Arthritis Care & Research

Vol. 68, No. 4, April 2016, pp 454–462

DOI 10.1002/acr.22679
C 2016, American College of Rheumatology
V

ORIGINAL ARTICLE

Physical Functioning and Prediction of Physical

Activity After Total Hip Arthroplasty: Five-Year
Followup of a Randomized Controlled Trial
KRISTI E. HEIBERG AND WENDER FIGVED

Objective. To examine whether the 1-year effects from a previous walking skill training program on walking and
stair climbing still persist 5 years following total hip arthroplasty (THA), to examine recovery of physical functioning
from before to 5 years after surgery, and to identify predictors of physical activity 5 years after THA from preopera-
tive measures.
Methods. We performed a 5-year followup of a randomized controlled trial and a longitudinal study. Sixty partici-
pants with a mean age of 70 years (range 50–87 years; 95% confidence interval 68, 72 years) were assessed. Outcome
measures were the 6-minute walk test, the stair climbing test (SCT), active hip range of motion (ROM), self-efficacy,
Hip Dysfunction and Osteoarthritis Outcome Score (HOOS), and University of California, Los Angeles (UCLA) activity
scale. Data were analyzed by Student’s t-tests, generalized linear model, and multivariate regression analyses.
Results. The training and control groups were approximately equal on outcome measures of physical functioning,
pain, and self-efficacy at 5 years (P > 0.05). In the total group, the recovery course was unchanged from 1 to 5 years
(P > 0.05), except for 9% improvement in ROM (P < 0.001) and an increase in time on SCT of 18% (P 5 0.004). Preop-
erative HOOS pain (P 5 0.022) and HOOS sport (P 5 0.019) predicted UCLA activity scale 5 years after THA.
Conclusion. At 5 years after THA, the control group had caught up with the training group on physical functioning,
and the participants led an active lifestyle. Those with worse preoperative scores on pain and physical functioning in
sport were at risk of being less physically active in the long term following THA.

INTRODUCTION enable patients to regain a physically active lifestyle (7).

Total hip arthroplasty (THA) is one of the most widely
used and successful orthopedic procedures (1), with more
than 80,000 implants yearly in the UK and 8,000 implants
yearly in Norway (2,3). The 15-year survival of the pros-
theses with revision as an end point is 87% in Norway (4).
The procedure is the advised course of action for people
with hip osteoarthritis (OA) when conservative treatment
is no longer effective on physical functioning and pain (5).
Traditionally, physiotherapy has been a common prac-
tice after THA (6). The overall aim of physiotherapy is to
optimize functional outcomes like walking and thereby
Dutch trial registry: NTR262, NTR265.
Supported by Vestre Viken Hospital Trust.
Kristi E. Heiberg, RPT, PhD, Wender Figved, MD, PhD:
Baerum Hospital, Vestre Viken Hospital Trust, Drammen,
Norway.
Address correspondence to Kristi E. Heiberg, RPT, PhD,
Vestre Viken, Baerum Hospital, Department of Medical
Research, 3004 Drammen, Norway. E-mail: kristi.elisabeth.
heiberg@vestreviken.no.
Submitted for publication January 21, 2015; accepted in
revised form July 21, 2015.
No evidence-based clinical guidelines exist with recom-
mendations or consensus on the best exercise program
after discharge from the hospital (8), but a 2009 systematic
review stated there is a lack of interventions that include
functional exercises (6). We therefore developed, con-
ducted, and examined the effects of a supervised walking
skill training program (9). The program, performed
between 3 and 5 months after THA in only weight-bearing
positions, consisted of usual ambulatory activities. It
aimed at improving walking, muscle strength, flexibility,
balance, and endurance. We found effects on several out-
come measures of physical functioning and self-efficacy
immediately after the intervention. The effect persisted
1 year after surgery on walking and stair climbing (9).
A recent systematic review by Di Monaco and Castiglioni
(10) included 9 randomized controlled trials (RCTs) that
examined the effect from exercise on physical functioning
after THA. Only the study by Liebs et al (11) examined
effects beyond 1 year. Early ergometer cycling and usual
physiotherapy compared to usual physiotherapy alone
were effective on Western Ontario and McMaster Univer-
sities Osteoarthritis Index (WOMAC) physical function
(the primary outcome) and stiffness 2 years after THA

454
Five-Year Followup of THA and Physical Activity
Significance & Innovations
 The control group caught up with the training
group in physical functioning 5 years after total hip
arthroplasty (THA).
 Although the participants were 4 years older and
had more osteoarthritis in their knees and contra-
lateral hip, their outcomes in physical functioning
were sustained from 1–5 years.
 Training in weight-bearing walking activities is
safe in the long term and can be recommended for
clinical use.
 Better preoperative scores on pain and physical
functioning in sport before surgery predict an active
lifestyle 5 years after THA.
(11). Although long-term followup is important, to explore
whether the effect from interventions persists and to
reveal possible adverse effects, it is still rare.
Many patients continue to have functional limitations,
such as muscular weakness and slower walking speed
than healthy older adults, for several months or years after
THA (5,12). In a longitudinal study, we found that our
participants improved in all of the outcome measures dur-
ing the first year (13), but they did not quite reach the level
of healthy peers in walking capacity (14,15). In line with
this, we found that they still desired to improve their abil-
ity to walk and participate in recreational activities 1 year
after THA (16). Patients’ desires are poorly understood
and have received relatively little evaluation (17). How-
ever, prior research has revealed that patients express
increasing expectations regarding physical activity and
sport participation after surgery (18), and regular physical
activity is considered to be one of the most important
lifestyle behaviors affecting health (19,20). Few studies
have examined the recovery of physical functioning and
impact on physical activity level several years after sur-
gery. With regard to physical functioning, both Nilsdotter
and Isaksson (21) and Gould et al (22) reported worse
scores from 1–7 years and from 5–8 years to 12–16 years
after THA, respectively, and these scores were worse than
those of reference groups (21,22). However, Vissers et al
(23) reported improvements in physical functioning from
6 months to 4 years, despite the fact that the actual level of
physical activity did not change. Therefore, it remains
unclear what to expect in the long term following THA
regarding level of physical functioning and physical activ-
ity, and the connection between these outcomes. There-
fore, we decided to include a measure of physical activity
in the long-term followup.
For health professionals and participants, in order to
give realistic information, set attainable therapeutic goals,
and provide adequate advice and treatment, it is impor-
tant to know whether the participants’ preoperative physi-
cal functioning outcomes are of any significance to their
long-term level of physical activity. A recent study found
that predictors of high physical activity at 5 years after
455
THA were younger age, male sex, lower body mass index
(BMI), and an active lifestyle prior to surgery (24). We pre-
sumed that preoperative pain and physical functioning,
such as walking capacity and sport participation, also
relate to long-term activity level, and we entered these var-
iables as plausible predictive factors in a regression model
together with personal characteristics.
The aims of this followup study of participants 5 years
after THA were threefold: 1) to examine long-term effects
from a supervised walking skill training program on
walking, stair climbing, hip range of motion (ROM), and
self-reported physical functioning, pain, and self-efficacy
compared to a control group without supervised physio-
therapy; 2) to examine recovery on physical functioning
from before surgery to 5 years after THA; and 3) to identify
predictors of physical activity outcome 5 years after THA
among personal and preoperative variables.
PATIENTS AND METHODS
Study design and participants. We performed a long-
term followup study of a single-blind RCT (9) and a longi-
tudinal study of the recovery course (13). The participants
were recruited consecutively to the previous studies from
2 hospitals on the day before THA surgery from October
2008 to March 2010, a mean of 4.7 years prior (95% confi-
dence interval [95% CI] 4.6, 4.8 years).
Inclusion criteria were scheduled primary THA for OA
and residence within a radius of approximately 30 km
from the hospital to facilitate participation in a training
group. Patients were excluded if they had neurologic dis-
ease, dementia, heart disease, drug abuse, inadequate abil-
ity to read and understand Norwegian, or OA in at least
one knee or in the contralateral hip that restricted walking.
Assessments were performed before surgery and 3 months,
5 months, 1 year, and 5 years following THA. Detailed
information regarding the sample size estimation and ran-
domization process was reported in a previous article (9).
Ninety-two participants were included in the study
before surgery, 68 were randomized at 3 months, and 64
were assessed 1 year after THA. These 64 participants
received written information about the 5-year followup
study and an invitation to participate by telephone. Those
who approved gave their written consent for participation
in the followup study. Assessments were conducted from
May to August 2014. A physiotherapist blinded to group
allocation performed all measurements. The study was
conducted in compliance with the Helsinki Declaration,
and formal approval was given by the Regional Committee
for Medical Research Ethics.
Surgery and postoperative physiotherapy. The partici-
pants were operated on with either a Spectron (Smith &
Nephew) or an Exeter (Stryker) cemented THA using a
posterior surgical approach. There were no restrictions on
weight bearing after surgery, but to prevent dislocation par-
ticipants were instructed to avoid hip flexion beyond 90
degrees, and hip adduction and internal rotation beyond
the neutral position, for 3 months.
456
During the hospital stay, all participants received daily
routine physiotherapy care for approximately 30 minutes
(9). Between discharge and 3 months postoperatively, par-
ticipants reported in training logs that they did home exer-
cises and walked more than twice a week. Seventy-three
percent of the participants went to outpatient physio-
therapy, and approximately 50% of these participants
received more than 13 sessions.
Intervention. The walking skill training program con-
ducted between 3 and 5 months after THA was led by a
physiotherapist. The participants exercised for 12 super-
vised sessions, 70 minutes per session, twice a week. There
were 2–8 participants in the group, depending on the
number allocated at the relevant time. The walking skill
training program consisted of ambulatory activities like
sit-to-stand, stair climbing, walking in different ways, obsta-
cle course, lunges, squats, balance exercises, step up/step
down, and throwing a ball while moving around (9). Two
main principles were followed: to train neuromuscular func-
tioning by doing several repetitions of the ambulatory tasks
and activities, and to relearn adequate movement patterns
from the physiotherapist’s guidance and feedback. During
the sessions, the physiotherapist adjusted the program on an
individual level.
The control group was not allowed to attend supervised
physiotherapy during the same period between 3 and 5
months after THA, but they were encouraged to continue
training on their own and to keep generally active.
Measures of physical functioning, pain, self-efficacy,
and physical activity performed 5 years after THA. The
6-minute walk test (6MWT), which was the primary out-
come, measures the distance in meters walked indoors on
a flat floor for 6 minutes (25). The participants walked
back and forth along a 40-meter hospital corridor at a com-
fortable speed (26). The 6MWT is a measure of submaxi-
mal exercise capacity (25) in subjects with OA and THA
and is found to be reliable and valid (27).
The stair climbing test (SCT) measures participants’
capacity to climb stairs. Participants ascend 8 steps and
descend 8 steps with a step height of 16 cm by alternating
legs as fast as they can without running. They are allowed to
support themselves by holding onto the stair rail, but with-
out using a walking aid. Time was registered in seconds.
Active hip ROM in flexion and extension was measured
in degrees by a goniometer in the supine position follow-
ing the procedures of Norkin and White (28). The flexion
and extension degrees were added and reported as one
measure of active hip ROM.
The 30-second chair stand test (CST) is a measure of
functional lower extremity strength and dynamic balance
through repeated sit-to-stand activity (29). The number of
times within 30 seconds that the participant succeeds in
standing upright from the chair (height 46 cm) with the
arms across the chest is registered. The 30-second CST is
considered to have good validity (30) and reliability (31).
The Hip Dysfunction and Osteoarthritis Outcome Score
(HOOS) LK 2.0 is a disease-specific questionnaire devel-
oped to evaluate self-reported problems with hip disabil-
ities in persons with hip OA and after THA (32). Five
Heiberg and Figved
subscales address symptoms, pain, activities of daily liv-
ing (ADL), functions of sport and recreation, and quality
of life (QOL). Each item scores from 0 (no symptoms) to 4
(extreme symptoms) and the scores range from 0 (worst)
to 100 points (best) (33). The questionnaire has adequate
measurement properties of validity, reliability, and res-
ponsiveness to change after THA (32,33). We applied the
Swedish HOOS, version 2.0 and translated it into Norwe-
gian according to a standard procedure (34). The Swedish
version is valid and responsive to change (32). The Scan-
dinavian countries Norway and Sweden are culturally
close; therefore, the psychometric properties of the Nor-
wegian version were not tested.
Self-efficacy for activities is best evaluated when the
questions are tailored to the particular domains of interest
(35). Ten questions about challenging everyday ambula-
tory activities were constructed. The questions were: “How
certain are you that you can climb two floors of stairs with-
out using a rail, walk 2 km in the woods at normal speed,
bend down, squat, kneel, go shopping in a crowd, avoid fall-
ing 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). In
our material, there was very good internal consistency reli-
ability of the responses to the items, with a Cronbach’s alpha
coefficient of 0.87.
The University of California, Los Angeles (UCLA) activ-
ity scale is a 10-point scale that evaluates persons’ activity
based on 10 descriptive activity levels ranging from
wholly inactive and dependent (level 1), to moderate
activities such as unlimited housework and shopping (lev-
el 6), to regular participation in impact sports such as jog-
ging or skiing (level 10) (36). The scale is reliable, valid,
and adequate in persons with THA (18,37). We used a
Norwegian version translated from English according to a
standard procedure (34). The Norwegian version has not
been tested for reliability and validity.
Characteristics of the participants reported at 5 years are
age, sex, educational level, cohabiting status, level of satis-
faction regarding the ability to participate in sport and rec-
reational activities, number of weekly training sessions,
recent falls, and complications, such as loosening of the
prosthesis or hip dislocations. Also, recent diagnosis of
OA in a knee and/or contralateral hip, set by a physician
according to the clinical criteria published by the Ameri-
can College of Rheumatology (38,39), is reported.
Statistical analyses. The data were analyzed using the
software application SPSS, version 18.0. Descriptive data
are reported as means with SDs or 95% CIs and as fre-
quencies. Parametric analyses were used, since the data
were mostly normally distributed.
The chi-square test and Yates’ correction for continuity
were used to analyze categorical data, and continuous
data were analyzed by Student’s sample t-tests. Differ-
ences between the groups from 3 months (baseline) to
5 years after surgery were examined by analysis of covari-
ance using a generalized linear model to control for base-
line scores and sex. The 5-year scores were entered as
dependent variables, and group (walking skill training
Five-Year Followup of THA and Physical Activity
Figure 1. Flow chart of the participants throughout the study.
group or control group), sex, and 3-month scores as
covariates.
Because there was only a minor effect from the walking
skill training program on walking after 1 year, we decided
to collapse the groups and report analyses of the total
group at 5 years. Changes in physical functioning and self-
efficacy over time in the total group were analyzed by
repeated-measures analysis of variance, with group
included as a covariate. If Mauchly’s test of sphericity was
violated, we applied a Greenhouse-Geisser correction.
Post hoc tests were run with Bonferroni corrections.
457
The differences between men and women were ana-
lyzed by independent-sample t-tests. The associations
between the different candidate predictors and between
the predictors and the 5-year UCLA score were analyzed
by Pearson’s correlation analysis. Candidate predictors for
the regression analysis were sex and variables that showed
significant correlations (P # 0.05) in the bivariate analysis
to the outcome in the UCLA activity scale at 5 years. These
variables were included in a multiple regression analysis.
The scatter plots of the distribution of the residuals for the
model were acceptable. The regression coefficients are
458 Heiberg and Figved

Table 1. Characteristics of the participants 5 years after total hip arthroplasty*

Training group Control group

(n 5 30) (n 5 30)

Age, mean 6 SD years 70.2 6 6.5 70.6 6 8.4

Women 21 (70.0) 13 (43.3)
Men 9 (30.0) 17 (56.7)
Educational level #12 years 13 (43.3) 13 (43.3)
Educational level .12 years 17 (56.7) 17 (56.7)
Exeter prosthesis 21 (70.0) 23 (76.7)
Spectron prosthesis 9 (30.0) 7 (23.3)
Married/cohabiting 22 (73.3) 21 (70.0)
Osteoarthritis in knees and/or contralateral hip 13 (43.4) 8 (26.7)
Satisfied/very satisfied with ability to participate in 28 (93.3) 27 (90.0)
sport and recreational activities
Aseptic loosening of the prosthesis 0 (0.0) 0 (0.0)
No. of participants reporting a fall during the 7 (23.3) 9 (30.0)
last 6 months
No. of training sessions per week, mean 6 SD 3 6 0.8 3 6 1.0
UCLA activity scale, mean 6 SD score 8 6 1.3 7 6 1.9
30-second chair stand test, mean 6 SD repetitions 12 6 3.7 12 6 4.6

* Values are the number (percentage) unless indicated otherwise. There were no statistically signifi-
cant group differences. UCLA 5 University of California, Los Angeles.

reported with 95% CIs. A P value of 0.05 or less was con-
sidered statistically significant.
RESULTS
Participant flow throughout the RCT is shown in Figure 1.
Sixty-eight participants were randomized. Four were lost
to followup at 1 year after surgery, and 4 more at 5 years; 1
participant had died, 1 had psychological problems, 1 had
a recent leg fracture, and 1 withdrew from the trial. There
were no statistically significant differences preoperatively
between the 8 dropouts and those assessed at 5 years (P .
0.05). At 5-year followup, 60 participants (34 women and
26 men) were assessed. Mean age was 70 years (range 50–
87 years [95% CI 68, 72 years]). Characteristics of the par-
ticipants are shown in Table 1.
Long-term effects of the walking skill training program
on physical functioning, self-efficacy, and physical activity.
Both groups improved from 3 months to 5 years on most of
the outcome measures (P , 0.05), except on stair climbing

Table 2. Long-term effects of a walking skill training program in participants with total hip arthroplasty (n 5 60)*

Training group (n 5 30), Control group (n 5 30),

mean (95% CI) mean (95% CI) Adjusted differences between
groups from 3 mos to 5 years,
3 mos 5 years 3 mos 5 years mean (95% CI)†

Performance-based measures
6MWT, meters 419 (390, 447) 524 (483, 564)‡ 449 (418, 481) 530 (487, 573)‡ 13 (233, 59)
SCT, seconds 13 (12, 15) 13 (11, 15) 12 (11, 13) 13 (11, 15) 21 (23, 1)
Active hip ROM, 8 85 (80, 90) 104 (99, 109) 85 (81, 88) 100 (94, 106) 2 (26, 10)
Self-reported measures
Self-efficacy 69 (61, 77) 87 (83, 92)§ 78 (72, 85) 87 (79, 96)‡ 5 (24, 14)
HOOS symptoms 75 (70, 79) 84 (79, 89)¶ 79 (76, 83) 88 (83, 92)§ 0 (27, 6)
HOOS pain 84 (79, 89) 92 (87, 96)¶ 91 (87, 94) 95 (91, 98) 21 (26, 5)
HOOS ADL 80 (76, 84) 90 (87, 94)‡ 87 (84, 90) 93 (89, 97)§ 1 (24, 6)
HOOS sport 59 (51, 66) 75 (69, 82)‡ 69 (62, 77) 82 (75, 90) 21 (210, 8)
HOOS QOL 66 (58, 73) 85 (80, 90)‡ 72 (66, 78) 84 (78, 90) 5 (23, 12)

* No between-group differences were found (P . 0.05). 95% CI 5 95% confidence interval; 6MWT 5 6-minute walk test; SCT 5 stair climbing test;
ROM 5 range of motion in hip flexion and extension; HOOS 5 Hip Dysfunction and Osteoarthritis Outcome Score; ADL 5 activities of daily living;
QOL 5 quality of life.
† The data are adjusted for sex and 3-month (baseline) scores.
‡ Within-group differences from 3 months to 5 years at the 0.1% level.
§ Within-group differences from 3 months to 5 years at the 5% level.
¶ Within-group differences from 3 months to 5 years at the 1% level.
Five-Year Followup of THA and Physical Activity 459

Table 3. Long-term recovery of physical functioning in patients from before surgery to 3 months, 1 year, and 5 years after
total hip arthroplasty (n 5 60)*

Overall Differences
5 years time before Differences Differences
Before 3 mos after 1 year after after effect, surgery to 3 mos to 1 to 5
surgery surgery surgery surgery P 3 mos, P 1 year, P years, P

Performance-based
measures
6MWT, meters 398 434 509 527 , 0.001 0.024 , 0.001† 0.603
(373, 423) (413, 455) (487, 532) (498, 556)
SCT, seconds 14 (13, 16) 12 (12, 13) 11 (10, 12) 13 (11, 14) , 0.001 0.090 , 0.001 0.004
Hip ROM, 8 82 (78, 86) 85 (82, 88) 94 (91, 98) 102 (98, 106) , 0.001 0.938 , 0.001 , 0.001
Self-reported measures
Self-efficacy 57 (52, 62) 74 (69, 79) 86 (81, 90) 87 (83, 92) , 0.001 , 0.001 , 0.001 1.000
HOOS symptoms 49 (45, 53) 77 (74, 80) 86 (83, 89) 86 (83, 89) , 0.001 , 0.001 , 0.001 1.000
HOOS pain 53 (49, 56) 87 (84, 91) 94 (92, 96) 93 (91, 96) , 0.001 , 0.001 0.001 1.000
HOOS ADL 57 (53, 61) 84 (81, 86) 91 (89, 94) 92 (89, 94) , 0.001 , 0.001 , 0.001 1.000
HOOS sport 36 (30, 41) 64 (59, 69) 79 (73, 84) 79 (74, 84) , 0.001 , 0.001 , 0.001 1.000
HOOS QOL 31 (27, 35) 69 (64, 74) 82 (78, 86) 85 (81, 88) , 0.001 , 0.001 , 0.001 1.000

* Values are the mean (95% confidence interval) unless indicated otherwise. 6MWT 5 6-minute walk test; SCT 5 stair climbing test; ROM 5 range
of motion in hip flexion and extension; HOOS 5 Hip Dysfunction and Osteoarthritis Outcome Score; ADL 5 activities of daily living; QOL 5 quality
of life.
† Significant interaction between the 6MWT and the exercise variable (P 5 0.017).

and hip ROM for both groups and on HOOS pain, sport,
and QOL in the control group (P . 0.05) (Table 2).
There were no statistically significant differences
between the groups in change from 3 months (baseline) to
5 years after surgery on any outcome measures of physical
functioning, pain, or self-efficacy (P . 0.05) (Table 2), nor
were there any statistically significant differences between
the groups when we adjusted for OA in another joint (P .
0.05) (data not shown). At 5 years following THA, there
were no statistically significant differences between the
groups on 30-second CST, UCLA activity scale, number
of weekly training sessions, number of participants
who were satisfied/dissatisfied with ability to participate
in recreational activities, or number of recent falls (P .
0.05) (Table 1). None reported aseptic loosening of the
prosthesis.
Long-term recovery of physical functioning and self-
efficacy in the total group. From before surgery to 5 years
after surgery, there were statistically significant overall
time effects on all outcome measures (P , 0.001). From
1–5 years, time on SCT increased by a mean of 18%
(P 5 0.004), while hip ROM improved by 9% (P , 0.001).
There were no statistically significant differences in
the other outcome measures from 1–5 years (P . 0.05)
(Table 3).
Predictors of physical activity 5 years after THA.
There were statistically significant differences between
men and women on preoperative scores of the 6MWT
(P 5 0.038), SCT (P 5 0.045), self-efficacy (P , 0.001),
HOOS ADL (P 5 0.023), and HOOS sport (P 5 0.010). In
the regression model, we included sex and preoperative

Table 4. Bivariate correlation matrix between the UCLA activity scale at 5 years and the control variables and plausible
preoperative predictive variables in patients with total hip arthroplasty (n 5 60)*

UCLA score HOOS HOOS HOOS

at 5 years 6MWT STC Hip ROM Self-efficacy pain ADL sport BMI

Age 20.26† 0.01 0.05 0.11 20.06 0.17 0.09 0.05 20.21
BMI 20.08 20.22 0.16 20.35‡ 20.10 20.18 20.29† 20.13
HOOS sport 0.32‡ 0.42§ 20.42§ 0.10 0.56§ 0.57§ 0.68§
HOOS ADL 0.05 0.47§ 20.41§ 0.10 0.63§ 0.72§
HOOS pain 0.02 0.40§ 20.31‡ 0.22 0.48§
Self-efficacy 0.23 0.56§ 20.50§ 0.06
Hip ROM 0.14 0.37‡ 20.24†
SCT 20.38‡ 20.57§
6MWT 0.42§

* Values are by Pearson’s correlation coefficients. UCLA 5 University of California, Los Angeles; 6MWT 5 6-minute walk test; STC 5 stair climbing
test; ROM 5 range of motion in hip flexion and extension; HOOS 5 Hip Dysfunction and Osteoarthritis Outcome Score; ADL 5 activities of daily
living; BMI 5 body mass index.
† P , 0.05.
‡ P , 0.01.
§ P , 0.001.
460
Table 5. Preoperative predictors of UCLA activity scale outcome in participants at 5 years after total hip
arthroplasty (n 5 60)*
Crude estimates
B (95% CI)
Age, years 20.057 (20.113, 20.001)
Sex (women [ref.]/men) 0.206 (20.654, 1.065)
Body mass index 20.029 (20.131, 0.073)
Preoperative variables
6MWT 0.007 (0.003, 0.011)
SCT 20.103 (20.170, 20.037)
HOOS pain 0.002 (20.026, 0.030)
HOOS sport 0.023 (0.005, 0.041)
* Unstandardized b, 95% confidence interval (95% CI), and P value given for crude and adjusted estimates in the multiple regression analyses.
The total model explained 26% of the variance in the University of California, Los Angeles (UCLA) activity scale 5 years after total hip arthro-
plasty (adjusted R2 5 0.26). 6MWT 5 6-minute walk test; SCT 5 stair climbing test; HOOS 5 Hip Dysfunction and Osteoarthritis Outcome Score.
age, BMI, and HOOS pain. These variables, and the preop-
erative variables of physical functioning, which were sta-
tistically significantly correlated with UCLA activity scale
5 years after THA (Table 4), were included in the multiple
regression analysis. Preoperative HOOS pain (P 5 0.022)
and HOOS sport (P 5 0.019) were associated with outcome
in UCLA activity scale 5 years after THA, and the total
adjusted model explained 26% of the variance in UCLA
activity scale at 5 years (P 5 0.002) (Table 5).
DISCUSSION
At 5-year followup, the control group had caught up with
the level of the walking skill training group on outcome
measures of physical functioning and self-efficacy. The
outcome scores of the total group were approximately sim-
ilar to those at 1 year after THA. Preoperative measures of
pain and function in sport explained 26% of the variance
in physical activity level 5 years after THA.
Training walking skills in only weight-bearing positions
between 3 and 5 months after surgery seems safe in the
long term, since we found no adverse effects, such as pain
and loosening of the prosthesis, at 5 years. This study may
be the first to examine the effect from exercise on physical
functioning with followup exceeding 2 years after THA. In
our prior study, the training group had a more rapid
improvement than the control group on walking skills
throughout the first year after THA (9). However, some-
time between 1 and 5 years, the control group obtained
the gap. This may be related to the equal amount of regular
weekly training, since the training group no longer exer-
cised more frequently than the control group at 5-year fol-
lowup. Consequently, it seems that the walking skill
training program failed to establish a more active lifestyle
among the participants. Liebs et al (11) found that the
effects from early ergometer cycling were sustained after 2
years. Different length of followup probably explains the
discrepancy in results between these studies. In addition,
a sport activity, such as cycling, may have better potential
to inspire participants to maintain the activity on a regular
basis than repetitive physical exercises. A clinical impli-
cation may be to include physical activities in therapy
Heiberg and Figved
Adjusted estimates
P b (95% CI) P
0.046 20.036 (20.090, 0.184) 0.184
0.633 20.342 (21.186, 0.502) 0.419
0.568 0.005 (20.103, 0.094) 0.923
0.001 0.005 (0.000, 0.010) 0.072
0.003 20.051 (20.131, 0.029) 0.207
0.905 20.039 (20.073, 20.006) 0.022
0.014 0.028 (0.005, 0.052) 0.019
that motivate the participants to adopt a more active
lifestyle.
In the total group at 5 years, the participants’ outcome
scores were approximately the same as at 1 year after
THA, except with an increased hip ROM. In walking, a
decrease is expected with increasing age (14,40,41) and
would have been reasonable, since 35% reported that they
recently had been diagnosed with OA in the knees or con-
tralateral hip. In line with this, the participants’ ability to
climb stairs decreased from 1–5 years. Vissers et al (23)
reported a better 6MWT score at 4 years than we found at
5 years. However, they reported a worse score on HOOS
sport than ours. This discrepancy may be explained by
their lower participant number on 6MWT than on HOOS
sport, which may indicate that those most impaired were
only assessed by the self-reports and not by the functional
capacity tests. In our study, all participants performed all
of the tests. Our 5-year scores on 30-second CST reached
the level of reference standards (42), and the HOOS ADL
scores were approximately at the same level as the 2-year
WOMAC scores reported by Liebs et al (11), both exceed-
ing 90% of maximal scores. Furthermore, the high UCLA
scores, which nearly reached the level of healthy adults
with no hip or knee pathology (43), indicate that our par-
ticipants are physically active to very active (44). Prior
studies revealed a more moderate activity level after THA
(44–47). Summarized at 5 years, the participants are gen-
erally well recovered on measures of physical functioning,
and their level of physical activity tends to be even higher
after THA than reported in prior studies.
Today, many patients choose THA for OA, hoping to
restore ability to participate in demanding physical activi-
ties (48). In contrast to L€ubbeke et al (24), we found that
age, sex, and BMI could not predict long-term level of
physical activity, while preoperative pain and function in
sport matter. Vissers et al (23) revealed that their healthy
patient population improved in physical functioning fol-
lowing THA, but they did not adopt a more active life-
style. In line with this, our results may underpin that
lifestyle behaviors are difficult to change, since worse pre-
operative function in sport predicts a low level of physical
activity 5 years after THA. The model explained 26% of
Five-Year Followup of THA and Physical Activity
the variance in physical activity level. Different psycho-
logical and social aspects probably also contribute to the
variance (49).
These findings should be interpreted in the context of
the limitations of the study. We have no data between 1
and 5 years after surgery and may have missed a peak of
physical functioning during this time span. More frequent
measuring of time points would have provided a more
accurate description of the recovery course and should be
included in future studies. Furthermore, we could not
measure the change in physical activity level, since we
have no preoperative or 1-year data of physical activity.
Instead of using the self-reported UCLA activity scale,
accelerometers would have given more accurate and
objective measures of physical activity not dependent on
participants’ considerations and memory. The Norwegian
version of the UCLA activity scale is not tested for validity
and reliability. Some cultural differences regarding which
activities Americans and Norwegians prefer to attend may
exist. For example, many Norwegians like to go for walks
in the forest and mountains, while only a few are active
bowlers. The dropout rate in the RCT was 12% at 5 years.
We consider this to be an acceptable dropout rate after
such a long period. The dropouts probably are not related
to the intervention. Therefore, we decided to analyze and
report only the data from those participants actually
assessed at the 5-year followup.
We discussed external validity in the prior studies and
concluded that the results can be generalized to other rela-
tively healthy, motivated, and nonobese patients with
THA (9,13). Presently in this study, the high level of phys-
ical activity that approached the level of healthy peers
underpins this (43).
In conclusion, this 5-year followup after THA showed
that the control group had caught up with the training
group on physical functioning outcomes. Despite higher
age and incidence of OA, the outcomes in physical func-
tioning from 1 year were sustained and they led an active
lifestyle. Those at risk of being less physically active 5
years after THA had more pain and impaired physical
functioning in sport before surgery. Whether interventions
could be more focused on physical activities rather than
exercises in order to increase long-term level of physical
activity is a topic for future research.
ACKNOWLEDGMENT
The authors would like to thank Liv Marie F. Odland,
RPT, MSc, at Baerum Hospital Vestre Viken Hospital
Trust, for her effort in performing all of the measurements
and collecting the data of this 5-year followup study.
AUTHOR CONTRIBUTIONS
Both authors were involved in drafting the article or revising it
critically for important intellectual content, and both authors
approved the final version to be submitted for publication. Dr.
Heiberg had full 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.
461
Study conception and design. Heiberg, Figved.
Acquisition of data. Heiberg.
Analysis and interpretation of data. Heiberg, Figved.
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