Clinical Consult

I am working with a 46 y/o female who underwent THR revision one week ago. While in the hospital the PT told her not to do SLR because of the negative impact of posterior glide of the femoral head. I have never heard of this and have always included SLR as a core exercise. I researched this question and could find no information. Does anyone know of a reference? Thank you for your help.

Terri Greenfield

 

Comments

[Arthur Veilleux, PT, DPT, OCS]

There may be legitimate reasons to question the value of the SLR, but I would think that if it was other than benign, even for patients with revisions, than there would be many, many patients in trouble.

[Bryan Cummings, PT, MS, OCS, ATC]

I'll look for a reference, but I was taught that the arthrokinematic motion during flexion and extension of a hip was a "spin" (no glide).

[Dale Avers]

Terri,
I suspect what the hospital PT was referring to was the excessive forces at the hip during a SLR. You might want to check this reference out.....Strickland E, Fares M, Krebs D, et al. In vivo acetabular contact pressures during rehabilitation, Part I: Acute phase. Physical Therapy. 1992;72(10):691-699.

Briefly, "A pressure-instrumented Moore-type endoprosthesis was implanted in a 73-year-old woman who had sustained a femoral neck fracture. Acetabular contact pressures during the first 2 weeks after surgery were rank-ordered. Clinical data, including range of motion, manual muscle test grade, use of pain medication, and independence in gait, were collected simultaneously. Acetabular pressures did not follow the predicted rank order corresponding to the commonly prescribed temporal order of inpatient rehabilitation activities. Isometric hip extension and active hip flexion generated the highest pressures of all the studied activities, including those measured during gait activities. Isometric exercises, therefore, may not be entirely benign preparation for ambulatory activity. Clinical data did not correspond with peak pressure data, suggesting that observed responses to rehabilitation may not be dependable criteria for progressing the acute hip rehabilitation protocol."

Dale

[David]

Consider the funtional utility of a straight leg raise relative to an elderly individuals needs. SLR might be useful in that the length of the leg would help them arise from a supine position when on their back; counter weight for upper body, with buttock as pivot/fulcrum.
During gait leg mass in barely horozontal to gravity requring much less force to bring the leg forward. Ambulation speed is usually low so angular acceleration reqirements are low also.
Another curious application of the mal utility of SLR might be in its effects on the lumbar spine. On initial raising the length of the torque arm (illioopsoas/pectinius) from the axis of rotation is very short and the leg mass is teribly far from the that axis. The resultant forces create compressive and shear at the lumbar spine that would seem quite high. This is a spine that has likely lost much of it passive stabilization, and nuclear preload on the annulus, could be destabilizing. In a stenotic spine, central or lateral, this may create symptoms.
I think in the same article as mentions above forces were high for supine abduction, really a SLR with little relative effect on abduction force generation.
I don't have much use for SLR's in any population but the young and/or athletic who can coordinate abdominal control and the length of the leg is a usefull level to create difficulty.
I've used what I term a psoas shear sign as an indicator of spinal instability. Sitting hip flexion moves the vector of psoas much closer to horozontal, and more parallel with end plates, setting up for reactivity to spondylitic forces.
David

[Marsha Rutland< PT, OCS]

I avoid SLR in my THR population during the first 3-4 weeks, which helps patients with the pain aspect as well. Articles to support forces on the hip are Strickland's article listed above, Given-Heiss DL,Krebs D, o"Riley P, et al. "In vivoacetabular contact pressures during rehabilitation, Part II: Post acute phase, Phys Therapy, 72(10), Oct. 1992:700-710. and Krebs D, Elbaum L, O'Riley P, etal; "Exercises and gait effects on in vivo hip contact pressures" Phys Ther, 71(4), Apr 1991: 301-309. Carol Lewis had a good article on THR in PT Forum in May 20, 1994 with these articles mentioned. She reported that David Krebs article "found that exercises involving maximal effort generated greater acetabular contact pressure than did gait. This suggests that gait training may be a more functional and safer activity than maximal exercises for THR pts." She also stated that SLR may be beneficial, but should be initiated once the patient has regained partial or full weight bearing.

[David Wise, PT, Ph.D]

Shirly Sahrmann in her book makes the point that hamstring unnopposed or "insufficiently" opposed by gluteus maximus can cause posterior glide of the femoral head in the acetabulum (a dominant synergist dysfunction). This, she says, occurs because there is a strong pull on the bottom of the femur without a balancing pull in the same direction at the proximal end. Maybe the hospital therapist was postulating there is a similar dominant synergistic dysfunction between rectus femoris and iliopsoas causing anterior glide. The iliopsoas would probably be inhibited following THR and the rectus femoris would be working hard during a SLR. I have not seen this in the literature. I am just speculating as two why a PT would suggest anterior glide during SLR.

[Jeff Hogan PT, MPT]

The avoidance of the SLR post-operatively may be related to the compressive forces on the acetabulum from the iliopsoas tension. In my experience with hip arthroscopies, the physician avoids the SLR for 6 to 8 weeks for this reason.

[Terri Greenfield]

Thank you all for the references and information. Given the sheer number of hip replacements performed each year, I am surprised by the dearth of evidence related to rehab issues/ contraindications. My experience with post-op SLR has been neutral. I have never had a surgeon state no SLR nor have I heard this issue brought up in continuing ed. At the very least this question has given me pause and a reason to research and reassess my own protocol parameters. I appreciate the input and initial guidance.