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Pendulum Exercises After Hip Arthroscopy: A Video Technique
Pendulum Exercises After Hip Arthroscopy: A Video Technique Ryan Sauber, M.D., George Saborio, M.D., Beth M. Nickel, P.A.-C., Benjamin R. Kivlan, Ph.D., P.T., and John J. Christoforetti, M.D.
Abstract: Advanced hip jointepreserving arthroscopic techniques have been shown to improve patient-reported functional outcomes with low rates of postoperative complications. Prior work has shown that formation of adhesive scar is a potential source of persistent pain and cause for revision surgery. As resources for postoperative in-studio physical therapy become scarce, a home-based strategy to avoid scar formation without adding formal therapy cost may be beneficial. The purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery of manual hip pendulum exercises in the postoperative setting. This video technique offers access to our method for pendulum exercise as part of early recovery after advanced hip arthroscopy.
T
he use of arthroscopic hip-preserving procedures in the management of hip conditions such as labral tears, chondral lesions, ligamentum teres rupture, osteonecrosis, hip instability, and femoroacetabular impingement has increased dramatically over the past decade.1,2 The rate of hip arthroscopic procedures has increased by 600% since 2006,3 and this rate is expected to continue to grow. Despite this high rate of growth, there remains little consensus on the role of formal in-studio physical rehabilitation in the postoperative management of patients undergoing hip arthroscopy. Many postoperative protocols have been proposed in the peer-reviewed literature.2,4-8 Most, however, have been formulated with a lack of objective evidence using validated patient-oriented outcome scores.5 Current studies are underway to
From the Center for Athletic Hip Injury, Allegheny Health Network (R.S., G.S., B.M.N., J.J.C.); Department of Orthopaedic Surgery, Drexel University School of Medicine (R.S., G.S., B.M.N., J.J.C.); and John G. Rangos Sr. School of Health Sciences, Duquesne University (B.R.K.), Pittsburgh, Pennsylvania, U.S.A. The authors report the following potential conflict of interest or source of funding: J.J.C. receives support from International Society for Hip Arthroscopy, Arthrex, Breg, Allegheny Health Network, and Allegheny Singer Research Institute. Received October 3, 2015; accepted April 19, 2016. Address correspondence to John J. Christoforetti, M.D., Center for Athletic Hip Injury, Allegheny Health Network, 4815 Liberty Ave, Ste 252, Pittsburgh, PA 15224, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15953/$36.00 http://dx.doi.org/10.1016/j.eats.2016.04.013
evaluate the efficacy of a formalized rehabilitation program regarding health-related quality of life and physical function,4 and stronger evidence is needed to define the standard of care in postoperative management of patients undergoing arthroscopic hippreservation surgery.2,4-8 Despite variation in postoperative rehabilitation programs, most protocols reported in the literature have asserted that early mobilization is an important component of postoperative care. Passive motion helps to nourish joint surfaces, promote tissue remodeling, and increase tensile strength.9-13 Early passive motion may also reduce the risk of joint stiffness and adhesions that may impair normal joint motion.1 Patients who undergo passive circumduction exercises performed by a physical therapist in the early postoperative phase of rehabilitation after hip arthroscopy are 4.1 times less likely to have development of adhesions compared with those who do not.1 Thus passive motion in the form of circumduction exercises may be beneficial to promote healing and lower the risk of complications. The current health care climate demands efficiency in the delivery of care. Insurance carriers are more restrictive on the number of physical therapy visits afforded to subscribers, and more financial burden is placed on patients through co-pays and deductibles. As a result, physical therapists are often confronted with the challenge to manage a lengthy postoperative period with fewer visits. A home-based passive motion regimen that decreases the number of necessary outpatient therapy sessions could be a valuable
Arthroscopy Techniques, Vol 5, No 4 (August), 2016: pp e897-e900
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R. SAUBER ET AL.
Table 1. Passive Hip Circumduction Exercises at Home Versus Formal Physical Therapy Advantages No cost No travel required Performed by trusted caregiver Performed multiple times daily Disadvantages Labor and time intensive Time required to educate patient and caregiver Inconsistency of technique
cost-reduction tool. This incentivizes patients to perform exercises that are critical to their recovery within their home setting without the direct supervision of a physical therapist. In an effort to decrease formal physical therapy visits in the early postoperative period, we have used passive hip circumduction exercises that are administered by a caregiver (spouse, parent, family member, and so on) at home as the cornerstone of an independent home program within the first 2 to 4 weeks after hip arthroscopy. The purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery of manual hip pendulum exercises in the postoperative setting (Tables 1 and 2, Video 1).
Methods An early postoperative protocol was standardized for patients receiving arthroscopic hip-preservation procedures including labral repair, labral debridement, femoroplasty, acetabuloplasty, synovectomy, ligamentum teres debridement, gluteus medius repair, and capsular plication. The postoperative protocol featured the following components: (1) passive circumduction exercises performed by a caregiver, (2) use of a continuous passive range-of-motion machine (Spectra; Kinetec) providing passive hip flexion from 0 to 90 for a total of 6 hours per day, (3) use of axillary crutches with a foot-flat gait at 20 lb of partial weight bearing, and (4) use of a hip orthotic brace (T Scope Post-Op hip brace; Breg) to limit flexion to 90 and extension to 0 . The pendulum exercises were taught to the patient and
Fig 1. The patient is relaxed in the supine position, with the orthotic brace removed.
caregiver by a member of the orthopaedic surgical team (physician assistant or surgeon) on the first day of the postoperative period.
Technique Hip pendulum exercises are performed at home by a trusted member of the patient’s family or a friend. The patient assumes a supine position on an elevated surface, often a couch or a bed, with the orthotic brace removed (Fig 1). The caretaker stands perpendicular to the patient’s limb. Open and continual communication is essential to ensure that the exercise is performed in a truly passive manner, without the assistance of the patient. It is essential that the muscles surrounding the hip joint remain relaxed. The caregiver should be mindful to offer support to the patient’s lower limb by gently cradling the leg across both of the caregiver’s
Table 2. Pearls and Pitfalls Pearls The patient must be relaxed throughout. A slow, consistent, fluid motion of the limb is required. Trust between the caregiver and patient must be established. The technique should be performed multiple times daily for the greatest effect. Communication is needed to avoid painful motion. Pitfalls Excessive flexion >90 can be painful. Performance on a low surface can cause fatigue for the caregiver. Patients often try to assist; relaxation should be encouraged.
Fig 2. The caregiver is mindful to offer support to the patient’s lower limb by gently cradling the patient’s leg across both of the caregiver’s forearms (red arrows).
PENDULUM EXERCISES AFTER HIP ARTHROSCOPY
Fig 3. The caregiver performs the hip circumduction exercise using small clockwise (red arrow) and counterclockwise (blue arrow) circles of the lower limb by moving the caregiver’s arms back and forth in a sawing motion (green arrows).
forearms (Fig 2). The caregiver performs the hip circumduction exercise by moving the hip in small clockwise and counterclockwise circles using a backand-forth sawing motion of the caregiver’s arms (Fig 3). The patient’s patella should remain pointed toward the ceiling throughout the entire exercise (Fig 4). The circumduction movements are repeated continuously through an arc of 30 to 70 of hip flexion for 20 minutes, 3 times per day (Fig 5).
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Fig 4. The patient’s patella (red opaque circle) should always remain pointed toward the ceiling (red arrow).
benefits of physical therapy later in the recovery process. As the cost of physical therapy continues to rise annually, the home caregiver may reduce the cost of therapy by instituting home pendulum exercises during the early postoperative period.
Discussion Evidence has shown that hip pendulum exercises may provide protection because they lower the risk of adhesion formation. Willimon et al.1 presented a Level IV evidenceebased study using a rehabilitation program that included pendulum exercises performed throughout the day to reduce the rate of adhesions and arthroscopic revision rates. The results showed a 4.1fold increased risk of adhesions in patients who did not perform circumduction therapy.1 We believe that physical therapy plays an important role in restoring normal function after hip jointepreserving arthroscopic surgery. Initiating a caregiver-based intervention in the early stages of recovery allows the patient to maximize
Fig 5. Circumduction is repeated continuously through an arc of 30 to 70 of hip flexion for 20 minutes, 3 times per day.
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References 1. Willimon SC, Briggs KK, Philippon MJ. Intra-articular adhesions following hip arthroscopy: A risk factor analysis. Knee Surg Sports Traumatol Arthrosc 2014;22: 822-825. 2. Malloy P, Malloy M, Draovitch P. Guidelines and pitfalls for the rehabilitation following hip arthroscopy. Curr Rev Musculoskelet Med 2013;6:235-241. 3. Bozic KJ, Chan V, Valone FH III, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28:140-143. 4. Bennell KL, O’Donnell JM, Takla A, et al. Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingementdThe FAIR trial: A randomised controlled trial protocol. BMC Musculoskelet Disord 2014;15:58. 5. Edelstein J, Ranawat A, Enseki KR, Yun RJ, Draovitch P. Post-operative guidelines following hip arthroscopy. Curr Rev Musculoskelet Med 2012;5:15-23. 6. Enseki KR, Kohlrieser D. Rehabilitation following hip arthroscopy: An evolving process. Int J Sports Phys Ther 2014;9:765-773.
7. Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health 2010;2:222-230. 8. Wahoff M, Dischiavi S, Hodge J, Pharez JD. Rehabilitation after labral repair and femoroacetabular decompression: Criteria-based progression through the return to sport phase. Int J Sports Phys Ther 2014;9:813-826. 9. Greene WB. Use of continuous passive slow motion in the postoperative rehabilitation of difficult pediatric knee and elbow problems. J Pediatr Orthop 1983;3:419-423. 10. O’Driscoll SW, Giori NJ. Continuous passive motion (CPM): Theory and principles of clinical application. J Rehabil Res Dev 2000;37:179-188. 11. Simkin P, De Lateur B, Alquist A, Questad K, Beardsley R, Esselman P. Continuous passive motion for osteoarthritis of the hip: A pilot study. J Rheumatol 1999;26:1987-1991. 12. Skyhar MJ, Danzig LA, Hargens AR, Akeson WH. Nutrition of the anterior cruciate ligament Effects of continuous passive motion. Am J Sports Med 1985;13:415-418. 13. Takai S, Woo SLY, Horibe S, Tung DKL, Gelberman RH. The effects of frequency and duration of controlled passive mobilization on tendon healing. J Orthop Res 1991;9: 705-713.
Abstract: Advanced hip jointepreserving arthroscopic techniques have been shown to improve patient-reported functional outcomes with low rates of postoperative complications. Prior work has shown that formation of adhesive scar is a potential source of persistent pain and cause for revision surgery. As resources for postoperative in-studio physical therapy become scarce, a home-based strategy to avoid scar formation without adding formal therapy cost may be beneficial. The purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery of manual hip pendulum exercises in the postoperative setting. This video technique offers access to our method for pendulum exercise as part of early recovery after advanced hip arthroscopy.
T
he use of arthroscopic hip-preserving procedures in the management of hip conditions such as labral tears, chondral lesions, ligamentum teres rupture, osteonecrosis, hip instability, and femoroacetabular impingement has increased dramatically over the past decade.1,2 The rate of hip arthroscopic procedures has increased by 600% since 2006,3 and this rate is expected to continue to grow. Despite this high rate of growth, there remains little consensus on the role of formal in-studio physical rehabilitation in the postoperative management of patients undergoing hip arthroscopy. Many postoperative protocols have been proposed in the peer-reviewed literature.2,4-8 Most, however, have been formulated with a lack of objective evidence using validated patient-oriented outcome scores.5 Current studies are underway to
From the Center for Athletic Hip Injury, Allegheny Health Network (R.S., G.S., B.M.N., J.J.C.); Department of Orthopaedic Surgery, Drexel University School of Medicine (R.S., G.S., B.M.N., J.J.C.); and John G. Rangos Sr. School of Health Sciences, Duquesne University (B.R.K.), Pittsburgh, Pennsylvania, U.S.A. The authors report the following potential conflict of interest or source of funding: J.J.C. receives support from International Society for Hip Arthroscopy, Arthrex, Breg, Allegheny Health Network, and Allegheny Singer Research Institute. Received October 3, 2015; accepted April 19, 2016. Address correspondence to John J. Christoforetti, M.D., Center for Athletic Hip Injury, Allegheny Health Network, 4815 Liberty Ave, Ste 252, Pittsburgh, PA 15224, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15953/$36.00 http://dx.doi.org/10.1016/j.eats.2016.04.013
evaluate the efficacy of a formalized rehabilitation program regarding health-related quality of life and physical function,4 and stronger evidence is needed to define the standard of care in postoperative management of patients undergoing arthroscopic hippreservation surgery.2,4-8 Despite variation in postoperative rehabilitation programs, most protocols reported in the literature have asserted that early mobilization is an important component of postoperative care. Passive motion helps to nourish joint surfaces, promote tissue remodeling, and increase tensile strength.9-13 Early passive motion may also reduce the risk of joint stiffness and adhesions that may impair normal joint motion.1 Patients who undergo passive circumduction exercises performed by a physical therapist in the early postoperative phase of rehabilitation after hip arthroscopy are 4.1 times less likely to have development of adhesions compared with those who do not.1 Thus passive motion in the form of circumduction exercises may be beneficial to promote healing and lower the risk of complications. The current health care climate demands efficiency in the delivery of care. Insurance carriers are more restrictive on the number of physical therapy visits afforded to subscribers, and more financial burden is placed on patients through co-pays and deductibles. As a result, physical therapists are often confronted with the challenge to manage a lengthy postoperative period with fewer visits. A home-based passive motion regimen that decreases the number of necessary outpatient therapy sessions could be a valuable
Arthroscopy Techniques, Vol 5, No 4 (August), 2016: pp e897-e900
e897
e898
R. SAUBER ET AL.
Table 1. Passive Hip Circumduction Exercises at Home Versus Formal Physical Therapy Advantages No cost No travel required Performed by trusted caregiver Performed multiple times daily Disadvantages Labor and time intensive Time required to educate patient and caregiver Inconsistency of technique
cost-reduction tool. This incentivizes patients to perform exercises that are critical to their recovery within their home setting without the direct supervision of a physical therapist. In an effort to decrease formal physical therapy visits in the early postoperative period, we have used passive hip circumduction exercises that are administered by a caregiver (spouse, parent, family member, and so on) at home as the cornerstone of an independent home program within the first 2 to 4 weeks after hip arthroscopy. The purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery of manual hip pendulum exercises in the postoperative setting (Tables 1 and 2, Video 1).
Methods An early postoperative protocol was standardized for patients receiving arthroscopic hip-preservation procedures including labral repair, labral debridement, femoroplasty, acetabuloplasty, synovectomy, ligamentum teres debridement, gluteus medius repair, and capsular plication. The postoperative protocol featured the following components: (1) passive circumduction exercises performed by a caregiver, (2) use of a continuous passive range-of-motion machine (Spectra; Kinetec) providing passive hip flexion from 0 to 90 for a total of 6 hours per day, (3) use of axillary crutches with a foot-flat gait at 20 lb of partial weight bearing, and (4) use of a hip orthotic brace (T Scope Post-Op hip brace; Breg) to limit flexion to 90 and extension to 0 . The pendulum exercises were taught to the patient and
Fig 1. The patient is relaxed in the supine position, with the orthotic brace removed.
caregiver by a member of the orthopaedic surgical team (physician assistant or surgeon) on the first day of the postoperative period.
Technique Hip pendulum exercises are performed at home by a trusted member of the patient’s family or a friend. The patient assumes a supine position on an elevated surface, often a couch or a bed, with the orthotic brace removed (Fig 1). The caretaker stands perpendicular to the patient’s limb. Open and continual communication is essential to ensure that the exercise is performed in a truly passive manner, without the assistance of the patient. It is essential that the muscles surrounding the hip joint remain relaxed. The caregiver should be mindful to offer support to the patient’s lower limb by gently cradling the leg across both of the caregiver’s
Table 2. Pearls and Pitfalls Pearls The patient must be relaxed throughout. A slow, consistent, fluid motion of the limb is required. Trust between the caregiver and patient must be established. The technique should be performed multiple times daily for the greatest effect. Communication is needed to avoid painful motion. Pitfalls Excessive flexion >90 can be painful. Performance on a low surface can cause fatigue for the caregiver. Patients often try to assist; relaxation should be encouraged.
Fig 2. The caregiver is mindful to offer support to the patient’s lower limb by gently cradling the patient’s leg across both of the caregiver’s forearms (red arrows).
PENDULUM EXERCISES AFTER HIP ARTHROSCOPY
Fig 3. The caregiver performs the hip circumduction exercise using small clockwise (red arrow) and counterclockwise (blue arrow) circles of the lower limb by moving the caregiver’s arms back and forth in a sawing motion (green arrows).
forearms (Fig 2). The caregiver performs the hip circumduction exercise by moving the hip in small clockwise and counterclockwise circles using a backand-forth sawing motion of the caregiver’s arms (Fig 3). The patient’s patella should remain pointed toward the ceiling throughout the entire exercise (Fig 4). The circumduction movements are repeated continuously through an arc of 30 to 70 of hip flexion for 20 minutes, 3 times per day (Fig 5).
e899
Fig 4. The patient’s patella (red opaque circle) should always remain pointed toward the ceiling (red arrow).
benefits of physical therapy later in the recovery process. As the cost of physical therapy continues to rise annually, the home caregiver may reduce the cost of therapy by instituting home pendulum exercises during the early postoperative period.
Discussion Evidence has shown that hip pendulum exercises may provide protection because they lower the risk of adhesion formation. Willimon et al.1 presented a Level IV evidenceebased study using a rehabilitation program that included pendulum exercises performed throughout the day to reduce the rate of adhesions and arthroscopic revision rates. The results showed a 4.1fold increased risk of adhesions in patients who did not perform circumduction therapy.1 We believe that physical therapy plays an important role in restoring normal function after hip jointepreserving arthroscopic surgery. Initiating a caregiver-based intervention in the early stages of recovery allows the patient to maximize
Fig 5. Circumduction is repeated continuously through an arc of 30 to 70 of hip flexion for 20 minutes, 3 times per day.
e900
R. SAUBER ET AL.
References 1. Willimon SC, Briggs KK, Philippon MJ. Intra-articular adhesions following hip arthroscopy: A risk factor analysis. Knee Surg Sports Traumatol Arthrosc 2014;22: 822-825. 2. Malloy P, Malloy M, Draovitch P. Guidelines and pitfalls for the rehabilitation following hip arthroscopy. Curr Rev Musculoskelet Med 2013;6:235-241. 3. Bozic KJ, Chan V, Valone FH III, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28:140-143. 4. Bennell KL, O’Donnell JM, Takla A, et al. Efficacy of a physiotherapy rehabilitation program for individuals undergoing arthroscopic management of femoroacetabular impingementdThe FAIR trial: A randomised controlled trial protocol. BMC Musculoskelet Disord 2014;15:58. 5. Edelstein J, Ranawat A, Enseki KR, Yun RJ, Draovitch P. Post-operative guidelines following hip arthroscopy. Curr Rev Musculoskelet Med 2012;5:15-23. 6. Enseki KR, Kohlrieser D. Rehabilitation following hip arthroscopy: An evolving process. Int J Sports Phys Ther 2014;9:765-773.
7. Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health 2010;2:222-230. 8. Wahoff M, Dischiavi S, Hodge J, Pharez JD. Rehabilitation after labral repair and femoroacetabular decompression: Criteria-based progression through the return to sport phase. Int J Sports Phys Ther 2014;9:813-826. 9. Greene WB. Use of continuous passive slow motion in the postoperative rehabilitation of difficult pediatric knee and elbow problems. J Pediatr Orthop 1983;3:419-423. 10. O’Driscoll SW, Giori NJ. Continuous passive motion (CPM): Theory and principles of clinical application. J Rehabil Res Dev 2000;37:179-188. 11. Simkin P, De Lateur B, Alquist A, Questad K, Beardsley R, Esselman P. Continuous passive motion for osteoarthritis of the hip: A pilot study. J Rheumatol 1999;26:1987-1991. 12. Skyhar MJ, Danzig LA, Hargens AR, Akeson WH. Nutrition of the anterior cruciate ligament Effects of continuous passive motion. Am J Sports Med 1985;13:415-418. 13. Takai S, Woo SLY, Horibe S, Tung DKL, Gelberman RH. The effects of frequency and duration of controlled passive mobilization on tendon healing. J Orthop Res 1991;9: 705-713.