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.