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AOTW: The 'HAPI' Project- Preoperative Hip Strengthening for Post-Surgical Success

This week's article of interest comes from the United Kingdom, published in 2017- so I'm arguably a little late to the party here. Evidence for "pre-habilitation" or "prehab" has been done in the hip and knee for improved function and quicker recovery in total joint replacement And ACL reconstruction surgeries. We also know that the healthier you are prior to surgery (including the stronger & more mobile), the quicker you recover afterward.

This week’s article tested this theory on patients undergoing hip arthroscopy for the treatment of femoro-acetabular impingement, otherwise known as FAI, and labral tears.

The Article

Louise F. Grant, et al published this study in the Journal of Hip Preservation Surgery in January 2017:

18 participants with symptomatic FAI and labral tears (male & female, >18 years old) were divided into 2 groups: the first performed no regular home exercise program (HEP) prior to surgery, and the second group was given an 8-week HEP emphasizing hip strength and flexibility. The authors’ hypothesis was that pre-surgery strengthening would improve the post-surgical function & accelerate strength return, in a similar way that previous studies have shown benefits for the knee. Hip arthroscopies were performed on all participants and everyone underwent standard therapy after surgery. Participants were followed for 12 weeks afterward and their hip strength measured with a hand-held dynamometer.

The Intervention

Participants in the control group had their operative limb massaged for pain control & the intervention group got to do exercises (isn't that some kind of luck? haha!). The intervention group was instructed to do these exercises within a painfree range daily:

  • Heel raises

  • Single leg mini squat

  • Standing hip abduction

  • Standing hip flexion (knee bent at 90deg- aka a march)

  • Straight leg raises in abduction & adduction

  • Double leg bridge

  • Bent Knee Fall Out

  • Prone hip flexor/quadriceps stretch

  • Kneeling hip flexor stretch

The Findings

The intervention group (to no surprise) had higher values, however due to the small sample size, nothing everything was statistically significant. Here's what was:

  • Operative side hip flexion strength

  • Operative and non-operative knee extension strength

  • EQ-5D-5 L health (subjective measurement of mobility, self care, usual activity, pain, and anxiety/depression)

Improving post-surgical outcomes for hip arthroscopy doesn't have to be rocket science. It could happen in one visit.

This is a great start in analyzing the impact of pre-operative rehabilitation on post-surgical outcomes- patients are stronger and more satisfied with their outcomes when prehab was performed. Arguably, rehabilitation goals could be met sooner with fewer precious therapy visits required in the presence of such a program.

This study shows that you don't need multiple therapy visits prior to surgery either- it could just be one education session with supplemental written materials to ensure that these patients are gaining full benefit from the program and performing exercises effectively. And these exercises aren't exactly rocket science- they target the areas that many patients with FAI and hip labral tears have been shown to be weak: hip abductors, adductors, extensors and flexors, as well as a few other support areas. I would be interested to see the results in hip strength (primarily abductors and extensors) with variations of exercises prescribed- as I often struggle to see meaningful changes in strength with SLR's and standing hip abduction, unless the patient is dramatically weak.

I can hear every rehabilitation specialist saying "now, if they'll just DO it". Patient compliance is certainly a huge issue with programs like this. Consider our approach to patient education: highlighting the benefits of such a program ("these 10 exercises will help you recover faster" or "you'll be in therapy for less time because you'll be stronger going into surgery") instead of using negative consequences ("you'll be weaker if you don't do it" or "you will recover slower if you don't do the exercises") tends to yield better results and more compliant patients. This is particularly advantageous for patients that have minimal therapy visits allowed in a calendar year based on their insurance plans.

Next steps: Talk with your referring physicians about using a program like this one. The improved post-surgical outcomes are a win for everyone! What exercises would your pre-surgery program include? Comment below!


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