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Rehabilitation following total hip arthroplasty evaluation over short follow-up

time: Randomized clinical trial

Article  in  The Journal of Rehabilitation Research and Development · January 2014

DOI: 10.1682/JRRD.2014.05.0132

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JRRD Volume 51, Number 10, 2014
Pages 1567–1578

Rehabilitation following total hip arthroplasty evaluation over short

follow-up time: Randomized clinical trial

Carolina Sant’anna Umpierres, MSc;1–2 Tiango Aguiar Ribeiro, PhD;1–2 Ângela Elisabete Marchisio;1–2 Lívia
Galvão;1–2 Íngrid Nemitz Krás Borges;2 Carlos Alberto de Souza Macedo, PhD;2 Carlos Roberto Galia, PhD1–2*
1
Postgraduate Program of Surgical Sciences, Faculty of Medical Sciences, Federal University of Rio Grande do Sul, Rio
Grande do Sul, Brazil; 2Department of Orthopedics, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brazil

Abstract—Hip osteoarthritis (OA) is a degenerative disease, Key words: activities of daily living, arthroplasty, hip osteoarthri-
and total hip arthroplasty (THA) is one of the surgical proce- tis, Medical Outcomes Study 36-Item Short Form, musculoskele-
dures of choice to improve the OA patient’s quality of life. tal manipulations, osteoarthritis, physiotherapy, postoperative
Without a rehabilitation program, THA patients will develop care, randomized controlled trial, total hip arthroplasty.
functional limitations. A randomized double-blind trial was
performed between July 2009 and October 2011 to compare
over a short follow-up time two groups of patients who under- INTRODUCTION
went THA for OA. The THA protocol (THAP) group received
verbal instructions and physiotherapy exercise demonstrations, Hip osteoarthrosis or osteoarthritis (OA) is a degener-
and the THA physiotherapy care protocol (THAPCP) group
ative disease that affects the synovial joints. OA is consid-
received the same verbal instructions and demonstrations asso-
ciated with daily exercise practice guided by a physiotherapist.
ered the most common disease of the locomotor system
The outcomes that were assessed preoperatively and 15 d post- [1–4] and is prevalent among middle-aged and elderly
operatively in 106 patients were muscle strength force, goni- adults [5]. In these populations, a clear relationship
ometry, Medical Outcomes Study 36-Item Short Form Health between overweight and physical activities is observed
Survey, and Merle d’Aubigné and Postel score. Higher muscle [6–7]. Characterized by focal degeneration in joint carti-
strength force scores and degrees in range of motion were lage, microfractures, cysts, subchondral bone sclerosis,
found in the THAPCP group. Greater improvements were also and osteophyte formation in the articular borders, OA
observed for the THAPCP group than the THAP group in the
Merle d’Aubigné and Postel score. At the end of the follow-up
period, the intervention in the THAPCP group improved func-
tional capacity, quality of life, mobility, muscle strength, goni- Abbreviations: ADL = activity of daily living, GLM = gener-
ometry, and pain. It appears to be a safe tool for accelerating alized linear models, IQR = interquartile range, OA = osteoar-
recovery in THA patients. thritis, SF-36 = Medical Outcomes Study 36-Item Short Form
Health Survey, THA = total hip arthroplasty, THAP = total hip
arthroplasty protocol, THAPCP = total hip arthroplasty physio-
therapy care protocol.
*Address all correspondence to Carlos Roberto Galia, PhD;

Clinical Trial Registration: ClinicalTrials.gov; NCT01491048, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos
“Evaluation of functional rehabilitation in patients undergoing 2350, CEP: 90035-003, Porto Alegre, Rio Grande do Sul,
physiotherapy after total hip arthroplasty (arthrosis)”; Brazil; +55-51-2101-8628. Email: [email protected]
https://clinicaltrials.gov/ct2/show/NCT01491048 http://dx.doi.org/10.1682/JRRD.2014.05.0132

1567
1568

JRRD, Volume 51, Number 10, 2014

leads to clinical signs of pain, stiffness, walking difficulty, The inclusion time was from July 2009 to October
deformity, and progressive loss of movements in the 2011. All patients admitted with hip OA and receiving
affected hip joint [1–4]. Symptom severity does not THA surgery were eligible. For this analysis, participants
always correspond to the degree of damage displayed on who refused to participate in the study, who lived in
the radiograph [7]. Currently, no cure for OA exists and another city, who had cognitive disorders that did not
treatments focus on controlling pain and improving func- allow completion of the questionnaire, and who under-
tion [8]. Physiotherapy is one of these treatments [9]. In went THA for hip fracture were excluded. All admitted
the case of lack of response to treatment, total hip arthro- participants were informed about the aim of the study.
plasty (THA) is the surgical procedure of choice, because Before enrollment, participants were informed that one
this treatment improves the patient’s quality of life and group would receive the assistance already offered to
facilitates the patient’s return to activities of daily living THA patients by the hospital while the other group would
(ADLs) and even to labor activities [7,10–12]. receive extra active assistance. The patients were not
informed of their assigned group. All patients agreed to
Patients who received THA without a rehabilitation
participate and provided consent. The study flow diagram
program will develop functional limitations within 1 yr
is shown in the Figure.
after surgery [13–14], and physiotherapy plays an impor-
A total of 106 patients participated in this study.
tant role in the care of these patients. Physiotherapy can
Patients were randomly subdivided into the two specific
improve strength and gait speed after THA [15] and help
groups. This allocation of participants was blinded to the
prevent frequent complications, which include luxation
researcher and to the physiotherapist who assessed and
and thromboembolic disease [16–17]. In addition, phys-
collected the information from participants, and this ran-
iotherapy increases the patient’s mobility and offers edu- domization was conducted by the Hospital Ethics Com-
cation about the exercises and precautions that are mittee staff. Patients were assigned to this previously
necessary during hospitalization and after discharge [8– selected allocation into the study groups in the order in
9]. Nevertheless, no consensus for the most effective which they were admitted to the hospital for the arthro-
physiotherapy has been reached in the field. Early post- plasty surgery. The admission team was also unaware of
operative protocols with additive interventions or late the order of the randomization process. All patients were
postoperative programs associated with weight-bearing evaluated by a blinded physiotherapeutic professional.
exercises have been described [18]. Although several The THA protocol (THAP) group (n = 52) received only
reviews have been published, the overall effectiveness of the assistance provided by the multidisciplinary hip
physiotherapy in functional and quality-of-life outcomes group, which was comprised of the head nurse and the
remains unclear [15]. The aim of this study was to per- medical hip staff. This group received introduction and
form a randomized double-blind trial to determine the orientation about the rehabilitation protocol without the
effectiveness of a physiotherapeutic in-hospital interven- presence of a physiotherapeutic professional. This assis-
tion protocol compared with just the orientation (verbal tance was performed once a day for 60 min and consisted
instructions and exercise demonstrations) of the same of the following:
protocol to reduce the functional impairment of THA • Day 1. Patients received verbal orientation and dem-
patients over the course of a short follow-up period. onstration of the physiotherapy exercises that would
strengthen the gluteal and thigh muscles, as well as a
recommendation for three repetitions of 12 complete
METHODS movements for each exercise. Patients were encour-
aged to sit outside the bed in a chair to perform these
A randomized double-blind trial was performed at exercises. Movements that should be avoided and the
the Universidade Federal do Rio Grande do Sul in the correct positions of the repaired limb were also indi-
Department of Orthopedic Surgery of the Hospital de cated to these patients.
Clínicas de Porto Alegre. The research was approved by • Day 2. Patients were provided instructions and demon-
the Hospital Ethics Committee and the Office for Human strations for gait training.
Research Protections and followed the ethical guidelines • Day 3. Patients performed the physiotherapy and gait
of the 1975 Declaration of Helsinki. training exercise until their discharge day. The patients
 1569

UMPIERRES et al. Rehabilitation after hip arthroplasty: Randomized trial

Figure.
Study flow diagram. THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.

were instructed to continue to perform the physiother- according to the same parameters measured previously. In
apy exercises at home after hospital discharge and addition, the following postoperative outcomes were inves-
were told what movements should be avoided as well tigated: functional impairment according to goniometry and
as the correct positions of the surgically repaired limb. muscle strength assessment; discrepancy of the lower
The other group, the THA physiotherapy care protocol limbs; quality of life by the Medical Outcomes Study 36-
(THAPCP) group (n = 54) received the same assistance by Item Short Form Health Survey (SF-36) [19]; and motor,
the multidisciplinary hip group with the additional pres- gait, and pain performances assessed by the Merle
ence of a physiotherapy professional. All physiotherapy d’Aubigné and Postel [20] scores. Goniometry was used to
exercises and gait training were performed with the phys- evaluate the range of motion in flexion, extension, adduc-
iotherapy professional, who was associated with the hip tion, abduction, and internal and external rotation of both
group. hips of the patients [21]. Muscle strength was measured
On the 15th postoperative day after discharge during a based on Kendall’s criteria, and the forces of the muscle
scheduled outpatient visit, all patients were re-evaluated by groups responsible for flexion, extension, adduction,
the same blinded researcher. The groups were reassessed abduction, internal and external rotation of the hips, and
1570

JRRD, Volume 51, Number 10, 2014

flexion and extension of the knees were measured [22]. The THAPCP groups), discrepancy differences in the two
muscle strength force scale varies from zero (absence randomization groups, and in-hospital stay differences
of contraction) to five (normal movement and ability to between the sexes and in the two randomization groups.
perform and overcome major resistance). To assess the To verify the homogeneous distribution of the groups
lower-limb discrepancy, the distance between the umbili- according to the two randomization groups, Pearson chi-
cus (proximal reference point) to the medial malleolus of square test was used. To compare preoperative and post-
both ankles (distal reference point) was used and reported operative results in the same randomized groups and the
in centimeters. The Merle d’Aubigné and Postel scores are differences in the postoperative results between the two
composed of a clinical performance evaluation and a motor randomized groups, generalized linear models (GLM)
performance evaluation. The clinical evaluation consists of and the Bonferroni test were employed. The muscle
evaluated gait (normal walking), pain (total absence), and strength force scale was ordinal, but insufficient numbers
mobility (equal to the hip without OA). Each of these items of participants were allocated in all scale groups; there-
had a maximum score of 6 points, and the maximum score fore, the scores were analyzed according to the Likert
of the clinical performance evaluation was 18. The motor scale as a continuous variable, followed by GLM with
performance evaluation examined gait and pain, and the the Bonferroni test. Differences were considered signifi-
total score ranged from 7 (worst) to 12 (best). The SF-36 cant when the two-tailed p-value was less than 0.05.
[19], which was translated and validated for the Portuguese
language [23], consisted of 36 items with combined scores
ranging from 0 to 100, with 0 indicating the worst outcome RESULTS
and 100 indicating the best outcome.
Database and statistical analyses were performed in All 106 patients enrolled in this study were included
SPSS version 18.0 (IBM Corporation; Armonk, New in the final analysis. The mean age at the time of hospital
York). A priori sample size was calculated based on a admission was 61.4 ± 15.0 yr (mean ± standard devia-
report by Galia [11] and was estimated at 51 participants tion) with a range of 27–89 yr (median 64, IQR 49.5–
per group in order to yield a level of significance of 73.0). No age differences between the randomization
5 percent and a test power of 95 percent. Quantitative groups were detected (p = 0.59). The mean in-hospital
variables were described with means, standard devia- stay was 5.3 ± 1.1 d, with a range of 4–7 d (median 5,
tions, medians, and interquartile ranges (IQRs), and qual- IQR 4.2–6.0), and no differences were observed between
itative variables were described by their frequencies. the sexes (p = 0.83) or between the randomization groups
Analysis of variance was used to analyze age differences (p = 0.72). The descriptive characteristics of this popula-
among groups (sex, race, professional status, THAP, and tion are displayed in Table 1. The study included more

Table 1.
Population characteristics.
Group
Characteristic
All (n = 106) THAP (n = 52) THAPCP (n = 54)
Age (yr)
Mean  SD 61.4  15.0 60.9  14.5 61.8  15.6
Range (IQR) 27–89 (49.5–73.0) 27–89 (49.5–72.0) 27–87 (50.0–73.7)
Sex, n (%)
Male 49 (46.2) 23 (44.2) 26 (48.1)
Female 57 (53.8) 29 (55.8) 28 (51.9)
Race, n (%)
Black 12 (11.3) 10 (19.2) 2 (3.7)
White 94 (88.7) 42 (80.8) 52 (96.3)
Profession, n (%)
Working 52 (49.1) 29 (55.8) 23 (42.6)
Retired 54 (50.9) 23 (44.2) 31 (57.4)
IQR = interquartile range, SD = standard deviation, THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.
 1571

UMPIERRES et al. Rehabilitation after hip arthroplasty: Randomized trial

women than men, and on average, the women were older Improvements in the muscle strength force were
than the men, with a mean age of 64.7 ± 14.5 yr (median observed for all movements in both groups (within-group
70, IQR 55.0–75.0) for women and 57.5 ± 14.8 yr comparison); however, higher scores were noted in the
(median 59, IQR 44.5–70.0) for men (p = 0.01). Sex was THAPCP group than in the THAP group. Comparison of
equitably distributed between the two groups of our study the postoperative results between these two groups
(p = 0.77). The proportion of retirees and active workers revealed that the intervention (THAPCP) group had signif-
was homogeneous in the study and in the randomization icantly greater improvements in muscle strength force in
groups (p = 0.18). Retirees were older, with a mean age the vast majority of evaluated motions (flexion, extension,
of 66.1 ± 13.8 yr (median 70, IQR 59–75), while active adduction, abduction, internal rotation, and external rota-
workers had a mean age of 56.5 ± 14.8 yr (median 56, tion) compared with the nonintervention group (Table 3).
IQR 45–70; p = 0.001). White patients were more preva-
Clinical and motor performance evaluations were
lent than black patients in this trial, and their distribution
assessed with the Merle D’Aubigné and Postel scale
in the two experimental groups was significantly differ-
ent (p = 0.01), but no differences in age distribution (Table 4). The global clinical evaluation of the THAPCP
among races were observed (p = 0.67). group exhibited a superior and significant improvement
Upon evaluation of the preoperative and postopera- compared with that of the THAP group (p = 0.007 vs p =
tive goniometry results within groups, the intervention 0.10 for within-group improvements; p < 0.001 for com-
group (THAPCP) had higher outcomes than the noninter- parison of postoperative improvements between the two
vention group (THAP). The THAP group had less change groups). In the clinical evaluation, pain showed an
or even insignificant p-values for all items measured improvement in both groups upon comparison of preoper-
compared with the THAPCP group. When postoperative ative and postoperative scores (within-group comparison,
results between the two randomized groups were com- p < 0.001 for both groups). In a comparison of final out-
pared, differences in adduction and abduction were comes between groups, the intervention group had higher
noted. These results are displayed in Table 2. scores (p = 0.02) for pain than the nonintervention group.

Table 2.
Results of comparison assessing goniometry.
Movement Preoperative (Mean  SE) Postoperative (Mean  SE) p-Value* p-Value†
Flexion () 0.43
THAP 64.3  2.3 67.3  2.2 0.15
THAPCP 66.1  2.3 73.1  2.1 <0.001
Extension () >0.99
THAP 20.6  2.7 24.3  3.1 0.001
THAPCP 19.2  1.2 25.1  1.2 <0.001
Adduction () 0.002
THAP 18.5  1.1 21.1  1.1 <0.001
THAPCP 23.7  1.5 27.2  1.3 <0.001
Abduction () 0.01
THAP 23.8  1.4 25.7  1.3 0.08
THAPCP 27.7  1.3 31.7  1.4 <0.001
Internal Rotation () 0.15
THAP 15.5  1.0 18.5  1.0 <0.001
THAPCP 16.9  0.9 22.0  1.1 <0.001
External Rotation () 0.21
THAP 16.6  1.0 17.8  0.8 0.07
THAPCP 17.2  1.1 21.1  1.2 <0.001
*Bonferroni test comparison preoperative and postoperative in same randomized group.
†Bonferroni test comparison postoperative results between randomized groups.
SE = standard error, THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.
1572

JRRD, Volume 51, Number 10, 2014

Table 3.
Results of comparison assessing muscle strength.
Movement Preoperative (Mean  SE) Postoperative (Mean  SE) p-Value* p-Value†
Flexion <0.001
THAP 3.5  0.1 3.9  0.7 <0.001
THAPCP 3.8  0.1 4.3  0.1 <0.001
Extension <0.001
THAP 3.8  0.1 4.1  0.1 0.004
THAPCP 4.1  0.1 4.5  0.1 <0.001
Adduction 0.003
THAP 3.6  0.1 4.0  0.1 <0.001
THAPCP 3.8  0.9 4.3  0.1 <0.001
Abduction 0.002
THAP 3.6  0.1 4.0  0.1 <0.001
THAPCP 3.9  0.1 4.3  0.1 <0.001
Internal Rotation <0.001
THAP 3.3  0.1 3.9  0.1 <0.001
THAPCP 3.6  0.1 4.3  0.5 <0.001
External Rotation <0.001
THAP 3.4  0.1 3.9  0.1 <0.001
THAPCP 3.8  0.1 4.3  0.1 <0.001
Knee Flexion Mean 0.22
THAP 4.2  0.1 4.4  0.1 0.001
THAPCP 4.3  0.1 4.6  0.1 0.003
Knee Extension Mean 0.19
THAP 4.1  0.1 4.4  0.1 <0.001
THAPCP 4.2  0.1 4.6  0.1 <0.001
*Bonferroni test comparison preoperative and postoperative in same randomized group.
†Bonferroni
test comparison postoperative results between randomized groups.
SE = standard error, THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.

Table 4.
Results of clinical and motor evaluation by Merle d’Aubigné and Postel score.
Variable Evaluated Preoperative (Mean  SE) Postoperative (Mean  SE) p-Value* p-Value†
Motor Performance Evaluation 0.47
THAP 8.7  0.1 8.3  0.1 0.16
THAPCP 9.2  0.1 8.6  0.1 0.03
Clinical Evaluation
Pain Clinical Evaluation 0.02
THAP 1.7  0.2 3.4  0.1 <0.001
THAPCP 2.2  0.2 4.1  0.1 <0.001
Mobility Clinical Evaluation 0.01
THAP 3.3  0.1 3.5  0.1 0.08
THAPCP 3.6  0.1 4.1  0.1 <0.001
Gait Clinical Evaluation 0.34
THAP 2.6  0.2 1.6  0.1 0.004
THAPCP 2.9  0.2 2.2  0.2 0.17
Global Clinical Evaluation <0.001
THAP 7.7  0.3 8.6  0.2 0.10
THAPCP 8.8  0.4 10.4  0.3 0.007
*
Bonferroni test comparison preoperative and postoperative in same randomized group.
†
Bonferroni test comparison postoperative results between randomized groups.
SE = standard error, THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.
 1573

UMPIERRES et al. Rehabilitation after hip arthroplasty: Randomized trial

Improvement in the mobility score was noted only in the limb without THA. The preoperative discrepancies, which
intervention group (THAPCP). The motor performance were defined as the length of the nonoperated leg minus the
evaluation revealed higher results for the THAPCP group length of the leg with OA/THA, were 1.9 ± 1.2 cm (median
(pre- to postoperative comparison within group); however, 2, IQR 1–3) for the THAP group and 1.9 ± 2.0 cm (median
taking only the postoperative assessment into account, no 1, IQR 1–2) for the THAPCP group (preoperative compari-
differences in the final results comparison were found son between groups, p = 0.90). Postoperatively, these dif-
between the two groups. ferences were 0.6 ± 1.2 cm (median 0, IQR 0–1) for the
According to the results of the scores of the SF-36, THACP group and 0.7 ± 1.4 cm (median 0, IQR 0–1) for
both trial groups showed less improvement in the areas of
the THAPCP group (postoperative comparison between
physical functioning, role physical, and role emotional
groups, p = 0.74).
(within-group comparison; Table 5). Improvements were
observed in both groups for all other items in within-
group comparisons, whereas higher scores were noted for
the THAPCP group. Bodily pain was the only issue that DISCUSSION
exhibited significant improvement in the comparison
between the groups (p = 0.01). Concern about patient rehabilitation and high hospital
Regarding the discrepancy and the length in the lower costs has motivated many hospitals to create and/or
limbs, the 106 patients had an average length of 90.4 ± upgrade their rehabilitation protocols to reduce the length
0.6 cm in the limb with OA/THA and 91.1 ± 0.6 cm in the of the hospital stay without affecting the outcome of the

Table 5.
Outcome of subitems on Medical Outcomes Study 36-Item Short Form Health Survey.
Subitem Preoperative (Mean  SE) Postoperative (Mean  SE) p-Value* p-Value†
Physical Functioning >0.99
THAP 9.9  2.5 12.7  2.5 >0.99
THAPCP 13.8  2.5 13.5  2.5 >0.99
Role Physical >0.99
THAP 12.7  4.0 9.6  4.0 >0.99
THAPCP 11.8  4.0 11.1  3.9 >0.99
Bodily Pain 0.01
THAP 26.1  2.2 43.9  2.2 <0.001
THAPCP 29.2  2.2 53.8  2.2 <0.001
General Health 0.86
THAP 71.3  2.2 79.02  2.2 0.09
THAPCP 70.4  2.1 83.5  2.1 <0.001
Vitality 0.27
THAP 52.6  2.6 66.5  2.6 <0.001
THAPCP 52.9  2.6 74.1  2.6 <0.001
Social Functioning 0.19
THAP 39.1  3.1 52.8  3.1 0.01
THAPCP 45.6  3.1 62.2  3.1 0.001
Role Emotional >0.99
THAP 24.3  5.9 28.8  5.9 >0.99
THAPCP 32.7  5.8 40.1  5.8 >0.99
Mental Health 0.08
THACP 54.7  2.6 67.7  2.63 0.003
THAPCP 63.9  2.5 76.9  2.58 0.002
*Bonferroni test comparison preoperative and postoperative in same randomized group.
†
Bonferroni test comparison postoperative results between randomized groups.
SE = standard error, THAP = total hip arthroplasty protocol, THAPCP = total hip arthroplasty physiotherapy care protocol.
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JRRD, Volume 51, Number 10, 2014

surgical treatment employed. These measures would were obtained for hip flexion, and worse but statistically
thereby provide greater safety and patient satisfaction. As significant outcomes were obtained for hip extension.
a result, the physiotherapeutic rehabilitation protocol was Based on a report by Hodge et al. [30], Ewen et al. sug-
created in an attempt to improve the efficiency of the gested that these findings in combination with a signifi-
assistance provided by the multidisciplinary hip group cant reduction in the hip range of motion may be
protocol to patients receiving THA surgery. This protocol, associated with a reduction in the various hip stem posi-
which was developed by Galia [11], was implemented by tions [29]. This hypothesis can be neither supported nor
our hospital, and we expected that patients would exhibit refuted with evidence from this study, however, because
better functional outcomes 15 d after THA surgery. our study did not evaluate the stem position. Neverthe-
According to Viliani et al. [24], the main aspects that less, the goniometry assessment made during this study
should be addressed in rehabilitation protocols are atten- revealed that the results for the THAPCP group were
tion to and caution with the posture and the position of the higher than for the THAP group, and these data support
operated limb, thromboembolic disease prevention, return the use of physiotherapy according to Viliani et al. [24].
of mobility, and patient education for taking care of the Muscle strength declines 3–4 percent each day during
prosthesis after hospital discharge. Rehabilitation success the first week of immobilization [31], and patients who
and the reduction in length of hospital stay should also receive THA commonly experience a period of inactivity
take into account an exercise program with daily mobili- ahead of surgery [32], possibly due to the presence of pain
zation, physiotherapy, and gait training during hospitaliza- [33]. This negative effect on muscle mass has been reported
tion [11,25]. Our study adhered to these principles, and all previously [31,34]. Adequate muscle strength in the lower
patients in the intervention group were discharged without limbs, primarily in the abductor muscle, is required for sat-
related complications and in good clinical and functional isfactory rehabilitation [35]. Initiation of strength training
condition as expected. No statistical differences, however, as soon as possible after surgery is of great importance to
were observed between the randomization groups with decrease the influence of postsurgery immobilization on the
regard to the length of hospitalization. Therefore, it is impairment of muscle mass [36], as recommended by the
assumed that there was no reduction in costs related to the present study. The current study demonstrated significant
difference in length of hospital stay between the random- positive results in the improvement of muscle strength
ized groups due to implementation of the rehabilitation force in the intervention group compared with the noninter-
protocol. vention group, and these findings were similarly high-
The results of this randomized trial revealed that the lighted by Husby et al. [33] in another randomized study.
physiotherapeutic in-hospital intervention (physiotherapy Even with good outcomes in the muscle strength force as
and gait training) in conjunction with information about measured by Kendall’s criteria [22], this method may be
arthroplasty care (movements that should not be per- imprecise when compared with a previously described
formed) and home exercises was effective in improving method using a dynamometer, an instrument that is thought
muscle strength force, range of motion, and the mobility to have higher measurement accuracy [26,28,37]. Kendall’s
and pain scores in the Merle D’Aubigné and Postel scale criteria [22] can be incorrect due to the negative influence
over a short follow-up period. The decision to examine a of the patient’s pain as well as due to measurements
short follow-up period resulted from our conclusion that obtained by different researchers. Similarly, these factors
no previous study has shown the efficacy of a rehabilita- can also influence measurement when using a dynamome-
tion protocol in a very short follow-up period of 15 d ter. In a systematic review, Minns Lowe et al. indicated a
postsurgery. Most of the previous studies [13,26–28] lack of a standard method among researchers for the mea-
made assessments over periods of 4, 8, 12, and 16 wk. surement of muscle strength [38]. In fact, some authors use
In a meta-analysis by Ewen et al. [29], the flexion manual measurement [39–40], while others use a dyna-
and extension range of motion was reduced, with a range mometer [26,28,37]. Even those who use a dynamometer
of 31.2–51.0 in the control group and 23.1–40.7 in often measure the strength of different muscle groups.
the intervention group. Our study demonstrated that the Regardless of the method used to measure the muscle
flexion and extension movements were 67.3° and 24.3°, strength force, we demonstrated a significant improvement
respectively, in the control group and 73.0° and 25.1°, after a short follow-up time in the intervention group com-
respectively, in the intervention group. Better outcomes pared with the nonintervention group. This finding
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UMPIERRES et al. Rehabilitation after hip arthroplasty: Randomized trial

strengthens our conclusions that our protocol leads to a (enhanced program) [43], and Dwyer et al. demonstrated
clinically relevant improvement in muscle strength in a a reduction in hospital stay from 8.3 to 5.3 d following
short period of time and that this improvement is essential implementation of the program [44]. These authors docu-
for fast patient recovery. mented a real improvement with the enhanced program.
The lack of available trials concerning the functional In this study, the overall mean hospitalization time was
evaluation of patients after THA indicates the absence of similar to that of the enhanced groups from these studies.
a consensus among authors regarding the best way to The major outcome of the intervention in this study was in
evaluate functional status [38]. A variety of tools has muscle strength force and range of motion rehabilitation.
been described: the Oxford Hip score [13], The McMas- The question of whether improvements in the length of
ter Toronto Arthritis Patient Preference Disability Ques- hospitalization decrease muscle strengthening and range
tionnaire [41], and the Japanese Orthopedic Score [40]. of motion gain remains. These previous studies did not
The SF-36 [19] and the Merle d’Aubigné and Postel [20] evaluate these issues.
score are other examples of validated scores [10]. All This study has several strengths. First, this study is a
these scores can determine the functional capacity of randomized clinical trial that was conducted in southern
patients with a degenerative hip and can provide a useful Brazil in order to evaluate the applicability and the func-
quantification of the disease extension. These tools may tional results of a physiotherapy care protocol for THA
provide an indication for a certain surgical procedure as surgical patients. Not only the functional status according
well as evaluate the results of the procedure. The Merle to goniometry and muscle strength force assessment, but
d’Aubigné and Postel and SF-36 scores were chosen for also the clinical status and quality of life assessment
this study. Mehta et al. [42] evaluated 1,700 THA surger- according to the SF-36 [19] and the Merle d’Aubigné and
ies in 1,560 patients and found that pain and the general Postel [20] scales were determined. Moreover, an atten-
health status of these patients were significantly corre- tive randomization process was performed before the
lated with validated hip scores and general health ques- beginning of the study and a blinding process that mini-
tionnaires, such as the Merle d’Aubigné and Postel [20] mized bias was employed. The current study also has
and the SF-36 [19] scores. Galia [11] evaluated the func- some limitations due to the nature of the data collection
tional results of a multidisciplinary hip group interven- method. Patient comorbidities were not included, and the
tion in patients receiving THA by using application of the gait evaluation was reported as the measurement of
Merle d’Aubigné and Postel [20] score. In the Galia speed. Both of these factors may have influenced the
study [11], positive outcomes were associated with high final status evaluation. Despite the fact that this was a
scores on the Merle d’Aubigné and Postel [20] index. single-center study, the population is highly representa-
Similar results were obtained for most aspects assessed in tive of our region because the center is the reference cen-
the current randomized trial. Significant improvements ter for 4 million people.
were found in comparisons of the two groups for pain,
mobility, and clinical evaluation. Even without differ-
ences between groups in the other areas, the intervention CONCLUSIONS
group showed significant improvement and higher values
in within-group comparisons in the following areas: gen- The developed physiotherapy rehabilitation protocol
eral health, vitality, social functioning, and mental health. implemented in routine care by the hip multidisciplinary
These findings confirm that the Merle d’Aubigné and care group yielded functional improvement in patients
Postel [20] and the SF-36 [19] scores are effective and receiving THA. Results of this study indicate that this
reliable and indicate that the proposed interventions intervention provided pain relief, promoted rehabilitation
result in a clinical application with improvement in most and the reintegration of patients into ADLs (evaluated by
of the issues assessed. social functioning aspects, vitality, general health, and
Several enhanced recovery programs for THA are mental health status), and provided a better quality of life
currently under discussion [43–44]. One of the goals of through the patients’ reintegration into social life [11,45].
these programs is to decrease the length of hospitalization. The results obtained in this study also demonstrated that
Malviya et al. showed that mean overall hospitalization the intervention protocol improved functional capacity
time decreased from 8.5 d (conventional care) to 4.8 d over a short period of time and improved the quality of
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JRRD, Volume 51, Number 10, 2014

life in the vast majority of assessed aspects. In conclu- [PMID:16462520]

sion, these findings confirm that this physiotherapeutic http://dx.doi.org/10.1097/01.bor.0000209426.84775.f8
protocol intervention is a safe tool for accelerating recov- 5. Alviar MJ, Olver J, Brand C, Hale T, Khan F. Do patient-
ery after THA surgery when compared with instructions reported outcome measures used in assessing outcomes in
and demonstrations. Our study emphasizes that the action rehabilitation after hip and knee arthroplasty capture issues
of a physiotherapist is of great importance for the suc- relevant to patients? Results of a systematic review and
ICF linking process. J Rehabil Med. 2011;43(5):374–81.
cessful rehabilitation of the patient after THA surgery.
[PMID:21448553]
http://dx.doi.org/10.2340/16501977-0801
6. Zavadak KH, Gibson KR, Whitley DM, Britz P, Kwoh CK.
ACKNOWLEDGMENTS Variability in the attainment of functional milestones dur-
ing the acute care admission after total joint replacement. J
Author Contributions: Rheumatol. 1995;22(3):482–87. [PMID:7783066]
Study concept and design: C. S. Umpierres, T. A. Ribeiro, C. R. Galia, 7. Trigueiro G. Estudo clínico e radiográfico do fêmur nas
C. A. S. Macedo. artroplastias totais do quadril com a haste não cimentada de
Acquisition of data: C. S. Umpierres, Â. E. Marchisio, L. Galvão, Spotorno. São Paulo (Brazil): Universidade Federal de São
Í. N. K. Borges.
Paulo; 1997. Portuguese.
Analysis of data: C. S. Umpierres, T. A. Ribeiro.
8. Nicolaides AN, Fernandes e Fernandes J, Pollock AV.
Interpretation of data: C. S. Umpierres, T. A. Ribeiro, Â. E. Marchisio,
Intermittent sequential pneumatic compression of the legs
L. Galvão, Í. N. K. Borges, C. R. Galia.
in the prevention of venous stasis and postoperative deep
Drafting of manuscript: C. S. Umpierres, T. A. Ribeiro, Â. E. Marchisio,
L. Galvão, Í. N. K. Borges, C. A. S. Macedo, C. R. Galia. venous thrombosis. Surgery. 1980;87(1):69–76.
Financial Disclosures: The authors have declared that no competing [PMID:6985760]
interests exist. 9. Caiafa JS. Medidas profiláticas da doença tromboembólica.
Funding/Support: This material was unfunded at the time of manu- In: Thomás JB, editor. Síndromes venosas: diagnóstico e trata-
script preparation. mento. Rio de Janeiro (Brazil): Revinter; 2001. Portuguese.
Institutional Review: The research was approved by the Hospital 10. Freburger JK. An analysis of the relationship between the
Ethics Committee and by the Office for Human Research Protections utilization of physical therapy services and outcomes of
and followed the ethical guidelines of the 1975 Declaration of Hel- care for patients after total hip arthroplasty. Phys Ther.
sinki. All patients agreed to participate and provided consent. 2000;80(5):448–58. [PMID:10792855]
Participant Follow-Up: The authors do not plan to inform partici- 11. Galia CR. Avaliação preliminar de um protocolo assisten-
pants of the publication of this study.
cial de artroplastia total de quadril. Rev Fac Méd Córdoba.
2002;59(1):101–7. Portuguese.
12. Bergqvist D, Hull RD. Effective thromboprophytaxis
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