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Rui Tsukagoshi, MS
Hiroshige Tateuchi, PhD
Yoshihiro Fukumoto, MS
Hideo Okumura, PhD
Noriaki Ichihashi, PhD




From the Department of Physical
Therapy, Graduate School of Medicine,
Kyoto University, Kyoto, Japan.

All correspondence and requests
for reprints should be addressed to:
Rui Tsukagoshi, MS, Department of
Physical Therapy, Graduate School
of Medicine, Kyoto University, 53
Kawahara-cho, Sakyo-ku,
Kyoto 606-8507, Japan.

Stepping Exercises Improve Muscle
Strength in the Early Postoperative
Phase After Total Hip Arthroplasty
A Retrospective Study

Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2011 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0b013e31823c7433

Tsukagoshi R, Tateuchi H, Fukumoto Y, Okumura H, Ichihashi N: Stepping
exercises improve muscle strength in the early postoperative phase after total hip
arthroplasty: a retrospective study. Am J Phys Med Rehabil 2012;91:43Y52.

Objective: This study aimed to evaluate the effect of stepping exercises in
addition to conventional physical therapy on the recovery of muscle strength and
walking speed after total hip arthroplasty.
Design: This was a retrospective study with 6 wks of follow-up care and
evaluation. Patients (n = 30) undergoing primary total hip arthroplasty for hip
osteoarthritis were divided into two groups based on whether stepping exercises
were performed after surgery. The control group (n = 15) received supervised
conventional physical therapy for 6 wks. The stepping group (n = 15) performed
stepping exercises with conventional physical therapy. Outcome measures were
lower limb muscle strength and walking speed at 6 wks postoperatively.

Results: The stepping group showed significantly higher recovery of the hip
abductor and the knee extensor muscle strengths on the involved side compared
with the control group. There were no significant differences between the two
groups in walking speed and hip extensor, hip flexor and knee flexor strength on
the involved side.

Conclusions: Our findings suggest that stepping exercises may be effective
in facilitating the muscular recovery of the hip abductors and knee extensors in the
early postoperative phase after total hip arthroplasty.
Key Words: Total Hip Arthroplasty, Stepping Exercises, Maximal Isometric Strength,
Walking Speed

Stepping Exercises After THA

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


3 and Frost et al. However. and functional performance than standard rehabilitation or electrical stimulation.24 This reluctance to load the leg inhibits muscular activity and may delay muscle recovery after surgery. high-frequency weight-bearing training for muscle recovery after THA was not examined.8. More than 60% of one repetition maximum was necessary to increase the cross-sectional area of a muscle in healthy individuals.9 impaired postural stability. and swelling may also decrease muscle activation.14 However. extensor.16 demonstrated that maximal strength training using leg press and hip abduction exercises improve leg press strength and hip abductor muscle strength more than conventional physical therapy.2 However. Because muscle weakness may lead to motor functional deficits and impairments in activities of daily living. stepping exercises should be safe and convenient to use for rehabilitation after lower limb joint surgery. A few studies investigated high-intensity resistance training for postoperative rehabilitation after THA.4 gait abnormality. Although the efficacy of high. Med.19. Postoperative physical inactivity. Maximal flexion angle of the knee joint during this exercise was about 50 degrees. functional status. Although surgical approach would be an important factor affecting recovery after THA. which increases the hip abductor moment arm.18 and cardiovascular fitness.3. 1. We hypothesized that the group who performed the stepping exercises in addition to conventional physical therapy would significantly improve lower limb muscle strength and gait ability.22 Therefore.13. J. we hypothesized that this low-intensity and high-frequency training would be suitable for patients who are early postoperative. The purpose of this study was to retrospectively investigate how stepping exercises in the early THA postoperative phase would influence the recovery of muscle strength and gait. Bertocci et al. In June 2006. Unauthorized reproduction of this article is prohibited. Stepping exercises are expected to facilitate weight bearing on the affected limb and increase muscle activity because the repeated step motion causes the center of mass to shift bilaterally while in the standing position. . Husby et al. such as walking and standing.1. and muscle weakness.4 reported that the isokinetic strength of hip abductor. we have not found any previous research that investigates whether stepping exercises are effective in patients undergoing THA. Minimally invasive surgical techniques are now widely used for THA. Similarly. compared with the group who were treated using conventional physical therapy only. Stepping machine exercises involve rhythmically bending and extending the bilateral hip and knee joints.23 Although the intensity of the stepping exercises might be insufficient for healthy individuals to increase muscle strength. These exercises have been used to improve lower limb strength and aerobic capacity in knee rehabilitation17. that of low. January 2012 Copyright © 2011 Lippincott Williams & Wilkins.11.T otal hip arthroplasty (THA) is an effective treatment of end-stage hip osteoarthritis. a previous study indicated that the anterior and anterolateral approaches provided similar recovery of isometric hip abductor strength and hip kinematics and kinetics during gait after THA. No. & Vol. Suetta et al. Rehabil.21. in the early phase after THA because of hip pain. and flexor and the isometric strength of hip flexor several months after THA were still weak compared with healthy subjects. strengthening the hip and knee muscles is a major goal in early rehabilitation after THA.12 Muscle weakness after THA might partially be caused by surgical invasion of the hip muscles. do not adequately improve after surgery. the cross-sectional area of the quadriceps muscle.and 44 Tsukagoshi et al.5Y7 reduced walking efficiency. THA relieves pain and reconstructs the hip joint position. Phys. muscle weakness is still distinct in the early phase after operation. Previous studies have reported that hip muscle weakness.and low-frequency strength training has been confirmed by these studies.12 Furthermore.15 indicated that high-intensity knee extension training is more effective in improving muscle strength. METHODS Study Design and Subjects We conducted a retrospective study of THA patients who underwent THA surgery at Rakuyo Am. hip pain. these measurements were lower at 16 wks after surgery compared with healthy control subjects. which could partially be caused by the surgical invasiveness. 91. such as lower limb muscle strength and gait capacity. These techniques hasten the recovery of muscle strength and functional performance compared with conventional incision because of minimizing soft-tissue dissection such as muscle and tendon.20 Mean muscular activity of the hip and knee muscles during stepping exercises ranged from 10% to 40% of maximum voluntary isometric contraction in healthy subjects.10 and motor performance deficit11 exist after THA. fear of loading. The weight bearing on the surgical leg is insufficient during daily activities. we introduced the stepping exercises into our rehabilitation program after THA surgery.

15 of these patients who received THA surgery before May 2006 were allocated to the control group that performed conventional physical therapy only. Strength tests were performed in the following order in each lower limb: hip abductors. hip flexors. we investigated whether there were any reports of adverse events from the stepping exercises. FIGURE 1 Flow diagram of the study subjects. Japan)..ajpmr. A total of 82 of the 201 patients were excluded because of revision THA. These measurements were assessed by a single examiner with 7 yrs of clinical experience who was not blinded to group allocation. Warsaw. Kyoto. A total of 201 women who received a primary unilateral THA for hip osteoarthritis in Rakuyo Hospital between June 2004 and August 2007 were enrolled in this retrospective study according to medical charts (Fig. IN or K-MAX ABC Hip System. knee extensors. leg perpendicular to the floor. hip extensors. the participants held the edge of platform during testing of the hip flexors. prone with neutral hip flexion/extension. Similarly. hip flexors.5 kg. and anterior Stepping Exercises After THA Copyright © 2011 Lippincott Williams & Wilkins. Zimmer. a total of 30 patients were enrolled.27 hip fracture. The cementless acetabular and femoral implants were used (Trilogy Acetabular System & Versys Hip System. All testing sessions were performed in the same order. Testing Procedures All of the patients were evaluated 2 days before and 6 wks after surgery. In addition. Japan. and knee flexors. weight. Maximal Isometric Strength of the Lower Limb The strength of bilateral hip abductors. the patients performed 5 mins of walking at a comfortable speed or 5 mins of exercise on a stationary ergometer with an intensity of 0. Eventually. seated on a platform with 90 degrees of hip and knee flexion. 1). The remaining 15 subjects who received surgery after June 2006 were assigned to the stepping group that performed stepping exercises in addition to conventional physical therapy. To stabilize the body and to minimize muscle compensation. Kobelco. These variables were measured according to the testing procedures described in the next section. and knee flexors. height. Isometric strength of the lower limb and walking speed both before surgery and 6 wks postoperatively were obtained from the medical charts to evaluate the effects of the stepping exercises. Unauthorized reproduction of this article is prohibited. using a combination of bone graft or femoral osteotomy. supine with neutral hip adduction/ abduction. performed all THA surgeries. Before conducting this retrospective study. and tensor fasciae lata were partially incised. Tokyo. the examiner fixed the pelvis during hip extension and the contralateral thigh during hip abduction testing. posterior. The position of the patient for each muscle test was as follows: hip abductors. knee extensors. who had performed more than 2000 THA procedures.25 and the length of the skin incision was 10 to 12 cm. At the beginning of each testing session. Okumura). gluteus minimus muscle. oral informed consent for participation was obtained from all patients. This study was approved by the ethical board of Kyoto University Graduate School of Medicine. A total of 79 of these 119 patients were excluded because they did not complete all the testing procedures. Good interrater and testretest reliability of handheld dynamometer measurements have been verified in previous studies of older. Kobe. body mass index.28 and THA10. Japan). 45 . knee extensors. and knee flexors were measured using a handheld dynamometer (MEDIX. the gluteus medius muscle. knee extensors.Hospital. hip flexors. The sensor pads of the handheld dynamometer were placed on the lateral. All 119 remaining patients received diagnoses of osteoarthritis as the main cause for THA and underwent anterolateral approach in THA surgery. During the surgical Assessments Information regarding age. The anterolateral approach was performed as described by Mostardi et al. www. and feet off the floor. and knee flexors. hip extensors. One orthopedic surgeon (H.29 patients. and preoperative Japanese Orthopaedic Association hip score26 were obtained from medical charts to evaluate the anthropometric characteristics of the subjects. hip extensors. Because stepping exercises were introduced into postoperative rehabilitation in June 2006.

and mean values were obtained. The range of step inclination was 0 to 30 degrees. & Vol.915 for the hip flexors. muscle strength exercises. resistance was applied by a Thera-band fixed to the ankle or knee with the patient in a supine position.945 for the knee flexors. 0. They were considered excellent. J. For the maximal speed walking trials. In each testing condition. No encouragement was given during the tests. resistance consisted of a sandbag fixed to the ankle with the patient in a seated position. The walking distance on a level surface was increased gradually. parametric analysis was performed. Med. 0. The length (in meters) of the lever arms were measured from the estimated center of rotation of the joint to the center of the sensor pad. abduction. hip flexion/extension. and the mean values were used for analysis. extension. Conventional physical therapy consisted of joint range of motion.31 Isometric muscle strengths were measured twice for 3 secs after three practice trials. Initially. For the hip abductors. Calf raise exercises and squatting and single legYstanding exercises were also performed to increase muscle strength and improve the capacity of balance. For the comfortable speed walking trials. and flexors. Muscle strength exercises were single joint exercises in hip abduction/adduction. Before surgery. The 10-m walking test was chosen because it could be easily and safely measured soon after surgery and is frequently used as a clinical outcome measure. The intraclass correlation coefficients (1. the patients used a cane. Gait training started from the fifth day after surgery using a parallel bar. The pads were positioned on the anterior and posterior leg just proximal to the ankle joint for the knee extensors and flexors. If needed. As the normal distribution of the all variables was confirmed using the Shapiro-Wilk test.935 for the hip extensors. Fig. Analysis of variance with repeated Am. exercises against progressive resistance were introduced. For the hip flexors and knee extensors. Rehabil. so 1 to 5 mins were required to perform these exercises. Phys. Handle bars were available in front of the stepping machine. the test-retest reliability of the handheld dynamometer was estimated by calculating the intraclass correlation coefficients (1. Exercises to increase the range of motion of the hip joint consisted of passive flexion. Exercise resistance was applied manually by the physical therapist. Sessions lasted 1 hr a day and were performed 6 days a week for 6 wks. and then stair climbing was added. 2) in addition to the conventional physical therapy. they were asked to walk as fast as they were safely able to without running.thigh just proximal to the knee joint for the hip abductors. they were instructed to walk at their preferred speed. and knee flexion/extension. and external rotation performed manually by the physical therapist. Tokyo. .917 for the hip abductors. step inclination was lowered if patients could not perform the exercises at maximal inclination. Participants were provided with several meters to accelerate and decelerate before and after the test distance. crutch or cane were used. assistive devices such as a walker. No. and functional exercises. and the duration was 10 to 15 mins. and the step load was adjustable by changing the angle of inclination. 91. active assisted and then active exercises without resistance were used.902 for the knee extensors. Japan. Walking Tests Comfortable and maximal gait speeds were measured before and 6 wks after surgery on a 10-m unobstructed path using a digital stopwatch. Participants were given a brief rest (30 secs) between consecutive contractions and at least 1 min of rest between the tests of each muscle group. but the participants were encouraged to perform the exercises without them. Each strength value (in newtons) and lever arm (in meters) was converted into a ratio of torque to body weight (in newton-meters per kilogram).30. Cycling exercises using the stationary ergometer were performed 2 to 3 wks after surgery. These walking speeds were measured twice. according to patient’s fatigue or muscle pain. Later. a make test was used because a make test has been shown to be more reliable than a break test. Verbal encouragement was given during the test. Each exercise was repeated 10 to 50 times. In the present study. Statistical Analysis Postoperative Rehabilitation All subjects received conventional physical therapy treatment in a rehabilitation unit from the third day after surgery. The stepping rate was about 60 steps per minute. The subjects in the stepping group performed stepping exercises using a machine (Fighting Load. 46 Tsukagoshi et al. Thereafter.1) for all measurements in seven healthy women. January 2012 Copyright © 2011 Lippincott Williams & Wilkins. Fifty repetitions were added each week. extensors. The load during the cycling exercises was 25 to 60 W. Data is expressed as mean T SD. with up to 250 repetitions at 5 wks postoperatively. 0. 1. Unauthorized reproduction of this article is prohibited. Stepping exercises were performed for 50 repetitions starting 1 wk after surgery. At the beginning of the exercises. the anthropometric variables for the two groups were compared using unpaired t test.1) was 0. and 0.

4 T 3. BMI. whereas the number of steps taken is digitally displayed (C). There were no significant differences between the two groups in age.92 Weight.0 51.FIGURE 2 Stepping exercise during training (A). The anthropometric data for the two groups are given in Table 1.1 T 6.33 RESULTS Participants According to the evaluation by medical charts.2 T 7.ajpmr. Japan Orthopaedic Association. 6 wks after]) was used for the lower limb muscle strength and walking speed. yrs 59.5 T 5. We used the software program SPSS (version 17. In rehabilitation research. body mass Stepping. Relative difference ¼ ½ð$S  $CÞ=Allbase   100Q TABLE 1 Preoperative anthropometric data for the two groups where $S and $C are the mean within-group changes from baseline of the stepping group and the control group.4 T 3. height.84 P values represent the probability for differences between the two groups as evaluated using an unpaired t test. relative to a control group.3 T 4. the relative differences between the stepping group and the control group were calculated using the following equation: exercises in addition to the conventional physical therapy and were allocated to the stepping group. body mass index.95 Height. and Japanese Orthopaedic Association hip score before surgery.9 59. 47 . Stepping Exercises After THA Copyright © 2011 Lippincott Williams & Wilkins. when a significant interaction was observed. Unauthorized reproduction of this article is prohibited. Of them.0 152.3 T 9.8 0. respectively.5 T 3. The remaining 15 subjects were assigned to the control group. cm 152. mean T SD mean T SD P n 15 15 Age.7 T 1.4 0. There were no reports of adverse effects caused by the stepping exercises in the medical chart. clinical importance has been defined as a clinical improvement of 15% or more.05. control]  time [before surgery vs. and Allbase is the mean value of the baseline measures of the two groups. mass.32 Therefore. JOA.0.0 54. measures (group [stepping vs.41 BMI.5 T 5. Tokyo.46 JOA hip score (0Y100) 51.5 23. Japan) for statistical analysis. kg 52.5 0.3 0. The level of significance was set at P G 0.2 0. a total of 30 of 201 patients were enrolled in the study. The step boards slide alternately from 0 to 30 degrees (B). Control. kg/m2 22. 15 subjects performed the stepping www.

with the stepping group showing a significantly higher recovery than the control group (P G 0.14 0.87 T 0.17 0.28 T 0.6 T 11. and the training effects were validated.78 0.97 T 0.28 0.21 T 0.83 T 0. Stepping exercises can be performed easily and safely. a clinically important difference may exist in these muscle strengths.10 P values represent the probability for interaction effect (group  time) as computed using a repeated-measures analysis of variance.93 0.90 1.93 T 0.20 T 0.18 0. There were no group  time interaction effects in the involved hip extensor. Nm/kg Hip extensor Hip flexor Knee extensor Knee flexor Uninvolved Hip abductor.32 0.94 T 1.0 T 13.88 T 1. Unauthorized reproduction of this article is prohibited.19 0. Neither comfortable nor maximal walking speed showed significant interaction effects between the two groups. Rehabil. 48 Tsukagoshi et al.19 0.04 0.63 T 0.19 0.9 55. In this study.85 T 0.22 T 0.2 72. mean T SD P 0.14 0.20 0. we calculated the relative difference when evaluating the clinical TABLE 3 Walking speeds for the two groups Stepping Group (n = 15) Comfortable walking speed. m/min Control Group (n = 15) Preoperative.68 0.89 0.22 T 0. J.63 0.16 0.6 T 10.2 55.90 T 0.58 T 0.4 T 14.05 T 0. .97 T 0.12 0. The stepping group showed a significantly higher recovery than did the control group according to repeated-measures analysis of variance.61 0.19 0.21 0. 1.2 69.34 T 0.8 T 10. However.17 0. & Vol.85 T0.65 0. Phys. Muscle Strength Measurements DISCUSSION Table 2 lists the results of the muscle strength tests. this study has the potential of making a type I error because of multiple comparisons. Therefore.32 T 0.3 0.10 0.28 0.05). January 2012 Copyright © 2011 Lippincott Williams & Wilkins.63 T 0.18 T 0.30 0.24 0.75 0.22 0.56 P values represent the probability for interaction effect (group  time) by a repeated-measures analysis of variance. stepping exercises were introduced for postoperative rehabilitation.25 0. mean T SD Involved Hip abductor. The relative differences of the involved hip abductor and knee extensor muscles between the two groups were 17% and 19%.14 0. Analysis of variance showed a significant group  time interaction effect in hip abductor and knee extensor strength in the involved limb.47 0.11 0.14 0.73 T 0. mean T SD 6 Wks.60 0. Med.14 0.8 51. hip flexor and knee flexor and in the strength of all the muscles on the uninvolved limb between the two groups. Am.9 74. mean T SD Preoperative.57 T 0. 91.87 T 0. muscle activation is effectively improved by promoting weight bearing on the involved leg during the early postoperative phase.63 T0. This study revealed that stepping exercises were effective for the recovery of the hip abductor and knee extensor muscles on the involved side.30 0.18 0.13 0. mean T SD 6 Wks.67 T 0. Walking Tests Comfortable and maximal walking speeds before and 6 wks after surgery are shown in Table 3.26 0.80 T 0. mean T SD 6 Wks.64 T 0. mean T SD P 53.25 0.70 T 0. respectively.18 0.65 T 1. To facilitate the muscle strength recovery of the lower limb after THA surgery.74 T 0. m/min Maximal walking speed.19 0. Stepping exercises were expected to promote loading of the surgical leg through the repeating step motion.9 68.3 T 10.5 T 17. and no reports of adverse effects were noted in the stepping group performing exercises. No.9 T 16.98 T 1.63 T 0.21 0.69 T0.10 0. mean T SD Control Group (n = 15) Preoperative.43 0.19 T 0.14 T 0. Nm/kg Hip extensor Hip flexor Knee extensor Knee flexor 6 Wks.67 T 0.92 T 0.22 0.02 0.TABLE 2 Muscle strength measurements for the two groups Stepping Group (n = 15) Preoperative.90 0.22 T 0.

22 Moreover. and loosening or dislocation of the prosthesis. immobilization and hip pain. Because massive strength training increases the risk of muscle soreness and hip pain in the early postoperative phase.implications.36. such as squatting and stair stepping. whereas Suetta et al. maximal strength training for THA patients did not improve Stepping Exercises After THA Copyright © 2011 Lippincott Williams & Wilkins. appears to be unsuitable in improving single joint muscle strength measured in a nonYweightbearing position. gluteus medius muscle activation would be enhanced to control the mediolateral stability of the hip. Unauthorized reproduction of this article is prohibited. It has been reported that resistance training15 and low-frequency electrical muscle stimulation intervention44 for the quadriceps do not improve walking speed compared with standard rehabilitation at 35 and 45 days after THA. Reynolds et al. the atrophy of the gluteus medius38 and the quadriceps39 muscles are particularly notable and persist for at least 6 mos after surgery. It was thought that low-intensity training like the stepping exercises was sufficient in improving muscle strength in these patients. such as standing up from a chair and stair climbing. low-intensity and high-frequency training could be more safety performed. so the intensity of the lateral step-up exercise is too low for healthy subjects. such as Trendelenburg or Duchenne sign. Hip abductor weakness is considered one of the causes of gait abnormality. The relative difference in the recovery of these muscles was more than 15% between the intervention group and the control group. Moreover. a randomized controlled trial comparing these two types of training is necessary. Husby et al. Suetta et al. This indicates that the addition of stepping exercises to conventional physical therapy has clinically important benefits compared with conventional physical therapy only.40 The stepping exercises performed in this study effectively improved the function of these two muscles after THA surgery. Similarly. Because the stepping exercises were performed in a standing posture and did not require a large range of hip joint motion. Previous studies indicated that the activation of the quadriceps was higher than 40% of maximal voluntary contraction in the extension phase. which is similar to the stepping exercises used in the current study.42 reported that step training did not improve isokinetic knee extension strength in healthy improve muscle strength. Although intervention was initiated on a similar time frame in these previous studies. performed by healthy subjects for 6 wks.43 also demonstrated that resistance training intervention improved knee extension strength by approximately 106% relative to preoperative strength at 5 wks postoperatively.34. The results of the walking tests did not indicate the efficacy of this intervention for walking ability. In the present study. the subjects who participated in this study were patients in early postoperative phase after THA whose muscle force production was inhibited by surgical invasion. Exercise intensity of at least 60% of maximal voluntary contraction is necessary to www.16 reported that maximal strength training intervention caused hip abduction to increase 150% and leg press to increase 93% relative to preoperative strength on the involved side 5 wks after THA surgery. 6 wks after surgery. According to the principle of training specificity. In previous studies.41 reported that the lateral step-up training. respectively. Stepping movements consist of the hip and knee extension phase and the hip and knee flexion phase. Better improvement of the hip abductor and knee extensor muscles compared with the hip flexor and knee flexor muscles in the involved limb in the intervention group could be caused by this characteristic of stepping exercises. hip abduction and knee extension strength recovered to 128% and 102%. 49 .16 used an intensity of 85% of one repetition maximum and frequency of 20 repetitions.21.37 According to previous studies assessing muscle atrophy in patients with hip osteoarthritis. The training specificity and overload principles of muscle training may explain the inadequate effect on muscle strength gain in these previous studies. because bilateral perturbation of the center of mass was induced by the stepping motion. did not change the isokinetic strength of the knee extensors. Husby et al. the stepping exercises were of lower intensity and higher frequency compared with both previous studies. they would have little effect on gait factors such as stride length and step frequency. multijoint weight bearing training. according to the overload principle.ajpmr.35 The knee extensor strength is also related to the ability to perform activities of daily living. In the present study. two major dissimilarities were training intensity and frequency. The extent of muscle strength gain from the intervention in the present study is comparable with that of other clinical trials. Worrell et al.43 applied the 50% to 80% of one repetition maximum and 30 to 50 repetitions for resistance training. However. to investigate whether low-intensity and high-frequency training is a better intervention than training with a high load and few repetitions. whereas the activation of the hamstrings was lower than 10% of maximal voluntary contraction in both the extension and flexion phases in healthy subjects. However.

No. The patients who performed stepping exercises in the early postoperative phase after THA showed higher recovery of hip abductor and knee extensor muscle strengths than the patients who received only conventional physical therapy. Perron M. Emerson R. Of 119 patients who received primary THA without bone grafts.16 Although the only functional assessment in this study was walking speed. Clin Orthop Relat Res 1990. January 2012 Copyright © 2011 Lippincott Williams & Wilkins. Miki H. Munin MC. Rehabil. 91. J Bone Joint Surg Br 1995. REFERENCES 1.254:170Y9 9. Sisto SA. Clin Biomech 2000. Sugano N. et al: Threedimensional gait analysis in women with a total hip arthroplasty. Bertocci GE.32: 260Y7 Am. & Vol. It is therefore possible that subjects in both 50 Tsukagoshi et al. Gait Posture 2004. stepping exercises did not show positive effects on comfortable and maximal walking speeds. Hagio K. McGrory BJ. it is conceivable that the results could have been influenced by other causes that might have changed over time. or other care that could have influenced the outcomes of this study. In addition.83:1Y9 4. Wassinger CA. Morrey BF. Trudelle-Jackson E. we assume that there were no major changes of medical. et al: Effect of femoral offset on range of motion and abductor muscle strength after total hip arthroplasty. J Orthop Sci 2007. 30 patients who completed all the gait tests and the muscle strength tests were included in this study. monitoring activity level for 1 wk could have contributed valuable information on the functional impact of stronger lower limb muscles. This retrospective study showed that stepping exercises were an effective intervention after THA surgery. J Rehabil Res Dev 2006. In addition.20:414Y20 2. Asayama I. However. Furthermore. Because all subjects in this study were women who underwent primary THA for hip osteoarthritis and were nonobese patients and could bear weight postoperatively. where the hip abductor muscle strength would be more challenged.[ and therefore any such changes could only be minimal. Nankaku M. Simpson KJ. In the present study. Tsuboyama T. J Biomech 2004. J Arthroplasty 2005.gait patterns such as step length and stance time after 12 wks of intervention. Linnarsson D: Walking efficiency after cemented and noncemented total hip arthrolasty. There is a possibility that those who did not undergo these tests could not perform them because of low activity level or pain. Kakinoki R. Med. Frost KL. differences in gait function between the intervention and control groups might have been revealed more in a 6-min walk test. Am J Phys Med Rehabil 2004. A severe limitation of this study is that the study design was not a randomized controlled trial but a retrospective study. et al: Gait analysis of patients in early stage after hip arthroplasty: Effect of lateral trunk displacement on walking efficiency. J Orthop Sports Phys Ther 2002. 1. A randomized controlled trial is a better design to evaluate the clinical efficacy of an intervention. Bertocci GE. et al: Isometric performance following total hip arthroplasty and rehabilitation. Batavia M. because the study period was continuous and relatively short. and patients with restricted weight bearing after THA. Cahalan TD. J. we thank the physical therapists and physicians of the Rakuyo hospital for their support. Further studies are warranted to examine the effects of stepping exercises on other measures of functional status. it is difficult to generalize the efficacy of stepping exercises to men. the effect of stepping exercises in those who did not fulfill these tests is not clear. The results of this study could be generalized only to those who have relatively high activity level and in whom recovery after operation was favorable. However. those who have undergone revision THA.19:141Y7 8. Frost KL. Chamnongkich S. Therefore. groups recovered more in muscle strength and walking speed compared with patients who are hospitalized for shorter periods.45 In exercises of short duration such as a 10-m walking speed test. Mattoson E. Phys. the operation method and rehabilitation protocol were identical for both periods as described in BMETHODS. et al: Reconstructed hip joint position and abductor muscle strength after total hip arthroplasty.15:504Y15 6. because the subjects in the control group and stepping group were selected from early and later periods. respectively.37:443Y55 7. Sliwinski MM. obese patients. 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