR > loss of hip ER<br />End-feel usually empty and painful.<br />
    111. 111. MET – manual stretching<br />Soft tissue and capsular tightness<br />Have not moved hip though this motion in years<br />
    112. 112. Gait<br />Hip extension<br />15-20 degrees<br />Pelvic<br />Rotation<br />Side bending<br />Most patients will have LBP<br />
    113. 113. Rhythmic Stabilization<br />Neutral Position<br />Manual resistance in ER and IR<br />
    114. 114. Muscle Energy Technique<br />Hamstrings<br />Psoas<br />Lumbar Spine<br />
    115. 115. Hamstring Stretch<br />Lumabr spine is protected<br />Increase stretch with APT<br />Contract quads will inhibit hamstrings<br />
    116. 116. Exercises<br />Exercise Pro Handout Week 2-3<br />
    117. 117. Week 5-6<br />Hip Flexion 100-110, add. 40, ER 40, IR 30<br />Quad/Ham strength 70%<br />(-) Trendelenburg<br />Initiate Hip PRE<br />Neutral alignment lumbar spine<br />
    118. 118. Treatment<br />Myofascial Release<br />Psoas<br />Posterior Hip Capsule<br />PROM/Jt. Mobilization<br />Core Stabilization<br />
    119. 119. Thomas Test<br />Psoas Stretch<br />Thigh off the table<br />Tight iliopsoas and rectus femoris muscle (knee flexion)<br />
    120. 120. Mobilization<br />Leg traction – inferior glide<br />Distraction – inferior or caudal glide.<br />Mobilization with movement<br />Belt<br />MET to restore IR/ER or hip flexion<br />
    121. 121. Joint Mobilization<br />
    122. 122. Whitman & ClelandSeptember 2007<br />Hip OA when treated with manual therapy (mobilization)<br />5 PT sessions<br />Total PROM increases 82 degrees<br />Harris Hip Score 25 points<br />
    123. 123. Case Report JOSPT Dec. 2007Vol. 37, Num. 12<br />73 yo female with THA revision<br />2 yrs s/p revision admitted to hospital 10/10 hip pain after lifting her foot to put on her shoe<br />X-ray normal d/c<br />PT – manual therapy – 4 PT visits<br />4 year follow up <br />
    124. 124. Proprioception<br />Arthritic hips lose input secondary to loss of articular cartilage.<br />THR – no input from the hip joint. Must retrain neuromuscular system.<br />Balance activities.<br />
    125. 125. Airplane<br />Balance<br />Hip Strength<br />Functional<br />
    126. 126. Therapeutic Exercise<br />THA Protocol Exercise Pro Handout<br />Week 5-6<br />
    127. 127. Week 6-12<br />Walk 1 mile<br />C-V Endurance 20-40 minutes<br />Pain Free<br />Equal strength between legs<br />Flexion 130, ER 45, IR 35<br />
    128. 128. S.E.R.F. Strap<br />Pulls the hip into ER<br />JOSPT September 2008 Vol 38, N 9<br />50% self report decrease pain<br />Decreases hip impingement<br />
    129. 129. Treatment<br />D/C all modalities<br />Manual techniques if necessary<br />Exercise Pro Week 6-12<br />
    130. 130. 10 days S/P 12 Weeks<br />
    131. 131. Contraindications<br />Home exercises. Exercises were commenced following manual physical therapy in the clinic<br />Upright bicycle: 10 – 20 min<br />Gluteus medius clamshell exercises: 3 sets of 12<br />Hip abduction in sidelying: 3 sets of 12<br />Core transverse abdominus: 2 sets of 20 in supine with hips flexed to 45°<br />Bridge with straight leg raise: 3 sets of 10<br />Hip flexor stretch kneeling or sidelying: 30 sec × 3<br />Single leg balance: up to 60 sec<br />Tandem stance eyes open or closed: up to 60 sec<br /><ul><li> Recumbent Bike
    132. 132. SLR
    133. 133. Aggressive Glut Medius Strengthening</li></li></ul><li>Questions<br />

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