Hip Replacement Surgery: The Next Step, Rehab and Going Home

By Roberta Nubile

There is a simple prescription for successful rehabilitation after hip replacement surgery: Do your prescribed exercises faithfully; take your pain medication before the discomfort is too great; plan ahead for your home recovery period; and most importantly, don’t compare yourself with your cousin Ellen’s recovery, as each person, and each surgery, is unique.

David Copley, a physical therapist at the Visiting Nurses Association in Colchester, explains how each patient’s post-operative plan is developed. “An evaluation is done by the physician, specific to each individual. Some people go home direct from the hospital, some go to inpatient rehab, and some go to what is called a sub-acute rehabilitation facility. People have varying degrees in their need for nursing care and physical and occupational services.”

Nursing care may consist of medication checks, dressing changes, and blood pressure checks. Physical therapy focuses on specific exercises. And occupational therapists will work with the patient on activities of daily living. “With hip precautions, one can’t bend over to put on shoes and socks, so they must use tools and techniques to get dressed and bathe independently,” Copley explains.

The length and amount of these services vary widely depending on the patient’s physical progress and existing knowledge of the surgery and therapy. “Some have had the surgery before, some have read up on the Internet or even had a preoperative evaluation at home. Others are relying completely on that first home visit for information on the recovery process,” he notes.

Mary Lou Robinson, 63, underwent a left total hip replacement in January 2009 (see preceding article). She suffered from osteoarthritis brought on by “numerous childhood accidents and sports injuries, and a car accident. I had no tissue left in that joint.” Her rehabilitation story encompasses key components, such as careful planning, identification of resources like family and friends, and flexibility to deal with the unexpected.

Because she had stairs at home, Robinson chose to rent a room at the Comfort Inn for a week following the surgery. She was also proactive in organizing help for herself, arranging for her sister to stay with her. “She was my caregiver, that was our understanding. She helped with meals and phone messages, and lifted my left leg on the bed every time I laid down.” Other friends signed up to bring meals to Robinson as well. Physical therapists came to the Comfort Inn and taught her how to climb stairs in the stairwell.

Although Robinson had arranged to move to a friend’s house for a second week of recovery, she didn’t need to. “Once I was home, my roommate rolled up the carpet so I could use the walker easily. I used a special elevated seat in the bathroom, so I wouldn’t bend my hip past a right angle. After nine days, I could put my leg up on the bed myself, and I was compliant about going up and down stairs two times a day as directed.” Physical therapists continued to visit Robinson until her therapeutic goals were met.

The goals of postoperative home care focus on restoring mobility of the hip safely, building strength, and regaining a smooth walking gait. Some precautions Copley cited include not flexing the hip beyond a 90-degree angle, not internally rotating the leg beyond neutral, and not crossing the operation leg over the midline of the body. “Usually this means a patient will start off sleeping on their backs for the first week or two after surgery,” says Copley, “but with education, they can use pillows between knees toward the non-operated side, or sleep on their stomach, depending on their mobility.”

Robinson was diligent with her exercises. “I did everything I should do to rebuild my strength,” she says. “I was really happy to go back into my shop for the first time to get a pedicure. I didn’t go back to work until March, and started back to work slowly. I was at full capacity after five months when I’d graduated to a cane, which I still occasionally use when I’m tired.” When her home physical therapy prescription stopped, Robinson chose to continue at Dee Physical Therapy in South Burlington.

Even when it was difficult, Robinson didn’t get discouraged. “I walked for so long without a good hip joint that I was in bad shape hip-wise when I finally went in,” she says. “The thing I didn’t expect was that, as I did my exercises, I found other parts would hurt! For example, my knee would hurt then go away, then my sciatica in my right hip would start up and that would go away as well. With the realignment came other issues that flared up and eventually would go away. That part was a rocky road, but I pushed through it.”

Robinson took some typically prescribed postoperative pain medications, such as laxatives and opiates, but also attributes her successful rehabilitation to a variety of factors. “I did very well, mentally and emotionally, and I really surrendered to the whole experience. I felt secure because of my careful planning and being good with my exercises. I have a good immune system, I haven’t smoked since my early twenties, I take good supplements, and I get a massage once a month. I think all those things contributed to my healing. What I learned from this experience is that it is important to accept help when it is offered.”

Now, in September, Robinson says she has 90 to 95 percent function in her hip, and she’s doing pedicures again in her shop. “I’m still working at not going past right angles,” she says, “though it’s not imperative. The rule is, for about six months don’t bend greater than a right angle. I look forward to being at a hundred percent by November or December before the snow flies, and to not be worried about my footing with the snow and ice.”

Copley described the variety of hip replacement surgeries currently available as the largest change in his 18 years as a home physical therapist.

“While it’s great when people educate themselves prior to surgery,” Copley says, “they need to be aware that every surgery is different. Sometimes people get frustrated because their outcome or progress is not identical to their cousins’ or neighbors’. This is where it’s very helpful to work with their healthcare provider during recovery. They offer a perspective of experience and will know where the patient falls within the spectrum of recovery.”

Southern Vermont’s Polly Hennessey, 86, had her right hip replaced in 1999, and her left hip done this past year. This time, due to her functional level, she went to an inpatient rehabilitation facility for two weeks after leaving the hospital. When she went home, she continued to have physical therapy, as well as visiting nursing care, so her blood levels for her medication could be monitored.

“This time I knew what was going to happen,” Hennessey says, “but before, even though I came right home, I think it took me longer to get to walking right away. It seems like this time I recovered quicker.” Hennessey suffered a setback in July, when she had a slight stroke, which slowed down her exercise routine. Now she says, “My knees are stiffer, and not as steady.” Hennessey also had both knees replaced within two years, in between her hip surgeries.

Hennessey, used to living alone, prides herself on her self-sufficiency, but like Robinson, allows herself to accept help from others. “My son comes in every morning to check on me. I get my own meals. There is a lady who works in the [family business] office who takes me to appointments. One of my daughters comes every two weeks and does housecleaning and food shopping for me. I have a very conscientious family.”

One issue for some patients is the cost of equipment enabling a comfortable and speedy recovery. Some insurance plans cover part of the costs, but patients need to be familiar with their policies. A medical supply store such as Yankee Medical in Burlington supplies items such as raised toilet seats, commodes, tub benches, crutches, walkers, and hospital beds – depending on what is prescribed by the physician or physical therapists.

“Many come prior to surgery to buy their basic equipment,” says Claudine Deslandes, sales representative for Yankee Medical in Burlington. “We can’t rent it out because of infection guidelines, but some insurances will cover; the person has to check. Others buy it used through the Good Samaritan Shop at Fanny Allen or at Recycle North. We deliver the wheelchairs and larger items at no extra cost, but the smaller items can be brought home right from the store.”

“Private insurance coverage for hip replacement surgery doesn’t vary too much in terms of what they cover,” says Martha Brown, staff consultant for physical therapy at VNA. “Usually, it’s whatever is prescribed in terms of physical and occupational therapy, and nursing care, though they do require pre-authorization. Each case is specific to the patient’s prior functional status. Medicare does not require pre-authorization for the surgery, but for the home rehab services the patient must be deemed homebound after surgery – that it makes more sense to receive services at home.”

Current Bostonian Dan Williams, 47, had a left hip replacement done in 1995 at Dartmouth Hitchcock. The White River Jct. native found the physical rehabilitation process less difficult than he anticipated. “I was adamant and meticulous about following the hip precautions and prescribed exercises, because I knew it was very easy to undo what had been done.” But, for a young person in his thirties, Williams recalls “the immobility and the sheer boredom of being housebound were the hardest parts for me. I’d never been unemployed up to that point. I had visitors, I read books and watched movies, but this was in the pre 24/7 Internet days! I developed a ritual where I would walk to the village store on crutches and get the Times.”

It took Williams three months to return to work, and for the first month he was on a cane. “It took me four months to return to 100 percent function. I did a lot of swimming for exercise, as you have to avoid any sport that comes down hard repeatedly, like jogging or basketball. Now my hip still feels great. I only have a little pain when it rains. I really thought the whole thing would be harder than it was, but I almost went insane with the boredom.”

One unique option for patients in the greater Burlington area is the Rehab Gym, located in Colchester and Williston. “Our gym is a hybrid between an athletic club and a rehab clinic,” says co-owner Sharon Gutwin says. “And, because I employ physical therapists, my clients come either by physician’s order or on their own will. There doesn’t need to be a referral unless they are under Medicare.”

While Gutwin’s gym shares the same goals as a home physical therapist, Gutwin advocates for exercise beyond just the recovery period. “For us, it goes beyond rehabilitation of just the hip function. It is about getting people to the point where they can be outside walking for their overall health. Exercise is fundamentally the best thing for our bodies. It is key to preventing so many illnesses, like depression, high cholesterol, diabetes, and arthritis. It is the most underutilized medical treatment to keep people healthy.”

Rehab gyms such as Gutwin’s provide a way for hip patients to raise their level of fitness even higher than before surgery. As Gutwin points out, “The benefit over a regular gym is that when they come, they are under our supervision. We form relationships with them and keep them motivated. We change their program as needed, and make exercise desirable. After hip replacement rehab, often patients feel better after surgery than before.”

Hennessey sums up the best attitude for recovering from hip surgery. “My advice is not to worry. The more you move and work at and do exercises, it heals very quickly. I also think my determination got me through.”

Roberta Nubile lives and writes in Shelburne.