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Effect of a walking skill training program in patients who have undergone total
hip arthroplasty: Followup one year after surgery

Article in Arthritis Care and Research · March 2012

DOI: 10.1002/acr.20681 · Source: PubMed

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Arthritis Care & Research
Vol. 64, No. 3, March 2012, pp 415– 423
DOI 10.1002/acr.20681
© 2012, American College of Rheumatology
ORIGINAL ARTICLE

Effect of a Walking Skill Training Program in

Patients Who Have Undergone Total Hip
Arthroplasty: Followup One Year After Surgery
KRISTI ELISABETH HEIBERG,1 VIGDIS BRUUN-OLSEN,2 ARNE EKELAND,3 AND
ANNE MARIT MENGSHOEL2

Objective. To investigate the effect of a 12-session walking skill training program of weight-bearing activities on physical
functioning and self-efficacy initiated in patients 3 months after total hip arthroplasty (THA).
Methods. Sixty-eight patients with THA, 35 women and 33 men, with a mean age of 66 years (95% confidence interval
[95% CI] 64, 67 years), were randomized to a training group (n ⴝ 35) or a control group without physiotherapy (n ⴝ 33).
Assessments were performed before the intervention at 3 months (pretest), at 5 months (posttest 1), and at 12 months
(posttest 2) after surgery. The primary outcome was the 6-minute walk test (6MWT). The secondary outcomes were the
stair climbing test (ST); figure-of-eight test; Index of Muscle Function (IMF); active hip range of motion (ROM) in flexion,
extension, and abduction; Harris Hip Score (HHS); self-efficacy; and Hip Dysfunction and Osteoarthritis Outcome Score.
Results. The training group had larger improvements than the control group at posttest 1 on the 6MWT with an adjusted
mean difference of 52 meters (95% CI 29, 74 meters; P < 0.001) and on the ST of ⴚ1 second (95% CI ⴚ2, 0 seconds; P ⴝ
0.01).There were also improvements on the figure-of-eight test (P ⴝ 0.02), IMF (P ⴝ 0.001), active hip ROM in extension
(P ⴝ 0.02), HHS (P ⴝ 0.05), and self-efficacy (P ⴝ 0.04). The difference between the groups persisted at posttest 2 on the
6MWT of 52 meters (95% CI 24, 80 meters; P < 0.001) and on the ST of ⴚ1 second (95% CI ⴚ3, 0 seconds; P ⴝ 0.05).
Conclusion. The walking skill training program was effective, especially in improving walking both immediately after
the intervention and 1 year after THA surgery.

INTRODUCTION lated to living an active and independent life and is there-

Total hip arthroplasty (THA) is a common surgical proce-
dure that is used when other methods, such as medical
treatment and physiotherapy, have failed to modify pain
or physical limitations caused by osteoarthritis (OA) of the
hip. Patients report that their highest priorities after THA
are to obtain pain relief, return to normal daily function-
ing, and maintain an active lifestyle (1,2). Walking is re-
ClinicalTrials.gov identifier: NCT00808483.
Supported by the South-Eastern Norway Regional Health
Authority.
1
Kristi Elisabeth Heiberg, RPT, MSc: Institute of Health
and Society, University of Oslo, Oslo, and Bærum Hospital,
Vestre Viken Hospital Trust, Bærum, Norway; 2Vigdis
Bruun-Olsen, RPT, MSc, Anne Marit Mengshoel, RPT, PhD:
Institute of Health and Society, University of Oslo, Oslo,
Norway; 3Arne Ekeland, MD, PhD: Martina Hansens Hospi-
tal, Bærum, Norway.
Address correspondence to Kristi Elisabeth Heiberg, RPT,
MSc, Institute of Health and Society, Department of Health
Sciences, University of Oslo, PO Box 1089 Blindern, N-0317
Oslo, Norway. E-mail: k.e.heiberg@medisin.uio.no.
Submitted for publication May 10, 2011; accepted in re-
vised form October 19, 2011.
fore important for achieving these goals (3). Previous
research has shown that 3 months after THA, patients have
less pain and improved walking than before surgery (3–5).
However, studies show that several months and years after
THA, patients’ walking is impaired compared to that of
healthy peers (6 –13), and hip flexibility and muscle
strength are poorer than in their unaffected hip (14 –16).
As prostheses are developed to tolerate more vigorous
activity, it seems increasingly likely that these patients
should be able to approximate their walking to that of
healthy peers.
Physiotherapy, especially related to exercises, is a major
part of patient rehabilitation following THA. A systematic
review of effect studies on exercises showed variations in
both program content and the time period after surgery
when the program was administered (17). For example, the
program focus varied from flexibility exercises, strength-
ening exercises, and cardiorespiratory fitness training in
non–weight-bearing positions (18 –21) to postural stability
and aerobic dance in weight-bearing positions (22,23). The
start of the intervention varied from shortly after surgery to
several months or even years afterward (19 –21). The au-
thors of the review stated that it was not possible to estab-

415
416
Significance & Innovations
● The walking skill training program performed 3 to
5 months after total hip arthroplasty had immedi-
ate effects on walking distance and stair climbing
that still persisted 1 year after surgery.
● Training in weight-bearing activities was safe and
well tolerated by the patients.
lish the efficacy of the various exercise programs in im-
proving physical functioning after THA (17).
It seems likely that patients with THA have a longstand-
ing history of hip pain and dysfunction before surgery that
may have resulted in behavioral adaptations and altered
movement patterns. Therefore, if the goal of physiotherapy
is to restore some degree of previous walking (24), an
adequate improvement for the patients would be to relearn
the movement patterns they had prior to their illness, i.e.,
to improve their walking skill. According to one theory of
motor control, skills are learned by practicing the partic-
ular activity in different ways (25,26); in the present case,
this would mean practicing walking tasks and activities.
Guidance and feedback when practicing the task may pro-
mote the relearning of motion. By practicing these tasks
and activities, it is also thought that joint flexibility, mus-
cle strength, balance, and muscle endurance are trained.
We therefore designed a program in which the patients
relearned motor skills by practicing walking on uneven
surfaces, stepping over different obstacles, and climbing
stairs. To avoid limiting factors such as pain and mobility
restrictions to prevent hip dislocation, the present walking
skill training program was implemented 3 months postop-
eratively. A better movement pattern, balance, and muscle
endurance were assumed to improve walking distance,
and an assessment of walking distance during 6 minutes
was chosen as the primary outcome variable.
The aims of the study were to examine the immediate
effects of a walking skill training program on walking, stair
climbing, balance, self-reported physical functioning,
pain, and self-efficacy compared to a control group with-
out supervised physiotherapy, and second, to examine
whether the effects persisted 12 months after surgery.
PATIENTS AND METHODS
Study design and sample size estimation. A single-
blind randomized controlled study design was used. The
patients were randomized to either the training group or
the control group receiving no physiotherapy by drawing
an opaque envelope containing a note assigning them to
one of the groups. Thirty-five envelopes were prepared for
each group. The measures were administered before the
intervention started at 3 months after surgery (pretest), on
completion of the program at 5 months after surgery (post-
test 1), and at 12 months after surgery (posttest 2). The
assessments were performed by a single physiotherapist,
who was blinded for group allocation. The primary out-
Heiberg et al
come was the distance walked during 6 minutes. To detect
a clinically relevant difference of 50 meters (27) with an
SD of 70 meters (28), a statistical power of 80%, and a
statistical significance of 0.05, the size of the sample was
estimated to be 32 patients in each group (29). To take
account of possible dropouts, we wanted to include 70
participants. The study was approved by the regional com-
mittee for medical research ethics and Norwegian Social
Science Data Services, and registered online at Clinical-
Trials.gov.
Participants. Patients who were scheduled for primary
unilateral THA at 2 hospitals were sent information about
the ongoing study before hospitalization. They were asked
to participate in a longitudinal study the day before sur-
gery if they met the following criteria: diagnosis of OA of
the hip joint (30) and residence close to the hospital so as
to be able to attend training sessions, i.e., within a radius
of approximately 30 km. They were excluded if they had
OA in a knee or the contralateral hip that restricted their
walking, a neurologic disease, dementia, heart disease,
drug abuse, and inadequate ability to read and understand
Norwegian. Three months after surgery, those willing to
participate preoperatively were asked again to participate
in the present study. The patients were enrolled consecu-
tively from October 2008 to March 2010.
Surgery and physiotherapy during the hospital stay.
Exeter or Spectron hip prostheses were used, and for the
operation a posterolateral approach was chosen with a
curved incision of approximately 13 cm posterior to the
gluteus medius muscle and the greater trochanter. The
short external rotators were detached, and reattached dur-
ing closure (31). The acetabular and femoral components
were cemented and the posterior capsule was sutured.
While in the hospital, all of the patients followed the same
anesthetic procedure during and after surgery, which in-
cluded intraarticular local injection analgesia. After sur-
gery there were no restrictions on weight bearing. To pre-
vent dislocation, the patients were told to avoid hip
flexion beyond 90°, hip adduction, and hip internal rota-
tion beyond the neutral position in the operated hip for the
first 3 months (32). All of the patients got daily routine
physiotherapy care for approximately 30 minutes, which
consisted of self-care instructions, joint mobility and mus-
cle-strengthening exercises in a bed or on a bench, and
learning to walk with a supporting device.
Physiotherapy and training after discharge from the
hospital. The patients got requisition for physiotherapy
when they were discharged from the hospital. From train-
ing logs we know that 73% of the patients exercised under
supervision of a physiotherapist, mainly comprising flex-
ibility and strengthening exercises on a bench or in an
apparatus. All but 1 patient reported additionally that they
had done home exercises and walks for more than twice a
week.
Walking skill training program. The program was per-
formed in groups of 2 to 8 patients, and the group was led
Walking Skill Training Program Effects in THA Patients 417

Table 1. Components of the walking skill training program

Weight-bearing tasks with supervision,

guidance, and feedback Target Description

Warm-up with music Ten minutes of standing with weight transfers, sidesteps
with arm swing, walking in a circle at different
speeds, and step length
Sit to stand Strength and flexibility Five minutes of rising from and lowering onto a chair
and squats at different speeds and with weight
transfers
Lunges Strength, stretching, and Five minutes of lunges forward and sideways on
balance alternative legs
Single-leg stance Strength and balance Five minutes of single-leg stance on alternative legs
while moving the other leg
Standing on foam balance pad Balance and strength Ten minutes of squats, forward, backward, and
sideways, with increasing angles in the hips and
knees
Step up/step down Balance, strength, and Five minutes of ascending and descending a step,
flexibility forward and backward and at different speeds and
different step heights
Stair climbing Balance, strength, and Five minutes of going up and down 5 steps with
flexibility different heights and at different speeds
Obstacle course Balance Ten minutes of stepping over obstacles; stepping onto,
along, and down from an aerobic step and Bosu ball;
walking over a foam mat and progressing by
increasing the speed, height, and number of obstacles
Throwing ball Balance and coordination Five minutes of throwing and catching a ball to each
other in a circle while moving around
Walking Endurance, balance, and Five minutes of walking in a crowded corridor at
flexibility different speeds and step lengths, with turns and
progression to maximal walking speed
Stretching Flexibility Five minutes of stretching the calf, leg, thigh, neck, and
shoulder muscles

by a physiotherapist. Each patient participated in 12 ses-
sions, which were held twice a week. Each session lasted
for 70 minutes. Before the training started the patients
were asked to identify some activities they wished to be-
come better at, and 79% reported that they wished to
improve their walking ability and 21% to improve their
balance. This was taken into consideration when adjusting
the training program to the individual patient.
The program was based on 2 main principles: to train
neuromuscular functioning by doing several repetitions of
different ambulatory tasks and activities, and to relearn
more adequate movement patterns from guidance and
feedback of the physiotherapist (Table 1). During the ses-
sions the difficulty and number of repetitions of the exer-
cises were continuously adjusted by the physiotherapist to
each individual’s level of physical functioning, personal
goals of improvement, and progress over time. When the
patient managed to do one activity, they had to practice
the activity in a more demanding way, for example, by
increasing the speed of the movements and height of the
walking obstacles, as well as making the ground more
uneven. To avoid cardiovascular risks, the patients should
be able to talk while exercising.
Control group. The control group did not attend any
supervised physiotherapy programs during the same time
period, but were encouraged to continue with the exer-
cises they had learned in the hospital or during their
rehabilitation stay, and to keep generally active.
Performance-based measures of physical functioning.
The 6-minute walk test (6MWT) measures the distance in
meters walked indoors at a comfortable speed for 6 min-
utes (33), and is considered an adequate measure of phys-
ical functioning in subjects with OA after THA (28,34).
The patients walked back and forth along a 40-meter hos-
pital corridor for 6 minutes. The test is considered reliable
and valid (35). A change in walking distance of 50 meters
has been proposed to be of substantial clinical relevance
(27), and the number of patients in the training and control
groups who increased their walking distance by 50 meters
or more was registered.
In the stair climbing test (ST), the patients ascend and
descend 8 steps with a step height of 16 cm as fast as they
can without running. The patients were instructed to use
alternate legs and were allowed to support themselves by
holding onto the stair rail. The time was measured in
seconds.
The figure-of-eight test consists of a double set of circles,
where the outer circles have a diameter of 180 cm and the
inner circles have a diameter of 150 cm. During walking
the feet must be placed in the 15-cm space between the
lines. Every step on and outside the lines was registered,
418
and the higher the number the worse the score. The test is
reported to be reliable and valid (36).
The Index of Muscle Function (IMF) consists of tests of
general mobility, muscle strength, balance/coordination,
and endurance. A patient’s performance is evaluated by
the assessor on a 3-point scale (range 0 –2) (37). The total
score ranges from 0 (best) to 40 (worst). The IMF has been
tested for validity and reliability for patients with OA (37).
Active range of motion (ROM) of hip flexion, extension,
and abduction was measured by a goniometer according to
the procedures of Norkin and White (38).
Self-report measures of physical functioning and self-
efficacy. The Harris Hip Score (HHS) is a widely used
disease-specific measure of hip disabilities after THA. The
physiotherapist administers the test in the form of a struc-
tured interview with the patient. The domains include
pain, functions of daily living, and gait (39). The rating
scale is from 0 (worse) to 100 points (best). The HHS is
considered to have good validity and reliability (40).
According to Bandura, self-efficacy for activities is best
evaluated when the questions are tailored to the particular
domains of interest (41). Therefore, we constructed 10
questions about challenging everyday ambulatory activi-
ties. The questions were: “How certain are you that you
can climb two floors of stairs without using a rail, walk 2
km in the woods at normal speed, bend down, squat,
kneel, go shopping in a crowd, avoid falling indoors and
outdoors, cross the street at a green light, and lead an
active life style?” Each question had a scale ranging from 0
(very uncertain) to 10 (very certain). The responses were
calculated as a sum score (range 0 –100). The internal
consistency of the responses to the items was found to
have a Cronbach’s alpha of 0.78 in our material.
The Hip Dysfunction and Osteoarthritis Outcome Score
(HOOS) LK 2.0 is a disease-specific questionnaire that
consists of 5 subscales that address pain, other symptoms,
activities of daily living (ADL), functions of sport and
recreation, and hip-related quality of life (QOL). The
scores range from 0 (worse) to 100 points (best). The HOOS
has been found to be valid and responsive (42). We trans-
lated the Swedish HOOS 2.0 version into Norwegian ac-
cording to a standard procedure (43).
Adverse events during the training sessions, such as
injuries and falls, were registered by the physiotherapist.
At posttest 2 the patients filled in a questionnaire to reg-
ister whether they had experienced any falls, hip disloca-
tion, or loosening of the prosthesis, thrombophlebitis, or
deep vein thrombosis.
Statistical analyses. We used the software program
SPSS, version 18.0, for the statistical analyses. Descriptive
data are shown as means with their 95% confidence inter-
vals (95% CIs). Data from all randomized subjects were
included in the data analysis. Few dropped out during the
study period (Figure 1), and the missing data were consid-
ered to be unrelated to the intervention and the outcome of
the subjects. In order to obtain a complete data set, the last
observation of the subject was carried forward to replace
the missing data. The chi-square test was used for compar-
ison of categorical variables, and the continuous data were
Heiberg et al
analyzed by Student’s sample t-tests. There were no sta-
tistically significant differences between the groups in the
change from posttest 1 to posttest 2. At pretest, there was
a statistically significant difference between the groups in
HOOS ADL. There was also a trend toward more women in
the training group than in the control group, and that the
training group had worse pretest scores. Therefore, the
effects of therapy were analyzed by a general linear model
with the posttest scores as dependent variables, and sex,
group variable, and pretest scores as covariates. The re-
sults are given as adjusted means, their 95% CIs, and the
partial eta-squared effect sizes. A partial eta-squared value
between 0.01 and 0.05 (range 1–5%) is considered a small
effect, between 0.06 and 0.13 (range 6 –13%) is considered
a moderate effect, and between 0.14 and 1 (range 14 –
100%) is considered a large effect (44). A P value of less
than or equal to 0.05 was considered statistically signifi-
cant.
RESULTS
Approximately 250 patients with residence close to the
hospital were operated on in the 2 hospitals during the
inclusion period. Some of those did not fulfill the inclu-
sion criteria, and others were not asked because of the
busy time schedules at the hospitals. The number of these
patients was not registered. There were 128 patients ful-
filling the inclusion criteria and were asked to participate
preoperatively. Ninety-two patients agreed to participate
before surgery, but 24 of them declined to participate
when asked again at 3 months postoperatively. These pa-
tients, 19 of them women, had worse scores preoperatively
than the participants on the 6MWT, ST, hip ROM in flex-
ion and extension, HHS, and HOOS ADL, sport, and QOL
(P ⬍ 0.05) (data not shown). Sixty-eight patients were
randomized to 2 groups, with 35 patients in the training
group and 33 in the control group. Before starting the
intervention, 1 patient in each group withdrew from the
study, 1 patient in the training group attended 5 sessions
and then dropped out because of a busy working schedule,
and 1 patient in the training group was lost to followup at
posttest 2 because of cancer treatment (Figure 1).
The study sample comprises 35 women and 33 men ages
45– 81 years, with a mean age of 66 years (95% CI 64, 67
years). The patient characteristics are shown in Table 2.
There were no statistically significant differences between
the groups at pretest, apart from those for the HOOS ADL
(P ⬍ 0.05) (Table 3), but there was a trend toward more
women in the training group than in the control group,
which was adjusted for in the analysis. In the training
group, 30 patients attended 12 sessions and 4 attended 8 to
11 sessions.
Effects of the walking skill training program. Both
groups improved from pretest to posttest 1 on most of the
outcome measures (P ⬍ 0.05) and on several outcome
measures from posttest 1 to posttest 2 (P ⬍ 0.05) (Table 3).
Compared with pretest scores, the training group had a
statistically significant larger improvement at posttest 1 on
the 6MWT (P ⬍ 0.001), ST (P ⫽ 0.01), figure-of-eight test
Walking Skill Training Program Effects in THA Patients
Figure 1. Flow chart of the participants through the study.
(P ⫽ 0.02), IMF (P ⫽ 0.001), active hip ROM in extension
(P ⫽ 0.02), HHS (P ⫽ 0.05), and self-efficacy (P ⫽ 0.04)
than the control group (Table 4). For the 6MWT the effect
size was 0.24, for the ST the effect size was 0.10, and for
the other variables the effect sizes varied from 0.06 – 0.12.
Twenty-three patients (66%) in the training group and 5
(15%) in the control group had increased their walking
distance to ⱖ50 meters at posttest 1 compared to the pre-
test distance (P ⬍ 0.001). There were no adverse events
registered in the training group at posttest 1.
There were no statistically significant differences be-
tween the groups in the change from posttest 1 to posttest
2 (P ⬎ 0.05). However, the improvements from pretest to
posttest 2 were larger in the training group than in the
control group on the 6MWT (P ⬍ 0.001) and ST (P ⫽ 0.05)
(Table 4). The partial eta-squared effect size was 0.18 for
6MWT and 0.06 for ST. Twenty-six patients (74%) in the
training group and 15 (46%) in the control group had
increased their walking distance to ⱖ50 meters at posttest
419
2 compared to the pretest distance (P ⬍ 0.001). At posttest
2, nine patients in the training group and 15 patients in the
control group reported falls (P ⬎ 0.05). No complications
were reported in terms of hip dislocation, loosening of the
prosthesis, thrombophlebitis, or deep vein thrombosis.
DISCUSSION
Immediately after completing the walking skill training
program, the training group had better scores than the
control group on performance-based and self-reported
physical functioning, pain, and self-efficacy scores. The
improvement was found to be particularly great for walk-
ing distance, and at 12 months after surgery the differences
between the groups on walking distance and stair climbing
time still persisted. No complications were reported, and
the program seemed to be well tolerated by the patients.
The walking skill training program was designed to im-
420 Heiberg et al

Table 2. Characteristics of the patients who had undergone total hip arthroplasty*

Training group Control group

(n ⴝ 35) (n ⴝ 33)

Age, mean (95% CI) years 65 (63, 68) 66 (63, 69)

Women 21 (60) 14 (42)
Men 14 (40) 19 (58)
BMI, mean (95% CI) kg/m2 27 (26, 29) 27 (25, 28)
Educational level ⱕ12 years 14 (40) 15 (46)
Educational level ⬎12 years 21 (60) 18 (55)
Exeter prosthesis 26 (74) 24 (73)
Spectron prosthesis 9 (26) 9 (27)
Married/cohabitating 27 (77) 25 (76)
Comorbidity, no.
Cancer 1 2
Osteoporosis 0 2
Musculoskeletal disorders 6 3
Stomach/intestinal problem 2 2
Lung disease 0 1
Psychological disorder 0 1

* Values are the number (percentage) unless otherwise indicated. There were no statistically significant
group differences. 95% CI ⫽ 95% confidence interval; BMI ⫽ body mass index.

prove walking. Our results suggest that the program served
its purpose, as both walking distance and stair climbing
time had improved more in the training group than in the
control group immediately after the intervention. Despite
the fact that both groups improved further from immedi-
ately after the intervention to 1 year after surgery, the
training group kept their advantage above the control
group at 1 year. The question is, however, whether the
differences between the groups were of any clinical impor-
tance. The mean difference in effects on walking distance
between the groups from pretest to posttest 1 and 2 was
approximately 50 meters in favor of the training group at

Table 3. Within-group changes in walking and physical functioning from pretest (3 months) to 5 months (posttest 1) and 12
months (posttest 2) in patients who had undergone total hip arthroplasty*

Training group (n ⴝ 35) Control group (n ⴝ 33)

Pretest Posttest 1 Posttest 2 Pretest Posttest 1 Posttest 2

Performance measures
6MWT, minutes 431 (403, 459) 507 (478, 537)† 530 (501, 559)‡ 446 (415, 477) 468 (436, 500)† 489 (457, 521)‡
ST, seconds 13 (12, 14) 11 (10, 12)† 11 (10, 11)§ 12 (11, 14) 12 (10, 13)§ 11 (10, 13)
Figure-of-eight test, 11 (6, 16) 8 (4, 12)§ 7 (4, 11) 9 (5, 13) 9 (5, 13) 7 (4, 11)
steps
IMF 13 (11, 15) 9 (7, 10)† 8 (6, 10) 11 (9, 14) 10 (8, 13)§ 9 (7, 11)
Active ROM in hip 85 (81, 89) 88 (85, 91) 95 (91, 99)† 87 (84, 90) 92 (89, 94)† 94 (90, 98)
flexion, °
Active ROM in hip ⫺1 (⫺2, 1) 1 (⫺1, 2) 0 (⫺1, 1) ⫺2 (⫺4, 0) ⫺2 (⫺4, ⫺1) ⫺1 (⫺3, 0)
extension, °
Active ROM in hip 18 (16, 19) 23 (21, 25)† 24 (22, 27)§ 20 (18, 22) 22 (20, 25)† 25 (23, 28)‡
abduction, °
Self-report measures
HHS 83 (79, 88) 92 (90, 95)† 94 (92, 97)§ 87 (84, 90) 91 (88, 94)† 93 (89, 97)§
Self-efficacy 71 (64, 79) 84 (79, 89)† 86 (81, 90) 79 (72, 85) 83 (77, 90)† 86 (79, 93)
HOOS symptoms 77 (73, 81) 80 (76, 84)† 85 (81, 89)‡ 79 (76, 82) 82 (77, 86) 88 (84, 92)†
HOOS pain 85 (80, 90) 91 (87, 95)† 93 (90, 96) 89 (86, 93) 91 (87, 95) 95 (92, 98)‡
HOOS ADL 81 (77, 86)¶ 88 (85, 92)† 91 (88, 94) 87 (84, 90) 90 (88, 93)‡ 92 (89, 96)
HOOS sport 61 (54, 69) 76 (70, 83)† 77 (70, 84) 69 (61, 76) 76 (69, 82)§ 80 (73, 88)
HOOS QOL 66 (59, 73) 76 (70, 82)† 80 (74, 85) 71 (65, 76) 77 (71, 83)§ 84 (78, 89)§

* Values are the mean (95% confidence interval). 6MWT ⫽ 6-minute walk test; ST ⫽ stair climbing test; IMF ⫽ Index of Muscle Function; ROM ⫽ range
of motion; HHS ⫽ Harris Hip Score; HOOS ⫽ Hip Dysfunction and Osteoarthritis Outcome Score; ADL ⫽ activities of daily living; QOL ⫽ quality of
life.
† Within-group differences from pretest to posttest 1 and from posttest 1 to posttest 2 at the 0.1% level.
‡ Within-group differences from pretest to posttest 1 and from posttest 1 to posttest 2 at the 1% level.
§ Within-group differences from pretest to posttest 1 and from posttest 1 to posttest 2 at the 5% level.
¶ Between-group difference at pretest at the 5% level.
Walking Skill Training Program Effects in THA Patients 421

Table 4. Descriptive data at posttests and effects of a walking skill training program in patients who had undergone total hip
arthroplasty*

Posttest 1 (5 months after surgery) Posttest 2 (12 months after surgery)

Training group Control group Group Training group Control group Group
(n ⴝ 35) (n ⴝ 33) difference (n ⴝ 35) (n ⴝ 33) difference

Performance measures
6MWT, minutes 513 (497, 529) 462 (445, 478) 52 (29, 74)† 535 (516, 555) 483 (463, 503) 52 (24, 80)†
ST, seconds 11 (10, 11) 12 (11, 13) ⫺1 (⫺2, 0)‡ 10 (9, 11) 12 (11, 13) ⫺1 (⫺3, 0)§
Figure-of-eight test, steps 7 (5, 9) 10 (8, 12) ⫺3 (⫺5, 0)§ 7 (5, 8) 8 (7, 10) ⫺1 (⫺3, 1)
IMF 8 (7, 9) 11 (9, 12) ⫺3 (⫺4, ⫺1)† 7 (6, 9) 10 (8, 11) ⫺2 (⫺5, 0)
Active ROM in hip flexion, ° 88 (86, 91) 91 (89, 94) ⫺3 (⫺7, 0) 95 (91, 98) 94 (90, 98) 1 (⫺5, 6)
Active ROM in hip extension, ° 0 (⫺1, 2) ⫺2 (⫺3, ⫺1) 2 (0, 4)§ 0 (⫺2, 1) ⫺1 (⫺3, 0) 1 (⫺1, 3)
Active ROM in hip abduction, ° 24 (22, 25) 22 (20, 23) 2 (0, 4) 25 (23, 27) 25 (23, 27) 0 (⫺3, 3)
Self-report measures
HHS 93 (91, 96) 90 (87, 92) 3 (0, 7)§ 96 (93, 98) 92 (90, 95) 3 (⫺1, 7)
Self-efficacy 86 (82, 90) 81 (77, 84) 6 (0, 11)§ 88 (83, 92) 84 (79, 88) 4 (⫺2, 10)
HOOS symptoms 81 (77, 84) 81 (78, 84) 0 (⫺5, 4) 86 (82, 89) 87 (84, 91) ⫺2 (⫺6, 3)
HOOS pain 92 (89, 95) 90 (87, 93) 2 (⫺2, 6) 94 (91, 96) 94 (92, 97) ⫺1 (⫺4, 3)
HOOS ADL 90 (88, 92) 89 (86, 91) 2 (⫺1, 5) 92 (90, 95) 91 (88, 94) 1 (⫺3, 5)
HOOS sport 78 (73, 83) 74 (68, 79) 4 (⫺3, 12) 79 (73, 86) 78 (72, 84) 1 (⫺8, 10)
HOOS QOL 77 (73, 82) 76 (71, 80) 2 (⫺5, 9) 81 (76, 86) 83 (78, 88) ⫺2 (⫺9, 5)

* Values are the adjusted mean (95% confidence interval). The data are adjusted for sex and pretest scores. 6MWT ⫽ 6-minute walk test; ST ⫽ stair
climbing test; IMF ⫽ Index of Muscle Function; ROM ⫽ range of motion; HHS ⫽ Harris Hip Score; HOOS ⫽ Hip Dysfunction and Osteoarthritis
Outcome Score; ADL ⫽ activities of daily living; QOL ⫽ quality of life.
† Between-group differences at posttest 1 and posttest 2 at the 0.1% level.
‡ Between-group differences at posttest 1 and posttest 2 at the 1% level.
§ Between-group differences at posttest 1 and posttest 2 at the 5% level.

both time points, which is considered to be a substantial
meaningful improvement (27). A larger number of patients
in the training group than in the control group showed
improvements above 50 meters compared with pretest
scores at both posttest 1 and 2, and the effect sizes at both
posttests were large (44). It is unknown, though, how
much change in stair climbing time is necessary to reach
clinical significance, but the effect sizes indicate that the
changes were moderate. Less fall events were reported by
the patients in the training group than in the control group
1 year after surgery. Taken together, these results suggest
that the effects of the walking skill training program had
clinical importance.
Improvements in walking have also been reported in
previous studies (18 –20,23). However, it is difficult to
compare the effects across studies because walking has
been assessed in different ways and at different time peri-
ods after surgery. The exercise programs focused mostly
on training of muscle strength and joint flexibility in non–
weight-bearing positions (18 –20). Only 1 study comprised
weight-bearing exercises through aerobic dance (23). Fur-
thermore, the sample sizes were mostly small, from 7 to 26
patients in the exercise groups, and consequently the stud-
ies tended to have low statistical power. In these studies,
clinical relevance of the findings was not considered, and
the long-term effects of the programs were not examined.
Therefore, the substantial and maintained effects of our
walking skill training program with no adverse events are
promising. However, the study has to be replicated by
others before definite conclusions about its effectiveness
can be drawn.
Before starting the training, the patients in the training
group reported that their highest priority was to improve
walking and balance, and they considered that their walk-
ing was not as good as they would have liked it to be. We
could therefore be sure that the walking skill training
program was in line with the patients’ priorities and likely
to be motivating. In this particular training program, the
patients practiced exercises that involved walking in many
different ways and with several repetitions under guid-
ance and feedback from a physiotherapist. The patients in
the training group said that this kind of training was more
mentally and physically demanding than any physiother-
apy program they had experienced previously. Despite the
fact that the program was demanding, it was well tolerated
by the patients during the training sessions and no com-
plications occurred. Consequently, the walking skill train-
ing program appears to be safe and well tolerated by the
patients.
Although improvements were shown for most of the
performance-based measures and self-reports of self-effi-
cacy and the HHS at posttest 1, the groups differed only
with respect to walking and stair climbing at posttest 2.
Except for walking distance, the differences between the
groups in the outcome measures were small at posttest 1.
The scores on several measures of both groups were rela-
tively high at all times of assessment. Therefore, ceiling
effects may have appeared. The activities listed in the
questionnaires as well as the performance-based measures
might have been too easy or unsuitable for our patients
being examined several months after surgery.
The physiotherapist’s supervision and guidance was an
important integrated part of the program, but it is well
known that attention alone may have a substantial effect
422
(45). This issue has to be kept in mind when interpreting
the data. Furthermore, missing data are a concern for re-
searchers because no statistical method will ever be able to
replace missing information (46). However, only 4 patients
dropped out, and they were likely to be missed at random
and not threatening our randomization. The last observa-
tion carried forward is widely used in clinical trials (46),
and it is not likely to overestimate the effects in our study
because all of the patients improved during the study
period. Some uncertainty is related to the results of self-
reports, but the primary outcome is not affected by this
and is considered to be robust.
Another important issue is the external validity of the
study. The patients in the catchment area of the hospitals
tend to have a higher educational level than the general
Norwegian population (47). However, educational level
did not influence the effect estimates when included as a
covariate in our statistical model. More patients were op-
erated on at the hospitals during the inclusion period than
we have data from. In most cases these patients did not
fulfill the inclusion criteria, but there were also some not
asked because of a busy clinical time schedule. However,
these patients are likely to be missed at random and
should not cause any skewness in our data material. Those
who were lost from preoperatively to 3 months postoper-
atively or declined to participate in the training study had
worse preoperative scores than the participants, and they
may also have been worse after surgery. It is probably a
methodologic problem in most training studies that the
unmotivated and less healthy people decline to partici-
pate. Our patients had a rather normal body mass index,
which is in line with our impression that obesity is not
necessarily typical among Norwegian patients receiving
THA. Altogether we believe that our results can be gener-
alized to relatively healthy, motivated, and nonobese pa-
tients who have undergone THA.
In conclusion, the walking skill training program per-
formed 3 to 5 months after THA was effective in improving
physical functioning, especially walking distance, and the
effect on walking distance and stair climbing still persisted
12 months after surgery in relatively healthy and nonobese
patients. No adverse events occurred, and the weight-bear-
ing training was well tolerated by the patients.
ACKNOWLEDGMENTS
We would like to thank physiotherapist Mary Deighan
Hansen at Martina Hansens Hospital and physiotherapist
Anne Gunn Kallum at Bærum Hospital, Vestre Viken Hos-
pital Trust, for their efforts in recruiting the patients, per-
forming the measurements, and collecting the data. We
also thank the physiotherapy staff at Martina Hansens
Hospital and Bærum Hospital, Vestre Viken Hospital
Trust, for their support and the patients for their partici-
pation.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be published. Ms Heiberg had full
Heiberg et al
access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.
Study conception and design. Heiberg, Bruun-Olsen, Mengshoel.
Acquisition of data. Heiberg, Bruun-Olsen.
Analysis and interpretation of data. Heiberg, Ekeland, Meng-
shoel.
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