| PHYSIOTHERAPY AND COMPLEMENTARY THERAPIES/ FISIOTERAPIA

Effect of Combined Training Program on Gait Parameters after Bilateral Total Hip Arthroplasty: A Case Study

College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, IndiaRicha Singh^*, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, IndiaKeerthi Rao, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, IndiaDeepak Anap, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, IndiaChandra Iyer and College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, IndiaSubhash Khatri

Keywords Total hip replacement; Computerized dynography

Introduction Rheumatoid arthritis (RA) is a chronic and progressive disorder. Inspite of the various drug (disease modifying antirheumatic drugs) therapy, joint erosion and destruction develops with the passage of time and the major symptom being joint pain. As the disease, progresses there are signs of reduced range of motion, decrease in muscle strength and ultimately a decline in functional activity. Total joint replacement considered a milestone and an important therapeutic option in the management of RA [1]. The indication for surgery is unbearable joint pain with activity or at rest, or a severe functional impairment leading to change in the lifestyle. The aim of total hip arthroplasty (THA) is not only to relieve pain but also to restore hip biomechanics, leading to a minimal functional deficit and to secure the longevity of the implant. Post operative impairments include reduced walking efficiency, pain, muscle weakness of the hip abductors, hip extensors and flexors, contracture of the hip, gait disorders [1,2]. Due to the above problems, it may lead to complications such as loosening of the implant and joint instability. To prevent falls and to avoid limping gait, there should be adequate strength in lower extremity. Post operatively, the rehabilitation program focuses on hip joint mobilization, strengthening of surrounding muscles and gait retraining, initially with a walking aid [2]. It has already suggested; in neurological rehabilitation, that treadmill training with partial body weight support is effective. It follows modern principles of motor learning and helps the patient to practice complex gait cycles in rehabilitation, before they start walking unsupported and independently on the ground. A preceding biomechanical study of ambulatory total hip arthroplasty patients with a fully loadable implant compared their walking on the treadmill with 15% body weight support (BWS) [3] and walking on the ground with two crutches placed reciprocally. In both the situations, though the patients walked symmetrically, the activation of the affected hip abductor muscle was larger in amplitude and occurred at a more normal time of the gait cycle when walking on the treadmill [3]. Past studies have shown supportive evidence for improvement in gait parameters by using treadmill on unilateral total hip replacement [3]. Other studies have also shown that the strengthening of selective musculature helped in improvement of gait parameters [4,5]. As there is paucity of research in identifying the combined effect of treadmill training and strengthening protocol in bilateral total hip arthroplasty on gait parameters. Hence, the study presenting here, has an aim to find out the combined effect of treadmill and strengthening exercises on gait in bilateral total hip arthroplasty.

Suppliers Computed dynography (CDG^® system) manufactured by Infotronic, AB Tubbergen Netherlands, http://www.infotronic.nl.This system measures the vertical ground reaction force distribution during gait, and can be expanded with EMG, joint angle measurements (Goniometer) and video. This system consists of sensor shoes, connecting cables, internal memory unit and computer with ultra tech software. The CDG system provides quantitative data about histogram, cyclogram, gait line, force gait line, step times and force graphics. The system is fully portable, hence not restricted to one specially prepared room.

Case Report History A 44-year-old male who had undergone bilateral THA referred to physiotherapy department for gait rehabilitation after 2 months of surgery. No pain history has observed.
Examination Patient thoroughly assessed by therapist. Manual muscle testing for bilateral hip abductors and extensors was grade 3 (full range of motion against gravity). Resisted isometric contraction for bilateral hip abductors and extensors was strong and painful. End feel for bilateral hip abductors and extensor was tissue stretch.
Outcome measures: Before and after the intervention the following outcome measures have measured. Gait parameters: It has taken on gait analysis- computer dynography (Figures 1 and 2). 1. Step time/ step duration 2. Single swing 3. Single support time 4. Double support time 5. Stance 6. Cadence Oxford Manual muscle testing Harris Hip score [6].
Treatment The intervention period was of 4 weeks with 5 days per week. The protocol given was strengthening of hip abductors (after calculating 10 RM, the cuff weight of respected weight was applied to ankle joint in supine lying position and Oxford technique was followed) [7]. Strengthening of extensors (after calculating 10RM, the cuff weight of respected weight was applied to ankle joint in prone lying position and oxford technique was followed) [7]. For gait retraining on floor- forward walking and side walking for 10 minutes each have given in parallel bars and was progressed with obstacles, 25 minutes of treadmill walking without inclination at participant’s comfortable speed. Stair climbing taught on staircase with the help of railing for 10 minutes. Each session lasted for 45 minutes to 1 hour including rest periods. Before and after the 4 weeks on intervention the participant was made to walk for 60 seconds and average of 3 trails was taken for the distance covered.

Results

	Pre			Post
Gait parameters	right	left	Right	left
Step time (seconds)	0.699	0.689	0.610	0.600
Single swing (seconds)	0.448	0.434	0.441	0.429
Single support time (seconds)	0.434	0.448	0.430	0.441
Double support time (seconds)	0.266	0.241	0.250	0.230
Stance (seconds)	0.940	0.955	0.820	0.860
Cadence (steps/ min)	86			105
Cycle (seconds)	1.39			1.31
Manual muscle testing
Hip abductors	3			4
Hip extensors	3			3+
Harris Hip score	62			82
Distance covered (meters)	120			160

In the above table, shows that, there was significant improvement in the affected gait parameters as well as the strength and in the various components of Harris Hip score.

Discussion The result of our study shows that combined training of treadmill and muscle strengthening has improved various gait parameters. Isometrics hip strengthening contributes in trunk control and stability, which plays an important role in gait. Sicard-Rosenbaum et al. reported that there is muscle weakness of the quadriceps, hip abductors and hip extensors, which in turn affects the various gait parameters in subjects with total hip arthroplasty [5]. Jan et al. in their study obtained significant improvement in strength and function without including walking in their 12 weeks home exercise program [4]. Sashika et al. and Unlu et al. in their respective studies have shown significant improvement in isometric strength in hip flexors, extensors and abductors in 6 weeks home exercise program [8-10]. In our study, there was significant improvement in the strength of hip extensors and abductors in 4 weeks due to the combined training program, which has given. On the other hand, treadmill training improved the various gait parameters. Treadmill training offers a task specific repetitive movement, which helps to practice the complex gait cycle. Participant takes more number of steps on treadmill rather than on ground. Hence, there is improvement in gait pattern. Studies have also shown that well functioning and strong hip muscles are important for walking ability, gait symmetry, and the prevention of implant loosening. Treadmill training also helps in early gait rehabilitation and prevention of complications [1]. The combined effect of treadmill training, gait training and strength training has significantly improved double support time, stance and increase in cadence in 4 weeks of intervention. It has also given better control and strength to the lower extremities and endurance to the participant.

Conclusion Treadmill training combined with hip strengthening exercise is beneficial in improving gait parameters.

Future Scope of Study Further studies can be done with large sample size and by increasing the duration of the intervention.

References