By Catherine Fiscella, MS
Golfing After Total Hip Replacement
Understanding this surgery and how to tailor a postrehab training program for it will prepare you and your active client for success.
ach year, more than 850,000 total hip replacements are performed worldwide. The number continues to grow, and the patient population continues to diversify. According to the American Academy of Orthopaedic Surgeons, the average age of people who receive total hip replacements is 67, and more than 60 percent of these people are women. Moreover, advancements in prosthetic materials and design have extended the life span of various prosthetic devices, and technological breakthroughs have enabled younger, more active individuals to become candidates for this surgery. Wouldn't it feel great to have the knowledge and confidence to train a client during the postrehab phase of a total hip replacement? Understanding why certain exercises should be avoided or emphasized can be the key to your client's successful, complete recovery and return to activity. Surgeons agree that an active lifestyle can continue after hip replacement surgery; many of them endorse golf as an appropriate postrehab sport. However, personal trainers must consider the effects of movement on a total joint replacement when designing exercise regimens for these clients. Consequently, personal trainers have to understand the nuances of hip replacement surgery, the rehab process and their role in postrehab training. This article suggests guidelines based on current scientific and biomechanical knowledge, including indications and considerations for hip replacement, progression of an appropriate exercise program and golf-specific training details.
Primary Indications and Considerations The primary indications for total hip replacement surgery are pain and decreased tolerance for walking longer distances. Hip joint disorders that may necessitate total hip replacement include osteoarthritis; avascular necrosis (local bone tissue death due to disruption of the blood supply by injury or disease); bone tumor, fracture or dislocation; osteomyelitis (an infectious inflammatory bone disease often bacterial in origin); and slipped capital femoral epiphysis. Because individuals with osteoarthritis typically have less strength and endurance than do others, many of them are already weakened before the surgery. Furthermore, the artificial hip joint's lack of normal proprioception and pain feedback hampers their ability to assess "at risk" sport or fitness situations. Exercise Recommendations Although prospective randomized studies are limited, orthopedic surgeons have many exercise recommendations for individuals recovering from hip replacement surgery. The 1999 Hip Society Survey's consensus recommendations for activity after total hip replacement included stationary cycling, golf, swimming, doubles tennis, hiking and walking. The survey did not recommend high-impact aerobics, jogging, racquetball, squash or singles tennis. The surgeons surveyed took into account wear on joint replacements, joint load and movements during sport activities, and activity and fixation of the prosthesis. Evidence shows that an active person's total joint replacement wears more than
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does a sedentary individual's. However, the data do not suggest that an active person should be condemned to a life of inactivity after surgery. Improved muscle strength and balance can prevent the client from falls and injuries, increase her bone density and improve prosthesis fixation. Joint load and wear have an exponential correlation. Therefore, only
activities with low joint loads--such as swimming, cycling, walking and golfing--are recommended. One study found revision rate smaller among active patients (1.6 percent) than among inactive patients (14.3 percent) and concluded that participation in low-joint-load activities produces sufficient bone regeneration to improve the osseous bed for the pros-
thesis (Dubs, Gschwend & Munzinger 1983). Commitment to a low-joint-load postoperative exercise program not only assists in regenerating bone but also improves aerobic capacity and increases overall fitness.
Postoperative Movement Restrictions Precautions, or restrictions on move-
TWO-PHASE EXERCISE PROGRAM
PHASE I: REHAB The first phase of exercise begins during the hospital stay. It includes learning to transfer into and out of bed; learning to ambulate with an assistive device (such as crutches or a walker); stretching the hip flexors; and doing straight-leg raises and isometric exercises for the quadriceps, gluteals and abductors. Brotzman (1996) calls the abductors the most important muscle group to strengthen to avoid limping during ambulation. Patients usually continue physical therapy at home or, in some cases, a rehabilitation center. The exercise regimen includes hip abduction (isometric and Theraband), lateral step-ups with a low step, side stepping with a sports cord, and prone hip extension with and without knee flexion to strengthen the hamstrings and gluteus maximus. The program also integrates endurance training, cardiovascular fitness and general strengthening of all extremities. Muscles to Strengthen After Surgery
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PHASE II: POSTREHAB (3 TO 6 MONTHS AFTER SURGERY) Once range of motion (ROM) and coordination are restored, Phase II, in which personal trainers can help significantly, can begin. This phase shifts the focus to strength and endurance building. Health care benefits do not cover Phase II, so clients should seek a personal fitness trainer (PFT) for exercise advice. (As a certified PFT and licensed physical therapist, I have advanced clients through both phases.) In addition, although clients can generally participate in sports 3 to 6 months after hip replacement surgery, obtain the approval of the client's surgeon before beginning Phase II with any postoperative client. Before starting your client on Phase II, you must assess your client's health status. The benefits of physical activity may have been demonstrated repeatedly, but you always have to be aware of your client's health status to create a program with minimal risk. For example, disuse atrophy and muscle imbalance are likely in hip replacement clients but secondary to immobilization or pre- and postsurgical compensatory patterns during movement. You can use a standard health screening form to identify not only old injuries but also potential new ones. The following checklist can serve as a guide for assessing your postrehab hip replacement client. The results can serve as a baseline to show the client's progress:
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quadriceps hip flexors hamstrings hip extensors hip rotators gastrocnemius complex
posture ROM (spine, shoulder, forearm, wrist, hip, knee and ankle) ankle stability balance thigh circumference (thigh circumference of treated leg compared with that of untreated leg) strength (postural and rotational muscles of the shoulders, hips, trunk and lower extremities) general cardiovascular endurance, body composition and other factors (depending on client's goals) cardiopulmonary limitations due to age or medical history
Golf-Specific Muscles to Strengthen After Surgery
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rotator cuff forearms (pronators, supinators and wrist extensors/flexors) upper, middle and lower trapezius latissimus dorsi abdominals lower-extremity muscles (same as in previous list)
Phase II is divided into two segments. The first emphasizes strengthening the lower extremities and improving overall endurance. The second focuses on golf-specific training.
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ment, are implemented postoperatively so the client can avoid dislocation. They are dictated by the site of the surgical incision. (Most hip replacement patients receive a posterolateral incision through the gluteals to expose the hip joint.) These precautions usually last 3 months: 1. Do not flex or bend the hip at
an angle greater than 90 degrees. 2. Do not twist or pivot on the treated leg (by internally rotating at the hip). 3. Do not cross legs at the ankles or knees. Andrew Bender, MD, a surgeon specializing in joint replacement at Shady Grove Orthopedics in Rockville, Maryland, cautions individuals never
to combine precautionary movements, even after the 3-month period. For example, he says, "If squatting at an angle greater than 90 degrees, the client should avoid performing any twisting motions in that position."
Look on the Bright Side Hip replacement candidates can be very active after surgery. Indeed, I often tell
Segment I The main purpose of Segment I is to restore the client's general strength and especially the strength of the treated lower extremity. General flexibility should be included, but never aggressively. Although muscle lengthening should be attained over time, passive stretching of the hamstrings is also usually necessary. Exercises have been chosen for their carryover into functional activities and balance to highlight commonly deficient muscle groups and decrease overloading of the prosthetic hip joint. Pay attention to the client's posture and ensure that she maintains equal weight bearing during all closed-chain movements. Perform one or two sets of eight to 20 repetitions per set of each exercise, adjusting to your client's needs and objectives. Because of the increased joint load from weight lifting, the client's body weight may initially be sufficient for lower-extremity exercises done in a weightbearing position (such as bench stepping or lunges). However, the American Academy of Orthopaedic Surgeons does not recommend lifting anything heavier than 40 pounds after total hip replacement surgery. Segment I Exercises Strengthening Focus:
Segment II Continue with Segment I exercises and add golf-specific movements as your client can tolerate them. Full-body strength training and muscle balancing can enhance one's game and reduce the risk of injury. The rotator cuff muscles are essential in controlling the club during the swing phase. The abdominals, erector spinae and latissimus dorsi help stabilize the trunk and dissipate forces. Pro golfers know how to draw maximum power from their hips, which are very active during the golf swing. The hip rotators, whose pivoting action initiates upper-body rotation, are extremely important during the downswing; the abductors and adductors help golfers stabilize and maintain balance throughout the movement. Without strong hip musculature, your client's low back and arms must compensate, increasing the risk of back strain. Because of the high prevalence of low-back injuries among golfers, you should integrate core exercises into your program. Be creative in choosing core stability exercises, but keep in mind that your client's ability to handle a stability ball can provide a bonus carryover into your client's balance training. For the proper intensity and numbers of sets and repetitions, use the same guidelines recommended in Segment I. Segment II Exercises (Golf-Specific)
leg press (To increase adductor recruitment, place 0-to-4-pound medicine ball between distal thighs to squeeze simultaneously.) leg curls 3-way low pulley (abduction, adduction to midline and extension)
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prone Superman extensions (Lying prone, start with arms overhead and then lift both arms simultaneously while contracting spinal extensors and maintaining neutral spine.) prone scapular retractions prone opposite-arm-and-leg lift pulley external and internal rotation lat pull-downs pronation/supination (Sit and bend elbow 90 degrees while keeping it pinched into your side. Lift 5-to-8-pound weight straight up toward ceiling. Slowly rotate palm down while keeping upper arm at side and elbow at 90 degrees. Rotate palm and forearm until weight is horizontal with palm side down and then up.) bridges V-rotations (Begin in bridge position with shoulder blades resting on stability ball, hands pointing toward ceiling, palms pressed together and feet planted firmly on ground. Maintaining bridge position, rotate upper torso first to one side as unit and then slowly to opposite side.) basic abdominal crunches (advancing as tolerated)
wall squats with stability ball
bench stepping (front and lateral step-ups)
single-leg stance (Begin in doorway with eyes open and progress to standing unsupported with eyes closed.) standing on uneven surfaces (using Styrofoam rollers, rocker board or thick mats)
7-to-10-minute warm-up with light cardio (using modes recommended by 1999 Hip Society Survey, such as stationary cycling, walking, swimming and low-impact aerobics)
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clients hip replacement success stories about my mother, who regularly hikes the Appalachian Trail, and another client invited to join an exclusive doubles tennis league. Prosthetic technology has given younger people the option to continue a fitness-oriented lifestyle, even if they suffer hip pain. It may seem a long and daunting journey to advance your client from shuffling behind a walker to swinging away on a golf course, but understanding hip replacement surgery and knowing how to tailor a training program for this population will pay off for you and your client.
Catherine Fiscella, MS, PT, practices physical therapy at Physiotherapy Associates in Germantown, Maryland. In addition to treating sports medicine patients, she works as a personal trainer at Washington Sports Clubs in Bethesda, Maryland, and was named one of SHAPE magazine's 2002 Target Trainers. You can contact Catherine at firstname.lastname@example.org.
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