Necessity of Inclusion of Muscular Belt Training Exercises in the Complex Rehabilitation Programme of Osteoarthritic Patients after Total Hip Replacement (A Case Report)

Koleva I, Papathanassiou Y, Yoshinov B and Hadjiyanev C

Published on: 2020-04-15


Introduction: During last years, we observe an increase of the number of joint replacement in lower extremities, especially in geriatric osteoporotic population. The rehabilitation protocol after arthroplasty includes physiotherapy, oriented to training of muscles (around the joint) and to gait recovery. Nevertheless, in some cases, during this period a complication or comorbidity can occur. The goal of current study is to present a patient after hip replacement with unexpected low back pain and related clinical signs and symptoms; and the subsequent adaptation of our rehabilitation complex to this comorbidity.

Patient’s Presentation: The presented patient is a 74 years old male; transferred to our Department one week after left total hip replacement, with the objective of complex rehabilitation; for persistent clinical manifestations. At the moment of admission, the patient suffers from excessive pain in the hip region and muscles around it; low back pain and paravertebral stiffness, leg tingling; difficulties in standing-up, transfers and mobility; gait instability; altered autonomy in everyday life. Clinical exam before rehabilitation demonstrates Reduced and painful Range of Motion in the operated hip; vertebral (lumbar) syndrome and bilateral lumbo-sacral radicular syndrome (L5-S1). The imagery (X-ray, CT, and MRI) demonstrated lumbar osteochondrosis, spondylosis and spondylarthrosis. In the complex rehabilitation program we included exercises for hip mobility, muscle strength, gait training; and for spine mobility and muscular dysbalance. The algorithm of orthopedic rehabilitation is presented and explained in details. For improvement of the efficacy of the rehabilitation we must consider the kinesiological and pathokinesiological analysis of the typical posture and gait of every patient, especially after operation of one lower extremity. The adaptation of the complex rehabilitation programme to the individual case at the concrete moment of his condition is obligatory. The adapted rehabilitation stimulates the functional recovery of patients with orthopedic conditions, ameliorating their autonomy and quality of life.


Back pain; Hip joint; Physical and rehabilitation medicine; Physiotherapy; Rehabilitation; Total hip replacement


During last years, we observe an increase of the number of joint replacement in lower extremities, especially in geriatric osteoporotic population. Total hip replacement (THR) is realized in cases of osteoarthritis and in case of severe fractures [1,2]. Patients with hip and knee arthroplasty are transferred from acute orthopedic clinic to the subacute or rehabilitation clinic at the ever-earlier stage. In rehabilitation, we work for enhancement of the range of motion and for gait recovery. Gait is an important element of the everyday life functionality of our patients in rehabilitation practice, and is crucial for their independence in activities of daily living (ADL), respectively for their autonomy. The consultation with a medical doctor – specialist in Physical and Rehabilitation Medicine (PRM) is required [3,4]. The PRM Algorithm traditionally includes functional evaluation and a complex PRM programme of care, including natural and preformed physical modalities. The pre-defined PRM protocol includes only physiotherapy (PT) [5-12]. Oriented to training of muscles (around the hip joint) and to gait recovery. Nevertheless, in some cases, during this period, an unexpected complication or comorbidity can take place.

The goal of current study was to present a patient after hip replacement with unexpected low back pain and related clinical signs and symptoms; and the subsequent adaptation of our rehabilitation complex to this comorbidity.

Case Presentation

Patient’s presentation

The presented patient is a 74 years old male. Transferred to our PRM Department one week after left total hip replacement (THR), with the objective of complex rehabilitation for persistent clinical manifestations.

Patient complaints at the moment of admission

Patient suffers from excessive pain in the hip region and muscles around it; low back pain and paravertebral stiffness, leg tingling; difficulties in standing-up, transfers and mobility; gait instability; and subsequent altered autonomy in everyday life.

Active co-morbidities

Arterial hypertension, controlled with anti-hypertensive drugs (Amlodipine 10 mg daily). Diabetes mellitus – type 2, controlled with diet and per-oral anti-diabetics (Metformin 3 1000 mg). No obesity. No previous history of low back pain. No family history of rheumatologic diseases. The patient denies addictions to alcohol or tobacco use.

Clinical exam before rehabilitation

Reduced and painful Range of Motion (ROM) in the operated hip. Pot-operative cicatrix – without complications. Vertebral syndrome in the lumbar region (with reduced lumbar lordosis, paravertebral muscle spasm, limited range of motion of the lumbar spine); Bilateral lumbo-sacral radicular syndrome (L5-S1) with positive and negative sensory signs (pain in the points of Valleix – in the lumbar region and in lower extremities, positive sign of Lassegue bilaterally at 75 degrees; hypoesthesia in L5 and S1 dermatomes); Absence of the Aquilles reflexes bilaterally. No muscle weakness.

BMI = 23.

Functional assessment before rehabilitation

Kinesiological analysis

  • Goniometry of the operated hip joint - Limited range of motion (ROM) of the operated hip: active flexion - 25°, passive flexion - 30° (with tolerable pain); abduction – at 10 degrees.
  • Reduced mobility of the lumbar spine – Schober test of 1.5 cm;
  • Muscular dysbalance at the lumbar level; Paravertebral muscle spasm D>S;
  • Difficulty in transfers, normal gait impossible. Patient can walk with a walker and an assistant PT – for 5 meters. The patient can’t effectuate 10 meters walk test or Standing-Up-and-Go (SUG-test).

Manual muscle test (MMT) for lumbar paravertebral muscles and muscles of lower extremities: MMT=3+/5 for ilio-psoas utriusque (utr. – bilaterally) & MMT 4/5 for gluteus medius utr. Reduced capacity for autonomic gait: possible only with technical aids and with an assistance. Reduced rehabilitation potential. The pain was evaluated using Visual Analogue Scale (VAS) – from 0 /no pain/ to 10 /intensive pain/. Before PRM, the patient suffered from intensive pain in different body positions: lying, sitting and standing straight (in bed - VAS=6/10; in vertical position – VAS=7/10), and during lumbar and hip movements (VAS=9/10).

Assessment according the international classification of functioning, disability and health (ICF) [13]

  • Impairments of body functions and changes in body structures: hip pain, lumbar paravertebral pain, reduced spine mobility, muscle weakness, and restricted hip and spine ROM;
  • Activity limitation – altered gait stability and limited walking ability;
  • Participation restrictions - reduced participation in leisure activities;
  • Reduction of the patient’s level of autonomy.

Biological constants

RR 130 / 85 mm Hg, frequency – 74 beats/min., saturation – 95%.

LAB exam

Normal Hb, Leuco, Thrombo; CRP, ionogram, quasi-normal lipid and glucidic patterns.

X-Ray imagery of the spine

Cervical and lumbar osteochondrosis, spondylosis and spondylarthrosis. Suspicion for osteoporosis. Static disturbances with significant alteration of the physiological lumbar lordosis.

Computer tomography (CT) of the lumbar spine

Osteochondrosis, spondylosis, spondylarthrosis; discal hernia L5-S1.

Magnetic Resonance Imagery (MRI) of the lumbar spine

Lumbar osteochondrosis, spondylosis and spondylarthrosis. Multi-level discal herniation, predominantly at level L5-S1, without reduction of the lumen of the vertebral canal. Figures 1, 2 and 3 present images of the patient’s hips and spine: X-ray radiography, CT and MRI (Figure 1-3).

PRM Program Of Care


The GOAL is functional reeducation by a complex rehabilitation program, accentuating on ROM, muscular balance and gait training.

Figure 1: Radiographies (X-Ray) (Static disturbances of the lumbar spine, right hip with osteoarthritis, left hip arthroplasty).

Figure 2: CT of the patient’s lumbar spine (a/ – sacro-iliac joints arthritis; b/ and c/ - levels L4-L5 and L5-S1 discal herniation).

Figure 3: MRI of the lumbar spine (T1 & T2).


  • Recovery of the stability and mobility of the lower limb joints; Control of joint ROM;
  • Reconditioning of ROM and muscle force;
  • Restoration of the muscle and ligament balance, accentuating on muscles around the operated hip and the lumbar spine; keeping the hip in the economic limb biomechanics;
  • Pain relief;
  • Control of the cicatrix;
  • Education of transfers;
  • Autonomic gait recovery with correction of the eventual abnormal walking scheme and restauration of the correct gait pattern;
  • Recovery of the stability;
  • Retrieval of spine flexibility and mobility;
  • Improvement of circulation and of general patient condition;
  • Prevention of possible complications (deep vein thrombosis,
  • Activities of daily living (ADL) training; amelioration of autonomy in everyday life;
  • Psycho-emotional stimulation;
  • Enhancement of the health-related quality of life;
  • Re socialization.


  • Anti-coagulants – Fraxiparine 0.6 mg, s.c.;
  • Per oral antalgics – Paracetamol (2 x 1000 mg), per os;
  • Paravertebral infiltrations – 5 applications of Cortisone, Lidocaine and B-vitamins (B1, B6, B12) – once daily;
  • Patient’s education;
  • Posture and activity modification;
  • Preformed physical modalities: Interferential electric currents and low intensity low frequency Magnetic field – for pain relief;
  • Cryotherapy & Massage – ice-massage for the hip region, classic relaxing paravertebral massage for the lumbar region;
  • Individualized physio-therapeutic (PT) programme for the hip: c correct position of lower limb, analytic exercises for gluteal muscles especially for gluteus medius muscle, lower limb joint mobilization (active range of motion), post-isometric relaxation /PIR/ for iliopsoas muscle; gait training with supporting walker or two crutches, education in mobility up and down the stairs;
  • PT – programme for the lumbar spine - correct spine position, exercises for muscle belt – from lying position; adapted Williams exercises for spine flexors and adapted “Superman” exercises for spine extensors; stretching of the lumbar fascia;
  • Gait training with technical aids (at the beginning – with walker, after 3 days – with crutches); education in mobility with obstacles, up and down the stairs.
  • Occupational therapy (OT) & ADL training.

Results of the Applied PRM Programme and Future Recommendations after the Rehabilitation of one week (10 days after the operation)

We Observed:

  • Amelioration of the ROM of the left hip: active flexion 75 , abduction - 15 ;
  • Pain relief in lumbar spine and hip joints – VAS 2/10;
  • Amelioration of the functional capacity: 10 meters walk test – 9, 4 seconds;
  • Independent stand up and transfers
  • Independent gait with crutches- in the room and the corridor (with technical aids, but without any assistance);
  • Balance & Gait stabilization (Figure 4);
  • Decrease of dysesthesias and pain in distal parts of lower limbs;
  • Amelioration of the autonomy in ADL.

    Figure 4: Gait Training.

    Recommendations after the rehabilitation course the treatment plan after the departure from the hospital includes [13-15]

    • Auto-PT at home: physiotherapy every day at the 3-th month after the arthroplasty; Analytic exercises for the paravertebral muscles (muscle belt) and for muscles of lower extremities; Balance training; Gait – with one or two crutches;
    • Next rehabilitation course at hospital – after 3 months (Figure 4).

    Recommendations for long-term protection – 6 to 9 months after the arthroplasty [16-18]

    The aim of the long-life hip conditioning program is to stimulate the patient to return to daily activities, to sport and other recreational activities - using strengthening exercises and flexibility exercises (stretching the muscles for ROM -restoration and prevention of eventual complications). The target muscles will be Gluteus maximus and Gluteus medius; Hamstrings; Piriformis; Hip Adductors and Abductors; Tensor fasciae latae. The recommended structure of the procedure is: Warm-up (5-10 minutes); Stretch, Strengthening exercises, stretching exercises. Exercises must be done without pain (or without increase of current pain). The patient can make exercises at home only if the therapist is sure that the realization of exercises is correct.


The current case

The current case demonstrates that after a unilateral lower extremity operation, the muscular dysbalance is inevitable. In these cases, we must include in the rehabilitation complex some physical modalities oriented to re saturation of the muscle balance and to recovery of the normal body posture and gait.

Rehabilitation in orthopedics and traumatology (OT rehabilitation)

The first step of an algorithm of OT-rehabilitation is the qualitative and quantitative functional evaluation, including ICF assessment (ICF, 2001) and evaluation scales, applied commonly in the clinical practice of OT and rehabilitation [23, 24].

According ICF principles the complex functional evaluation must include [19].

  • body functions (pain, range of motion, muscle force or motor deficiency, alterations of coordination);
  • activities (mobility, grasp, gait, activities of daily living /ADL/, transport);
  • participation (family relationship, relaxing activities, social life, political activity);
  • environmental factors (conditions of life and work, transport, family and friends, health insurance, social relationship);
  • Personal factors (life style, co-morbidities, age, sex).

During clinical assessment, we accentuate on some analyses:

  • pain (localization, type, intensity – verbal or visual analogue scale; modifying pain activities);
  • joint stability (including joint position sense) and range of motion (active and passive);
  • presence of oedema, muscle or joint contractures;
  • evaluation of the muscle force / muscle insufficiency, motor deficit;
  • analysis of the grasp and gait;
  • mobility (necessity of technical aids - canes, walking sticks, crutches, walkers, wheelchairs and other devices);
  • fatigue (physical endurance, necessity of rest during the examination or the functional activity);
  • Autonomy in everyday activities (bathing, dressing, eating, putting shoes on, personal hygiene, need of help in ADL).

Evaluation of problems must be qualitative and quantitative, including: fatigue, motor deficiency, coordination problems (body position, gait, grasp); pain; conscience for the necessity of technical aids; difficulties in ADL; limitations in functional mobility [3]. The complexity of rehabilitation in OT cases imposes the necessity of a holistic approach to the patient – detailed functional analysis before and after the rehabilitation courses; application of therapeutic methods of different medical specialties (principally orthopedics and traumatology; neurology and neurosurgery; rheumatology; PRM) and from non-medical fields (kinesitherapy, sociology, psychology, occupational therapy). We apply basic principles of the specialty Physical and Rehabilitation medicine [20,21]. Depending on the results of the assessment of the rehabilitation potential of the concrete patient, we use different physical modalities and methods in different (but synergic) combination – the rehabilitation puzzle.

Table 1:  Elements of the complex rehabilitation programme.

Elements of the complex rehabilation programme



Pre-formed modalities

Thermo-Thi Balane-Th


Patient Education



Electic currents

Cryo-th: Ice;

Protiens, Amino-acids;




magnetic field;

Thermo-Th: paraffin;



Manual therapy


Light, Lasser;

Balneo-Th: Mineral waters;

Hypo-glucidic diet.

Weight control



peldio-Th: Therapeutic muds


Osteoporosis control

In every stage of the rehabilitation processes we define precisely the goal, tasks and algorithms of rehabilitation. In every case, our goal is to assure a high quality of the rehabilitation, optimal for the clinical form of the principal disease or condition, adapted to the age, co-morbidities, capacity and desire of the concrete patient; with the strategic goal to receive the best result for his quality of life. The complex rehabilitation programme includes physical and drug therapy, diet, patient education (Table 1).

In our clinical practice we apply a synergic combination) of two (2-3) procedures with pre-formed modalities (electro- and photo-therapy, LASER; magnetic field; ultra-sound, etc.); one (1-2) cryo-/ hydro- / balneo- / thermo-therapeutic procedure with three (3-4) kinesi-therapeutic methods and one (1-2) ergo-therapeutic activity [23]. The functional recovery depends principally from the training of grasp and gait, and the education in activities of daily life. The control before and after rehabilitation is obligatory. At the end of every course we realize a detailed clinical, para-clinical and functional (including instrumental) revision of the obtained results, and we prescribe a periodical control and periodical PRM courses. We consider that the functional evaluation is very important not only for control of the quality of rehabilitation, but too for amelioration of independence in everyday activities and of health-related quality of life of patients. The control after the rehabilitation course and the prescription of periodical ambulatory PRM courses are very important. We consider necessary the continuity of PRM-care: in-patients in acute care hospitals and in PRM clinics (Departments), in-patients in long-term specialized hospitals; out-patients in ambulatory medical and PRM centres; balneo-kinesitherapy in resorts [24,25].


For improvement of the efficacy of the OT-rehabilitation we must consider the kinesiological and pathokinesiological analysis of the typical posture and gait of every patient, especially after operation of one lower extremity. The adaptation of the complex rehabilitation programme to the individual case at the concrete moment of his condition is obligatory. The adapted rehabilitation stimulates the functional recovery of patients with invalidating diseases and conditions of the locomotory system, ameliorating their independence and the health-related quality of life.


Written informed consent was obtained from our patient before any examination or procedure, and before the publication of current manuscript.

Funding Information

Authors declare that the current article was prepared without sources of funding.


Elements of the Physiotherapeutic program are elaborated by the first author under the ERASMUS Plus programme – project “Collaborative learning for enhancing practical skills for patient-focused interventions in gait rehabilitation after orthopaedic surgery (COR-skills)”, No 2015-1-RO01-KA202-015230.

Competing Interests

Authors have declared that no competing interests exists.



  1. Harris WH, CB Sledge. Total hip and total knee replacement. N Engl J Med. 1990; 323: 725-731.
  2. Kelly M, Ackerman R. Total joint arthroplasty: a comparison of post-acute settings on patient functional outcome. Orthop Nurs. 1999; 18: 75-84.
  3. White book on physical and rehabilitation medicine in Europe. Produced by the Section of physical and rehabilitation medicine, union europeenne des medicines specialists (uems), the European board of physical and rehabilitation medicine and l’academie europeenne de medicine de preadaptation in conjunction with the European Society of Physical and Rehabilitation Medicine. J Med. 2007; 1: 1-48.
  4. White Book on Physical and Rehabilitation Medicine in Europe. European PRM Bodies Alliance. European J Physical Rehabilitation Med. 2018; 54: 125-321.
  5. Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Phys Ther. 2000; 80: 448-458.
  6. Johnsson R, Melander A, Onnerfalt R. Physiotherapy after total hip replacement for primary arthrosis. Scand J Rehabil Med. 1988; 20: 43-45.
  7. Mahomed N, Lin KSM, Levesque J. Determinants and outcomes of inpatient versus home based rehabilitation following elective hip and knee replacement. J Rheumatol. 2000; 27: 1753-1758.
  8. Mahomed NN, Aileen MD, Hawker G, Badley E, Davey JR, Khalid AS, et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008; 90: 1673 -1680.
  9. Physical therapy protocols. 2016.
  10. Physical therapy post-operative rehabilitation protocols. 2016.
  11. Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Current op rheumatol. 2003; 15: 160-162.
  12. Shankman G. Fundamental orthopedic management for the physical therapist Assistant. St. Louis: Mosby Year Book. 1997.
  13. Koleva I, Yoshinov RD, Zheleva M, Yoshinov B, Yoshinov RR, Zhelev Y, et al. Grasp and gait rehabilitation. Monograph. Sofia, SIMEL PRESS. 2017.
  14. Jesudason C, Stiller K. Are bed exercises necessary following hip arthroplasty. Aust J Physiother. 2002; 48: 73-81.
  15. Munin M, Rudy T, Glynn N. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA. 1998; 279: 847-852.
  16. Nilsdotter AK, Roos EM, Westerlund J, Roos HP. Comparative responsiveness of measures of pain and function after total hip replacement. Arthritis Care Res. 2001; 45: 258-262.
  17. Ottenbacher K, Smith P, Illig S. Prediction of follow-up living setting in patients with lower limb joint replacement. Am J Phys Med Rehabil. 2002; 81: 471-477.
  18. Sashika H, Matsuba Y, Watanabe Y. Home program of physical therapy: effects on disabilities of patients with total hip arthroplasty. Arch Phys Med Rehabil. 1996, 77: 272-277.
  19. World Health organization. International classification of functioning. Disability Health. WHO. 2001.
  20. ??leva I. Repetitorium physiotherapeuticum basic principles of the modern physical and rehabilitation medicine. Book for English speaking students of Pleven Medical University. Sofia, SIMEL. 2006.
  21. Koleva I, Avramescu E, Kamal D, Kamal C, Traistaru MR. Rehabilitation guidelines of operational standard procedures in rehabilitation after lower limb orthopedic surgery. Ed New Developments. 2017; 594-598.
  22. Koleva I, Yoshinov R, Yoshinov R. Impact of the pain management in the complex rehabilitation algorithm of orthopedic and traumatic conditions.  Osterreichisches Multi sci J. 2018; 1: 11-19.
  23. Koleva I, Yoshinov RD, Yoshinov B. Physical Analgesia Connaissances et Savoirs. Sciences Sante. 2018.
  24. DeLisa JA. Physical medicine and rehabilitation principles and practice. 4th Philadelphia, Lippincott. Williams Wilkins, 2005.
  25. Dillingham TR. Musculoskeletal rehabilitation: current understandings and future directions. American j physical medicine rehabilitation Asso Academic Phys. 2007; 6: 19-28.