Physiotherapy 103 (2017) 283–288

Randomised controlled trial to evaluate a physiotherapy-led

functional exercise programme after total hip replacement
B. Monaghan a,∗ , P. Cunningham b , P. Harrington c , W. Hing d , C. Blake e ,
D. O’ Dohertya a , T. Cusack e
a Department of Physiotherapy, Our Lady’s Hospital, Navan, Co Meath, Ireland
b Department of Radiology, Our Lady’s Hospital, Navan, Co Meath, Ireland
c Department of Orthopaedics, Our Lady’s Hospital, Navan, Co Meath, Ireland
d Faculty of Health and Sciences and Medicine, Bond University, Robina, QLD, Australia
e School of Public Health, Physiotherapy and Population Science, University College Dublin, Belfield, Dublin, Ireland

Abstract
Background At present, there is an insufficient evidence base to evaluate the effectiveness of physiotherapy following total hip replacement
(THR). This study evaluated the effectiveness of a physiotherapy-supervised functional exercise programme between 12 and 18 weeks
following THR. These time-points coincide with increased functional demand in patients.
Design Adequately powered assessor-blinded randomised controlled trial.
Setting Patients were recruited at a pre-operative assessment clinic and randomised following surgery.
Participants Sixty-three subjects were randomised to either the usual care group (control, n = 31) or the functional exercise + usual care
group (n = 32).
Interventions Patients in the functional exercise group attended a physiotherapy-supervised functional exercise class twice weekly from 12
to 18 weeks following THR. Patients in the control group followed the usual care protocol with no exercise intervention.
Main outcome measurement The main outcome measurement tool was the Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC) questionnaire, and the secondary outcomes included walking speed, hip abduction dynamometry, Short Form 12 physical and
mental health scores, and visual analogue pain scale score.
Results At 18 weeks post surgery, WOMAC function and walking speed improved significantly more in the functional exercise group [mean
difference −4.0, 95% confidence interval (CI) −7.0 to 1.0 (P < 0.01); mean difference 21.9 m, 95% CI 0.60 to 43.3 (P < 0.04)] than the control
group, but there was no significant difference in hip abductor strength.
Conclusion This study demonstrated that patients who undertake a physiotherapy-led functional exercise programme between 12 and 18
weeks after THR may gain significant functional improvement compared with patients receiving usual care.
Clinical trial registration number NCT01683201.
© 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Total hip replacement; Late-stage functional exercise; Postoperative rehabilitation; Physiotherapy

Introduction performed in the UK in 2012 [1]. Similar figures have been

Total hip replacement (THR) is a successful surgical
procedure performed for end-stage arthritis. Rates of THR
are increasing internationally, with 86,488 replacements
∗ Corresponding author. Address: Department of Physiotherapy, Our
Lady’s Hospital, Navan, Co Meath, Ireland. Tel.: +353 469242481.
E-mail address: brenda.monaghan@hse.ie (B. Monaghan).
reported in the Republic of Ireland, where approximately
117/100,000 population underwent THR in 2011 [2].
In most cases, THR provides improved quality of life, pain
relief and improved function [3,4]. Pain, physical impair-
ment, gait change and reduced muscle strength have also
been reported at 1- and 2-year intervals, even in groups who
received physiotherapy as part of their early rehabilitation
programme [5–7]. Postoperatively, a number of studies have

http://dx.doi.org/10.1016/j.physio.2016.01.003
0031-9406/© 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
284 B. Monaghan et al. / Physiotherapy 103 (2017) 283–288
reported functional problems, in some cases up to 1 year
following surgery [4,5]. Dissatisfaction with outcome follow-
ing THR is reported to be 7–8%, and more recent evidence
has correlated patient satisfaction with postoperative levels
of function [2,8,9].
Traditionally, physiotherapy has been a routine part of
patient rehabilitation following THR [10–13]. More recently,
the physiotherapy provision for this clinical group has been
reduced across the UK [14], with few centres now offering
physiotherapy follow-up after surgery. A number of sys-
tematic reviews have failed to establish the effectiveness of
physiotherapy [10,15–17]. All reviews reported insufficient
evidence to establish the effectiveness of therapeutic inter-
vention, and noted the poor quality of the trials included.
A recent systematic review which informed the current
study focused on patients in the post-acute stage of recovery
[16], and found low-grade evidence that a rehabilitation pro-
gramme at this stage after THR may serve to improve gait
speed and hip abductor strength.
As such, this single-blinded randomised controlled trial
was designed with the primary aim of evaluating the effec-
tiveness of an outpatient physiotherapy-supervised functional
exercise programme in the post-acute stage of recovery, and
was set in the period from 12 to 18 weeks after THR. The
specific primary outcomes evaluated were pain, stiffness and
physical function.
Study design
This randomised controlled trial allocated patients to
either a 6-week physiotherapy-supervised functional exer-
cise + usual care group or a usual care group (control group)
after THR.
Functional exercise intervention
Three experienced physiotherapists supervised the func-
tional exercise classes at each of the three community
hospital-based clinical sites. Training was provided prior
to the commencement of classes in the form of a practical
workshop, and written illustrated manuals were provided that
included an exercise log book which was completed by the
treating therapist at each attendance. This recorded patient
compliance with the programme. During the functional exer-
cise classes, the participants were taught 12 exercises by
the supervising physiotherapist. The physiotherapist moni-
tored form and exercise intensity, progressing the exercises
as necessary. Each session was 35 minutes in length. Patients
attended classes twice weekly for 6 weeks, and were not
given any additional exercises as a home exercise programme.
The specific exercise programme in this study was based
on an exercise programme that had previously been shown
to improve pain and function in patients at this stage of
recovery after THR [18] (see Table A, online supplementary
material).
Usual care
Both the control group and the functional exercise group
followed the usual care pathway. This involved the provision
of an educational and immediate postoperative exercise book-
let on admission, and assessment by the orthopaedic surgeon
at 6 weeks. The exercises outlined in the educational book-
let for both groups consisted of early postoperative exercises
for the duration of the hospital stay. These included foot and
ankle pumps, static quadriceps, static gluteal contractions,
active hip flexion and hip abduction. Following surgery, all
patients are advised to walk daily with crutches until review
by the orthopaedic surgeon at 6 weeks, increasing the dis-
tance gradually to approximately 1 mile after 1 month. No
instructions for any additional exercises were given to either
group on discharge.
The inclusion criteria have been published previously [19],
and consisted of: patients who had undergone primary THR
for osteoarthritis, aged ≥50 years, able to read and understand
instructions in English, willing to attend classes twice weekly
for 6 weeks, and willing to participate in an exercise pro-
gramme without physical assistance. Exclusion criteria were:
medical instability, underlying terminal disease and suspi-
cion of infection following joint replacement. Patients with
previous THR or total knee replacement were not excluded.
Having gained ethical approval from the Health Service
Executive Committee of the North East Hospital Group,
patients were recruited at the pre-assessment clinic of the
elective orthopaedic regional unit by the principal investi-
gator, and then enrolled fully into the study 12 weeks after
surgery. Following a standard interview, a written description
of the study was given to patients, together with a stamped
addressed envelope to return their written consent. This
allowed for a cooling-off period. All patients were sched-
uled for primary THR for osteoarthritis under the care of one
of the seven surgeons in the unit.
Randomisation was achieved using a computer-generated
random number table. Concealed allocation was achieved
using sequentially numbered envelopes that were adminis-
tered by an independent third party (physiotherapy manager).
All patients were contacted directly for baseline assessment
at 12 weeks after THR, and those randomised to the exer-
cise group were contacted directly by the physiotherapists
responsible for conducting the exercise classes. Patients were
asked not to discuss their group allocation, and were asked
not to disclose their group allocation until the final outcome
assessments had been completed.
All outcome measurements were recorded 12 weeks after
surgery (baseline) and 18 weeks after surgery by the princi-
pal investigator, who was blinded to group allocation. The
primary outcome measurement tool was the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC)
questionnaire, which consisted of 24 questions on pain
(scored 0 to 20), stiffness (scored 0 to 8) and function (scored
0 to 68). Secondary outcome measures were visual ana-
logue pain scale score, walking speed [6-minute walk test
 B. Monaghan et al. / Physiotherapy 103 (2017) 283–288 285

(6MWT)] and Short Form (SF)12 self-reported physical and the fact that some of the tests of normality on the baseline
mental health scores, as described in the previously published scores (Kolmogorov–Smirnov) showed a significant effect,
protocol [19]. it was assumed that the dependent variable was approxi-
Following the literature review [16], a strength assessment mately normal, and as the sample size was greater than 30,
outcome was added in the form of a dynamometry isomet- the general linear model analysis of covariance (ANCOVA)
ric strength test as an additional secondary outcome. Hip would be sufficiently robust to accommodate the approximate
abduction strength was assessed as this has been cited in pre- normality.
vious studies to be positively correlated with self-assessed Parametric tests were therefore deemed to be appropriate
function [6]. The dynamometry measurements of mean and for analysis of all of the outcome measures. ANCOVA models
maximum hip abduction strength were recorded for both were used to compare treatment effects over the 6-week study
hips using a hand-held dynamometer (Power Track 11 Com- period between the functional exercise group and the control
mander, JTECH Medical, Midvale, UT, USA), as described group. In all tests, the independent variable was allocation to
by Thorborg et al. [20]. This has been shown to be reliable either the functional exercise group or the control group, and
and valid for the measurement of hip abduction. The patient the dependent variables were WOMAC questionnaire, SF12,
was positioned in a supine position, with the hip to be tested 6MWT, visual analogue scale and dynamometry recordings
in the neutral position. The test leg and the resistance point at Week 18. Baseline measures were included as a covariate,
were positioned over the end of the table. The opposite leg and surgical approach (posterior/anterolateral) was included
was flexed. The patient held the plinth with both hands. The as a random factor.
principal investigator applied resistance in a fixed position,
and the patient abducted maximally against the dynamome-
Results
ter and the examiner. Resistance was applied at a premarked
point 5 cm proximal to the lateral malleolus. The standard- Sixty-three patients completed the study; 31 in the con-
ised command of ‘go, push, push, push, push and relax’ was trol group and 32 in the functional exercise group. At Week
used on each patient. 12 (baseline), there was no significant difference between
For patients randomised to the functional exercise group, the functional exercise group and the control group in either
follow-up rehabilitation was performed at one of three outly- the parametric or non-parametric tests (see Table 1). At
ing community hospital sites. Informed consent was obtained Week 18, the function component of the WOMAC score was
from 72 patients, but nine patients did not complete the base-
line assessment at Week 12. Table 1
Demographic data and baseline scores for functional exercise and control
groups.
Sample size
Functional Control group P-value
exercise group
Sample size calculations were based on the physical func-
Sex (% male) 63 74 0.33
tion subscale of the WOMAC questionnaire. The minimal
clinically important difference (MCID) on the WOMAC Surgical approach, %
questionnaire has been established in the literature to be Anterolateral 69 74 0.64
Posterior 31 26 0.64
−10.4, with a standard deviation (SD) of 13.6, as described
in the study protocol [19]. The sample size was calculated
Mean (SD) Mean (SD) P-value
requiring a power of 80% in a two-tailed test with signifi-
cance of 0.05. The effect size was calculated as 10.4 (MCID) Age (years) 68 (8) 69 (9) 0.41
Weight (kg) 79 (15) 82 (20) 0.56
divided by 13.6 (SD), and found to be 0.764 or a moder- Height (cm) 166 (8) 167 (9) 0.61
ate/large effect. The sample size required was then calculated WOMAC pain 2.5 (2.2) 1.8 (2.1) 0.38
to be 27 patients per group or 54 patients in total, and this WOMAC stiffness 2.2 (1.2) 2.4 (1.2) 0.40
was increased to 60 to allow for attrition. WOMAC function 10.7 (9.5) 9.7 (7.1) 0.99
Statistical analysis was conducted using Statistical WOMAC total 15.3 (12.0) 14.0 (8.7) 0.98
Dyn (BVNOP) (lbs) 15.2 (4.8) 16.9 (6.3) 0.23
Package for the Social Sciences Version 20 (IBM Corp., Dyn (MVNOP) (lbs) 14.5 (4.6) 16.0 (5.9) 0.26
Armonk, NY, USA). Two patients enrolled in the interven- 6MWT (m) 443.8 (71.9) 439.7 (92.5) 0.85
tion group did not receive the intervention, but were analysed SF12 Phy 43.7 (9.2) 42.8 (9.6) 0.71
in the exercise group according to intention-to-treat princi- VAS (units) 1.5 (2.2) 0.71 (1.3) 0.10
ples. There were 63 patients in total; 32 in the functional Dyn BVOP 13.2 (4.3) 14.5 (5.6) 0.44
Dyn MVOP 12.4 (4.1) 13.7 (5.4) 0.43
exercise group and 31 in the control group. Compliance SF12 55.7 (9.1) 42.7 (9.6) 0.09
with the functional exercise programme was good at 88%
6MWT, 6-minute walk test; WOMAC, Western Ontario and McMaster
(341/384 sessions). Preliminary checks were conducted to Universities Osteoarthritis Index; Dyn, dynamometry; BVNOP, Best value
ensure that the assumptions of normality, linearity, homo- non-operated side; MVOP, Mean value non-operated side; SF12 Phy, Short
geneity of variances, homogeneity of regression slopes and Form 12 physical health score; VAS, visual analogue scale; BVOP, best value
reliable measurement of the covariate were upheld. Despite operated side; MVOP, mean value operated side; SD, standard deviation.
286 B. Monaghan et al. / Physiotherapy 103 (2017) 283–288

Table 2
Comparison of functional exercise and control groups for all outcomes (pre and post intervention).
Variable Functional exercise group Control group Mean difference at P-value
Mean (SD) Mean (SD) Week 18 (95% CI)
Pre n = 32 Post n = 32 Pre n = 31 Post n = 31
WOMAC pain 2.5 (2.1) 0.9 (1.5) 1.8 (2.1) 1.6 (2.4) −0.81 (−1.8 to 0.2) 0.10
WOMAC stiffness 2.1 (1.2) 1.3 (1.2) 2.4 (1.5) 1.7 (1.6) −0.44 (−1.2 to −0.28) 0.20
WOMAC function 10.7 (9.50) 5.4 (6.6) 9.7 (5.09) 8.8 (8.9) −4.0 (−0.71 to 1.0) 0.01a
6MWT (m) 443.8 (71.9) 490.5 (74.6) 439.7 (92.5) = 30b 462.8 (106.4) = 29b 21.9 (0.60 to 43.3) 0.04a
VAS (units) 1.5 (2.2) 0.8 (1.4) 0.7 (1.3) 1.0 (1.4) 0.42
BVOPa (lbs) 13.2 (4.3) 15.7 (5.2) 14.5 (5.6) 17.1 (6.7) n = 29b 0.87
BVNOPa (lbs) 15.2 (4.82) 16.4 (5.5) 16.9 (6.3) 19.0 (6.8) n = 29b 0.55
MVNOP (lbs) 14.5 (4.6) 15.9 (5.4) 16.0 (5.9) 18.1(6.6) n = 29b 0.73
SF12 Phys 43.7 (9.1) 49.0 (8.1) 42.8 (9.6) 44.8 (10.5) n = 30b 0.05a
SF12 MHS 55.7 (9.13) 56.38 (8.6) 60.0 (7.53) 58.6 (7.15) n = 30b 0.85
a Significant (P ≤ 0.05).
b Change in group number from normal.
MV, mean value; SD, standard deviation; VAS, visual analogue score; Dyn, dynamometry; BVOP, best value operated side; MHS, Mental Health Score; SF12
Phys, Short Form 12 physical health score; 6MWT, 6-minute walk test.

significantly lower, with a large partial eta squared effect size
indicating improvement in the functional exercise group com-
pared with the control group. In addition, distance walked on
the 6MWT and the physical score for SF12 also improved
significantly in the functional exercise group, with moderate
partial eta squared effect size (see Table 2). This significant
difference was present regardless of the surgical approach.
There was no significant difference in the stiffness and
pain components of the WOMAC questionnaire between the
groups. In addition, the between-group differences in visual
analogue scale scores, hip dynamometry and mental health
score for the SF12 were not significantly different.
Discussion
To the authors’ knowledge, this study is the first ade-
quately powered randomised controlled trial to demonstrate a
significant difference in function following a physiotherapy-
supervised functional exercise intervention delivered to
patients between 12 and 18 weeks after THR. This clinical
finding is very important as physical therapy is increasingly
deemed to be unnecessary for this patient group.
Exploration of whether or not a significant difference
reflects a true clinical change for patients was explored
by comparing the significant difference with the MCID for
this patient group, and the patient acceptable symptom state
(PASS). Examination of the literature demonstrated that the
minimal clinical important difference for the function score
of the WOMAC questionnaire varies from 1.33 (scale 0–10)
or larger than 12% of baseline [21] score, to −7.9 function
95% CI (−8.8–−5.0) where the total score was normalised to
a 0–100 score [22]. Clinically, however, these scores reflect a
diverse patient group. The disparity in the groups for whom
MCID were reported was the topic of a recent review in phys-
ical therapy [23]. This review concluded that a wide range
of MCIDs has been published relevant to WOMAC scores,
but that caution in interpretation was critical as values vary
widely depending on the study population and the follow-
up timeframe and intervention. Similarly, the literature has
reported a PASS score in patients with hip osteoarthritis of
34.4 for WOMAC function [12], which would indicate that
the patients in both groups in this study were very satisfied
with their level of function 18 weeks after THR. However,
no PASS scores for WOMAC function were found for the
post-THR group specifically. Again, caution is advised in
the interpretation of scores in the absence of publication of
specific THR figures. This is the first study to evaluate a
functional exercise programme at this stage of rehabilita-
tion following THR using the WOMAC questionnaire as a
primary outcome measurement tool; therefore, direct com-
parison with other trials is not possible.
Distance walked on the 6MWT was found to differ sig-
nificantly between the intervention group and the control
group by 27.73 m. This falls within the levels of small and
meaningful change described in previous work [13]. There-
fore, the clinical relevance of these figures for a group
of patients undergoing rehabilitation following THR has
yet to be proven. Another randomised controlled trial used
the 6MWT to evaluate the effect of a walking skill train-
ing programme in patients following THR [24]. This study
demonstrated a significant difference (mean of 52 m) in the
distance walked on the 6MWT between the exercise group
and the control group at 5 months and 12 months after
surgery. Of note, the exercise programme was performed
over the same timeframe as the current study (twice weekly
for 6 weeks), but the duration of each session was twice
as long (70 vs 35 minutes), and it incorporated a walking
programme. Given the similarity between the programmes,
the addition of a walking component to the current study
is worth exploring, specifically to improve outcome in this
timeframe for the THR population. Other studies [11,24–26]
reported significant differences in improvements in gait speed
in their exercise groups following THR; however, none of
the studies commented on the clinical relevance of their
findings.
 B. Monaghan et al. / Physiotherapy 103 (2017) 283–288
This randomised controlled trial found no significant dif-
ference in hip abductor strength between the functional
exercise group and the control group. This is surprising and
contrary to previous work [17,25,27]. Of note, the mean time
from surgery in these studies was longer than that in the
present study, by which time the natural improvement in
the control group would have slowed and improvement in
the experimental group would be more marked. In the cur-
rent study, both groups showed a significant improvement
over the 6-week study period, but the difference between
groups was small. Evaluation of both groups in the longer
term would be of interest. Previous work on compliance in a
similar patient group [25] evaluated the effect of exercise on
low and high compliance with exercise following THR. The
patients in the high-compliance group reported significant
improvement in hip abductor and flexor strength compared
with the control group. No significant difference was noted
in the low-compliance group. Although compliance in the
present study was high (88%), the patients in the func-
tional exercise group attended twice weekly and completed a
programme lasting approximately 35 minutes, which is com-
parable with the low-compliance group described previously
[25]. Whilst clinical resources may not stretch to supervised
functional exercise classes more than twice weekly, a home
exercise strengthening programme may be needed in addi-
tion to functional exercise if an improvement in strength is
required. This warrants further exploration in future studies.
In conclusion, Sashika et al. [27] attributed improvement in
strength to the motivation gained from the discovery of a
difference in the operated and non-operated sides at the ini-
tial evaluation, and this motivated patients to improve for
the second evaluation, even in the absence of any change in
exercise routine. This motivation factor was not considered
in the current study, but does warrant consideration in future
studies.
Limitations of this study
This study was undertaken in the clinical environment
to reflect current practice; this reality is reflected in the
involvement of a number of surgeons and the surgical
approaches used. Unfortunately, the duration of follow-
up was also dictated by clinical constraints, and does not
allow for assessment of longer-term outcomes. The mean
difference in the WOMAC function score between the func-
tional exercise group and the control group in this study
was small (4.0) compared with other published studies
[22,23], so the true clinical difference between the reha-
bilitation groups is not clear cut. It is also acknowledged
that the exercise levels in the control group were not
measured specifically, and this could confound the study
findings.
Further adequately powered studies using single surgeons
and identical implants and surgical approaches would prove
very useful to verify the findings of this study. It is noteworthy
that the power of this study was based on WOMAC and SF12
287
scores, and therefore it may not have been adequately pow-
ered to detect changes in dynamometry. The figures provided
should assist with accurate calculation of power for these out-
comes in future studies. Finally, it is acknowledged that the
patients in this group were not blinded to the study inter-
vention, and this lack of blinding has the potential to bias
the results by exaggerating the intervention effects. However,
given the physical nature of the intervention in a clinically
based study, blinding of participants was not deemed to be
possible.
Conclusion
The results of this study provide important evidence that
patients benefit functionally from attending a programme
of physiotherapy-led functional exercise rehabilitation from
12 to 18 weeks following THR. This study provides evi-
dence of improved patient function and walking speed in
patients following THR using assessment tools that incorpo-
rated patient-reported outcomes. Further studies are needed
to determine if the favourable outcomes are maintained in the
long term.
Acknowledgements
The authors wish to acknowledge the patients who took
part in the study without whom this work would not be pos-
sible.
We also wish to acknowledge the work of the Physio-
therapy Managers; Ms Karen Gunn and Ms Lara-Bourton
–Cassidy for all their support throughout the project par-
ticularly in the initial stages, and with the randomisation
phase.
We acknowledge the help and support of the Physiother-
apy staff; Ciara Rowe, and Jacqui Given, and in particular
the supervising therapists Deirdre O Doherty, Lana Brennan,
Breda Smith, and Emer Griffin without whom this project
would not have been possible.
We acknowledge the help and assistance of all the nurs-
ing staff in the Orthopaedic ward under the management of
Ms Davnet Madden and Ms Deirdre Carroll and the staff in
pre-assessment Ms Peig Banville and Ms Ann Birch for their
help with initial patient recruitment.
Finally the authors wish to acknowledge the support of
the Orthopaedic Consultants at Our Lady’s Hospital Navan;
Mr Harrington, Mr Walshe, Mr Awan, Mr Mahapatra,
Mr Khan and Mr Zubovic for allowing their patients to take
part in this study.
Ethical approval: Ethical approval for this study was pro-
vided by the Ethics Committee of the Dublin North East
Hospital Group of the Health Service Executive in November
2013, prior to commencement of the study.
288 B. Monaghan et al. / Physiotherapy 103 (2017) 283–288
Funding: This study was funded by a research training fel-
lowship for healthcare professional’s award 2012–2014 as
part of a PhD programme.
Conflict of interest: None declared.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.physio.2016.01.003.
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