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Physiotherapy â Management of Hip Replacement
Osteoarthritis (OA) is the commonest joint degeneration condition in the world, resulting in huge amounts of pain and suffering, work loss, expense and disability. Ageing of western developed populations, soon to be followed by some developing countries such as China, will place an increasing burden on medical services as the occurrence of OA rises steadily with age. There will be an increasing need to provide medical and physiotherapy treatment for OA over the next 50 years and for many thousands of people this will involve joint replacement. Medical interventions can be rated on a scale which calculates the improvement in quality of life which results and here hip replacement comes out top of all treatments. The 1960s saw its development into a standard treatment for hip arthritis but the 21st century has seen the technique evolve into a complex and predictable approach to many hip conditions, with brilliant fifteen year plus results. Once conservative treatments have been exhausted due to a worsening joint then joint replacement becomes the standard choice. Total hip replacement involves removal of the arthritic joint surfaces and their replacement with metal and plastic components. The top of the femur, the ball of the hip joint, is removed and the socket is reamed out to make it larger to accept the new part. Cement is pressurized into the bony areas and a steel alloy femoral component with a ball and stem is inserted down the femur and a plastic cup of ultra high density polyethylene into the socket. The metal-plastic interface allows very low friction and wear, ensuring a long life for the joint.On return from operation the physiotherapist will check the patient’s operative record, medical observations and assess the patient. Initial physio treatment consists of checking respiratory status and the muscle power and feeling in the legs to exclude nerve injury. Exercises are given to restore normal movement although an epidural can cause loss of movement in the legs and delay progress. The physiotherapist will then mobilise the patient with an assistant, taking care of the hip precautions, stand them up and walk them a small distance with elbow crutches or a frame. Toes, ankles, quadriceps, hip flexion and buttock exercises continue to restore normal muscle activity to the legs and maintain the circulation. Routine painkillers should be taken as this helps patients get up and about and once safe they can get up three times a day or more with a helper to walk, toilet and wash. Usual precautions are taken and when sat out the chair must be the right height and normally patients do not place their feet up whilst sitting. After hip replacement patients require instruction and correction to achieve a normal walking pattern, develop muscular power and improved function. Physiotherapists teach the appropriate gait at the time, often starting with “step to” where the patient moves the walking aid, steps the operated leg forwards and steps up to it with the other leg, a stable and safe pattern. Progression is to ’step through” where the unaffected leg steps beyond the other in an approximation of a normal walking pattern. Patients often progress naturally then to a gait where they go both the crutches and the affected leg forward at the same time and start to walk in a fully natural pattern.Once they return for their follow up appointment at six weeks after operation patients have often achieved a excellent gait, reasonable hip strength and returned to some activities of daily living. The physio may advise a stick if they are unsteady, slow or older, and they can gradually regain their previous abilities provided they observe the precautions to prevent hip dislocation: Avoid hip flexion over 90 degrees by not sitting down in low seating, not sitting down or standing up too quickly, not bending over to the floor quickly and not crouching. Weight bearing on the leg and rotating the body weight is unwise. Get medical advice if an infection develops e.g. in the bladder, chest or teeth, as this can transfer to an artificial joint. Avoid crossed legs in sitting.
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The Management Of Joint Pain-Part 2
If the joint is thought to be the pathology causing the symptoms the clinician will have to choose the likely process. Of the three major diagnostic categories one is arthritis of an inflammatory cause, involving the synovial joint linings and the bone-ligament and bone-tendon junctions (the entheses). The function and structure of a joint can be affected by arthritic changes not of an inflammatory nature, secondary to meniscal or articular cartilage hurt or caused by other joint changes which can be from a number of causes.The third possibility is joint pain or arthralgia in the absence of significant pathology, such as fibromyalgia or with sub clinical changes that have yet to declare themselves. Different types of joint disorders can occur in the same joint with inflammatory disorders typically destabilising a joint and leading to structural abnormality. Pain is a significant symptom of these joint disorders and in inflammatory conditions the pain is present whether the joint is moving or still, with it typically being worse as the movement is started. With arthritic changes that are not secondary to inflammation pain occurs typically with movement and improves with resting.If the arthritic changes become very advanced in the spine or major joints patients may suffer pain even when they are resting and also at night. Larger joint pain is less clearly localised to the joint than pain from smaller joints, with hip pain possibly referred to the buttock, lateral thigh, groin or front of thigh. Stiffness is common with arthritis and a hard symptom to define, but it means difficulty moving a joint, especially after a period of resting, which goes off with movement. Inflammatory joint stiffness may last longer, for example half an hour to an hour, while osteoarthritic stiffness may ease after 10-15 minutes.There are several changes which can occur in a joint to make it swell. If the joint is affected by non-inflammatory arthritis then bony growths form at the margins of the joints and the end of the fingers or the knees become knobbly joints. Or an effusion, a collection of fluid within a joint capsule, can form secondary to inflammatory disease and can be drawn off by injecting the joint. It is common for an affected joint to show a degree of loss of movement either because the soft tissues have tightened up, the joint is hurt anatomically or by restriction from pain and inflammation.Getting dressed, looking after oneself and mobility such as walking and stairs are some of the activities of daily living which can be affected by arthritic disease. Loss of bulk and power in the muscles can clarify at least some of functional loss and if pain and weakness occur in a joint then a muscular or neurological pathology is unlikely. Having problems with stable gait, getting up from a chair or the floor and holding things can all be interfered with by the weakness. Feeling unwell and suffering fatigue occurs in systemic arthritic conditions as the whole body is affected. Arthritic symptoms can come on slowly or quick, with rapid onset due to infection, crystal arthritis and traumatic events.Rheumatoid arthritis and osteoarthritis, the two most occurring joint diseases, typically come on slowly like many arthritic conditions. The classification of joint involvement is acute if the joint presents problems for less than six weeks, sub-acute if it persists for between six and twelve weeks and chronic if it continues beyond twelve weeks, although this is not rigidly adhered to. Joints exhibit varying patterns of involvement, with one type showing affected joints continuing to be affected whilst new ones develop problems and another type, for instance gout, where sudden bouts of arthritis are punctuated by clear periods without problems.Non-symmetrical and symmetrical joint patterns of involvement can occur. SLE and rheumatoid arthritis tend to affect the same joints on each side of the body in a symmetrical pattern while psoriatic arthritis and reactive arthritis involve different joints on each side of the body, the asymmetrical pattern. Joints may be involved in different patterns also, for example distal finger joints in osteoarthritis and psoriatic arthritis but not in rheumatoid arthritis.
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Hip Replacement and Physiotherapy
Total hip replacement has matured into a routine operation for the relief of hip pain and disability due to hip arthritis, giving some of the greatest quality of life increases of all medical procedures. Typically performed in older people, many get a excellent result from their hip replacement surgery but many do not reach their greatest potential due to lack of follow up rehabilitation in the post-operative period.An osteoarthritic hip joint is likely to cause a degree of pain and disability for a year or more before the person comes to operation. This period of difficulty can cause influential changes in the tissues around the hip which can be relevant in the postoperative period. Pain and weakness can make us use our joints less, avoiding pushing them to the ends of their movement, a process which gradually reduces the joint’s range of motion. Adaptive shortening occurs in the hip’s ligaments, as the structures shorten in response to the fact that the joint is not being place through its full range any more in the normal daily pattern. A second consequence of the pain and the stiffness is the development of weakness in the large muscles which serve the hip joint. The hip is a weight bearing joint involved in moving the bodyweight around and it generates very high forces in activity. To manage this the hip has the largest muscles in the body either attached to it or nearby to it. The hip extensors, including the glutei, are large powerful muscles which facilitate walking, running, stairs and getting up from a seated position. Loss of power in these muscles can be disabling and threaten independence.The hip abductors, a smaller muscle group of the gluteal muscles, are vital in controlling the side to side stability of the pelvic girdle in gait, with weakness of these muscles interfering with walking. Standing on one leg in walking we hold the opposite side of the pelvis up to avoid it dropping and make bringing through the moving leg more hard. The hip abductor muscles do this and if weak we feel unstable in walking and tend to lurch towards the weak side, making us lean our trunk towards the other side to restore balance. This is described as a positive Trendelenberg sign.The abnormal Trendelberg gait imposes unnatural forces on the hip and requires side flexion of the spine to hold balance on each step. The abnormal gait which results fails to strengthen the hip abductors and remedy the problem. With hip problems we tend not to extend our hips fully so the gait cycle is shortened as the hip extensor muscles fail to attain full movement and power. A restriction in hip joint movement and the presence of muscular weakness makes mobility more hard and can make the outcome of the operation less satisfactory in the absence of rehabilitation.Coordination and balance can also be compromised and is often not particularly excellent before the joint replacement. Insertion of a normal joint into the hip does normalise the joint and immediately improves the mechanical actions of the muscles acting upon it. But, the feedback from the hip area, the joint position sense, may be poor and leave the patient with poor balance and a tendency towards the risk of falling.Physiotherapy assessment of a hip problem covers many aspects of joint function which relate to the ability to perform routine daily functional activities. The pattern of gait will be noted and corrective work prescribed to improve the cycle of walking as an abnormal gait can be habitual and easily improved. Knee, hip and spinal ranges of motion will be assessed to ascertain whether stiffness or any limitation is interfering with normal movement.Large ranges of movement are discouraged in the hip due to the possibility of dislocation and so the physiotherapist checks the hip muscle power in all the muscles around the joint and the joint position sense and balance. The physiotherapy rehabilitation will consist of hip joint mobilising exercises, strengthening work, gait correction and balance practice. Hip arthroplasty generally gives a very excellent outcome but this could be improved at times by rehabilitation.
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