**3. Methodology of the study**

Thirty patients of the Department of Orthopedics and Traumatology of Přerov Hospital (SMN Přerov), branch of the business Středomoravská nemocniční a.s., took part in the study. In order to be included in the study the patients had to meet the following criteria: they had not undergone any endoprosthesis or lower extremities surgery in the past and they were not diagnosed with any mental illness or neurological disorder of central or peripheral nervous system.

"Only" 30 patients out of total 352 applicants who had undergone total hip joint replacement in Přerov Hospital met these criteria. Collecting data for this study took 12 months.

### **3.1. The CKC group (CKC=closed kinetic chain)**

The CKC group consisting of 15 patients (7 men and 8 women) of the Department of Orthopedics and Traumatology of SMN Přerov went through postoperative rehabilitation according to the Acral Coactivation Therapy principles. The average age of the patients was 59 ± 13.9 years.

#### **3.2. The OKC group (OKC=open kinetic chain)**

Also the OKC group included 15 patients (8 men and 7 women) of the Department of Orthopedics and Traumatology of SMN Přerov who underwent postoperative therapy, which is based mostly on open kinetic chain exercises, according to the standard procedures of SMN Přerov. The average age of the patients was 58 ± 9.7 years.

The probands were divided into individual groups by means of adaptive randomization. At the beginning of the study both groups of the patients did not differ considerably in terms of the observed parameters (**Table 1**). At-entry differences of the observed groups did not show any statistical significance.

### **3.3. The CKC group therapy**

stimuli increases. Movement patterns in closed kinetic chains are involved. Due to increasing demand on movement patterns the CNS is forced to choose an adequate movement pattern in

The closed kinetic chain activities provide the basis for postural presumptions of all motor activities of a child. The open kinetic chain motor activity is focused mainly on movements

Many authors consider learning and mastering closed kinetic chain (CKC) activities as a factor indispensable for carrying out physiological movements in an open kinetic chain (OKC). It means that the therapy itself should start in a position which is relatively easy for muscle chain activation, i.e. applying pressure. Closed kinetic chain movements optimize activity of the engaged muscle groups. Correct involvement of muscle groups as well as centration of key joints in closed kinetic chains requires correct physiological position of the trunk and the limbs. The ACT method uses mainly closed kinetic chain movements since many authors

The Acral Coactivation Diagnostics (ACD) is irreplaceable in the Acral Coactivation Therapy. It includes evaluation of position of upper and lower extremities and straightening of the

terms of its economy and function [7, 13–15].

164 Total Hip Replacement - An Overview

with a particular purpose, i.e. teleological movements [3, 4, 7, 13].

**Figure 2.** Evaluation of arches of the hand and the foot by means of the ACD.

consider them more functional, thus more effective in the therapy [3–5, 7].

The CKC group therapy followed the basic principles of the Acral Coactivation Therapy. The rehabilitation plan consisted of (on average) six 30-min workout units under the guidance of a qualified physiotherapist who supervised quality of the carried out motor patterns. The therapy itself began the second postoperative day and continued until the patients were discharged and took part in subsequent rehabilitation treatment.


**Table 1.** Entry parameters.

The managed therapy took place only during working hours of the physiotherapist (i.e. working days). In order to improve quality the patients got an aid: Functional Hand Arch Support (only for the purpose of the managed therapy). These gloves, specially tailored for the ACT method, maintain optimum setting of arches of the hand. Outside the time set aside for the therapy (i.e. at weekends, in free time) the probands carried out autotherapy according to the ACT without the physiotherapist's intervention. For these purposes the patients got the publication of The Acral Press Up Exercises for Straightened Spine where the ACT positions used in the therapy were marked. First, the patients carried out all the safe exercises in the managed therapy conducted under the guidance of a physiotherapist to avoid wrong fixation of motor patterns and subsequent errors in autotherapy. The therapy took place in SMN Přerov in the gym of the department of orthopedics and traumatology. This place was calm with suitable conditions for working out. Selected positions from the CKC group therapy are depicted in **Figures 3**–**10**.

**Figure 4.** A press up on the healthy hip: Static coactivation.

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**Figure 5.** A press up in the low oblique sitting: Static coactivation.

**Figure 6.** A press up on all fours: Static coactivation.

#### **3.4. List of CKC group static positions and their variants**

When selecting static positions for therapy in a closed kinetic chain we took into consideration regime measures (anti-luxation regime) that the patients had to observe. The applied positions were chosen from the publication of The Acral Press Up Exercises for Straightened Spine in order to make autotherapy easier [16].

**Figure 3.** A press up in the supine position variant of flexion: Static coactivation.

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**Figure 4.** A press up on the healthy hip: Static coactivation.

The managed therapy took place only during working hours of the physiotherapist (i.e. working days). In order to improve quality the patients got an aid: Functional Hand Arch Support (only for the purpose of the managed therapy). These gloves, specially tailored for the ACT method, maintain optimum setting of arches of the hand. Outside the time set aside for the therapy (i.e. at weekends, in free time) the probands carried out autotherapy according to the ACT without the physiotherapist's intervention. For these purposes the patients got the publication of The Acral Press Up Exercises for Straightened Spine where the ACT positions used in the therapy were marked. First, the patients carried out all the safe exercises in the managed therapy conducted under the guidance of a physiotherapist to avoid wrong fixation of motor patterns and subsequent errors in autotherapy. The therapy took place in SMN Přerov in the gym of the department of orthopedics and traumatology. This place was calm with suitable conditions for working out. Selected positions from the CKC group therapy are depicted in **Figures 3**–**10**.

When selecting static positions for therapy in a closed kinetic chain we took into consideration regime measures (anti-luxation regime) that the patients had to observe. The applied positions were chosen from the publication of The Acral Press Up Exercises for Straightened Spine

**3.4. List of CKC group static positions and their variants**

**Figure 3.** A press up in the supine position variant of flexion: Static coactivation.

in order to make autotherapy easier [16].

**Table 1.** Entry parameters.

166 Total Hip Replacement - An Overview

**Figure 5.** A press up in the low oblique sitting: Static coactivation.

**Figure 6.** A press up on all fours: Static coactivation.

**Figure 7.** A press up in the sitting position, initial stage of dynamic transition from the sitting to the standing position.

**Figure 9.** A press up in the standing position with 2 forearm crutches; putting a foot forward on the step: Static

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**Figure 10.** A press up in the standing position with 2 forearm crutches, extension against the wall: Static coactivation.

coactivation.

**Figure 8.** A final stage of dynamic transition from the sitting to the standing position.

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**Figure 9.** A press up in the standing position with 2 forearm crutches; putting a foot forward on the step: Static coactivation.

**Figure 7.** A press up in the sitting position, initial stage of dynamic transition from the sitting to the standing position.

168 Total Hip Replacement - An Overview

**Figure 8.** A final stage of dynamic transition from the sitting to the standing position.

**Figure 10.** A press up in the standing position with 2 forearm crutches, extension against the wall: Static coactivation.


**1.** A press up from the supine to the side-lying position.

standing position (hands on thighs – the CKC).

**1.** A press up from the supine to the lateral position. **2.** A press up from the lateral to the prone position.

leg); with support of 1 forearm crutch if needed.

port of a chair or a forearm crutch if needed).

therapist, next the exercises became part of their autotherapy.

• flex your feet, straighten your knees and squeeze your buttocks

• move the extended leg sideways (on the bed) and back to the body axis

**3.6. The OKC group therapy**

**the SMN Přerov standards**

• point and flex your feet rhythmically

1. In the supine position

with an arm and having lower extremities hanging off the bed.

the sitting position with lower extremities hanging off the bed.

**3.** A press up from the prone position to the position on all fours.

**4.** A press up from the position on all fours to the upright kneeling position.

**2.** A press up from the lateral to the side-lying position while pressing up the upper body

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**3.** A press up from the side-lying position while pressing up the upper body with an arm to

**4.** A press up from the sitting position with lower extremities hanging off the bed to the

Dynamic transitions for verticalization from the supine to the standing position (from the floor).

**5.** A press up from the upright kneeling position to putting the foot forward (i.e. the healthy

**6.** A press up from the position of having a foot forward to the standing position (with sup-

Also the patients in this group went through managed (on average) six 30-min workout units. These patients worked out according to the standardized SMN Přerov rehabilitation plan intended for patients after total hip joint replacement. The exercises were analytical exercises mostly in an open kinetic chain, without a direct link to the ADL therapy. The beginning and the end of the therapy collided with the CKC group. In order to maintain the same conditions this group worked out in the same gym of the department of orthopedics and traumatology of Přerov Hospital as well. In their free time the probands performed autotherapy based on a list of standardized SMN Přerov exercises intended for patients after total hip joint replacement (see below). First, the patients carried out all the exercises under the guidance of a physio-

**3.7. The list of exercises for patients after total hip joint replacement according to** 


#### **3.5. List of dynamic transitions in the CKC group**

The patients carried out dynamic transitions from individual press up (static) positions. These were functional dynamic changes in positions according to the ACT principles. Two sets of dynamic transitions selected in advance were applied. Dynamic transitions were chosen on the basis of the similarity principle in order to evoke the movement patterns the patients used in ADL. The therapy was aimed at integration of physiological movement patterns into motor expression of the patients in ADL [16].

Dynamic transitions for verticalization from the supine to the standing position (i.e. getting up from the bed).

**1.** A press up from the supine to the side-lying position.

**1.** A press up in the supine position and its variants:

• alternating flexion of lower extremities in the CKC

**4.** A press up in the prone position and its variants:

**5.** A press up in the position on all fours and its variants:

• alternating flexion and extension of lower extremities

**7.** A press up while sitting on the chair and its variants:

**3.5. List of dynamic transitions in the CKC group**

**6.** A press up in the upright kneeling position.

(after mastering the OKC exercises)

expression of the patients in ADL [16].

up from the bed).

• pressing up on all fours while lifting the knees above the floor

• abduction of lower extremities while lifting the knees above the floor

**8.** A press up while standing with two forearm crutches and its variants:

(after mastering the OKC exercises)

170 Total Hip Replacement - An Overview

lower extremities and its variants:

• alternating knee joint flexion

• gait movement pattern: alternating flexion and extension of lower extremities in the CKC

**2.** A press up in the side-lying position (lying on the healthy hip) with neutral position of

• gait movement pattern: alternating flexion and extension of lower extremities in the CKC

• putting a foot forward on the step (alternating lower extremities) with subsequent support

The patients carried out dynamic transitions from individual press up (static) positions. These were functional dynamic changes in positions according to the ACT principles. Two sets of dynamic transitions selected in advance were applied. Dynamic transitions were chosen on the basis of the similarity principle in order to evoke the movement patterns the patients used in ADL. The therapy was aimed at integration of physiological movement patterns into motor

Dynamic transitions for verticalization from the supine to the standing position (i.e. getting

• training of extension while leaning against the wall (alternating lower extremities)

**3.** A press up in the side-lying position while pressing up the upper body with an arm.

• abduction of the operated leg in the CKC after mastering OKC exercises


Dynamic transitions for verticalization from the supine to the standing position (from the floor).


#### **3.6. The OKC group therapy**

Also the patients in this group went through managed (on average) six 30-min workout units. These patients worked out according to the standardized SMN Přerov rehabilitation plan intended for patients after total hip joint replacement. The exercises were analytical exercises mostly in an open kinetic chain, without a direct link to the ADL therapy. The beginning and the end of the therapy collided with the CKC group. In order to maintain the same conditions this group worked out in the same gym of the department of orthopedics and traumatology of Přerov Hospital as well. In their free time the probands performed autotherapy based on a list of standardized SMN Přerov exercises intended for patients after total hip joint replacement (see below). First, the patients carried out all the exercises under the guidance of a physiotherapist, next the exercises became part of their autotherapy.

#### **3.7. The list of exercises for patients after total hip joint replacement according to the SMN Přerov standards**


computer-based evaluation of B.E.S.S. The studies show that the MobileMat™ programme can run a more precise analysis of B.E.S.S., in particular lifting a part of the foot off the force plate, lifting an arm from the base position or changing the position of a non-weight bearing hip (i.e. when standing only on the other leg). However, MobileMat™ programme cannot evaluate if the testee closes their eyes. In this case, this factor is supervised by a qualified physiotherapist [17–19].

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Evaluation of postural stability took place in a calm environment of the department of orthopedics and traumatology in the gym of SMN Přerov. The measurement included three positions that were repeated three times by the probands. With regard to an early postoperative stage alternative positions were chosen (see below) which could be carried out by the patients without being exposed to dangerous positions or inadequate physical load of the operated leg. The patients held each position for 20 seconds and had their eyes closed during the whole measurement.

1. Standing with feet hip-width apart on both feet; the entire feet are in touch with the Teks-

**2.** Standing on both lower extremities, in tandem left forward position; the entire feet are in touch with the Tekscan force plate; standing straight with the hands on the hips.

**3.** Standing on both lower extremities, in tandem right forward position; the entire feet are in touch with the Tekscan force plate; standing straight with the hands on the hips.

Two physiotherapists made measurement while one of them operated the computer and the other one supervised correct posture of the probands in the selected positions. Due to personnel reasons the persons who were not familiar with classification of the probands into the test groups could not make measurement. Evaluation was carried out properly without any intervention leading to distorting results. Measurement was performed 1 day before surgery, the fourth postoperative day and finally on the tenth postoperative day (i.e. the last day of the managed rehabilitation). During evaluation of postural stability the measured values of the

Both groups had the same average values, i.e. 5.3 postural errors, during entry measurement. In the postoperative stage the CKC group showed 5.1 errors per patient, while the OKC group had 3.5 errors on average. The measured values were entered in a table (see **Table 2**). **Graph 1**

The final measurement showed a significant statistical difference (p = 0.008975) between the entry values of the individual groups. The CKC group reached 1.2 error, while the OCK group had 4.1 errors on average. This difference shows also high effect size (Cohen's d = 0.875). Non-parametric

A day before surgery a qualified physiotherapist evaluated functional skills of the patients according to the Functional Test Questionnaire (see **Table 3**). This specific questionnaire was

Mann–Whitney U test was used to determine statistical significance of two selected files.

individual positions were counted up and the arithmetic mean was calculated.

shows the differences in the reached B.E.S.S. values of the observed groups.

*3.8.2. Evaluation of the patient functional movement skills*

can force plate; standing straight with the hands on the hips.

*3.8.1.1. Selected positions*


#### **3.8. Common therapy**

Both groups of probands went through the same locomotion training using stairs and mobility aids, i.e. two forearm crutches in this case. Another common therapy element was practising forward bends (picking things up off the floor) while extending the operated hip joint.

#### *3.8.1. Evaluation of postural stability by means of MobileMat™ Programme*

Postural stability and reactivity was evaluated by means of a force plate by Tekscan using the MobileMat™ programme. This programme works on the Balance Error Scoring System (B.E.S.S.) principle developed by researchers Guskiewitz, Riemann and Shields.

MobileMat™ programme was developed mainly in order to improve the accuracy of B.E.S.S. evaluation, which can be influenced by a human factor, i.e. subjective inputs of a testee. It is a computer-based evaluation of B.E.S.S. The studies show that the MobileMat™ programme can run a more precise analysis of B.E.S.S., in particular lifting a part of the foot off the force plate, lifting an arm from the base position or changing the position of a non-weight bearing hip (i.e. when standing only on the other leg). However, MobileMat™ programme cannot evaluate if the testee closes their eyes. In this case, this factor is supervised by a qualified physiotherapist [17–19].

Evaluation of postural stability took place in a calm environment of the department of orthopedics and traumatology in the gym of SMN Přerov. The measurement included three positions that were repeated three times by the probands. With regard to an early postoperative stage alternative positions were chosen (see below) which could be carried out by the patients without being exposed to dangerous positions or inadequate physical load of the operated leg. The patients held each position for 20 seconds and had their eyes closed during the whole measurement.

#### *3.8.1.1. Selected positions*

• bend the knee (i.e. move the heel along the bed)

• lie on your side and raise your top leg

body

**2.** In the prone position

172 Total Hip Replacement - An Overview

• lift the entire extended leg

• raise your feet slightly

• stand on your toes

**3.8. Common therapy**

**4.** Standing at the head of the bed:

• move your operated leg sideways and back

• extend your operated leg backwards

• flex your operated hip (no more than 90 degrees)

• bend the knees, put a pillow between them and squeeze you knees together

• squeeze your buttocks and push your pelvis toward the floor

• push your toes to the floor and straighten your knees

• alternate flexion and extension of your knees

**3.** Sitting with legs hanging off the bed

• bend your knees, lift your buttocks (hold for a few seconds), your arms rest along your

• straighten your knee while pushing your thigh toward the bed (hold for a few seconds)

Both groups of probands went through the same locomotion training using stairs and mobility aids, i.e. two forearm crutches in this case. Another common therapy element was practising forward bends (picking things up off the floor) while extending the operated hip joint.

Postural stability and reactivity was evaluated by means of a force plate by Tekscan using the MobileMat™ programme. This programme works on the Balance Error Scoring System

MobileMat™ programme was developed mainly in order to improve the accuracy of B.E.S.S. evaluation, which can be influenced by a human factor, i.e. subjective inputs of a testee. It is a

• put your hands on your thighs, squeeze your buttocks and then release

*3.8.1. Evaluation of postural stability by means of MobileMat™ Programme*

(B.E.S.S.) principle developed by researchers Guskiewitz, Riemann and Shields.


Two physiotherapists made measurement while one of them operated the computer and the other one supervised correct posture of the probands in the selected positions. Due to personnel reasons the persons who were not familiar with classification of the probands into the test groups could not make measurement. Evaluation was carried out properly without any intervention leading to distorting results. Measurement was performed 1 day before surgery, the fourth postoperative day and finally on the tenth postoperative day (i.e. the last day of the managed rehabilitation). During evaluation of postural stability the measured values of the individual positions were counted up and the arithmetic mean was calculated.

Both groups had the same average values, i.e. 5.3 postural errors, during entry measurement. In the postoperative stage the CKC group showed 5.1 errors per patient, while the OKC group had 3.5 errors on average. The measured values were entered in a table (see **Table 2**). **Graph 1** shows the differences in the reached B.E.S.S. values of the observed groups.

The final measurement showed a significant statistical difference (p = 0.008975) between the entry values of the individual groups. The CKC group reached 1.2 error, while the OCK group had 4.1 errors on average. This difference shows also high effect size (Cohen's d = 0.875). Non-parametric Mann–Whitney U test was used to determine statistical significance of two selected files.

#### *3.8.2. Evaluation of the patient functional movement skills*

A day before surgery a qualified physiotherapist evaluated functional skills of the patients according to the Functional Test Questionnaire (see **Table 3**). This specific questionnaire was


**Table 2.** B.E.S.S. evaluation.

**Graph 1.** Results of the balance error scoring system explanatory notes: B.E.S.S. 1-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (preoperative measurement), B.E.S.S. 2-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (postoperative measurement), B.E.S.S. 3-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (after termination of the managed rehabilitation), SK CKC-the CKC group, SK OKC-the OKC group.

developed solely for the purpose of this study. The Functional Test Questionnaire included those movement patterns that the patients used in ADL. Evaluation of functional movement skills consisted in assessment of a manner of execution of the selected movement patterns. Finally, these results were quantified in the questionnaires. The highest achievable score was 50.

average value of 35.5 points of functional skills at the beginning of the research. The average reached value after surgery was 7.3 points. However, the OKC group reached only 17.1 points

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**Table 4** shows results of the individual measurements. In order to visualize the results a graph (see **Graph 2**) was developed in order to depict changes in the result values of both groups.

The difference between exit values (i.e. those measured after termination of rehabilitation) of the individual groups was statistically significant (p = 0.00001). This result showed also a significant effect size (Cohen's d = 4.04). Non-parametric Mann–Whitney U test was used to

on average within the final measurement.

**Table 3.** Functional tests.

determine statistical significance of two selected files.

Functional skills were evaluated again on the fourth postoperative day in order to visualize the differences between the preoperative and postoperative physical condition of the patients. Exit measurement took place on the tenth postoperative day (i.e. the last day of the managed rehabilitation). The testing was done by one qualified physiotherapist in order to avoid data distortion.

Before surgery the CKC group patients reached 36.1 points on average. The fourth postoperative day the average value of functional skills fell to 11.1 points. However, the patients reached 38.1 points on average within the final measurement. The OKC group showed an Physical Therapy Based on Closed Kinematic Chain Patterns for Patients after Total Hip… http://dx.doi.org/10.5772/intechopen.76756 175


**Table 3.** Functional tests.

developed solely for the purpose of this study. The Functional Test Questionnaire included those movement patterns that the patients used in ADL. Evaluation of functional movement skills consisted in assessment of a manner of execution of the selected movement patterns. Finally, these results were quantified in the questionnaires. The highest achievable score was 50. Functional skills were evaluated again on the fourth postoperative day in order to visualize the differences between the preoperative and postoperative physical condition of the patients. Exit measurement took place on the tenth postoperative day (i.e. the last day of the managed rehabilitation). The testing was done by one qualified physiotherapist in order to avoid data

**Graph 1.** Results of the balance error scoring system explanatory notes: B.E.S.S. 1-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (preoperative measurement), B.E.S.S. 2-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (postoperative measurement), B.E.S.S. 3-evaluation of postural errors according to the balance error scoring system in the MobileMat™ programme (after termination of the managed rehabilitation), SK CKC-the CKC group, SK OKC-the OKC group.

Before surgery the CKC group patients reached 36.1 points on average. The fourth postoperative day the average value of functional skills fell to 11.1 points. However, the patients reached 38.1 points on average within the final measurement. The OKC group showed an

distortion.

**Table 2.** B.E.S.S. evaluation.

174 Total Hip Replacement - An Overview

average value of 35.5 points of functional skills at the beginning of the research. The average reached value after surgery was 7.3 points. However, the OKC group reached only 17.1 points on average within the final measurement.

**Table 4** shows results of the individual measurements. In order to visualize the results a graph (see **Graph 2**) was developed in order to depict changes in the result values of both groups.

The difference between exit values (i.e. those measured after termination of rehabilitation) of the individual groups was statistically significant (p = 0.00001). This result showed also a significant effect size (Cohen's d = 4.04). Non-parametric Mann–Whitney U test was used to determine statistical significance of two selected files.


**Table 4.** Evaluation of movement skills (Functional tests).

**Graph 2.** Results of the functional tests explanatory notes: FT 1-functional tests (preoperative measurement), FT 2-functional tests (postoperative measurement), FT 3-functional tests (final measurement after rehabilitation), SK CKCthe CKC group, SK OKC-the OKC group.

Within the entry measurement of the Harris Hip Score the CKC group reached 48.4 points on average. The OKC group's average score in the questionnaire was 52.8. Both groups reached equal values in the postoperative measurement, i.e. 40.5 points per patient on average. The measured values were entered in a table (see **Table 5**). **Graph 3** shows the differences between

**Graph 3.** Harris hip score results explanatory notes: HHS 1 - Harris hip score (preoperative measurement), HHS 2 - Harris hip score (postoperative measurement), HHS 3 - Harris hip score (final measurement after rehabilitation), SK

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The exit measurement showed a significant statistical difference (p = 0.00001), where the CKC group reached 78.4 points and the OKC group 54.2 points on average. This difference showed also a high effect size (Cohen's d = 3.63). Non-parametric Mann–Whitney U test was used to

The Harris Hip Score questionnaire has been used in the department of orthopedics and traumatology of SMN Přerov since the beginning of 2015 and it replaced the Staffel Score questionnaire used formerly, which is not globally recognized and is less specific in terms of

the reached values of the individual group.

CKC – The CKC group, SK OKC – The OKC group.

**Table 5.** Harris Hip Score values.

evaluation activities of daily living.

determine statistical significance of two selected files.

*3.8.3.1. Two-year study assessing Harris hip score results*

#### *3.8.3. Objectivization of the closed kinetic chain therapy results based on the Harris hip score*

The patients who took part in the study filled in a Harris Hip Score questionnaire before their surgery. This is a specialized questionnaire assessing skills within ADL in patients with hip joint diseases (arthrosis, necrosis of the ball). William H. Harris developed this questionnaire in order to evaluate level of pain and movement skills of patients before and after surgery. For the purpose of our study a modified version of the questionnaire was used, i.e. evaluation of the range of motion of the hip joint. The highest achievable score is 100. If a patient reaches 70 points or less, their physical condition is considered bad. Willim H. Harris considered a surgery successful when the score reached after surgery was at least 20 points higher than before surgery [20–24].

The patients filled in the Harris Hip Score questionnaire again on the fourth postoperative day in order to visualize the difference between the preoperative and postoperative physical condition. The final evaluation took place on the last day of the managed rehabilitation, i.e. on the tenth postoperative day.

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**Table 5.** Harris Hip Score values.

*3.8.3. Objectivization of the closed kinetic chain therapy results based on the Harris hip score*

before surgery [20–24].

on the tenth postoperative day.

the CKC group, SK OKC-the OKC group.

**Table 4.** Evaluation of movement skills (Functional tests).

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The patients who took part in the study filled in a Harris Hip Score questionnaire before their surgery. This is a specialized questionnaire assessing skills within ADL in patients with hip joint diseases (arthrosis, necrosis of the ball). William H. Harris developed this questionnaire in order to evaluate level of pain and movement skills of patients before and after surgery. For the purpose of our study a modified version of the questionnaire was used, i.e. evaluation of the range of motion of the hip joint. The highest achievable score is 100. If a patient reaches 70 points or less, their physical condition is considered bad. Willim H. Harris considered a surgery successful when the score reached after surgery was at least 20 points higher than

**Graph 2.** Results of the functional tests explanatory notes: FT 1-functional tests (preoperative measurement), FT 2-functional tests (postoperative measurement), FT 3-functional tests (final measurement after rehabilitation), SK CKC-

The patients filled in the Harris Hip Score questionnaire again on the fourth postoperative day in order to visualize the difference between the preoperative and postoperative physical condition. The final evaluation took place on the last day of the managed rehabilitation, i.e.

**Graph 3.** Harris hip score results explanatory notes: HHS 1 - Harris hip score (preoperative measurement), HHS 2 - Harris hip score (postoperative measurement), HHS 3 - Harris hip score (final measurement after rehabilitation), SK CKC – The CKC group, SK OKC – The OKC group.

Within the entry measurement of the Harris Hip Score the CKC group reached 48.4 points on average. The OKC group's average score in the questionnaire was 52.8. Both groups reached equal values in the postoperative measurement, i.e. 40.5 points per patient on average. The measured values were entered in a table (see **Table 5**). **Graph 3** shows the differences between the reached values of the individual group.

The exit measurement showed a significant statistical difference (p = 0.00001), where the CKC group reached 78.4 points and the OKC group 54.2 points on average. This difference showed also a high effect size (Cohen's d = 3.63). Non-parametric Mann–Whitney U test was used to determine statistical significance of two selected files.

#### *3.8.3.1. Two-year study assessing Harris hip score results*

The Harris Hip Score questionnaire has been used in the department of orthopedics and traumatology of SMN Přerov since the beginning of 2015 and it replaced the Staffel Score questionnaire used formerly, which is not globally recognized and is less specific in terms of evaluation activities of daily living.


Patients undergo total hip joint replacement in particular in order to improve the quality of their life. On the grounds of our study's results it can be stated that the ACT based therapy, compared with the open kinetic chain therapy, influences the quality of the patients´ life after

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I would like to thank to my co-workers from the department of rehabilitation and the department of orthopedics and traumatology of SMN Přerov for their cooperation on development

1 Rehabilitation Department, Středomoravská nemocniční a.s, Přerov Hospital, Czech

2 ACT centrum s.r.o., Postgraduate Education Centre, establishment accredited by the

3 Department of Orthopaedics and Traumatology, Středomoravská nemocniční a.s, Přerov

4 Faculty of Health in Bánska Bystrica, St Elizabeth College of Health and Social Work in

[1] Cannale TS, Beaty JH. Campbell's Operative Orthopaedics, 12th ed. Philadelphia:

[2] Dungl P.A Kol. Ortopedie. Praha: Grada Publishing, a.s; 2005. 1273 p. ISBN 80-247-0550-8 [3] Dvořák D. Některé teoretické poznámky k problematice otevřených a uzavřených biomechanických řetězců. In: Rehabilitace a fyzikální lékařství. Praha; ČSL JEP: 2005a;**12**(1):

[4] Dvořák D. Otevřené a uzavřené biomechanické řetězce v kinezioterapeutické praxi. In: Rehabilitace a fyzikální lékařství. Praha: ČSL JEP; 2005b:**12**(1):18-22. ISSN 1211-2658 [5] Enoka RM. Neuromechanics of Human Movement (4th). Champaign, United States:

Human Kinetics Publishers; 2008. 560 p. ISBN 978-07-360-6679-2

, Pavel Přikryl<sup>3</sup>

, Šárka Tomková<sup>4</sup>

and

http://dx.doi.org/10.5772/intechopen.76756

179

total hip joint replacement in a significant way.

\*, Ingrid Palaščáková Špringrová<sup>2</sup>

\*Address all correspondence to: mgrjanvagner@gmail.com

Ministry of Health of the Czech Republic, Praha, Czech Republic

Bratislava, Slovak Medical University in Bratislava, Slovakia

Mosby; 2013. 4253 p. ISBN 978-0-323-07243-4

5 Department of Orthopaedics, Kroměříž Hospital, Czech Republic

**Acknowledgements**

of this study.

Jan Vagner<sup>1</sup>

Rafi Moheb<sup>5</sup>

Republic

**References**

**Author details**

Hospital, Czech Republic

12-17. ISSN 1211-2658

**Table 6.** Harris Hip Score results of two-year observation.

On the grounds of the two-year research efficacy of the therapy based on the ACT principles, i.e. therapy in a closed kinetic chain, was assessed. In order to get long-term results the time during which the patients filled in the questionnaire was modified.

The first time the patients filled in the questionnaires was standard, i.e. 1 day before surgery, next after termination of the managed rehabilitation in the department of orthopedics and traumatology of SMN Přerov (6 therapies on average) and the last time was 4 months after hip joint replacement, i.e. within a regular orthopedic check-up. The patients were observed from the beginning of 2015 until the end of 2016. During this period 168 patients who underwent total hip joint replacement went through the therapy based on the ACT principles. The measured values were entered into a table (see **Table 6**). Before surgery the patients had 43.3 points of Harris Hip Score, after termination of the managed rehabilitation they reached 74.3 points on average. After leaving the department of orthopedics and traumatology of SMN Přerov the patients started subsequent rehabilitation treatment, they followed up the existing therapy and went on improving their functional and conditional skills. Within the regular orthopedic check-up, i.e. during the fourth month after surgery, the patients reached on average 94 points in the Harris Hip Score questionnaire.

The benefit of the therapy applied in a CKC consists mainly in relatively easy performance and understanding of exercises which can be modified according to the skills and needs of an individual. The therapy based on the ACT principles helps to reduce subjective perception of pain and to improve motor skills in patients. Patient satisfaction with surgery depends on improvement of the quality of their life, i.e. on reduction or elimination of pain and renewal of motor skills they could do with a healthy hip joint [25–29].
