Recovery of physical functioning after total hip arthroplasty
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AbstractPurpose. The overall aim of this thesis was to examine recovery of physical functioning in patients with hip osteoarthritis (OA) during the first year after total hip arthroplasty (THA). The specific aims were 1) to examine the desires of a group of patients regarding improvements in physical functioning before they underwent THA and at three and 12 months after surgery, 2) to examine changes in physical functioning during the first year of recovery and examine which preoperative measures predicted outcomes in walking distance at 3 and 12 months after surgery, and 3) to examine the immediate and long-term effect of a walking skill training program performed between three and five months after surgery on physical functioning.
Materials and Methods. This study had a prospective, longitudinal design. Patients with hip OA scheduled for primary THA were consecutively recruited from two hospitals the day they were hospitalized for surgery (Paper I-III). One hundred and three patients were included in the study. Assessments were performed four times; before surgery, and at three, five, and 12 months after surgery. At three months, 68 patients were randomly allocated to a training group (n = 35) or a control group (n = 32) without supervised physiotherapy (Paper III). The walking skill training program comprised two sessions a week for a total of 12 sessions. It consisted of functional exercises and activities in a weight-bearing position aimed to improve walking, muscle strength, flexibility, balance and endurance. There were continuous supervision and feedback from a physiotherapist during the training sessions.
Both performance-based and self-reported measures were applied. The performancebased measures in Papers II and III were the 6-minute walk test (6MWT), which was the primary outcome measure in Papers II and III, the stair climbing test (SCT), the figure-ofeight test, the Index of Muscle Function (IMF), and the active hip range of motion (ROM). Self-reported outcome measures were a modified version of the Patient Specific Functional Scale (PSFS) in Paper I, the Harris Hip Score (HHS) and the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) in Papers II and III, and the self-efficacy for physical activity in Paper III.
The free-text responses from the PSFS were coded according to the International Classification of Functioning, Disability and Health (ICF) to the 1st, 2nd, and 3rd category levels (Paper I). Group differences were analyzed by student sample t-tests (Paper II and III). Differences over time within groups were examined by Friedman’s test (Paper I), one-way repeated measures analysis of variance (ANOVA) (Paper II), and differences in changes over time between groups with adjustment for sex and pretest scores were examined by analysis of covariance (ANCOVA) (Paper III). Relationships were analyzed by bivariate and multivariate regression analyses (Paper II).
Results. Eighty-eight percent of the desires of improvements in physical functioning reported by the patients were classified into the Activities and Participation component of the ICF, while 12 % were classified into Body Functions and Structures. The categories of Walking (d450), Moving around (d455) and Recreation and leisure (d920) included about half of the responses at all the assessment times. At three months after surgery, there were fewer responses classified into the Recreation and leisure category, while more responses were classified into the category of Dressing (d540). The number of functional improvement desires decreased during the first postoperative year (P < 0.001) (Paper I).
In performance-based measures of physical functioning, small improvements were found from preoperative to three months postoperatively in 6MWT (P < 0.01) and SCT (P < 0.05) scores, while all measures of physical functioning had improved from three to 12 months postoperatively (P ????????.001). In contrast, all the self--reported measures showed substantial improvements at three months with small further improvements at 12 months (P < 0.001). Older age, being a woman, impaired preoperative 6MWT distance and hip ROM predicted a worse outcome in 6MWT at three and 12 months (P ????????????????0.01)(Paper II).
The training group had larger improvements than the control group immediately after the intervention on 6MWT with an adjusted mean group difference of 52 meters (95% CI 29, 74; P < 0.001) and on the SCT of -1 (-2, 0) second (P = 0.01). There were also differences between the groups in the figure-of-eight test (P = 0.02), IMF (P = 0.001), active hip ROM in extension (P = 0.02), HHS (P = 0.05), and self-efficacy (P = 0.04). On the 6MWT the difference between the groups persisted at 12 months after surgery with an adjusted mean group difference of 52 (24, 80) meters (P < 0.001) and on the SCT of -1 (-3, 0) seconds (P = 0.05) (Paper III).
Conclusions. The patients wanted to improve the ability to walk long distances and to participate in usual recreation and leisure activities. Their physical functioning improved during the first year after THA, and those with poor preoperative walking distance gained the most from surgery. Age, sex and preoperative walking capacity and hip flexibility predicted postoperative walking capacity. The walking skill training intervention was effective in improving walking capacity and no adverse events were registered. The effect still sustained one year after surgery.
List of papers. Papers II and III are removed from the thesis due to publisher restrictions.
Paper I Heiberg KE, Ekeland A, Mengshoel AM. Functional improvements desired by patients before and in the first year after total hip arthroplasty. BMC Musculoskelet Disord 2013;14(1):243 doi:10.1186/1471-2474-14-243 Copyright 2013 Heiberg et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
Paper II Heiberg KE, Ekeland A, Bruun-Olsen V, Mengshoel AM. Recovery and prediction of physical functioning outcomes during the first year after total hip arthroplasty. Arch Phys Med Rehabil. 2013;94(7):1352-9. doi:10.1016/j.apmr.2013.01.017
Paper III Heiberg KE, Bruun-Olsen V, Ekeland A, Mengshoel AM. Effect of a walking skill training program in patients who have undergone total hip arthroplasty: Followup one year after surgery. Arthritis Care Res (Hoboken). 2012;64(3):415-23. doi:10.1002/acr.20681