Total hip replacement is now a common procedure in most countries. The surgical techniques have improved and the artificial components continue to evolve. The reasons for choosing to have a hip replacement include restoration of functional capabilities, restoring joint motion, and elimination of pain. The pain factor is, in most cases, the predominant deciding factor.
If the results of surgery are analyzed with respect to the deciding factors, the post-operative care provided to the patients can be considered less than optimal. Almost all patients experience dramatic reduction, if not complete elimination, of pain. Because the pain-producing “parts” have been removed, the relief is immediate and long lasting. Of course, there is post-operative pain from the tissues traumatized during the surgery, but this is controlled with medication and resolves in a reasonable amount of time.
Motion also improves immediately. The degenerative joint surfaces have been replaced with new “smooth” surfaces. Some patients may have some residual muscular tightness, but motion limitations are uncommon. If fact, one of the biggest concerns is that the replacement joint could dislocate. Until the muscle stability returns, patients are placed on “motion restrictions / precautions”. These restrictions are accompanied by fear on the part of patients that the joint could dislocate. In some cases, this fear becomes a strong behavioral driver. The patient may limit their activities, even to the extent that joint motion may be lost.
In terms of the return to the activities that had been limited prior to surgery, the results are disappointing in a substantial number of people who have hip replacements. The elimination of pain (satisfaction) combined with the motion restrictions (concern) can become counter-productive with regard to the ultimate functional improvement.
The specific reasons for this are many, but include:
* Self-imposed restrictions based on the fear discussed above
* Limited post-operative physical therapy
* Post-op protocols designed by physicians that (over) prioritize safety at the expense of function
* Lack of physical challenge in the rehab process
* Failure of education programs to teach function-based strategies
The last 3 factors listed above, can be linked to a failure to appreciate the difference between joint motion and joint position. During weight-bearing function, the chances of the hip joint dislocating are small, but increase if the joint is moved to certain positions. The most common restrictions are adducted, internally rotated, and externally rotated positions. It is the valid concern about these positions that leads to the restrictions of the same motions. The motion is not dangerous when allowed based on a functional strategy. In fact, the motion will activate the appropriate muscles that will ultimately provide the joint stability that is desired by the patient, surgeon, and movement practitioner. Motion restrictions need to be renamed Position restrictions, and even the positions need to gradually be re-introduced if function is to be maximized.
Let’s use the example of restricted adduction of the hip. Remember it is an adducted position that is dangerous, not the motion of adduction. The motion of adduction will activate the abductors muscles. This muscle activation and strengthening become an important part of the solution. But how can the joint go though the motion of adduction while avoiding an adducted position? Very simply start with a wide base of support so the hip is in an abducted position. When the motion of adduction occurs, the hip is still in an abducted or neutral position. The beneficial motion is utilized, but the unwanted position is avoided!
The Principles-Strategies–Techniques process (PST) of Applied Functional Science® provides a number of different strategies to allow mobility and stability to be complementary rather than conflicting aspects of the rehabilitation and function-restoration process. Some of these strategies will be demonstrated in the accompanying VLOG.