Search the Community

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2023 A “new” Low Cost Treatment for Knee/Hip OA Without NSAID and Tylenol Side Effect Risks and Downstream Medical Costs… by Karen Napierala MS, AT, PT, CAFS What would you do? A 67 yo female enters your office with pain in her L anterior thigh traveling up into her anterior hip/groin. She has pain on heel strike and late stance phase of gait, which is visibly shortened. She can stand 30 minutes maximum while leaning forward to prepare meals at the counter, but can only stand upright < 10 minutes socializing at a family gathering. Hip flexion for tying her shoe is painful and limited. Hip scouring is (+) for pain and limited motion. All hip AROM and PROM are limited, especially with loss of IR, Faber’s, and hip ext. Plain films confirm moderately severe L hip DJD. The Pt’s goals are to resume WNL ADL, watching grandchildren BIW for 5 hr each, fitness class BIW 45min and occasional doubles pickleball. I would prescribe… A. A normal course of NSAID’s along with continued usual activity until 6 wk FU B. A normal course of paracetamol along with continued usual activity until 6 wk FU C. Surgical consult for THR consideration D. Customized PT to include Class IV laser, manual therapy, biomechanical exercise with FU 6 wks E. Provide handout of simple HEP drills for ROM and light strengthening with FU 6-8 wks F. Intra-articular corticosteroid injection with FU 4 wks CURRENT EVIDENCE Weng Q, Goh SL et al. Comparative efficacy of exercise therapy and oral nonsteroidal antiinflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomized controlled trials. BJSM, Jan 2, 2023(online). https://bjsm.bmj.com/content/early/2023/01/02/bjsports-2022-105898 SUMMARY: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. NSAID’s and paracetamol are commonly prescribed medicines but their cost-benefit analysis regarding potential adverse effects and comorbidity profiles (Tuhina Neogi , Amer College of Rheumatology) may make these drugs inappropriate. Exercise is a recommended treatment for restoring ROM, strength, balance, and overall function but pain reduction is more so considered a secondary benefit. Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants with hip or knee OA comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function. The results showed that exercise was comparably effective vs NSAID’s and paracetamol in reducing pain and improving physical function at 4 weeks, 8 weeks, and 24 weeks comparisons. It was also superior to “usual care” (ie. continued daily activities). Exercise may present some challenges regarding the delayed benefit of symptom reduction, requiring compliance by patients, the challenge in slowing down “over-exercisers”, and that oftentimes we find (especially for “failed PT” cases we see) specific biomechanical adjustments and considerations are necessary beyond traditional PT approaches in order to produce successful outcomes. The use of medications, however, does not produce the same expected gains in needed ROM, strength/endurance, and balance these patients require to optimize function and quality of life. Patients relying mainly on continued dosing of NSAID’s and Tylenol also are habituating into a mindset reinforcing quick fixes to symptom control and return to activity that will not serve them long-term regarding their need to modify activity and actively participate in restorative/preventative exercise. Downstream costs for patients relying on these medications also have been shown to increase significantly over time, including due to adverse effects on numerous body systems. The other risk is that patients will contribute unknowingly to accelerated degenerative changes as they medicate their way “successfully” through impact activities that are deleterious to their joint health long term. Expert physical therapy should include specific customizing intended to off-load the compartment mainly effected via specific reaching/shifting maneuvers to allow pain-free/minimized functional strengthening work. Prescriptions should also order kinetic chain evaluation and exercise/manual therapy to address contributing factors (ie., lack of hip IR and ITB length both contributing to varus knee tendency and subsequent medial joint loading). Simple traditional therapy exercises for knee and hip OA do not take these biomechanical considerations into account. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Purpose: Comparing analgesic benefits of exercise vs NSAID’s and paracetamol in hip and knee OA patients. Study Design: Network meta-analysis Methods: Studies included were: 1. RCT’s, 2. Participants with knee or hip OA, 3. Comparisons of exercise with oral NSAIDs , 4. Studies comparing exercise therapy with any common comparator that may be shared with NSAID’s (i.e. usual care/no treatment/waiting list control, glucosamine sulfate/chondroitin/intra-articular hyaluronic acid, topical NSAID’s, acupuncture), and 5. Studies reporting pain or function. Any study with less than 1 week follow up, use of a cross-over design, or postoperative pain were excluded. The full texts of 2738 potentially eligible articles were reviewed. There were 152 studies (17,431 participants) meeting the inclusion criteria. There were 49 studies with data available at or nearest to four weeks, two studies had data available at eight weeks and nine studies at 24 weeks. Most trials recruited participants with knee OA, while 12 studies investigated hip OA and 13 studies were both. Results: For pain relief there was no difference between oral NSAID’s and Tylenol at or nearest to 4, 8, and 24 weeks. Similar findings were noted for function as well. Authors Conclusion: Exercise has similar positive benefits to oral NSAID’s and Tylenol for pain relief and function. Since exercise has an excellent safety profile it should be given more prominence in clinical care, especially for older patients with comorbidity or higher adverse event risks related to NSAID or Tylenol use. THE PEAK PERFORMANCE PERSPECTIVE: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. With pain relief ultimately comes the expectation that function will be improved significantly as well, optimizing quality of life. NSAID’s and paracetamol are among the most commonly prescribed medicines used for OA, however, the cost-benefit analysis for these medicines presents some challenges for physicians due to both potential adverse effects and comorbidity profiles (ie. Tuhina Neogi , Amer College of Rheumatology) that may make these drugs inappropriate long term or at all. Exercise is often considered a valuable treatment for restoring ROM, strength, balance, and overall function. Pain reduction is often more so thought of as a secondary benefit. Prescribed physical therapy to include formal supervised exercise is frequently delayed until more significant losses of function (i.e., ROM and strength deficits evident on clinical exam) are noted. Boston rheumatologist Jean Liew, MD noted that over 50% of patients receive NSAID’s and the same percent were given an opioid prescription when diagnosed with OA (American College of Rheumatology Convention 2021). Liew, updating their group’s findings looking at patterns of NSAID, opioid, and physical therapy (PT) use among more than 30,000 newly diagnosed patients with knee or hip OA found 9% had NSAID contraindications and 22% had NSAID precautions. This begs the question: Are NSAID’s and paracetamol being prescribed too frequently for hip and knee OA? Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function knee or hip OA. The results not only showed that exercise was a clinically effective treatment (better than usual care) for reducing pain and improving physical function in people with knee or hip OA, but it was comparable in efficacy to NSAID’s and paracetamol at 4 weeks, 8 weeks, and 24 weeks comparisons. NSAID’s, for example, while effective for control of that knee/hip OA pain and inflammation, have been associated with gastrointestinal, renal, and cardiovascular complications, especially in older adults with comorbidities, There are also patients whose comorbidities deem NSAID’s as strictly contraindicated. Together these facts leave physicians and patients in a difficult position regarding ideal options if left to typical medications alone. Exercise, on the other hand, has the multi-faceted benefits of decreasing pain, increasing range of motion, increasing balance and strength - thus improving function, without the ongoing cost or risks associated with medications. Does exercise have some limitations also? There remains no absolute agreed protocols or best practices based on the evidence, however, this also should be viewed in the light that even heterogeneous “exercise” has been shown not only in this study but in numerous others to nevertheless be effective. Numerous orthopedic and rheumatology organizations have included exercise as strongly recommended based on review findings.. Three particular difficulties must be considered and addressed with prescribing exercise, especially if chosen over NSAID’s and paracetamol alone. One, the patient's desire to do the least and get the most results. We live in a society where people often “want results yesterday, not four weeks from now!” If I am told that I can take a pill today and do nothing, or I can go to PT and exercise, but it will probably take four to six weeks to work, what would I do? If I knew that I would get stronger, get off the ground easier, climb stairs better after exercise, and not just relieve the pain, patients would be more likely to follow those orders. Educating patients about these “long term” expectations and benefits fosters the compliance needed for good outcomes. Secondly, patients unaccustomed to exercise may struggle with commitment to an exercise program. There are patients who will flat out refuse to put the effort in. Third, is slowing down those who are avid exercisers. We have to be careful not to overdose, or allow exercise that will overload the joints. Many patients become their own “worst enemy” as they swing the exercise pendulum in the direction of excess, be it volume, frequency, or oftentimes intensity (especially for impact related activities). One study corroborated that the exercise for 8 weeks was very effective, but the effect of exercise gradually decreased when reassessed a year from the original study. We must approach such facts with caution, however, as the same would be true for medications taken for 6 weeks and not expecting patients to remain substantially better one year later. Exercise is a treatment that must be continued to have maximum results. Siew-LiGoh et al (Sports Medicine, 2019) compared a variety of exercises with “usual care” (i.e. continuing normal daily activity without other treatment). They found that aerobic, flow and pattern exercise, strength and coordination exercises all reduced the pain in knee and hip OA subjects. The question for physicians remains - if exercise, as shown in this and other studies, can be as effective at pain control as NSAID’s and paracetamol, have positive effects on increased function, strength, movement, coordination, and potential decrease risk in falls, and, lack the adverse effects and downstream medical costs associated with those side effects, then why would exercise not be used with every patient that presents with knee or hip OA in the office? The final but not least important points about exercise prescribing and treatment is that the RIGHT exercise will bring the BEST results. Careful attention to detail is necessary for many OA patients to succeed with exercise. Many patients will appear to succeed early on using simple NWB exercises. Unfortunately that often leaves a large “gap to bridge” to more authentic functional demands. For many of these cases, sometimes becoming “failed PT” cases, although finding effective pain-free/minimized PWB and WB functional strength methods can be a much more daunting task, it provides a more effective impact on day to day life. Expert Physical Therapy applies understanding of key biomechanics in order to both intentionally load healthier portions of articular surfaces and also in order to address key kinetic chain shortcomings that are contributing to joint overload. For example, in a common knee medial joint OA case, where the knee is in a varus presentation, PT exercise should focus on unloading the medial knee joint especially via the frontal plane but also the transverse plane. Specific reaching and shifting during otherwise typically painful exercises like split squats or step ups/downs etc can significantly reduce or abolish symptoms, allowing patients to more effectively strengthen. Key biomechanical shortcomings related to having caused the genu varum or that will perpetuate those forces such is poor hip IR, poor ITB length, poor STJ eversion all should be assessed and custom exercises done to treat. These are not approaches common to traditional physical therapy for knee/hip OA. The following case illustrates an example of simple/traditional exercises not working for his case of knee OA. THE PEAK PERFORMANCE EXPERIENCE: Mark said: “ I came to Peak after other physical therapy didn’t work for me. I was on the verge of needing surgery that I didn't want. I came to a Peak PT knee arthritis workshop. After starting PT I I know what to do, and I’m doing it. I can get through work and vacations now pain free!” History: Mark is a 64 year old male who had prior physical therapy and tried to exercise on his own, but was finding the things that he usually did created medial knee pain. He tried NSAIDs for a few months with some relief, but decided that he didn't see that as a long term solution. His job requires climbing ladders and stairs, squatting and carrying. By the end of the day his R > L medial knee is painful. He knows there is some OA on films, but he is not ready to think about a knee replacement yet. Subjective: He complained of knee pain and stiffness that limited walking, climbing ladders for work, and by the start of PT that his knees “hurt all the time.” Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 10 Single leg squat knee angle L 400/ R Unable ** L 650/R 500 Hip IR standing L 150/R 120 L 300 / R 250 2” quad dom step down (eccentric ) painful * 10 # front racked with ant lateral op toe reach ( inc valg at knee) L 24x / R 15x Step up 6” w 10# wts doing P-L opp foot reach ($ knee valgus for med jt unload) L 5x / R painful** L 16x / R 12x Sit stand to seat 15 sec 7x 12x Single leg balance rotation 15 sec painful ER L 15x R 13x WOMAC 41 % 16 % Key Findings: Poor knee ext and flex ROM, lacking hip IR (B) - slightly worse on R, poor tol of WB rotation, limited/painful squat function Treatment: Mark needed to regain as much knee extension as possible initially before moving into flexion exercises. This immediately decreased his pain with walking. He also worked on his limited hip IR NWB and then he progressed to functional WB methods to improve ADL and work applications. He began strengthening with PWB squats (using 0-300 and 60-950 pain-free depths) that were hip and ankle dominant to offload the knee. He used hands holding onto a stationary pole to unweight using arms also. A small yoga ball between his knees allowed Mark to maintain valgus alignment at the knees, thereby unloading his painful medial joint. All sagittal knee motions such as squats, split squats, step ups, and step downs were modified to decrease forces on the medial compartment of the knee. Frontal plane motion into valgus, and increased pronation or tibial IR were allowed as this relieved symptoms. When Mark was able to progress to impacting he began with crossover lunges focusing on valgus force from the foot up. Even once he progressed to lateral lunges, medial joint unloading was maintained by landing laterally on a wedge. Mark also received 6 sessions of Class IV Laser treatments on his R knee. The pain relief for him was immediate and lasting. This allowed faster progressions and improved his functional status quicker. After 6 weeks: Mark was ambulating at 3.0 mph pain free for 30 min, and could sit stand easily and was pain- free up and down ladders at work. He knows he has a limit for the total amount of weight bearing and work during each day, but has kept himself well under that. Outcome: Pt was DC’d to an (I) HEP, pain-free, able to remain at work full duty performing all tasks w/o troubles, walking and sitting were WNL, and he was able to go on vacation as well. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE May 2022 Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 62 yr old male with 6+ months of progressive hip pain seen for ortho consult referred by PCP. Pt had been taking NSAID’s for 6 weeks and attending physical therapy for 4 wks with limited improvements in pain, ROM, and overall function. Plain films show Gr III-IV degenerative changes in the R painful hip joint and Gr II-III changes on the pain free L side. He enjoys fitness classes including low to moderate impact drills, playing golf and tennis, and hiking with his wife, including mild-moderate elevations. Clinical exam shows NWB A/PROM asymmetric R hip limited in flexion, IR, extension more so than other directions. I would... Recommend 3 series gel injection and reassess in 3-4 months. Advise to continue HEP given by PT and limit activity to non and low-impact only. Recommend patient stop impact activity and switch to pool exercise and cycling for exercise for 2 months and then FU to consider other options such as injection. Update PT prescription or change providers to include BIW manual therapy (+ advancing exercise for ROM and functional strengthening) for at least 4-6 wks before considering HA gel injections. Perform single cortisone injection. Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration. Change NSAID’s and advise the patient to continue the present PT program for 4 more weeks. CURRENT EVIDENCE Shepherd, et al. “The Influence Of Manual Therapy Dosing On Outcomes In Patients With Hip Osteoarthritis: A Systematic Review”. Journal of Manual & Manipulative Therapy. (2022) 10. 1080/10669817.2022.2037193 Summary: Hip OA is a common ailment causing symptoms and limiting function. While joint mobilization techniques have been shown to be helpful and clinical practice guidelines have formally recommended them, there is a lack of clear dosing parameters known to produce best outcomes. This systematic review initially found 4,675 potential studies on the topic but only 33 were eligible for further review, with only 10 meeting all criteria - this included being an RCT, measuring outcomes, and having specific dosing parameters reported. Of the 768 total participants, it was noted that sessions were most frequently 2-3x/wk, patients had a mean of 6-12 sessions over 1-12 wks, with manual therapy performed in 7 sessions. Effect sizes ranged from small to large depending on the variable measured (pain, ROM, function). While no clear dosing parameter could be recommended based on findings, there were ranges noted that can serve as evidence based starting point. Hip arthritis care, for patients as well as for providers, risks being viewed as an accepted “routine” and “keep it simple” care model mentality. Many experienced physicians may be relying on evidence based “best practices” from studies published many years or even a decade or more ago. Physicians seeing patients themselves and who are training upcoming physicians in residency or fellowship may be unaware of newer evidence published in recent years around the use of joint mobilization efficacy with hip OA. This is a key factor when considering treatment recommendations and prescription content for physical therapy, along with specific recommendations vs a “wherever is most convenient” thinking that is intended to ease the burden on patients but may unintentionally lack discernment regarding extent of manual therapy performed. Often patients have been told prior to PT that “they’ll show you some stretches to do at home” - setting patients up for expectations about PT that may not be consistent with best practices. This study did not find a specific set of parameters supported by the evidence that can be applied “across the board” for joint mobilization in hip OA cases. The heterogeneity of the mobilization parameters does, however, support the idea that there is no single parameter that needs to be followed to achieve results. It suggests that knowledgeable, skilled PTs have the ability to make clinical judgments regarding the customization of techniques used, application of force, directions, and volume/frequency of treatment that result in (+) outcomes. Physicians should know, when ordering PT, that manual therapy techniques lasting 10-30minutes, 2-3x/week, for 6-12 sessions are an evidence based part of appropriate hip OA care. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Hip OA is a common cause of pain and limitation with functional activities for many older adults. There currently is good evidence that joint mobilization is effective in improving pain, ROM, and function however there is not documented well studied specific dosing recommendations for hip OA manual therapy treatment parameters. This review study attempts to establish more specific treatment guidelines for this diagnosis based on RCT level evidence. Methods: This is a systematic review that included randomized controlled trials (RCTs) and utilized joint-focused manual therapy. Inclusion criteria were detailed dosing parameters of manual therapy type, direction of force, session duration, frequency of interventions, and numbers of sessions, were published between January 2000 and December of 2021, and met the criteria for hip OA according to the American College of Rheumatology. Findings: Within 4,675 studies, 33 were eligible and 10 were included meeting all the criteria. There were 768 participants with treatments performed by physical therapists and two chiropractors. A variety of manual therapy interventions were performed, including the Mulligan concept (MWM), long-axis high-velocity low-amplitude thrust (LA-HVLAT) mobilization, and non-thrust mobilizations. Parameters used ranged widely. Risk of bias assessment was also done along with outcome-level certainty using the GRADE approach. The most common MT type used was LA-HVLAT. The most common directions of non-thrust mobilizations were lateral and caudal glides with some form of hip IR. Long-axis distraction was used in 7/10 studies. All forms of MT when compared to a control group, improved hip ROM in the short term. Quality of life improvements were documented as medium and large between-group effects after 6 weeks of treatment but small after one year, with regards to the HOOS QoL subscale. Five studies assessed functional performance including walk speed, step-count or a walk test, and large between-group effects were found with walk-test improvements. The largest between-group effect sizes were seen for pain and ROM using MWM into hip flexion and IR when compared to a sham, no-force intervention. Author’s Conclusion: There were some trends that clinicians can consider from this study. The largest within-group effects for pain and ROM and self-reported functional gains were from LA-HVLAT, specifically performing thrust techniques (up to 9 times) and for longer durations of three to six sets (30-45 seconds). When considering non-thrust mobilizations LADM for 10 minutes with 30 second bouts. If hip flexion and IR ROM are limited, then MWM into these motions was shown to have the greatest improvements. There was a lack of specific dosing parameters for many studies so further research is recommended to allow for MT frequency and techniques to be more concisely recommended. Clinical trials should also include baseline sensory and pain neurophysiology assessments, as well as psychosocial assessments as they can influence clinical outcomes. THE PEAK PERFORMANCE PERSPECTIVE Hip OA is a common diagnosis that both primary care and orthopedic physicians see in the office routinely. The pain, progressive loss of motion, and weakness that negatively impact function require consideration of what the best options for treatment recommendations are. Physical therapy has been shown effective in the care of hip OA but physicians considering best practices are oftentimes uncertain regarding the specific recommendations to make on therapy prescriptions and in educating patients about what to expect. Shepherd et al, in this systematic review, analyzed RCT’s to discern if there were specific treatment parameters with manual therapy treatments for hip OA that could be identified for purposes of understanding best practices related to optimizing outcomes. This is critical for both referring physicians writing prescriptions and educating patients regarding therapy expectations. Physicians are also discerning next steps when a patient is apparently “failing” an episode of therapy and the adequacy of care provided must be assessed before deciding if different therapy or escalating care to injections or surgery is called for. And of course these dosing parameters would be critical for practicing therapy providers to understand. While the question on dosing parameters is a good one, this study, like many others, may suffer from the challenge we all see as clinicians. The attempt at a homogeneous answer for the sake of minimizing variability in treatments of the “same condition/diagnosis” is admirable and logical but often ignores the heterogeneity of the patients themselves. Also, many diagnoses have multifactorial considerations. Sometimes evidence exists demonstrating a common approach or parameter that can be consistently used. But, there also exists significant variability within our patients’ lives and bodies that impacts treatment decision making, often leaving linear, singular treatment decisions inappropriate or non-specific to this case. External validity factors in applying research recommendations are often forgotten or neglected too often. Clinical judgment based on both evidence and experience, leaving a “range” of options vs a singular algorithm-like, mathematical equation-like answer that every single provider could and should arrive at equally, is a key portion of our day to day practice as providers. Manual therapy is an effective and necessary component of hip OA care but the evidence does not support a strict and specific dosing parameter that is “one-size-fits-all” in nature. That is not a “bad” finding but speaks to the “art and science” of clinical practice. Our patients are unique - they come with a variety of preconceptions. Oftentimes they verbalize their own expectations of what therapy will entail and will do for them. We have heard requests of massaging the tightness away or to provide them with three or four “easy exercises” to help get them back to where they were years ago or just a quick morning “stretch routine” that can be done daily. Some, of course, say they’ll do whatever it takes to perform their favorite activity again. Many are under the impression or have been expressly told by their physician that physical therapy will be a few short weeks only to learn a home routine. While evidence from the past has certainly demonstrated the efficacy of simple ROM and strengthening exercises with hip OA cases there can sometimes be an unawareness of what the newest research and clinical practice experiences show regarding the efficacy of other treatments in optimizing hip OA outcomes. That can contribute to physicians having mistaken paradigms and providing patients with inaccurate expectations of what physical therapy will include and the length of time likely for formal care. For patients, the disconnect that happens when the PT’s treatment recommendations differ sometimes significantly from their own preconceptions or physician’s advice can sabotage their confidence and trust in therapy, their “buy-in” to the treatment process, and their compliance. It’s helpful, therefore, for physical therapists to share important evidence and experience based updates with referring physicians to update current thinking on best practices in hip OA care. What we as therapists typically do is often different from what physicians and patients expect, both in terms of the extent of biomechanical considerations within the evaluation as well as the variety of treatment options available within therapy. Many patients may have already looked up information from Google that there are the “3 best movements” for everyone’s arthritic hip or have a sheet of six exercise pictures from a friend or other PT or even a physician. Most of the time patients become pleasantly surprised when therapists educate them on all the ways therapy will help them achieve their goals, and it’s much more than exercise. Good evidence exists and clinical practice guidelines now formally recommend the use of manual therapy, especially joint mobilization and/or thrust techniques, for the benefit of pain reduction, ROM gains, and eventual function improvements. While stretching and strength are very important components to be able to move comfortably, it is specifically manual therapy (MT) techniques that decrease pain the fastest and assist in movements with more fluidity and ease, as well as decreasing someone’s compensatory strategies causing pain onset in other joints or even the opposite extremity. Shepherd et al found trends in MT techniques that show the most gains in ROM and pain control, mentioning mobilization with movement techniques (MWM) and long axis high velocity low amplitude thrust (LA-HVLAT) techniques among others, consisting of 10-30 minutes of treatment, 2-3 times per week, for a duration of care from 2-6 weeks as the ranges noted in the RCT’s examined where (+) outcomes were noted using manual therapy to reduce pain, increase ROM, and or function was examined. That is a general suggestion but also needs to be based on individual presentations, level of current and past functional abilities, motivation, fear avoidance, and psychosocial status. All patients are individuals and we as providers need to treat them as they are. Very often a “simple” approach is considered a starting point for all patients. For many this can be appropriate. For many others the case is more complex or goals are loftier. That is where customization of treatment planning comes in…starting with a thorough biomechanical/orthopedic evaluation. We often find that the “regional interdependence” considerations of the kinetic chain result in the need to address other body parts affecting or being affected by the arthritic hip. If one’s goal is to walk 3 miles per day and there is a significant hip flexion contracture, there is a high likelihood of compensations into the spine or opposite knee or hip as that person’s ipsilateral stride is shortened from lack of hip extension. The lumbar spine often hyperextends to take up the lack of extension, potentially contributing to low back pain but also forcing the opposite extremity to be overloaded on impact over time. Carefully assessing the functional mechanics of gait and other ADL, work, or sport movements is key. Many hip OA cases likely require manual joint mobilizations to assist increasing ROM and reducing pain where there hasn’t been correct mobility and mechanics in months or even years. Multi-plane functional hip mobility exercises in all three planes in standing, as well as ankle and knee mobility will all be incorporated into a patient’s treatment plan. Once patients start to feel more comfortable, functional strength and dynamic stability has to be applied through patient specific therapeutic exercises to control their newly achieved hip ROM, thus allowing for functional gains in ADLs and recreational activities. THE PEAK PERFORMANCE EXPERIENCE Diane said: “I feel so great walking, it’s not catching anymore like it used to!” History: Diane was coming into PT for c/o L buttock pain, anterior L hip pain and knee stiffness and pain. She is a nurse and stated she required assistance to help her even walk without limping. She couldn’t quite figure out why she was limping so significantly, but has a history of back, pelvic/SI joint and hip/knee issues on that L leg. Objective: Diane fell off of a step onto her L knee in 2015 initially injuring L knee. She also had been in a MVA in 2000 with c/o L posterior hip pain ever since as well as posterior pelvic pain. She was unable to sit > 20 min, standing > 20 was painful, and any walking was painful at the time of PT exam. Bending forward and squatting was painful as well. Pain could get up to 4/10 and at times was constant. Initial Exam Re-evaluation Hip extension -10deg (flexion contracture) 10deg Prone hip ER 25deg 30deg Prone hip IR 45deg 45deg FABER test Pos Neg O’ber’s test Pos Neg Thomas test Pos Neg Hip Scour Pos Neg Pivoting for directional change L fear of instability No fear/no issue Anterior step down L unable/fear of buckling 2” step down w 8# DB Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: Diane had a L knee flexion contracture and almost no L hip ER and extension and also was observed to have her L leg longer than her R. She was limping and almost falling into her R leg during gait and her tolerance to any walking was limited (facial grimacing). Treatment: Diane received manual therapy treatment for at least 15 min at the start of every treatment consisting of L hip lateral and caudal (long axis) distraction with a mobilization belt, with 10-20 oscillations followed by 20 sec holds, as well as MWM hip extension and ER mobs 2x10 each direction, each visit. She was also advised to get fitted for a custom external shoe lift as her LLD was of much significance. She performed self SI joint correction, hip ER stretching, elevated hip flexor stretching followed then by resistance band ER pivot step outs and hip flexor loading in/out of extension with sliding discs in WB for ease of increased stride in gait. Other exercises performed including hip adductor stretching and lateral weighted lunges loading adductors instead of abductors, and SLB with transverse plane top-down loading, eccentric step downs for quad loading, incline side planks in/out of hip adduction for ease of WS in gait. Outcome: Diane can walk, squat and negotiate stairs as well as complete all transfers without pain limiting her. She is very happy with her progress and soon to be discharged from PT to live an active lifestyle. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com