Question: In patients having unilateral elective total hip replacement, do supervised and independent post-discharge rehabilitation differ for improving pain and function? Design: Randomized (unclear allocation concealment), blinded (outcome assessor s), controlled trial with 26 weeks of follow-up. ACTRN 12611000167965. Setting: 1 private and 1 acute care public teaching hospital in Australia. Patients: 98 patients > 18 years of age (median age, 64 years; 58% women) who were having primary unilateral elective total hip replacement for osteoarthritis. Exclusion criteria were revision total hip replacement; preoperative University of California at Los Angeles (UCLA) activity scale score <2; metastatic disease, pathological fractures, infection, or acute trauma; systemic disease; or postoperative inability to bear weight or need for inpatient rehabilitation. 80% completed the Timed Up and Go [ TUG] test, and 92% completed follow-up for other outcomes. 130 patients were needed to achieve 80% power to detect aminimal clinically important difference of 8 on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, assuming a within-group standard deviation of 20. The study was stopped early due to recruitment difficulties and did not randomize the planned number of patients. Intervention: Patients were allocated to supervised (n = 56) or independent (n = 42) postoperative rehabilitation. On postsurgical Day 1, all patients began physiotherapy (lower-limb range-of-motion exercises, a supine strengthening program, mobilizing with a gait aid, and general education). Patients received physiotherapy sessions twice daily starting on Day 2 and were usually discharged home with crutches on Day 5. Before discharge, patients were taught home-based exercises to be done 3 times/day. The supervised group attended a once-weekly 9-station circuit class for 4 weeks. The class comprised sit-to-stand training, standing and supine hip abductor and gluteal strengthening, stair training, standing arm ergometer, step-ups, quadriceps strengthening, exercise bike, and gait retraining with progression of gait aid. The therapist increased the level of difficulty on an individual basis with use of TheraBand and/or leg weights. The independent group was instructed to continue the exercises that they had been taught in the hospital, gradually increasing the number of repetitions so that each exercise remained challenging. Exercises were done in supine and standing positions without resistance. Patients were also to begin a daily walking program and to progress from crutches/frame through 2 walking sticks to no aids. Patients could telephone their physiotherapists if needed. Main outcome measures: The primary outcome was pain, stiffness, and physical function (WOMAC total and individual scores). Secondary outcomes included health-related quality of life (Short-Form 36-item Health Questionnaire [SF-36] mental component summary [MCS] and physical component summary [PCS]); mobility, balance, walking ability, and fall risk (TUG); and daily activity level (UCLA activity scale). Main results: Supervised and independent groups did not differ for theWOMAC total score (mean, 22.60 vs. 23.10; mean difference, -0.50 [95% confidence interval, -6.75 to 5.73]), pain, stiffness, or physical function overall (across 3 time points) postoperatively (p >= 0.78) or for the WOMAC total score at 5, 12, or 26 weeks. Groups did not differ for the overall SF-36 MCS, SF-36 PCS, or TUG scores postoperatively or at 5, 12, or 26 weeks. Groups did not differ for overall UCLA activity scale scores. Conclusion: In patients having unilateral total hip replacement, supervised and independent post-discharge rehabilitation did not differ for improving pain and function.
