Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations (PHYSICIAN UPDATE: May 2022)

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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...

 

1. 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.
    
2. 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.
    
3. 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.
4. Perform single cortisone injection.  Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration.
    
5. 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.

 

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