Supervised or Unsupervised Rehabilitation After Total Hip Replacement Provides Similar Improvements for Patients: A Randomized Controlled Trial


      • A randomized controlled trial comparing home- versus group-based rehabilitation after total hip replacement is presented.
      • There were no differences in outcomes between the groups at any time point up to 26 weeks.
      • For most patients well enough to be discharged from the hospital within a week of surgery, independent (home-based) rehabilitation is a viable option.
      • Longitudinal examination of group differences may provide further insights into the benefits of group-based rehabilitation.



      To determine whether patients do better with unsupervised (home-based) physiotherapy or in an outpatient setting.


      Acute care public hospital in the region, supporting a population of ∼540,000.


      Single-blind randomized controlled trial.


      Adult patients (N=98) after unilateral elective total hip replacement (THR) were randomly assigned to a supervised (center-based) exercise (n=56) or a unsupervised (home-based) exercise (n=42) program and followed for 6 months postsurgery.


      The supervised group attended a 4-week outpatient rehabilitation program supervised by a physiotherapist. The unsupervised group was given written and pictorial instructions to perform rehabilitation independently at home.

      Main Outcome Measures

      Western Ontario and McMaster Universities Osteoarthritis Index; Short-Form 36-item Health Questionnaire (SF-36) mental and physical component summary measures; University of California, Los Angeles activity scale; and timed Up and Go test.


      There were no differences between the groups for any measure. The overall differences between the adjusted means were as follows: Western Ontario and McMaster Universities Osteoarthritis Index, 0.50 (95% confidence interval [CI], −6.8 to 5.7); SF-36 physical component summary, 0.8 (95% CI, −6.5 to 8.1); SF-36 mental component summary, 1.7 (95% CI, −4.1 to 7.4); University of California, Los Angeles activity scale, 0.3 (95% CI, 5.2 to 6.1); and timed Up and Go test, 0 seconds (95% CI, −1.4 to 1.3s).


      The results demonstrated that outcomes in response to rehabilitation after THR are clinically and statistically similar whether the program was supervised or not. The results suggest that early rehabilitation programs can be effectively delivered unsupervised in the home to low-risk patients discharged home after THR. However, the relative effect of late-stage rehabilitation was not tested.


      List of abbreviations:

      CI (confidence interval), MCID (minimal clinically important difference), MCS (mental component summary), PCS (physical component summary), RCT (randomized controlled trial), SF-36 (Short-Form 36-item Health Questionnaire), THR (total hip replacement), TUG (timed Up and Go test), UCLA (University of California, Los Angeles), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)
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      1. Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. Australian Orthopaedic Association, Adelaide2015
        • Badley E.
        • Crotty M.
        An international comparison of the estimated effect of the aging of the population on the major cause of disablement, musculoskeletal disorders.
        J Rheumatol. 1995; 22: 1934-1940
        • Jones C.A.
        • Beaupre L.A.
        • Johnston D.
        • Suarez-Almazor M.E.
        Total joint arthroplasties: current concepts of patient outcomes after surgery.
        Clin Geriatr Med. 2005; 21: 527-541
        • Coulter C.L.
        • Scarvell J.M.
        • Neeman T.M.
        • Smith P.N.
        Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review.
        J Physiother. 2013; 59: 219-226
        • Di Monaco M.
        • Castiglioni C.
        Which type of exercise therapy is effective after hip arthroplasty? A systematic review of randomized controlled trials.
        Eur J Phys Rehabil Med. 2013; 49: 893-907
        • Minns Lowe C.J.
        • Barker K.L.
        • Dewey M.E.
        • Sackley C.M.
        Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials.
        BMC Musculoskelet Disord. 2009; 10: 98
        • Brander V.
        • Stulberg S.D.
        Rehabilitation after hip-and knee-joint replacement: an experience- and evidence-based approach to care.
        Am J Phys Med Rehabil. 2006; 85: S98-S118
        • Sashika H.
        • Matsuba Y.
        • Watanabe Y.
        Home program of physical therapy: effect on disabilities of patients with total hip arthroplasty.
        Arch Phys Med Rehabil. 1996; 77: 273-277
        • Shih C.-H.
        • Du Y.-K.
        • Lin Y.-H.
        • Wu C.-C.
        Muscular recovery around the hip joint after total hip arthroplasty.
        Clin Orthop Relat Res. 1994; 302: 115-120
        • Trudelle-Jackson E.
        • Smith S.S.
        Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial.
        Arch Phys Med Rehabil. 2004; 85: 1056-1062
        • Galea M.P.
        • Levinger P.
        • Lythgo N.
        • et al.
        A targeted home- and center-based exercise program for people after total hip replacement: a randomized clinical trial.
        Arch Phys Med Rehabil. 2008; 89: 1442-1447
        • Mahomed N.N.
        • Davis A.M.
        • Hawker G.
        • et al.
        Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial.
        J Bone Joint Surg Am. 2008; 90: 1673-1680
        • Unlu E.
        • Eksioglu E.
        • Aydog E.
        • Aydoð S.T.
        • Atay G.
        The effect of exercise on hip muscle strength, gait speed and cadence in patients with total hip arthroplasty: a randomized controlled study.
        Clin Rehabil. 2007; 21: 706-711
        • Zahiri C.A.
        • Schmalzried T.P.
        • Szuszczewicz E.S.
        • Amstutz H.C.
        Assessing activity in joint replacement patients.
        J Arthroplasty. 1998; 13: 890-895
        • Bellamy N.
        • Buchanan W.W.
        • Goldsmith C.H.
        • Campbell J.
        • Stitt L.W.
        Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
        J Rheumatol. 1988; 15: 1833-1840
        • Ehrich E.W.
        • Davies G.M.
        • Watson D.J.
        • Bolognese J.A.
        • Seidenberg B.C.
        • Bellamy N.
        Minimal perceptible clinical improvement with the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire and global assessments in patients with osteoarthritis.
        J Rheumatol. 2000; 27: 2635-2641
        • Ware Jr., J.E.
        • Sherbourne C.D.
        The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Wright A.A.
        • Cook C.E.
        • Baxter G.D.
        • Dockerty J.D.
        • Abbott J.H.
        A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis.
        J Orthop Sports Phys Ther. 2011; 41: 319-327
        • Coulter C.L.
        • Weber J.M.
        • Scarvell J.M.
        Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study.
        Arch Phys Med Rehabil. 2009; 90: 1727-1733
        • Steffen T.M.
        • Hacker T.A.
        • Mollinger L.
        Age-and gender-related test performance in community-dwelling elderly people: six-minute walk test, Berg Balance Scale, timed Up & Go test, and gait speeds.
        Phys Ther. 2002; 82: 128-137
      2. Monaghan B, Cunningham P, Harrington P, et al. Randomised controlled trial to evaluate a physiotherapy-led functional exercise programme after total hip replacement. Physiotherapy 2016 Feb 15. [Epub ahead of print].

        • Husby V.S.
        • Helgerud J.
        • Bjørgen S.
        • Husby O.S.
        • Benum P.
        • Hoff J.
        Early maximal strength training is an efficient treatment for patients operated with total hip arthroplasty.
        Arch Phys Med Rehabil. 2009; 90: 1658-1667
        • Rahmann A.E.
        • Brauer S.G.
        • Nitz J.C.
        A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial.
        Arch Phys Med Rehabil. 2009; 90: 745-755
        • Stockton K.A.
        • Mengersen K.A.
        Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial.
        Arch Phys Med Rehabil. 2009; 90: 1652-1657
        • Suetta C.
        • Magnusson S.P.
        • Rosted A.
        • et al.
        Resistance training in the early postoperative phase reduces hospitalization and leads to muscle hypertrophy in elderly hip surgery patients—a controlled, randomized study.
        J Am Geriatr Soc. 2004; 52: 2016-2022
        • Mikkelsen L.R.
        • Mechlenburg I.
        • Søballe K.
        • et al.
        Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations: a single-blinded randomised controlled trial.
        Osteoarthritis Cartilage. 2014; 22: 2051-2058
        • Jan M.-H.
        • Hung J.-Y.
        • Lin JC- H.
        • Wang S.-F.
        • Liu T.-K.
        • Tang P.-F.
        Effects of a home program on strength, walking speed, and function after total hip replacement.
        Arch Phys Med Rehabil. 2004; 85: 1943-1951
        • Australian Bureau of Statistics
        National health survey: SF36 population norms, Australia, 1995.
        Australian Bureau of Statistics, Australia1995
        • March L.M.
        • Cross M.J.
        • Lapsley H.
        • Brnabic A.J.
        • Tribe K.L.
        • Bachmeier C.J.
        • et al.
        Outcomes after hip or knee replacement surgery for osteoarthritis: a prospective cohort study comparing patients' quality of life before and after surgery with age-related population norms.
        Med J Aust. 1999; 171: 235-238
        • Health Quality Ontario
        Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis.
        Ont Health Technol Assess Ser. 2005; 5: 1-91
        • Hurley M.
        • Walsh N.
        • Mitchell H.
        • et al.
        Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial.
        Arthritis Rheum. 2007; 57: 1211-1219