A PHYSIOTHERAPY PROGRAMME FOR THE TOTAL HIP REPLACEMENT

2. To assess the patient initially. This should in ­ clude functional ability ; use, type and number of walking aids: distance capable o f walking: type of gait pattern, lum bar spine, h ip , knee and ankle jo in t range, muscle strength about the hip and knee. In particular patients w ill be examined for positive Trendclenberg sign and fixed flexion deform ity of the hip (which will be corrected routinely during operation if present).

This is especially true in the re h a b ilita tio n o f the Total H ip R e placem ent, e.g. the C h arn le y arthroplasty, and therefore it is im p o rta n t to understand the fu nctio A. Pre-Operative Stage: Pre-operative treatm ent is im p o rta n t for a n u m b e r of reasons: 1.
To find out the history o f the patient.

2.
T o assess the patient in itially . T his sho u ld in clude fu n c tio n al a b ility ; use, type an d nu m b e r o f w alking aids: distance capable o f w alking: type o f gait pattern, lu m b a r spine, h ip , knee and an kle jo in t range, muscle strength ab o u t the h ip and knee. In p articular patients w ill be exam ined fo r positive T rendclenberg sign and fixed flexion d e fo rm ity o f the h ip (w hich will be corrected routinely d u rin g operation if present). Im m ediately post-operativelv. the patient lies supine with his/her head supported by one p illo w , and a trapezoidal C h arn le y a b d u c tio n p illo w (see F ig. 1), be tween the legs, fro m knees to ankles. T his has the advantage o f m a in ta in in g 15° o f h ip a b d u c tio n (to prevent any strain on the greater trochanter) and it is maintained for a week or two.

T o gain
The bed is elevated in itia lly to aid venous return and the patient has an intravenous a n tib io tic drip, 1-2 portovae drains fro m the h ip and o ccasionally a c o tto n wool spica, re m ainin g on for 48 hours. Programme: 1. D eep b reathing (d ia p h ra g m atic and lateral costal) with coughing.

3.
Static contractions are given to the quadriceps and h ip extensors, but not to the h ip abductors.
T his is repeated 4 tim es per day for 4 days.
Points to note: (a) It is im p o rta n t to help prevent pressure sores which tend to occur on the heels.
(b) T he tendency for the patient to lie w ith the hips in external ro tatio n. T his is due to gravity and weakness o f the internal rotators and m ay be pre vented by getting the patient to rotate the whole body till feet are in the neutral p osition, then re laxing the b ody to neutral p o sitio n. A ltern ativ e ly sandbags m ay be used to prevent this.

Programme.
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.)

PHYSIO THERAPY SEPTEM BER 1974
(c) The physiotherapist must instruct the patient, in avoiding possible positions of dislocation, i.e.
(i) The hip must not be flexed beyond 45°, adducted across the m idline or internally rotated.
(ii) The patient is warned not to. cross the legs, or (iii) to force adduction by turning into side lying unsupervised.
(iv) The lockers should be placed on ithe un operated side of the patient. I f the patient should be reaching for this item the operated lim b will tend to stay in a relative position of abduction with relationship to the pelvis. (See Fig. 1).

2.
Pre-Ambulatory Stage: This stage usually com mences between the 5th and 6th day but may vary de pending entirely on the individual's state of fitness. This stage must not be pushed.
Aims of treatment: (a) To get the patient out of bed standing (usually partially weight-bearing) with legs in abduction (weight-bearing itself is considered an exercise).
(b) To allow balance reactions to readjust.
The patient gets out of bed with the assistance of an overhead 'monkey chain', and the opposite leg first m oving towards the side of the bed. Here one can allow up to 45° of hip flexion but the leg must remain in the inner range o f abduction and external rotation is. also avoided. The patient's operated leg should be fully supported by the physiotherapist in the early stages. The patient stands for a few minutes with the hips abducted holding onto the back of a chair. A t this stage the patient m ay be measured for crutches, or previously taken measurements checked.
In getting back to bed the leg is again supported in abduction and less than 45° of flexion and patient uses the chair, opposite leg and overhead monkey chain to assist the manoeuvre.
A t this stage (5th to 6th day) active sling exercises in the pain-free range may be commenced, emphasis being on the functional aspects of range. These, sling exercises are carried out on a modified G uthrie Sm ith suspension system with the Charnley abduction pillow still placed between the legs. (Sec. Fig. 1). Exercises:

1.
Patient does assisted-active hip flexion with passive knee flexion.

2.
Patient does assisted-active hip flexion with knee extension.
3. Patient does resisted hip extension with m anual re sistance through the handle. This may be called auto resisted hip extension.
The above are done one after the other in sequence.

4.
Patient does exercise 2, then moves leg into abduc tion with internal rotation as far as possible. The other leg must be stabilized in extension and abduc tion to prevent pelvis from moving. This may be called assisted-active hip abduction.
The exercises are done on a 10 repetition basis where possible.

3.
Ambulatory Stage: This stage usually begins on the 7th or 8th day post operatively.
Aims of treatment: to teach the patient the correct gait pattern.
The patient starts walking as soon as he/she has good abductor control, is stable on his/her feet with norm al balance. Axillary crutches are used and a three nninl gait is taught.
T h e importance of norm al walking style is stressed A long mirror is often found useful to eliminate anv bad postural habits and faults in gait. y Common Faults in Gait:

1.
Stiff knee gait. The patient tends to rotate pelvis rather than flex the hip through.

2.
A tendency to heel-raise on the opposite leg to compensate for stiffness in hip flexion o f operated limb.

3.
External rotation: As the patient is in the 'push off stage the Charnley leg goes into external rotation.

4.
Patients with bilateral hip arthroplasty often have stiffness in hip flexion and therefore compensate^ by decreasing the lum bar lordoses thus appearing to gain more h ip flexion.

5.
Uneven steps: usually the unoperated leg is brought through quickly.

6.
Patient should flex the knee in front of them.

7.
Clim bing stairs the patient tends to heel-raise on opposite leg in order to compensate for lack of hip flexion in Charnley lim b.
Some patients such as those with rheumatoid arthritis, having severail joints involved, benefit both physically and psychologically from pool therapy.
This may be begun only 24 hours after the sutures have been removed (this is usually between 12th and 14th day).
The patients are encouraged to take as much weight on the h ip as possible.
Patients often experience pain in the knee for the first week after operation and this is attributed to various manoeuvres done during operation.
Sitting: This commences as an activity on the 10th day O N L Y as slope-sitting.
Exercises in sitting such as static contractions of glutei, quadriceps and foot dorsi-and plantar flexion are given.
Before discharge the patient is taught to clim b stairsK slopes and practise is given in turning. The patient isJ also taught how to lie in side lying with pillows between the legs to m aintain h ip abduction.
The patient may also be given general maintenance exercise in a simple home programme and is usually discharged in 2-3 weeks. Patients are instructed about avoiding various positions of dislocation, to sleep on a firm mattress and to walk daily.
They m ay play such sports as bowls, golf, swimming but exercises involving jarring movements such as running are advised against.
C. Average Level of Function at Discharge.
The hip musculature can be generally graded a 3 and the patient does not have fu ll hip flexion. This allows him /her to sit in a high chair, but not to do up his shoe laces.
In general the patient will rem ain on two crutches until the end of six weeks post-operatively, one crutch at the end of eight weeks, then a cane.
They are often free of am bulatory aids by . the end o f three months post-operatively.

Kote on (he Charnley-Muller arthroplasty
Like the Charnley arthroplasty, this is also a metal _ lastic articulation but has a larger femoral head °n j is available in three different neck lengths. It does not necessitate the transfer of the greater trochanter. T h e aim of the design was to provide 110° of motion ( s opposed to about 90° in the Charnley arthroplasty) without subluxation because this range of m otion in excess of 90° is very im portant in many activities of daily living-

Post-Operative Management:
This is much the same as the Charnley arthroplasty but the periods are much shorter. The patient may be walking as soon as 48 hours post-operatively, and re habilitation is generally m uch more rapid.

SEPTEMBER 1974
Summary / The striking feature of this operation is that the patient is subjected to very little or no post-operative stress, in contrast to the rigorous rehabilitation de manded after partial hip replacement such as cup arthroplasty. Provided there is no mechanical mishap 9 or infection, pain vanishes, and because there is no reflex inhibition, movement of the new jo in t is easily regained.
It is also unquestionable that the procedure of total hip replacement demands a high standard of team work am ong the members o f the 'Unit, and successful outcome is dependent on this, factor.

LETTERS TO THE EDITOR
Forest Town School for Cerebral Palsied Children. Firstly, may I acknowledge the article as a valuable summary of the neurodevelopmental approach, which should be useful to all students and therapists who are working in this field. T hat this approach is basic in the treatment of cerebral palsy is now generally ac cepted. (That is why acquisition of knowledge of this approach is a prerequisite in this D epartm ent and eight of the eleven therapists are fully Bobath trained). U n fortunately, the approach falls into disrepute when its disciples fail to keep up with its originators, who declare that they take the ideas of Peto, V oijta, P N F , absorb them, make them their own and use them, also claiming eclecticism (Personal com m unication 1972). This is why the originator o f the approach remains the greatest therapist in the world in the treatment of cerebral palsy.
It cannot, however, be stressed enough that an .eclectic approach can only be successfully employed by therapists with a thorough understanding of norm al development (Peiper 1936) and the disturbances o f motor function in cerebral palsy (as far as present knowledge allows) (Bobath 1972) as well as of the different treatment methods. It is therefore safer for undergraduates or. inexperienced therapists to stick to one approach, even though the end result of treatment may not be as good as it would have been had different methods been used to deal with the multifarious problems which arise in cerebral palsy.
It is also necessary to recognise that different methods of treatment have evolved, using the same sound neurophysiological principles on which the neuro developmental approach is based. One cannot ignore the work o f K a b a t and Knott, R ood, Brunnstrom and Voijta. In addition, as a caution, the oft quoted thought "neurophysiclogic" doctrine is a most perishable com m odity and it is a mistake to pin one's hopes on a current interpretation" (M ead 68).
As far as planning treatment is concerned, do we really w ant to retain prim itive patterns by utilising them early in treatment (as does Brunnstrom) or do we want to inhibit theiir effect and facilitate secondary re sponses? I think that here misunderstanding may be merely a matter of semantics. The argument against surgery and bracing adm irably describes the difficulties which may arise and be perpetuated when conditions for using surgery in cerebral palsy are not favourable. It is absolutely necessary to have a unit where the surgeon is not only conversant with the neurological condition of the child who has secondary orthopaedic problems (Samilson 66) but who is also prepared to work w ith the therapists (H o lt 66), thereby ensuring that the patient is w holly controlled and all treatment integrated.
M ost o f the unfavourable changes should be avoided or overcome, but it should be pointed out that certain others, e.g. circulatory problems, are a prim ary symptom in cerebral palsy (Ingram 73) as are sensory disturb ances. These may in fact be improved by the increased m obility produced by surgery.
As far as the shunting of spasticity is concerned, more recent studies have shown that even simple tendon release often results in unexpected improvement in a tone in a whole extremity as well as the homologous lim b. (N athan and D m itrijevic 1967). This has been one empirical observation also.