Table 1 Characteristics of randomised controlled trials on hip arthroplasty rehabilitation interventions to improve functional outcome

Galea et al., 2008 [20]

Home based group (n = 12);

Centre based group (n = 11)

Centre and Home

8 weeks

Immediate post-operative period

All participants: Standard inpatient physiotherapy with functional tasks, instructions to take home and 4 visits at home by physiotherapist

Home group: Exercise as above with no advice or further instruction

Centre group: 2 visits/week for 45 minutes each time. 5 bouts of exercise per week

No differences in both groups at final follow up although all parameters improved significantly from baseline in both groups.

Timed up and go: centre 11.1 ± 2.5 s vs home 11.7 ± 1.5.

6 minute walking test: centre 427 ± 78.2 m vs home 457.8 ± 112.2 m.

Stair Climb: centre 3.1 ± 1.8 s vs. 2.9 ± 0.5 s.

None recorded

Patients had significant access to advice and physiotherapy visits. Even though they had the instructions and no advice in the home group, as part of standard protocol, they could all see physiotherapists on a further 3 or 4 occasions if they requested it.

Giaquinto et al., 2010

[21]

Control (n = 33), Intervention (n = 31)

Centre

6 months

< 10 days

Control group: Physiotherapy + 'neutral' massage of scar

Intervention group: Hydrotherapy in special pool for 40 minutes after 20 minutes of passive joint exercises

All sessions performed x6/week for 3 weeks

At 6 months:

WOMAC pain subscale:

No pain 45.6% intervention group vs. 23% control

WOMAC stiffness subscale:

No stiffness 67.7% intervention group vs. 35.8% control

WOMAC function subscale:

Score of 0 in function 19.3% intervention group vs. 2.56% control

None recorded

-3 week follow-up data initially reported by authors showed objective improvements in speed; stance for example but no further attempt was made to see if this was maintained at 6 months.

-No absolute values of the WOMAC subscales given? effect sizes between groups

Greameaux et al., 2008

[22]

Intervention n = 16; Control n = 16

Centre

45 days

Immediate post-operative period

Intervention group: low frequency electrical stimulation of both quadriceps and calf muscles bilaterally. 1 hour session 5 days a week for 5 weeks and conventional physiotherapy (2 hours a day for 5 days/week for 5 weeks (25 sessions))

Control group: Conventional physiotherapy - range of motion exercises, muscle strengthening static and dynamic

Maximal isometric knee extension:

Significant ↑ in power of operated limb for intervention vs control (66.7 N(77%) vs 26.7 N(23%)), p < 0.05.

No significant difference for length of stay nor walking assessment (6MWT and 200 mFWT)

None recorded

-Small sample size

-Absence of a true placebo group

-Absence of standardisation for the rehabilitation programme

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Hesse et al., 2003 [23]

Control n = 40

Intervention n = 40

Centre

12 months

Within 3 weeks post-operatively

All patients: 45 minute individualised treatment on each of 10 consecutive days including passive physiotherapy (massage, heat ultrasound), group therapy in pool.

Control: Passive hip and knee mobilisation, strengthening of hip abductor and extensor muscles, gait retraining on floor and stairs

Intervention: Treadmill training after above hip and knee mobilisation(20 min days 1-5); days 6-10, 35 minutes treadmill training with 10 minutes physiotherapy

Primary outcome:

Harris Hip Score: Intervention vs. control significantly higher (p < 0.0001) at 10 days (13.6 points), 3 months (8.9 points) and 12 months (16.5 points).

Secondary outcomes:

No change in walking velocity between groups

Mean interval to abandon crutches 3.2 wks intervention vs 7.9 wks control

At end of 10/7 program, for intervention group:

Hip extension deficit 6.8° less

Gait symmetry 10% greater

Affected hip abductor stronger

Amplitude of gluteus medius activity 41.5% greater (ALL above p < 0.0001)

Above differences persisted at 3 and 12 months

None recorded

37.5% drop out rate at 1 year

Husby et al., 2009 [24]

Control (n = 12)

Intervention (n = 12)

Centre

5 weeks

Within 1st week postoperatively

Control: Inpatient rehabilitation treatment with sling exercise therapy in hip abduction/adduction, flexion/extension; low resistance exercises for 1 hour, 5 days a week for 4 weeks. Patients discharged before 4 weeks had outpatient treatment 3×/week and were encouraged to do exercises at home 2×/week.

Intervention: Above regime and 5 training bouts per week: ~10 minute warm up then stationary cycling at Vo2 max 50%; strength training with 2 exercises leg press and hip abduction on operated leg only. 4 series with rest periods of 2 minutes

Bilateral leg press: 40.9% improvement in intervention vs. control group at 5 weeks (p < 0.002).

Operated leg strength increased by 65.2% vs. control at 5 weeks (p < 0.002)

Abductor strength in operated leg 87% more pronounced in intervention vs control at 5 weeks (p < 0.002).

No difference in gait parameters and health related quality of life outcomes (SF36) at 5 weeks between groups.

For work efficiency, the intervention lowered the heart rate by 11.4% relative to the control group at 5 weeks and it also led to a 32.3% trends towards better work efficiency (p = 0.065) after 5 weeks.

None recorded

Lack of adequate sample size to demonstrate significant differences in parameters used to assess work efficiency

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Jan et al., 2004

[25]

Control (n = 29),

Intervention (n = 29

Home

12 weeks

At least 1.5 years

Control group: no exercises

Intervention group: 12 week exercise program inclusive of hip flexion range of motion, isotonic strengthening of hip flexors, extensors and abductors using ankle weights, walking + weekly telephone calls

Strength measured with an isokinetic dynamometer.

High compliance intervention group, n = 13(> 50% adherence to protocol), showed significant improvement in strength of hip abductors, flexors and extensors on both operated and non-operated legs, as well as greater walking speed and functional activity component of Harris hip score compared to low compliance group, n = 12 and normal control.

None recorded

Subjects in the intervention group were not allowed to visit any physiotherapy department but if they raised issues with the program, they were invited to return to the laboratory for further instructions. No detail is given as to what proportion of the cohort required this and how often.

Jesudason et al., 2002

[26]

Intervention n = 21; Control n = 21

Centre

7 days

1st post-operative day

Control group: Standard protocol for mobilisation, progression of mobility as determined by treating physiotherapist

Exercise group: Bed exercises; hip, knee, ankle range of movement exercises. Progressed from 5 repetitions once a day to 10 repetitions as tolerated 2-3 times per day

Pain severity:

Significant ↓ in pain (p = 0.01) in both groups from days 3-7 post-op.

No significant difference in both groups in terms of hip flexion, abduction range of movement, function using the ILOA scale, or length of stay at 3 or 7 days post-operatively.

None recorded

Short intervention

Short period of follow up

No objective assessment of muscle strength

Liebs et al., 2010

[27]

Hip arthroplasty subgroup.

Control n = 104; Intervention n = 99

Centre

24 months

2 weeks postoperatively

Control: No ergometer cycling

Intervention: Physiotherapist guided sessions with ergometer initially. Sessions 3/week for ≥3 weeks.

All patients: standard program of physiotherapy including range of motion exercises, ADL based movements and walking on stairs and uneven surfaces

Primary outcomes:

WOMAC function subscale: Intervention more improved than control at 3 months (16.4 vs. 21.6 (p = 0.046)) and 24 months (9 vs. 14.7 (p = 0.019))

Secondary outcomes

WOMAC stiffness subscale: Intervention more improved than control at 24 months (13.4 vs. 18.6 (p = 0.047))

WOMAC pain: Intervention more improved than control at 3 months (11.1 vs. 15.9 (p = 0.049))

Improvements also noted in intervention vs control in Lequesne hip and knee score (at 24 months), SF36 (6 and 24 months) and patient satisfaction (92% vs. 80%)

1 dislocation in both groups

Mixed hip and knee arthroplasty population

77% follow up at 24 months

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Mahomed et al., 2008 [28]

Home based n = 115;

Centre based n = 119

Home/Centre

12 months

On discharge from hospital

All patients: standard physiotherapy regimen: deep breathing, coughing, active and assisted bed/chair gait training

Home regime: Referral to community team: nursing, home support etc. Patients discharged when functionally improved as determined by attending therapist

Centre-regime: 14 day stay in rehab centre with established pathway (regime not specified)

Primary outcomes:

WOMAC function subscale: no difference between groups at 3 and 12 months

Hip and Knee satisfaction scale: no difference between groups at 3 and 12 months

SF36 short form: no difference at 3 and 12 months

Impatient rehabilitation more expensive than home based ($14531 vs. $11082)

2% dislocation rate in both intervention and control groups

Hip and knee arthroplasty patients included. No specific detail given for hip population

Munin et al., 1998

[29]

Mixed hip and knee arthroplasty.

Total n = 70

Hip cohort:

Control n = 12;

Intervention n = 14

Centre

16 weeks

Immediate post-operative period

Intervention group: Commenced rehabilitation protocol at 3 days post-op

Control group: Commenced rehabilitation protocol at 7 days post-op.

Median length of stay: intervention 12.2 days vs. control 14.8 days

Cost of surgery and rehabilitation lower for intervention ($28256) than control ($29437).

RAND 36 functional self assessment: No difference between both groups through the follow-up period

1 dislocation each in control and intervention groups

Mixed hip and knee arthroplasty population

Analysing both hips and knees together, the intervention group shows more rapid attainment of short term functional milestones such as ambulation, walking distance and stair climbing ability at 6-10 days post-op. No difference existed for stratifying patients to type of surgery.

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Rahmann et al., 2009 [30]

Control n = 17, Aquatic group n = 18, Water exercises n = 19

Centre

180 days

From post-op days 4 - 10

All patients: Standard physiotherapy x1/day

Ward control: as above

Water exercise group: General exercises in water but not targeted at specific functional retraining in the aquatic environment (40 minutes once daily till discharge)

Aquatic group: Hip abductor/adductor exercises with increasing progression- squat, heel raises in various positions in pool (40 minutes once daily till discharge)

Hip subgroup:

No significant difference across the 3 groups for primary outcomes such as hip abductor strength, 10 m walk, WOMAC score and secondary outcomes such as timed up and go, quadriceps strength.

None recorded

Mixed group of hip and knee arthroplasty patients

Small number of participants

Smith et al., 2008

[31]

Control n = 30; Intervention n = 30

Centre

6 weeks

Immediate post-operative period

Control group: Standard gait re-education protocol from post-operative day 1

Intervention group: Gait re-education with programme of bed exercises from day 1 including; active hip flexion, ankle dorsi/plantarflexion, static quads and gluteal exercises. 10 repetitions each, 5 times a day during hospital stay. Patients encouraged to continue same regime on discharge

Iowa level of assistance (ILOA): Significant improvement from baseline in both groups but no difference in both groups at 3 days and 6 weeks

SF12: No difference in both groups

At week 6, 1 dislocation in control group; no dislocations recorded in intervention group

No concealed allocation of randomisation so possible selection bias

No objective assessment of hip strength performed

Stockton et al., 2009 [32]

Control n = 27;

Intervention n = 30

Centre

6 days

Immediate post-operative period

Control group: Once daily physiotherapy including mobilisation exercises and transfer practice. Encouragement to perform 4× daily till independently mobile

Intervention group: 2 physiotherapy sessions per day. Similar protocol to above

Length of stay:

No significant difference -Intervention (8.2 days) vs control (8 days)

ILOA: Significant difference at 3 days (intervention 28.5 vs control 32.2 (p = 0.041) but not at 7 days (intervention 18.2 vs control 20.6)

None recorded

Length of follow up

No objective measurement of muscle strength

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Suetta et al., 2004

[14]

Total n = 36;

Standard rehabilitation (SR) n = 12,

Electrical stimulation (ES) n = 11,

Resistance training

(RT) n = 13

Centre/Home

12 weeks

Immediate post-operative period

SR: 15 exercises in 2 parts. 1^st part 6 bed exercises; 2^nd part knee extensions in seated position and hip abduction, knee flexion, step training and calf stretching while standing. The attending physiotherapist added ambulation and transfer during the inpatient stay. Exercise was encouraged in the home setting 2×/day and attendance was arranged at a physiotherapy department once a week.

NM: Electrodes placed over quadriceps of operated leg 5 cm below inguinal ligament and 5 cm above patella. Pulse rate 40 Hz, pulse width 250 μs, stimulation ~10 s with 20 s of rest. Total stimulation 1 hour per day for 12 weeks.

RT: Unilateral progressive resistance training for quadriceps of operated leg. Exercises included knee extension in seated position with sandbags on ankles, leg presses in supine position, supervised by trained physiotherapist. Intensity increased from 50% of 1RM in week 1 to 65% 1RM weeks 2-4, 70% 1RM weeks 5, 6 and 80% 1RM last 6 weeks. For each session patients performed 3-5 sets of 10 repetitions during weeks 1-5 and 2-5 sets of 8 repetitions weeks 6-12.

Length of Stay:

RT led to the shortest length of stay compared to ES and SR (10 ± 2.4 days vs. 12 ± 2.8 and 16 ± 7.2 respectively). The difference (37%) between RT and SR was statistically significant (p < 0.05).

Functional performance:

Gait speed: RT ↑ maximal gait speed by 30% at 12 weeks (p < 0.001) whilst ES increases it by 19% (p < 0.05). No increase was seen in the SR group.

Sit to stand: RT ↑ 30%, ES ↑ 21% (both p < 0.001) at 12 weeks. SR no improvement.

Stair Climb: RT↑ 28% (p < 0.005), ES 21% (p < 0.001). SR no improvement.

Quadriceps cross sectional area (CSA):

At 12 weeks, CSA of operated leg was ↑12% in RT group, ↑7% in ES group and ↓9% in SR group (all p < 0.05). The non-operated leg was unaffected in all the groups.

Peak torque on operated leg at 12 weeks was ↑22% in RT group (p < 0.05) and unchanged in ES and SR groups. No change was noted in any of the groups for the non-operated leg.

None recorded

No assessment of compliance in the SR group

No documentation as to whether ES group received additional support for ambulation and transfer

No use of subjective outcome measures

Length of stay assessed was cumulative: did not discriminate between acute surgical inpatient stay and rehabilitation centre length of stay

Article

Number of participants

Site

Follow up period

Interval from surgery to intervention

Exercise intervention

Outcome measures

Dislocation

rate

Limitations

Trudelle-Jackson et al. 2004

[5]

Control n = 14;

Intervention n = 14

Home

8 weeks

4-12 months post-operatively

Control: 7 basic isometric and active range of movement exercises including the glutei, quads, hamstring sets, ankle pumps, heel slides, hip abduction in supine position and hip internal and external rotation in supine position.

Intervention: Sit to stand, unilateral heel raises, partial knee bends, 1-legged standing stance, knee raises with alternate arm raise, side and back leg raises in standing, unilateral pelvic lowering and raising in standing

Both groups: Progressively increasing repetitions of exercises encouraged 3-4/week for 8 weeks

No difference in fear of falling between both groups.

Significant increase in following in the intervention group compared to control at 8 weeks:

Hip flexor strength (↑47.8%)

Hip extensor strength (↑41.2%)

Hip abductor strength (↑23.4%)

Postural stability (↑36.8%)

None recorded

Not clear whether the intervention and control groups both received the same amount of encouragement with the visits to increase repetitions

Short follow up period