Is physiotherapy required after hip replacement surgery?

Physiotherapy After Hip Replacement: Essential for Optimal Recovery

Yes, physiotherapy is required after hip replacement surgery to optimize functional outcomes, strength, and quality of life. The evidence strongly supports structured rehabilitation programs, though the specific setting (inpatient vs. outpatient) can be tailored based on patient factors.

Why Physiotherapy is Necessary

Rehabilitation constitutes the majority of a patient's recovery after hip replacement and is essential for returning patients to pre-surgical activity levels. 1 Without structured physiotherapy, patients experience persistent impairments including:

• Hip and trunk muscle weakness, particularly gluteus medius deficiency 1
• Altered gait mechanics and reduced walking speed 2
• Diminished dynamic balance and single-leg stability 1
• Functional limitations in daily activities 3

Evidence-Based Rehabilitation Approach

Setting: Where Should Physiotherapy Occur?

High-quality evidence supports home-based physiotherapy as equally effective to inpatient rehabilitation for most patients after hip replacement. 4 Specifically:

• Home-based physiotherapy produces equivalent functional outcomes at 1 year compared to inpatient rehabilitation for patients who are younger than 71 years, do not live alone, and lack significant comorbidities 4
• Outpatient clinic-based and home-based programs show similar effectiveness when both include physiotherapist direction 2
• Only 44% of patients return directly home within 30 days, with 22% requiring residential or nursing home placement, indicating some patients need more intensive inpatient support 1

Duration: How Long Should Physiotherapy Continue?

Exercise-based treatment should be at least 3 months in duration for optimal benefits. 1 Evidence shows:

• Programs lasting 3+ months demonstrate larger effect sizes compared to shorter programs (3-7 weeks) 1
• Twelve or more directly supervised sessions are more effective than fewer sessions for pain reduction and functional improvement 5
• Benefits may diminish if programs are discontinued prematurely 1

Exercise Components: What Should Be Included?

Physiotherapy programs must include progressive strengthening exercises, particularly targeting hip abductors, combined with functional training. 1

Early Phase (0-4 weeks post-surgery):

• Immediate weight-bearing as tolerated with correct gait pattern monitoring 6
• Isometric quadriceps exercises starting in the first week when pain-free 6
• Gentle hip and trunk strengthening avoiding positions that compromise the surgical site 6

Mid-Phase (4-8 weeks post-surgery):

• Progressive dynamic strengthening for hip and trunk muscles, especially gluteus medius 6
• Balance and proprioceptive training to address single-leg stability deficits 6
• Low-impact aerobic activities (stationary cycling, aquatic exercises) 6
• Treadmill training with partial body-weight support shows convincing effectiveness 3
• Unilateral resistance training of the quadriceps muscle (operated side) 3

Advanced Phase (8-12 weeks and beyond):

• Weight-bearing exercises with hip-abductor eccentric strengthening are the crucial component 3, 7
• Functional strengthening mimicking daily activities and recreational pursuits 6
• Progressive resistance training for hip and lower extremity muscles 6
• Challenging balance activities and functional task training 6

Quantifiable Outcomes

Meta-analysis demonstrates physiotherapy rehabilitation improves:

• Hip abductor strength by 16 Nm (95% CI 10-22) 2
• Gait speed by 6 m/min (95% CI 1-11) 2
• Cadence by 20 steps/min (95% CI 8-32) 2

Critical Implementation Points

Patients require input from physiotherapists, occupational therapists, social workers, and nursing staff to return to pre-fracture functional status. 1 The rehabilitation process should:

• Monitor for exercise intolerance signs including increased pain, joint effusion, or limping 6
• Use patient-reported outcome measures (HAGOS, IHOT questionnaires) to track response 6
• Address specific impairments rather than applying generic protocols 1
• Continue periodic strengthening exercises long-term to maintain muscle strength 6

Common Pitfalls to Avoid

• Discontinuing exercise programs before 3 months leads to suboptimal outcomes 1
• Failing to address hip muscle weakness, altered gait mechanics, or balance deficits results in persistent functional limitations 1
• Not monitoring treatment response with appropriate outcome measures prevents optimization of care 1
• Avoiding all activity due to pain causes deconditioning and worsening function 5

Special Considerations

Orthogeriatricians should ideally coordinate rehabilitation to provide patient-centered care packages. 1 For older patients with hip fractures (a subset of hip replacement patients), rehabilitation is particularly critical as:

• Up to 60% are malnourished on admission, requiring nutritional supplementation 1
• 25% experience postoperative cognitive dysfunction requiring multimodal optimization 1
• Secondary prevention of falls and osteoporosis must be addressed early postoperatively 1