Randomized controlled trial to compare conventional physiotherapy with task-oriented exercises after total hip replacement

Abstract

BACKGROUND:

Different interventions are used during rehabilitation after hip replacement surgery, but it is unclear if task-oriented exercise is more effective than conventional physiotherapy.

OBJECTIVE:

This study compared the effectiveness of conventional physiotherapy (CPT) programme with task-oriented exercise (TOE) on hip pain, function, static and dynamic balance during the early rehabilitation stage after total hip replacement.

METHODS:

This randomized controlled parallel-group trial was executed in an inpatient physical medicine and rehabilitation centre. The study included 40 patients who were randomly classified into CPT and TOE groups ( $n=$ 20 in each). Hip pain (assessed by visual analogue scale), function in the operated leg (assessed by modified Harris Hip Score, mHHS), static balance (assessed by Abili Balance analyser system) and dynamic balance (assessed by Berg Balance Scale) were evaluated at baseline and after 18 days of rehabilitation. Cohen’s effect size ( $d$ ) was calculated.

RESULTS:

Greater pain reduction ( $p<$ 0.05; $d=$ 0.08) was observed after TOE (1.6 $\pm$ 0.68 scores) compared with the CPT programme (2.2 $\pm$ 0.83 scores). Hip function assessed by the modified mHHS improved more ( $p<$ 0.05; $d=$ 0.30) in the TOE group (73.45 $\pm$ 6.23 scores) than in the CPT group (54.90 $\pm$ 6.28 scores). Static balance improved significantly in both groups after the interventions but did not differ significantly between the groups. The improvement in dynamic balance was significantly greater ( $p<$ 0.05; $d=$ 0.45) after TOE (50.55 $\pm$ 1.57 scores) than after CPT (38.55 $\pm$ 3.43 scores).

CONCLUSION:

Both interventions reduced pain and improved function of the operated leg and static and dynamic balance. The effect on hip function was superior for TOE compared with CPT.

Keywords

Inpatients leg quality of life pain osteoarthritis

1. Introduction

Total hip replacement is a highly successful surgical procedure whose main purpose is to relieve pain and improve function of the hip joint [1]. Given the increasing average of life expectancy, the need for hip replacement surgery is increasing throughout the world [2]. Despite the success of hip replacement surgery, it is insufficient to simply restore the quality of life and function. Postoperative pain, muscle weakness and impairment in functional mobility of the operated leg and body balance are common complaints [3, 4], so rehabilitation is needed to prevent these impairments.

Physiotherapy (PT) intervention is a routine component of patient rehabilitation following hip joint replacement [5]. Rehabilitation plays a key role after surgery and is designed to optimize function and to reduce disability in people with health problems [6]. The time spent in rehabilitation depends on the patient’s health status and has decreased from 4–10 days to 1–3 days in recent years [7]. Inpatient rehabilitation begins after surgery, and postoperative PT focuses on the following: controlling pain and swelling; restoring mobility, strength, range of motion (ROM), function and balance; teaching correct and safe movements; adapting appropriate support tools; and educating the patient and family [8]. Swelling, pain and inflammation around the operated joint can limit the patient’s ability to activate the surrounding muscles [9]. Failure to begin muscle-strengthening exercises in time can lead to muscle atrophy, which further contributes to the loss of muscle strength [10].

Different PT interventions are used after hip replacement surgery [11, 12], but it is unclear which exercise programmes are most effective [13, 14]. Colibazzi et al. [15] state that clinical practice is still dependant on dogma and traditions, which highlights the need for additional high-quality clinical studies. In early phases structured rehabilitation is more effective to improve strength and functionality, and in the late phases home programmes can also be effective [16]. Madara et al. [17] found that modern PT protocols after hip arthroplasty focus mainly on the restoration of muscle strength and ROM but not on the restoration of function and balance. Madara et al. [17] declare that function and balance are the most important components for returning to a socially active life after rehabilitation. Task-oriented exercise (TOE) is used for training balance and gait [18], and improving physical function and disability [19, 20]. Given these findings, the hypothesis was raised that compared with conventional PT (CPT), TOE would be more effective for restoring balance and leg function after hip replacement surgery. The aim of this single-blinded randomized controlled trial was to examine the effects of TOE and CPT on hip pain, function, static and dynamic balance in the early rehabilitation stage after total hip replacement (THR) because of osteoarthritis.

2. Methods

2.1 Ethical approval

Ethical approval was obtained from the Bioethics Committee of Lithuanian Sports University (No. MNL-KIN(M)-2021-367). All participants were informed in detail of the purpose and procedures of the study and signed an informed consent form. The study was conducted in accordance with the Declaration of Helsinki Ethical Principles and Good Clinical Practices. The study was registered at Clinicaltrials.gov (ID#: NCT05343195).

2.2 Study design

This randomized controlled trial allocated patients after THR surgery to either an 18-day supervised inpatient CPT group ( $n=$ 20) or a TOE group ( $n=$ 20). The patients were randomly assigned into the two groups using a list of previously generated blinded intervention codes, and an automatic assignment system to conceal the allocation.

2.3 Participants

Patients who received a THR in the physical medicine and rehabilitation centre of one hospital in Kaunas, Lithuania, were invited to participate in this study. Forty-eight participants were assessed for eligibility to participate in this study (Fig. 1). The inclusion criteria were primary unilateral THR for hip arthrosis, posterior surgical approach, starting rehabilitation within 1 week after surgery, age 55–75 years, body mass index (BMI) $<$ 40 kg/m ${}^{2}$ and the ability to understand instructions and perform the tasks. Patients were excluded if they had undergone revision surgery or surgery for other reasons (fracture, rheumatoid arthritis) or had visual, vestibular or proprioceptive impairment, or any illness or disorder that could affect the study results. Forty patients (32 women, eight men) with a mean age of 66.18 $\pm$ 5.26 years (range 57–75) met the inclusion criteria and were enrolled in the study; THR was performed on the right hip in 28 patients and on the left hip in 12 patients.

Figure 1.

CONSORT flowchart of the study.

2.4 Interventions

The State Health Insurance Fund allocates an 18-day rehabilitation period in the inpatient ward after THR surgery in Lithuania. The PT programmes began on day 3–4 after the operation and continued for 18 days for both the CPT and TOE groups. Each patient received 15 PT sessions on every consecutive workday, supervised by an experienced physiotherapist. Each PT session lasted for 30 minutes and was performed individually.

2.4.1 CPT group

During CPT group sessions, the patients performed 7–10 exercises under the supervision of a physiotherapist. Each training session comprised 20 min of active ROM and strengthening exercises and 10 min of gait training [8]. The major muscle groups of the lower limb and lumbar area were targeted. The following exercises were performed in the supine position: ankle flexion/extension, hip flexion/extension with sliding heel, hip abduction, knee extension, pelvic lift, foam rolling with both legs and straight leg raise. In week 3, additional hip flexion, extension and abduction exercises were performed in the standing position. Participants in the CPT group performed three sets of 10–15 repetitions of each exercise. To reduce friction, exercises were performed on a slippery surface. The CPT programme is described in supplementary material (Table S1).

2.4.2 TOE group

The TOE programme comprised 10–15 min of active ROM exercises and 15–20 min of TOEs. The most important activities of daily living and recovery of functional ability were targeted [20]. The following TOEs and combinations were used: walking backward, sideways or forward while lifting the knee on an unstable surface; walking while changing speed and direction on the physiotherapist’s command; moving from a standing to a sitting position and then reaching for a ball held by the physiotherapist; ascending and descending stairs and then reaching for a ball held by the physiotherapist; climbing over obstacles; and catching and throwing a ball while standing on an unstable surface. Progressive training was used, in which the number of the exercise was adjusted every week. The TOE programme is described in supplementary material (Table S2).

2.5 Outcome measures

For each participant, the same measurements were obtained at the baseline (day 1 of rehabilitation) and at discharge (day 18 of the rehabilitation programme). Experimental assessments started on day 1 in the morning before the intervention. Upon arrival, the participants were asked to rate their current pain and, with the assistance of a physiotherapist, to complete the modified Harris Hip Score (mHHS) questionnaire. Dynamic and static balance were then assessed. All measurements were repeated after the 18 days in the same order. During the course of the study, all participants had high rates of adherence (100%) to the intervention sessions, and no patients withdrew.

Pain. Pain intensity was assessed using a visual analogue scale (VAS) that used a 10-cm line with end-point descriptors such as ‘no pain’ marked at the left end and ‘worst pain imaginable’ marked at the right end. Patients were asked to mark a point on the line that best represented their pain at the time of the evaluation. The distance from ‘no pain’ to the patient’s mark was then measured and recorded as the VAS score: 0 cm was defined as no pain, 1–3 cm as mild pain, 4 or 5 cm as moderate pain, 6–8 cm as severe pain and 9 or 10 cm as the worst pain imaginable [21].

Hip function. The modified mHHS was used to assess the function of the operated leg. This is a reliable and validated tool for evaluating hip disabilities and assessing the results of THR surgery [22]. The questionnaire covers eight domains, including pain, gait (limp, support, distance walked) and functional activities (stairs, socks/shoes, sitting, public transportation). The maximum mHHS score is 91, and the mHHS scores were interpreted as follows: $<$ 70 (poor), 70–79 (fair), 80–89 (good) and $>$ 90 (excellent).

Dynamic balance. The Berg Balance Scale (BBS) was used to assess dynamic balance. The BBS is commonly used for clinical testing of balance in elderly patients [4] and includes 14 different mobility tasks, including static and dynamic balance performance, which are scored on a five-point ordinal scale (0–4), with a maximum total score of 56. Higher scores on the BBS indicate better functional balance.

Static balance. Static balance was assessed using the Abili Balance analyser system (Abili, Kaunas, Lithuania). This system comprises a one-plane instability platform and is used in rehabilitation and training [23]. The system includes a balance platform with a wireless virtual reality system and software package for balance testing and virtual reality games. The platform plate moves in a horizontal plane, which makes it safe for patients of all fitness levels. The device can be used at three levels of difficulty: basic, medium and advanced. The handles are adjustable according to the height of the patient.

The basic level of difficulty was used in this study because the participants were untrained and were recovering from THR surgery. For this measurement, the participant stepped onto the device platform with feet apart and stood straight with the arms crossed on the chest. Before the test, each participant performed one control trial for 30 s. The experimental task comprised three trials of 30 s each with 10 s of rest between each trial. During the testing, participants were provided with real-time biofeedback about their balance swings. The average of three experimental trials was calculated and considered as the overall stability index. The reference values for untrained individuals are as follows: $<$ 0.8 very good stability, 0.8–1.8 good stability and $>$ 1.8 poor stability.

2.6 Statistical analysis

All statistical analyses were performed using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Values are reported as mean and standard deviation. The data were tested for normal distribution using the Shapiro-Wilk test and all values were normally distributed. A mixed-design analysis of variance (ANOVA) was used to determine the effects of interventions. If a significant effect was found, the observed power was calculated (OP). If a significant interaction of time $\times$ group was observed, paired Student’s $t$ test was used to compare the results from before to after the intervention and independent Student’s $t$ test was used to evaluate differences between groups. The level of significance was set at $p<$ 0.05. Cohen’s effect size ( $d$ ) was calculated to compare two groups, and the effect size was interpreted as follows: 0.2 small, 0.5 medium and 0.8 large.

3. Results

Forty patients met the inclusion criteria and fully completed the rehabilitation programme. Age, sex distribution, body weight and height, and BMI did not differ significantly between the two groups (Table 1). The two groups were generally similar ( $p<$ 0.05) on baseline characteristics in terms of pain intensity, hip function, static and dynamic balance.

Table 1
Characteristics of the participants

	CPT group ( $n=$ 20)	TOE exercises ( $n=$ 20)	$p$ between groups
Age (years)	66.50 $\pm$ 5.61	65.90 $\pm$ 5.15	0.801
Sex (female/male)	15/5	17/3	0.122
Weight (kg)	73.90 $\pm$ 13.93	72.20 $\pm$ 15.90	0.744
Height (cm)	165.90 $\pm$ 10.66	167.50 $\pm$ 9.68	0.496
Body mass index (kg/m ${}^{2}$ )	26.90 $\pm$ 3.75	25.20 $\pm$ 2.68	0.324

Figure 2.

Pain intensity values in the conventional physiotherapy (CPT) and task oriented-exercise (TOE) groups pre and post interventions. ${}^{*}p<$ 0.05 compared with baseline values; ${}^{\#}p<$ 0.05 between groups.

The pain intensity scores are presented in Fig. 2. A mixed-design ANOVA of the pain intensity values revealed a significant effect of time ( $p<$ 0.001; OP $=$ 1.00) and a time $\times$ group interaction ( $p=$ 0.029; OP $=$ 0.60). Further analysis showed that pain decreased significantly both in the CPT group (from 5.35 $\pm$ 1.27 to 2.20 $\pm$ 0.83 scores; $p<$ 0.05; $d=$ 0.48) and in the TOE group (from 5.55 $\pm$ 1.00 to 1.60 $\pm$ 0.68 scores; $p<$ 0.05; $d=$ 0.63). Greater pain reduction was observed after the 18-day TOE compared with the CPT programme ( $p<$ 0.05; $d=$ 0.08).

Figure 3.

Hip function scores in the conventional physiotherapy (CPT) and task oriented-exercise (TOE) groups pre and post interventions. ${}^{*}p<$ 0.05 compared with baseline values; ${}^{\#}p<$ 0.05 between groups.

The data for hip function as measured by the mHHS are presented in Fig. 3. A mixed-design ANOVA of the hip function values revealed a significant effect of time ( $p<$ 0.001; OP $=$ 1.00) and a time $\times$ group interaction ( $p<$ 0.001; OP $=$ 1.00). Subsequent analysis showed that hip function improved significantly in both the CPT group (from 22.80 $\pm$ 6.76 to 54.90 $\pm$ 6.28 scores; $p<$ 0.05; $d=$ 0.49) and in the TOE group (from 22.55 $\pm$ 6.27 to 73.45 $\pm$ 6.23 scores; $p<$ 0.05) and the effect size was considered large ( $d=$ 0.82). Hip function improved significantly more in the TOE group than in the CPT group ( $p<$ 0.05; $d=$ 0.30).

Figure 4.

Static balance in the conventional physiotherapy (CPT) and task oriented-exercise (TOE) groups pre and post interventions. ${}^{*}p<$ 0.05 compared with baseline values.

The results of the assessment of static balance are presented in Fig. 4. A mixed-design ANOVA of the static balance values revealed only a significant effect of time ( $p<$ 0.001; OP $=$ 1.00). Further analysis showed that static balance improved significantly in both the CPT group (from 1.08 $\pm$ 0.17 to 0.71 $\pm$ 0.17 scores; $p<$ 0.05; $d=$ 0.22) and in the TOE group (from 1.05 $\pm$ 0.16 scores to 0.73 $\pm$ 0.14; $p<$ 0.05; $d=$ 0.22). Static balance did not differ significantly between groups after the interventions.

Figure 5.

Dynamic balance scores in the conventional physiotherapy (CPT) and task oriented-exercise (TOE) group pre and post interventions. ${}^{p}<$ 0.05 compared with baseline values; ${}^{\#}p<$ 0.05 between groups.

Data for the BBS scores as an indication of dynamic balance are presented in Fig. 5. A mixed-design ANOVA of the dynamic balance values revealed a significant effect of time ( $p<$ 0.001; OP $=$ 1.00) and a time $\times$ group interaction ( $p<$ 0.001; OP $=$ 1.00). Subsequent analysis showed that dynamic balance improved significantly after the interventions in both the CPT group (from 22.00 $\pm$ 2.32 to 38.55 $\pm$ 3.43 scores; $p<$ 0.05; $d=$ 0.57) and in the TOE group (from 21.10 $\pm$ 1.99 to 50.55 $\pm$ 1.57 scores; $p<$ 0.05; $d=$ 0.98). The improvement in dynamic balance was significantly greater after TOE than after CPT ( $p<$ 0.05; $d=$ 0.45).

4. Discussion

The main aim of this study was to compare the effects of early CPT and TOE on hip pain, function, static and dynamic balance in patients after THR because of osteoarthritis. All patients received an 18-day rehabilitation in the inpatient ward and participated in 15 intervention sessions. In both study groups, there were no cases of postoperative complications and no dropouts. The results of the study showed that both applied early interventions significantly improved the subjects’ functional status, but task-oriented exercises were more effective when comparing three of the four evaluated indicators.

The aim of post-operative rehabilitation is to get the patient as functional as possible prior to discharge [8]. Early mobilization has shown to give patients more confidence in their post-operative mobility and activities of daily living [24].

Hip osteoarthritis is more common in women than in men [25]. A 2014 study by Tarasevičius et al. [26] found that 80% of hip replacement surgeries in Lithuania are performed on women. As expected, 80% of the participants in this study were women.

The hip joint is crucial for walking [27] because it is one of the body’s largest weight-bearing joints. Now considered to be necessary after hip replacement [28], PT aims to strengthen the hip muscles and maintain joint mobility [10]. Strength training can be initiated early after THR [29, 30]. The patients of the study started exercising 3–4 days after the surgery. The same start time of interventions was used in the study by Hasebe et al. [31], who aimed to investigate the short-term effects of cross trainer exercise on physical function and walking ability following total hip arthroplasty (THA). Cross trainer exercise commencing 3 days postoperatively were found to improve physical function and walking ability after THA [31].

As a clinical outcome, pain in the operated leg decreased significantly in both groups and was defined as mild, which reflected the positive effects of active exercise in relieving pain [32]. Patients in the TOE group reported significantly less perceived pain than those in the CPT group. Similar data were reported by Monticone et al. [19], who compared postoperative joint pain between a CPT group and TOE group, and found TOE to be superior to CPT, however, the duration of one session in their study was 90 min. Other researchers found that an inpatient rehabilitation programme based on balance task-specific training is useful for improving physical function, pain, activities of daily living and quality of life [20].

As expected, the function of the operated leg after the interventions was significantly better in the TOE group. One possible explanation is that a task-oriented functional programme promotes a faster return to normal nervous and muscular activities, and normal daily movements, and conversely, a routine PT programme without any functional activity may inhibit or slow complete recovery [19]. Task-oriented training in rehabilitation focuses on improvement of performance in functional tasks and there is increasing evidence of brain plasticity and motor control changes associated with training [33].

Compared with younger adults, older adults rely more on hip muscles to maintain static balance because of the decrease of distal proprioception and strength of the trunk muscles with age [34]. The static stability of the participants was rated as good after the THR surgery and very good for untrained people after the interventions. Static balance ability, as measured with the Abili Balance analyser system [23], did not differ significantly between the two groups both before and after the interventions. Few studies have examined the response to TOEs, but similar studies were found that examined the changes in static balance after THR. However, in a study of stroke patients, TOE was superior to CPT for improving static balance [35].

In this study, the improvement in dynamic balance was greater (larger effect size) in the TOE group than in the CPT group (0.98 vs 0.57, respectively). Both interventions included hip extension muscle exercises, which have been shown to increase the ROM, which contributes to improved dynamic balance and hip function [36].

Minimal clinically important difference scores are used increasingly by clinicians when determining a patient’s response to treatment [37]. In this study, TOE had medium and small effect sizes for pain and static balance, and high effect sizes for dynamic balance and hip function (0.98 and 0.82 respectively).

This study was undertaken in a clinical environment and had some limitations that should be considered when interpreting the results. The short follow-up period is the main limitation, but the intensity of the interventions seemed to compensate it because statistically significant changes between pre and post interventions were found. Another limitation is the small number of participants. However, the age, height, weight, BMI and sex distribution did not differ significantly between groups at the start of the study.

In conclusion, this clinical trial confirmed the benefits of task-oriented exercise, which is consistent with previous research [19, 20, 33]. As expected, patients who performed TOEs achieved significantly better pain relief, hip function and dynamic balance compared with those who performed CPT. Contrary to expectations, static balance did not differ significantly between the groups. Further studies are needed to determine whether the effects of TOE are maintained over the long term.

5. Conclusions

This study demonstrated that both early interventions significantly reduced pain and improved function of the operated leg and static and dynamic balance, but rehabilitation programme based on task-oriented exercise was superior to conventional physiotherapy programme in terms of improving pain, function of the operated leg and dynamic balance. Early postoperative rehabilitation protocols should include task-oriented exercise after total hip replacement.

Ethical approval

The Bioethics Committee of Lithuanian Sports University approved the study (Approval no. MNL-KIN (M)-2021-367).

Funding

No funding sources were reported for this study.

Informed consent

Written informed consent was obtained before testing procedures.

Author contributions

Conceptualization, V.D., A.A. and L.Ž.; data curation, A.A.; formal analysis, A.A., L.Ž., investigation, A.A.; methodology, V.D. and L.Ž.; project administration, V.D.; writing-original draft, V.D and L.Ž.; writing-review & editing, V.D. and L.Ž. All authors have read and agreed to the final version of the manuscript to be published.

Footnotes

Acknowledgments

The authors wish to thank all patients who participated in the study.

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary data

Table S1

Conventional physiotherapy exercise programme

Exercise	Week 1 Intensity (repetition/set) or duration	Week 2 Intensity (repetition/set) or duration	Week 3 Intensity (repetition/set) or duration
Supine, ankle dorsiflexion and plantar flexion	10/3	12/3	15/3
Supine, hip flexion/extension while sliding the heel on the sliding board	10/3	12/3	15/3
Supine, hip abduction	10/3	12/3	15/3
Supine, knee extension (roller under the knee)	10/3	12/3	15/3
Supine, pelvic lift (big roller under the knees)	10/3	12/3	15/3
Supine, foam rolling with both legs (roller under the heels)	10/3	12/3	15/3
Supine, straight leg raise (3x10) when the other is flexed	10/3	12/3	15/3
Standing at the Swedish wall, hip flexion	–	–	15/3
Standing at the Swedish wall, hip extension	–	–	15/3
While standing at the Swedish wall, hip abduction	–	–	15/3
Gait training between parallel bars	10 min	10 min	–
Cycling stationary ergometer or walking on a treadmill	–	–	10 min

Table S2

Task-oriented exercise programme

Exercise	Week 1 Duration (min)	Week 2 Duration (min)	Week 3 Duration (min)
Active exercises in supine (the same first 7 exercises as in the CPT group)	15	10	$-$
Cycling stationary ergometer or walking on a treadmill	$-$	$-$	10
Task-oriented exercises:	15	20	20
1. Walking backwards/sideways/forwards while lifting knee high (on unstable surfaces)	$+$	$+$	$+$
2. Catching and throwing the ball while standing on an unstable surface	$+$	$+$	$+$
3. Moving from standing to sitting position (after standing up, reach for the ball held by the PTs)	$+$	$+$	$+$
4. Climbing/descending the steps (after climbing, reach for the ball held by the PTs)	$+$	$+$	$+$
5. Walking while changing speed and direction (after the PTs command)	$-$	$+$	$+$
6. Climbing obstacles	$-$	$+$	$+$

Note: PTs – physiotherapists; $+$ included, $-$ excluded.

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