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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 133-137

Effect of home-based exercise program in patients with hip arthroplasty


College of Physiotherapy, Sumandeep Vidyapeeth, Gujarat, India

Date of Submission28-May-2020
Date of Decision18-Nov-2020
Date of Acceptance25-Jan-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Neha Mukkamala
Assistant Professor, College of Physiotherapy, Sumandeep Vidyapeeth. (Declared as Deemed to be University u/s. 3 of UGC Act. 1956), PO. Pipariya, Waghodia, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_207_20

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  Abstract 


Background: Physiotherapy has been a routine component of rehabilitation to improve strength and function following hip arthroplasty (HA). Supervised outpatient exercise program can be costly and inconvenient for people who live in the remote areas. Hence, the present study developed Home-based exercise program (HEP) and studied its effect in patients with HA. Materials and Methods: Thirty-six patients with HA were allocated into HEP and control group through the lottery method. Both groups received physiotherapy during hospital stay and were assessed for muscle strength of hip abductors and extensor apparatus with sphygmomanometer, Numerical Pain Rating Scale (NPRS), and Harris hip score (HHS) at discharge. At discharge, HEP group was given a written home program leaflet, record sheet, and telephonic reminder once a week. The control group received all instructions and demonstration of exercises. All patients were assessed at the 1-month follow-up. Results: A total of 36 patients; 18 in HEP group, (12 males and 6 females) with a mean age 39.24 ± 14.59 years and 18 in the control group (11 males and 7 females) mean age 53.44 ± 19.24 years, out of which 35 completed follow-up (18 in HEP, 17 in control group). A statistically significant difference was found in NPRS (P = 0.001), muscle strength-hip abductors (P < 0.001), extensors apparatus (P = 0.008), and HHS in HEP group between discharge and follow-up. No significant difference was found between the two groups. Conclusion: HEP was effective in reducing postoperative pain, improving hip muscle strength, and function in patients with HA. There was no difference found between the groups

Keywords: Hip arthroplasty, home-based exercise program, Harris hip score, muscle strength


How to cite this article:
Vyas A, Mukkamala N, Mehta M, Parmar L, Golwala P. Effect of home-based exercise program in patients with hip arthroplasty. J Datta Meghe Inst Med Sci Univ 2021;16:133-7

How to cite this URL:
Vyas A, Mukkamala N, Mehta M, Parmar L, Golwala P. Effect of home-based exercise program in patients with hip arthroplasty. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:133-7. Available from: http://www.journaldmims.com/text.asp?2021/16/1/133/322610




  Introduction Top


Avascular necrosis of femoral head, osteoarthritis of hip, fractures around the hip, rheumatoid arthritis, and ankylosing spondylitis are some of the conditions that can lead to severe hip pain, joint stiffness, limited mobility, and function. When conservative methods of treatment fail, hip arthroplasty (HA) becomes a viable surgical intervention which effectively decreases pain and significantly improves mobility and health-related quality of life.[1],[2],[3],[4],[5]

Physiotherapy is traditionally a routine component of patient rehabilitation following HA which helps in reducing complications.[6],[7] During hospital stay, physiotherapy helps in promoting healing and early ambulation, preventing strength decline and complications, and maintaining high functional level.[8],[9],[10]

Studies have shown that there is the persistence of strength deficit in muscles around the hip and functional deficits even after 1 year of HA despite decreased hip pain and improvement in function.[11] Supervised outpatient exercise programs are costly and inconvenient for people who live in remote areas, lacking personal transportation, or have restricted mobility and may lead to low rates of adherence. Home-based exercise program (HEP) seems to have become important. HEP gives the advantages of home-based exercises, safety, and feasibility for patients to practice at home.[12]

In our setting, most of the patients come from the rural areas of neighboring state. Due to poor economic condition, less availability of physiotherapy centers and difficulty in undergoing supervised physiotherapy after discharge, they demand/ask for a HEP.

Therefore, this study aimed to see the effect of HEP following inpatient rehabilitation in patients with HA.


  Materials and Methods Top


After getting approval from the Institutional Ethical Committee, this interventional study on patients with HA was carried out at the general hospital attached to the institute.

Males and females ≥18 years of age who had undergone primary HA were included in the study. Patients with surgical complications post HA, neurological conditions in either of the lower limbs, and unaffected lower limb pathology that compromises walking were excluded from the study.



Procedure

Thirty-six patients with HA referred for physiotherapy were included. Written informed consent was obtained from those willing to participate, and patient information sheet was provided to them. Patients were allocated to two groups: home exercise program (HEP) group and control group using the lottery method.

All the patients received a standard physiotherapy program during their hospital stay twice in a day. On the day of discharge, Numerical Pain Rating Scale (NPRS), muscle strength of hip abductors and extensor apparatus with sphygmomanometer, and Harris hip score were taken.

NPRS was taken according to standard procedure, on a 11-point scale from “0” to “10” in which “0” was “No pain” and “10” was “Worst imaginable pain.”



Muscle strength of hip abductors and extensor apparatus was taken with sphygmomanometer on both operated and nonoperated limbs. The therapist placed her right hand inside the cuff and the instrument was inflated to register 60 mm of mercury. The valve of the sphygmomanometer remained closed to prevent any release of air. Hold test was used for recording the strength values. The patient was asked to apply his/her maximum effort. The patient was in the supine position for measuring the strength of hip abductors and extensor apparatus. For hip abductor strength [Figure 1], the cuff was placed at the lateral aspect of distal thigh, and the patient was asked to push the therapist's hand by bringing the limb out in abduction without rotating the hip. For extensor apparatus [Figure 2], the cuff was placed below the heel and the patient had to push the heel down by maintaining hip in neutral and knee in the extended position. Therapist resisted the movement by maintaining the same position and did not allow the patient to do movement. The maximum pressure exerted on the cuff was then recorded. Patients were given 30–35 s rest in between each trial. After each trial, the pressure within the cuff was totally released, and the cuff was again inflated to 60 mm of mercury, before commencing the next trial. Total three trials were taken for each group of the muscle on both the sides. The average of three trials was taken for the analysis.
Figure 1: Muscle strength of hip abductors

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Figure 2: Muscle strength of extensor apparatus

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The Harris hip score was administered on one to one basis.

After taking the outcome measures, patients in the HEP group were given a home-based exercise program leaflet and were instructed to follow the same at home twice in a day. HEP program was prepared in three languages: Hindi, Gujarati, and English so that the patient could understand easily. It had a detailed description of the exercises including the number of repetitions for each exercise. It had self-explanatory pictures, and a special emphasis on 'do's and don'ts' which could help in avoiding postoperative complications. The program included strengthening exercises such as isometric strengthening of hip abductors, hip extensors and knee extensors, mobility exercises such as heel drag, high sitting knee flexion extension, hip abduction in supine and side lying, and weight bearing/functional exercises like one leg standing, standing hip abduction, stepping and walking. Exercises chosen were simple to ensure safety and as they required minimal to no equipment, they could be performed easily without supervision.

Patients were also provided with a record sheet, in which they had to document adherence to the home exercise program. If they were unable to do exercises then the reasons for the same had to be mentioned in the sheet. A telephonic reminder was given once a week on every Wednesday, if the patient did not pick up the phone on Wednesday then he/she was given a reminder call immediately the next day or the day after that. This was to ensure the adherence to the home exercise program. Report was taken of any adverse effect or complains. The control group was demonstrated the home-based exercises like the HEP group at discharge and was not given leaflet, record sheet, or telephonic reminder.

At follow-up, the outcome measures were taken again for both the groups and record sheet was taken back from the patients in HEP group for the analysis.

Statistical analysis

The data were normally distributed. Descriptive statistics, including mean, standard deviation, and standard error mean were calculated. Paired t-test was used to see the differences within the groups and independent t-test was used to see the difference between the groups. The significance level was kept at P < 0.05.

Ethical clearance

This study was approved by the Institutional Ethics Committee of Sumandeep Vidyapeeth SVIEC/ON/Phys/BNMPT17/DI8003 dated : 11th May 2008.


  Results Top


A total of 36 patients were included in the study.

Home exercise program group: 18 (6 females and 12 males).

Mean age: 39.24 ± 14.59 years.

Control group: 18 (7 females and 11 males).

Mean age: 53.44 ± 19.24 years.

Out of 36, 35 patients completed follow-up – 18 in HEP group and 17 in control group. [Figure 3] shows the type of fixation in both the groups.
Figure 3: Type of fixation in both groups

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[Figure 4] shows the number of patients with unilateral and bilateral hip arthroplasty in both the groups.
Figure 4: Number of patients with unilateral and bilateral hip arthroplasty in both the groups

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[Table 1],[Table 2],[Table 3],[Table 4] show the hip muscle strength and harris hip score in the HEP group and control groups.
Table 1: Hip muscle strength in the home-based exercise program group at discharge and follow-up

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Table 2: Hip muscle strength in the control group at discharge and follow-up

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Table 3: Harris hip score at discharge and follow-up in home-based exercise program group

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Table 4: Harris hip score at discharge and follow-up in control group

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[Table 5] shows difference in hip muscle strength and Harris hip score between HEP and control group.
Table 5: Difference in hip muscle strength and Harris hip score between the home-based exercise program and control group

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Compliance of record diary ranged from 65% to 100% with an average of 83% compliance in the HEP group.


  Discussion Top


HEP has been shown to be safe, feasible, and effective in improving the mobility and quality of life after HA.[12],[13],[14]

In the present study, the HEP group showed significant increase in muscle strength at follow-up. The reasons for which could be many, first, in the home program, the patient had to perform 10 repetitions each of mobility, strengthening, and weight bearing exercises twice in a day. Through repetitive use, exercises are known to increase the muscle strength.[15] Second, the compliance in the HEP group was on an average 83% which is far more than 70% reported in a similar study.[2] According to Jan et al. in 2004, the effectiveness of a home exercise program depended not only on the content of the program but also on patients' compliance, which in turn significantly influenced the exercise effects.[2]

The patients were also given a telephonic reminder once a week which might have motivated the patients to adhere to the exercise program. None of the patients complained or reported any problem related to the exercises during weekly reminder on the telephone or on follow-up. The home program might have helped the patients in learning and performing the exercises with confidence.

HEP group showed a significant increase at follow-up in Harris hip score also. The improvement was seen in the following components: “Pain,” “limp,” “support,” “distance walked,” “sitting,” and “enter public transportation.” Ten patients were allowed weight bearing at discharge (02 cemented fixation and 08 uncemented fixation in HEP group). The other 6 (all were uncemented fixation) started weight bearing 15 days after discharge and 2 were advised weight bearing (uncemented fixation) when they came for follow up. The weight bearing status was at the discretion of the operating surgeon.

At follow up HEP group also showed a significant reduction in pain component of Harris hip score (HHS) which is supported by studies that report strengthening exercises effectively reduce pain, improve muscle strength and function.[16],[17]

Out of 18 patients in HEP group, 8 were able to do stair climbing with or without support and 10 had not attempted stair climbing. HEP included weight bearing exercises such as standing hip abduction, one leg standing, stepping, and walking, which could have helped in improving the walking capacity and ability to walk with either no support or less support. This improvement is important in patients who have undergone HA as it increases their independence in the community.[16] There are the number of studies that report home program effectively improves gait variables such as cadence, velocity, step length, walking speed, and ability to use stairs and public transport.[2],[16],[18] The component “Put on shoes and shocks” was not applicable in all patients as the patients here are not habituated to wearing shoes.

There was a reduction in pain in both the groups, but the HEP group showed significant reduction compared to the control group.

At the time of discharge, patients in the control group had mild-to-moderate pain on movement. They were given a demonstration of all the home exercises as well as “Do's and Don'ts” at discharge and instructed to do all exercises twice at home regularly. However, on enquiry about home exercises, the control group was unable to recall and/or demonstrate the exercise program shown at discharge; this group however only depended on walking as their main exercise.

The control group at follow-up also showed difference in all the parameters, namely NPRS, strength, and HHS as they continued to ambulate, although the difference was not statistically significant. This suggests that proper education and incorporation of exercises which are a part of activities of daily living, especially walking, if done at appropriate intensity and frequency could also be effective rather than a structured HEP which involves extra effort from therapist, cost and also effort from the patients for compliance.

The assessment of the strength of nonoperated side also improved considerably, though not statistically, at follow-up in both the groups. There was no significant difference seen between HEP group and control group at follow-up, we need to study this in bigger sample; however, literature strongly supports the effect of HEP.


  Conclusion Top


  • HEP significantly reduced pain and improved hip muscle strength
  • HEP significantly improved function after HA
  • Between the groups, no significant difference was seen.


Acknowledgment

We are thankful to all the patients who volunteered to participate in the study and Sumandeep Vidyapeeth Trust.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lugade V, Klausmeier V, Jewett B, Collis D, Chou LS. Short-term recovery of balance control after total hip arthroplasty. Clin Orthop Relat Res 2008;466:3051-8.  Back to cited text no. 1
    
2.
Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. Effects of a home program on strength, walking speed, and function after total hip replacement. Arch Phys Med Rehabil 2004;85:1943-51.  Back to cited text no. 2
    
3.
Mariconda M, Galasso O, Costa GG, Recano P, Cerbasi S. Quality of life and functionality after total hip arthroplasty: A long-term follow-up study. BMC Musculoskelet Disord 2011;12:222.  Back to cited text no. 3
    
4.
Dreinhöfer KE, Dieppe P, Stürmer T, Gröber-Grätz D, Flören M, Günther KP, et al. Indications for total hip replacement: Comparison of assessments of orthopaedic surgeons and referring physicians. Ann Rheum Dis 2006;65:1346-50.  Back to cited text no. 4
    
5.
Brueilly K, Schoenfeld B, Darbouze M, Kolber M. Postrehabilitation Exercise Considerations Following Hip Arthroplasty 2013;35:19-30.  Back to cited text no. 5
    
6.
Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: A systematic review. J Physiother 2013;59:219-26.  Back to cited text no. 6
    
7.
Monaco M, Vadero F, Tappro R, Cawanna A. Rehabilitation after total hip arthroplasty: A systemic review of controlled trials on physical exercise programs. Eur J Phys Rehabil Med 2009;45:303-17.  Back to cited text no. 7
    
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Jensen C, Aagaard P, Overgaard S. Recovery in mechanical muscle strength following resurfacing vs. standard total hip arthroplasty-A randomised clinical trial. Osteoarthritis Cartilage 2011;19:1108-16.  Back to cited text no. 8
    
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Pivec R, Johnson A, Mearshael S. Hip arthroplasty. Lancet 2012;380:1768-77.  Back to cited text no. 9
    
10.
Benz T, Angst F, Oesch P, Hilfiker R, Lehmann S, Mueller Mebes C, et al. Comparison of patients in three different rehabilitation settings after knee or hip arthroplasty: A natural observational, prospective study. BMC Musculoskelet Disord 2015;16:317.  Back to cited text no. 10
    
11.
Judd DL, Dennis DA, Thomas AC, Wolfe P, Dayton MR, Stevens-Lapsley JE. Muscle strength and functional recovery during the first year after THA. Clin Orthop Relat Res 2014;472:654-64.  Back to cited text no. 11
    
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Chang CF, Lin KC, Chen WM, Jane SW, Yeh SH, Wang TJ. Effects of a home-based resistance training program on recovery from total hip replacement surgery: Feasibility and pilot testing. J Nurs Res 2017;25:21-30.  Back to cited text no. 12
    
13.
Steinhilber B, Haupt G, Miller R, Boeer J, Grau S, Janssen P, et al. Feasibility and efficacy of an 8-week progressive home-based strengthening exercise program in patients with osteoarthritis of the hip and/or total hip joint replacement: A preliminary trial. Clin Rheumatol 2012;31:511-9.  Back to cited text no. 13
    
14.
Sashika H, Matsuba Y, Watanabe Y. Home program of physical therapy: Effect on disabilities of patients with total hip arthroplasty. Arch Phys Med Rehabil 1996;77:273-7.  Back to cited text no. 14
    
15.
Kumagai M, Shiba N, Higuchi F, Nishimura H, Inoue A. Functional evaluation of hip abductor muscles with use of magnetic resonance imaging. J Orthop Res 1997;15:888-93.  Back to cited text no. 15
    
16.
Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, et al. A targeted home- and center-based exercise program for people after total hip replacement: A randomized clinical trial. Arch Phys Med Rehabil 2008;89:1442-7.  Back to cited text no. 16
    
17.
Joyal J, Harikesavan K, Venkatesan P. Influence of Hip muscle motor control training on pain and function post total hip replacement. Ann Med Health Sci Res 2017;7:96-100.  Back to cited text no. 17
    
18.
Tsauo JY, Leu WS, Chen YT, Yang RS. Effects on function and quality of life of postoperative home-based physical therapy for patients with hip fracture. Arch Phys Med Rehabil 2005;86:1953-7.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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