Lecture 5 (Hip interventions) COPY Flashcards
What should you tell someone w/ OA about their condition?
There is inflammation and irritation within your joint, but movement can help clear some of that inflammation and make you feel better
Does approximation or gaping help OA pts?
gaping (think hip traction)
What kind of exercise is best for OA pts and why?
Aerobic Exercise
Because were getting bloodflow to the area (= pain reduction)
Pt walks in w/ severe hip OA. Your first thought is to get them doing aerobic exercise to get the blood flowing. It is quickly obivous that this is not going to work. What is a less intense option we can do to get their blood flowing?
Aquatic EX (this off loads the joint, however you will want to eventually get them on land)
What is the best hip OA manual therapy intervention to do for pain management?
Traction / Distraction (gaping the joint to seperate the articulating cartilage)
If I want to do hip flexion what part of the joint should I mobilze towards?
Inferior glide mobilization (superior roll inferior slide)
If the patient is getting an inferior hip glide to improve flexion but is a pain dominant patient. What grade glide would I perform?
1 or 2
What muscles are proably most affected for a hip patient (3)
- NOTE: if were doing soft tissue work for a hip pt these are proably the ones you want to target (think ischemic release) (think trigger point release)
Iliopsoas
Piriformis
Glute Med / TFL
KNOW: Some pain management techquies we could use for pain maangement for OA are things like heat / estem / cold (normally pt directed)
KNOW: Exercise is the strongest intervention for OA
NOTE: we also need to work on ROM so that we can strengthen in a full ROM
Also make the EX functional or they wont want to do it - you need to make this EX specififc to your pts
Whats the easiest way to find a functional EX for the pt?
Ask them their goals. Figure out what they want to get out of PT - then make the EX around that
Research recommends how many sessions for hip OA pts?
12-14
We would also want to front load the first few weeks (do more then than later)
Which thermal modality effects pain - heat or cold?
Both!
Which modality affects inflammation - heat or cold?
Cold
KNOW: both exercise and manual help w/ short term pain of hip OA
In a pt w/ acute hip OA what modalities would we use? (4)
Would you use thes modaltities before or after therapy?
Heat
Ice
ultrasound (only on really superficial areas of the hip)
E-stem (overwhelming system so we don’t sense the pain)
It’s up to you to decided before vs after
When would we choose heat over ice (2)
If theres no inflammation
pt preference if theres no inflammation (ask them what feels better then we can get them exercising)
* I’m guessing you would typically lean toward heat before to get the blood flowing to that area and lean to ice after to calm it down.
When would we choose ice over heat?
If there inflammation involved
What areas work best w/ ultrasound?
very superficial areas
Why would you use ultrasound on someone w/ grater trochanteric pain syndrome but not w/ someone who has an acetabular issue?
Because greater trochanteric painsyndrome is very superficial
KNOW: Tell pts that we need to move OA around to lubricate the joints / get the blood flowing
What modalitites would you do w/ a chronic / subacute hip OA pt?
Hopefully none but if they’re needed its the same ones as acute
KNOW: Know the arthrokinematics for the hip when treating hip OA. he might phrase a questions about hip extension being messed up and I would need to pick which intervention to use
KNOW: most manual therapy for hip OA is those arthrokinemtaic movements + distract / traction. Lateral glides also do really well w/ lots of hip pts
Soft tissue work for these individuals is typically ischemic release (trigger point release) –> think pushing on iliopsoas / glute med / piriformis / TFL
KNOW: Lumbar manipulation might also help hip pain pts due to regional interdependence (especially for those pts that don’t want u messing w/ hip)
What muscles are most likely to be tight w/ hip OA?
Rec Fem / Iliopsoas (due to proably sitting a lot in that recliner because they don’t want to move)
Glute med / TFL
Piriformis
What test lets us differenitate iliopsoas vs rec fem tightness?
Thomas Test
What test would you use to check TFL tightness?
Ober test
What tests would I use to check hamstring tightness?
Straight leg raise / 90:90 test
If something is weak you ______
strengthen it
If something is tight you _______
Stetch it then straighten it
right hip is raised w/ trendelenburg. Which muscle is weak?
right glute med
What kind of exercise are we doing w/ acute hip OA pts? Why?
Proably doing mat style EX because weight bearing still hurts
KNOW: w/ hip OA i want to get them off that mat ASAP. We want to get them upright –> the hip is meant to be upright. When the hip is upright its muscle surrounding are going to be on and activiated (working on endurance) and will hypertrophy
KNOW: Cardio works gret w/ hip OA pts to get blood flowing and synovial fluid moving
How do we subjectly get a pt to tell us how difficult an EX was?
Ask “how challenging was that 1-10”
Get that RPE
If pain is high a pt, what kind of lifting would I do?
Isometric
Isometric is done for pain
KNOW: Isometrics are good for pain and begining of the session when you’re trying to wake up the muscle (and helps work on that musular indurance)
Test question: Hip OA conservative treatment is not working for out pt. What needs to be done?
Total Hip Arthroplasty
Is lots of PT required for THA?
Most people don’t typically need it
What is the #1 indication for total hip arthroplasty?
Advanced OA
KNOW: Lots of joint issues can lead to a THA
* Think OA, avascular necrosis, RA, traumatic arthritits (think jumping out of planes) / hip fractures / bone tumors / ankylosing spondyitis
* **NOTE: OA is by far the most common (has to be servre OA that is limiting quality of life) ** - and must have tried conservative rehab
KNOW: Pain w/ hip OA must be really extreme before surgery is indicated
* Serve pain daily
* Pain at rest several days a week
* Pain sit to stand several days a week
* Radiographic evidence of destruction of joint space
* No relief from non-operative interventions (think pT)
JUST BECAUSE IT HURTS SOMETIMES DOESNT MEAN YOU’RE RIGHT FOR SURGERY
KNOW: For a total hip replacement they replace the acetabulum rim and femoral head / shaft.
NOTE: In a partial hip replacement they only do one of those 2
What muscles is an anterior THA approach between?
between sartorius and rec fem and TFL and glut med/min
What is the biggest advantage to an anterior THA appraoch?
Low dislocations
What is the biggest disadvantage to an anterior THA?
Glute med weakness (need to cut through it)
KNOW: Anterior is becoming more common because they don’t have to cut through too much muscle (pull muscles apart don’t cut through) - however - is becoming more common
Why does the THA anterior appraoch have a low dislocation rate?
Because instead of cutting through the muscles they’re able to pull them apart –> leading to that lower dislocation rate
An Elhers Danlos pt walks into your clinic and you notice they’ve had a hip replacement. What kind of hip replace did they most likely have done and why?
Anterior hip location because of its lower idslocation rate
Any of those connective tissue / lax joint issues get ones done w/ lower dislocation rate (note: we want chronic dislocaters to get the surgery that has the least dislcoations)
Which kind of hip replacement invloves releasing the abductors form the greater trochanter?
Direct Lateral approach
What is the advantage to a direct latearl appraoch to hip replacements?
Lower idslocations (however anterior is still less)
What are the disadvantages to a direct latearl appraoch for THA?
increased chance of getting a limp
Which THA appraoch would you expect was done if pt comes into the clinic w/ a trendelenburg gate?
Direct Lateral (highest limp rate)
This makes sense, this appraoch is litteraly discontecting the abductors from the greater trochanter - and weak abductors = trendelenburg gate
What is the most common THA approach?
Posteriolateral appraoch
What is the biggest advantage of a posterolateral approach to a THA? Why?
Low incidence of limp. They essentially are able to pull the glute med up and work around it instead of cutting through it - which leads to less gate problems because the muscle wasnt cut through
What is the biggest disadvantage of a posteriolateral apporach?
Dislocations
(think because they need to go through more muscles because they’re going form the back side)
KNOW: basically the reason that the posteriolatearl approach is the most common is because it has the least likely chance to cause a limp in a pt
How long after surgery can you get up with a THA?
Day - no wt bearing precautions
What is the biggest disadvantage of cemented THA?
It can break open and cause gangreen
KNOW: Most hip THA are WBAT
KNOW: DVT can happen have THA. Normally 2 weeks - 3 months after
What is heterotopic ossification?
Abnormal bone growth within the muscle (can happen after THA)
KNOW: Leg length discrepencies can happen after THA
KNOW: You can have nerve damage w/ hip THA
Should be able to know what peripheral nerve was most likely innvolved depending on what appraoch was taken and where the numbness is
When do most hip dislocations happen after THA?
1-2 months after
Typically this far out because this is when they’ve gotten comfertable moving again
How long do hip precautions normally last for THA?
12 weeks - life long
Can you break hip precaustions in therapy? Why?
Yes, because its the combination of them not just one motion
Would crossing legs while sitting break hip precautions for someone w/ an anterior or posteriorlatearl THA?
Posteriorlateral
Adduction / Flexion / Internal rotation
What are posteriorlateral hip pre caustions?
No flexion past 90
No internal rotation past neutral
No adduction past midline
What are hip precautions for someone w/ an anterior hip replacement?
No abduction
No extension beyond neutral
No medial rotation past neutral
KNOW: w/ a posterior THA were worried about dislocating posterior and w/ anterior were worried about dislocating anterior
What singular motion can someone w/ inter trochatneric hip replacement not do?
abduction - can be done passively not actively (don’t want to stress glute med)
How long does a THA last?
20 years (active = less)
KNOW: Indications for a THA revision
Disabling pain
Stiffness
Functional Impairment
Bone loss on radiograph
Implant loosening on radiograph
Fracture
Recurrent dislocation
Infection
KNOW: Typicaly Post-op impairments:
Edema
Pain
Impaired motor contorl
Impaired ROM
Impaired gait
Impaired balance
When is home health indicated for rehab following THA
When they arent community ambulators and can’t get out
THA pt asks “when can I drive’
talk to doctor - I didn’t take them
* PT’s cannot remove this
* But usually 6-8 weeks - use a pillow
THA pt “Can a lay on my side”
Usually no, only if you use a pillow to keep legs from crossing (breaking hip precautions)
THA pt “can I lay on stomach”
Sure
THA pt “does it matter what side of the bed I sleep on”
night stand on non surgical side so that you can step out of bed instead of trying to roll across (non surgical side on edge side) - sleep on the side of the bed that does not have issues
what kind of toilet should THA pts use?
raised toilet (doesnt break flexion restrictions)
KNOW: Tell THA pts to avoid funiture that dips down due to hip flexion resitrcions
Can THA pt’s go up stairs?
Yes, never breaks that 90 degrees of hip flexion
KNOW: For THA post-op
Must know surgical approach
Must know cemented vs non cemented
Goals for rehab:
* Pain free motion of the hip
* Independent ambulation w/o gait deviations
* Functional independence in ADL’s
What are muscle setting exercises?
Isometric (think muscle sitting still)
What are quad sets?
Just contracting your quads without using them
quad sets, gluteal sets are typically prescribed in the acute phase after THA
Can someone w/ a recent posteriolatearl THR bent over to pick up stuff?
No, this is still hip flexion passed 90
What stage of THA post-op should you beging cardio interventions?
Acute - Its never too early!!
KNOW: Start LE strengthening / weightbearing in the acute phase (that proably means they’re doing body wt stuff on a mat)
When should you start closed kinetic chain EX when a THA pt
2 week mark (think shallow squats (not breaking 90)
When should you start anti gravity movements after THA?
2 weeks
KNOW: Need to work on balance work w/ THA (saftey and gets all the muscles working)
What should you avoid doing w/ FAI?
Deep hip flexion
KNOW: Its important to individualize hip FAI treatment because there can be several different causes to it (cam, pincer, mixed - can be tight anterior capsule of hip)
What two areas do we need to strengthen w/ FAI / Labral tears?
Hip / Trunk
What arthro kinematic would be best for hip FAI?
Hip inferior glide
this is because deep hip flexion makes the pain w/ this worse (think because those cam / pincer deformities are pushing down making it painful)
Also lateral distraction / distraction helps because its pulling apart those capsules
Also stretching helps these pts
What positions would someone w/ hip FAI (or labral tear) want to avoid due to pain?
Hip flexion, IR, ADD
This is because all of these motions work together and compress down on that labrum
KNOW: Tight anterior joint capsule / musculature could be involved w/ FAI / Labral tears (could stretch anterior)
what kind of motions are bad for hip FAI / Labral tears?
repetitive motions that go into deep hip flexion IR / add
With FAI / Labral tear we normally have weak muscles where and tight ones where?
Weak posterior tight anterior
Glute med / max = weak
TFL / ilipsoas / rec fem = tight
What range should you strengthen hip FAI / Labral tear pts w/ first?
Mid range
early range (stretched) = bad overlap
end range = to far into that flexion = bad
NOTE: its important to strengthen core as well for these - anytime you’re moving your legs you’re really using your core
What percent of FAI / Labral tears return to sport?
57% but only 30% get back to full (bad)
surgery is not great for this either
Greater Trochanter Pain syndrome = gluteal tendinopathy = greater trochanteric bursitits
What is the most common thing that we do chronically that brings on greater trochanter pain syndrome?
How do we help manage it?
Sitting at a desk = adaptive shortening of glute med
managed by fixing posture (especially when sleeping = compressing on bursa needs to be fixed)
Do extra articular issues (such as greater trochanteric pain syndrome) do well with distraction?
No - doesnt help
If I distract the hip and it hurts worse am I thinking its extra articular or intra?
Extra
If it was inside the capsule we’d be specifically targeting it w/ distraction (or any arthro kinematics) –> however those extranal things are just stretchde in a way they don’t like which makes them not do well w/ distraction / arthrokinematics
KNOW: Glute med inserts on the greater trochanter
KNOW: We want to do abduction strengthening things w/ greater trochanteric pain syndrome (because abductors are the issue) and avoid adduction strengthening because that is going to stertch the muscle
Think doing a lateral step up would help a lot
For greater torchanteric pain syndrome what is the most important thing to strengthen
Glute med w/ abduction (because it inserts on the greater trochanter)
NOTE: if you’re going to do any stretching you should work on stretching TFL because its going to try and do all that abduction for glute med and is going to get really taut
