| | A Targeted Home- and Center-Based Exercise Program for People After Total Hip Replacement: A Randomized Clinical TrialPreliminary results presented to the Australian Health Outcomes Conference, August 2005, Canberra, Australia. published online 01 July 2008. Abstract Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. A targeted home- and center-based exercise program for people after total hip replacement: a randomized clinical trial. ObjectiveTo examine the physical function, gait, and quality of life of patients after total hip replacement (THR) randomly assigned to either a targeted home- or center-based exercise program. DesignRandomized controlled trial. SettingRehabilitation research center in Australia. ParticipantsTwenty-three patients with unilateral THR were randomly assigned to a supervised center-based exercise group (n=11) or an unsupervised home-based exercise group (n=12). InterventionThe center-based group completed an 8-week targeted exercise program while under the direct supervision of a physiotherapist. After initial instruction, the home-based group completed the 8-week targeted exercise program at home without further supervision. Main Outcome MeasuresQuality of life, physical function, and spatiotemporal measures of gait. ResultsNo significant interaction (group by time) or main effects of grouping were found. Within each group, quality of life, and stair climbing improved significantly (P<.05) as did Timed Up & Go test and 6-minute walk test performances (P<.05). Walking speed increased by 16cm/s (P<.01), cadence by 8 steps/min (P<.05), step length by 4.7cm (P<.05), and double-support time reduced by a factor of 16%. Step length symmetry showed significant improvement (P<.05) over time. Step length differential between the affected and unaffected limbs reduced from 4.0 to 2.7cm. ConclusionsThe targeted strengthening program was effective for both the home- and center-based groups. No group differences were found in the majority of the outcome measures. This finding is important because it shows that THR patients can achieve significant improvements through a targeted strengthening program delivered at a center or at home. List of Abbreviations: AQoL, Assessment of Quality of Life, BMI, body mass index, LOS, length of stay, MANOVA, multivariate analysis of variance, OA, osteoarthritis, QOL, quality of life, 6MWT, six-minute walk test, THR, total hip replacement, TUG test, Timed Up & Go test, WOMAC, Western Ontario and McMasters University Osteoarthritis Index TOTAL HIP REPLACEMENT is a surgical procedure that is used to improve hip joint stability, QOL, mobility, and locomotion in patients with OA of the hip.1, 2, 3, 4 Early targeted rehabilitation has been shown to reduce hospital LOS without an increase in complication rates after THR.5 However, it is well known that these patients have significant muscular atrophy and weakness in the affected limb that can persist for months after surgery6 with mobility deficits remaining for a number of years.1, 7, 8, 9, 10 Gait dysfunctions and asymmetries, both pre- and post-THR surgery, are also evident in patients with unilateral hip OA.10, 11, 12, 13, 14 This is inherently dangerous because it is well known that gait dysfunctions or lower-limb muscular weakness heighten the risk of a fall15 especially when negotiating uneven terrain such as a step or stair.16 Dysfunction can also lead to reduced physical activity levels, mobility, and living independence. Exercise programs beyond the initial postoperative rehabilitation period have been shown to reduce pain and leg stiffness, improve physical function and lessen the chance of accidental falls in THR patients.17, 18 Generally, these programs have used strengthening exercises and functional tasks such as stair climbing to improve muscular strength and power, walking speed, and mobility.19, 20, 21, 22 A disadvantage of these programs, however, is the need for patients to exercise under the supervision of professional staff at a hospital or rehabilitation center. This makes program delivery expensive due to the high costs associated with supervision, treatment and transport. In addition, some THR patients are excluded because difficulties with mobility and transport to a center preclude participation.23, 24, 25, 26 Studies comparing supervised home- and center-based rehabilitation programs for THR patients have found greater improvements in function and QOL for the home-based patients.27, 28 Studies of unsupervised home-based exercise programs beyond the immediate postoperative rehabilitation period have also reported increases in lower-limb muscle strength and walking speed of patients after THR.10, 22 Furthermore, a home-based rehabilitation program with supervision has been shown to be less expensive and more accessible for THR patients than a center-based program.27 Recent reductions in the hospital LOS after THR surgery have increased the need for the delivery of efficient yet effective exercise programs beyond the initial standard rehabilitation programs completed in the 5 to 6 days postsurgery. The purpose of this study, therefore, was to examine the outcomes of an intensive 8-week exercise program (after the initial inpatient program) completed by THR patients at home without formal supervision or at a center with formal supervision. The first hypothesis was that the 8-week targeted exercise program will improve measures of physical function, QOL, and gait. The second hypothesis was that a home-based program without formal supervision provides the same outcomes as a center-based program with formal supervision. This is important because past work shows that home-based programs are more equitable and cost less to deliver. Methods  This study was a randomized controlled trial. Twenty-five patients who had undergone THR surgery were screened and recruited 8 weeks after surgery. Two of the patients recruited for the study withdrew before the commencement of the exercise treatment. All had undergone uncomplicated, unilateral THR surgery for the primary diagnosis of OA of the hip. Inclusion criteria for the study included the ability to walk at least 45m independently with a mobility aid, independence in sit-to-stand transfer, and the ability to adequately comprehend written and verbal instructions. Patients had been instructed by their surgeon that they were permitted to weight bear as tolerated on the operated hip. All participants gave informed consent. Exclusion criteria were uncontrolled systemic disease, a preexisting neurologic or other orthopedic condition affecting walking, more than 4 weeks physiotherapy postsurgery, and revision surgery or significant postoperative complications, such as significant residual pain or wound infection. Ethics approval for the study was obtained from the Human Research Ethics Committee at Austin Health in Melbourne, Australia. Each of the participants had completed an initial standard inpatient rehabilitation program provided by Austin Health. This involved a 5- to 6-day program of functional tasks such as gait, stairs, and transfers that address specific physical issues related to THR such as circulation, range of movement, and muscular strength. Of these participants, nineteen were discharged with instructions to continue the functional exercises for a period of 3 weeks. These participants were routinely allowed to have up to 4 home visits by a physiotherapist through the Post-Acute Care Program. After these visits they could (if needed) have 1 or 2 further physiotherapy sessions as an outpatient to change gait aids, and progress weight-bearing exercises. The 4 remaining participants were referred to a rehabilitation center where they completed the same functional exercises under physiotherapy supervision for an average period of 15 days. These patients were referred to this program because they had not achieved independence in the functional tasks required for safe discharge after the 5- to 6-day program. Participants met with a physiotherapist who explained the research program and obtained informed consent. They were then randomly assigned to a supervised center-based exercise group (n=11) or to a principal investigator. The center-based group attended the Royal Talbot Rehabilitation Centre twice a week for 45 minutes for an exercise intervention program that included 7 exercises. During the center-based exercise program, a physiotherapist modified the exercises according to the participants' physical performance and kept a record of their progress. The home-based group received an illustrated guide of the same prescribed exercises that included basic instructions for the exercise with illustrations. Participants in the home-based group were not given any further instruction regarding performance of the exercises at home or any advice on progressing or modifying the exercises. Participants in both groups were given a diary and instructed to keep a daily record of the exercises they performed including the time or number of sets and repetitions as well as other therapeutic interventions or physical activities undertaken. Participants underwent an initial baseline assessment of functional tasks, QOL, and gait and repeated the same tests after the 8-week exercise program. The functional tasks included the TUG test, stair climbing, and 6MWT. Physical function, pain, and stiffness were also measured. The TUG test was measured using a high arm chair (seat height, 56cm). Participants were instructed to get up from the chair, walk forward 3m to a line marked on the floor, cross the line, turn around, and sit back down, all at their preferred walking pace.29 The time taken to complete the task was recorded with a stop watch. An initial practice trial was followed by 3 test trials, with a 2-minute rest between trials. The mean of the 3 trials was used in the analysis. The stair climbing test was performed on a set of 4 steps with an adjustable rail (stair riser, 17.5cm; tread, 29.8cm). Participants were instructed to climb the stairs step over step as fast as they could. They were not allowed to pull on the rail but could have their hand on the rail, which was on the side of the unaffected limb, for support. The test was performed twice after 1 practice trial, with a 2-minute rest between trials, and the best score was recorded. Lower-limb power used in climbing the stairs was calculated using the formula: [(weight [in newtons] by height of stairs [in meters]) divided by time (in seconds)].30 The 6MWT was conducted around a 25-m oval track on a flat carpeted surface. Patients walked continuously wearing their usual walking shoes and with a walking aid if required, at the fastest comfortable speed possible to cover the longest distance over 6 minutes.31 Time was measured with a stopwatch and was called every minute. The total distance walked within the 6 minutes was recorded. We used the WOMAC to investigate the effect of training on the patient's symptoms on the affected hip.32 The index consists of 24 questions, divided into 3 sections: pain, stiffness, and difficulty with physical function. The items were scored with the use of a 10-cm visual analog scale, where 0 represents no pain, stiffness or difficulty with physical function with higher scores representing worse functional health. In addition, the AQoL utility instrument, a self-administered health-related questionnaire on QOL, was used to assess the QOL of the THR patients.33 The AQoL instrument assesses the QOL over 5 domains including illness, independent living, social relationship, physical senses, and psychological well-being and is more sensitive to health states than many other similar instruments.34 It is measured on a scale on which zero (0.00) represents death and unity (1.00) is full health. Gait parameters, including walking speed, cadence, step length, step time, the stance time as a percentage of the gait cycle, single-support time for both the affected and unaffected legs, and double-support time, were recorded using a GAITRitea instrumented mat. The mat consists of a flat instrumented (457×90×0.6cm) walkway with a series of embedded pressure sensitive switches connected to a computer installed with GAITRite application software.35, 36 The symmetry index of step length, step time, single-support time, and double-support time was also calculated by the following equation: where SI is the symmetry index, a refers to the affected leg, and u refers to the unaffected leg. A symmetry index value of 0 represents perfect symmetry between the limbs. A negative value indicates the affected limb parameter is less than the unaffected limb parameter, whereas a positive value indicates the affected limb parameter is greater than the unaffected limb parameter. Patients were allowed to practice walking along the GAITRite walkway in bare feet and were then asked to walk at their self-selected speed over 3 trials, with a 2-minute rest between trials. On average there were 2 to 3 complete strides per trial. Exercise Intervention Program The exercise intervention program consisted of 7 exercises that focused on functional tasks, daily living tasks, balance, strength, and endurance. Both groups performed the same exercises. However, participants in the center-based group were provided with advice about how to progress the exercises, whereas those in the home-based group were not given any further instruction on progressing or modifying the exercises. The maximum time period for each exercise was 5 minutes, which included a rest period if required. Participants were instructed to stop an exercise if they felt pain or were tired. Figure-of-eight path walk Participants were asked to walk at a comfortable pace on a figure-of-eight path (total distance, 15m) that was drawn on the floor. They changed direction half way through the 5-minute time allocation. Progression strategies included (in the following order): increase in the number of laps, stepping over obstacles (walking sticks), walking over foam mats, and a combination of walking over the mats and stepping over the obstacles. Sit to stand Participants were asked to stand up from a sitting position (chair height, 53cm) as many times as possible for 5 minutes. Progression included an increase in speed, therefore increasing the number of repetitions. Active single-leg stance Participants were instructed to stand on a line with both feet together. Dots were marked on the floor in a semicircle and the patients were asked to reach with their toes toward the middle dot and then progress outward to the furthest dots and back to the middle dot. The exercise started with the patients standing on their unaffected leg and reaching forward with their affected leg. This process was repeated with alternate legs during the 5-minute time period. A chair was provided at the side so the back of the chair could be used as a support if required. Progression included an increase in speed and therefore an increase in the number of repetitions. Climbing steps Participants were instructed to climb 3 steps (step riser, 18cm; tread, 27cm) then turn at the top and walk down the steps. The rails could be used for support if needed. Progression included an increase in speed and an increase in the number of repetitions. Hip abduction Participants were instructed to stand holding onto a rail or support and abduct their leg then return to the starting position. Alternate legs were exercised. Progression included an increase in the number of repetitions and adding a weight to the ankle. Heel raise Participants were instructed to stand holding onto a rail or support and slowly rise up onto their toes then lowering down to the starting position. The number of repetitions was increased gradually and weights were added for resistance. Side stepping Participants stood on a 10-m line and were instructed to step sideways down the line and back facing the same direction at all times. The total distance was measured during the 5-minute exercise time for progress. Data Analysis A 1-way MANOVA was used to compare the age, mass, height, and BMI of the groups. Due to the number of outcome measures, data were grouped into 2 categories for statistical analysis: (1) general and functional outcomes (pain, stiffness, function), QOL, functional tests (TUG test, stair climbing, 6MWT), walking velocity, and cadence; and (2) spatiotemporal gait measures. Two-way MANOVAs (group by time) with pairwise comparisons were used to examine interaction and main effects of group (center-based vs home-based) and time (pre- vs postexercise) on these measures. An independent t test was used to examine differences in exercise frequency between the groups. All data were reported as mean ± SD and the level of significance was set at the 5% level for all statistical analyses. Results The descriptive statistics of the participants are listed in table 1. No significant group differences in age, mass, height, or BMI were found (F4,18=.702, P=.601). | | |  | Subject Characteristic | Center-Based Group (n=11) | Home-Based Group (n=12) | P | |
|---|
| Sex (male/female) | 3/8 | 4/8 | NA | | | Age (y) | 68.6±9.7 | 66.6±7.9 | .55 | | | Mass (kg) | 76.3±14.4 | 81.6±20.3 | .47 | | | Height (m) | 1.6±0.1 | 1.6±0.1 | .83 | | | BMI (kg/m2) | 28.1±4.5 | 29.6±5.2 | .49 | | | Affected side (left/right) | 5/6 | 6/6 | NA | | | | |
Exercise Frequency The center-based group exercised 4.7 times per week (SD=5.3). They completed 2 sessions of the prescribed exercises under supervision at the center plus an additional 2.7 exercise sessions at home of either the prescribed exercises or other activities such as walking, general exercises at a community gym, swimming, and cycling. The unsupervised home-based group exercised 5.8 times per week (SD=4.3); they completed 3.7 sessions of the prescribed exercises plus an additional 2.1 exercise sessions of either walking, gym work, or cycling. An independent t test revealed no significant difference in exercise frequency of the groups (P=.20). WOMAC, AQoL, and Functional Tasks Table 2 lists the results of the 2-way MANOVA (group by time) analysis for the measures of pain, stiffness, function, QOL, TUG test, 6MWT, stair time, and power. No significant interaction (group by time) effects were found (F10,12=.438, P=.90). Only the post TUG test differed significantly (P=.042) between the groups. For both groups, no significant pre- and post differences were found for the measures of pain and stiffness. Over time, however, both groups significantly improved their measures of function and QOL (P<.05). Both groups showed significant improvements (P<.05) in stair climbing (stair time and power), TUG test, and 6MWT measures. Gait Parameters Table 3 lists the results of the 2-way MANOVA (group by time) analysis for the measures of gait. No significant interaction (group by time) effects or group differences were found for any of the gait measures (interaction: F14,8=1.014, P=.515; group: F14,8=.577, P=.824). Over time (post- vs pre-exercise), both groups significantly increased walking speed, cadence, and step length (P<.05). The participants' step length, for example, on the unaffected limb increased by 10%, whereas it increased by 7% on the affected limb. For the center-based group, step time, percentage in stance time, and double-support time reduced on both limbs (P<.05), whereas it remained unchanged for the home-based group. Over time, single-support time reduced on the affected and unaffected limbs for both groups (P<.05). Step length symmetry showed significant improvement over time for both groups (P<.05). On average, step length differential between the affected and unaffected limbs reduced from 4.0 to 2.7cm. Discussion The targeted exercise program was effective for the THR patients in this study. All outcome measures improved with the majority showing significant improvement by the end of the 8-week program. Function (WOMAC), QOL (AQoL), functional task performance, and gait showed significant improvements. Interestingly, no fundamental group differences were found before or after the exercise program, which provides some evidence that it may be used successfully with or without formal supervision. It is acknowledged that there was no control group (nonexercising) in this study and hence the program's true effect is untested but the results of this study show good outcomes for the patients and previous work17, 18 has shown that exercise programs aid recovery after THR surgery. The diary records showed that the groups were highly motivated and physically active over the 8-week exercise period. It is possible that there was a self-report bias in the recording of exercise sessions by the home-based group, which the authors acknowledge could be a limitation of the study. The improvements in function, pain, and QOL found in this study are supported by previous work27 that reported similar improvements for THR patients after completing an inpatient or home-based rehabilitation program. Other studies of patient recovery after THR have also reported significant improvements in physical function and QOL after home- or center-based programs.28 Reductions in stair climbing and TUG test times combined with an increased distance for the 6MWT were found in this study. This shows improvement in the patients' ability to perform everyday tasks such as chair rising and stair climbing. This is supported by past work that similarly found improvements in functional tests such as the 6MWT and the TUG test for THR patients after a resistance training program.17, 37 For both groups, walking speed, cadence, and step length (both limbs) increased significantly, whereas single-limb support time reduced (both limbs). It is important to note that both groups achieved similar results in these measures after the 8-week program. Previous work has also shown increases in walking speed, cadence, and step length for THR patients after an exercise program17, 20, 37 with some suggesting the changes are due to increased strength of the hip muscles.17, 20 These gait changes are important because any improvement in a THR patient's mobility or ambulation increases their independence in the community.38 The only outcome measure to differ significantly across the groups was the TUG test performance (see table 2). There was no significant group by time interaction, so the groups responded similarly to the intervention. The group difference is due to greater pre- and postintervention values for the center-based group. Asymmetric gait has been shown to predict functional status and falls risk in older persons.15, 39, 40 Moreover, it has been linked to unequal limb loading and joint pathology.13 It is important, therefore, to develop strategies to improve symmetry in patients recovering from THR41 because asymmetric gait has been observed 6 to 12 months after surgery.10, 14 Although an improvement in the symmetry of lower-limb vertical loading has been reported after a walking program in patients with total hip arthroplasty,42 no previous study has specifically examined the effect of an exercise program on the symmetry of the spatiotemporal aspects of gait. This study found significant improvement in step length symmetry for both groups after the exercise program. This outcome is important because it shows that the program may be effective in improving gait symmetry and associated falls risk. Study Limitations Although this study had no control group and sample size was small, the significant results show that functional impairments after THR significantly improved after participation in a targeted exercise program. Conclusions Both groups had similar improvements in physical function, pain, QOL, and gait after the targeted exercise program. The findings suggest the exercise program might be used successfully by THR patients at home. Supplier Acknowledgment We thank Neil Bergman, MBBS, FRACS, for assistance with recruitment of participants for this study. References 1. 1Murray MP, Brewer BJ, Gore DR, Zuege RC. Kinesiology after McKee-Farrar total hip replacement (A two-year follow-up of one hundred cases). J Bone Joint Surg Am. 1975;57:337–342. MEDLINE 2. 2Wilcock GK. Benefits of total hip replacement to older patients and the community. Br Med J. 1978;2:37–39. MEDLINE 3. 3Laupacis A, Bourne R, Rorabeck C, et al. 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a Rehabilitation Sciences Research Centre, University of Melbourne, Parkville, Victoria, Australia b School of Physiotherapy, University of Melbourne, Parkville, Victoria, Australia c Austin Health, Heidelberg, Victoria, Australia.  Correspondence to Mary P. Galea, PhD, School of Physiotherapy, University of Melbourne, Parkville, Victoria 3010, Australia
Supported by Arthritis Australia and the National Arthritis and Musculoskeletal Health Initiative. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprints are not available from the author. Published online June 30, 2008 at www.archives-pmr.org PII: S0003-9993(08)00305-5 doi:10.1016/j.apmr.2007.11.058 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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