What are the guidelines for physical therapy after total hip replacement?

Physical Therapy Guidelines for Total Hip Replacement

Physical therapy after total hip arthroplasty should focus on early mobilization with weight-bearing exercises and hip abductor eccentric strengthening to optimize functional recovery and reduce postoperative morbidity and mortality.

Pain Management Foundation

Effective pain management is critical for successful physical therapy after total hip replacement. The PROSPECT guidelines recommend:

• Primary analgesic approach should be either:

  • General anesthesia combined with peripheral nerve block continued after surgery, or
  • Intrathecal (spinal) injection of local anesthetic and opioid 1

• This should be combined with a step-down multimodal approach:

  • Paracetamol (acetaminophen)
  • Conventional NSAIDs or COX-2 inhibitors
  • Strong or weak opioids as required 1

Proper pain management enables early mobilization and participation in physical therapy, which directly impacts functional outcomes.

Early Postoperative Phase (0-2 weeks)

1. Day 1-2 post-surgery:

   • Begin mobilization as soon as medically stable
   • Expect substantial reduction in hip muscle strength (41-58% decrease) 2
   • Focus on basic transfers and ambulation with appropriate assistive device

2. First week exercises:

   • Ankle pumps and isometric exercises
   • Gentle hip and knee range of motion within precautions
   • Bed mobility training
   • Transfer training (bed to standing, sitting to standing)
   • Gait training with appropriate assistive device

3. Specific beneficial interventions:

   • Treadmill training with partial body-weight support
   • Unilateral resistance training of quadriceps (operated side)
   • Arm-interval exercises with arm ergometer 3

Intermediate Phase (2-8 weeks)

1. Progressive weight-bearing:

   • Advance from partial to full weight-bearing as tolerated and per surgeon protocol
   • Gradually decrease dependence on assistive devices

2. Progressive strengthening:

   • Focus on hip abductor strengthening
   • Begin closed-chain exercises as tolerated
   • Address residual strength deficits (expect 23-31% reduction at day 8) 2

3. Functional training:

   • Stair climbing
   • Transfer training
   • Balance and proprioceptive exercises
   • Gait training on various surfaces

Late Postoperative Phase (>8 weeks)

1. Advanced strengthening:

   • Weight-bearing exercises with hip-abductor eccentric strengthening (crucial component) 3
   • Progressive resistance training
   • Functional movement patterns

2. Endurance training:

   • Stationary cycling
   • Walking program with progressive distance/time
   • Aquatic exercises if available

3. Return to activities:

   • Activity-specific training based on patient goals
   • Gradual return to recreational activities as appropriate

Recovery Expectations

Patients and providers should have realistic expectations regarding recovery:

• Perceived physical functioning: Recovery from <50% preoperatively to ~80% of healthy controls by 6-8 months 4
• Functional capacity: Recovery from 70% preoperatively to ~80% of healthy controls by 6-8 months 4
• Actual daily activity: Recovery from 80% preoperatively to 84% of healthy controls by 6 months 4

Preoperative Physical Therapy Considerations

While the American College of Rheumatology conditionally recommends proceeding to total joint arthroplasty without delay over delaying for physical therapy 1, evidence suggests preoperative physical therapy may provide benefits:

• Short-term preoperative programs with education and physical therapy can accelerate early functional recovery 5
• Patients who receive preoperative exercise programs demonstrate:
  • Earlier independence with stairs, toilet use, and chair transfers 5
  • Greater independence in basic activities by day 3 post-surgery 5
  • Improved endurance while walking 5
  • Fewer physical therapy sessions needed during hospital stay 5

Common Pitfalls and Caveats

1. Avoid excessive hip flexion, adduction, and internal rotation in early phases to prevent dislocation (especially with posterior approach)

2. Monitor for signs of infection or deep vein thrombosis during rehabilitation

3. Balance between progression and protection - advancing too quickly may cause setbacks, while progressing too slowly may lead to stiffness and weakness

4. Address compensatory movement patterns that may develop due to pain or weakness

5. Consider individual factors that may affect recovery:

   • Age
   • Preoperative functional status
   • Comorbidities
   • Surgical approach
   • Implant type

6. Do not delay TJA for physical therapy alone in patients with moderate-to-severe pain or functional limitations who have completed trials of appropriate nonoperative therapy 1

Physical therapy protocols should be implemented early and consistently following total hip replacement, with particular emphasis on weight-bearing exercises and hip abductor strengthening to optimize functional outcomes and quality of life.