Hip Rehabilitation Progression

As a reminder, movement progression should consider the rehabilitation stage, goals (increase ROM, increase strength, increase stability, or some combination) and exercise and movement progressions should consider the health condition, contextual factors, and clinical practice guidelines

  1. Acute-phase/Joint protection: Goal is to reduce pain, allow damaged structures time to go through the acute healing process, submaximal effort in affected muscles, conditioning to areas unrelated to surgery/injured area to maintain endurance, modalities and manual therapies to promote soft tissue healing and break pain cycle, stretching of affected areas is typically passive.
  2. Subacute-phase/Controlled motion: Goal is to gradually restore normal movement in positions where patient can be most successful and use the least amount of compensation. Continued use of an assistive device for gait is common. Activities transition toward active stretching and progression through AAROM and AROM with respect to any surgical precautions; functional activities are introduced with modifications as needed to allow for progressive return to prior level of function through increased control of muscle timing, stability, and coordination; open and basic closed chain exercise with some body weight and/or gravity as resistance is common. Cross-friction massage to well-healed scars or to the musculotendinous junction may be indicate to restore muscle extensibility and function. Manual therapy to increase joint mobility may be introduced
  3. Return to function: Goal is to increase the ability for the affected limb to accept increasing weight for increasing periods of time (increase strength and endurance); patient-specific return to function may include work-retraining, and return to recreation/sport.

Time to Stretch Your Brain

What should you observe during functional mobility that indicates a patient is independent with post-operative precautions? For example, what is the best:

  1. Sit to stand pattern?
  2. Dynamic gait adaptation?
  3. Supine to sit pattern?

In order to be sure the iliopsoas group is the primary hip flexor, how many degrees of SLR should the patient attain during active or active-assisted exercise?

Use the Can You Help Me? forum to confirm your understanding or help clear muddy points.

Summary of Rehab Principles

 

Intervention

Early Training; Protection

Basic Training; Controlled Motion

Intermediate to Advance Training; Return to Function

Pain management

PRICE, modalities as indicated, positioning for ease

Allow for adequate rest and recovery; monitor for excessive compensatory motion to prevent pain from overuse; may include soft tissue or other manual techniques to improve muscle response

Continue with adequate rest and recovery consistent with workload over time and overload principles

Training in safe movement and postures (kinesthesia/proprioception)

Modify WB, consider AD

PROM-AAROM-AROM hip

 

Stabilization during functional activities; hip coactivation in progressively challenging WB positions

Progress and normalize gait and balance responses

Integrates hip stability and control into ADLs/iADLs

Mobility/Flexibility

Stretching in pain-free ranges;

and gentle joint mobilization for restricted motion

(lumbar spine, pelvis and hip and extremities);

Soft tissue mobilization as indicated

 

Increase flexibility of major muscle groups and lower kinetic chain, working toward end-range;

Self-mobilization in WB positions

Stretching into limitations, including discomfort

Muscular strength and power

submaximal isometrics; maintain strength of muscles within the lower kinetic chain

Progressive resistance of major hip muscles in open and closed chain positions

Progression to dynamic hip strengthening using challenging surfaces and resistance

Cardiopulmonary Endurance

Promoted in positions or activities that minimize stress to the hip; maintain fitness

Low to moderate intensity (RPE) with emphasis on normalizing WB response

High intensity -sustained cardio activity consistent with health promotion (30 min, 3+ x week)

Functional Activities

Safe postures; safe and adaptive techniques for rolling/supine to sit and transfers to control WB

Adaptive gait training for joint protection

Functional activities that include hip control with standing, stepping, squatting, kneeling, stairs, lifting, etc.

Emphasis on body mechanics and control of the lower kinetic chain

Practice prevention

Normalize balance responses

Individualized instruction in specific, higher level functions the patient engages in at work/home/sport

 

Active Learning Exercise

 Create a tables as illustrated below for each of the following conditions:

  • hip flexion contracture
  • hip osteoarthritis
  • hip muscle strain (adductor, iliopsoas, quadriceps, hamstrings)
  • iliotibial band syndrome
  • greater trochanteric pain syndrome (GTPS)
  • hip fracture repair (ORIF)
  • total hip replacement ( posterior and anterior lateral approaches)

Then use a 0-5 scale to rate your understanding and confidence in selecting the intervention and delivering clear and evidence-based treatment

Test your understanding by using forums to discuss with your classmates. Apply your ratings of confidence and understanding to help guide further or reinforced study

Exercises in Dutton provide some context for possible interventions depending on tissue healing stage. Don't forget to access your APTA PTNow resources for exercise examples. Just be sure you can defend a clinical decision before selecting an exercise

Acute / Joint Protection Intervention Planning

Condition:

Plan of Care

Intervention and Parameters

Self-rating of understanding - defend your decision

Self-rating of confidence

Educate the patient in joint protection and safety considerations / red flags

 

 

 

Decrease acute symptoms

 

 

 

Initiate gentle flexibility and range of motion to affected and related areas

 

 

 

Initiate appropriate strengthening and conditioning exercise 

 

 

Teach safe performance of basic ADLs

 

 

 

Subacute / Controlled Motion Intervention Planning

Condition:

Plan of Care

Intervention and Parameters

Self-rating of understanding -defend your decision

 

Self-rating of confidence

Educate the patient in self-management and how to decrease episodes of pain

 

 

 

Progress awareness and control of hip and postural alignment in WB positions

 

 

 

Increase mobility in tight muscles/joints/fascia

 

 

 

Teach techniques to develop neuromuscular control, strength and endurance

 

 

 

Teach safe body mechanics and functional adaptations

 

 

 

 

Now compare your intervention plans for joint protection and controlled motion stages related to the selected hip conditions. How do they differ? Can you see indications for a progression? Would you be able to identify when it is appropriate to progress a patient? Can you provide patient-centered education in the above areas? Use the CAN YOU HELP ME? forum to discuss your findings.