Rehabilitation Exercise Prescription Program

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Rehabilitation Exercise Prescription Program

• Group 1
• Carlos Leon-Carlyle 0317752
• Loriana Costanzo 0308293
• Bruce Monkman
• Michael Bois

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Henry Hiploss

• Henry is an ex athlete triple jumper who
  fractured his left hip in an automobile accident
  ten years ago and has never really recovered from
  the accident. Although the fracture healed he
  developed osteoarthritis which has since caused
  the joint surfaces to deteriorate and the
  acetabulum collapsed therefore requiring a hip
  transplant.
• The surgery was a success and he is ready to
  receive an exercise prescription to get his hip
  back to normal and correct his gait pattern. He
  was weight bearing using crutches within 24 hours
  but has little muscle tone in the hip and leg
  musculature

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Henry Hiploss (Cont)

• Henry is 6 ft 2 inches and 190 lbs and his
  activity level has dropped since his car accident
  so that he is sedentary and works 12 hour days
  while commuting in his car for 2 hours each way.
  He sits at a desk all day when he works as a
  computer statistical analyst and experiences high
  psychological stress to meet deadlines. Henry is
  separated from his wife and is currently single
  so he has time available when he is not with his
  children every second week.
• After the surgery Henry has been attending rehab
  with a physiotherapist and is now ready to
  strengthen the musculature around his hip and
  start to fully weight bare without crutches.

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Range of Motion Measurement

• The leg is capable of moving in many different
  planes and along many axes at the hip joint.
• These motions include
• Flexion
• Extension
• Abduction
• Adduction
• Internal and External Rotation

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Active Range of Motion

• Patient lies supine with their legs in the
  anatomical position.
• They then bring their heel toward the
  contralateral hip.
• The therapist observes the AROM of hip flexion,
  abduction, external rotation, and knee flexion.
• Next the patient extends the knee, adducts,
  internally rotates, and extends the hip to move
  the great toe toward the corner of the table.
• The therapist observes the AROM of hip extension,
  adduction, internal rotation, and knee extension.

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Flexion PROM

• Patient lies supine with the knee on the test
  side in a neutral position.
• The therapist stabilizes the pelvis. The trunk
  is stabilized through body positioning.
• While maintaining pelvic stabilization, the
  therapist applies slight traction to move the
  femur anteriorly to the limit of hip flexion.
• End feel should be soft.
• Possible tricks include posterior pelvic tilt and
  flexion of the lumbar spine.

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Flexion Measurement

• The patient is supine, with the hip and knee on
  the test table in a neutral position. The
  contralateral hip may be flexed or extended. The
  trunk is stabilized through body positioning, and
  the therapist stabilizes the pelvis.
• The axis of rotation is the greater trochanter of
  the femur
• The stationary arm should be parallel to the
  midaxillary line of the trunk.
• The movable arm should be parallel to the femur,
  pointing toward the lateral epicondyle.
• The end position should have the hip flexed to
  the limit of motion (120 degrees) while flexing
  the knee.

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Extension PROM

• The patient should lie prone with both hips and
  knees in neutral positions. The feet should lie
  over the end of the table. The therapist
  stabilizes the pelvis.
• The therapist grasps the anterior aspect of the
  distal femur and applies slight traction to and
  moves the femur posteriorly to the limit of hip
  extension.
• There should be a firm end feel to the motion.
• Common tricks/substitutions include anterior
  pelvic tilt and extension of the lumbar spine.
• Common tricks/substitutions include external
  rotation and flexion of the hip.

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Extension Measurement

• The patient lies prone with the hips and knees in
  a neutral position and the feet overhanging the
  edge of the table.
• The pelvis is stabilized through strapping.
• The axis of rotation is the greater trochanter of
  the femur.
• The stationary arm should be parallel to the
  midaxillary line of the trunk.
• The movable arm should be parallel to the
  longitudinal axis of the femur, pointing toward
  the lateral epicondyle.
• The patients knee is maintained in extension.
  The hip is extended to the limit of motion (30
  degrees).

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Abduction PROM

• The patient lies supine with the pelvis level and
  the lower extremities in the anatomical position.
• The therapist stabilizes the pelvis. If
  additional stabilization of the trunk and pelvis
  is required, the contralateral lower extremity
  may be positioned in hip abduction with the knee
  flexed over the edge of the table with the foot
  supported on a stool.
• The therapist grasps the medial aspect of the
  distal femur and applies slight traction to and
  moves the femur to the limit of hip abduction
  motion.
• There should be a firm end feel to the motion.

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Abduction Measurement

• The patient lies supine with the lower
  extremities in the anatomical position with the
  pelvis level.
• The axis is placed over the ASIS on the side
  being measured.
• The stationary arm should be placed along a line
  between the two ASISs.
• The movable arm should be parallel to the
  longitudinal axis of the femur. The goniometer
  should indicate 90 degrees in the start position
  described. The PROM should be 30 degrees with an
  end reading of 60 degrees on the goniometer.
• The hip is abducted to the limit of the motion
  (45 degrees).

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Adduction PROM

• The patient lies supine with the pelvis level and
  the lower extremity in the anatomical position.
  The hip on the nontest side is abducted to allow
  full ROM in adduction on the test side.
• The therapist stabilizes the pelvis.
• The therapist grasps the distal femur and applies
  slight traction and moves the femur to the limit
  of hip adduction ROM (30 degrees).
• The end feel of the motion should be soft or
  firm.
• Common tricks/substitutions include internal
  rotation and hiking of the contralateral pelvis.

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Adduction Measurement

• The patient lies supine with the lower extremity
  in the anatomical position. The hip on the
  nontest side is abducted to allow full range of
  hip adduction on the test side. The pelvis
  should be level.
• The axis is placed over the ASIS on the side
  being measured.
• The goniometer is aligned the same as for hip
  abduction ROM measurement.
• The hip is adducted to the limit of motion (30
  degrees).

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Internal and External Rotation PROM

• This test can be performed sitting or supine with
  the hip and knee flexed to 90 degrees.
• The pelvis is stabilized through body
  positioning. The therapist maintains the
  position of the femur, without restricting
  movement.
• The therapist grasps the distal tibia and fibula
  and applies slight traction to the distal femur,
  then moves the tibia and fibula in a lateral
  direction to the limit of hip internal rotation
  and in medial direction the limit of hip external
  rotation.
• The end feel of internal and external rotation is
  firm.

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Muscle Testing

• Testing for True Leg Length Discrepancy
• Place the patients in a supine position with the
  legs in outstretched in a coomparable position.
  Next, measure the distance from the anterior
  superior iliac spines to the medial malleoli of
  the ankles. Unequal distances between these
  fixation points would verify that one lower
  extremity is shorter than another. Finnaly, if a
  leg length descrepancy is appearent, the
  physition needs to establish where the
  descrepancy lies. Ask the patient to lie in
  supine and knees flexed at 90 degrees. If one
  knee is higher than the other, then the
  descrepancy is asscociated with one tibia being
  longer than the other. If one knee projects
  further than the other, than the descrepancy is
  associated with different femur lenghts. These
  length descrepancys are often treated with
  orthotics and muscle thearapy.

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Appearent Leg Length Discrepancy

• After establishing a negitive result for a true
  leg length discrepancy, it is time to determine
  if the appearent shortning is due to a deformity
  with the pelvis. Appearent shortning often
  results from pelvic obliquity, or from either
  adduction or flexion deformity of the hip joint.
• Have the patient stand and palpate the patient
  posteriorly. Inspect for any uneven heights of
  either the anterior or posterior superior iliac
  spine. Next have the pateint lie supine and
  measure from the umbilicus (belly button) to the
  medial mallioli. Unequal distances signify an
  apparent leg length discrepancy.

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Ober Test for Contraction of the Iliotibial Band

• Have the patient lie on their side with the
  involved leg uppermost. Abduct the leg as far as
  possible and flex the knee to 90 degrees while
  keeping the hip joint in a neutral position to
  relax the iliotibial tract. Release the the
  abducted leg and look for it to adduct towards
  the other leg. An inability to adduct results in
  a positive ober test. This indicates there may be
  a contracture of the fascia lata or iliotibial
  band.

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Thomas Test for Flexion Contracture

• The patient lies supine with the pelvis level and
  square to the trunk. Stabilikze the pelvis by
  placing a hand under the patients lumbar spine.
  Flex the patients hip joint by bringing their leg
  towards the trunk. As you flex the hip take note
  of when the lumbar lordosis touches your hand.
  Normal flexion limits allow the anterior portion
  of the thigh to rest against the trunk. Make sure
  to repeat with the other leg. Next, have the
  patient raise both legs towrd the chest. Have the
  patient hold on leg next to the trunk and extend
  the other leg at the knee and hip joints. If the
  hip does not extend fully, then this is an
  indication of a fixed flexion contracture. Also
  look for the patient to lift thoracic spine and
  rock forward as it is also an indication of a
  fixed flexion contracture.

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Telescoping Test for Congenitally Dislocated Hip

• Have the patient lie on their side with the
  involved leg on towards the celling. With one
  hand apply tration to the femur at the level of
  the knee. With the other hand, stabilize the
  pelvis and place your thumb on the greater
  trochanter. Feel for the greater trochanter to
  move distally when a force is applied to the
  femur. Allow for the femur to return to its
  original position upon the release of traction.
  This abnormal to and fro motion of the greater
  trcochanter is called telescoping.

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Ortolani Click Test for Congenital Dislocation of
the Hip

• Have patient flex thigh. With the thigh flexed
  abduct and externally rotate the thigh listen and
  palpate for a click or watch for the thigh to
  jerk as the femoral head leaves the acetabulum.
  Congenital dislocated hips limit abduction on the
  involved side.

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Exercise PrescriptionFlexibility

• All of the following exercise should be done
  after the body is warmed up. A proper warm-up
  consist of any activity that elevates the heart
  rate. Perform the activity until a light sweat is
  achieved.
• Each exercise should be performed at 2-4 times
• Each exercise should be held for 20-30 seconds
• It is recommended to perform the flexibility
  portion of the program before performing the
  strengthening portion.

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Tensor Fascia Lata Stretch

• Can be done in a standing or sitting position
• In standing, the patient places the affected side
  closest to a wall about an arms length away from
  the wall. The feet are crossed, with the affected
  extremity behind the uninvolved extremity.
  Placing the hand on the wall, the patient pushes
  the hips toward the wall, keeping both feet on
  the ground as the hand on the wall provides a
  push force. The patient should not rotate the
  body or bend the elbow. The stretch should be
  felt on the outside of the thigh.
• In sitting the patient has the uninvolved
  extremity out straight and the involved extremity
  flexed at the knee and hip the foot f the
  involved extremity is placed flat on the floor on
  the ground on the outside of the uninvolved knee.
  The patient uses the hands to pull the uninvolved
  knee across the body towards the opposite shoulder

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Hip Flexors (Iliopsoas Rectus Femoris) stretch

• Can be done standing or kneeling.
• In kneeling, the involved leg is the kneeling leg
  and the opposite leg bears weight on the front
  foot. The patient transfers weight from the back
  knee to the front foot so the center of mass
  moves in front of the back knee. The back should
  remain erect. An additional stretch can be
  applied by attempting to flex the knee. A pad can
  be placed under the knee for comfort.
• In standing, the patient grasp the ankle of the
  involved leg from behind to bring the heel to the
  buttock while keeping the knee pointing to the
  floor. The back must remain erect during the
  stretch. The patient can apply an additional
  stretch by pushing the hip forward.

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Adductors Stretch

• The adductors should be done with the knee bend
  and extended since the short adductors do not
  cross the knee, while the long adductors cross
  the knee.
• In a sitting position, the patient flexes and
  abducts the hips and knees to place the bottom of
  the feet together, and pulls the feet towards the
  buttocks. In this position the hands are placed
  on the feet and the forearms are placed along the
  inner legs.a stretch force is applied along the
  forearms to lower the knees. The back should
  remain upright.
• An alternative to position is sitting with the
  knees extended, and the hips abducted the patient
  flexes at forward from the hips, keeping the back
  straight, and placing the hands on the floor to
  support the body weight in order the keep to the
  adductors relaxed. An additional stretch can be
  applied by rotating towards the affected leg, and
  reaching for the toes.

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Hip Extensor (Hamstrings Gluteus Maximus)
Stretch

• Both stretches can be done in the supine position
• To stretch the hamstrings lay in the supine
  position with the uninvolved leg in full hip and
  knees extension. With the involved knee the
  patient places their hands around the posterior
  thigh and pulls the leg towards the chest. The
  back should not arch and the uninvolved leg
  should not come off of the ground. The knee is
  extended until the stretch is felt.
• The gluteus maximus is stretched in a position
  similar to the hamstring stretch, with the
  difference being that the involved extremitys
  knee is flexed and the force pulls the knee
  towards the chest. The pelvis should not roll
  posteriorly, and the opposite thigh should not
  lift off of the ground

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Piriformis Stretch

• The piriformis can be stretched effectively in
  the supine or quadruped position.
• In the supine position, the patient lies with the
  knees crossed, the involved extremity on top of
  the uninvolved extremity. the knees are brought
  to the chest, and the patient pulls on them with
  the involved extremitys knee directed towards
  the opposite shoulder.
• In a quadruped position, the patient crosses the
  involved extremity under the uninvolved extremity
  and leans the hips backward, keeping the
  uninvolved extremitys knee off of the floor,
  allowing it to move back. This position adducts,
  flexes, and medially rotates the hip.

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Strengthening Exercises

• The exercises should be performed in a smooth,
  controlled motion of the hip through a full range
  of motion. Substitution of other muscles occur
  easily in the hip, the patient must be careful to
  avoid trick movements while the hip is weak. It
  is recommended to perform the exercises at a low
  intensity with a high volume of sets.
• Body weight exercises will be used until the
  patient can complete the workout pain-free, with
  full range of motion. If the patient is unable to
  lift the extremity against gravity, flexing the
  knee to perform the exercise can shorten the
  resistance level-arm length resulting in a
  reduced workload.

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Hip Abduction

• With the patient lying on their side of the
  uninvolved extremity, with the uninvolved
  extremity flexed at hip and the knee for
  stability. The patients involved leg will remain
  extended, while lifting the leg against gravity.
• To insure proper form do not allow the patient to
  roll onto their back, and lift leg using the hip
  flexors. Try to prevent the patient from rotating
  the limb. This exercise should isolated the hip
  abductors

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Hip Adduction

• Have the patient lay on the involved extremity
  with the uninvolved extremity flexed at the hip
  and the knee, with the foot placed in front of
  the bottom knee. Keeping the involved extremitys
  knee and hip full extended, raise the leg against
  gravity.
• To insure proper form do not allow the patient to
  roll onto their back, and lift leg using the hip
  flexors.
• If the patient lacks the core strength to keep
  the body stabile during exercise, you can place
  the patients uninvolved leg on a supportive
  object such as a chair.

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Hip Extension

• The patient lies in prone with the extremity
  either supported in extension or positioned in
  flexion. Have the patient extend the leg against
  gravity. Since hip hyperextension is limited to
  about 15o, any movements that appear to be past
  15o will indicate hip and or trunk rotation.
• Hip extension can also be done using a bridging
  exercise. The patient lies supine with the hips
  and knees flexed with the feet flat on the floor.
  The hips are raised so that the hips and trunk
  form a straight line. Hold this position for a
  several second, then return to the starting
  position.

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Hip Flexion

• The patient lies in the supine position, with the
  uninvolved leg flexed at the hip and knee with
  the foot flat on the supporting surface. The
  patient tightens the abdominals to prevent the
  back from arching, tightens the quadriceps to
  maintain knee extension, and lifts the involved
  extremity upward toward the ceiling.
• Do not allow the patient to rotate or abduct the
  hip during this exercise.

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Functional tests

• To test Henrys functional ability, he should
  perform a walking and/or running test, to make
  sure his gait pattern is corrected, and to watch
  for any irregular patterns. Since he is also a
  triple jumper, Henry can attempt at breaking down
  the skill and performing each action seperately.
  (run up, hop, skip, jump)

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Pool Workouts

• To maintain fitness, range of motion, and aid in
  healing Henrys osteoarthritis, it is useful for
  Henry to perform aquatic therapeutic exercises.
  Cardiovascular and strength exercises in the pool
  will increase Henrys ability to perform
  exercises for longer periods of time without
  adding stress from weight bearing on the joints.
  Henry may also perform many of his stretching
  exercises while he is in the pool.

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Pool Exercises

• Inner tube exercises performed in the shallow
  end using a flotation tube, the patient maintains
  a vertical position in the water. The hips and
  knees are flexed, and the patient rotates the
  hips first in one direction, and then the
  opposite side. The exercise is more demanding if
  the knees are fully extended.

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Pool Exercises

• Inner tube lateral flexion performed in the
  shallow end, using a flotation tube, the patient
  flexes the hips and knees to 90 degrees. He
  should maintain this position while lifting both
  hips laterally toward the left ribs and then
  lifting both hips laterally toward the right ribs.

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Pool Exercises

• Jumping jacks performed in the deep end, with a
  flotation device around the waist, the elbows and
  knees are kept straight, and the spine is in
  neutral. The arms begin in an abducted position.
  As the hips are abducted, the arms are adducted
  and vice versa. In addition to staying afloat,
  the patient must also work to maintain an upright
  posture and stable trunk.