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 or allowing m ng me to o grow w with Na Nashville Hip I Institute
Anatomy and surgical procedure • There remains a wide variety of opinions and standards for total hip arthroplasty approach and selection of prosthesis • No significant scientific evidence exists with regards to long term outcomes 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 of 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 of 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 Neurophysiological Effects •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. Mechano- transduction •Use of instruments to break up immature collagen tissue, followed by exercise used to: •Stimulate new fiber production Breaking of Cross- •Re-align fibers in direction of force Links **IASTM does not work by one single mechanism. Likely there are multiple potential effects that may •Fluid movement needed for tissue health •Cross-links can limit fluid mobility vary depending on the injury and the dysfunction – it •Hypertonicity of muscle can limit blood flow Fluid Dynamics 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
Transitional postures • 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
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
The mechanoreceptors in and around The main objective of the Establishing the respective joints offer information rehabilitation program for about the change of position, motion, neuromuscular control is to develop and loading of the joint to the CNS, or reestablish the afferent and neuromuscular which, in turn, stimulates the muscles efferent characteristics about the around the joint to function. If a time joint that are essential for dynamic lag exists in the neuromuscular control restraint. reaction, injury may occur.
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 Ultimately, this results in subconcious Slow to fast speed activities control of the joints and body position at a variety of speeds, loads, Low to high force activities and environments. Controlled to uncontrolled activities
Advanced technology and equipment • Use of motion capture systems such as the TRAZER allows us to identify asymmetries and functional deficits objectively down to one 100 th 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!
Recommend
More recommend
