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Chiropractic Journal of Australia : CJA December 2012
Chiropractic Journal of Australia Volume 42 Number 4 December 2012 133 FEMOROACETABULAR IMPINGMENT JAROSZ Table 2 PREHABILITATION PROGRAM EXERCISE PRESCRIPTION AND PROGRESSIONS SETS AND REPETITIONS • Stationary cycling • SB squat with resisted hip abduction* • Single leg step-down* • Supine bridge with resisted hip abduction* • Side-lying hip external rotation* • Side-lying straight leg abduction* • PHE* (with correct motor control patterns) • AIS to promote hip range of motion in all directions* 20 min 3x6-15a 3x6-15eachlega 3x6-15b 3x6-15eachlega 3x6-15eachlega 3x6-15eachlegb 2x10eachleg N.B.: The patient was encouraged to progress to the maximum number of repetitions for each exercise over a 4-week period prior to surgery. * = performed once daily a = each repetition occurs over 5-10 seconds; b = hold each repetition for 5-10 seconds; 5 seconds rest between repetitions; SB = Swiss-ball; PHE = prone hip extension; AIS = active isolated stretching program can provide clinically meaningful change in a patient with clinically diagnosed FAI.14 However, the results presented here revealed that the multi-modal chiropractic management approach did not improve hip internal rotation range of motion in the two patients where there was no surgical treatment intervention. This is supported by Emara et al15 who demonstrated that conservative treatment did not improve hip range of movement, despite improvement in patient function and symptoms. According to the literature, conservative therapy of FAI can achieve good results so long as patients can modify activities of daily living to adapt to their abnormal hip morphology.15 For the athletic population, this may require modifcation of specifc exercise and/or sports techniques.20 However, many athletes are unable to remove or modify their activities, and also have ambitions to return to their previous asymptomatic athletic endeavours. An initial period of conservative treatment is certainly recommended, but chiropractors should not dismiss the fact that many athletically inclined patients may require surgical intervention.20 It is the opinion of the author that the improved outcomes seen in Patient 1 (as compared with Patients 2 and 3) were related to the orthopaedic and multi-modal chiropractic co-management. It should be noted that the joint preservation surgery corrected the joint pathomechanics (by eliminating the underlying morphological abnormalities), and treated the associated acetabular cartilage and labral pathology present in Patient 1. Surgical treatment of FAI, whether Cam-type, pincer- type or a combination of both, not only relieves symptoms and encourages a return to athletic activity, it also improves prognosis of concomitant and pre-existing DJD, and ultimately may avert the progression of DJD.22,23 In cases of FAI that require orthopaedic intervention, chiropractors serve an important role in the early diagnosis, prehabilitation and post-surgical rehabilitation. Prehabilitation is the practice of improving the functional capacity of an individual to withstand a stressful event (e.g. surgery).24 According to the literature, prehabilitation is effective in enhancing postoperative functional ability, decreasing the risk of postoperative complications and hospital stay, and reducing the need for extensive inpatient rehabilitation.25,26 Swank et al27 demonstrated that 4-8 weeks of prehabilitation was effective for increasing leg strength and the ability to perform functional tasks in individuals with severe OA prior to total knee arthroplasty. Furthermore, Topp et al28 indicated that prehabilitation was effective at improving functional ability, decreasing pain, and increasing muscle strength after total knee arthroplasty surgery. FAI patients demonstrate specifc muscle weaknesses in hip adduction, fexion, external rotation and abduction, as well as restrictions in hip fexion and internal rotation in fexion range of motion.3,29 Therefore, FAI prehabilitation should be directed toward improving hip range of motion and increasing hip muscle strength. Post-surgical rehabilitation occurs at different rates depending on the specifc procedure performed, patient age, pre-injury health status and rehabilitation compliance. The patients pre-surgical health status and post-surgical goals/ physical demands will direct the rehabilitation program and its progressions.30 Edelstein et al30 developed a four phase guideline for rehabilitation following hip arthroscopy for FAI: (1) progressively regain 75% of full range of motion and normalise gait while respecting the healing process; (2) gain adequate lumbopelvic-hip control during low demand exercises, e.g. be able to achieve an uncompensated step up/ down on a 20cm box; (3) achieve a grade 5/5 on resisted manual muscle testing of all hip girdle musculature, and improve trunk stabilisation and body proprioception; and (4) return to a pain free competitive state and be asymptomatic following workouts. Importantly, it should be noted that
CJA September 2012
CJA March 2013