A goal orientated Pilates Program to improve strength in the hip joint following Total

Hip Arthroplasty- A case report

Lisa-Mari De Villiers

October 2nd, 2017

2016 Vancouver

Abstract

Osteoarthritis (OA) is degenerative joint disease involving the cartilage and surrounding

structures. OA of the hips and knees cause the greatest burden to the population as pain

and stiffness in these joints may cause disfunction and may require surgical intervention.

One in 4 people may develop symptomatic hip osteoarthritis in his or her lifetime. The total

number of replacement surgeries are increasing while the average age of candidates

receiving surgery are decreasing, especially in younger and more active individuals who

want to stay active and maintain good, pain free range of motion (ROM) of their joints. By

the year 2030 it is estimated that more than 4 million people would receive replacement

surgery annually.

In South Africa, the costs of private care and medical aids are rising and there is a

demanding need for earlier functional recovery post total hip replacement (THR) surgery

by a younger population. Consequently, there is an increased need for cost effective

outpatient intervention, specifically exercise programs as an alternative or as a

supplementary to rehabilitation. It would make sense to say that younger clients would

benefit from a more aggressive approach to post operative rehabilitation as they have

more functional demands and have higher implant life expectancy. The goal of

rehabilitation for these younger patients in the long-term is to maintain a good functional

hip for as long as possible without having to undergo revision surgery.

In this case report a goal orientated pilates based exercise program was used to improve

hip control in a 48 year old female patient 6 weeks post total hip arthroplasty surgery.

Taking hip replacement precautions into consideration, a 6 weeks exercise program was

compiled after assessing the patient’s ability to perform simple functional strength tests as

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� well as performing some basic fundamental pilates exercises. The necessary adaptations 3

and modifications were made to protect the joint and to ensure gradual strengthening to

improve hip control especially during Gait.

After 6 weeks of Pilates training and a thorough re-assessment it was found that there was

an improvement in the performance of the functional tests, as well as an improvement in

the quality of movement when performing the pilates exercises. Functionally there was an

overall improvement in Gait, demonstrating better hip control and balance.

The aim of this study is to prove that a goal orientated pilates program could be useful in

improving and addressing weakness in the hip joint complex and improve overall

functional ability of the hip joint following hip replacement surgery.

Table of Contents

1. Introduction

2. Anatomy of the hip joint and THR

3. Client History

4. Physiotherapy Assessment

5. Therapeutic Approach and Goal setting

6. Conditioning Program

7. Results

8. Conclusion

9. References

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1. Introduction

OA of the hips and knees could be described as the greatest burden to society mainly due

to the rising costs of health care. Pain and stiffness in these weight baring joints often lead

to significant disability requiring surgical intervention.

Arthroplasty for the management of hip OA is increasing in frequency. It has been shown

to to improve pain, disability, function, physical activity and quality of life (QOL). There has

been a shift from hip replacements for the crippled elderly mainly to an increasing younger

generation presenting with OA, wanting to improve their QOL as well as wanting to

continue physically demanding activities. Improvements in the prosthetic design also

contributes to an increased demand for surgery. Candidates for THR’s require a more

complex management strategy in terms of rehabilitation. They have higher functional and

physical demands.

Because most individuals receiving THR surgery have had pain and dysfunctional walking

patterns for a period of time before the operation, it is evident that there would also be

significant weakness of surrounding muscles of the hip joint even after surgery. A strong

emphasis is placed on strengthening the muscles around the hip for better hip control and

to improve functional recovery.

Due to limited evidence exercise programs appear to be based on clinical experience and

surgeon preference. However some evidence have shown that an eight week exercise

program focussing on strength and stability around the hip joint, resulted in a statistically

significant improvement in function and muscle strength in patients between 4 and 12

months post THR surgery. It has also been suggested in this study that patients should

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continue with functional strengthening exercise programs for at least one year after the

surgery and that the program should be progressed as function improved.

Pilates as an exercise approach could be useful in the management of THR’s. According

to a study by Levine et al 2009, the pilates method provides simple goal orientated

exercises resulting in a whole body approach to rehabilitation, and could be easily

modified to meet each clients individual needs with specific precautions taken into

consideration. These exercise could easily be progressed and made more difficult as the

clients function improves. Furthermore in this study, 38 patients were using Pilates as a

form of rehabilitation post joint arthroplasty, 21 of which were THR’s. At one year follow up,

it was revealed that 25 clients were extremely satisfied with the outcome of using pilates in

their rehabilitation. There were no dissatisfying or somewhat satisfying feedback from the

group.

Pilates also known as “contrology” puts emphasis on strengthening the core of the body.

This is also referred to as the powerhouse. By creating a strong powerhouse, Pilates

believed that ones ability to function during daily activities is optimised. The stability of the

core creates a stable base for movement of the extremities and could potentially prevent

injuries to the peripheral extremities. Quality of movement instead of quantity is important

in the Pilates method. The exercises are performed with control and therefore a strong

focus is drawn to the stabilizing role of muscles around the joints. Furthermore the 10

principles of pilates are Awareness, Balance, Control, Efficiency, Precision, Breath,

Concentration, Centre, Flow and Harmony. Pilates focuses on maintaining a neutral spine

during exercise and movement. This enforces balanced muscular development and

correct muscle recruitment in the whole body, focussing on the body as a whole

contributing to functional improvements.

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2. Anatomy of the hip joint and THR

The hip is the structural link between the lower body and the axial skeleton as it transmits

forces from the ground upwards and also carries forces from the trunk, head neck and

upper body. The hip is a ball and socket joint, enabling a wide range of mobility in different

planes as well as stability.

Stability around the hip joint is formed by a strong ligamentous capsule. It consists of the

iliofemoral ligament, the pubofemoral ligament, the ischiofemoral ligament, the ligamentum

teres and the angular ligament. These ligaments along with the labrum of the hip joint

contributes to the passive stability of the joint.

The active stability of the hip is determined by a large number of controlling muscles. The

22 muscles surrounding the hip joint also provides rotational motion in all directions. These

muscles can contribute to movement in several different planes, depending on the position

of the hip. This is called inversion of muscle action. For example gluteus medius and

minimus muscles act as hip abductors when the hip is extended and as internal rotators

when the hip is flexed.

For the purpose of this study, a trendellneburg gait could be described as the pelvis

sagging to the contra-lateral side due to weakness of the abductor muscle group on the

weightbaring side. This causes the individual to shift their centre of gravity (COG) towards

the affected joint by leaning over, therefore reducing the force required by the abductors to

counteract the movement. This is normally accompanied by a limp.

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Stability around the hip joint during the stance phase of gait is mainly contributed by the

hip abductors for hip control. This group of muscles include the upper fibres of the gluteus

maximus, tensor fascia lata, gluteus medius and minimus, piriformis and obturator internus

muscle. Hip control could be described as the stabilising muscles around the hip joint

working together to control the hip in the socket and therefore preventing a trendellenburg

gait.

With a total hip replacement the ball and socket of the joint is removed and replaced by

new artificial surfaces on either sides of the femur and acetabulum as shown in the picture.

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3. Client History

Mrs. X is 6 weeks post operative left THR. She is a 48 year old female working as a high

school teacher. She has had multiple injuries to her left hip after falling on her hip as a

child at the age of 5 years old. After that incident numerous injuries followed, to such an

extent that she was diagnosed with Osteoarthritis a couple of years ago.

She had considerable groin pain with walking and climbing steps. She also noted that she

was developing a limp and struggled to put on shoes as the hip was becoming stiff. These

symptoms made it difficult for her to perform her daily activities as a teacher, as her job

required her to be on her feet constantly from morning to late afternoon. Considering all

possible options in the management of her condition, she decided along with an

orthopedic surgeon that the best solution was a total hip replacement.

Up to now, Mrs. X has had 6 sessions of intense physiotherapy, one session per week.

These sessions included soft tissue mobilization, light joint mobilization and stretching. A

general inpatient strengthening and ROM exercise program was continued and

progressed using a theraband and core activation exercises was commenced. The focus

was to decrease pain, increase ROM and to create body-awareness.

After 6 weeks Mrs. X still struggled with a limp, however she was ambulating pain free with

one crutch to eliminate the limp and the ROM in her left hip had improved significantly. At

this stage the orthopedic surgeon was happy with her progress and said she could now

leave the crutches if she feels comfortable. I advised her to keep one crutch on her right

side to help and improve the limp. As specified by the surgeon, Mrs. X was able to return

to normal day to day activities. However; further ongoing precaution for her hip

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replacement was pain free activity and exercise, no crossing of the legs and no twisting or

internally rotating of the hip. She was also not allowed to run for the next 6 months.

4. Physiotherapy assessment

On a 6 weeks post op THR evaluation Mrs. X had no more pain with walking, however she

still had to use one crutch in her right hand to eliminate the limp. It was also found that the

ROM in her hip was closely resembling her non-affected side. This included flexion, lateral

rotation and abduction of her left hip. Extension of her hip was limited due to tight hip

flexors and quadriceps muscle. All these movements were pain free and no overpressure

was applied. She had no leg length discrepancy. A few other tests were performed to

assess function and strength. The diagram illustrates the findings:

Test Observation

Gait without walking aid • Trendellennburg gait, sagging of pelvis to non weightbaring side during weight-baring (WB)

• Hyperextension of left knee during WB phase

• Decreased balance and proprioception• Decreased hip dissociation during swing

phase• Decreased hip extension during swing

phase• Poor lumbar pelvic stability, almost

throwing left leg forward• poor left leg control during swing phase• Fear to put full weight on left leg

Straight leg raise (SLR) • Decreased hip dissociation and pelvic stability

• Neural tightness• Weak hip flexors and quadriceps-could

only perform 5 with full lock of left knee• Tight hamstrings

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After observation and evaluation, I had a discussion with Mrs. X about her expectations

and wishes. She explained to me that her biggest wish was to to be able to walk without a

crutch and without a limp. I responded by explaining what the trendellenburg gait was and

that there were a few factors that could contribute to this walking pattern. I told Mrs. X that

this pattern of walking was adopted by her body long ago because of pain and weakness

that had developed around her hip joint. By walking with a limp, less strain was put on

weak muscles to control the hip joint and consequently helped to ease pain.

I also explained that now that she was pain free however, more emphasis could be placed

on rehabilitation and strengthening of the structures that are contributing to the limp. I

assured her that the limp would continue to improve with time with an appropriate

exercises program. I suggested an exercise routine that would be safe, enjoyable and

could become part of her lifestyle. I introduced her to Pilates.

Bilateral squat • Decreased weightbaring on left leg• Decreases Lumbar Pelvic stability• Decreased hip control/maintaing

alignment of hip,knee over ankle • Decreased balance and proprioception

One leg standing on left leg with support, right leg to 90 degrees hip flexion

• Decreased balance• Sagging pelvis to non WB leg, decreased

hip control• left knee hyperextension

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5. Therapeutic approach and Goal setting

Together Mrs. X and I discussed and decided that she would attend two pilates sessions

per week for 6 weeks after which joining a group class would be considered. The first

pilates private session was used to do a physical examination, to determine goal setting,

create body awareness and to introduce principle concepts. During the physical

examination I observed Mrs. X perform a few pilates mat exercises. All exercises were

pain-free. These were the findings:

Exercise Observation

Standing posture using the plumb line • Sway back posture, slight increased thoracic (Tx) kyphosis

Roll down with hips to 90 • Decreased dissociation between Tx and Lumbar (Lx)/articulation

• Decreased Lx flexion, fixed Lx spine• Decreased equal WB through legs

Pelvic curl • Asymmetry, left pelvic drop, weak hip and back extensors

• Poor adductors to keep knees forward• Decreased WB left leg• Poor pelvic stability, keeping Lx neutral• Poor spinal mobility with the roll up• Decreased articulation of spine with roll

down

Chest lift • Poor Lx pelvic stability• Decreased strength of abdominals to lift

chest• Excessive tension in neck and shoulders

Chest lift with rotation • Unable to maintain hight of chest• Side-flexion of trunk instead of rotation,

decreased obliques and abdominals• Poor Lx pelvic stability

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Using the above information as well as information from the physiotherapy assessment, I

was able to compile a list of factors that needed to be addressed in order for Mrs. X to

achieve better hip control and balance, and hopefully decrease her limp. I had a

discussion with her on my findings and wanted to include Mrs. X in the rehabilitation

process. I was also able to explain to Mrs. X what the factors were that needed to be

addressed, why they needed to be addressed and how pilates would be able to address

these factors. See the table below:

Single leg change/leg changes • Excessive ext of Lx spine with alternating of legs

• Decreased hip dissociation• Buldging abdominals• Poor quality of movement with leg

changes• Uncontrolled movement of legs and spine

with leg changes

Main factors that needed attention

Impact on patient’s condition

How would pilates address these factors

Lumbar pelvic stability Decreased core stability causes poor function of lower extremities

The powerhouse is activated and strengthened throughout, emphasis to maintain neutral spine throughout.

Spinal mobility and articulation

Stiffness and decreased dissociation of the spine may lead to other structures compensating: increased sensitivity of erector spina muscle preventing core and hip extensor activation

Improvement of stability and mobility of the spine through articulation and rotation exercises

Abdominal stength Poor and unstable base for the limbs to function properly and generate power

Abdominals as well as obliques muscle emphasis

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After discussing the list, I gave Mrs. X an introduction to the Pilates method. I gave a brief

history of Pilates and discussed the goal of the Pilates method; to condition the whole

body using positions and movement to achieve the ultimate correction of body alignment

and balance by addressing the physical as well as the mental aspects while performing the

exercises. Other fundamental principles during the first session included:

• Explaining the core and muscles involved.

• Finding neutral spine, proprioception of pelvis position.

• Activating Transverse Abdominus and pelvic floor muscles to achieve and maintain

neutral pelvis.

• Progressing the above mentioned: activate core muscles while performing a heel slide or

bent knee fall out or alternate leg lifts.

Hip dissociation Utilisation of lumbar mobility to move hip joint due to weakness of hip flexors and poor lumbar pelvic stability

Improvement of lumbar pelvic stability, hip control and hip flexor strength, hip extensor length

Hip extensor strength and back extensor strength

Tight hip flexors can contribute to decreased extensor ROM and therefore weakness of hip extensors and back extensors

Stretch hip flexors and strengthen hip and back extensors while maintaing lumbar pelvic stability to improve hip dissociation

Hip abduction strength Contributes to patients limp and trendellenburg gait

Emphasis on alignment of pelvis and core stability during exercises increasing proprioception and hip control

Balance and proprioception Poor body awareness and postural control

Improvement of core stability and making use of tactile, verbal and imagery input to achieve better quality of exercise and increase body awareness. Co-ordination of breath with movement

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• Addressed lateral breathing pattern while maintaining neutral pelvis and spine using a

theraband.

• What does “imprinting the spine” mean and how to achieve this, i.e. slight post tilt of the

pelvis.

• Improve standing posture, improve body awareness using a mirror.

6. Conditioning program

The Plates conditioning program was started at 6 weeks post operatively. The conditioning

program consisted of 6 weeks with private one on one sessions after which Mrs. X could

possibly join a pilates class if her progression was satisfactory. During the next 6 weeks

strong emphasis was placed on protecting the hip replacement joint on request of the

surgeon. This included:

• No exercise to be performed with pain or discomfort at groin site.

• No adduction of the left hip.

• No internal rotation or twisting on the left leg.

• No bending of left hip to more than 90 degrees.

It was important to maintain a slow pace, with the goal to introduce Mrs. X to pilates and in

order for her to master the fundamental principles of Pilates before introducing her to more

challenging exercises and concepts. The intensity, endurance and pace was increased as

Mrs. X became functionally stronger. Constant feedback was required from Mrs. X in terms

of pain and discomfort to modify exercises accordingly.

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The table below illustrates the use of the exercises according to the block system. The

block system was used as a framework to plan and execute specific classes throughout

the 6 weeks.

The table below illustrates the exercises that were performed for 6 weeks with the

necessary adaptations and limitations. The exercises were chosen according to the

Block Exercise

Supine warm-up • Chest lift• Chest lift with rotation• Single leg lifts/Leg changes• Leg Circles• Rolling like a ball

Abdominal Section • Hundred Prep• Roll Up• Hundred• Double leg stretch• single leg stretch• Criss Cross• Hamstring pull 1/2/3

Sitting spinal Articulation • Spine Stretch

Back Extension • Back Extension• Single leg kick• Cat stretch• Double leg kick• Swimming• Swan Dive Prep

Sitting Stretches • Spine twist

Supine Rotation • Corkscrew

Full Body Integration • Front support• Back support• Teaser Prep

Hip Extension • Shoulder Bridge Prep

Lateral Flexion/Rotation • Side Kick• Side Bend

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findings or missing objectives retrieved from the physical examination. Some exercises

could be used for more than one objective and are included in the table:

Objective Exercise Modifications/progressions

Lumbar Pelvic Stability

+Chest liftDouble leg stretchSingle leg stretchSingle leg lifts/leg changesLeg circles

Pelvic curl • Initially breaking up the exercise starting with post pelvic tilt and activation of deep core muscles

• Progress exercise by small pulses at end of curl, alternate heel rises, squeezing knees together, squeeze one glut only, holding the curl for longer, before rolling down, lifting one foot off ground and ultimately pogress to shoulder bridge prep

• Using props like small ball between knees, theraband around knees, spine corrector under feet

Spine twist supine • Maintain good tabletop position first

• keep the movement small• Use small ball between

legs

hundred prep • start with legs in crook-ly position first, progress to one leg tabletop position, then extending one leg

• Progress to bilateral tabletop position on spine corrector and small ball, then attempt bilateral tabletop position

• Use theraband to assist legs before attempting full hundred

Spinal mobility and articulation

+Cat Stretch

Roll down • Only with hips to 90• Keep knees bend initially• Perform exercise against

wall

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Spine stretch • Attempt exercise in sitting on physioball to prevent excessive bending in hip joint. Emphasis on lumbar pelvic stability and upper trunk articulation

Spine twist • Sit on stable surface, then spine corrector(more stable) or physioball (less stable), then sitting on mat with legs straight for hamstring and Lx stretch

Roll up • Start with knees slightly bend and anchored

• Do within pain limits

Catstretch • Attempt Lx flexion and Tx flexion simultaneously, than attempt dissociation between Tx and Lx

Abdominal strength

+Hundreds prep/hundredsHamstring pull

Chest lift & chest lift with rotation

• Emphasis on maintaing lumbar pelvic stability.

• Small pulses at end of lift• Assist rotation in supine• Rotate and extend

opposite arm, small pulses• Squeeze between legs

small ball while performing chest lift

Double leg stretch • Start with bilateral bend knees resting on spine corrector and perform exercise with arms only

• Progress to one leg to tabletop position

• Stretch unilateral leg with arms and back to tabletop position, while other leg maintains on spine corrector

• Bilateral legs to tabletop position

• Start extending both legs at the hip joint within pain limits

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Single leg stretch • Start exercise with legs on spine corrector and alternate bilateral legs to tabletop position with knees bend, before extending one leg alternatively

Criss Cross • Attempt exercise with bend legs on spine corrector first

• Alternate legs with knees bend on spine corrector

• Keep one leg straight on spine corrector, while other leg is in tabletop position, rotate only to the one side before alternating

• Remove spine corrector and do exercise with knees bend, before attempting full criss cross

Corkscrew • Keep knees to tabletop position or slightly bend at the knees

• Keep movement small• Attempt side to side

movement first before attempting full circle

• emphasis on abdominals and obliques, pelvis and legs move as a unit

Front support • Start with maintaining front support position on elbows

• maintain front support position with elbows extended

• Maintain front support position on foam roller

• Attempt full front support with pelvis slightly lifted then dropped to a straight line

Teaser prep • Start with legs on spine corrector

• One leg to tabletop position, other on spine corrector

• Bilateral legs to tabletop position with theraband

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Hip Dissociation

+Front support

Single leg lift/ leg changes • Keep knee flexed instead of tabletop position

• feet on spine corrector for single leg lifts

• Make small circles or hip abduction/adduction to neutral with leg in tabletop position, maintain lumbar pelvic stability

• Leg changes with legs on spine corrector

Leg circles • Keep one leg flexed on mat with other leg slightly flexed or in tabletop position

• Start with hip abduction/adduction to neutral or flexion and extension of hip before attempting circles

• Stay within 90 hip flexion and limit adduction of hip

• Use theraband to assist movement

hamstring pull • Keep knees slightly bend• start with legs on spine

corrector• Stay within 90 hip flexion• Use theraband to assist• Progress to hamstring pull

2 & 3

Hip and back ext strength

+Pelvic curlCatstretch

Back extension • start over spine corrector to work in mid range of extension first while maintaing Lx pelvic stability

Single leg kick & double leg kick

• Good stretch for hip flexors

• Lower knees to mat to make it easier

Swimming • alternate arm with opposite leg first with control without loosing Lx pelvic stability

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Back support • Bend one knee• Maintain back support

position first• keep movement small

Swan dive prep • Perform exercise within pain limits and discomfort

• Start with half elbow extension first

• Good hip flexor stretch

Shoulder Bridge Prep • Maintain top leg within 90 degree hip flexion

• Relax knee and start below 90 hip flexion before attempting tabletop position

• Progress to shoulder bridge

Hip abduction strength/Hip control

+Side bend

Side kick • Keep movement slow, small and controlled first

• First attempt abduction/adduction of hip before kick into hip flexion

• Can also do hip side series and standing side leg lifts, squats while maintaining hip/knee alignment

• Progress to one leg standing exercises

• Progress to full Side kick kneeling

Balance and Proprioception

Rolling like a ball • Keep hips below 90 hip flexion or within pain limits

• Can also do standing balance exercises

Side bend • Do exercise on elbow, knees first

• First maintain the T-position

• One leg bend in front of body

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7. Results

After 3 months, Mrs. X had already been with a group class for approximately 4 weeks. A

follow up physical assessment was performed with the following results:

• Standing posture: Big improvement of posture and alignment. Better body awareness

and proprioception of the pelvis and spine to achieve neutral spine.

• Gait: Decreased trendellenburg gait. Able to walk with no walking aid and limp

significantly decreased. Also more confident.

• SLR: Good hip dissociation and lumbar pelvic stability. Strength in hip flexors has

improved.

• Bilateral squat: good and equal bilateral WB on legs, good alignment of hips and knees.

• 1 leg standing with right leg to 90 degrees hip flexion: slight drop of pelvis to the opposite

side when WB on left leg, but balance significantly improved, no support needed. Able to

maintain good posture throughout movement.

• Pelvic curl: Improved hip ext and back ext strength maintaining hight of pelvis with good

lumbar pelvic stability. Able to do shoulder bridge prep with no difficulty. Good spinal

mobility and symmetry. Improvement in abdominal strength.

• Chest lift & chest lift with rotation: good lumbar pelvic stability, abdominal strength had

improved with chest lifted higher.

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• Leg changes: Good hip dissociation and lumbar pelvic stability, better control of exercise

8. Conclusion

The trendellenburg gait and limp is a common side effect post THR surgery. One of the

factors that could be responsible for this dysfunctional walking pattern is weakness of the

muscles surrounding the hip complex providing control, balance and proprioception in the

hip joint. These muscles mainly include the hip abductors and extensors, but core

stabilizers also play a role. Weakness could be due recurrent pain and inflammation in the

joint after surgery or could be due to weakness even before the operation.

In this case report, Pilates as an exercise routine was used to improve functional ability as

a whole by addressing lumbar pelvic stability, spinal mobility and articulation, abdominal

strength, hip dissociation, hip and back extensor strength, hip abduction strength and

balance and proprioception. Pilates develops stabilization, refines posture, and re-

educates movement patterns that previously caused disability. Pilates also influences body

awareness and control of movement to ensure that the body is addressed as a whole.

To conclude, improved abdominal strength and lumbar pelvic stability could lead to a more

stable base from which the lower limbs including the hip joint can generate power from.

Furthermore, good proximal stability could increase hip control and decrease the

trendellenburg gait to improve overall functional performance after a THR .

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9. References

Articles:

• Levine B, Kaplanek B, Jaffe WL. Pilates training for use in rehabilitation after total hip

and knee arhroplasty. A preliminary report. Clinical Orthopaedic Related Research.

2009;467:1468-1475

• Gilbey HJ. Exercise improves early functional recovery after total hip arthroplasty

(Abstract). CORR No 2003;408:193-200

• Levine B, Kaplanek B, Scafura D, Jaffe WL. Rehabilitation after total hip and knee

arthroplasty. A new regime using Pilates training. Bulletin of the NYU Hospital for Joint

Disease. 2007;65(2):120-125

• Byrne DP, Mulhall KJ, Baker JF. Anatomy and Biomechanics of the Hip. The open Sport

Medicine Journal. 2010;4:51-57

• Lutwic A, Edwards M, Dennison E, Cooper C. Epidemiology and Burden of

Osteoarthritis. Br Med Bull. 2013;105:185-199

• Murphy LB, Helmick CG, Schwartz TA, Renner JB, Tudor G, Koch GG, Dragomir AD,

Kalsbeek WD, Luta G, Jordan JM. One in 4 people may develop symptomatic hip

osteoarthritis in his or her lifetime. (Abstract). Osteoarthritis Cartilage. 2010;18(11):

1372-1379

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• MacDonald Wood A, Brock TM, Heil K, Holmes R, Weusten A. A Review of the

Management of Hip and Knee Osteoarthritis. International Journal of Chronic Disease.

2013;Article ID:845015

• Trudelle Jackson E. Effects of a late phase exercise program after total hip arthroplasty.

A randomised controlled trial. Arc Phys Med Rehabill. 2004;85(7):1056-1062

Other:

• Basi Study Guide (Mat Work Course)

• Basi Mat (Movement Analysis Workbook)

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