Tag Archives: Physiotherapy
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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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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Neuropathic Pain
The brain’s sensory cortex, which receives and interprets incoming information, maintains a representation of the body physically within itself. The homunculus is the name given to the diagram obtained when each part of the body is plotted against its place on the sensory cortex, with more vital areas of the body being illustrated as larger areas of the brain. Various areas, such as the hands and the lips, take up much more brain area due to their importance in normal function, and it is these most vital areas to control which need greater sensory awareness and greater processing power to work out responses.When we suffer an injury the pain comes directly from that part, streaming in from the highly irritated nerve ends and the normally silent nerves woken up by the chemical soup of the injury. As the barrage of impulses comes in to the spinal cord it meets the second stage nerves which will take the messages on into the central nervous system. These second stage nerves become highly excited by the incoming torrents of impulses and amplify the signal significantly, passing on much higher pain levels to the higher brain centres.We don’t feel pain until it reaches the higher brain centres and intrudes upon our consciousness. In a sense, all our pain is in our minds, as it does not exist unless it gets up to our conscious brain. Our pain is not imaginary, our brains are constantly making a virtual reality for us to know the world, a virtual visual reality, a virtual touch reality and also a virtual pain reality when it’s appropriate. This concept is vital in that it is the brain which constructs our pain reality and not the broken ankle, the slipped disc or the burnt hand.When a limb in amputated it is obvious the muscles, ligaments and bones are all cut, but what is less clear, and much more vital for the future, is that the nerves travelling down the part are also cut through. Cutting the part of the nervous system off from the centre means a sudden loss of incoming signals from the amputated part, with serious side effects for the individual. When the nervous system is deprived of its incoming information the consequences can be unpleasant.The second stage nerves react terribly to being deprived of their incoming streams of impulses, not by going off-line but by doing the opposite, by increasing their reactivity and responsiveness. Because the nerve has been cut and there are not messages coming through they can start to fire off impulses for no reason, spontaneously. These overexcited nerves can produce a significant pain problem as while the leg does not exist any more the nerves which serve the leg areas are still present in the central nervous system. The brain’s sensory areas responsible for the leg are still capable of manufacturing leg pain.Pain which appears in an area of the body which is now absent is known as phantom pain and is a common side effect of amputation which develops in the weeks and months after the trauma. Phantom pain can be very unpleasant in nature, very deep and cold, or sharp and stabbing and so can be a particularly hard pain to treat or to cope with. Neuropathic pain is the term for a pain like this which is generated internally by the central nervous system and not as normal pains which are secondary to tissue hurt.Drug treatment of phantom pain is hard as the morphine chemicals such as morphine, fentanyl, tramadol and codeine are often not very effective. The nerve treatment agents such as amitriptyline, gabapentin and pregabalin are used against neuropathic pain with some effectiveness. Other treatments include transcutaneous electrical nerve stimulation (TENS), an electrode based stimulation treatment which can be self-managed. Cognitive therapy may also be useful to start to cope with what can be a long term problem.Phantom pain can be an intractable, serious problem for anyone with an amputation, and having significant pain before the amputation may make the likelihood of phantom pain greater. A multidisciplinary approach involving a pain clinic is most likely to be helpful.
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