The effi cacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis : a review

Introduction Standard physiotherapy rehabilitation fails to restore normal levels of muscle mass, strength and physical function in patients following elective total hip arthroplasty for osteoarthritis. Consequently, more intense forms of exercise rehabilitation have been advocated for these patients. The aim of this article was to review the controlled trials that have evaluated post-total-hip-arthroplasty exercise interventions aimed at improving function. Materials and methods The electronic databases MEDLINE and CINAHL were searched using the following terms: ‘total hip arthroplasty/replacement’, ‘exercise’, ‘rehabilitation’ and ‘function’. This search was expanded by hand-checking the reference lists of the studies and reviews identi ied by electronic scanning. Results Thirteen appropriate studies (18 papers) were identi ied, comprising 8 ‘early’ intervention studies (<5 weeks from surgery) and 5 ‘delayed’ intervention studies. Conclusion The studies reviewed suggest that centre-based, but not home-based, exercise rehabilitation are effective in restoring muscle mass, strength and function in total hip arthroplasty patients during the immediate post-surgery phase, and that the ef icacy of the centre-based interventions is most likely due to higher training intensity that is facilitated by supervision and access to specialised equipment and facilities. When commencement of training is delayed, however, both homeand centrebased training programs provide signi icant improvements in patient strength and function. Introduction Total hip arthroplasty (THA) surgery is among the most commonly performed and clinically successful surgical procedures, with the number of operations performed rapidly escalating; that is, 88,984 THAs were carried out in England and Wales in 2011–2012 compared to 51,981 in 2006–20071. Given that end-stage osteoarthritis (OA) accounts for 93% of THA cases1 and that the prevalence of OA is increasing as the population ages, the number of THA procedures is expected to continue rising worldwide. Standard physiotherapy rehabilitation programs for post-THA patients, though varying from centre to centre, are usually based on hip range-of-movement (ROM) exercises and functional activities, typically without external loading. However, since persisting muscle loss and functional limitations are characteristic of post-THA patients2–16, these widely used programs are clearly not optimal. For example, following completion of a standard rehabilitation program, Suetta et al.14,15 found 13% and 9% reductions in quadriceps muscle cross-sectional area (CSA) on the operated side, 5 and 12 weeks, respectively, following THA. Similarly, Reardon et al.12 showed that signi icant atrophy of the quadriceps on the operated side persisted for at least 5 months following THA, despite a structured rehabilitation program that included hydrotherapy sessions, daily hip and thigh exercises and regular walking or cycling, that is, considerably more than most post-THA rehabilitation regimes. Since muscle strength is directly related to muscle mass14, and current rehabilitation programs are unable to prevent atrophy4,7,15–18, it follows that strength will be typically compromised in post-THA patients. Suetta et al.14 found that, despite uncomplicated recovery and 12 weeks of standard rehabilitation following THA, maximal voluntary knee extensor strength on the operated side was reduced by 30% relative to the healthy contralateral leg. Extending the recovery period, Trudelle-Jackson et al.4 identi ied 10% to 20% reductions in strength of the hip lexors, extensors and abductors, and the knee extensors on the operated leg compared to the contralateral leg 1 year after THA. Whilst Rasch et al.3 reported that de icits in hip muscle strength on the operated side relative to the uninvolved side persisted for 2 years following surgery. However, due to the extreme deconditioning and reduced physical-activity-level characteristic of end-stage hip OA patients19, a better comparison is with community-dwelling ageand sex-matched controls9,10,14. In support of this, Frost et al.10 found that THA patients, 4 to 5 months following surgery, could only generate 60% of the maximal hip lexion force produced by matched, healthy controls. More pertinently, although Bertocci et al.20 The effi cacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review AB Lemmey1*, T Okoro1,2 *Corresponding author Email: a.b.lemmey@bangor.ac.uk 1 School of Sport, Health & Exercise Sciences, Bangor University, Bangor, Gwynedd, UK 2 Department of Orthopaedics, Gwynedd Hospital, Betsi Cadwaladr University Health Board, Penrhosgarnedd, Bangor, UK


Introduction
Total hip arthroplasty (THA) surgery is among the most commonly performed and clinically successful surgical procedures, with the number of operations performed rapidly escalating; that is, 88,984 THAs were carried out in England and Wales in 2011-2012 compared to 51,981 in 2006-2007 1 .Given that end-stage osteoarthritis (OA) accounts for 93% of THA cases 1 and that the prevalence of OA is increasing as the population ages, the number of THA procedures is expected to continue rising worldwide.
Standard physiotherapy rehabilitation programs for post-THA patients, though varying from centre to centre, are usually based on hip range-of-movement (ROM) exercises and functional activities, typically without external loading.However, since persisting muscle loss and functional limitations are characteristic of post-THA patients [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] , these widely used programs are clearly not optimal.For example, following completion of a standard rehabilitation program, Suetta et al. 14,15 found 13% and 9% reductions in quadriceps muscle cross-sectional area (CSA) on the operated side, 5 and 12 weeks, respectively, following THA.Similarly, Reardon et al. 12 showed that signi icant atrophy of the quadriceps on the operated side persisted for at least 5 months following THA, despite a structured rehabilitation program that included hydrotherapy sessions, daily hip and thigh exercises and regular walking or cycling, that is, considerably more than most post-THA rehabilitation regimes.Since muscle strength is directly related to muscle mass 14 , and current rehabilitation programs are unable to prevent atrophy 4,7,[15][16][17][18] , it follows that strength will be typically compromised in post-THA patients.Suetta et al. 14 found that, despite uncomplicated recovery and 12 weeks of standard rehabilitation following THA, maximal voluntary knee extensor strength on the operated side was reduced by 30% relative to the healthy contralateral leg.Extending the recovery period, Trudelle-Jackson et al. 4 identi ied 10% to 20% reductions in strength of the hip lexors, extensors and abductors, and the knee extensors on the operated leg compared to the contralateral leg 1 year after THA.Whilst Rasch et al. 3 reported that de icits in hip muscle strength on the operated side relative to the uninvolved side persisted for 2 years following surgery.However, due to the extreme deconditioning and reduced physical-activity-level characteristic of end-stage hip OA patients 19 , a better comparison is with community-dwelling age-and sex-matched controls 9,10,14 .In support of this, Frost et al. 10 found that THA patients, 4 to 5 months following surgery, could only generate 60% of the maximal hip lexion force produced by matched, healthy controls.More pertinently, although Bertocci et al. 20 Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.could identify signi icant de icits of hip lexion, extension and abduction in THA patients when compared to matched, non-OA controls, this disparity was not apparent when they compared the patient's operated and contralateral sides.These de icits in strength have serious adverse consequences for THA patients in respect to physical function, maintenance of independence and requirement for revision surgery.Speci ically for these patients, reduced leg strength has been associated with poorer gait symmetry, speed and cadence 8,9,11,[13][14][15]21,22 , impaired stair-climbing 14,15 , chairrising 14 , access to public transport 22 , exacerbated risk of falling 9 , and loosening of the prosthesis 21,23 . Inaddition, evidence from the general population demonstrates the links between leg strength and the ability to perform activities of daily living, maintain independence, and reduce falling 24,25 .Given these associations and the inability of standard rehabilitation programs to adequately restore muscle mass, muscle strength and physical functioning, it is not surprising that more intense exercise rehabilitation programs have been widely advocated for post-THA patients [2][3][4][6][7][8][9][10][11][12][13][14][15][16][17][19][20][21][25][26][27][28][29][30][31] .
The aim of this article is to evaluate the ef icacy of exercise rehabilitation programs performed by elective (i.e.hip OA) THA patients following surgery in attenuating muscle loss and restoring strength and physical function.Particular attention is given to the timing of these exercise interventions as there are advocates for very early training interventions 7,11,14,15,17,19,21,[27][28][29][30][31][32] and advocates for training to commence at a later stage, that is, months after THA 4,6,8,10,13,16,22 .Those who favour early rehabilitation point out the need to both counter the dramatic losses of muscle and strength in the immediate post-surgical phase 12 (e.g.strength is observed to decline 3%-4% per day during the initial week of immobilization 7 ) and to address the issues of muscle atrophy and strength loss before these de icits peak 14 .In addition, it is argued that early restoration of strength and function reduces post-surgical complications and enables quicker resumption of normal activities 14,21,30 .Conversely, later intervention is favoured by some because there are fewer problems concerning patient transport to centres, and training can be performed at a higher intensity 4,16 , that is, at the intensities optimal for increasing muscle mass and strength.Arbitrarily, the time taken by this review to distinguish 'early' and 'delayed' exercise rehabilitation interventions is whether commencement of these programs occurred within 5 weeks of THA, as at this time substantial de icits in muscle mass, strength and functional capacity have been identi ied in patients who have performed standard physiotherapy rehabilitation 7,10,14,15 .Thus, in keeping with the perspective that rehabilitation interventions are best initiated during the period when de icits are greatest, within 5 weeks of surgery could be viewed as an optimal time for training to commence.In addition, this review considers the ef icacy of home-based interventions given that they are more accessible and convenient, especially in the early post-THA period, require less supervision and are considerably cheaper compared with centrebased interventions.Finally, because the length of stay in hospital following THA has been reduced to about 4 days 1 , thereby diminishing the role of in-patient rehabilitation, this review only considers interventions performed, at least primarily, following hospital discharge.

Materials and methods
Studies were eligible for review if they met the following criteria: (i) controlled trial of exercise rehabilitation designed to improve physical function in the postoperative period; (ii) subjects had undergone elective THA for hip OA; (iii) the exercise intervention was conducted, at least primarily, after the patient had been discharged from hospital; and (iv) publication was after 1990, and in English.'Exercise' was defined as structured movements that were of greater intensity and volume than the 'standard physiotherapy' offered to rehabilitating THA patients, with 'standard physiotherapy' varying widely according to centre.
Studies were initially identi ied by searching MEDLINE and CINAHL databases using a set created with the terms: 'total hip arthroplasty/ replacement', 'exercise', 'rehabilitation' and 'function'.This search identi ied 103 publications, each of which was checked to con irm suitability.To expand the search, bibliographies of eligible studies and appropriate reviews were scanned.When full papers could not be retrieved electronically, the corresponding author was contacted and a reprint requested.For the purpose of this review, interventions were designated 'early' if they commenced within 5 weeks of THA surgery, and 'delayed' if commenced more than 5 weeks post-THA.

Results
Eighteen papers describing 13 controlled, intervention studies were judged as suitable for review.These comprised eight 'early' intervention studies (Table 1, 13 publications) and ive 'delayed' intervention studies (Table 2, ive publications).Tables 1 and 2 also describe the study design, number of participants, intervention site, follow-up period and hip dislocation/revision rate and brie ly outline the exercise intervention, main study outcomes and study limitations.Of the 'early' interventions, six were exclusively centre based 7,14,15,17,19,21,[28][29][30][31][32] , one was home based 11 , and one featured a comparison of centre-and home-based interventions 27  three were home based 13,16,22 , and one involved comparison of centre-and home-based interventions 8 .

Discussion
Although there are relatively few studies and no large multi-centre trials on post-THA exercise rehabilitation, discernible trends emerge.With regard to interventions commenced in the initial post-surgery period (Table 1), it appears that centre-based training programs are more ef icacious than home-based programs.Of the centrebased interventions, Hesse et al. 21bserved that 10 days of treadmill walking, with 15% bodyweight support, begun within a month of surgery, reduced time on crutches and signi icantly improved the Harris Hip Score, hip abductor strength, hip ROM, gait symmetry and gluteus medius activity, compared to patients who received standard physiotherapy.Furthermore, these advantages were maintained at 3 and 12 months post-THA.Husby et al. 7,17 showed that 4 weeks of unilateral (operated leg) high-intensity progressive resistance training (PRT; leg press and hip abduction, progressed to loads of 85% 1-repetition maximum [1-RM]), initiated during the irst week of recovery, improved leg strength and reduced cardio-respiratory strain during a sub-maximal walk test, relative to standard physiotherapy rehabilitation, and that these effects were generally maintained at 12 months.Liebs et al. 29 found that low-intensity cycling performed thrice weekly for at least 3 weeks produced improved physical function, stiffness and pain (assessed by WOMAC subscales) and quality of life (QoL) more than standard rehabilitation, and that these bene its persisted for at least 2 years.Maire et al. 19,28,31,32 studied THA patients performing high-intensity upper-body interval training for 6 weeks starting a week after surgery.At the end of the intervention period, compared to standard rehabilitation controls, the exercise group scored better for WOMAC function and global scores, the 6-minute walk test (6MWT), stride length and cadence, and aerobic capacity (VO 2 peak), whereas perceived effort and heart rate were lower when undertaking a ixed sub-maximal workload.Unfortunately, not all these assessments were repeated at 12 months post-THA, but those that were (WOMAC function and global, 6MWT) remained better in the training group.Lastly, Suetta et al. 14,15 investigated the effects of 12 weeks unilateral (operated leg) high-intensity PRT initiated whilst the subject is still in the hospital bed.Relative to standard rehabilitation patients, those in the PRT group had a shorter hospital stay and improved function (gait speed, sit-to-stand, stair climbing and maximal knee extension strength) by approximately 30%.The PRT group's improvements in strength and function were associated with quadriceps muscle hypertrophy, whereas the controls, performing standard physiotherapy, experienced continued muscle loss over this period.
In contrast to these centre-based programs, the early home-based intervention of Mikkelsen et al. 11 , which featured 12 weeks of twicedaily unsupervised low-intensity resistance training (RT), failed to improve WOMAC function, stiffness and pain scores, QoL, hip abductor strength, standing balance, gait speed and habitual physical activity levels, beyond the levels achieved by standard physiotherapy.These results were replicated in an unpublished study by our group in which elective THA patients (n = 20) who completed 6 weeks of daily, unsupervised lowintensity, bilateral RT at home showed no improvements in knee extensor strength, function (sit-to-stands, gait speed, stair climb, timed-up-and-go [TUG], 6MWT) or leg lean mass relative to patients who received standard physiotherapy (n = 15).In accordance with previous indings [2][3][4]7,12,[14][15][16][17][18] and despite good training compliance for both groups, it is of note that at 12 months, function for patients in our study was generally 30% less than that of age-and sex-matched healthy individuals. An exption to the inding that centre-based interventions are more effective than home-based interventions is provided by Galea et al 27 .In this study, patients approximately 1 month post-THA were randomised to perform the same 8-week exercise program of low-intensity RT and functional tasks either at home, unsupervised, or at a centre, supervised.No between-group differences in the improvements in WOMAC scores, 6MWT, TUG, stair climb or gait parameters were observed.However, since subjects in both groups completed the same training program the design of this investigation failed to address the most likely reason for the apparently greater ef icacy of centrebased programs, namely, the higher intensity of exercise these programs typically achieve.An additional law of this study was the absence of a standard physiotherapy group, thus preventing any evaluation of whether the exercise program prescribed conferred additional bene it.
Liebs et al. 30 considered how early the commencement of 'early' exercise rehabilitation should be in post-THA patients by comparing the effects of aquatic therapy initiated on either the 14th or the 6th post-surgical day.Despite receiving a week less training, the group that commenced later tended to have better WOMAC function, stiffness and pain scores at the 3-, 6-, 12-, and 24-month post-THA assessments, suggesting that very early training commencements (≤1 week) 7,11,17,19,28,31,32 may be partially counterproductive.
For the delayed interventions (Table 2), there is evidence that both centre-based and home-based exercise interventions can signi icantly improve function in THA patients.In a centre-based intervention, Heiberg et al. 6  With the home-based exercise interventions, Jan et al. 22 showed that reasonable adherence (≥50% of scheduled sessions completed) to a 12-week, daily program of bilateral hip RT, hip lexion ROM exercises and walking produced improvements in Harris Hip function score, hip abductor, lexor and extensor strength on both sides and walking speed in patients who had received THA at least 1.5 years previously.In contrast, similar patients who either had poor exercise compliance or were randomised to a nonexercise control group showed no improvement in these measures 22 .In an earlier non-randomised trial by Sashika et al. 13 , subjects who were 6 to 48 months post-THA, performed a similar low-intensity program 22 twice daily for 6 weeks.The exercisers were divided into two groups (' A' and 'B'), with Group B additionally doing two standing hip abductor exercises.At the conclusion of the training period, the exercise groups, but not the nonexercising controls, had improved gait speed and cadence.Hip abduction strength on the THA side increased in all groups, but on the contralateral side, only in Group B. Trudelle-Jackson et al. 16 compared the effects of 8 weeks of weight-bearing functional and strengthening exercises with those of standard physiotherapy exercises (supine isometric and ROM exercises, with no weight-bearing) in subjects who were 4 to 12 months post-THA.The weight-bearing exercises signi icantly improved hip abductor, lexor and extensor, and knee extensor strength (range: 23%-48%), postural stability (37%) and self-perceived function, whereas standard physiotherapy failed to change any of these measures (range: 1%-7%).As in the study by Galea et al. 27 , Unlu et al. 8 directly compared the effects of the same exercise program performed either unsupervised at home or supervised in a hospital.In addition, this study featured a walking-only control group.The training consisted of low-intensity ROM and isometric and eccentric RT hip exercises performed twice daily for 6 weeks.In contrast to the control group that showed no change, both the home-based and centrebased training groups improved hip abduction strength, gait speed and cadence.The improvement in abductor strength was signi icantly better for the centre-based relative to the home-based group, whereas the gains in gait speed (16.9% vs. 9.7%) and cadence (15.4% vs. 13.6%)showed a trend in the same direction.
Although not all of the studies reviewed assessed both strength and function, those that did show that functional gains are dependent on increased muscle strength 8,11,[13][14][15][16]21,22 . More peci ically, Husby et al. 17 and Sashika et al. 13 highlight the need to increase hip abductor strength so that gait symmetry can be restored 21 , thereby reducing asymmetrical loading that increases fall risk 9 and may contribute to development of OA in the contralateral hip 17 .These conclusions support the rationale that RT should be a key feature of rehabilitation following THA [2][3][4][7][8][9][10][11][12][13][14][15][16][17][20][21][22][25][26][27]29,30 .To maximise gains in strength and muscle hypertrophy it is necessary to perform high-intensity RT, as only maximal or near-maximal loads ensure recruitment of all motor units 33 . Ths, programs such as those used by Husby et al. 7,17 and Suetta et al. 14,15 , which featured loads of 85% and 80% 1-RM, respectively, are recommended.However, since performing high-intensity RT requires high levels of motivation, it is encouraging that several of the reviewed studies observed signi icant increases in strength, and subsequently improvements in function, following low-intensity RT 8,13,16,22 . Inerestingly, each of these successful low-intensity RT interventions was performed months after THA, and the attempts by Mikkelsen et al. 11 and ourselves at initiating low -intensity RT interventions within days of surgery have failed to be more effective than standard physiotherapy.Conversely, high-intensity RT programs commenced shortly after THA have proved to be more ef icacious in improving strength and function than standard rehabilitation 7,14,15,17 .All of these suggest that timing could be an important consideration when planning rehabilitation programs aimed at rectifying the de iciencies in muscle mass, strength and function that exist in patients following THA, especially when the planned training involves low-intensity exercise, that is, the type of program more likely to be widely acceptable.
As well as RT, there is a strong case for post-THA patients and endstage OA patients generally also performing aerobic training.Individuals awaiting THA are typically severely deconditioned due to reduced physical activity levels; for example, the mean VO 2 peak of Maire et al's. 19subjects prior to THA was 9.6 ml/kg/ min.As well as improving exercise capacity and function 19,31,32 , traininginduced increases in VO 2 max also reduce the cardio-respiratory strain involved in performing daily activities 7,17,28  acceptable to post-THA patients.A primary concern regarding mobilisation following THA is prosthetic dislocation.In the studies reviewed, the pooled incidence of dislocation or loosening (Tables 1 and 2) in exercising subjects (n = 604) was 3 (rate = 0.5%) and in standard rehabilitation or non-exercising controls (n = 286) was 5 (rate = 1.7%).Predictably, all dislocations/loosenings occurred during the 'early' (<5 weeks) post-THA period.For this period, the respective rates were exercisers (3/496) = 0.6% and controls (5/196) = 2.6%.Thus, exercise programmes are not associated with increased dislocation rate.Patient acceptability of the programs is evidenced by the very good compliance (>70% of scheduled sessions completed) of all bar one 22 of the home-based interventions 8,11,13,16,27 .This high compliance rate for homebased interventions is encouraging because in the current economic climate, with its accompanying budget constraints, it is unlikely that health authorities will favour provision of expensive hospital-or gym-based outpatient programs that necessarily incur high costs for supervision, transport and facilities.The economic attractiveness of home-based programs, allied to their greater convenience for patients (especially during the initial post-surgery period when travelling is dif icult), is unfortunately counterbalanced by the lack of evidence demonstrating ef icacy of early home-based exercise programs.

Conclusion
Due to long-standing deconditioning and muscle loss exacerbated by surgery and bed rest, post-THA patients typically have persistent poor physical function that is not adequately corrected by standard physiotherapy rehabilitation.It is clear that more intense exercise programs are required to address this.The studies reviewed suggest that centre-based, but not home-based, exercise rehabilitation are effective in attenuating muscle loss and strength and function de icits in THA patients during the immediate post-surgery phase and that the ef icacy of centrebased interventions is most likely due to higher training intensity, which is facilitated by supervision and access to specialised equipment and facilities.When commencement of training is delayed, however, both home-and centre-based training programs provide signi icant improvements in patient strength and function.A pragmatic compromise between economic and practical considerations may be that post-THA patients are encouraged to regularly perform weight-bearing functional exercises at home during the initial post-surgery period, with the understanding that even good compliance is unlikely to fully restore function, and then when mobility is suf iciently recovered, subjects are encouraged to undertake, either at home or in a community gym, a higher-intensity program featuring both resistance and aerobic training.For this training, supervision, at least initially, should be sought to ensure that training is conducted safely and that workloads are progressed to account for improving itness.Due to a general lack of studies and the absence of large, multi-centre trials, the veracity of these recommendations awaits con irmation.
had patients, 3 months after THA, perform 12 sessions of a 'Walking skill training' program.This supervised, group Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.training emphasised low-intensity functional and advanced walking activities.Relative to a matched, nonexercising control group, the training group showed greater improvement in the 6MWT, stair climbing, the igure-of-8 test, active hip extension ROM, the Index of Muscle Function (a composite score of mobility, muscle strength, balance/coordination and endurance tests), Harris Hip Score and self-ef icacy at the conclusion of the intervention.At 12 months postsurgery (approximately 7 months post-intervention), those who performed the 'Walking skill training' remained signi icantly better at walking and had experienced fewer falls than controls.
and presumably CVD risk of post-THA patients.It is important to note that each of the exercise interventions reviewed, whether high or low intensity, home or centre based, or commenced early or late, were considered safe and Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . Characteris cs of trials on early (<5 weeks) post-total hip arthroplasty exercise interven ons to improve func onal outcome Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven on Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.
. For the 'delayed' interventions, one was centre based 6 , Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.F : Lemmey AB, Okoro T.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 1 . (Continued) Ar cle Study design: number of par cipants Exercise interven on site Interval from THA surgery to interven on start Exercise interven oncv Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
RCT, randomised controlled trial; ADL, ac vi es of daily living; 200mFWT, 200-metre fast walk test; IMF, index of muscle func on; 6MWT, 6-minute walk test; 1-RM, one repe on maximum; ROM, range of movement exercises; SF-12, Short-form 12; SF-36, Short-form 36; WOMAC, Western Ontario and McMasters University Osteoarthri s scale; RAND 36, Research and Development 36-item health survey ques onnaire Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 2 Characteris cs of trials on delayed (>5 weeks) post-total-hip-arthroplasty exercise interven ons to improve func onal outcome Ar cle Study design: number of par cipants Exercise interven on site Interval from total hip arthroplasty (THA) surgery to interven on start Exercise interven on Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 2 . (Con nued) Ar cle Study design: number of par cipants Exercise interven on site Interval from total hip arthroplasty (THA) surgery to interven on start Exercise interven on Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 2 . (Con nued) Ar cle Study design: number of par cipants Exercise interven on site Interval from total hip arthroplasty (THA) surgery to interven on start Exercise interven on Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
) Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.

Table 2 . (Con nued) Ar cle Study design: number of par cipants Exercise interven on site Interval from total hip arthroplasty (THA) surgery to interven on start Exercise interven on Follow-up period Eff ect of interven on Disloca ons, or re-implant due to joint loosening Limita ons
RCT, randomised controlled trial; ADL, ac vi es of daily living; 200mFWT, 200-metre fast walk test; IMF, index of muscle func on; 6MWT, 6-minute walk test; 1-RM, one repe on maximum; ROM, range of movement exercises; SF-12, Short-form 12; SF-36, Short-form 36; WOMAC, Western Ontario and McMasters University Osteoarthri s scale; RAND 36, Research and Development 36-item health survey ques onnaire Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) F : Lemmey AB, Okoro T. The ef icacy of exercise rehabilitation in restoring physical function following total hip replacement for osteoarthritis: a review.OA Musculoskeletal Medicine 2013 Jul 01;1(2):13.