A step ahead
Monday March 12, 2012
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A physical therapist-led walking-skill training program resulted in improved functioning for total hip arthroplasty patients over control-group patients in a recent Norwegian study.
"There was a marked difference between the two groups," said Vigdis Bruun-Olsen, RPT, MSc, a physical therapist in the Department of Health Sciences, Institute of Health and Society, University of Oslo, Norway.
Most notably, patients receiving the therapy were able to walk farther, and climb and descend stairs faster than those who did not take part in the intervention.
The therapy team developed the intervention after noting that months or years after surgery, THA patients' walking abilities remained impaired, perhaps because of a preop history of hip pain and dysfunction that resulted in gait adaptations.
The research team thought patients needed to relearn movement patterns used prior to developing osteoarthritis. "This walking-skills intervention is quite different from how we usually treat these patients," Bruun-Olsen said. "It is based on physiological theories. To achieve a skill you don't just improve strength or flexibility, you have to focus on the whole complexity of the skill — walk over obstacles, walk downhill."
The intervention
The intervention began three months postop with a walking-skill program aimed at helping participants relearn motor skills by repeatedly walking on uneven surfaces, stepping over obstacles, walking quickly and slowly, turning, stopping, and climbing and descending stairs. The control group was encouraged to continue their home exercise programs and remain active.
The home program after three months is similar to U.S. patients' plans of care, said John Corcoran, PT, DPT, Cert. MDT, director of inpatient therapy at Rusk Institute for Rehabilitation Medicine at New York University Langone Medical Center in New York City. But he added that patients often do not follow through because they are more comfortable exercising with someone to guide them.
At three months, activity restrictions, such as flexion and adduction typically are lifted, allowing physical therapists greater freedom to challenge patients, Corcoran said.
THA patients typically experience a rapid recovery and feel good at three months, but at that point, they start to plateau, said Jill Horbacewicz, PT, PhD, chair, director and associate professor of the Touro College physical therapy department in New York.
The 68 people in the intervention cohort, age 45-81 years, worked in groups of two to eight patients with a physical therapist during 12 twice-weekly, 70-minute sessions. The program was tailored to the individual patient and his or her goals, with 79% wanting to improve their walking ability and 21% stating they hoped to improve their balance.
Bruun-Olsen said therapists stayed with the patients, observed what they were doing, guided them and progressed the exercises. "We used our clinical eye to see what they were doing, try to adjust or correct and try to make them experience and feel for themselves how they could improve their walking," he said.
Corcoran emphasized the importance of specificity of training in this population and practicing activities the patient will do at home, since improving those activities in the clinic will carry over to their environment. "The whole program was performed in weight-bearing positions, and the patients were moving around most of the time," said lead author Kristi E. Heiberg, a PhD candidate at the University of Oslo in Norway, in a written statement. "Patients were asked to rise from the chair at different speeds, with several holds within the range, and with emphasis on the experience of the movement."
Heiberg described the obstacle course, through which patients stepped over objects and navigated high steps or uneven ground. "The exercises are in line with the activities and demands of [patients[']] everyday life, and also in line with the patients' future functional priorities, which generally were to improve walking," she said.
The balance exercises done in the study require taking the patient almost to the point of falling, Corcoran said. The training group participants reported that the activities were more mentally and physically demanding than any prior physical therapy program, but the sessions were well-tolerated with no complications.
"This program showed you could push patients pretty hard," Horbacewicz said.
Study results
At the end of the six weeks and again at one year, the team measured the patients' ability to walk in a hospital corridor at a comfortable speed for six minutes; ascend and descend eight steps as quickly as possible, using alternate legs; walk in a figure eight; their general mobility, muscle strength, balance/coordination and endurance; and their range of motion. Participants also self-reported about their physical functioning and how it pertained to their daily activities.
Twenty-three training group participants and five control patients improved their walking distance to more than or equal to 164 feet compared to the pretest distance, and at the second test, one year after surgery, 26 people in the training group and 15 in the control group could walk that far.
Also at the second test, nine intervention participants and 14 control patients reported falling. "That is significant, especially in this population," Corcoran said. "They are at risk when they fall to dislocate, based on the nature of the surgery."
With the results being as good as they were, Bruun-Olsen said, a walking-skill program for THA patients could become the standard of care, but that practical issues, such as insurance coverage, could be a barrier.
Horbacewicz agreed that an additional intensive physical therapy program, shown to improve clinical outcomes further, would benefit patients. "Why wouldn't you want more one-on-one with a skilled physical therapist who could give you improvements," she said. "The harder you work and the more active you are, it's going to have an effect on your physical functioning. Wouldn't it be wonderful if everyone could have an additional two months of therapy?" •
Debra Wood is a freelance writer.
"There was a marked difference between the two groups," said Vigdis Bruun-Olsen, RPT, MSc, a physical therapist in the Department of Health Sciences, Institute of Health and Society, University of Oslo, Norway.
Most notably, patients receiving the therapy were able to walk farther, and climb and descend stairs faster than those who did not take part in the intervention.
The therapy team developed the intervention after noting that months or years after surgery, THA patients' walking abilities remained impaired, perhaps because of a preop history of hip pain and dysfunction that resulted in gait adaptations.
The research team thought patients needed to relearn movement patterns used prior to developing osteoarthritis. "This walking-skills intervention is quite different from how we usually treat these patients," Bruun-Olsen said. "It is based on physiological theories. To achieve a skill you don't just improve strength or flexibility, you have to focus on the whole complexity of the skill — walk over obstacles, walk downhill."
The intervention
The intervention began three months postop with a walking-skill program aimed at helping participants relearn motor skills by repeatedly walking on uneven surfaces, stepping over obstacles, walking quickly and slowly, turning, stopping, and climbing and descending stairs. The control group was encouraged to continue their home exercise programs and remain active.
The home program after three months is similar to U.S. patients' plans of care, said John Corcoran, PT, DPT, Cert. MDT, director of inpatient therapy at Rusk Institute for Rehabilitation Medicine at New York University Langone Medical Center in New York City. But he added that patients often do not follow through because they are more comfortable exercising with someone to guide them.
At three months, activity restrictions, such as flexion and adduction typically are lifted, allowing physical therapists greater freedom to challenge patients, Corcoran said.
THA patients typically experience a rapid recovery and feel good at three months, but at that point, they start to plateau, said Jill Horbacewicz, PT, PhD, chair, director and associate professor of the Touro College physical therapy department in New York.
The 68 people in the intervention cohort, age 45-81 years, worked in groups of two to eight patients with a physical therapist during 12 twice-weekly, 70-minute sessions. The program was tailored to the individual patient and his or her goals, with 79% wanting to improve their walking ability and 21% stating they hoped to improve their balance.
Bruun-Olsen said therapists stayed with the patients, observed what they were doing, guided them and progressed the exercises. "We used our clinical eye to see what they were doing, try to adjust or correct and try to make them experience and feel for themselves how they could improve their walking," he said.
Corcoran emphasized the importance of specificity of training in this population and practicing activities the patient will do at home, since improving those activities in the clinic will carry over to their environment. "The whole program was performed in weight-bearing positions, and the patients were moving around most of the time," said lead author Kristi E. Heiberg, a PhD candidate at the University of Oslo in Norway, in a written statement. "Patients were asked to rise from the chair at different speeds, with several holds within the range, and with emphasis on the experience of the movement."
Heiberg described the obstacle course, through which patients stepped over objects and navigated high steps or uneven ground. "The exercises are in line with the activities and demands of [patients[']] everyday life, and also in line with the patients' future functional priorities, which generally were to improve walking," she said.
The balance exercises done in the study require taking the patient almost to the point of falling, Corcoran said. The training group participants reported that the activities were more mentally and physically demanding than any prior physical therapy program, but the sessions were well-tolerated with no complications.
"This program showed you could push patients pretty hard," Horbacewicz said.
Study results
At the end of the six weeks and again at one year, the team measured the patients' ability to walk in a hospital corridor at a comfortable speed for six minutes; ascend and descend eight steps as quickly as possible, using alternate legs; walk in a figure eight; their general mobility, muscle strength, balance/coordination and endurance; and their range of motion. Participants also self-reported about their physical functioning and how it pertained to their daily activities.
Twenty-three training group participants and five control patients improved their walking distance to more than or equal to 164 feet compared to the pretest distance, and at the second test, one year after surgery, 26 people in the training group and 15 in the control group could walk that far.
Also at the second test, nine intervention participants and 14 control patients reported falling. "That is significant, especially in this population," Corcoran said. "They are at risk when they fall to dislocate, based on the nature of the surgery."
With the results being as good as they were, Bruun-Olsen said, a walking-skill program for THA patients could become the standard of care, but that practical issues, such as insurance coverage, could be a barrier.
Horbacewicz agreed that an additional intensive physical therapy program, shown to improve clinical outcomes further, would benefit patients. "Why wouldn't you want more one-on-one with a skilled physical therapist who could give you improvements," she said. "The harder you work and the more active you are, it's going to have an effect on your physical functioning. Wouldn't it be wonderful if everyone could have an additional two months of therapy?" •
Debra Wood is a freelance writer.
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Monday March 12, 2012