Postoperative Physical Therapy

The strength of recommendation was downgraded to moderate for several reasons including heterogeneity in the duration, timeframe, types of modalities and interventions, and frequency of the physical therapy interventions in these studies, making direct comparisons and definitive conclusions difficult. There were few studies that compared a progressive outpatient physical therapy program against an active placebo group in the three months after surgery, which is the time frame of interest for most surgeons.

Three high quality articles, one moderate quality article, and one low quality article showed that patients who underwent formal physiotherapy had a significant positive outcome on at least one of the following: Hip Disability and Osteoarthritis Outcome Score (HOOS), Short Form 12-Item Survey (SF-12), Western Ontario McMaster Universities Arthritis Index (WOMAC), 5-Level EuroQuol 5 Dimension self-report survey (EQ-5D), 6-Minute Walk Test, Stair Climb Test, Figure-of-Eight Test, Sit-to-Stand Test, range of motion (ROM), and strength when compared to unsupervised exercise, home-based therapy, or usual care. Specifically, Monaghan (2017) (high-quality) had significant positive results for the 6-Minute-Walk Test and self-reported function. Heiberg (2012) (high-quality) showed evidence of improved walking and stair climbing ability and these benefits persisted 1 year after surgery. Mikkelsen 2014 (high-quality) showed significant Stair Climb Test and maximal walking speed outcomes in the intervention group compared to the control group.

Two high quality articles and one moderate quality article showed no significant difference in outcomes between guided physiotherapy or unguided home exercises. It is important to note that one high quality article (Coulter 2017) only examined early recovery up to four weeks and the other high-quality article (Austin 2017) only evaluated self-reported outcome measures and the Harris Hip Score and did not include performance-based outcomes.

In reviewing the quantity of articles in favor of supervised physical therapy versus those that showed no difference, there was a slight favor for formal physical therapy after surgery. There were no studies that demonstrated unsupervised exercise was superior to supervised physical therapy. Additional research is warranted before a high strength of recommendation can be provided.

Benefits/Harms of Implementation
There is concern that recommending home exercise after surgery may limit the recovery of patients who need a more structured and supervised rehabilitation program to achieve optimal outcomes. At this point, there are no formal guidance measures to identify patients who may have an acceptable outcome with home exercise versus supervised physical therapy. A home program in which patients do not routinely interact with a health care professional after surgery may also result in delayed or missed negative sequalae after surgery.

Outcome Importance
The impact of exercise, mobility, and physical activity is an important aspect of postoperative recovery and should be a part of postoperative care, regardless of the manner in which it is implemented.

Cost Effectiveness/Resource Utilization
While there is a cost associated with supervised physical therapy, these costs are a relatively small portion of the total course of peri- and postoperative care. Cost-benefit analyses that have not been conducted with regard to this recommendation are warranted in future research.

Acceptability
Structured physical therapy is commonly prescribed for patients after THA. Some stakeholders may have concerns that there is no guidance as to which patients are likely to have equivalent outcomes with unsupervised exercise after total hip arthroplasty (THA).

Feasibility
There are no major concerns related to the feasibility of implementing this recommendation.

Future Research
Future research is warranted to obtain a better understanding of the benefit of physical therapy after THA. Current evidence is mixed, showing either a benefit to physical therapy or no difference when compared to unsupervised home exercise. Future studies should include intervention groups with an individualized plan of care and progressive rehabilitation programs, and study outcomes should include both short- and long-term performance-based and self-reported measures. Studies that provide evidence as to which patients are likely to succeed without formal physical therapy are needed.