Flick the Flap after hip replacement

What does that mean? Flick the Flap? We’ll get back to that, but first a brief look at the success of exercise interventions for rehabilitation or prehabilitation for total hip arthroplasty, and why we might need to rethink our programs.

How successful is prehabilitation and rehabilitation for hip replacement?

The authors of one of the most recent systematic reviews on this topic were able to perform a meta-analysis on 26 studies with 1004 patients that used land-based exercise in hip prehabilitation or rehabilitation following total hip replacement.¹ Their primary conclusions were as follows:

• ‘Compared with usual care or no or minimal intervention, supervised exercise interventions were not associated with improved self reported physical function.’
• ‘These findings suggest that supervised preoperative and postoperative exercise interventions are probably not necessary for patients with total hip replacement.’

Such conclusions always make my heart sink. Should all patients now be advised that pre and post operative exercise for hip replacement is ‘not necessary’? Sure, some patients with higher baseline level of function and/or lower physical post-operative requirements, may manage adequately with removal of the offending joint and some simple advice. However, from what we are seeing in current clinical practice, this would seem to be the exception rather than the rule, particularly with increasing numbers of younger patients with higher expectations and needs undertaking total hip replacement.

When interpreting the results and conclusions of this recent systematic review, we need to consider the limitations of the review conclusions:

• The level of certainty of the evidence was very low-moderate.
• There were no studies with a low risk of bias.
• There was large heterogeneity in programs – exercises, intensity, frequency, duration.
• There was a lack of adequate compliance data – we don’t even know if the patients completed most of these programs.
• Studies included spanned back to 1988.

While it might seem best practice to include all papers available, the quality of earlier papers is likely to be lower, and the patient groups 20 or more years ago may not closely match the demographics and situation of patients currently presenting for arthroplasty.

What type of patients are now presenting for total hip replacement?

There appears to be much greater heterogeneity in the patients we have been seeing more recently for rehabilitation pre or post total hip replacement. There are a couple of groups that stand out, who might be particularly in need of high-quality rehabilitation:

1. The older patient with poor quality-of-life and physical health after extended wait times for hip replacement surgery

Particularly in the public health system, patients may be waiting longer and be at a lower level of conditioning prior to surgery, and only be afforded 3 days of in-hospital stay. With the aging population and rising demands on health systems that are struggling to keep up, wait times have been on the rise in many countries. The Covid pandemic catapulted our health systems into a situation of massive delay for ‘elective surgeries.’ A UK nationwide survey of patients waiting for total hip arthroplasty was published last year, comparing Quality of Life in the 2020 cohort to a control cohort from 2014 – 2017.² The 2020 group had a significantly worse EQ-5D (Quality of Life outcome measure) score compared to the control group and over 1/3 (35%) of the 2020 cohort rated their quality of life as less than 0, defined as a health state ‘worse than death.’ Over 80% of this group felt that their quality of life had deteriorated while waiting, and time spent on the waiting list was independently associated with a decrease in quality-of-life.²

Patients waiting for extended periods for surgery, who are told that ‘there is nothing that can be done except take medications to manage the symptoms and wait for the surgery’ may develop greater losses in physical capacity, range of motion and muscle health and function. Can we then compare these patients to participants of studies that are 15-20 years old? The baseline capacity may well be much lower, meaning that there may be much more to gain from physical therapies and particularly exercise interventions and individualised advice.

2. The younger patient with higher physical needs and expectations following hip arthroplasty

In recent times, we have also increasingly been seeing much younger patients undergoing hip replacement, with much higher expectations and physical needs and goals. Advancements in materials and surgical technique has made this possible. Prosthetic materials have advanced substantially in the last couple of decades, with much higher tolerance to physical loads and resistance to wear. Patients can often return to high demand physical pursuits, and given the opportunity, would much prefer to reclaim their quality-of-life rather than sit on the sidelines of their life for a decade or more, waiting to be ‘old enough for surgery.’ Surgeons have worked to find ways to reduce rates of dislocation, early revision and impact on soft tissues, through prosthetic choice and surgical technique. Have we seen comparable advancement in post-operative rehabilitation?? Or are these younger patients being provided with the same cookie cutter program, often delivered only online or on paper, as their 70+ year old counterparts?

Ok, ok, I’m getting there! So, what’s all this about Flick the Flap? Flick the Flap after hip replacement is my call for physiotherapists and other rehabilitation professionals to choose safe, high-value exercises after hip arthroplasty … and flick the long standing, low-value components of traditional programs, particularly what I refer to as the ‘Leg Flapping’ exercises.