clinical outcomes following manual physical therapy and exercise for hip osteoarthritis- a case...

8/12/2019 Clinical Outcomes Following Manual Physical Therapy and Exercise for Hip Osteoarthritis- A Case Series

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Clinical Outcomes Following ManualPhysical Therapy and Exercise for HipOsteoarthritis: A Case SeriesCameron W. MacDonald, PT, DPT, GCS, OCS, FAAOMPT1

Julie M. Whitman, PT, DSc, OCS, FAAOMPT2

Joshua A. Cleland, PT, DPT, PhD, OCS, FAAOMPT3

Marcia Smith, PT, PhD4

Hugo L. Hoeksma, PT, PhD, MSc, MT5

Study Design: Case series describing the outcomes of individual patients with hip osteoarthritistreated with manual physical therapy and exercise.Case Description: Seven patients referred to physical therapy with hip osteoarthritis and/or hippain were included in this case series. All patients were treated with manual physical therapyfollowed by exercises to maximize strength and range of motion. Six of 7 patients completed aHarris Hip Score at initial examination and discharge from physical therapy, and 1 patientcompleted a Global Rating of Change Scale at discharge.Outcomes: Three males and 4 females with a median age of 62 years (range, 52-80 years) andmedian duration of symptoms of 9 months (range, 2-60 months) participated in this case series.The median number of physical therapy sessions attended was 5 (range, 4-12). The median

increase in total passive range of motion of the hip was 82 (range, 70-86). The medianimprovement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient whocompleted the Global Rating of Change Scale at discharge reported being a great deal better.Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-pointscale.Discussion: All patients exhibited reductions in pain and increases in passive range of motion, aswell as a clinically meaningful improvement in function. Although we cannot infer a cause andeffect relationship from a case series, the outcomes with these patients are similar to othersreported in the literature that have demonstrated superior clinical outcomes associated withmanual physical therapy and exercise for hip osteoarthritis compared to exercise alone. J OrthopSports Phys Ther 2006;36(8):588-599.doi:10.2519/jospt.2006.2233

Key Words: arthritis, Harris Hip Score, manipulation, mobilization, passiverange of motion

1

Physical Therapist, Centennial Physical Therapy, Colorado Sport and Spine Centers, Colorado Springs,CO; Fellow, Manual Physical Therapy Fellowship Program, Regis University, Denver, CO.2 Assistant Professor, Department of Physical Therapy, Regis University, Denver, CO; Faculty, ManualPhysical Therapy Fellowship Program, Regis University, Denver, CO.3 Assistant Professor, Department of Physical Therapy, Franklin Pierce College, Concord, NH; PhysicalTherapist, Rehabilitation Services, Concord NH; Fellow, Manual Physical Therapy Fellowship Program,Regis University, Denver, CO.4 Associate Professor, Department of Physical Therapy, Regis University, Denver, CO.5 Professor, Department of Rehabilitation and Health Services, St Antonius Hospital, Nieuwegein, TheNetherlands; Physical Therapist, Clinical Epidemiologist, Manual Therapy Certified, Netherlands Institutefor Health Services Research, Utrecht, The Netherlands.This project is attributed to Centennial Physical Therapy, CSSC and the Regis University FellowshipProgram in Orthopedic Manual Physical Therapy, Denver, CO, and received approval from theInstitutional Review Board at Regis University, Denver, CO.Address correspondence to Dr Cameron MacDonald, Centennial Physical Therapy, Colorado Sport andSpine Centers, 5731 Si lverstone Terrace #120, Colorado Spr ings , CO 80919. E-mail : [email protected]

Osteoarthritis (OA)of the hip is de-scribed as a pro-gr es siv e lo ss o f hyaline cartilage

within the hip joint, sclerosis ofsubchondral bone, and the forma-tion of bone spurs at the jointmargins.2,18,34 Hip OA has been

identified as a major cause of dis-ability, with a prevalence of 10% to20% in the aging population.20,52

When viewed as a predictor offunctional disability, the overallcondition of OA ranks fourthamong women, and eighth amongmen.7,20,52 In addition to the per-sonal disability associated with thedisorder, OA also has a significanteconomic impact on thehealthcare system. In the UnitedStates it is estimated that the num-

ber of people with OA in anyregion of the body will increasefrom 43 to 60 million by 2020,resulting in an estimated cost ofover 100 billion healthcare dollarsper year.20 Considering the per-sonal and economic impact of OA,and the currently accepted stan-dard of care for hip OA reportedas joint replacement surgery,46 in-terventions with the potential tolimit the disability and/or slow theprogression of hip OA, potentially

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TABLE 2. Inclusion and exclusion criteria.

Inclusion Criteria

Referral to physical therapy with a diagnosis of hip pain orhip osteoarthritis

50-90 years of age Meet ACR classification for hip osteoarthritis

Exclusion Criteria

Prior hip surgery

Patient refusal of mobilization/manipulation techniques Clinical exam consistent with nonmusculoskeletal etiology

of symptoms (malignancy, infection, etc) Rheumatoid arthritis Severe low back pain Recent spinal or knee orthopedic surgery Radicular pain below the knee* Osteoporosis

Abbreviation: ACR, American College of Rheumatology.*Radicular pain was defined as presenting with radiating pain into

the lower extremity, in a recognized dermatomal path, consistentwith pain primarily of spinal origin and not from the hip.

TABLE 3. Patient demographics and outcomes at baseline.

Patient Age (y) SexInvolved

Hip

SymptomDuration

(mo)

1 53 M Right 602 52 M Left 93 66 F Right 364 62 F Left 95 59 F Left 36 80 M Right 2

7 76 F Left 9

with appropriate patient privacy maintained per insti-tutional standards in The Netherlands.

Examination

Patients completed a number of baseline self-reportquestionnaires, followed by a comprehensive historyand physical examination. The historical examinationincluded patient age, sex, duration of symptoms,location and nature of symptoms, aggravating andeasing positions or activities, occupation, symptom

irritability, recreational and leisure activities, patientgoals, medical history, and past surgical history.Baseline variables for all patients are shown in Table3.

The physical examination included a postural as-sessment,42 neurological assessment,44 hip passiverange of motion (PROM) measurements, manualmuscle testing (MMT) of the lumbopelvic, gluteal,and hip musculature,42,53 and assessment of passiveaccessory mobility of the hip joint.8,45,50 PROM wasassessed using a standard dual-arm goniometer forhip flexion, abduction, internal/external rotation,and extension. Goniometric measures of hip PROM

have been shown to be reliable, and the summationof hip PROM (including flexion, extension, abduc-tion, and internal and external rotation) has beenshown to be valid in comparing total hip PROMbetween subjects.36

Because a loss of strength is purported to be aconsequence of hip OA, and a potential cause offunctional impairments, we believe that addressingstrength deficits may be an important component ofa rehabil itation p rogram for thi s p opu la -tion.1,16,19,59,62 MMT was utilized to assess the majormuscle groups of the hip. MMT has been reported tohave good reliability (82% interrater agreement,55 = 0.6757) and validity for assessment of the hipextensors and flexors; however, no reliability data formeasurements of hip abduction or rotation havebeen reported in the literature. The specific tech-niques for MMT of the hip are consistent with those

reported in Magee.49

Techniques used to determine joint impairmentsincluded the assessment of hip joint end feels andevaluation of hip joint accessory motion.38,49,50 Theinterexaminer reliability of hip joint mobility throughmanual assessment has been reported to be good toexcellent for pain provocation in flexion and internalrotation ( = 0.88 and 0.74), and fair to good withoutpain provocation, but the reliability of specific assess-ment of passive accessory mobility of the hip joint isunknown.8

Gait assessment was also included in this caseseries, with visual observation of the trunk, pelvis,

and lower extremities during ambulation on a levelsurface. Deviations from normal hip and pelvic mo-tion were recorded individually, with attention to avisible Trendelenburg sign, antalgic gait, or an al-tered step length.9,66

Outcome Measures

PROM, numeric pain rating score (NPRS), and ameasure of disability (HHS) was collected at baseline.PROM and pain scores were included because thesefactors have been shown to be significantly associatedwith the disability experienced by those with hip

OA.69

The NPRS was collected at the baseline exami-nation and weekly thereafter until discharge. Patientswere asked to report the highest level of painexperienced over the last 24 hours on a 0-to-10 scale,with 0 representing no pain and 10 the worst painimaginable. Previous studies have demonstrated ad-equate reliability and validity for this type of NPRS,and a 2-point change has been reported to representclinically meaningful change.10,23 Patient-perceivedlevels of disability were measured with the HHS(Table 4). The HHS is a 10-item functional assess-ment tool yielding a score of up to 100, with lowerscores representing greater amounts of disability and

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TABLE 4. Outcome measure: Harris Hip Score. Referenced fromHarris.28

Category Points

PainNone 44Slight, occasional 40Mild, normal activity 30Moderate, activity concessions 20Marked, severe concessions 10Totally disabled 0

Range of motion (ROM)Full 5Partial* 4Limited* 2

Gait/limpNone 11Slight 8Moderate 5Unable to walk 0

Gait/support

None 11Cane for long walks 7Cane, full time 5Crutch 4Two canes 2Unable to walk 0

Gait/distanceUnlimited 116 blocks 82 or 3 blocks 5Indoors only 2Bed and chair 0

Function/stairsNormal 4Normal with banister 2Any method 1

Unable 0Socks and shoesEasy 4With difficulty 2Unable 0

SittingAny chair 1 hour 5High chair 12hour 3Unable to sit 12hour 0

Public transportAble 1Not able to use 0

Deformity

Absence of all 4 4Presence of 1 0

Total score: /100

*ROM: no specific instructions for definition of partial ROM wereavailable at the time of this case series for the HHS. For the purposesof this study, partial ROM was when either hip flexion was 115 orinternal rotation was 15. If both limitations were present this wasscored as limited ROM.Deformity: the presence of 1 of the following 4 deformities led to a0 score in this category: less than 10 abduction, leg lengthdiscrepancy 3.18 cm, flexion contracture 30, or leg fixed in10 internal rotation in extension.

a 4-point change indicating clinically meaningfulchange.28,32 This questionnaire has been shown to bereliable in a patient population with hip OA and is

utilized as a primary outcomes tool for clinicalresearch involving patients with hip OA.32,34,35,65 Ra-diographs were not used to guide clinical decisionmaking in this study, as the relationship betweenradiographic presentation and disability from hip OA

is variable and has not been shown to be predictive ofresponse to MPT interventions.15,33,40,58

Case Presentations

All 7 patients included in this case series exhibiteda loss of both passive hip flexion and internalrotation.45 Table 5 presents the initial PROM andNPRS and lists the initial examination ACR classifica-tion1 for each patient. Every patient presented withweakness of the hip external rotators and hip abduc-tors on the affected side. Variable muscle weaknessbetween patients was also identified in the ipsilateral

hamstrings, hip extensors, and quadriceps. Muscleperformance of the trunk and core (including thedeep abdominal muscles) was examined to identifyany primary control or muscle capacity deficits thatmay have indicated the need for interventions target-ing these impairments.31 Specific individual examina-tion findings for each patient participating in thiscase series are described in detail below.

Patient 1 A 53-year-old, 100-kg male with a diagnosisof right hip pain and a 5-year history of pain andmobility limitations reported a progressive decreasein the ability to participate in bike riding and golf. Inaddition to the common findings for all patients

previously described, this patients pain was repro-duced with passive internal rotation of the right hip.Additionally, the patient exhibited an antalgic gaitpattern and decreased step length on the right side.

Patient 2 A 52-year-old, 83-kg male with a 9-monthhistory of left hip pain reported increasing difficultyascending and descending stairs, walking, and gettinginto and out of his car. The patient demonstrated aTrendelenburg gait pattern on the left side, indicat-ing weakness of the left gluteus medius muscle.56

Additionally, he reported pain in the left hip regionwith a full squat and exhibited strength deficits in theleft hamstrings (4/5) and gluteus medius (4/5)muscles.

Patient 3 A 66-year-old female (body mass notreported) diagnosed with right hip OA and a progres-sive loss of functional status, reported that she hadpreviously completed a bout of physical therapy (PT),which included functional and active exercises. Ac-cording to the patient, this type of treatment was notbeneficial in improving her function or disabilitylevel. She did not recall receiving any MPT. Thispatient exhibited decreased right hip extension dur-ing gait and reported being unable to ascend stairscomfortably.

Patient 4A 62-year-old, 73-kg female with a diagno-sis of left hip pain reported a 9-month history of

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TABLE 5. Baseline measurements and ACR classification. From Altman et al. 1

Patient PROM Flex (deg) PROM IR (deg) NPRS Score*Meet ACR HipClassification?

1 95 0 6 Yes2 89 12 8 Yes3 100 0 6 Yes4 80 0 7 Yes5 90 2 9 Yes6 98 12 5 Yes7 95 2 6 Yes

Abbreviation: ACR, American College of Rheumatology; IR, internal rotation; NPRS, numeric pain rating scores; PROM, passive range of motion.*Pain was reported verbally by the patient on a 10-point NPRS, recording the worst pain felt over the last 24 hours. Zero represents no pain, with10 as the worst pain imaginable

progressive pain and dysfunction in the left hip. Shereported sharp pain upon upright stance that radi-ated into the anterior left thigh and difficulty withfunctional and recreational tasks, including drivingand skiing. The patient exhibited a left antalgic gaitwith decreased step length and no extension beyond15 of flexion of the left hip. She reported that painwas most severe with supine passive left hip flexion.

Patient 5A 59-year-old, 70-kg female with a diagno-sis of left hip OA reported left hip pain, withradiation down the medial thigh to the knee. A priorhistory of left buttock and low back pain was treatedwith chiropractic care, which resulted in mild im-provements in these symptoms. Through observationof the patients gait, the therapist visually notedexcessive pronation of the left midfoot. A valgusdeformity was also noted at the left knee. Pain was

most severe with passive left hip internal rotation.Patient 6This patient was an 80-year-old, 75-kg malewith a 10-week history of right hip and leg pain and adiagnosis of right hip OA. He reported difficulty withwalking, pain on weight bearing, and loss of function.A hip scour test was positive for primary pain in theright hip.38,49

Patient 7A 76-year-old, 61-kg female referred to PTwith a diagnosis of bilateral hip degenerative jointdisease greater in the left than the right hip. Thepatient reported the left hip pain resulted in a loss offunction, as she was unable to complete gardeningand was restricted in daily activities due to the lefthip. Weakness was present bilaterally, but greater in

the left abductors and external rotators (3+/5) com-pared to 4+/5 on the right side. No specific treat-ment was completed on the right hip.

Interventions

Three physical therapists completed all examina-tions and patient interventions in this case series. Fivepatients were treated by the primary author (C.M.), aphysical therapist with over 10 years of clinicalpractice, 1 patient by a physical therapist (J.C.) withmore than 5 years of clinical practice, and the finalpatient by a physical therapist (H.H.) with more than

TABLE 6. Hip mobilization/manipulation techniques.

Supine

Long-axis nonthrust oscillations in slight abduction Progression of above into abduction Nonthrust lateral glides of femur with a belt Lateral glides with combined rotations Long-axis thrust mobilization/manipulation in a loose-

packed position Thrust mobilization/manipulation in less abduction (15) Hip flexion nonthrust inferior glides

Sidelying

Anterior femoral nonthrust mobilization/manipulation Hip distraction with nonthrust medial femoral glide Hip distraction nonthrust medial glide plus abduction

Prone

Anterior nonthrust femoral glides

Anterior nonthrust glides in figure-four position

10 years clinical practice. A summary of the tech-niques used in this case series is presented in Table 6.The MPT methods for addressing joint mobility weredetermined by the treating therapist and based onthe clinical examination of each respective patient.We recognize that there is no reported reliability orvalidity of these techniques that might assist inselecting particular treatment interventions in MPT;however, each clinician used these techniques toguide the clinical decision making regarding thedirection and magnitude of joint mobilization/

manipulation in each patient case, and whether touse thrust or nonthrust mobilization/manipulationtechniques.4,38,49,50,63 Thrust mobilization/manipula-tion techniques were performed where a significantrestriction in capsular end feel was identified incomparison to the contralateral side or where, in thejudgment of the treating PT, there was an abnormallyhypomobile capsular end feel when bilateral hipinvolvement was present. Thrust mobilization/manipulation was not performed in the presence of anormal end feel when the hip was tested with acaudal distraction.14,38 Mobilization/manipulationswere performed in the direction of identified restric-



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tions, with immediate reassessment of PROM andjoint mobility to determine changes occurring afteradministration of the interventions. This was per-formed based on the clinicians belief that intrases-sion changes would be predictive of a positive overall

outcome given the recent reports on the positivepredictive value of intersession changes for MPTinterventions to the spine.26,67

Nonthrust mobilization/manipulations in this caseseries are defined as repetitive passive movement ofvarying amplitudes and of low velocity, applied atdifferent points through the range of motion, de-pending on the effect desired.25 Thrust mobilization/manipulation is defined as small-amplitude, high-velocity therapeutic movements of a joint.4 We areunaware of any reported adverse effects associatedwith hip nonthr ust and thr ust mobili zation/manipulation. However, Hoeksma et al34 reported

that if osteophytes were noted on radiographs of thehip, they performed hip thrust mobilization/manipulations with the hip in greater than 15 ofabduction, theoretically to avoid acetabular impac-tion.34

Description/Rationale of Selected Techniques

The following techniques are described as theywere most frequently implemented in this case series,along with the clinical decision making for theirutilization.

Nonthrust Long-Axis Oscillation Mobilization/

ManipulationThis technique was used with the intentof encouraging relaxation of the muscles of the hip,decreasing tension in the soft tissues of the hip, andimproving the elasticity of the joint capsule.18,51 Thistechnique was utilized on all subjects at the begin-ning of treatment. A failure of this technique torestore capsular mobility was an indication to usethrust mobilization/manipulation techniques for pa-tients treated in this case series.

For this technique, the patient was supine, with thecontralateral limb flat and slightly abducted or flexedat the hip and knee, based on patient comfort.Gentle and progressive long-axis distraction oscilla-tions were performed by the therapist, with a

2-handed hold at the ankle as shown in Figure 1.Oscillations in this case series were repeated grade IIor III nonthrust mobilization/manipulations with aprogressive increase in intensity.50 Every attempt wasmade to ensure patient comfort and, if needed, thetherapist performed the same technique with thehands above the knee. Progression of the distractionposition into more abduction was utilized as motionimproved to gain further ROM.

Hip Joint Thrust Mobilization/ManipulationThis tech-nique was used with the intent of creating temporaryrelaxation of the muscles of the hip, decreasingtension in the soft tissues of the hip, and improving

the elasticity of the joint capsule, allowing for pro-gression of mobility with other techniques.18,51 Thrustmobilization/manipulation was utilized on every pa-tient in this case series.

The thrust mobilization/manipulation of the hipjoint was performed in a manner very similar to thetechniques described by Hoeksma et al.34 It wasinitially performed in a position of approximately 30abduction and slight flexion, and was progressed intoless abduction (not less than 15) and internalrotation of the hip to gain further capsular flexibilityand to potentially decrease intra-articular pres-sure.18,51 Patient positioning was the same as forlong-axis nonthrust mobilization/manipulations (Fig-ure 1) and the technique was adjusted to address thedirection of restriction identified by the treatingtherapist for each individual patients hip. In this caseseries, no specific number of thrust mobilization/manipulations was utilized during each session, butcli ni ca l a ssessment fol lowi ng each thrust mobilization/manipulation was utilized to determinea change in joint end feel, and thrust mobilization/manipulations were repeated based on the judgmentof the treating physical therapist with considerationto the success of intervention and patient comfort.

Sidelying Nonthrust Medial Mobilization/Manipulation

This technique was intended to promote medial andinferior articular mobility of the femoral head in theacetabulum, with the ultimate goal of improving hipabduction and internal rotation. This technique wasutilized by the primary author (C.M.) on 5 patientsin this case series. Lateral nonthrust mobilization/manipulation of the hip joint with a belt, as shown inFigure 2, was also used for the intent to improve hipabduction and internal rotation.

As shown in Figure 3, a 2-person sidelying medialnonthrust mobilization/manipulation combined withdistraction was utilized. The distraction force was first

FIGURE 1. Long-axis nonthrust mobilization/manipulation of thehip in 15 to 30 abduction and 15 to 30 flexion.


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FIGURE 2. Lateral nonthrust mobilization/manipulation of the hipwith a belt, combining a lateral femoral glide with internal rotation.

FIGURE 3. Two therapist caudal hip nonthrust mobilization/manipulation with combined medial and inferior glide. One thera-pist (not visualized here) distracts the hip while the other therapistprovides a medial glide to the hip.

applied, then a medial and inferior translation of thefemoral head was provided by the second therapist,individualized to each patient based upon restrictionsin motion detected by the examiner and progressionof the treatment program. The technique was mostoften an oscillatory glide at the middle to end ofrange of osteokinematic motion, with the end rangebeing the passive limit of available hip motion in a

given direction at the point of first restriction.14

Prone Figure-Four Nonthrust Mobilization/ManipulationWith Knee off Table We used this technique with theintent to improve anterior femoral glide, ultimatelywith the goal of improving physiologic hip extensionand external rotation. This technique was utilized for5 of 7 patients in this case series.

Figure 4 shows the patient positioning and thera-pist hand placement for a prone anterior glide of thefemoral head. The knee was placed off the table toallow for the technique to be completed where therewas a restriction in abduction of the involved hip.This technique was also used in conjunction with an

active contraction by the patient of the externalrotators of the hip, with the intent of increasing theanterior glide of the femur through the contractionof the muscles across the posterior aspect of the hipjoint (Figure 5). The combination of nonthrustmobilization/manipulation with active contraction bythe patient was also used on a limited basis for thelateral gapping mobilization/manipulation combinedwith internal rotation in this case series (Figure 2).

Treatment progression for each patient focused onfrequent reassessment (both intrasession and at theend of each session of MPT) of joint accessorymotion and PROM by the treating clini-cian.24,38,39,64,74 Where a restriction in hip joint mo-bility was still perceived by the treating therapist,

FIGURE 4. Anterior hip nonthrust mobilization/manipulation inmodified figure-four position, allowing for less available abduction(knee on stool).

FIGURE 5. Anterior hip nonthrust mobilization/manipulation, usingan active contraction of the hip external rotators to assist with theanterior glide. The patient actively pushes the knee into thetherapists hand, facilitating a contraction, as the therapist mobilizesthe femur anteriorly with the proximal hand (dashed line representsdirection of push from patients muscle contraction).



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TABLE 7. Home exercises. Exercises were commenced follow-ing manual physical therapy in the clinic, and progressed intohome programs individualized to each patient. Completed 1 to2 times per day.

Upright bicycle: 10 min Gluteus medius clamshell exercises: 3 sets of 12 Hip abduction in sidelying: 3 sets of 12 Core transverse abdominus: 2 sets of 20 in supine with hips

flexed to 45 Bridge with straight leg raise: 3 sets of 10 Hip flexor stretch kneeling or sidelying: 30 sec 3 Single leg balance: up to 60 sec Tandem stance eyes open or closed: up to 60 sec

appropriate nonthrust and thrust mobilization/manipulative interventions were continued. JointMPT interventions were ceased once assessed jointend feel was considered normal, PROM equaled the

contralateral side, no further progression could bemade secondary to patient complaint of pain, orthere was no noted progression following repeatedmobilization/manipulations (3 sessions withoutchange). Following mobilization/manipulation, pa-tients were prescribed exercises, which were deter-mined individually based upon the outcomes of theirevaluation. Exercises were chosen primarily tostrengthen the hip external rotator and abductormusculature, given the examination findings of con-sistent lateral hip weakness in these muscles for eachpatient. A home exercise program was established foreach patient, with the most frequently prescribedexercises and hip stretches listed in Table 7. In

general, exercises were completed in 3 sets of 10repetitions without weight, then progressed with theaddition of weight up to 4 kg as a maximum forgluteus medius training in hip abduction and exter-nal rotation with the knee flexed to 90 and the hipflexed to 45.

Patients were discharged from PT care if there wasa plateau in improvements in pain and PROM, oronce the patient reported 0/10 NPRS with an abilityto continue home exercises independently. One pa-tient did not complete the HHS at the initial evalua-tion; therefore, he was asked to complete a GlobalRating of Change (GROC) at the time of discharge.10

This scale is a 15-point Likert scale ranging from avery great deal worse (7), to no change (0), to avery great deal better (+7), with changes greater than+3 indicating a moderate change in patient status.37

OUTCOMES

The total number of PT visits ranged from 4 to 12,with a median number of 5 visits over a 2- to 5-weekperiod. All 7 patients demonstrated and reportedimprovements in pain, hip mobility, and disabilitystatus over the course of PT care. The specificchanges in patient hip flexion PROM, hip internal

rotation PROM, total joint PROM, HHS, and NPRSare shown in Figures 6 through 10. The medianimprovement in total hip ROM was 82 (range,70-86), the median improvement in pain on theNPRS was 5 points (range, 2-7 points), and themedian improvement in disability on the HHS was 25points (range, 15-38 points).

Each patient in this case series progressed frommeeting the ACR classification criteria for hip OA atexamination, to not having the identified impair-ments for classification at discharge. Each patientregistered clinically meaningful changes in hip ROM,hip pain, and hip function. Individual significantfunctional changes were a return to golf for patient1, an ability to return to skiing by patient 4 immedi-ately following participation in this case series, and areturn to gardening by patient 7.

Although long-term outcomes were not collectedformally, the primary author of this study (C.M.)contacted 5 of the patients in this case series. Patient1 reported no change in discharge (DC) status at 6months post-DC, but sought further MPT care 15

FIGURE 6. Patients hip flexion passive range of motion as mea-sured at baseline and at discharge.

FIGURE 7. Patients hip internal rotation (IR) passive range ofmotion at baseline and discharge. Note: patients 1 and 3 had 0 hipIR at baseline.

60

70

80

90

100

110

120

130

1 2 3 4 5 6 7Patient

Degrees

Hip flexion: baseline

Hip flexion: discharge

0

5

10

15

20

25

30

1 2 3 4 5 6 7Patient

Degrees

Hip IR: BaselineHip IR: Discharge


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FIGURE 8. Patients total hip passive range of motion (PROM) atbaseline and discharge. PROM includes flexion, extension, internalrotation, external rotation, and abduction.

FIGURE 9. Harris Hip Scores (HHS) from evaluation and discharge,0 represents total disability, 100 represents normal hip function andmobility. Minimum clinically important difference (MCID) for theHHS is 4 points (Hoeksma et al35). Patient 2 did not complete aHHS.

FIGURE 10. Patients reported maximal pain levels in the previous24 hours, using a numeric pain rating scale (NPRS) where 0represents no pain and 10 the worst pain imaginable. The minimumclinically important difference (MCID) for patients with low backpain is 2 points (Childs10). Patients 1 and 3 reported a 0 score onthe NPRS at discharge.

months post-DC for symptoms at a lower intensitythan those present initially (NPRS score, 2/10; initialwas 6/10 with 0/10 at DC). Patients 5, 6, and 7 did

not require further care at 6 months post-DC. Two ofthese patients reported 100% function at 6 months,and one 80% improvement at 3 months and again at6 months post-DC. Patient 4 continued to receiveintermittent private care for hip MPT and was dis-

charged from all PT care 6 months post-DC from thiscase series, with further functional gains in PROMand activity levels.

DISCUSSION

This case series describes the rationale and clinicaldecision making regarding the incorporation of MPTand exercise into the treatment of hip OA. Patientsreceiving MPT interventions based upon the clinicalexamination, including directional nonthrustmobilization/manipulations and thrust mobilization/manipulations of the hip demonstrated similar out-

comes to the patients of the Hoeksma et al34randomized clinical trial who received MPT andexercise. Significant changes in function as measuredthrough the HHS and decreases in pain as recordedin the MPT group of the Hoeksma et al34 trial werealso noted in this case series. This case series demon-strates the incorporation of the best available evi-dence into clinical practice for the use of MPT andexercise in the treatment of patients with hip OA.

The fact that each patient satisfied the ACR classifi-cation for hip OA at initial examination, but not atdischarge, also suggests a positive outcome for thepatients in this case series. The primary impairments

identified in the ACR guidelines may have beeninfluenced by MPT.1 Improvements in PROM inflexion and internal rotation were the primary out-comes that changed the diagnostic classification ofthe patients in this case series. The specific MPTtechniques described in this case series serve toillustrate potential primary interventions for patientswith hip OA.

The treatments in this case series were not basedon a specific predetermined set of planned interven-tions or protocol but, rather, on the cliniciansindividual patient assessment of deficits in PROM,end feel, and loss of joint motion as perceivedthrough manual joint assessment. The apparent suc-

cess of manual interventions for hip OA promotesthe potential of a decreased reliance on pharmaceuti-cal management, improved quality of life, decreasedpain, and decreased personal and community costsassociated with hip OA.7,41,52 Medication usage wasnot recorded in this case series, and was not noted tobe recorded in previous reported studies of MPTinvolving the hip.12,34

The rationale for this type of treatment approachin the management of hip OA is to restore functionalmotion to the hip, allowing for an increase inexercise participation and to potentially improve thenutrition and tissue health of the hip joint.18,35,39,51

50

100

150

200

250

300

1 2 3 4 5 6 7Patient

Degr

ees

Total Hip PROM: BaselineTotal Hip PROM: Discharge

0

20

40

60

80

100

1 2 3 4 5 6 7Patient

HarrisHipScores

(Range0-100)

BaselineDischarge

0

2

4

6

8

10

1 2 3 4 5 6 7Patient

NPRS

(Range0-10)

Baseline

Discharge



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The actual pathophysiology behind the success ofMPT interventions for hip OA is beyond the scope ofthis case series and will require further research. It isalso recognized that improvements reported in thiscase series may be due to simply an increased level ofactivity, as causality can not be determined from acase series.

The potential cost containment benefits of utiliza-tion of MPT for hip OA can be seen by a theoreticalcomparison of the cost of participation in this caseseries, to the cost of the potential eventual treatmentof hip OA with a THA.46 The cost of PT services inthis case series is estimated at $900 dollars (8 visitsplus 1 evaluation) compared to an estimated $30 000for a THA (including surgery and hospitalization at$23 332 plus rehabilitation).21 It is recognized thatthere is not a direct relationship of hip OA to THA,but the value of a longitudinal study looking at the

number of patients needed to be treated to avoid 1THA over a prolonged period of time would be ofclinical value, especially given the decrease in totalknee arthroplasty of 75% at 1 year in the MPTtreatment group of the Deyle et al17 study withcomparison to the control group, and the currentreported number of THAs being 164 000 annually inthe United States.27

As previously mentioned, we cannot infer a cause-and-effect relationship from a case series. Furtherlimitations include the fact that no intrarater orinterrater testing or training was completed for theexamination tests and measures and the MPT tech-

niques utilized. No blinding occurred as the treatingphysical therapists completed all of the patient exami-nations in this case series. A directional causal effectcannot be extrapolated for specific MPT techniquesas multiple techniques were used. The influence ofthe Hawthorne effect, which is the tendency ofindividuals to perform better in a research setting asthey are being assessed,60 can not be ignored, as eachtherapist in this case series was aware that individualpatient outcomes were being measured, but no sub-jects were excluded from outcomes reporting. How-ever, despite the limitations of the case series, theoutcomes presented are encouraging for the clinicalutilization of MPT techniques and exercise in the

treatment of hip OA and patients with primary hippain satisfying the ACR classification for hip OA.

Future studies should investigate the physiologicalmechanism that promotes improved joint functionfollowing nonthrust and thrust mobilization/manipulation for hip OA. Research assessing theappropriateness of including MPT into the ACRguidelines for the treatment of hip OA, given theoutcomes of the Hoeksma et al34 trial and this caseseries, is warranted. Studies should investigatewhether thrust mobilization/manipulation generatesa different clinical outcome than nonthrustmobilization/manipulation techniques for hip OA,

and whether specific joint testing is necessary toguide mobilizations, or if general application ofmobilization/manipulation to the hip will providebenefits in pain and disability for patients with hipOA. Future studies should also inquire into the usage

of medications following MPT interventions for hipOA and identify the duration of long-term benefitfollowing MPT for hip OA.

CONCLUSIONS

This case series highlights the use of nonthrust andthrust mobilization/manipulative techniques and ex-ercise in the trea tment of hi p OA from a nimpairment-based MPT approach. Loss of PROM andpain in the hip formed the basis of the medicaldiagnosis in this case series, while restrictions inPROM, joint end feels, functional decline in mobility,

and pain guided the MPT interventions. The utiliza-tion of specific techniques to increase joint mobilitywith complementary exercises appears to have con-tributed to gains in PROM, decreases in pain, andincreased functional activity in this case series. Be-cause a case series cannot establish a cause-and-effectrelationship, further research, including randomizedclinical trials, is necessary to uncover the exact effectsof MPT and exercise for the treatment of hip OA.

ACKNOWLEDGEMENTS

We would like to graciously thank the faculty of

Regis University, Denver Colorado, for their ongoingsupport of clinical research.

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journal of orthopaedic &sports physical therapy | volume 37 | number 9 | september 2007 | 573

CORRECTION: ALTMANS CRITERIA

FOR OSTEOARTHRITIS OF THE HIP

AND KNEE

In 1991, Altman and colleagues1

published criteria for classification of

osteoarthritis of the hip, of which

one criterion was less than or equal to

60 minutes of morning stiffness. This

criterion was erroneously published by

the JOSPT as greater than 60 minutes

in TABLE 3of the article by Cibulka and

Threlkeld3 (August 2004) and in TABLE

1of the article by MacDonald et al5(Au-

gust 2006). Also, one of the criteria for

classification of idiopathic osteoarthritis

of the knee, as published by Altman etal2in 1986, was less than 30 minutes of

stiffness. This was incorrectly published

as stiffness greater than 30 minutes

in the text of the article by Cliborne et

al,4 in the November 2004 issue of the

JOSPT.

We apologize for these errors and

have corrected reprints of the articles,

which are available to members and

subscribers for download on the JOSPT

web site (www.jospt.org).

ERRATA

REFERENCES

1. Altman R, Alarcon G, Appelrouth D, et al. The

American College of Rheumatology criteria for

the classification and reporting of osteoarthritisof the hip.Arthritis Rheum. 1991;34:505-514.

2. Altman R, Asch E, Bloch D, et al. Develop-

ment of criteria for the classification and

reporting of osteoarthritis. Classification

of osteoarthritis of the knee. Diagnostic

and Therapeutic Criteria Committee of the

American Rheumatism Association.Arthrit is

Rheum. 1986;29:1039-1049.

3. Cibulka, MT, Threlkeld, J. The early clinical

diagnosis of osteoarthritis of the hip. J Orthop

Sports Phys Ther. 2004;34(8):461-467.

4. Cliborne AV, Wainner RS, Rhon DI. Clinical hip

tests and a functional squat test in patients

with knee osteoarthritis: reliability, prevalence

of positive test findings, and short-term re-

sponse to hip mobilization. J Orthop Sports

Phys Ther. 2004. 34(11):676-685.

5. MacDonald CW, Whitman JM, Cleland JA, Smith

M, Hoeksma HL. Clinical outcomes following

manual physical therapy and exercise for hiposteoarthritis: a case series. J Orthop Sports

Phys Ther. 2006;36(8):588-599.

clinical outcomes following manual physical therapy and exercise for hip osteoarthritis- a case...

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