971314

research-article2020
HPI0010.1177/1120700020971314HIP InternationalColibazzi et al.

Original Research Article

HIP HIP
International

HIP International

Evidence based rehabilitation after

2020, Vol. 30(2S) 20­–29
© The Author(s) 2020
Article reuse guidelines:
hip arthroplasty sagepub.com/journals-permissions
https://doi.org/10.1177/1120700020971314
DOI: 10.1177/1120700020971314
journals.sagepub.com/home/hpi

Virginia Colibazzi1, Adriano Coladonato1, Milco Zanazzo2

and Emilio Romanini3,4

Abstract
Background: Hip arthroplasty is considered the treatment of choice to improve the quality of life of patients affected
by degenerative arthritis. The post-op rehabilitation regimen, however, is still a matter of debate. The goal of this study
was to perform a systematic review of the available best evidence to provide recommendations for rehabilitation after
hip arthroplasty.
Materials and methods: Biomedical databases were accessed to identify guidelines, systematic reviews and randomised
controlled trials addressing rehabilitation after hip arthroplasty published between 2004 and 2019. Studies were selected
and extracted by two independent evaluators with standardised tools.
Results: 1 guideline, 8 systematic reviews and 5 randomised controlled trials were included. All included papers were
organised according the available evidence of clinical course chronology both in pre- and post-operation rehabilitation up
to 6 weeks and thereafter. Although the value of a rehabilitation program after hip arthroplasty is universally recognised,
the exact timing and number of sessions is still unknown. A solid literature review allows us to partially answer to this
question.
Conclusions: Evidence-based rehabilitation recommendations are proposed according to literature research findings.
Clinical practice is still somewhat dependent on dogma and traditions, highlighting the need for additional high-quality
clinical studies to address areas of uncertainty.

Keywords
Evidence-based medicine, guidelines, hip arthroplasty, rehabilitation, systematic review

Date received: 23 May 2020; accepted: 16 September 2020

Introduction term;5 however, clinical series describe persistence of

Prevalence of hip osteoarthritis changes depending on the
type of study and diagnostic criteria: 3–6% of the adult
European population suffers from symptoms in some way
related to arthritis and this data will increase in the future
because of population ageing.
Arthroplasty is considered the solution for advanced
degeneration of the hip joint and is 1 of the most widely
practised surgeries across the whole world which aims to
to reduce pain, increase mobility and functionality as well
as to increase quality of life.1–3
Over 100,000 primary hip procedures were performed
in Italy in 2018 in 750 hospitals, with a total expense of
over 1,000,000 Euro for the surgical DRG (diagnosis
related group) only, with an annual increase of almost 3%.4
Studies focusing on quality of life as an endpoint report
general satisfaction of patients and surgeons in the short
pain, deficit in range of motion or in strength and func-
tional limitations, including speed of gait and postural sta-
bility up to 1 year post operation in a small percentage of
patients.6,7 Other authors have shown weakness of the hip
muscles up to 2 years from surgery, even if gait pattern is
normal. This weakness seems to influence static and
1
F isiogruppo, Rome, Italy
2
Azimut Rehabilitation, Biella, Italy
3
Centre for Hip and Knee Arthroplasty, Polo Sanitario San Feliciano,
Rome, Italy
4
GLOBE, Evidence Based Orthopedics Working Group, Rome, Italy
Corresponding author:
Virginia Colibazzi, Fisiogruppo, Via della Stazione Ostiense 27, Rome,
00154, Italy.
Email: virginia.colibazzi@gmail.com
Colibazzi et al.
dynamic balance and could be a major risk factor for falls
in the elderly population.8
Some authors suggest that exercise in the first phases of
rehabilitation are not sufficient for patients to regain full
recovery of muscle function and postural stability and that
they should be continued for the whole first year.5
Today, even if rehabilitation is considered an important
factor in postoperative recovery, it is not clear what type of
exercises and what timing is necessary to improve out-
come in the short and medium term, or to enhance inde-
pendence and quality of life for patients.
Since the guidelines and protocols are not based on evi-
dence but mostly on clinical expertise, we have conducted
a systematic review of the existing literature to collate the
best evidence and to create a rehabilitative protocol based
on this.
Materials and methods
Research strategy
PubMed, PEDro and TRIP databases were searched (time
limit: last 15 years publications from April 2004 to
November 2019). A combined search strategy of subject
words and random words was adopted, including the fol-
lowing keywords: “hip arthroplasty”, “hip prosthesis” or
“hip replacement” with “rehabilitation” “exercise”, “phys-
ical therapy”, and “physiotherapy”.
Inclusion/exclusion criteria
Articles identified were independently analysed by 2
assessors.
Studies were included if they matched the following
criteria:
•• guidelines, systematic reviews and randomised
controlled trials
•• unilateral arthroplasty performed for osteoarthritis
•• surgery performed through antero, antero-lateral,
lateral or posterior approach
•• paper published in Italian, English, French or
Spanish
•• sample >30 patients.
All criteria not stated can be considered exclusion criteria.
Methodological quality evaluation
The PEDro rating scale was used to evaluate the methodo-
logical quality of the RCTs.9 PEDro is an 11 items scale
designed to measure the internal validity (criteria 2–9) and
statistical data (criteria 10–11) of a clinical study. An addi-
tional criterion (criterion 1) relating to external validity,
was not used to calculate the PEDro score. In order to
21
include only literature of good methodological quality,
articles with a PEDro score <6/10 have been excluded.
AMSTAR 2 scale was adopted for the quality assess-
ment of systematic research.10 AMSTAR 2 is a 16-item
tool, updated from the original version in 2017; the purpose
of the tool is to assist decision makers in the identification
of high quality systematic reviews, including those based
on non-randomised studies of healthcare interventions.
The selected studies were then extracted according to
the type of study, surgical approach, proposed physiother-
apy interventions, outcome measures, results, authors’
conclusions and/or any proposed rehabilitation protocol.
Research strategy, paper selection, methodological
quality evaluation and data extraction were conducted
independently by 2 evaluators (AC and VC) without any
previous consultation. Disagreements were discussed with
a third evaluator (ER).
Results
A systematic search of the available evidence led to the
identification and inclusion of 1 guideline (GL), 8 system-
atic reviews (SRs), and 5 randomised controlled trials
(RCTs) (see Figure 1). The overall quality assessment of
the SR is between low (Di Monaco et al.,11 Wijnen et al.,12
Wu et al.13) and moderate (Hoogeboom et al.,14 Hansen
et al.,15 Minns Lowe et al.16) confidence intervals with
only 2 SRs occupying the extreme categories (high confi-
dence for Smith et al.17 2014 and the critically low confi-
dence for Lemney et al.18). According to the inclusion
criterion of the PEDro score > 6/10, all RCTs show a
moderate quality with 2 RCTs scored at 6/10 (Matheis
et al.,19 Winther et al.,20), 2 at 7/10 (Huang et al.,21 Vesterby
et al.22) and 1 at 8/10 (Busato et al.23).
Syntheses of SR is reported in Table 1.
Critical analysis of the findings of the included papers
is presented below, with evidence found being chronologi-
cally organised into preoperative phase, postoperative
acute phase (until 6 weeks) and postoperative functional
phase (after 6 weeks).
Preoperative phase
Preoperative education has been identified as an integrated
component of rehabilitation programs for patients under-
going hip arthroplasty. Education may include a descrip-
tion of the procedure, expected results and potential risks
and complications, treatment of symptoms, hospital dis-
charge and an early rehabilitation program if indicated.
Various tools are used, from simple booklets to detailed
manual and audiovisual supports.25,26
Patient expectations should be seriously considered
during this preoperative phase. Psychological preparation
is critical and should be assisted via an interview with
healthcare professionals.27
 22

Table 1. papers included in the systematic review.

Authors Type Therapeutic intervention examined Results Methodological

quality (A
Di Monaco et al.11 Review Type and timing of physiotherapy exercises after Insufficient data to elaborate a rehabilitation AMSTAR 2
9 studies hip arthroplasty programme Low confidence
Wijnen et al.12 SR Exercise intervention with usual care vs. two Insufficient therapeutic validity and potentially AMSTAR 2
20 studies different types of exercise intervention. Outcome: high risk of bias limit the ability to assess Low confidence
joint and muscle function, functional performance the effectiveness of physiotherapeutic
and self-reported outcomes, length of follow-up interventions following THA.
Wu et al.13 SR Efficacy of exercise on functional outcomes after Compared to control groups, postoperative AMSTAR 2
10 studies THA. Primary outcome: walking speed, Other exercise provides better pain relief and clinical Low confidence
441 patients outcomes: physical activity, HHS, pain score, outcomes (higher walking speed score and
abduction strength HHS)
Hoogeboom et al.14 Review Validity of preoperative rehabilitation programme None of the studies shows therapeutic efficacy AMSTAR 2
12 studies Moderate confidence
Hansen et al.15 SR Supervised vs. non-supervised physiotherapy Supervised exercise is not significantly effective AMSTAR 2
7 studies sessions for at least 6 weeks. Outcome: patient- compared to non-supervised home-based Moderate confidence
389 patients reported function, hip-related pain, HRQoL and exercise
performance-based function
Minns Lowe et al.16 Update of previous Physiotherapy exercise vs. usual/standard care. Low quality studies that do not allow the AMSTAR 2
review. Outcome: patient-reported function, muscle assumption of the efficacy of physiotherapy Moderate confidence
11 studies strength, hip ROM, QoL after hip arthroplasty
Smith et al.17 SR Effects of provision of devices, education on hip Insufficient evidence to support hip AMSTAR 2
3 studies precautions, environmental modifications and precautions with or without additional High confidence
492 patients training in activities of daily living. Outcomes: pain; equipment and functional restriction for
function; HRQoL; global assessment of treatment prevention of dislocation, neither supports
success; re-operation rate; hip dislocation; and nor refutes the adoption of a postoperative
adverse events community rehabilitation programme
Lemney et al.18 Review Early vs. late physiotherapy In early phases structured rehabilitation AMSTAR 2
13 studies is more effective to improve strength Critically low
and functionality. In the late phases home confidence
programmes can also be effective
Matheis et al.19 RCT Intervention group (IG) had intensified active Improvements in IG compared to CG were Pedro Scale 6/10
39 patients treatment with additional mobilisation and strength recorded in ROM (flexion p < 0.01, extension
training vs. control group (CG) that completed p < 0.001, abduction p < 0.01) and gait
standard physiotherapy. Outcomes: active ROM, performance (p < 0.001)
thigh circumference, holding force of the GM, 1-leg
stance, 6MWT and subjective parameters

(Continued)
HIP International 30(2S)
Table 1. (Continued)
Authors Type Therapeutic intervention examined
Winther et al.20 RCT Muscle strength training group (MST) trained at
60 patients 85–90% of their maximal capacity in leg press and
abduction of the operated leg, 3 times a week
up to 3 months postoperatively vs conventional
physiotherapy group (CP). Assessment pre-
intervention, at 3, 6, and 12 months postoperatively.
Primary outcomes: abduction and leg press strength
at 3 months, pain, 6MWT, HHS and HOOS
Huang et al.21 RCT Education empowerment group vs. standard care.
108 patients Outcomes: self-efficacy and self-care competences,
ADL, mobility, depressive mood and QoL).
Assessment at 1 day, 3–6 months post op
Vesterby et al.22 RCT All patients were subjected to fast track
72 patients rehabilitation; the intervention group had
telemedicine support in addition to standard care.
Outcomes: length of stay, HRQoL, hip function
(OHS), TUG, anxiety, pain (VAS) 1-year follow-up
Busato M et al.23 RCT Both groups followed a standard protocol based
51 patients on two daily sessions of active exercises for
45 minutes; 2 sessions were replaced with fascial
manipulation in the study group
Outcomes: HHS, TUG, ROM, and VNS.
Assessment before and after treatment and at the
end of rehabilitation programme (10 days)
Swierstra et al.24 Guideline Efficacy of therapies in the management of patients
before and after hip replacement
THA, total hip arthroplasty; CI, confidence interval; HHS, Harris Hip Score; HRQoL, health-related quality of life; ROM, range of motion; 6MWT, 6 minute walk test; TUG, Timed Up and Go test;
HOOS, Hip disability and Osteoarthritis Outcome Score; OHS, Oxford Hip Score; VAS, visual analogue scale; VNS, verbal numerical scale.
Results Methodological
quality (A
Colibazzi et al.
MST patients were substantially stronger in leg Pedro scale 6/10
press and abduction than CP patients at 3 and
6 months postoperatively (p < 0.002). 1 year
postoperatively, no intergroup differences
were found. No other statistically significant
intergroup differences were found
The education empowerment group Pedro 7/10
demonstrated significantly higher self-care
competence and self-efficacy and lower
depressive inclinations. No differences on
activities of daily life, mobility and QoL
between groups
Length of stay was reduced from 2.1 days (95% Pedro 7/10
CI: 2.0–2.3) to 1.1 day (CI: 0.9–1.4; p < 0.001)
No statistically significant differences between
groups in HRQoL TUG and OHS at 3-month
follow-up, nor in the rates of complications
and re-admissions at 12 months
Statistically significant differences observed Pedro 8/10
in degrees of flexion between the study and
control groups with 25.4 (±11.3) and 18.7
(±9.5) respectively (p = 0.04); for abduction
with 16.8 (±7.0) and 11.1 (±6.1) respectively
(p = 0.005); for extension with 16.2 (±4.9) and
9.3 (±3.8) respectively (p = 0.001); bilateral
external rotation with heels together with 8.3
(±4.3) and 5.5 (±4.6) respectively (p = 0.04);
HHS score 23.3 24 (±8.9) and 14.5 (±8.5)
respectively (p = 0.002); VNS score 1,1 (±2.1)
and 0,5 (±1.1) respectively
Pre-op physiotherapy, included crutches
training, can be considered in older subject.
Post-op physiotherapy is recommended and
includes home exercises
23
24 HIP International 30(2S)

Postoperative acute phase (weeks 1–6)

Records idenfied through
database searching
(n = 607)
Records after duplicates removed
(n = 541)
Records screened Records excluded
(n =541) (n = 489)
Full-text articles assessed Full-text arcles excluded
for eligibility (n =38):
(n = 52) No full text available (n=3)
Redundant (n= 21)
Not relevant (n= 6)
Methodological design
other than RCT (n= 4)
Sample < 30 people (n= 2)
PEDro score <6/10 (n = 2)
Studies included in
qualitave synthesis
(n =14)
Figure 1. PRISMA flowchart of study selection process.
Patient dissatisfaction may be due to unrealistic expecta-
tions; there is often a gap between patients’ and surgeons’
expectations, especially concerning future ability to perform
sport and physical activities. Psychological preparation and
education in the preoperative phase may be useful to reduce
length of stay, drug administration and anxiety.16,28–30
A review by Hoogeboom et al.14 counteracts these
assumptions and claims the absence of additional benefits
in functional recovery during hospitalisation or at 3 months
after surgery, whether reported by patients or observed
with objective outcomes. None of the 13 included thera-
peutic exercise programmes met the predetermined criteria
for high therapeutic validity, making it unlikely that the
interventions evaluated in these studies would have elic-
ited relevant effects.
According to other studies, strengthening exercises,
stretching and aerobic activity have beneficial effects on pre-
operative status; thus, the intensity and frequency of exercise
sessions should be personalised. Training on crutches,
restriction of movements and positions should be included in
every education programme,31 especially for older people
with reduced independence.24 Knee extensors seem to be the
only muscular group whose isometric strength pre-op is
indicative of functional outcomes at 12 weeks post-op.32
Body mass could influence recovery; therefore, diet
and weight loss should be promoted, as well as the cessa-
tion of smoking.33
Education. Even after surgery, educational programs based
on the empowerment of patients can significantly improve
self-care competence and self-efficacy and lower an incli-
nation to depression in older adults after hip arthroplasty.21
The use of telemedical support and the provision of
educational materials in an interactive way, allows patients
to be followed at home and seems to reduce length of hos-
pitalisation without compromising patient perceptions or
clinical parameters in patients undergoing fast-track elec-
tive surgery. In the future most governments in the western
world should include telemedical health intervention and
digitalisation of the healthcare system as a way of reducing
costs and reducing waste, although this needs more evi-
dence to be confirmed.22
Bed exercises. Adding walking training (crutches, stairs
and sit to stand) and bed exercises (quadriceps isometric,
strengthening of gluteus and calf) does not improve
scores on 12-Item Short-Form Health Survey (SF-12)
and ILOA scale (Iowa level of assistance scale), despite
strengthening feeling of patients. However, there are no
contraindications.34
Strengthening. Progressive training of 4 weeks with leg
press and hip abductors, started in the first week post-op,
can increase strength and reduce cardiopulmonary effort
in a sub-maximal test compared to standard rehabilita-
tion.35 This effect seems to last until 12 months.36 This
result is not supported by Winther et al.20 2 find statistical
differences on leg press and hip abduction between groups
(strength training vs. conventional therapy) at only 3 and
6 months.
A unilateral programme of quadriceps strengthening
started early after surgery and continued for 12 weeks
reduces length of hospitalisation and disability (strength
and cross-sectional area of quadriceps, walking speed,
stairs and sit to stand ability).37
Wijnen et al.12 show that studies having intervention
protocols focused on strengthening exercises exhibit
higher scores of therapeutic validity on the Content Scale
than those involving other physiotherapeutic exercise
interventions. This could lead to greater external validity
for those wishing to replicate the described interventions.
Finally, strength training or resistance training seems to
have minimal or no effect on pain.37
Early mobilization. NERP (Norwich Enhanced Recovery
Programme) seems to be effective in reducing time of hos-
pitalisation and pain with minimal complications. This
program deals with early passive mobilisation by a thera-
pist at 4/6 hours after surgery (spinal anaesthesia).38
Matheis and Stöggl19 confirmed the efficacy and feasi-
bility of early intensive active physiotherapy within the
first week after intervention. The programme in the
Colibazzi et al.
intervention group focused on mobilisation, coordination,
stability and strengthening of the hip muscles, and
improves hip flexion, extension and abduction, together
with walking performance at 6MWT (6 minute walk test)
for a longer duration when compared with controls sub-
jected to conventional therapy. No differences have been
found in the 1-leg stance test or hip muscle strength
between the groups, and the authors suggest that walking
ability is a consequence of increased step length due to
greater extension mobility because of treadmill-training.
According to Busato et al.,23 Fascial Manipulation
should be added to standard therapy. Fascial Manipulation
is a manual therapy technique that focuses on deep muscu-
lar fascia aimed at correcting altered localised areas that
can affected muscle functionality.39 2 treatment sessions of
Fascial Manipulation combined with 17 sessions of stand-
ard post-surgical rehabilitation spanning 10 days after
intervention result in significant improvement in ROM
(range of motion) and Harris Hip Scores compared to 19
sessions of standard rehabilitation.
Walking training programme. Wu et al.13 chose walking
speed as primary outcome in their review: results show
that exercise can increase walking speed scores by
0.15 m/s. Subgroups analysis reveals that this result is
maintained both in short and long term follow up, up to
1 year. The authors’ conclusions support the efficacy of
different protocols of resistive training intervention as
more effective in increasing walking speed.
Previous studies have indicated TUG test (Timed Up
and Go test) and extensor muscle strength as predictors of
ambulation ability at 6 months. Hip abductors may have
an effect on walking ability, therefore strengthening these
muscles is recommended to reduce disability in daily life
activities.40
Weakness of hip abductors is considered a major factor
in complications and can lead to less control of the trunk
during ambulation and climbing stairs.41,42 Furthermore,
hip abductor weakness and low trunk control may persist
until 6 months post-op.43,44
This condition seems to be more frequent in the lateral
approach and could be related to iatrogenic damage of the
superior gluteus nerve or missed healing of the medium
gluteus tendon, resulting in Trendelenburg’s sign and lead-
ing to reduced patient satisfaction.45,46
Training on a treadmill with partial support of 15% of
body weight is effective in improving hip abductor
strength, range of motion, walking symmetry and medium
gluteus response when compared to standard rehabilitation
at 3 and 12 months.
An improvement in gait efficiency represents an
important functional target for patients. A secure gait
leads to more independence and reduces the risk of fall-
ing. With the current tendency towards fast-track reha-
bilitation and shorter hospital stays, which require earlier
25
patient independence, a safer gait and a reduction in the
risk of falling are important goals to achieve.
Weight-bearing. Patients should start rehabilitation early,
with immediate body weight bearing as tolerated. A pro-
tected load is recommended during stairs.47 Patients should
be encouraged to walk without crutches as early as possi-
ble. The use of walking aids is, however, recommended for
the first 6 weeks.48
Assistive devices, hip precautions and restrictions, training in ADL.
Assistive devices such as raised toilet seats, raised furniture,
dressing aids, perching stools, and long-handled grabbers are
often recommended to patients after THA in addition to edu-
cational advice on hip care and environmental modifications
to prevent hip dislocation. However, Smith et al.17 did not
find any statistically significant difference in the incidence of
hip joint dislocation, hip function or quality of life among
group interventions using postoperative equipment, func-
tional restriction and hip precautions and controls. Concern-
ing movement and ADL (activities of daily living) restriction,
at 6 months, participants in the restricted group report less
satisfaction regarding return to preoperative levels of ADL
compared to the group who did not receive postoperative
equipment and functional restrictions. Another difference
was found in societal reintegration and discretionary activi-
ties: it takes a longer period of time for participants allocated
to the restricted group to return to driving a car, to be pas-
sengers in cars and to return to work. According to the
authors, the small sample size and the very low quality of
evidence could have influenced the statistical power of the
study; furthermore, the surgical procedure (the antero-lateral
approach has been used in the studies included) could have a
specific impact on soft tissues affected via THA procedure.
Therefore, it may be suggested that specific movements and
activities reflect the risk of dislocation according to the surgi-
cal approach adopted and need specific considerations.
The use of crutches, as a mobility assistive device, is
commonly recommended to help patients modulate body
weight as tolerated. To better stabilise the operated hip,
patients should be instructed early to use crutches in a recip-
rocal way, like Nordic Walking. In the first week post-op, for
short distances at home, patients can keep the crutch on the
operated side. This strategy reduces body weight by 15% and
prevents bending of the operated side; functional demand to
hip abductors is therefore less important, and the risk of a fall
also seems to be reduced.49 The use of crutches is important
and highly recommended for climbing stairs.50,51
Functional exercises. A programme of “task oriented” exer-
cises associated with early full body weight-bearing seems
superior to traditional programmes of standard exercises
associated with partial body weight-bearing in terms of
pain reduction, stability and improved quality of life.
These improvements last until 12 months post surgery.47
26
Supervised versus non-supervised physiotherapy. According
to Hansen et al.15 no significant effect was observed for
supervised exercise compared to non-supervised exercise
for all outcomes. However, the majority of the included
studies did not report any data regarding the adherence to
exercise programme in the non-supervised groups. The
review does not address safety issues during unsupervised
exercise; however, a previous study by Mikkelsen et al.52
seems to affirm that patients experience safe execution and
high satisfaction when training at home. In conclusion,
supervised physiotherapy should be reserved for patients
with special needs (fast return to work, significant comor-
bidities, no experience with exercise). This could promote
cost-effective rehabilitation, improve empowerment of
patients and reduce over-medicalisation.
Sexual activity. A study of hip kinematics during common
sexual positions using optical markers and functional MR
showed that women present a higher risk of dislocation
because of greater hip range of motion (ROM) (flexion,
abduction and external rotation) than men.53
Postoperative functional phase (after 6 weeks)
Studies evaluating rehabilitation programmes after the
sixth postoperative week are uncommon.
A review from Di Monaco et al.54 states that rehabilita-
tion after the sixth week is still helpful and should focus on
body weight exercises and hip abductors to improve walk-
ing speed and step cadence.54 A programme of exercise
with total body weight can improve strength of hamstring,
hip abductors and extensors, quadriceps, and increase per-
ceived independence. Compliance is crucial to achieve
good results.18
Car driving is usually allowed at this time; indication
should be personalised considering patient’s self-confi-
dence with driving.55
We believe it is appropriate to study the type and fre-
quency of exercise to be carried out after the sixth week of
a post-intervention rehabilitation programme.
Discussion
Arthroplasty is the gold standard treatment for end stage
hip osteoarthritis. Numerous studies have shown its dra-
matic impact on quality of life. Data from international
registries consistently show long term survival over 95%
at 10 years for most of the models in use.
However, limited attention has been dedicated to unsatis-
fied patients and to the role of rehabilitation. While the
value of physiotherapy in the postoperative phase is univer-
sally recognised, less is known about the effectiveness of
exercise according to type, frequency, intensity and duration
of the programme.
A sound literature review according to EBM criteria
allows us to answer to this question incompletely; our
HIP International 30(2S)
analysis has highlighted some areas in which the gap
between available evidence and clinical practice is more
striking, generally in the direction of an excess of prudence
that could affect recovery times. For example, the delay in
early muscle recovery translates into reduced performance
even in the short term.
Our review has some limitations: first, the search strategy
used was systematic, however, we might have missed some
grey literature (i.e. research that is either unpublished or has
been published in non-commercial form); furthermore, the
heterogeneity of the outcome measures did not allow us to
perform a quantitative synthesis through meta-analysis, so
that the evidence must be interpreted with caution.
A series of open questions remain on many topics that
need to be further investigated, specifically:
•• Specific educational programmes, including those
with telemedicine support and virtual reality
•• Criteria to identify subgroups of patients needing
supervision or in-patient rehabilitation programmes
•• Inclusion of functional ADL exercise in the reha-
bilitation programme
•• Assessment of the therapeutic validity of exercise
programmes proposed
•• Continuation of rehabilitation programme after the
sixth week.
Conclusion
The results of this review allowed the drafting of the evidence-
based recommendations for rehabilitation reported in
Appendix 1. The literature analysis, however, showed that the
practice is still somewhat dependent on dogmas and school
traditions:56 over 25 years after the introduction of EBM, there
is still a lack of RCTs focusing on specific questions (time/
duration of treatment, types of aids, effectiveness of functional
exercise) that could provide stronger scientific support to cur-
rent rehabilitation practice after hip arthroplasty.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship and/or publication of this article.
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Appendix 1
Indications for rehabilitation
Preoperative
A multidisciplinary team is necessary to optimise prepa-
ration for surgery; it may be effective for anxiety and
length of stay, especially in subjects with complex assis-
tance needs. Therefore patients should have a meeting
with both surgeon and physiotherapist in a preoperative
period to receive information about hospital stay, type of
surgery, potentially dangerous movements in the acute
postoperative phase (flexion >90°, internal rotation and
adduction over middle line), standards for hospital dis-
charge and activities for daily living (occupational thera-
pist consultation), including sexual activity.
We recommend performing at least a short period of
physiotherapy preoperatively with the following goals:
•• Reducing pain
•• Stretching contracted musculature
•• Muscle strengthening (especially quadriceps and
abductors)
•• Cardiovascular training
•• Training in walking with crutches.
Postoperative
Days 0–2. Goals: controlling pain, thromboembolic
prophylaxis, ROM recovery, postural verticalisation.
Bed exercise
•• dorsal and plantar foot flexion
•• quadriceps, gluteus medius and adductor isometric
contractions
•• passive mobilisation in the allowed range of motion
•• postural transition from sitting to standing
•• walking with crutches or walker, as early as
possible.
Colibazzi et al. 29

Days 3–7. Goals: maintain standing position, gain con- •• training on treadmill from the 4th week, earlier if
fidence in the use of crutches and in postural transitions possible
(supine to sitting, sitting to standing). •• training in walking with one crutch (contralateral)

•• continue with previous exercises 5–7 weeks. Goals: absence of pain, regain pre-op life-
•• introduce concentric contractions (quadriceps, style.
adductor and abductor)
•• walking with crutches, reciprocal way •• continue with previous exercises
•• free walking in protected situation
2–4 weeks. Goals: increasing allowed ROM and mus- •• introduce functional exercises like sit to standing,
cular tone, controlling standing position, walking pattern go up the stairs, climb over obstacles
without deficit. •• balance exercises on unstable boards, walking with
changing of speed and direction.
•• continue with previous exercises
•• abductor contraction in standing position From 8th week
•• squat in standing position (<90°) •• continue with previous exercises
•• elevation on the toes •• increasing ROM and strength
•• bridge exercise •• go on with supervised rehabilitation.