Ankylosing Spondylitis

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Table of Contents

Topic Overview Symptoms Exams and Tests Treatment Overview Home Treatment Other Places To Get Help Related Information References Credits Appendix Biologics for Ankylosing Spondylitis Hip Replacement Surgery Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Sulfasalazine for Ankylosing Spondylitis Topic Images Spine Ankylosing Spondylitis Posture in Advanced Ankylosing Spondylitis Flexibility and Strengthening Exercises for Ankylosing Spondylitis Cartilage Hip Replacement Surgery

Topic Overview

What is ankylosing spondylitis?

Ankylosing spondylitis (say "ang-kill-LOH-sing spawn-duh-LY- tus") is a long-term form of arthritis that most often occurs in the spine (See figure in appendix) . It can cause pain and stiffness in the low back, middle back, buttocks, and neck, and sometimes in other areas such as the hips, chest wall, or heels. It can also cause swelling and limited motion in these areas. This disease is more common in men than in women. There is no cure, but treatment can control symptoms and prevent the disease from getting worse in most cases. Most people are able to do their normal daily activities and can still work.

This disease can cause several other problems. You may have redness and pain in the colored part of your eye (iritis). You also may have trouble breathing as your upper body begins to curve and your chest wall begins to stiffen.

What causes ankylosing spondylitis?

The cause is unknown, but it may run in families. Most people with ankylosing spondylitis are born with a certain gene, HLA-B27. But having this gene does not mean that you will get the disease.

Research suggests that bacterial infections and your environment may have roles in causing this disease.

What are the symptoms?

This disease causes mild to severe pain in the low back and buttocks that is often worse in early morning. Some people have more pain in other areas, such as the hips or heels. The pain usually gets better slowly as you move around and are active. Ankylosing spondylitis most often begins anywhere from the teenage years through the 30s.

It gets worse slowly over time as swelling of the ligaments, tendons, and joints of the spine causes the bones of the spine to join, or fuse (See figure in appendix) , together. This leads to less range of movement in the neck and low back.

As the spine fuses and stiffens, the neck and low back lose their normal curve. The middle back curves outward. This can keep you in a bent-forward position (See figure in appendix) and may make it hard for you to walk.

As the small joints that connect the ribs and collarbone to the breastbone get inflamed, you may find that it's harder for you to breathe. Other parts of the body, such as your eyes and your other joints, may also swell. Sometimes the disease affects the lungs, the heart valves, the digestive tract, and the major blood vessel called the aorta.

How is ankylosing spondylitis diagnosed?

The early signs of this disease—dull pain in the low back and buttocks—are common. Your doctor will ask about your symptoms and if they have become worse over time. Your doctor will also ask if you have a family history of this joint disease or others like it.

Your doctor may do several tests if he or she thinks that you have ankylosing spondylitis. You may have an X-ray, a test for the HLA-B27 gene, or an MRI of the sacroiliac joints. The clearest sign of the disease is a change in the sacroiliac joints at the base of the low back. This change can take up to a few years to show up on an X-ray.

How is it treated?

Treatment includes exercise and physical therapy. These will help reduce stiffness so that you can stand up straighter and move around better. Your doctor will also give you medicine for pain and swelling.

Because people with ankylosing spondylitis may be at a higher risk for spinal cord injury, it's important that you wear a seat belt every time you drive or ride in a car.

You will need to get regular eye exams to check for inflammation in your eye, called iritis. You may use a device such as a cane to help you walk and to help reduce stress on your joints.

Surgery for the spine is rarely needed. You may want to think about hip or knee replacements if you have severe arthritis in those joints.

There is no cure for this disease. But early diagnosis and treatment can help relieve pain and stiffness and allow you to keep doing your daily activities for as long as possible.

Frequently Asked Questions

Learning about ankylosing What is ankylosing spondylitis? spondylitis: What causes it? What are the symptoms? What are other spondyloarthropathy conditions?

Being diagnosed: How is ankylosing spondylitis diagnosed? What is a genetic test?

Getting treatment: How is ankylosing spondylitis treated? Can medicines reduce pain and stiffness? What assistive devices or orthotics can help ease movement?

Ongoing concerns: What can I do at home to reduce my symptoms? Will I need surgery for ankylosing spondylitis? What is hip replacement surgery? (See [ ] in appendix)

Living with ankylosing Can yoga help with my symptoms? spondylitis: Can acupuncture help with my symptoms? What happens over time with ankylosing spondylitis?

Symptoms

Ankylosing spondylitis is inflammation primarily of the joints of the spine. But it can also involve inflammation of the eye, other joints—especially those in the hips, chest wall, and around the heels—and, on occasion, the shoulders, wrists, hands, knees, ankles, and feet. Although it is unusual, ankylosing spondylitis can also cause changes such as thickening of the major artery (aorta) and the valve in the heart called the aortic valve.

If the inflammation continues over time, it will lead to scarring and permanent damage. In some people the disease is mild and progresses slowly, and symptoms may never become severe. Other people may have a more aggressive disease process.

Whether ankylosing spondylitis gets worse depends on a number of things such as how old you were when the disease began, how early it was diagnosed, and what joints are involved. It's too early to tell yet, but experts hope that early treatment with newer medicines will slow or minimize the inflammation, prevent scarring, and limit the progression of the disease.

Mild or early ankylosing spondylitis

Ankylosing spondylitis usually starts with dull pain in the low back and back stiffness. Some people with ankylosing spondylitis have "flares" of increased pain and stiffness that may last for several weeks before decreasing again.

Affected bones of the low back, middle back, hips, or neck may become painful, stiff, and limited in motion. Pain tends to increase slowly over a period of weeks or months, and it is often hard to point to exactly where the pain is. Stiffness is usually worse in the morning and usually lasts for more than one hour. Pain is often noticeable in the early morning hours of sleep, such as between 3 a.m. and 6 a.m. Physical activity often helps decrease pain and stiffness. Some people feel tired as the disease progresses. This tiredness comes from the body fighting the inflammatory process that is part of ankylosing spondylitis and also from ongoing stiffness and pain. The colored part of the eye (iris) may become inflamed. Symptoms of iritis include redness and pain in the eye and sensitivity to light.

Severe or advanced ankylosing spondylitis

If, over time, the inflammation continues, it will lead to scarring and permanent damage.

Scarring in the spine causes the joints of the spine to grow together (fuse, or "ankylose"). As the bones fuse (See figure in appendix) , back pain will gradually go away, but the spine will remain very stiff and unable to bend. The fused spine is more likely to break (fracture) if injured, especially the neck (cervical spine). Changes in the spine (See figure in appendix) can cause problems with balance, safety, and mobility. The upper spine can curve forward until eventually the person has a hard time looking straight ahead. Also, as the spine loses its natural curves, it becomes hard to balance while standing and walking, especially if the hips are also affected. Breathing can become difficult as the upper body curves forward and the chest wall stiffens. Severe ankylosing spondylitis can also cause scarring of the lungs (pulmonary fibrosis) and an increased risk of lung infection. This can cause even greater problems in smokers, because their lungs are already more prone to lung infection and scarring. Scarring in the eye from uncontrolled iritis can lead to permanent visual impairment and glaucoma. In rare cases, the heart muscle can become scarred and the heart valves may become inflamed. The heart may be unable to pump properly (heart failure). The main artery leading from the heart (aorta) can also be affected by becoming inflamed and enlarged near where it leaves the heart. Bowel inflammation is sometimes linked with ankylosing spondylitis. The kidneys can be affected by taking medicines over a long period of time. Some people who have ankylosing spondylitis for many years develop cauda equina syndrome from scarring around the nerves at the end of the spinal cord. This condition can cause loss of feeling in the saddle area of the groin and legs. It can also cause problems with bowel and bladder control and sexual activity. Talk to your doctor if you start having problems controlling your bowels or bladder.

The stiffening of the chest can feel like the discomfort or "heaviness" of a heart attack. Ankylosing spondylitis can also cause the heart to work less efficiently.

If you have any symptoms of heart or lung problems—including heaviness of the chest or pain with deep breathing—talk to a doctor right away to make sure you don't have any serious heart or lung problems. For more information on heart and lung problems, see the topics Heart Attack and Unstable Angina and Pleurisy.

Ankylosing spondylitis is one disease in a group of joint diseases called the spondyloarthropathies (say "spon-dill-o-ar-THROP-a-thees"). These include psoriatic arthritis, reactive arthritis (Reiter's syndrome), and enteropathic arthritis (joint problems linked with inflammatory bowel disease). Although inflammation of the spine also occurs in these other conditions, it is less common and less severe than the inflammation that occurs in ankylosing spondylitis.

Exams and Tests

Your doctor will use a medical history, physical exam, and X-ray to diagnose ankylosing spondylitis. By asking questions about your medical history, your doctor can evaluate your symptoms. Most people with ankylosing spondylitis have back pain with four or five of the following characteristics:

Begins before the age of about 35 Starts and gets worse gradually Persists for at least 3 months Is linked with morning stiffness that usually lasts for more than one hour Improves with exercise

Your doctor will want to know whether you have any family members who have ankylosing spondylitis or a related joint disease. Many people with ankylosing spondylitis have a family member with the same condition. He or she may also ask whether you have had ongoing diarrhea, abdominal (belly) pain, multiple infections of the cervix (in women) or urethra (more common in men), psoriasis, or inflammation of the eye chamber (uveitis). These could be clues to having a condition other than ankylosing spondylitis.

You will have a physical exam to see how stiff your back is and whether you can expand your chest normally. Your doctor will also look for tender areas, especially over the points of the spine, the pelvis, the areas where your ribs join your breastbone, and your heels. You may experience chest pain and stiffness with ankylosing spondylitis.

Tests related to ankylosing spondylitis include:

X-rays of the spine and pelvis to check for bone changes (bony erosions, fusion, or calcification of the spine and sacroiliac joints). Certain changes in the sacroiliac joint confirm the diagnosis of ankylosing spondylitis. But those changes can take several years to develop enough to show on X-ray. MRI and CT scan are more sensitive than X-ray. If no changes to the sacroiliac joints show on the X-ray but your doctor still suspects ankylosing spondylitis, an MRI or CT scan may allow an earlier diagnosis. Ultrasound is being studied as a way to diagnose ankylosing spondylitis earlier. Blood tests. These may include: C-reactive protein (CRP) or sedimentation rate (sed rate) to look for inflammation. Rheumatoid factor or antinuclear antibody test (ANA) to look for other types of arthritis or illness. A genetic test, which may be done to determine the presence of a gene (HLA-B27) that is often linked with ankylosing spondylitis. Many people who have the HLA-B27 gene will not develop ankylosing spondylitis, so having this test will not confirm whether you have the condition. But the test results can be helpful if your symptoms and physical exam have not clearly pointed to a diagnosis.

Treatment Overview Treatment for ankylosing spondylitis focuses on relieving pain and stiffness, reducing inflammation, keeping the condition from getting worse, and enabling you to continue daily activities. Early diagnosis and treatment may reduce pain, stiffness, inflammation, and deformity.

Talk with your doctor about the best treatment approach for your condition. A consultation with a rheumatologist is often recommended, especially to confirm the diagnosis and lay out a treatment plan. Your family medicine physician or internist can treat mild cases. Or you may be referred to a rheumatologist, orthopedist, or physiatrist.

Initial treatment

Initial treatment for ankylosing spondylitis may include:

Education, so you know what you can expect as ankylosing spondylitis progresses and how you can minimize problems that can be caused by your condition. Flexibility and strengthening exercises (See figure in appendix) , to maintain mobility and control pain. People who exercise regularly find they have less pain and stiffness than those who are less active. Nonsteroidal anti-inflammatory drugs (NSAIDs (See [ ] in appendix)), to relieve pain and stiffness, reduce inflammation, and help with physical therapy. Some people seem to get more benefit from daily NSAIDs than from taking NSAIDs just when they notice symptoms. Talk to your doctor about using NSAIDs for ankylosing spondylitis, including how much to take and how often to take it. Physical therapy, to help you keep proper posture, and deep breathing exercises, to enhance your lung capacity. A physical therapist can also help you learn to use heat and cold to help control your pain and stiffness. Heat can help with relaxation and pain relief, and cold can help reduce inflammation. Assistive devices such as canes or walkers, which allow you to be physically active while reducing stress on joints. Alternative therapies such as yoga or acupuncture, which may help relieve pain and improve quality of life.

Talk with your doctor about your job. People who have ankylosing spondylitis feel better if they stay active and exercise regularly. So a job that is physically demanding—such as a job that requires lots of heavy lifting—could increase your symptoms.

Ongoing treatment

If initial treatment does not sufficiently reduce the pain and inflammation linked with ankylosing spondylitis, and as your condition progresses, ongoing treatment may include:

Flexibility and strengthening exercises (See figure in appendix) , to maintain mobility and control pain. People who exercise regularly find they have less pain and stiffness than those who are less active. In addition to general flexibility and strengthening, walking and swimming are good activities for people who have ankylosing spondylitis. Some people continue to participate in sports also. Talk to your doctor or physical therapist about activities that will help you and that you will enjoy. Medicine. Doctors usually will first recommend nonsteroidal anti-inflammatory drugs (See [ ] in appendix) (NSAIDs) to reduce pain and inflammation. But you may need other, stronger medicines. Be safe with medicines. Read and follow all instructions on the label. Corticosteroids, which are similar to natural hormones produced in the body, help reduce inflammation. Corticosteroids are typically used for joints such as the hips, not for the joints of the spine. Disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine (See [ ] in appendix) and possibly methotrexate may help relieve pain in joints other than the spine and pelvis. Drugs known as "biologic agents (See [ ] in appendix)" or "anti-TNF alpha" drugs reduce inflammation by blocking a protein called tumor necrotizing factor (TNF), which causes inflammation. Physical therapy, to help you keep good posture, and deep breathing exercises, to enhance your lung capacity. A physical therapist can also help you learn to use heat and cold to help control your pain and stiffness. Heat can help with relaxation and pain relief, and cold can help reduce inflammation. Assistive devices such as canes or walkers, which allow you to maintain physical activity while reducing stress on joints. Alternative therapies such as yoga or acupuncture, which may help relieve pain and improve quality of life.

Your doctor will treat complications of ankylosing spondylitis as they occur. For example, iritis may be treated with medicines that can help reduce inflammation of the eye, such as corticosteroids and mydriatic eyedrops.

Treatment if the condition gets worse

In rare cases, you may need surgery to replace joints that are severely damaged by the inflammation of ankylosing spondylitis. The most common surgery done is hip replacement surgery (See [ ] in appendix). Spine surgery is done in a very small number of people who have ankylosing spondylitis. If there is loosening of the top two vertebrae in the neck and there are signs of pressure on the spinal cord such as numbness or clumsiness in the hands or arms, a surgeon may permanently join (fuse) the two vertebrae together. In very rare cases, spinal surgery may be done to straighten a part of the spine that has become severely curved, but the surgery is risky and cannot restore motion.

Because ankylosing spondylitis is a lifelong condition, other treatment may include complementary and alternative medicine therapies, which can reduce symptoms, help manage pain, and improve quality of life. Complementary and alternative medicine is the term for a wide variety of health care practices that may be used along with or in place of standard medical treatment. These therapies may include yoga and acupuncture. Even if your symptoms are under control, you should see your doctor (often a rheumatologist) every year to watch for and treat any complications. People with hip symptoms and perhaps those whose disease started in their teens may be at risk for a more severe progression of ankylosing spondylitis.

Home Treatment

If you have been diagnosed with ankylosing spondylitis, there are steps that you can take at home to help reduce pain and stiffness and allow you to continue daily activities. These steps include:

Educating yourself. Learn all you can about your condition and know what complications to watch for. This will help you control your symptoms and stay more active. Taking pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain. If NSAIDs do not relieve your pain, try acetaminophen. Heat, such as warm showers or baths or sleeping under a warm electric blanket, may also reduce pain and stiffness. Exercising regularly (See figure in appendix) . This reduces pain and stiffness and helps maintain fitness and mobility of the spine, chest, and joints. Your doctor may recommend physical therapy to get you started on an exercise program. Deep breathing exercises can improve or help you keep your lung capacity. Swimming as part of your exercise program helps to maintain chest expansion and movement of the spine without jarring the spine. Breaststroke is especially good for chest expansion. You should avoid contact sports, because joint fusion may make your spine more likely to fracture as the disease progresses. Your doctor may approve of other activities such as golf and tennis. Check with your doctor before you add any new activity. Maintaining proper posture and chest expansion. Good posture is important because it can help prevent abnormal bending of the spine (See figure in appendix) . Maintaining chest expansion may help prevent problems such as lung infection (pneumonia). It's a good idea to lie on your stomach a few times each day to keep your spine and hips extended. For sleeping, choose a firm mattress and a small pillow that supports your neck. Try to lie flat on your back to sleep. If it's comfortable for you, you can also sleep part of the night on your stomach. Using assistive devices such as canes or walkers. Your local chapter of the Arthritis Foundation, your physical therapist, or a medical supply company may be able to help you find assistive devices in your area. Taking steps to protect yourself in the car, such as always using a seat belt. Joints that are inflamed or damaged can easily be injured in an accident. If your neck is becoming stiff, your doctor may advise you to wear a soft neck brace when you ride in the car, to prevent injury in case of an accident. Avoiding smoking, to prevent serious breathing problems and lung scarring. Lung damage from smoking, combined with decreased chest expansion and the lung infections that sometimes go with ankylosing spondylitis, can seriously limit your ability to breathe freely. Seeing your doctor (often a rheumatologist) at least once each year, to check on your condition and watch for any complications. Catching complications early and treating them can prevent further problems. Having regular eye exams by an ophthalmologist, to check for inflammation of the colored part of the eye (iritis). Talking with your doctor about your job. People who have ankylosing spondylitis feel better if they stay active and exercise regularly. So a job that is physically demanding—such as a job that requires lots of heavy lifting—could increase your symptoms. Joining a support group. For more information, call the Spondylitis Association of America toll-free at 1-800-777-8189, or visit the association's website at www.spondylitis.org.

Other Places To Get Help

Organizations

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health 1 AMS Circle Bethesda, MD 20892-3675 Phone: 1-877-22-NIAMS (1-877-226-4267) toll-free Phone: (301) 495-4484 Fax: (301) 718-6366 TDD: (301) 565-2966 Email: [email protected] Web Address: www.niams.nih.gov

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is a governmental institute that serves the public and health professionals by providing information, locating other information sources, and participating in a national federal database of health information. NIAMS supports research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases and supports the training of scientists to carry out this research.

The NIAMS website provides health information referrals to the NIAMS Clearinghouse, which has information packages about diseases.

Spondylitis Association of America Web Address: www.spondylitis.org Related Information

Low Back Pain Lumbar Herniated Disc Lumbar Spinal Stenosis Osteoarthritis Rheumatoid Arthritis

References

Other Works Consulted

Braun J, et al. (2011). 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Annals of the Rheumatic Diseases, 70(6): 896–904.

Braverman SE (2008). Ankylosing spondylitis. In WR Frontera et al., eds., Essentials of Physical Medicine and Rehabilitation, 2nd ed., pp. 605–608. Philadelphia: Saunders Elsevier.

Inman RD (2012).The spondyloarthropathies. In L Goldman, A Shafer, eds., Goldman's Cecil Medicine, 24th ed., pp. 1690–1697. Philadelphia: Saunders.

Taurog JD (2012). The spondyloarthritides. In DL Longo et al., eds., Harrison's Principles of Internal Medicine, 18th ed., vol. 2, pp. 2774– 2785. New York: McGraw-Hill.

Credits for Ankylosing Spondylitis

By Healthwise Staff

E. Gregory Thompson, MD - Internal Medicine Richa Dhawan, MD - Rheumatology Last Revised May 14, 2013

Appendix

Biologics for Ankylosing Spondylitis

Examples Generic Name Brand Name

adalimumab Humira

etanercept Enbrel

golimumab Simponi

infliximab Remicade

How It Works

Another name for these medicines is Tumor Necrosis Factor-alpha antagonists (anti- TNF alpha agents). These medicines stop a protein that increases inflammation in the body. They block the inflammatory response that happens in ankylosing spondylitis. They are given as a shot.

Why It Is Used

Biologics are used to treat pain and inflammation in people who have active ankylosing spondylitis. They are usually used after other medicines such as nonsteroidal anti- inflammatory drugs (NSAIDs) have been tried.

How Well It Works

Biologics may improve symptoms of ankylosing spondylitis, such as morning stiffness and pain. These medicines might allow a person to be more active.1, 2 You may feel better in 6 to 12 weeks after starting this medicine. If one of these medicines does not work, you might find relief with another.

Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.

Here are some important things to think about:

Usually the benefits of the medicine are more important than any minor side effects. Side effects may go away after you take the medicine for a while. If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change your medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.

Call 911 or other emergency services right away if you have: Trouble breathing. Swelling of your face, lips, tongue, or throat.

Call your doctor right away if you have:

Hives. Signs of illness or infection, such as chills, cough, or fever. Chest pain or tightness. A rash on your head, face, or belly. Belly pain or fullness. Lower back or side pain, especially with painful urination.

Common side effects of this medicine include:

Stomach pain, nausea, and vomiting. Painful throat. Redness, itching, or swelling at the injection site. Skin problems, such as bleeding, blistering, or crusting.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Because biologics interfere with the immune system, it's possible that they may raise your risk for infection, anemia, and possibly even cancer. Medicines that suppress the immune system are not usually given to people who have impaired immune systems. If you take biologic drugs, you may have periodic tests for tuberculosis.

Warnings have been issued about the serious side effects of biologics. The U.S. Food and Drug Administration (FDA) and the drug's manufacturers have warned about:

An increased risk of a serious infection. Biologics affect the body's ability to fight all infections. So if you get a fever, cold, or the flu while you are taking this medicine, let your doctor know right away. An increased risk of blood or nervous system disorders. Call your doctor if you have symptoms of blood disorders (such as bruising or bleeding) or symptoms of nervous system problems (such as numbness, weakness, tingling, or vision problems). An increased risk of lymphoma (a type of blood cancer) in children and adolescents who take this medicine for longer than 2½ years (30 months). Adults, children, and adolescents who take this medicine also have a higher risk for leukemia and other cancers. An increased risk of liver injuries. Call your doctor if your skin starts to look yellow, if you are very tired, or if you have a fever or dark brown urine. An increased risk of psoriasis.

Taking medicine Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.

There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.

Advice for women

If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast- feeding, or planning to get pregnant.

Checkups

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.

Complete the new medication information form (PDF) to help you understand this medication.

References

Citations

1. Van der Linden S, et al. (2009). Ankylosing spondylitis. In GS Firestein et al., eds., Kelley's Textbook of Rheumatology, 8th ed., vol. 2, pp. 1169–1189. Philadelphia: Saunders Elsevier.

2. Golimumab (Simponi) for inflammatory arthritis (2009). Medical Letter on Drugs and Therapeutics, 51(1316): 55–56.

Credits for Biologics for Ankylosing Spondylitis

By Healthwise Staff E. Gregory Thompson, MD - Internal Medicine Richa Dhawan, MD - Rheumatology Last Revised May 14, 2013 Hip Replacement Surgery

Surgery Overview

Total joint replacement involves surgery to replace the ends of both bones in a damaged joint to create new joint surfaces.

Total hip replacement surgery uses metal, ceramic, or plastic parts to replace the ball at the upper end of the thighbone (femur) and resurface the hip socket in the pelvic bone.

Total hip replacement surgery replaces damaged cartilage (See figure in appendix) with new joint material in a step-by-step process (See figure in appendix) .

Doctors may attach replacement joints to the bones with or without cement.

Cemented joints are attached to the existing bone with cement, which acts as a glue and attaches the artificial joint to the bone. Uncemented joints are attached using a porous coating that is designed to allow the bone to adhere to the artificial joint. Over time, new bone grows and fills up the openings in the porous coating, attaching the joint to the bone.

Doctors often use general anesthesia for joint replacement surgeries, which means you'll be unconscious during surgery. But sometimes they use regional anesthesia, which means you can't feel the area of the surgery and you are sleepy, but you are awake. The choice depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

Minimally invasive surgery

Some doctors are doing hip replacement surgery through smaller incisions. This is called minimally invasive surgery. It may mean less blood loss and a smaller scar. But it can also mean a longer time in surgery, because the surgery is harder to do. And if the new hip cannot be fitted properly through the smaller incision, the doctor may have to make a larger opening anyway. These surgeries can also require special equipment that not all hospitals have. Minimally invasive surgery is not done often for hip replacement. If you are interested in this type of surgery, talk to your doctor. Whether the procedure is a good idea for you depends on your doctor's opinion and also on his or her training and practice.

What To Expect After Surgery

Right after surgery You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medicines to control pain and perhaps medicines to prevent blood clots. It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you feel ill.

When you wake up from surgery, you may have a catheter, which is a small tube connected to your bladder, so you don't have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots. And you may have a cushion between your legs to keep your new hip in the correct position.

Your doctor may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is reduced. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating. And you may begin to learn about how to keep your hip in the correct positions while you move in bed and get out of bed.

The first few days

You will probably still be taking some medicine. You will gradually take less and less pain medicine. You may continue medicines to prevent blood clots for at least ten days after surgery.

Rehabilitation (rehab) after hip replacement surgery may vary depending on whether the surgeon used cement or cementless methods to attach the joint replacement surfaces. Whether your surgeon used cement also determines how much weight you can put on your leg. Your surgeon will let you and your rehab team know what limitations you have. You'll probably need a walker, a cane, or crutches for several weeks.

In general, most people get out of bed with help on the day of surgery or the next day. Over the next few days, you will learn how to walk with a walker or crutches. Your physical therapist and sometimes an occupational therapist will teach you how to exercise, walk, and do activities such as dressing and cooking while you allow your hip to heal. Depending on the type of surgery you had and your doctor's instructions, you may learn the following precautions to keep your hip from dislocating:

Avoid combinations of movement with your new hip. For example, do not sit with your legs crossed, because in that position you both bend your hip and bring your hip across your body. Your doctor may not want your hip to bend more than 90 degrees. If so, your therapist may suggest these ideas: Do not sit on low chairs, beds, or toilets. You may want to get a special raiser for your toilet seat temporarily. Do not raise your knee higher than your hip. Do not lean forward while you are sitting down, or as you sit down or stand up. Do not bend over more than 90 degrees. This means you can't bend down to tie your shoes for a while. For about 8 weeks, your doctor may not want your leg to cross the center of your body toward the other leg. If so, your therapist may suggest these ideas: Do not cross your legs. Be careful as you get in or out of bed or a car, so your leg does not cross that imaginary line in the middle of your body. Your doctor may not want your leg to rotate in or too far out. If so, your therapist may suggest that you keep your toes pointing forward or slightly out.

Most people go home within a few days to a week after surgery. Some people who need more extensive rehab or those who don't have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

After you go home, monitor the surgery site and your general health. If you notice any redness or drainage from your wound, notify your surgeon. You may also be advised to take your temperature twice each day and to let your surgeon know if you have a fever over 100.5°F (38.1°C).

For a while, you may need to sit only in high chairs (not on low seats that flex your hip more than 90 degrees), use a toilet seat raiser, and sleep on your back.

You may need to use a walker or crutches for several weeks after surgery until you can bear your full weight, have less pain, and can safely move around without falling. How long you need to use crutches or a walker depends on the condition of your bones and what type of procedure your doctor used as well as his or her experience working with other people who had similar surgery.

Physical therapy typically continues after you go home from the hospital until you are able to function more independently. Total rehabilitation after surgery will take at least 6 months.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should also take a short walk several times each day. If you notice any soreness, try a cold pack on your hip and perhaps decrease your activity a bit, but don't stop completely. Staying with your walking and exercise program will help speed your recovery.

For most people it is safe to have sex about 4 to 6 weeks after a hip replacement. Talk to your doctor about how and when it is safe. And ask your physical therapist or occupational therapist about positions that will not put your new hip joint at risk.

Living with a hip replacement

Your doctor will probably want to see you at least once every year to monitor your hip replacement. Gradually, you will return to most of your presurgery activities. If you drive a car, your doctor will probably allow you to start driving an automatic shift car in 6 to 8 weeks, as long as the seat is not too low and you are no longer taking pain medicine. Because of the way the hip is structured, every added pound of body weight adds 3 pounds of stress to the hip. Controlling your weight will help your new hip joint last longer.

Stay active to help keep your strength, flexibility, and endurance. Your activities might include walking, swimming (after your wound is completely healed), dancing, golf (don't wear shoes with spikes, and do use a golf cart), and bicycling on a stationary bike or on level surfaces. More strenuous activities, such as jogging or tennis, are not advised after a hip replacement.

Your doctor may want you to take antibiotics before dental work or any invasive medical procedure for at least 2 years after your surgery. This is to help prevent infection around your hip replacement. After 2 years, your doctor and dentist will decide whether you still need to take antibiotics. Your general health and the state of your other health conditions will help them decide.

Why It Is Done

Doctors recommend joint replacement surgery when hip pain and loss of function become severe and when medicines and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your hip to see whether they are damaged and to make sure that the pain isn't coming from somewhere else.

Total hip replacement may not be recommended for people who:

Have poor general health and may not tolerate anesthetic and surgery well. Have an active infection or are at high risk for infection. Have osteoporosis (significant thinning of the bones). Are involved in heavy manual labor or physically demanding sports. Are severely overweight (replacement joints may be more likely to fail in people who are very overweight).

But doctors evaluate each person individually.

How Well It Works

People who have hip replacement surgery have much less pain than before the surgery and are usually able to resume daily activities. You will probably be able to do your daily activities more easily because the joint moves better.

It probably will be easier for you to do things such as climb stairs, get in and out of a car, walk without tiring, walk without a limp or with less of a limp, and take care of your feet. You probably will be able to resume activities, such as golfing, biking, swimming, or dancing, that you did before surgery. Your doctor may discourage you from running, playing tennis, and doing other things that put a lot of stress on the joint.

Most artificial hip joints will last for 10 to 20 years or longer without loosening, depending on such factors as:

Your lifestyle and how much stress you put on a joint. How much you weigh (being very overweight puts extra stress on the joint). How well your new joint and bones mend.

The younger you are when you have the surgery and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you are not overweight and if you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint probably will last the rest of your life.

Doctors continue to discover new ways to improve the life span of artificial hip joints. What we know today about the long-term outcomes of hip replacement surgery comes from studies of joints that were replaced 10 to 20 years ago or longer. People who have hip replacement surgery today may expect the artificial joint to last longer than joints replaced 10 to 20 years ago.

Risks

The risks of hip replacement surgery can be divided into two groups:

Risks of the surgery and recovery period Long-term risks that may occur months to years after the surgery

The risks of each complication depend in part on your other health problems and on the surgeon.

Risks of the surgery and recovery period

Blood clots. People may develop a blood clot in a leg vein after hip joint replacement surgery. Blood clots can be dangerous if they block blood flow from the leg back to the heart or if they move to the lungs. Blood clots are more common in older people, those who are very overweight, those who have had blood clots before, or those who have cancer. Infection in the surgical wound or in the joint. Infection is rare in people who are otherwise healthy. People who have other health problems, such as diabetes, rheumatoid arthritis, or chronic liver disease, or those who are taking corticosteroids are at higher risk of infection after any surgery. Infections in the wound usually are treated with antibiotics. Infections deep in the joint may require more surgery, and in some cases the doctor must remove the artificial joint. If the joint pieces have to be removed, they are usually replaced. But that surgical procedure (revision) is more complicated than the original hip replacement and has a greater risk of problems. Nerve injury. In rare cases, a nerve may be injured around the site of the surgery. This is more common (but still unusual) if the surgeon is also correcting deformities in the joint. A nerve injury may cause tingling, numbness, or difficulty moving a muscle. These injuries usually get better over time and in some cases may go away completely. Problems with wound healing. Wound healing problems are more common in people who take corticosteroids or who have diseases that affect the immune system, such as rheumatoid arthritis and diabetes. Deposits of bone in soft tissues around the hip joint. This is called heterotopic ossification. It usually doesn't affect how well the hip works, but it may decrease the range of motion at the hip. The condition needs treatment (surgery) only if it causes pain or greatly limits motion. Hip dislocation after surgery. It is rare to have a hip dislocation after hip replacement surgery. Your doctor can usually treat this by moving the hip back into place after giving you pain medicine or anesthetic. You also may wear a brace for a while. In a few cases, surgery may be needed to put the joint back in place. Difference in leg length. Usually, any difference in leg length is very small and does not cause any pain or functional problem. If you have a noticeable difference, it can often be corrected by using a shoe insert. The usual risks of general anesthesia. Risks of any surgery are higher in people who have had a recent heart attack and those who have long-term (chronic) lung, liver, kidney, or heart disease.

Long-term risks

Loosening of the artificial hip joint parts. Over time, loosening is the most common problem associated with total hip replacement. Tissue may grow between the components and the bone, leading to loosening. Loosening usually doesn't cause any symptoms and is visible only on X-rays. If a loosened joint causes severe pain, you may need a second joint replacement. Infection. People who have any sort of artificial material in their bodies, including artificial joint components, have a higher risk of infections around the artificial material. They may need to take antibiotics before and after procedures such as surgery, tests that involve inserting instruments into the body, and dental work to help reduce the risk of infection. After a hip replacement, tiny bits of the surface of the new hip joint wear off as the ball and socket pieces rub against each other. Some people are sensitive to the types of metal that can be used for joint replacements. Tell your doctor about any symptoms related to your hip, groin, or leg that are new or getting worse. And be sure all your health providers know you have a hip replacement.

What To Think About

Continued exercise (such as swimming and walking) is important for your general well- being and muscle strength. Discuss with your doctor what type of exercise is best for you. You may donate your own blood to use during surgery if needed. This is called autologous blood donation. If you choose to do this, start the donation several weeks before the surgery so that you have time to donate enough blood and rebuild your blood volume before surgery.

If you need more than one joint replacement surgery, such as a knee and a hip, talk to your doctor about guidelines that may help you and your doctor decide in which order to do the surgeries.

Arthritis: Should I Have Hip Replacement Surgery?

Complete the surgery information form (PDF) to help you prepare for this surgery.

References

Other Works Consulted

American Academy of Orthopaedic Surgeons (2009). Activities after hip replacement. Available online: http://orthoinfo.aaos.org/topic.cfm? topic=a00356.

Imamura M, et al. (2012). Single mini-incision total hip replacement for the management of arthritic disease of the hip: A systematic review and meta-analysis of randomized controlled trials. Journal of Bone and Joint Surgery, American Version, 94(20): 1897–1905.

Rethman MP, et al. (2012). Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures: Executive Summary on the AAOS/ADA Clinical Practice Guideline. Available online: http://www.aaos.org/research/guidelines/PUDP/dental_guideline.asp.

Credits for Hip Replacement Surgery

By Healthwise Staff

Anne C. Poinier, MD - Internal Medicine Kenneth J. Koval, MD - Orthopedic Surgery, Orthopedic Trauma Last Revised November 5, 2013

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Examples Nonsteroidal anti-inflammatory drugs (NSAIDs) you can buy without a prescription (not a complete list)

Generic Name Brand Name

ibuprofen Advil, Motrin

naproxen Aleve

Aspirin is another example of an NSAID that you can buy without a prescription. But aspirin works differently from these other NSAIDs. See the topic Aspirin for more information.

Prescription NSAIDs (not a complete list)

Generic Name Brand Name

celecoxib Celebrex

diclofenac Voltaren

ibuprofen

ketoprofen

naproxen Anaprox

piroxicam Feldene

sulindac Clinoril

Voltaren is available in a pill and also in a gel that can be rubbed on the skin over a painful area.

If your doctor prescribed NSAIDs, take them exactly as prescribed. Call your doctor if you have any problems with your medicine. Always read and follow all instructions on the label.

How It Works

NSAIDs reduce inflammation and relieve fever and pain by blocking enzymes and proteins made by the body. NSAIDs such as ibuprofen and naproxen block a protein (called prostaglandin) that makes heavy menstrual bleeding worse. Aspirin does not block this protein.

Why It Is Used

NSAIDs relieve pain and fever. They also reduce swelling and inflammation caused by an injury or a disease such as arthritis. Some NSAIDs, such as ibuprofen and naproxen, help ease cramping and reduce blood loss from heavy menstrual bleeding.

How Well It Works

NSAIDs work well to relieve pain, decrease fever, and reduce swelling and inflammation caused by an injury or disease.1 Some NSAIDs help reduce heavy menstrual bleeding.2, 3 NSAIDs can help relieve the pain of kidney stones.4

Side Effects

Here are some important things to think about:

Call 911 or other emergency services right away if you have:

Trouble breathing. Swelling of your face, lips, tongue, or throat. Signs of a heart attack or stroke.

Call your doctor if you have:

Hives. Blood in the stool. Unexplained bleeding of any kind.

Common side effects of this medicine include:

Stomach upset. Heartburn. Ulcers. Skin rashes.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About Do not use a nonprescription NSAID for longer than 10 days without talking to your doctor.

NSAIDs are strong medicines. The actions they take in your body to help one condition can cause problems in other ways. NSAIDs may increase the risk of heart attack, stroke, skin reactions, and serious stomach and intestinal bleeding.

These risks are greater if you take NSAIDs at higher doses or for longer periods than recommended. People who are older than 65 or who have existing heart, stomach, kidney, liver, or intestinal disease are more likely to have problems.

Do not take NSAIDs if you have had an allergic reaction to this type of medicine in the past. If you have been told to avoid a medicine, talk to your doctor before you take it.

Talk to your doctor before taking NSAIDs if you have:

Allergies to aspirin or other pain relievers. Ulcers or a history of bleeding in your stomach or intestines. Stomach pain, upset stomach, or heartburn that lasts or comes back. Anemia. Bleeding or easy bruising. A habit of drinking more than 3 alcohol drinks a day. This increases your risk of stomach bleeding. High blood pressure. Kidney, liver, or heart disease.

Be sure to tell your doctor about all the nonprescription and prescription medicines you take. Talk to your doctor before using NSAIDs if you take:

Blood thinners, such as warfarin (for example, Coumadin), heparin, or aspirin. Medicine to treat mental health problems. Medicine to decrease swelling (water pills). Medicine for arthritis or diabetes.

If you take NSAIDs regularly, your doctor may recommend that you also take a medicine such as a proton pump inhibitor (PPI). These medicines can help protect the stomach lining.5

Taking medicine

Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.

Checkups

Complete the new medication information form (PDF) to help you understand this medication.

References

Citations

1. Gøtzsche PC (2007). Non-steroidal anti-inflammatory drugs, search date December 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

2. Chandavarkar U, Roy S (2010). Dysmenorrhea. In T Goodwine et al., eds., Management of Common Problems in Obstetrics and Gynecology, 5th ed., pp. 253–255. Chichester: Wiley-Blackwell.

3. Duckitt K, Collins S (2008). Menorrhagia, search date October 2007. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.

4. Teichman JMH (2004). Acute renal colic from ureteral calculus. New England Journal of Medicine, 350(7): 684–693.

5. Chan FKL, et al. (2007). Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: A double-blind randomised trial. Lancet, 369(9573): 1621–1626.

Credits for Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

By Healthwise Staff

William H. Blahd, Jr., MD, FACEP - Emergency Medicine Robert B. Keller, MD - Orthopedics Last Revised May 14, 2012

Sulfasalazine for Ankylosing Spondylitis

Examples

Generic Name Brand Name

sulfasalazine Azulfidine

Sulfasalazine is a medicine made from salicylic acid—the same active ingredient found in aspirin—plus an antibiotic called sulfapyridine. The medicine comes in time- release tablets taken by mouth.

How It Works

Sulfasalazine reduces inflammation, but the exact way this happens is not known. It has been used to decrease bowel inflammation in inflammatory bowel diseases such as Crohn's and joint inflammation in rheumatoid arthritis. More recently, it has been used to fight inflammation in ankylosing spondylitis, but it does not seem to work on the spine. It is more effective if ankylosing spondylitis is causing symptoms in other areas such as the shoulders and the heels.

Why It Is Used

Ankylosing spondylitis causes pain, stiffness, and swelling of the spine and sometimes other areas such as the hips, chest wall, and heels. Many people who have ankylosing spondylitis also have inflammatory bowel disease. Sulfasalazine helps by decreasing bowel inflammation and abdominal (belly) pain.

How Well It Works

Sulfasalazine may help control pain and inflammation for some people in areas other than the spine. Its effectiveness is still being studied.1

Side Effects

Here are some important things to think about:

Usually the benefits of the medicine are more important than any minor side effects. Side effects may go away after you take the medicine for a while. If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change the medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.

Call 911 or other emergency services right away if you have:

Trouble breathing. Swelling of your face, lips, tongue, or throat.

Call your doctor right away if you have:

Hives. Aching joints. A continuing headache. Itching or a rash.

Common side effects of this medicine include:

Skin sensitivity to sunlight. Stomach pain, nausea, loss of appetite. Diarrhea.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Tell your doctor if you are allergic to aspirin, sulfa drugs, or any other drug. And be sure he or she knows about any other medicines, vitamins, or other supplements you are taking.

You could be sensitive to sunlight while taking sulfasalazine. Wear sunglasses, and use sunscreen.

Taking medicine

Checkups

Complete the new medication information form (PDF) to help you understand this medication.

References

Citations

1. Arnett FC (2008). Seronegative spondyloarthritis. In DC Dale, DD Federman, eds., ACP Medicine, section 15, chap. 3. New York: WebMD.

Credits for Sulfasalazine for Ankylosing Spondylitis

By Healthwise Staff E. Gregory Thompson, MD - Internal Medicine Richa Dhawan, MD - Rheumatology Last Revised May 14, 2013

Topic Images

Figure

Spine The spine (backbone) is composed of 33 interlocking bones called vertebrae that are separated by soft, compressible discs and supported by many different ligaments and muscles. It is divided into five segments: cervical (neck), thoracic (upper and middle back), lumbar (lower back), sacrum (pelvis), and coccyx (tailbone). In each segment, the vertebrae are numbered from top to bottom. For example, a C3 is the third vertebra in the neck area, while a T6 is the sixth vertebra in the thoracic area.

The vertebrae in the spine normally form three curves. These curves allow the spine to absorb shock as you move.

Figure

Ankylosing Spondylitis Ankylosing spondylitis is a form of joint inflammation (arthritis) that is long-lasting (chronic) and most often affects the spine. Ankylosing spondylitis commonly causes pain and stiffness, with swelling and limited motion in the low back, middle back, neck, hips, chest wall, and heels. Over time, joints in the spine can fuse together and cause a fixed, bent-forward posture.

In early ankylosing spondylitis, there is inflammation of the joints and of the ligaments where they attach near the joints.

In advanced ankylosing spondylitis, there is:

Fusion of joints in the spine. Flattening of the normal curve in the low back. Often a flattening of the normal curve of the neck, an increase in the forward curve of the upper back, and bent posture at the hips.

Other joints can become painful and stiff, including those in the shoulders, wrists, hands, knees, ankles, and feet.

Although it is unusual, ankylosing spondylitis can also cause changes such as thickening of the major artery (aorta) and the valve in the heart called the aortic valve. Scarring of the lungs also happens in rare cases. The kidneys and the digestive tract can also be affected.

Figure

Posture in Advanced Ankylosing Spondylitis As severe ankylosing spondylitis advances:

The head moves forward and the neck becomes stiff. The upper back curves forward (kyphosis). The normal curve in the low back flattens. The hips may become stiff and not straighten completely. People often keep their knees bent a little to make up for the changed curves in their back and stiffness in their hips. This bending of the knees causes the body to shift back a little so it's easier to balance and to see straight ahead.

Figure

Cartilage Cartilage is a type of hard, thick, slippery tissue that coats the ends of bones where they meet with other bones to form a joint. Cartilage lines the joint space between bones throughout the body, including the spine and the rib cage. It acts as a protective cushion between bones to absorb the stress applied to joints during movement.

Cartilage is made up of protein strands called collagen that form a tough, meshlike framework. The mesh is filled with substances that hold water, much like a sponge. When weight is placed on cartilage, water is squeezed out of the mesh. When weight is taken off, the water returns. Cartilage does not contain blood vessels or nerves.

Exercises for ankylosing spondylitis should be gentle and frequent. The exercises shown here are good to do twice each day. Don't do them first thing in the morning, when you may feel more stiff. In the morning, take a walk to get loosened up for the day. Then try doing these exercises around lunch time and in the evening. Or, do one or two exercises at a time and spread them out through the day. You can do the exercises in any order that you like.

Talk with your doctor or physical therapist if you have questions about how to do these or any other exercises.

Figure 5

Back stretches 1. Get down on your hands and knees on the floor. 2. Relax your head and allow it to droop. 3. Round your back up toward the ceiling until you feel a nice stretch in your upper, middle, and lower back. 4. Hold this stretch for as long as it feels comfortable, or about 15 to 30 seconds. 5. Return to the starting position with a flat back while you are on your hands and knees. 6. Let your back sway by pressing your stomach toward the floor. Lift your buttocks toward the ceiling. 7. Hold each position for 15 to 30 seconds. 8. Repeat 2 to 4 times.

Figure 6

Chest expansion 1. Sit comfortably with your feet shoulder-width apart. You can also do this exercise standing up. 2. Look straight ahead and do not allow your head to tilt back. As you take a deep breath, open your arms out to the sides and roll your arms back. Your palms will turn out and you will feel a stretch across your chest. 3. Breathe normally as you hold this stretch for 15 to 30 seconds. 4. Lower your arms to your sides and let your palms turn back toward your legs as you slowly let out your breath. 5. Repeat 2 to 4 times.

Figure 7

Upper back and shoulder stretch 1. Stand up straight, or sit in a firm chair. 2. Looking straight ahead, breathe in as you raise both arms over your head and reach toward the ceiling. Do not allow your head to tilt back. 3. Reach back with your arms to stretch your shoulders. 4. Breathe normally as you hold this stretch for 15 to 30 seconds. 5. Return to the starting position. 6. Repeat 2 to 4 times.

Figure 8

Neck stretches

Turning the head

1. Sit in a firm chair, or stand up straight. 2. Keep your chin straight, turn your head to the right, and hold for 15 to 30 seconds. 3. Turn your head to the left and hold for 15 to 30 seconds. 4. Repeat 2 to 4 times to each side. 5. Next, you can do some head tilts. Keeping your chin pointing straight ahead, tip your right ear to your right shoulder and hold for 15 to 30 seconds. 6. Tip your left ear to your left shoulder and hold for 15 to 30 seconds. 7. Repeat 2 to 4 times to each side.

Figure 9

Press-up back extension 1. Lie on your stomach, supporting your body with your forearms. 2. Press your elbows down into the floor to raise your upper back. As you do this, relax your stomach muscles and allow your back to arch without using your back muscles. As your press up, do not let your hips or pelvis come off the floor. 3. Hold for 15 to 30 seconds, then relax. 4. Repeat 2 to 4 times.

Figure 10

Alternate arm and leg (bird dog) exercise

Note: Do this exercise slowly. Try to keep your body straight at all times, and do not let one hip drop lower than the other.

1. Start on the floor, on your hands and knees. 2. Tighten your stomach muscles. 3. Raise one leg off the floor, and hold it straight out behind you. Be careful not to let your hip drop down, because that will twist your trunk. 4. Hold for about 6 seconds, then lower your leg and switch to the other leg. 5. Repeat 8 to 12 times on each leg. 6. Over time, work up to holding for 10 to 30 seconds each time. 7. If you feel stable and secure with your leg raised, try raising the opposite arm straight out in front of you at the same time.

Figure 11

Normal hip joint

Figure 12

Osteoarthritis of the hip In osteoarthritis, the cartilage that protects and cushions the joints breaks down over time. As the cartilage wears down, the bone surfaces rub against each other. This damages the tissue and bone, which then causes pain. The joint space in this hip joint is narrowed due to cartilage loss and bone spur formation.

Figure 13

Damaged cartilage and bone are removed from hip socket and femur

Removal of cartilage from the hip socket (acetabulum) and removal of the upper end of the femur Figure 14

Hip socket component is placed

Placement of acetabular component

Figure 15

Femoral component is placed

Placement of femoral component Figure 16

Hip replacement is complete

Completed hip replacement

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