finding center – improving body awareness after tha

C a r r o l l U n i v e r s i t y – D P T P r o g r a m

Finding Center – Improving body awareness after THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip: A Full Case Report Elizabeth Heerdt, SPT; Dr. Jane Hopp, PT, MS, PhD

08 Fall

April 10, 2013

ABSTRACT Title: Finding Center – Improving body awareness after THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip: A Full Case Report

Background and Purpose: Symmetry and alignment promote optimal mechanics and efficiency in the human body. Pain, compensations, and surgical interventions can lead to abnormal muscle tone, postures, and proprioception which may alters one’s body awareness and lower extremity weight bearing symmetry. The purpose of this full case report is to describe the physical therapy treatment of a patient with significant static stance weight bearing asymmetry following a THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip.

Case Description: The patient was a 47 year old female being seen by outpatient physical therapy 4 weeks following a right THA. Her history of developmental dysplasia and resultant end-stage advanced arthritis led to well-ingrained compensations, poor body awareness, and an altered perception of her center of mass.

Outcomes: The patient’s symmetry and body awareness improved with interventions aimed to equalize weight bearing in static stance. She was able to achieve near symmetrical weight bearing status between the lower extremities. She also demonstrated improvements in the Patient Specific Function Scale and Activity-Specific Balance Confidence Scale.

Discussion: The patient’s physical therapy treatment was affected by low back pain (LBP) and stress. Despite this, the patient demonstrated improved symmetry in static stance weight bearing. The Nintendo Wii Balance Board was an accessible tool for both collecting measures and providing treatment; however, it imposed on privacy and time. Future research should focus on weight bearing symmetry in dynamic, functional weight bearing activities for a variety of lower extremity diagnoses. Key Words: Weight bearing symmetry

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Background and Purpose The human body is complex and intricately designed with symmetry and alignment for optimal mechanics and efficiency.1 Malalignment and imbalances can lead to abnormal length tension relationships creating stress and strain on local anatomical structures.1 Since the body is a system of segments that are interconnected, a dysfunction at one point can cause problems further up or down the kinetic chain.2, 3 The hip joint consists of the articulation between the acetabulum of the pelvis and head of the femur. Its primary function is to supporting the weight of the upper body during static stance and dynamic activity.2 Developmental dysplasia of the hip is a condition of hip joint instability that occurs before the age of one and may persist if untreated. Long-term consequences include the development of osteoarthritis, pain, gait abnormalities, scoliosis, back pain, and the need of a total hip arthroplasty (THA).4 One may develop muscle guarding, altered posture, or disuse atrophy as a result of pain avoidance. Habitual compensations may also develop from developmental dysplasia of the hip, often notable in static stance with uneven weight bearing and gait with the Trendelenburg’s sign.4 Lastly, surgical procedures can alter proprioception. With soft tissue or joint injuries, neuromuscular control can be inhibited with damage to receptors responsible for kinesthesia and proprioception.5 Therefore, pain, compensations, and surgical interventions can lead to abnormal muscle tone, postures, and proprioception which may alters one’s body awareness and lower extremity weight bearing symmetry. Measuring a patient’s center of mass can be a challenge for therapist. Selection of a tool for the assessment of weight bearing symmetry is dependent on the resources of the clinic including budget, time, space, and technology expertice.6 The Nintendo Wii has been used in the clinic to assess center of pressure and has been found to be both valid and reliable.7, 8

A review of the current literature revealed that weight bearing asymmetries in static stance have been explored in populations following stroke, amputations, and TKA. The topic of weight bearing asymmetries has also been explored in patients following a THA; however, not to the extent of the populations previously mentioned. Research shows that in static stance, the weight bearing of the affected lower extremities after a THA is typically within 10% of unaffected limb.9 A direct correlation between static stance weight bearing asymmetries and severity of LBP also warrants concern due to the proximity of the hip and low back in the kinetic chain.10 The purpose of this full case report is to describe the physical therapy treatment of a patient with significant static stance weight bearing asymmetry following a THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip. Case Description: Patient History and Systems Review The patient was a 47 year old female being seen by outpatient physical therapy 4 weeks following a right THA. The THA was secondary to end-stage advanced arthritis due to congenital hip dysplasia. The patient had severe, debilitating right hip pain that had been

an ongoing problem since her teenage years and she referred to that lower extremity as her “rudder”. The continual progression of her symptoms and loss of function with conservative treatment led the patient to have the THA. Her chief complaint was hip pain that is minimal, described as a discomfort in the right hip, and ranged in intensity of 1/10 with rest and medication to 5/10 with activity. Following the surgical procedure, management to date included home physical therapy 2-3 times per week, icing, using a wheeled walker for ambulation, and pain medication every 4 hours throughout the day. She lived alone in a ranch home with one step to enter and worked in an office where she was seated at a desk for the majority of her day. At the time of examination and treatment, her sister moved in to care for her and she was working from home. The patient’s goals were to return to independent mobility, resume cycling for exercises, and to be able to go up and down a flight of stairs. The past medical history (PMH) was significant for low back pain (LBP), asthma, and cholecystectomy in 2010. Over the past three years, the patient made a significant lifestyle changes in diet and exercise to lose 120 pounds following the diagnosis of diabetes. Since the weight reduction, all symptoms of diabetes resolved. The patient also smoked 2 packs of cigarettes per day. Her family history was significant for hypertension, diabetes, cardiovascular disease, and lung cancer. The physician had given hip precautions for a posterior approach, weight bearing as tolerated status, and restricted driving at the time. Clinical Impression #1 The patient appeared to be very anxious during the subjective interview as noted by her non-verbals and expression of concern. The fear was not of pain, but failure of the surgical repair; therefore it was determined that a Tampa Scale of Kinesiophobia would not be an appropriate measure. The patient’s history of LBP was believed to be secondary to compensations made in her alignment and mobility due to the hip dysfunction. The LBP was reported to have been severe, rated at an intensity of 27/10; however, since the THA the LBP resolved. The dedication and adherence the patient demonstrated with her weight loss was expected to be seen in her rehabilitation as well. This, along with the support of her sister, were considered to be positive prognostic factors. The patients smoking status and prior level of function with a congenital history were considered to be negative prognostic factors. The initial examination included observation of functional mobility, posture, and the incision along with measures of range of motion (ROM), strength, sensory integrity, and palpation. It was anticipated that patient education and encouragement would be required with testing procedures to put the patient at ease. Examination All initial examination procedures were performed by the physical therapist. Inspection of the surgical incision revealed no signs of infection. Tenderness and edema were present

diffusely along the right posterolateral hip with palpation. The patient ambulated with a wheeled walker putting little to no weight through the affected limb. The Patient Specific Functional Scale (PSFS) was scored 0 when examining independent ambulation, cycling, and going up and down stairs; this indicated complete inability to perform these tasks. The PSFS has been found to be a valid, reliable, and responsive assessment of functional status for patients with lower extremity dysfunction.11 The Range of motion and strength testing revealed contractures and weakness of the right lower extremity; specific measures are described in Table 1. Active ROM (AROM) was used to give the patient control and put her at ease; ROM was tested using goniometry as described by Norkin and White unless noted otherwise.12 Goniometry of lower extremity AROM has been shown to be a reliable measure of range of motion.13 Manual muscle testing (MMT) was performed as described by Reese.13 MMT has been shown to have good reliability if the protocol is standardized for measures of strength.15 Hamstring flexibility was assessed using the distal hamstring length method; flexibility was found to be impaired with the R lacking 30° and the left (L) lacking 28°. No sensory alterations with light touch were identified. Clinical Impression #2 Throughout the examination, the patient demonstrated impaired body awareness and required maximal verbal and tactile cues to achieve the desired positioning. She was also fearful of dislocating the hip throughout the examination, as was anticipated during the subjective interview. Visualization of her right lower extremity was required for her to make sure she was abiding by her hip precautions. Due to the patient’s apprehension, additional examination measures were collected at later dates for a more comprehensive set of baseline measures. Her double limb standing balance was found to be intact with the ability to maintain her balance in standing on various surfaces, with and without visual input, and with moderate perturbations given by student physical therapist. It was however notable that the patient’s weight was significantly shifted over the uninvolved lower extremity. Following the first week of treatment, the patient was identified to be an interesting subject for a report due to her altered perception of center of mass and need of biofeedback for body awareness during therapeutic exercises. A Nintendo Wii balance board was used to assess center of pressure in standing balance two weeks into her outpatient therapy treatment. Research has shown that it is a valid tool for the assessment of standing center of pressure with good to excellent test-retest reliability.7 The testing application of the Wii Fit was used and the patient was instructed to stand (without an assistive device) with equal weight on both feet. Initial measures showed that 66.6% of the patients weight was shifted over the left (unaffected extremity) and 33.4% was over the right (affected extremity). This was very surprising to the patient and objectified the altered perception of center of mass. An Activities-specific Balance (ABC) scale was also administered two weeks into outpatient therapy treatment to determine the patient’s level of confidence in performing

functional activities. The patient scored 50%, which is the bottom range of a score indicating a moderate level of physical function.16 With these findings, it was determined that interventions would include proprioceptive challenges and fading of visual biofeedback to promote improved body awareness and centering of the patients center of mass in standing balance in addition to interventions targeting other found impairments typical after a THA. Intervention The interventions were targeted at addressing the impairments typically found in patients recovering from a THA (strength, ROM, flexibility, and pain) along with an added emphasis on proprioception, body awareness, and posture in static stance. Fading of visual biofeedback using mirrors and tactile cueing the student physical therapist was also implemented to reduce the dependency on external cues for proper alignment and technique. The patient was encouraged to self-analyze to increase her internal locus of control and build confidence in her ability to self-monitor and correct as needed. Proprioceptive challenges included the use of Airex pads, Dyna discs, tilt boards, wobble boards, and the BOSU. The Nintendo Wii Fit game system for balance training and the Rebounder trampoline for external perturbations were used as well. The patient was seen three times per week for four weeks, and then two times a week for the remaining three weeks. The initial set of interventions was intended to transition the patient from her home health physical therapy care to the outpatient therapy setting, establish her home exercises program (HEP), and promote weight shift over the involved lower extremity. Therapeutic exercises addressed strength, flexibility deficits. Neuro re-education addressed body mechanics with exercise and weight shifting. These interventions are further described in Table 3 under Initial Interventions. The patient was also instructed in the log roll technique with a pillow between the legs for supine to sitting transfers to reduce stress on the spine and maintain hip precautions. Gait training was done to progress towards independence regarding assistive device and a more acceptable base of support, heel strike, trunk rotation, velocity, and equivalence in stance time between the lower extremities. Manual soft tissue mobilization (STM) was used to address tissue abnormalities of the scar, IT band, and glutes along with desensitizing the areas surrounding the incision with the patient in left sidelying. Electric stimulation was used to address pain and reduce swelling. IFC was applied at 1-15 Hz and a moderate intensity for 15 min with ice to the right hip. (As the patient progressed and swelling reduced the parameters were adjusted to 80-150 Hz for pain relief.) The patient was positioned in supine with the limb elevated and she was instructed to do ankle pumps for the duration of the treatment. Lastly, patient education was provided throughout all treatment sessions to empower the patient with knowledge of her condition, the related pathokinesiology, purpose of exercises, and expectations for therapy. As the patient was spending more time on her feet both at home and in the clinic her back pain, which had resolved after the right THA, returned. The patient was very concerned with the relapse. In response core stabilization exercises were implements to

promote stability along with stretching of the hip flexors to decrease lordosis. These interventions are further described in Table 3 under Modifications with Onset of Back Pain. The change in status was discussed with the physician; he requested the continuation of core exercises and did not write a new script for the treatment of the back pain. With the modifications to the plan of care, the patient’s back pain continued, but did not progress. The Wii Fitness balance training games were used during treatment to encourage medial lateral weight shift in static stance with visual biofeedback from the virtual characters on screen.17 Games used included soccer heading, ski slalom, and penguin slide; these games are depicted in Table 4. The student physical therapist stood behind the patient to cue for movement purely in the frontal plane and keep spine in neutral during this activity. With progression through the plan of care, more advanced exercises were added that challenge greater portions of the kinematic chain; they are listed under late stage interventions in Table 3. The patient responded well to the interventions initially, but then had an onset of knee pain despite correct technique with the exercises. The pain was reduced when the interventions were temporarily on hold and then gradually resumed, but persisted at the reduced intensity. An overview of each week is outlined in Table 5 along with the content of daily treatment sessions that are outlined in Table 6. Outcome The patient was weaned from visual and tactile feedback throughout her course of treatment and upon the final weeks was able to perform both new and old exercises away from mirrors and with less cueing required from clinicians. The patient also progressively improved in centering of her center of mass with equal weight bearing between lower extremities in static stance. Final measures using the Nintendo Wii balance board revealed the patient measured weight bearing 51.1% over the left lower extremity and 48.9% over the right. The patient also improved in her ROM and strength as noted in Table 1 as well as with functional scales noted in Table 2. Upon conclusion of treatment, the patient reported no pain in the right hip with rest and pain rated 2/10 occasionally with intense movements. Discussion The purpose of this full case report is to describe the physical therapy treatment of a patient with significant static stance weight bearing asymmetry following a THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip. The patient began with lower extremity weight bearing asymmetry as noted by visual observation and confirmed with objective measures with the Nintendo Wii. Initial measures revealed that when the patient was instructed to stand with equal weight on each leg, she was bearing 66.6% of her weight over the left lower extremity and 33.4% over the right. That difference was three times greater than normally seen in patients after a THA.9 By the end of therapy episode, the patient measured nearly symmetrical with weight bearing 51.1% over the left lower extremity and 48.9% over the right.

The THA likely contributed to pain reduction with the elimination of the pathologic joint. Soft tissue mobilizations along with the use of modalities were aimed to reduce pain resulting from the surgical procedure. Strengthening exercises addressed weakness in the hip while flexibility and ROM exercises attempted to normalize length tension relationships, all to promote alignment and efficient mechanics.1 Therapeutic activities were used to retrain the patient in transfers, dressing, gait, and stairs to allow her to move more comfortably and freely throughout her environment. Neuro re-education was a large component of her plan of care and targeted weight shift, proprioception, and body awareness. An 86% gain in function was noted using the PSFS along with a 40% increase in confidence with functional tasks by the ABC Scale. The gain in the PSFS exceed the minimally clinically important difference (MCID), the MDIC for the ABC scale is yet to be established.11 Qualitatively this was noted also in the patient’s movement and demeanor in removing shoes, getting on and off treatment tables, and moving throughout the clinic. The rapport built with patient may have assisted in obtaining these improvements with genuine encouragement and patient education regarding her capabilities and concerns to empower her with knowledge and confidence in her body’s abilities. The patient’s history of LBP was assumed to be the result of malalignment resulting from years of compensations for her hip pain. X-rays (taken in standing) revealed mild degeneration at L2-L5 along with left lateral flexion of the lumbar spine. Following the patient’s surgical procedure, the LBP completely resolved and did not resume until the patient began to transition to ambulation with a single prong cane. It is believed that when the patient was not upright and walking, stress was reduced from her spine. Additionally, in using a walker the patient may have been experienced a traction force on the spine with gait.20 The pain medications she was taking at the time were likely to play a role in the temporary dissipation of her LBP as well. The LBP returned in conjunction with increased time spent in standing, progressively more independent ambulation, and weaning from pain medications. Although the patient’s LBP did not resolve with progression towards symmetry in weight bearing, it was not exacerbated either and the LBP was considered to be a barrier to accomplishing her therapy goals. Another barrier encountered was emotional stress when the patient was laid off from her job in the middle of her course of treatment. Research supports that both physical and psychological stress can impact a patients perception of LBP.18, 19 In response to the event, rapport that was built early on was used to uplift the patient and make her time in the clinic enjoyable. Incorporating biopsychosocial aspects and utilizing patient-therapist relationships have the potential to improve quality of care and enhance outcomes.11 The fact that the patient was off of work could have also positively impacted her recovery as she did not have the physical demands of prolonged sitting at her desk and prolonged standing with meetings. She also had more time available to commit to her home exercise program.

The Nintendo Wii Fit game system and Balance Board were found to be useful tools in measuring center of pressure and providing interventions to improve it, as it was supported by the literature.7, 8, 21, 22 There were some barriers however, that were encountered. For one, the set up of Wii and navigation to the Body Testing screen took time, which is a valuable resource of both the clinician and the patient. Also, to perform the body testing requires the input of patient information (including age and height) for the calculation of a body mass index (BMI). While fake values can be entered, the information is still displayed on the screen, which could be a concern to the patient in a public gym setting. Using games with a patient who has a competitive personality may lead them to attend less to the quality of their movement and more to the quantity of their score. If Nintendo could create a simplified Wii program to be used in conjunction with the Balance Board that provided measuring capabilities along with simplified visual biofeedback, the clinical usefulness could be greatly enhanced. This full case report demonstrated a normalization in lower extremity weight bearing in a patient following a THA secondary to end-stage advanced arthritis from developmental dysplasia of the hip. Due to the impact one joint’s malalignment or dysfunction can have on the surrounding kinetic chain, this topic should be of importance and considered in developing the physical therapy plan of care for patients with lower extremity pathology or impairments. Future research should expand on weigh bearing symmetry not only for a more broad variety of lower extremity disorders, but also during functional, dynamic activities such as sit to stand transfers. Research on the use of various Wii programs would also be beneficial in helping clinicians to utilize the most effective strategies.

References

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8 Clark R, McGough R, Paterson K. Reliability of an inexpensive and portable dynamic weight bearing asymmetry assessment system incorporating dual Nintendo Wii Balance Boards. Gait & Posture [serial online]. June 2011;34(2):288-291. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 26, 2013.

9 Talis V, Grishin A, Solopova I, Oskanyan T, Belenky V, Ivanenko Y. Asymmetric leg loading during sit-to-stand, walking and quiet standing in patients after unilateral total hip replacement surgery. Clinical Biomechanics [serial online]. May 2008;23(4):424-433. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 26, 2013.

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11 KOWALCHUK HORN K, JENNINGS S, RICHARDSON G, VAN VLIET D, HEFFORD C, HAXBY ABBOTT J. The Patient-Specific Functional Scale: Psychometrics, Clinimetrics, and Application as a Clinical Outcome Measure. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. January 2012;42(1):30-42. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 10, 2013.

12 Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia, OH: F.A. Davis Company; 2009.

13 Clapper MP, Wolf SL. Comparison of the reliability of the Ortho-Ranger and the standard goniometer for assessing active lower extremity range of motion. Phys Ther 68:214, 1988.

14 Reese NB. Muscle and Sensory Testing. 2nd ed. St. Louis, MO: Elsevier Saunders; 2005. 15 Iddings DM, Smith LK, Spencer WA. Muscle testing, II: reliability in clinical use. Phys Ther

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the ABC Scale. J Gerontol A Biol Sci Med Sci. 1998; 53:M287-M294. 17 Wii Fit Plus. Wii Fit Plus Balance Training. http://wiifit.com. Accessed February 26, 2013. 18 Courvoisier D, Genevay S, Perneger T, et al. Job strain, work characteristics and back

pain: A study in a University hospital. European Journal Of Pain [serial online]. July 2011;15(6):634-640. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed March 10, 2013.

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22 Hubbard B, Pothier D, Hughes C, Rutka J. A Portable, Low-Cost System for Posturography: A Platform for Longitudinal Balance Telemetry. Journal Of Otolaryngology -- Head & Neck Surgery [serial online]. February 2, 2012;41:S31-S35. Available from: Academic Search Premier, Ipswich, MA. Accessed April 10, 2013.

23 HEP for Rehab Pros. HEP 2 GO. http://www.hep2go.com/exercises. Accessed February 25, 2013.

Tables and Figures

Table 1: Examination and Re-Examination

AROM (GONIOMETRY) Right (affected)

Left (unaffected) Initial Final

Hip flexion 80° 110° 120° Hip extension (measured in supine) -20° -3° 0° Hip abduction 22° 18° 30° Knee flexion 140° 155° 150° Knee extension -22° -3° 0°

STRENGTH (MMT) Right (affected)

Left (unaffected) Initial Final

Hip abductors 2/5 5/5 5/5 Hip extensors 2/5 4/5 4/5 Knee flexors 5/5 5/5 5/5 Knee extensors 5/5 5/5 5/5

Table 2: Objective Measures, Scales, and Indices Specific Measure Initial

Measure Mid

Treatment Mid

Treatment Final

Measure Patient Specific Functional Scale

• Independent ambulation • Return to cycling • Go up and down of stairs

0 6.3 8.3 8.6

ABC Scale 50% NT NT 90% Wii Weight Distribution in Static Stance

L: 66.6% R: 33.4%

L: 57.5% R: 42.5%

L: 55.9% R: 44.1%

L: 51.1% R: 48.9%

Table 3: Interventions Initial Interventions

Exercise Description Progression

HAMSTRING STRETCH: While seated, rest your heel on the floor with your knee straight and gently lean forward until a stretch is felt behind you knee/thigh. Hold for 30 seconds. Patient was instructed to stay within hip precautions.

Increased range so stretch is felt to a point of mild discomfort

QUAD SETS: While lying or sitting with a small towel roll under your ankle, tighten your top thigh muscle to press the back of your knee downward towards the ground. Hold for 5 seconds then relax.

Quad set will be included during strengthening of the proximal hip musculature

CLAMS: Lie down on your back with your knees bent. Place an elastic band around your knees and then draw your knees apart. Slowly allow your knees to be drawn back together.

Increase resistance, lateral walking will replace when the hip abductor strength is adequate to maintain upright posture with gait

BRIDGE: While lying on your back with a pillow between the knees, raise your buttocks off the floor/bed while holding a medicine ball between your knees as shown.

Holds at end range, single leg bridges, reduced stability from upper extremities, a tilt board under the feet

SQUATS: While standing with feet shoulder width apart and in front of a stable support for balance assist if needed, bend your knees and lower your body towards the floor. Your body weight should mostly be directed through the heels of your feet. Return to a standing position. Knees should bend in line with the 2nd toe and not pass the front of the foot.

Holds at end range, altered velocities, greater range, varying stability of surfaces

WEIGHT SHIFTING: Standing near a stable object for safety with upper extremity support as needed, shift weight over one lower extremity while unweighting the other. Then repeat on the opposite lower extremity.

Tasks involving the upper extremities to incorporate functional reach with activities simulating functional tasks, varying stability of surfaces

SINGLE LEG STANCE (SLS): Standing near a stable object for safety with upper extremity support as needed, keep one leg up and from touching the stance leg for 30-90 seconds.

Tasks with the un-weighted leg including rolling a ball underfoot and tapping a cone with toes and heel for coordination with varying stability of surfaces

OBSTACLE NEGOTIATION: With wheeled walker, ambulate over obstacles keeping hips level and utilizing dorsiflexion for toe clearance.

Increase height of obstacles, decrease level of assistance with ambulation

STANDING HIP EXTENSION: While standing and keeping the toes turned out kick your leg behind you. Keep the motion slow and controlled and keep your body upright.

Resistance bands added to ankles, varying stability of surface

Modifications with Onset of Back Pain (Hip precautions had been lifted at this point) Exercise Description Progression

HIP FLEXOR STRETCH: While lying on a table or high bed, let the affected leg lower towards the floor until a stretch is felt along the front of your thigh. Keep from arching the back. Hold for 30 seconds.

Increase range so stretch is felt to a point of mild discomfort

TRUNK ROTATION: Lying on your back with your knees bent, gently move your knees side-to-side.


KNEE TO CHEST: While Lying on your back, hold your knees and gently pull them up towards your chest. Hold for 30 seconds.


TRACTION: Press up with arms from chair and let your lower body relax to allow your body weight to place a traction load on the spine. Hold as long as able with upper extremities.

Increase time position is maintained

ABDOMINAL ISOMETRICS: In hooklying and with fingers palpating transverse abdominis, contract the abdominal and hold for 10 seconds while continuing to breathe. Then relax.

Add movements of extremities, perform in other functional positions, increase duration of hold

90/90s: Maintaining abdominal contraction for neutral spine, hold lower extremities in the 90/90 position. Be sure to continue breathing. Hold for 30 seconds.

Add movements of extremities, increase duration of hold

DEAD BUG: While lying on your back with your knees bent, slowly raise up one foot and opposite arm. Return to starting position and then repeat on the opposite side. Keep your low back flat on the floor the entire time.

Increase range of the extremity movements, increase duration of exercise

SIT TO STAND: Holding Pilates ring to encourage abdominal contraction, move to and from sit to stand keeping a neutral spine.

Perform from lower surface, alter stability of surface

Late Stage Interventions Exercise Description Progression

STANDING HIP FLEXION: While standing with an elastic band attached to your ankle, draw your leg forward in front of your body. Keep your knee and back straight the entire time.

Standing on Airex pad, increased resistance, ski poles for upper extremity support

STANDING HIP EXTENSION: While standing with an elastic band attached to your ankle, draw your leg back behind you. Keep your knee and back straight the entire time.


STANDING HIP ABDUCTION: While standing with an elastic band attached to your leg, pull an elastic band out to the side. Keep the back straight.


LUNGE: Start by standing with feet shoulder-width-apart. Next, take a step forward and allow your front knee to bend. Your back knee may bend as well. Then, return to original position, or you may walk and take a step forward and repeat with the other leg. Keep your pelvis level and straight the entire time. Your front knee should bend in line with the 2nd toe and not pass the front of the foot.

Lunge onto BOSU, include upper extremity task

LATERAL WALKING: With an elastic band around both ankles, walk to the side while keeping your feet spread apart. Keep your knees bent the entire time.

Increase resistance, maintain squatted position

QUADRUPED HIP EXTENSION: While on hands and knees, slowly draw your leg back behind you as you straighten your knee. Keep core stable as you lift your leg.

Position on knees and forearms, unsteady surface under hands

STEP UPS: While standing with both feet on the floor, step up a step with one leg. Return backward towards the floor leading with the other leg.

Increase step height, decrease velocity

DIPS: Start with both feet on top of a step. Next, slowly lower the unaffected leg down forward off the step/box to lightly touch the heel to the floor. Then return to the original position with both feet on the step. Maintain proper knee alignment: Knee in line with the 2nd toe and not passing in front of the toes.

Increase step height

All of the exercise images used were obtained from HEP2GO website.23

Table 4: Wii Game Depictions

Soccer Heading Ski Slalom Penguin Slide

All of the images used were obtained from Wii Fit website.17

Table 5: Summery of Weekly Treatment Sessions Week 1

Manual: STM to glute med and IT band Therapeutic Exercise: Focus on supine exercises; beginning transition to standing exercises; obstacle negotiation Therapeutic Activity: Log roll technique; gait with wheeled walker; sit to stand transfers Neuro Re-Education: Weight shift in standing; right SLS with upper extremity support Modalities: E-stim and ice to reduce swelling and pain

HEP: Continuation and refinement of HEP from home health care

Proprioceptive Challenges: Standing balance without upper extremity support Biofeedback: Use of tactile cues from self and therapist to stay within hip precautions; standing exercises performed at mirror for visual biofeedback.

Week 2 Manual: STM to glute med and IT band Therapeutic Exercise: PROM to right hip within precautions; focus on core stability; increased standing exercises; introduction of upright bike Therapeutic Activity: Stairs; introduction of gait with single prong cane Neuro Re-Education: Standing exercises on Airex foam pad; introduction of Wii Fit balance games Modalities: E-stim and ice to reduce swelling and pain

HEP: Progression to include some standing exercises and promote hip flexibility

Proprioceptive Challenges: Airex foam pad used to challenge balance with standing exercises Biofeedback: Majority of exercises were performed in front of mirror for visual biofeedback

Week 3 Manual: STM to glute med and IT band Therapeutic Exercise: Progression of standing exercises in range, sets, and resistance; trunk stretching and ROM exercises Therapeutic Activity: Donning socks; increased height of stairs; instruction of golfer’s lift Neuro Re-Education: Standing exercises on Airex foam pad; Wii Fit balance games; standing balance on tilt board Modalities: Weaning from e-stim to use of ice only

HEP: Added flexibility exercises with the lifting of hip precautions

Proprioceptive Challenges: Tilt board introduced Biofeedback: Exercises performed further from the mirror to fade visual biofeedback

Week 4 Manual: Reduced time spent on STM to glute med and IT band Therapeutic Exercise: Progression of standing exercises and bike in resistance Therapeutic Activity: Standing to and from floor transfers; stairs; independent gait Neuro Re-Education: Standing exercises with Airex foam pad, tilt board, and BOSU; rebounder trampoline for external perturbations; Wii Fit balance games Modalities: Weaning from e-stim to use of ice only

HEP: Biking added along with reduction in frequency from 2x/day to 1x/day

Proprioceptive Challenges: More standing exercises that incorporate the Airex foam pad, tilt board, and BOSU Biofeedback: Only half of exercises performed at the mirror to reduce visual biofeedback.

Week 5

Manual: Weaning from STM to glute med and IT band Therapeutic Exercise: Progression of abdominal exercises; closed chain hip abductor and quad exercises Therapeutic Activity: Independent gait Neuro Re-Education: SLS with rebounder trampoline; Wii Fit balance games Modalities: Ice to reduce swelling and pain

HEP: Increased time spent biking for aerobic exercise and scar tissue mobilization added

Proprioceptive Challenges: More standing exercises that incorporate the Airex foam pad, tilt board, and BOSU Biofeedback: Only half of exercises performed at the mirror to reduce visual biofeedback.

Week 6 Therapeutic Exercise: Exercises with emphasis on body mechanics in absence of mirror. Therapeutic Activity: Independent gait Neuro Re-Education: SLS; Wii Fit balance games Modalities: E-stim and ice to reduce swelling and pain (Pain increased with reduction of medications)

HEP: Increased time spent biking for aerobic exercise

Proprioceptive Challenges: Dyna discs added to unstable surfaces used for exercises and neuro re-education Biofeedback: Mirror used minimally for visual biofeedback

Week 7 Therapeutic Exercise: Progression of hip flexors stretching; focus on eccentrics Therapeutic Activity: Independent gait; sit to stand transfers from low surfaces Neuro Re-Education: Dyna discs with rebounder trampoline; Wii Fit balance games Modalities: Weaning from e-stim and ice to reduce swelling and pain

HEP: Increased tome spent piking for aerobic exercise and quadruped hip extension added

Proprioceptive Challenges: Wobble board added to unstable surfaces used for exercises and neuro re-education Biofeedback: Mirror not used during treatment sessions

Table 6: Daily Treatment Sessions WEEK 1

Session 1 Manual Treatment

Positioned in left sidelying with pillows between knees; STM to right posterolateral glutes; 5 min

Therapeutic Exercise

Quad sets (1 set x 6 reps with 10 sec hold), Bridges (1 set x 10 reps), Hamstring stretch (1 set x 3 reps with 20 sec hold both sides), Clams (1 set x 10 reps with yellow Theraband)

Therapeutic Activity

Instruction of log roll technique to the left and right from hooklying

Modalities Positioned in supine; IFC 1-15 Hz with ice to right hip and right lower extremity elevation; 15 min


Positioned in L sidelying with pillow between knees; STM to glute med and IT band using foam roller; 10 min


Bridges (1 set x 10 reps), Hamstring stretch (1 set x 2 reps with 30 sec hold), Clams (1 set x 10 reps with orange Theraband), Squats (2 sets x 10 reps in small range), Obstacle negotiation (6 laps over 6 inch hurdles leading with right leg), Lateral walking (2 sets x 10 steps each direction with no resistance)


Review of log roll technique from hooklying, Gait training with wheeled walker (focus on R heel strike), Sit to stand from elevated seat (1 set x 10 reps)

Neuro Re-Education

Weight shifting (right to left with unweighting of foot x 2 min), Weight shifting (right to left with upper extremity tasks of moving objects side to side x 2 min), Standing balance (60 sec with eyes open, 60 sec with eyes closed, 60 sec on Airex with eyes open, 60 sec on Airex with eyes closed)

Modalities Positioned in left sidelying; ice to right hip; 15 min Session 3

Manual Treatment

Positioned in L sidelying with pillow between the knees; STM to glute med and IT band using hands and foam roller; 15 min


Squats (2 sets x 10 reps in small range), Obstacle negotiation (6 laps forward stepping and 4 laps lateral stepping over 6 inch hurdles leading with right leg), Lateral walking (2 sets x 10 steps each direction with no resistance), Standing hip extension (2 sets x 10 reps each leg)


Sit to stand from elevated seat (1 set x 10 reps)

Neuro Re-Education

Weight shifting (right to left with upper extremity tasks of moving objects side to side x 2 min), Standing balance (60 sec on Airex with eyes open, 60 sec on Airex with eyes closed, 60 sec on Airex with perturbations given by SPT), Heel taps (tapping L heel on 6 inch cone, 2 sets x 10 reps), Ball rolling (rolls soccer ball forward and back under foot, 1 set x 10 reps both legs)

Modalities Positioned in left sidelying with pillow between knees; IFC 1-15 Hz with ice to right hip; 15 min

HEP

To be performed 2-3x per day: Quad sets (2 set x 10 reps with 5 sec hold), Bridges (2 set x 10 reps), Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Clams (2 set x 10 reps with yellow Theraband), Squats (2 sets x 10 reps in small range)

WEEK 2 Session 1

Manual Treatment

Positioned in left sidelying with pillow between the knees; STM to glute med and IT band using hands and foam roller; 10 min


PROM stretching for right hip ABD and flexion (in supine and within hip precautions, 1 set x 2 reps with 60 sec hold each), Abdominal isometrics (1 set x 10 reps with 10 sec hold for hooklying, sitting, and standing), Clams (2 sets x 10 reps in conjunction with abdominal isometrics), Bridges (2 sets x 10 reps), Lateral walking (2 sets x 10 steps each direction with no resistance)


Gait instruction with single prong cane

Neuro Re-Education

Heel taps (tapping left heel on 8 inch cone, 2 sets x 10 reps), Squats (2 sets x 10 reps while standing on Airex), Marching (2 sets x 10 reps while standing on Airex), Standing hip abduction (2 sets x 10 reps each side while standing on Airex), Standing hip extension (2 sets x 10 reps each side while standing on Airex)



Positioned in left sidelying with pillow between the knees; STM to glute med and IT band using hands and foam roller; 15 min


PROM stretching for right hip ABD and flexion (in supine and within hip precautions, 1 set x 2 reps with 60 sec hold each), PROM stretching for right hip extension (in left sidelying, 1 set x 2 reps with 60 sec hold), Abdominal isometrics (1 set x 10 reps with 10 sec hold for hooklying), Bridges (1 set x 10 reps with abdominal isometrics), Clams (2 sets x 10 reps with abdominal isometrics), Obstacle negotiation (6 laps over 6 12 inch hurdles leading with right leg), Squats (2 sets x 10 reps in small range), Forward lunge (2 sets x 10 reps each leg)


Step ups (2 sets x 10 reps to 4 inch step leading with right leg)

Neuro Re-Education

Marching (2 sets x 10 reps while standing on Airex), Standing hip abduction (2 sets x 10 reps each side while standing on Airex), Standing hip extension (2 sets x 10 reps each side while standing on Airex)



Positioned in left sidelying; STM to glute med and IT band using hands and foam roller; 15 min


PROM stretching for right hip ABD and flexion (in supine and within hip precautions, 1 set x 2 reps with 30 sec hold each), PROM stretching for right hip extension (in left sidelying, 1 set x 2 reps with 30 sec hold), Clams (2 sets x 10 reps with orange Theraband and abdominal

isometrics), Forward lunge (2 sets x 10 reps each leg), Upright bike (light resistance, 10 min)



Neuro Re-Education

Wii Fit (2 Penguin Slide games), Standing hip abduction (2 sets x 10 reps each side while standing on Airex with white Theraband at ankles), Standing hip extension (2 sets x 10 reps each side while standing on Airex with white Theraband at ankles), Single leg stance (on left, 3 trials each for steady surface, on steady surface with eyes closed, on Airex)

Modalities Positioned in hooklying; IFC 80-150 Hz with ice to right hip; 15 min HEP

To be performed 2-3x per day: Quad sets (2 set x 10 reps with 5 sec hold), Bridges (2 set x 10 reps), Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction), Squats (2 sets x 10 reps in small range), Forward lunge (2 sets x 10 reps)

WEEK 3 Session 1


PROM stretching for right hip ABD, flexion, and hamstring stretch (in supine and within hip precautions, 1 set x 2 reps with 30 sec hold each), Hip flexor stretch (1 set x 2 reps with 30 sec hold), Squats (3 sets x 10 reps in small range), Forward lunge onto BOSU (2 sets x 10 reps each leg), Upright bike (light resistance, 15 min)



Neuro Re-Education

Standing hip abduction (2 sets x 10 reps each side while standing on Airex with white Theraband at ankles), Standing hip extension (2 sets x 10 reps each side while standing on Airex with white Theraband at ankles), Double limb standing balance (on tilt-board in frontal plane, 1 set x 3 reps with 60 sec hold)

Modalities Positioned in hooklying; IFC 80-150 Hz with ice to right hip; 15 min Session 2

Manual Treatment

Positioned in left sidelying; STM to glute med and IT band using hands and foam roller; 10 min


PROM stretching for right hip extension (in left sidelying, 1 set x 2 reps with 30 sec hold), Forward lunge onto BOSU (2 sets x 10 reps each leg), Upright bike (moderate resistance, 15 min), Lateral walking (3 set x 10 steps each direction with yellow Theraband at ankles), Dips (2 sets x 5 reps, from 4 inch step)


Step up and overs (stepping up on to and then down off of 6 inch step leading with right leg, 4 sets x 10 reps)

Neuro Re-Education

Rebounder throws (2 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps, patient standing with equal weight distribution between legs), Double limb standing balance (on tilt-board in frontal plane, 1 set x 3 reps with 60 sec hold)


Manual Treatment

Positioned in left sidelying; STM to IT band using foam roller; 5 min


Trunk rotation (2 min), Hamstring stretch (1 set x 2 reps with 30 sec hold both sides), Knee to chest (1 set x 2 reps with 30 sec hold), Sock stretch (sitting on the edge of a chair let the leg fall to the side so that hip is in external rotation and then stretch down to the foot, 1 set x 2 reps with 30 sec hold), Upright bike (moderate resistance, 15 min)


Golfers lift instruction, Donning socks

Neuro Re-Education

Wii Fit (3 Penguin Slide games and 3 Soccer Heading games)

Modalities Patient seated with ice to right hip, 10 min HEP

To be performed 1-2x per day: Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction with yellow Theraband at ankles), Squats (3 sets x 10 reps in small range), Forward lunge (2 sets x 10 reps), Sock stretch (1 set x 2 reps with 30 sec hold), Upright bike (15-30 min with light-moderate resistance), Scar tissue mobilization

WEEK 4 Session 1

Manual Treatment



Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Trunk rotation (2 min), PROM stretching for right hip extension (in left sidelying, 1 set x 4 reps with 30 sec hold), Upright bike (moderate resistance, 15 min), Forward lunge onto BOSU (2 sets x 10 reps each leg)


Standing to and from tall kneeling transfer (1 set x 5 reps), Golfers lift (1 set x 10 reps)

Neuro Re-Education

Standing hip abduction (2 sets x 10 reps each side while standing on Airex with yellow Theraband at ankles), Standing hip extension (2 sets x 10 reps each side while standing on Airex with yellow Theraband at ankles), Rebounder throws (2 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps, patient standing with 60% of weight on right leg and 40% on left leg), Squats (3 sets x 10 reps in moderate range while standing on Airex), Double limb standing balance (on tilt-board in frontal plane, 1 set x 3 reps with 60 sec hold)

Modalities Patient seated with ice to right hip, 10 min Session 2

Manual Treatment



Traction (self traction with chair, 1 set x 4 reps with 15 sec hold), Upright bike (moderate resistance, 15 min), Forward lunge onto BOSU (2 sets x 10 reps each leg), Dips (2 sets x 10 reps, from 6 inch step), Lateral walking (4 set x 10 steps each direction with orange Theraband at ankles)


Standing to and from tall kneeling transfer (1 set x 5 reps), Step ups (3 sets x 10 reps to 8 inch step leading with right leg)

Neuro Re-Education

Standing hip abduction (2 sets x 10 reps each side while standing on Airex with orange Theraband at ankles), Standing hip extension (2 sets x 10 reps each side while standing on Airex with orange Theraband at ankles), Rebounder throws (2 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps, patient standing with 60% of weight on right leg and 40% on left leg), Squats (2 sets x 10 reps in moderate range while standing on Airex), Double limb standing balance (on tilt-board in frontal plane, 1 set x 3 reps with 60 sec hold)


Manual Treatment



PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps)


Gait without assistive device (focus on increasing arm swing and equal stance time between limbs)

Neuro Re-Education

Wii Fit (2 Penguin Slide games and 3 Soccer Heading games), Squats (3 sets x 10 reps in moderate range while standing on Airex), Double limb standing balance (on tilt-board in frontal plane, 2 set x 15 reps of tapping from side to side with 5 sec hold in center)

Modalities Positioned in hooklying; IFC 80-150 Hz with ice to right hip; 15 min HEP

To be performed 1-2x per day: Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction with yellow Theraband at ankles), Squats (3 sets x 10 reps in moderate range), Forward lunge (2 sets x 10 reps), Sock stretch (1 set x 2 reps with 30 sec hold), Upright bike (20-40 min with light-moderate resistance), Scar tissue mobilization

WEEK 5 Session 1


PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps), 90/90s (1 set x 3 reps with 30 sec hold), Dead bugs (2 sets x 15 reps), Lateral lunge (2 sets x 10 reps each side), Reverse lunges (2 sets x 10 reps, stepping back with left foot), Lateral walking (2 set x 10 steps each direction with green Theraband at ankles)

Neuro Re-Education

Standing hip abduction (2 sets x 10 reps each side while standing on Airex with orange Theraband at ankles), Standing hip extension (2 sets x 10 reps each side while standing on Airex with orange Theraband at ankles), Rebounder throws (4 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps each side, patient in single leg stance with toe touch as needed), Squats (3 sets x 10 reps in moderate range while standing on Airex), Double limb standing balance (on tilt-board in frontal plane, 2 set x 15 reps of tapping from side to side with 5 sec hold in center)

Modalities Positioned in sitting; ice to right hip and both knees, x 15 min Session 2

Manual Treatment



PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Squats (on total gym to 80° of hip flexion at level 6, 2 sets x 10 reps)


Gait training (focus on keeping toes out, increasing base of support, and increasing arm swing)

Neuro Re-Education

Wii Fit (2 Penguin Slide games, 2 Ski Slalom games, and 2 Soccer Heading games), Standing hip extension, abduction, and flexion (2 sets x 10 reps each leg while standing on Airex pad with yellow Theraband at ankle and using ski poles for upper extremity support), Double limb standing balance (on tilt-board in frontal plane, 1 set x 3 reps with 60 sec hold), Rebounder throws (4 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps each side, patient in single leg stance with toe touch as needed)

Modalities Positioned in sitting; ice to right hip and left knee, x 15 min HEP

To be performed 1-2x per day: Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction with green Theraband at ankles), Sock stretch (1 set x 2 reps with 30 sec hold), Upright bike (30-60 min with moderate resistance), Scar tissue mobilization

WEEK 6 Session 1


PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Squats (on total gym to 80° of hip flexion at level 6, 3 sets x 10 reps), Lateral lunge (2 sets x 10 reps each side), Reverse lunges (2 sets x 10 reps, stepping back with left foot), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps), Lateral walking (2 set x 10 steps each direction with blue Theraband at ankles), Upright bike (moderate resistance, 15 min), Quadruped hip extension (2 sets x 10 reps each side)

Neuro Re-Education

Standing hip extension, abduction, and flexion (3 sets x 10 reps each leg while standing on Airex pad with orange Theraband at ankle and using ski poles for upper extremity support), Rebounder throws (4 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps each side, patient standing with a Dyna disc under each foot), Double limb standing balance (on tilt-board in frontal plane, 1 set x 30 reps tapping from side to side)


Manual Treatment



PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Forward lunge (2 sets x 10 reps each side), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps), Lateral walking (2 set x 10 steps each direction with blue Theraband at ankles)


Gait (focus on increasing velocity and equal stance time between legs)

Neuro Re-Education

Wii Fit (2 Penguin Slide games), Standing hip extension, abduction, and flexion (3 sets x 10 reps each leg while standing on Airex pad with orange Theraband at ankle and using ski poles for upper extremity support), Double limb standing balance (on tilt-board in frontal plane, 1 set x 30 reps tapping from side to side), Standing on Dyna discs (equal weight on each leg, 1 set x 3 reps with 2 min hold), Single leg stance (5 trials on each side, 10-30 sec hold)

HEP To be performed 1-2x per day: Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction with green Theraband at ankles), Sock stretch (1 set x 2 reps with 30 sec hold), Upright bike (30-60 min with moderate resistance), Scar tissue mobilization

WEEK 7 Session 1


PROM stretching into right hip ABD, flexion, and hamstring stretch (in supine, 1 set x 2 reps with 30 sec hold each), Lunge (2 sets x 10 reps each side), Reverse lunges (2 sets x 10 reps, stepping back with left foot), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps), Upright bike (moderate resistance, 15 min), Quadruped hip extension (2 sets x 10 reps each side), Squats (on total gym to 90° of hip flexion at level 6, 2 sets x 10 reps), Standing hip flexor stretch (standing with stability ball between the buttock and wall patient leans back and reaches overhead bending from the hips, 1 set x 5 reps with 10 sec hold)


Sit to stand (3 sets x 10 reps)

Neuro Re-Education

Standing hip extension, abduction, and flexion (3 sets x 10 reps each leg while standing on Airex pad with green Theraband at ankle and using ski poles for upper extremity support), Double limb standing balance (on tilt-board in frontal plane, 1 set x 30 reps tapping from side to side), Wobble board (standing on wobble board with both feet 30 circles each way clock-wise and counter clock-wise), Rebounder throws (4 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps each side, patient standing with a Dyna disc under each foot), Double limb standing balance (on tilt-board in frontal plane, 1 set x 30 reps tapping from side to side)

Session 2


PROM stretching for right hip ABD, flexion, and hamstring stretch (in supine and within hip precautions, 1 set x 2 reps with 30 sec hold each), Hip flexor stretch (1 set x 2 reps with 30 sec hold), Hip hikes (standing with left hip holding small ball against wall the hiking left hip up rolling ball up the wall and returning slowly to the starting position, 2 sets x 10 reps), Squats (on total gym to 90° of hip flexion at level 6, 2 sets x 10 reps, 10 sec eccentric phase and 2 sec concentric phase), Quadruped hip extension (2 sets x 10 reps each side), Standing hip flexor stretch (standing with stability ball between the buttock and wall patient leans back and reaches overhead bending from the hips, 1 set x 10 reps with 10 sec hold)

Neuro Re-Education

Wii Fit (2 Penguin Slide games, 1 Ski Slalom game, and 2 Soccer Heading games), Standing hip extension, abduction, and flexion (3 sets x 10 reps each leg while standing on Airex pad with green Theraband at ankle and using ski poles for upper extremity support), Double limb standing balance (on tilt-board in frontal plane, 1 set x 30 reps tapping from side to side), Wobble board (standing on wobble board with both feet 30 circles each way clock-wise and counter clock-wise), Rebounder throws (4 pound medicine ball thrown against trampoline and then caught by patient, 3 sets x 10 reps each side, patient in single leg stance, Standing on Dyna discs (equal weight on each leg, 1 set x 2 reps with 2 min hold),

Modalities Positioned in sitting; ice to right hip, x 15 min HEP

To be performed 1x per day: Hamstring stretch (1 set x 3 reps with 20 sec hold both legs), Hip flexor stretch (1 set x 3 reps with 20 sec hold both legs), Lateral walking (2 set x 10 steps each direction with blue Theraband at ankles), Sock stretch (1 set x 2 reps with 30 sec hold), Upright bike (30-60 min with moderate resistance), Scar tissue mobilization, Squats (3 sets x 10 reps in small range), Forward lunge (2 sets x 10 reps), Quadruped hip extension (2 sets x 10 reps each side)

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