Introduction
This essay will critically review the physiotherapy interventions a patient will receive from the point of being listed for an elective total hip replacement (THR) to discharge home. The profile of the patient, Mr Turner, can be seen in appendix 1.
According to a report by the National Joint Registry (1), joint replacements are increasing by 20,000 patients per year. THR are most commonly recommended for osteoarthritis or other inflammatory disorders (2) when a person no longer responds to conservative management (3). The majority of patients are over 60 years old (2) and slightly over half the patients who have THR surgery are women. THR’s help relieve pain and improve mobility and quality of life and approximately 90% of patients report a ‘good’ or ‘excellent’ outcome (4). However they roughly last 20 years in around 8 out of 10 patients. Therefore to optimise quality of life and function of a patients new hip, physiotherapists….
Preoperative
It is best practice to complete a preoperative assessment within 6 weeks of the surgery however this is not always possible (5). Prior to THR surgery, Mr Turner was provided with a heights form to help occupational therapists (OT) work out if any additional equipment is required. The most common piece of equipment needed is a raised toilet seat and chair or bed raisers to maximise height of furniture at home to prevent futher complications (Drummond et al 2012). This information prior to surgery will help speed up the process of ordering equipment, preventing a delayed discharge (reference). Mr Turner was also recommended to move his bed downstairs which would mean Mr Turner could practice the stairs in his home environment rather than rushing to be discharged. Ideally this should have been sorted out prior to admission for surgery as Royal College of Occupational Therapist guidelines (6) suggest all amendments to the house should be made prior to prevent a prolonged stay.
Additionally many tests are completed such as blood tests to check for anaemia and maximise kidney function, an MRSA swab, a urine sample to rule out infection and an electrocardiogram (ECG) tracing to make sure your heart is healthy.
Physiotherapy is recommended for management of osteoarthritis in the preoperative period (7) as preoperative physiotherapy can improve recovery times (8). Exercises involve…
A moderate quality study Gocen et al. (9), scoring 5/10 on the PEDro scale (10), used sixty patients waiting for a THR. They were randomly assigned to either a control group whom received no physiotherapy intervention or a preoperative physiotherapy group. The preoperative physiotherapy programme aimed to improve muscle strength and range of motion. Results found that patients who received preoperative physiotherapy were able to transfer earlier than the control group however there were no significant differences. Therefore this study concluded that preoperative physiotherapy and education was not useful for patients undergoing THR.
A study by Dauty et al. (7)…It concluded that preoperative physiotherapy does not seem benefit patients but suggests it may have an immediate post-operative benefit.
In a study Czyżewska et al. (11) 15 (83.33)% patients who did not receive pre-operative physiotherapy expressed an interest and all patients expressed their interest in postoperative physiotherapy (11). Therefore there is contrasting evidence in the benefits of pre-operative physiotherapy, but it is indicated that patients express an interest in completing this. One of the main National Health Service (NHS) values is patient centred care and therefore should be suggested that there may be a psychological influence on outcome.
In addition to pre-operative leg exercises, patients are encouraged to completed breathing exercises. Active cycle of breathing technique (ACBT)
Post-operative
MDT Handover
Checking post operation notes to understand weight bearing status, any complications to be aware of. Helps with D/C planning and to inform the patient when their outpatient appointment might be or when the drain is removed etc.
Introduced myself to Mr Turner using the ‘hello my name is’ campaign (12), allowing me to commence physiotherapy with the patient.
Informed consent.
Without Mr Turner verbal consent, physiotherapists are liable for negligence (13). Before mobilising Mr Turner, vital signs were observed using pulse oximeter and a blood pressure cuff. Ensuring a patient’s heart rate and blood pressure are within normal limits will result in a satisfactory outcome and prevents adverse reactions throughout physiotherapy. However, there are no clinical studies to indicate what is normal with respect to heart rate and blood pressure for individual patients in the post-operative period (14).
Hip Precautions
Physiotherapists must disclose all known risks to the patient whilst gaining informed consent prior to treatment (15). THR can be a complex procedure that can result in infection and dislocation of the prosthesis. Dislocation would require further surgery to complete a revision and therefore hip precautions have been introduced to inform all patients what they should avoid post surgery. Mr Turner was informed not to cross his legs over each other, avoid bending the hip more than 90 degrees, avoid twisting, avoid low chairs and avoid lifting heavy things. These hip precautions prevent hip dislocation and encourage faster healing (3). However a systematic review by Barnsley et al. (3) states that hip precautions are associated with a slower return to daily activities, and decrease patient satisfaction. Dislocation rate is low and is not improved by hip precautions. Clinicians views vary and in particular surgeons (16) and as a result some health care services exclude hip precautions. Therefore this may cause conflict and confusion between health care professionals. Do we stick to the guidelines or what the surgeons say? Is there a hierarchal effect?
Dementia – forgetting the hip precautions.
Airway Clearance Techniques
The first part of the physiotherapy assessment is to assist with airway clearance and maintaining good ventilation and perfusion matching. Mr Turner had a general anaesthetic which can cause reduced lung volume, resulting in impaired gas exchange and airway clearance (17). There are three methods to help resolve any effects caused through a general anaesthetic; mobilisation, positioning and deep breathing exercises (reference).
Active cycle of breathing techniques (ACBT) and autogenic drainage (18). With surgery, more emphasis is on the deep breathing component through thoracic expansion exercises rather than the forced expiration to avoid pain and discomfort for the patient, unless the patient has audible secretions. Holding the breath and sniffing at the end of inspiration will help expand the lungs.
In addition to ACBT, an important part of physiotherapy is to encourage patients to sit up and change positions regularly, which can help to improve ventilation and remove secretions if present. Additionally this gives Mr Turner a sense of normality and prevents a patient’s mobility to regress. ACBT is more effective in an upright position (reference) and thus was communicated to Mr Turner to ensure this could be completed throughout his stay in the hospital.
Incentive spirometers could be used with patients undergoing general anaesthetics however they are costly. THR already cost the NHS £… a year and the addition of these would further increase the strain on the NHS. Therefore ACBT is a cheap alternative method to minimising infection risk and ensures patients complete this independently (reference).
Mobilisation
Mobilisation is an important component that will improve lung volume, improve circulation, which helps to remove secretions. Mr Turner has Chronic Obstructive Pulmonary Disorder (COPD), which means he is at greater risk of picking up an infection in hospital with the inability to remove secretions. Removal of secretions through mobility will help decrease their stay in the hospital and will make it easier to independently remove secretions.
Pain is one of the biggest limiting factors post THR surgery (reference). If their pain can be managed, this may result in a reduced length of stay in the hospital, reduce their length of rehabilitation and their rehabilitation will be more efficient (17). To maximise mobilisation it is important to ask the nurses to administer pain relief 20-30 minutes prior to physiotherapy (reference). Opioids are commonly used in the post-operative period and oral opioids can be very effective, allowing earlier discharge from the hospital. National Institute for Health and Care Excellence (NICE) Guidelines (19) also encourage patients to wear their anti-embolism stockings day and night until they are mobile. Many of these stockings do not have anti grip on them and therefore it is essential that Mr Turner wears appropriate footwear to maintain health and safety standards all the time (reference). It is also recommended in the NICE Guidelines (19) that nurses administer Rivaroxaban to prevent venous thromboembolism in adults having elective total hip replacement.
The first step is to encourage leg exercises that include ankle pumping and rotations, knee flexion, static quadriceps contraction, hip abduction, straight leg raise and gluteal contractions. These can be completed in bed and later completed in seated and standing when Mr Turner becomes more mobile, preventing DVT. A high quality study by Smith et al. (20), scoring 7/10 on the PEDro scale (10), determined whether the addition of bed exercises after THR improved functional outcomes and quality of life in the first 6 weeks post surgery. Sixty patients were randomly assigned either a gait re-education programme and bed exercises, or gait re-education programme without bed exercises. Bed exercises consisted of ankle pumping, bending the knee and static quadriceps and gluteal exercises, all of which were used when treating Mr Turner. However Smith et al. (20) concluded that bed exercises in addition to a gait re-education programme does not significantly improve patient function or quality of life .
In order to mobilise Mr Turner on day 1 post-op, he needed to transfer from sitting upright in bed to sitting on the edge of the bed. This required assistance of 2 (AO2) as he was unable to lift his right leg due to surgery. Unfortunately as Mr Turner sat on the edge of the bed he appeared clammy, pale and was becoming less responsive. Mr Turner was experiencing vasovagal or orthostatic intolerance, a limitation to early mobilisation (reference). Orthostatic intolerance occurs in 20% of patients post surgery (reference). During mobilisation this is something to monitor closely, requiring constant communication between Mr Turner and physiotherapist. Mr Turner became less responsive and therefore was returned to bed with full AO2. Nurses were liaised with and a blood test was carried out. As a result Mr Turner had become anaemic due to surgical blood loss and therefore had a blood transfusion. Many patients will not require a blood transfusion and would be able to mobilise fully. However each patient is different and in this situation physiotherapy cannot continue whilst the patient is undergoing a blood transfusion due to an increased risk of bleeding (reference).
Day 2:
AM: WZF to T/F to chair.
PM: WZF to mobilise 5m FWB – patient was less reliant on upper body strength but was limited by pain when mobilising.
Day 3:
AM: WZF to mobilise 5-10m AO1 FWB – patient baseline is short distances and AO1 allows the patient to go home with care, decreasing POC and less pressure on community services.
PM: WZF to mobilise to toilet to improve independence AO1 FWB progress to crutches. Carried out a stair assessment but MR Turner failed. Unfortunately as no downstairs living, Mr Turner must remain in hospital until he is able to complete the stairs safely.
Day 4:
AM stair Ax – completed
PM discharge home.
Early mobilisation can result in a reduced length of stay by 1.8 days, therefore reducing the use of additional costly equipment and preventing the increased risk of picking up additional infections (21). Additionally it reduces the incidence of DVT and lowers the incidence of associated morbidity.
Reducing falls risk
An alternative method of physiotherapy is telerehabiliatio (22). It aims to deliver rehabilitation programmes in patients homes using technology. The study by Nelson et al. (22) suggests that it may help to reduce bealth care costs, enable earlier discharge and allow patients to be more independent with their physiotherapy.
Dementia patients prefer home environment…
Cryotherapy is commonly used during physiotherapy after joint replacements however evidence is contradictory. There are no clinical guidelines to inform effective treatment protocols within THR patients and as a result cryotherapy was not used to help relieve pain, swelling and/or inflammation.
There are no current guidelines or pathways that suggest a patient undergoing a THR should be in and out of hospital within x amount of days. The NHS have asked National Institute for Health and Care Excellence (NICE) to develop a clinical guideline on hip, knee and shoulder joint replacements. These guidelines will be available in 2020 and therefore in the meantime patients will be treated under the current guidelines.
Discharge
On discharge from the ward, it is the discharge coordinators responsibility to ensure Mr Turner has the correct transport home. According to the British Orthopaedics Association THR guidelines (5), “discharge planning should start before the patient’s admission and is one of the important functions of a pre-admission assessment clinic” (pg.26).
From a physiotherapist point of view, it is vital Mr Turner is independently mobile and safe with appropriate walking aids as well as being able to mobilise up and downstairs safely. Had Mr Turner been able to relocate his bedroom downstairs temporarily he would not have had to complete a stair assessment, and consequently could have been discharged earlier. It is also important that MR Turner is independent when transferring and also he is independent with his home exercise programme. Therefore he is considered safe if he will be able to cope with his home environment.
OT to order equipment – but cost on NHS
MDT
Throughout this two-three day process, a multidisciplinary team (MDT) are involved in patient centred care. Discharge coordinator, nurses, Orthopedic Consultant, physiotherapists, social worker, occupational therapists, psychologist, pain and dementia team.
Documentation
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Reference List
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