Primary hip pain affects 14% of adults.1 Management of these conditions is expected to reach 100 billion dollars by 2020 with exponential growth.2 Although, its neighboring partner – the knee – receives more literature attention, most likely attributable to increased prevalence of 25%. Although, what gives – where is the manual therapy literature love at the hip?
We see the hip gain some popularity when it continues to shake out in literature with importance in treatment during episode of low back pain and knee pain. For example – CPR for manipulation success is stronger with adequate hip internal rotation, indicating its possible importance within the concept of regional interdependence.5 Seemingly, this is making the hip a point of focus within manual therapy, even the epicenter of our attention within neighboring joints. This shift in literature elsewhere does not seem to be panning out into our attention to this syovial joint in localized treatments – especially in regards to manual therapy’s affects. In the many years of treatment of manual therapy at the hip – 5 pieces of literature is under-robust to say the least.
Regardless the attention it may deserve, there are four studies that evaluate effects of hands on approach to hip arthritis. Hando et al providing amongst most robust of outcomes stating benefits lasting at long term follow up of 29 weeks in Harris Hip Scores, pain and range of motion.1,2 These findings similarly matched to Hoeksma et al where manual therapy plus exercises also provided above stated benefits plus a bonus of increased walking speed.7 What I like about both of these studies is the ability to generalize treatments and techniques used as these are extremely similar to practice patterns in clinic. These include: anterior hip stretching, caudal mobilizations with belt, long axis distraction, prone posterior-anterior mobilizations and stretching of piriformis with follow up exercises of clamshells, single knee to chest, stretching of hip flexor and piriformis and bridging.2,7 All stated techniques I use, as they are easily transferrable and performed in clinic.
Possibility of lack of literature may be attributable from the relatively lack of flare in results gleaned from manual therapy studies at the hip. We know, if we get an arthritic joint moving – people feel better – motion is lotion – correct? Although I did find interesting that Hando et al captured the compliance with exercise routine and outcomes. Stating that the non compliant only felt “somewhat better” and the compliant felt “quite a bit better.” Even with more significance, the patients who only completed their program 0-1 times per week had a decline in their Harris Hip Score when patients who completed 6-7 times per week saw greater success not only short term but long term at 29 weeks.2 Driving home the obvious, but not very accepted, point of something I tell my patients. I will work my butt off to get that hip moving, these scrawny arms put a lot of effort in performing caudal mobilizations, BUT patients need to match my effort but equal amount of work on their end to see optimal outcomes and inter-session changes. Each episode of care is a partnership. Pointing out that all of the mobilizations in the world, belted, not belted, soft tissue, etc will provide little to no lasting effects for the patient who does not maintain its affects with range of motion exercises, and strengthen into that new range. Something we see anecdotally, now we have data in this population.
Now that the hip is moving and the patient is compliant with maintaining the motion and strengthening the joint. How do I know they are improving?
I match outcome tracking or asterisk tracking completely dependent on the patient. The topics touched on this week include FAI, OA, and labral lesions, which we all know, present in different types of patients. Typically, the OA patient is an older patient with limited overall function, which makes more sense to measure their comfort with self selected task (i.e duration of morning discomfort, sit to stand comfort, walking tolerance) and for FAI and labral lesions demonstrating improvement within FABER comfort means less to me than single leg squatting comfort if they are seeing me for running pain. Practical approach to re-test or outcome management should be quite patient specific to drive interest and reflect goals. For discussion sake, timed up and go is a reliable and responsive test for hip osteoarthritis demonstrating a MDIC of 2.49 seconds for patients with unilateral hip arthritis or replacement.4
Regardless the poison for tracking outcomes – be it outcome driven, asterisk driven, or symptom relating. It is important to collect as much data as possible but always present the most relevant to the patient to drive compliance and therapy buy in. Regardless the lack-luster of literature, manual therapy within the arthritic joint seems beneficial and regardless your patient, just as long as we sell them on strength and stability to match their goals.
Original post: March 25, 2014
- Julie Whitman. Manual Physical Therapy for Hip Disorders. Lecture by Evidence in Motion. March 15, 2014.
- Hando B, Gill N, Walker M, Garber M. Short and Long Term Clinical Outcomes Following a Standardized Protocol of Orthopedic Manual Physical Therapy and Exercise in Individuals with Osteoarthritis of the Hip: A Case Series. JMMT. 2012; 20: 1-4.
- Mellin G. Correlations of Hip Mobility with Degree of Back Pain and Lumbar Spinal Mobility in Chronic Low-Back Pain Patients. Spine; 1988
- Dobson F, Hinman RS, Hall M, Terwee CB, Roos EM, Bennell KL. Measurement Properties of Performance-Based Measures to Assess Physical Function in Hip and Knee Osteoarthritis: A Systematic Review. Osteoarthritis Cartilage. 2012; 20: 1548-1562.
- Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920–928
- Hoeksma HL, Dekker J, Ronday HK, Heering A, Van der Lubbe N, Vel C, Breedveld FC, Van Den Ende CH. Comparison of Manual Therapy and Exercise Therapy in Osteoarthritis of the Hip: A Randomized Clinical Trial. Arthritis Rheum. 2004; 51: 722-729.
- MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series. J Orthop Sports Phys Ther. 2006 Aug;36(8):588-99.