Total Hip Replacement


Total Hip replacement is a surgical procedure of removing the diseased the femur head and neck and replacing it with an artificial prosthesis.

Usually the patients considered for the total hip replacements are:

  • Young patient
  • Osteoarthritis of hip joint
  • Rheumatoid arthritis
  • Avascular necrosis
  • Septicemia
There is a progressive increase in chronic pain and difficulty in walking, stair climbing & even rising from a chair.
Difference in Cemented & Uncemented prosthesis:
Cemented prosthesis is usually used in older patients who are less active  and have less bone density.
Whereas uncemented can be used in younger andactive individuals.

The primary disadvantage of uncemented prosthesis is the extended recovery period.
Because it takes a long time for the natural bone to grow and attach to prosthesis, hence the person has to limit his activitites for upto 3 months to protect hip.

Your hospital stay may last for a week, if you go straight home you will need help for several weeks. The following steps can make you homecoming easier:

  1. In kitchen as well as other rooms, place items you use frequently within reach so you dont have to reach up or bend down.
  2. Rearrange furniture so you can walk easuily with walker or stick.
  3. Get a good chair: the one that is firm and higher than average sear
  4. Remove any throw rugs or area rugs that could make u slip.
  5. Securely fasten electrical cords around perimeter of the room.
  6. Install a shower chair, grab bar and raised toilet.
  7. Use assistive devices such as long andle sponge and a grabbing tool or reacher to avoid bending too far.
  8. Wear big pocket shirts or soft shoulder bag for carrying things.

Activities at Home:

  • Keep skin dry and clean,
  • Notify doctor if your wound drains.
  • Swelling is normal for first 3-6 months. elevate leg slightly <30 degrees on pillow and put ice pack for 15 20 min.
  • If u have calf pain, chest pain and shortness of breath notify immediately.

Resuming Activities at Home:
Once you get home, stay active. The KEY is not to overdo it, while you expect some good days and some bad days, you should notice gradual improvement over time.

Weight Bearing
Discuss with you physical therapist regarding the weight bearing of the operated leg as the rehabilitation protocol will be different for cemented and uncemented.

Driving
You can begin driving an automatic car in 4 to 8 weeks after consulting your doctor and your symptoms post surgery.

Sex
Some form of sex positions can be safely resumed 4-6 weeks after surgery. Ask you doctor regarding the same.

Sleeping positions

  • Sleep on you back with legs slightly apart on your side with abduction pillow.
  • Be sure to use pillow atleast 6 weeks ot untill doctor says not to use,Sleeping on stomach is alright,
Sitting
  • For atleast 3 months sit only on chairs that have arms.
  • Do not sit on low chair, reclining chairs.Donot cross your legs at knees.
  • Get up and move around possibly every 1 hour.

Climbing

  • Stair climbing should be limited if possible untill healing is far enough.
  • If you must go up stairs- The unaffected leg should step up first, then bring affected leg up to same step, then bring your cane.
  • To go down- Put cane first, next bring affected leg down to that step, finally step down with unaffected leg

Return to work:
Depending on the type of activiies you perform it may take as long as 3 months or 6 months to return to work.

Other activities:

  • Walk as much as you like once doctor given you go ahead, but remember don’t substitute walking for your prescribed exercise.
  • Swimming is recommended once sutures are removed and wound is healed, apporox 6-8 weeks after surgery,
  • Acceptable activities are dancing, golfing with spikeless shoes and cart , bicycling on level surfaces.
  • Avoid activites that involve impact or stress on joints such as tennis, badminton, contact sports such as baseball, football, squash, jumping or jogging
  • Lifting weight is not problem but carrying heavy awkward object thatr cause you to stagger is not advised esp if you must go up or down stairs or slopes

DOS AND DONTS:
The dos and donts vary depending on orthopaedic surgeon’s approach.
Your doctor and physical therapist will provide you with a list of do’s and dont’s to remember with your new hip.
The precautions will help you to prevent the new joint from dislocation and ensure proper healing.

  • Do not cross your legg at the knees for atleast 8 weeks
  • Do not bring your knee up higher than your hip
  • Do not lean forward while sitting or as you sit down
  • Do not try to pick something onfloor while you are sitting
  • Do not turn your feet excessively inward or outward when you bend down
  • Do not reach down to pull your blankets when lying in bed
  • Do not bend at waist beyond 90 degree
  • Do not stand pigeon toed
  • Do not kneel on knees on un operated leg
  • Do not use pain as a guide for what you may or may not do.
DO cut back on your exercise if your muscle aches but dont stop doing exercise.
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Core Muscles of Neck and Exercises


Everyone talks about strengthening of “CORE MUSCLES” to prevent back pain but, we rarely hear or talk about the core muscles of neck.
Research shows that 70% people experience neck pain at some point in their life.The cause of injury may range from accident to use of wrong pillow causing strain in their neck. Any injury has shown to inhibit recruitment and strength of muscles in neck. And these muscles are your DEEP NECK FLEXORS or Core muscles.
Similar to lumbar spine, cervical spine uses these deep muscles to ensure the intersegmental spinal control.

DEEP FLEXOR MUSCLES

Small stabilizing muscles are located in anterior and antero-lateral part of cervical spine. They are located deep to sternocleidomastoid.

LONGUS COLLI
ORIGIN and INSERTION
Superior oblique arises from anterior tubercle of transverse process of third fourth and fifth cervical vertebra and inserted into narrow arch of the tubercle of atlas.
Inferior fibres originate from first 2 or 3 bodies of thoracic vertebrae and is inserted intoanterior tubercle of the transverse process of 5th and 6th cervical vertebra.
It is the most common muscle injured during whiplash injuries.
Longus colli with other muscles forms a sleeve to stabilize the neck in antigravity positions.

LONGUS CAPITIS
ORIGIN and INSERTION
It arises from four tendinous slips from the transverse processes of third, fourth, fifth and sixth cervical vertebra and is inserted into inferior surface of basilar part of occipital bone.

Both the muscles together perform following role:

  • Responsible for initiating or starting neck flexion movement.
  • reduce shearing force across cervical facet joint and disc.
  • maintain neck posture.

Patients with neck pain exibit an increased EMG amplitude of superficial sternocleidomastoid and scalene muscles and decreased activation of deep flexors which causes a decrease in range of motion.
A low load program for craniocervical flexion exercise focusing especially on motor control of deep neck flexors have shown to reduce neck pain and headaches.

chin tuck in

EXERCISES TO ACTIVATE CORE MUSCLES


1) CHIN TUCK IN EXERCISE:
Lie on the floor with neck supported.Tuck your chin in or push your head on the floor without bending your neck. Repeat the exercise for 12 counts for 2 sets. Gradually try to hold each count for 5sec.

2)HEAD LIFT EXERCISE
Lie on the floor. Tuck your chin in and lift the head just 3-4 inches above the floor and return.

3)NECK FLEXION
Ask the patient to lie on the floor with knees bent and feet on floor. Put finger at base of the skull and lift about 1/8th inch off the floor. Make sure the neck is not liftitng off the floor. Remember core exercises are slow movements. Feel down  for a bony bump (7th cervical vertebra). Now ask patient to lift the neck till this bump and the skull but not the rest of the neck. Now gradually ask to release it.

4)BIOFEEDBACK
You can also keep a pressure sensor or pressure cuff beneath patients neck and ask him to slowly nod as if saying yes.Ask him to hold the position 2mmHg above the baseline and gradually increase the baseline to 4,6,8 10 mm Hg and 10 Sec hold. Highest level acheived in 10 repetitions 10 seconds hold.

PERFORMANCE INDEX MEASURE
Number of times patient can hold pressure level, multiply  it by pressure increment. For example: if patient can achieve 4mmHg and could do 6 repetitions of 10 sec hold without breaking the form then the performance is 24. The highest is 100 that is 10 mmHg and 10repetitions.

5) CRANIOCERVICAL FLEXION WITH CERVICAL FLEXION
It works on deep as well as superficial muscles.
Tuck in the chin and lift the head off  so that chin touches the chest.

PROGRESSION
a) Using resistance with help of theraband or manually applied resistance.
Patient is supine. The resistance is applied manually  and the patient is asked to do 12 repetitions of craniocervical and cervical flexion.
 Perform 3 sets of 12 repetitions for 2 weeks then by 4th week perform 15 repetitions.

 b) In quadruped position
Ask patient to assume quadruped (on all four) position and perform chin tuck in or nods without bending the neck.

EXERCISE IN FUNCTIONAL POSITION


a) Sit with feet flat n buttock supported.Gently roll the pelvis forward on ischial tuberosity.
Instruct the patient to move thorax slightly up and forward for slight lift.Gently and minimally lift the occiput to position the head in neutral position away from cervical extension.

b) Also, Patient must be taught to maintain optimal neck position while performing upper extremity task.

Shoulder blade stabilization is integral part of stabilization of neck and hence shoulder blade exercises should also be performed.

Also a heat pad can help to relax the muscles and the perform the exercises, make sure that mild stretches are done after the exercises are over.
While performing all exercises breathing is very very important. Make sure during the course of exercise you donot hold your breath and perform the exercise.

Thus, training these muscles along with the treatment commonly practiced by the physiotherapists will serve to prevent the later complications or recurrence of any chronic dysfunction.

 DISCLAIMER: The above given program is a general guideline to introduce the importance of the concept of core muscles of neck. Do thoroughly assess your patient before attempting any of the exercises.

Aquatic Cardiac Rehabilitation


Aquatic exercises are popular because of the buoyancy afforded by water which lowers joint stress and resistance created by moving one’s limb through water.


Recently water based activity is also becoming popular in cardiac rehabilitation. But it’s still controversial because of the safety concerns put forth by many doctors.

SAFETY CONCERNS:
Physiological changes after immersion could jeopardize diseased myocardium.

Possible problems
Physiological changes
Possible clinical outcomes
Increase in central blood volume
Increase stroke volume and cardiac output and left ventricular   volume.
Decrease in heart rate
Increase in left ventricular wall stress, angina, ST depression.
Cold Water exposure
Increase in PaCO2 and decrease in heart rate
Increase in ventricular irregularity
Increase in arrhythmia


PRACTICAL CONCERNS:
Heart Rate:  As its difficult to monitor it, there might be a problem in deciding intensity for exercise prescription
Monitoring: ECG and Blood pressure monitoring also becomes difficult.

PATIENT SELECTION:
Exercise is most beneficial for LOW-MODERATE RISK cardiac patients who either like swimming or have orthopedic or arthritis problems which may increase by land based exercise.
Water based exercises are particularly beneficial for individuals with peripheral vascular diseases. Particularly if temperature is 30-33 degree Celsius.Warmer water facilitates vasodilation and added buoyancy afforded by water decreases lower limb stress, allowing longer exercise duration.

EXERCISE PRESCRIPTION CONSIDERATIONS:
Water temperature: 26- 33degrees
Temperature at lower end is better for heat dissipation while upper end temperature is comfortable for most of the patients. If patient has orthopedic or PVD better is upper end temperature. Temperature should never be less than 15 degrees.

INTENSITY:
40-85% of the functional capacity. Start with a 40-50% of the functional capacity.

FREQUENCY AND DURATION:
Perform exercise at least 3 days per week
Aerobic portion: 20-30min. If you are performing Swimming: 1000 yards (500-2000) and Walking: 400-700 yards/workout
Warm up and cool down is very important. Warm up can be done for 3-5 min of stretches and light calisthenics on pool deck And Cool down in water3-5 min free standing and wall stretches.

MONITORING:
Frequent monitoring of Blood pressure and heart rate.
ECG should be done during early stages

EMERGENCY PROCEDURES: The staff should be well trained for CPR and defibrillator should also be present.

AQUATIC ACTIVITIES /EXERCISES:

1) WATER WALKING
It’s one of the safest and easiest activity. Energy cost is determined by depth, speed, and degree of arm involvement.The depth of the water should be between thighs and chest so as to have a greater energy cost. Going deeper may decreased the cost as buoyant forces affordable by water offsets the increased resistance that comes from having water coverage over greater body surface area. Energy cost increases with increase in speed. To increase intensity involve arms. Arms can be used in simulated swimming motion either above (front crawl)or below breast stroke.

2) GAIT TRAINING
Gait training and submerged interval training help you gain benefits of jogging or running without added impact on joints.
Similarly stretching and extensions help in flexibility with help of underwater leg movements such as kicks, bicycling maneuver and lateral rises.

THE PLOW
It’s a type of gait exercises .Once you are comfortable walking and jogging in water try using a wide hand held exercise tool called plow to increase resistance of your gait.
According to study in Journal of Athletic training: plow exercise mimics physical demands of aerobic sports like football and should be completed in shallow water sprints of 6 to 10 sec interval.

3) BUOYANCY RESISTED STERTCHES
Basic stretches: recovering joint .more intense variety can be used to create aerobic effect
Begin with underwater kicks.
Added effect: stretch your leg as much possible during end of each kick and gradually increase power and speed. If it’s difficult perform lunge/lateral raise in shallow water.


3) SWIMMING

Variants of strokes. For modified backstrokes, side strokes and breast strokes intensity can be controlled by most of the patients.
Front crawl not recommended by many people.



4) SWIMNASTICS/ WATER AEROBICS

These are Upright group water exercises, essentially aerobic dance conducted in water
5-10 min warm up in water then a 15-20 min of aerobic arm and leg exercise and 5 min cool down, resistive movements can also be done with help of  water dumbbells, floats/paddles.

Aqua stepping: step aerobics using weighted steps can also be done.

5) WATER VOLLEYBALL
Fun alternative: Played in shallow end. Water level: waist to nipple level. It should not be replaced to aerobics.

RECENT EVIDENCE:
Training induced increase in NO metabolites in CHF and CAD : an extra benefit of water based exercise. (European Journal of cardiovascular prevention rehabilitation Aug 2009)

CONCLUSION OF THE STUDY:
The cardio respiratory capacity of patients was significantly improved after rehabilitation.Water based exercise seemed to effectively increase the basal level of plasma nitrates. Such changes may not be related to an enhancement of endothelial function and may be important for health of patient.

DISCLAIMER: Please consult your doctor before attempting any of the above exercises.