Comparison of Effect of Hip Joint Mobilization and Hip Joint Muscle Strengthening Exercises With Knee Osteoarthritis a. Tanvi, r. Amrita, r. Deepak, p. Kopal Srji Vol 3-Issue 1 Year

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COMPARISON OF EFFECT OF HIP JOINT MOBILIZATION AND HIP

JOINT MUSCLE STRENGTHENING EXERCISES WITH KNEE

OSTEOARTHRITIS

*A. Tanvi, **R. Amrita, ***R. Deepak, ****P. Kopal

ABSTRACT

Purpose- The purpose of pre and post experimental study was to determine whether hip joint mobilization and

hip joint muscle strengthening of the hip muscles in patients with knee osteoarthritis are effective in comparison

to the conventional therapy in treatment of knee osteoarthritis. Background- Osteoarthritis is a chronic,

degenerative joint disease mainly affecting weight-bearing joint such as knee. Exercise programs for knee OA

have been described such as general aerobic exercise programs like walking or cycling as well as more specific

programs involving strengthening of particular muscle groups and/or flexibility exercises of lower limb muscle

groups. Method- A total of 30 patients were taken on the basis of inclusion (Kellgren grade 2 or 3) and

exclusion criteria and divided into two groups via convenient sampling. Group A (n=15) received conventional

treatment i.e.US+TENS, Knee range of motion strengthening and stretching exercises and Group B (n=15)

received conventional + hip joint mobilization and hip joint muscle strengthening exercise for six weeks. All the

outcome variables i.e .knee range of motion, pain and functional disability were measured at 0 (pre-test), 10th

and 21st sitting. Result- t-test indicated that Group B (experimental group) demonstrated significant

improvements in knee ROM, pain and functional disability, measurements. Within group analysis was found to

be significantly different. Conclusion- The results of the study suggest that hip joint mobilization and hip joint

muscle strengthening exercises are beneficial in improving knee ROM and functional disability and in reducing

pain.

Keywords: osteoarthritis, hip joint mobilization and hip joint muscle strengthening exercises, WOMAC, knee

ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

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ROM.

INTRODUCTION

Osteoarthritis (OA) is a degenerative condition

of articular/hyaline cartilage of synovial joints

and is a chronic, localized joint disease

affecting approximately one third if adults with

the diseases predominately affecting the medial

compartment of the tibio-femoral joint. Patients

with knee OA frequently report symptoms of

knee pain and stiffness as well as difficulty

with activities of daily living such as walking,

stair-climbing and housekeeping. Ultimately,

pain and disability associated with the disease

lead to a loss of functional independence and a

profound reduction in quality-of-life.1

Osteoarthritis of the knee, defined as a Kellgren

and Lawrence grade of two or higher in either

knee, was found in 121 women, a prevalence of

12.5%.2 Prevalence of OA increases with age

and aging is associated with decreasing

physiological functions.3 General health status

instruments measure multiple aspects of health,

including, specifically, physical function, social

function, and pain, and are suitable for

comparison of health status between diseases.5

A variety of exercise programs for knee OA

have been described in the literature. These

have included general aerobic exercise

programs such as walking or cycling as well as

more specific programs involving

strengthening of particular muscle groups

and/or flexibility exercises. Studies

investigating the effects of strengthening in

patients with knee OA have generally focused

on improving quadriceps strength. However,

little attention has been paid to improving the

strength of other lower limb muscle groups

such as the hip abductors and adductors.1

Reduced hip abductor strength has also been

shown in people with knee pathology and is

most likely to be a consequence of altered

loading during gait to rapidly move body

weight onto the unaffected limb. In contrast,

medial knee OA progressed more slowly in

people with stronger ipsilateral hip abductors

because adequate hip abductor strength may

control weight shift and maintain lateral pelvic

stability during the single-leg stance phase of

gait. Mobilization is one of the most commonly

recommended treatments for this condition.

The goal of mobilization is to restore the

normal arthro-kinematics of a joint, including

spins, rolls and glides, by improving the

extensibility of the ligamento-capsular tissue.

Mobilizations are often combined with

traditional physical therapy modalities as

well.11

Impaired hip mechanics have been associated

with increased medial compartment knee

loads.6 Less is known about the hip adductor

muscles in relation to knee OA but they may

also help reduce the knee adduction moment,

particularly in a varus malaligned knee. By

virtue of their attachment to the distal medial

femoral condyle, the adductors could

eccentrically restrain the tendency of the femur

to move further into varus. Yamada et al. found

Scientific Research Journal of India ● Volume: 3, Issue: 1, Year: 2014

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that patients with knee OA demonstrated

stronger hip adductors compared with age-

matched controls, and that those with more

severe OA had even stronger adductors than

their less severe counterparts. They

hypothesized that this increased strength may

be due to greater use of the hip adductors in an

attempt to lower the knee adduction moment.

The purpose of this study was to analyze the

efficacy of hip joint mobilization and hip joint

muscle strengthening exercise to improve knee

ROM, functional disability and improve pain in

knee OA.

METHODOLOGY

Subject’s criteria

This study was carried out on 34 patients, out

of which 30 continued the study and other drop

out in between the study and the patient was

collected from R K physiotherapy clinic

Khanpur, Delhi. Their ages ranged from 40-75

years old, according to Kellgren grade 1 or 2

radiologically, predominance of pain over

medial region of knee as well as hip pain,

clinical criteria described by Attman et al for

knee OA, VAS more than 5 on 10cm scale

were included6,7,8 and was excluded if history

of trauma, surgery of hip, knee and ankle joint,

and peripheral vascular diseases, any

neurological or cardiovascular pathology and

systemic diseases1,4,8.

Patients were informed that results drawn out

of study will facilitate them to measure their

performance and help in further enhancing the

variable that improve their performance. A

written consent form was taken from the

patients who volunteered for the study and

fulfilled the inclusion and exclusion criteria of

the study.

Outcome measures

Demographic variables of all subjects, such

as age, height, and weight were recorded. All

subjects underwent a detailed orthopaedic

assessment. A baseline measurement of

dependent variables were taken using

goniometer, WOMAC score and visual

analogue scale.

Knee Range of Motion measured using

universal goniometer which is a commonly

used method for the clinical assessment of

range of motion. The intraclass correlation

coefficients (ICCs) for intratester reliability of

measurements obtained with a goniometer were

.99 for flexion and .98 for extension. Intertester

reliability for measurements obtained with a

goniometer was .90 for flexion and .86 for

extension10.

Functional disability was assessed using

WOMAC questionnaire which consists of 3

sections A,B,C i.e. section A for pain and

section B for stiffness and section C for

functional difficulty. Patient is asked to rate

each question out of five grades of severity. the

test–retest reliability of the WOMAC was 0.74,

0.58, and 0.92 (ICC) for the pain, stiffness, and

physical function subscales.20

Pain was assessed using VAS (visual analogue


18

scale), used to measure the average intensity of

pain. In this patient is asked to mark their pain

on a 10 cm line marked with 0 marked on one

side and 10 on other end, where 0 indicated no

pain and 10 indicates maximum pain. The ICC

for all paired VAS scores was 0.97.9

Treatment

Both the groups received US and TENS at a set

dosage used for pain relief.32

Group A received set of knee range of motion

exercises, strengthening and stretching

exercises which includes knee in mid flexion to

full extension, knee in mid extension to full

flexion(two 30 s bouts with 3 sec hold), knee

strengthening exercises includes static quad

sets in knee extension (6 sec hold with 10 sec

rest for 10 repetitions), standing terminal

extension (hold for 3 sec for 10

repetitions),seated leg presses(hold for 3 sec

and repeat for 30 sec bouts), knee stretching

exercises includes standing calf stretch ,supine

hamstring stretch, prone quadriceps femoris

stretch (hold for 30 sec and repeat for 3).

Group B received all the exercises in group A

as well as additional exercises for hip joint

which includes all the glides in different planes

(caudal glide, anterior- posterior glide,

posterior – anterior glide, posterior to anterior

mobilization in flexion, abduction and external

rotation) and hip muscle strengthening

exercises include abduction and adduction in

side lying, abduction and adduction in standing,

standing wall hip isometric abduction, towel

squeezes ( 3 sets of 10 with 5 second hold).

Data was collected prior to start of treatment

program 0 sitting, at 10th sitting and after the

end of treatment session i.e. at 21st sitting.

DATA ANALYSIS

The mean and standard deviation of all the

variables were analysed. Data analysis was

done with the help of SPSS for windows in

order to verify the investigations of the study.

Independent t-test was used to compare

between group difference and repeated

ANOVA measures was used to analyze within

group difference for all the dependent

variables. The significance level set for this

study was 95% (p<0.05). The significance of

mean difference within and between the groups

was done by Newman-Keuls post hoc test after

ascertaining normality by Shapiro-Wilk’s test

and homogeneity of variances by Levene’s test.

RESULTS

The age of two groups i.e. Group A who

received conventional treatment along with US

and TENS and Group B who received hip joint

mobilization and hip joint muscle strengthening

are summarized graphically in Fig. 1.1. The

age of Group A and Group B knee OA patients

ranged from 41-70 yrs and 44-68 yrs,

respectively with mean (± SD) 53.93 ± 8.85 yrs

and 57.47 ± 7.46 yrs, respectively. The mean

age of Group B was comparatively higher than

Group A. Comparing the mean age of two

groups, t test revealed similar (p>0.05) age

between the two groups (53.93 ± 8.85 vs. 57.47


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± 7.46, t=1.18, p=0.247). In other words,

patients of two groups were age matched and

therefore age may not influence the outcome

measures.

Fig. 1.1 Mean age of two groups

Age (yrs)

0.0010.0020.0030.0040.0050.0060.0070.00

Group A Group B

Groups

Mea

n

Outcome variables

I. ROM

The pre and post treatments ROM levels

(degree) of two groups are summarized in

Table 1.1. which shows that the mean ROM

levels in both groups increased (improved)

after the treatments and at the end of the

treatments, the increase (improvement) was

found higher in Group B than Group A.

Table 1.1: Pre and post treatments ROM levels (Mean ± SD) of two groups

Groups 0 sitting

(n=15)

10th sitting

(n=15)

21st sitting

(n=15)

Group A 99.20 ± 9.66 104.87 ± 10.37 111.60 ± 10.52

Group B 94.60 ± 9.75 101.53 ± 8.94 112.00 ± 7.43

p value 0.194 0.344 0.909

Fig. 1.2. Comparative mean ROM levels

within the

groups.

Fig. 1.3. Comparative mean ROM levels

between the groups.


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Comparing the mean ROM levels within the

groups (Fig.1.2 and Fig. 1.3), the ROM levels

in both groups increased (improved)

significantly (p<0.001) at both 10th and 21st

sittings (post treatment) as compared to 0

sitting (pre-treatment). Further, the mean ROM

levels in both groups also increased

significantly (p<0.001) at 21st sitting as

compared to 10th sitting.

II. WOMAC

The pre and post treatments WOMAC scores of

two groups are summarized in Table 1.3. which

shows that the mean WOMAC scores in both

groups decreased (improved) after the

treatments and at the end of the treatments, the

decrease (improvement) was found higher in

Group B than Group A.

Table 1.3: Pre and post treatments WOMAC scores (Mean ± SD) of two groups

Groups 0 sitting

(n=15)

10th sitting

(n=15)

21st sitting

(n=15)

Group A 65.47 ± 13.26 48.40 ± 14.11 37.80 ± 14.62

Group B 64.27 ± 11.60 48.07 ± 15.25 31.07 ± 13.37

p value 0.813 0.948 0.189

Fig. 1.5. Comparative mean WOMAC scores

within the groups

Fig. 1.6 Comparative mean WOMAC scores

between the groups


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Comparing the mean WOMAC scores

between the groups (Fig 1.5 and Fig.

1.6), the WOMAC scores of two groups

did not differed (p>0.05) at 0 sitting i.e.

found to be statistically the same. In

others words, WOMAC scores of two

groups were comparable. Further, the

mean WOMAC scores of two groups

also not differed (p>0.05) at 10th sitting

and 21st sitting,

III. VAS

The pre and post treatments VAS scores of two

groups are summarized in Table 1.5 shows that

the mean VAS scores in both groups decreased

(improved) after the treatments and at the end

of the treatments, the decrease (improvement)

was found higher in Group B than Group A.

Table 1.5: Pre and post treatments VAS scores (Mean ± SD) of two groups

Groups 0 sitting

(n=15)

10th sitting

(n=15)

21st sitting

(n=15)

Group A 7.47 ± 0.83 6.07 ± 1.10 4.67 ± 1.59

Group B 7.33 ± 0.98 5.33 ± 0.98 3.60 ± 1.06

p value 0.745 0.078 0.012

Comparing the mean VAS scores within the

groups (Table 1.6), the VAS scores in both

groups decreased (improved) significantly

(p<0.001) at both 10th and 21stsittings (post

treatment) as compared to 0 sitting (pre-

treatment). Further, the mean VAS scores in

both groups also decreased significantly

(p<0.001) at 21st sitting as compared to 10th

sitting. The comparisons concluded that both

treatments are effective for improving VAS in

patients with knee OA.

Fig. 1.7. Comparative mean VAS scores

within the groups.


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Fig. 1.8. Comparative mean VAS scores

between the groups.

Comparing the mean VAS scores between the

groups (Fig 1.7 and Fig. 1.8), the VAS scores

of two groups did not differed (p>0.05) at 0

sitting i.e. found to be statistically the same.

The mean VAS scores of two groups also not

differed (p>0.05) at 10th sitting. However, the

mean VAS score of Group B at 21st sitting was

found significantly (p<0.05) different and

lower as compared to Group A, indicating

Group B is more effective than Group A for

improving VAS in patients with knee OA.

DISCUSSION

The aim of the study was to compare the

effectiveness of hip joint mobilization and hip

joint strengthening of the hip muscles with

conventional therapy in the treatment of

patients with knee osteoarthritis. The result of

the study suggested that hip joint mobilization

and hip joint strengthening exercises are

significantly more effective than conventional

treatment.

This finding supports the view that there are the

positive effects of hip joint mobilization

(Cliborne, et al. 2004)22 and hip muscle

strengthening on knee load, pain, and function

in people with knee osteoarthritis (Kim L

Bennell, et al. 2007)33. It appears that hip joint

mobilization and strengthening exercises are

effective in reducing pain and stiffness, and in

improving knee ROM and physical function in

patients with OA of the knee than conventional

treatment. This finding is in agreement with

Cliborne, et al. (2004)22 who stated that short

term response of hip mobilization on Knee OA

and of Bennell, et al. (2007) the hip

strengthening exercises were effective on OA

of the knee33. The present study while

demonstrating significant difference in the

effect of conventional treatment and hip joint

mobilization and hip joint strengthening

exercises on the selected clinical features of

OA have however shown that the hip joint

mobilization and hip joint strengthening

exercises affected greater pain relief as well as

gains in ROM and improves function. Pain is a

major contributory factor to the disability in the

patient with Knee OA hence it is

understandable that experimental group which

effected greater pain reduction in this study

brought about greater functional improvement.

Among subjects who completed the study,

those in the experimental group had a greater

improvement in WOMAC scores over the 6-

week period (P<.001) than those in the

conventional treatment group.

Impaired hip muscle performance can render

the hip joint susceptible to dysfunction in all

planes. Abnormal motion of the femur can have


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a direct effect on tibiofemoral joint kinematics

and strain the soft tissue restraints that bind the

tibia to the distal end of the femur. Chang and

colleagues, who reported that the ability to

generate greater hip abductor moments during

walking was protective against ipsilateral

medial compartment osteoarthritis progression

in older adults.29 Altered knee function as a

result of knee OA may affect the hip and result

in painful impairments.24 The faulty

biomechanical knee position can be a result of

a tight posterior and posterior–lateral hip

complex, causing the femur to not flex, adduct,

and internally rotate during the loading phase

of gait. This causes the knee to remain

relatively extended, abducted, and externally

rotated, and could lead to medial joint overload

over time.23

Mechanoreceptors that provide proprioceptive

function are located at the tendons, ligaments,

meniscus, joint capsule and muscle. Pain may

be a factor affecting the evaluation of muscle

strength and proprioceptive acuity.21 Joint

mobilization which involves low-velocity

passive movements within or at the limit of

joint range of motion reduces pain by

modulating the nervous tissues and increases

joint motion (Maitland 2005; Vicenzino

2001).16 Joint mobilization has been shown to

induce immediate hypoalgesia in individuals

with knee OA with a concurrent improvement

in function. The positive hypoalgesic affects

are believed to occur through stimulation of

mechanoreceptors and activation of pain

inhibitory cortical systems.30 Mobilization is

thought to reduce joint pain through the

stimulation of afferent nerve receptors or by

improving joint lubrication. Mobilization of the

hip is also used to help restore joint mobility.28

Since serotonin and noradrenaline releasing

neurons in the spinal cord originate in

supraspinal sites in the brainstem, these data

support a role for descending inhibitory

pathways in the hypoalgesia produced by joint

mobilization. It has been hypothesized that

mobilization may activate descending pain

inhibitory systems, mediated supraspinally

(Wright, 2002; Souvlis et al., 2004).31

During mobilization/manipulation, the

capsuloligamentous tissues of a joint are

mechanically stretched. One primary goal of

mobilization is to improve extensibility of

restricted capsuloligamentous tissue;

secondarily, articular mechanoreceptor

activation level is affected. Joint mobilization

has been demonstrated to improve physiologic

and accessory motions to hypomobile

structures. This in turn causes an alteration in

the articular mechanoreceptor resulting by way

of arthrokinetic reflex activity in enhanced

muscle strength.26 Joint mobilization also

causes physical loading and unloading of joint

cartilage to facilitate the flow of synovial fluid

within the joint. This flow of fliud ensures

adequate nutrition to the articular cartilage.

When compression is combined with

mobilization, there is thought to be even greater

stimulation of synovial fluid flow. 11

Other proposed benefits of manual therapy


24

include mechanical alteration of tissue,

neurophysiologic effects, and psychological

influence.30 Joint mobilization not only has an

impact on the motor unit activity in muscles

functioning over the joint, but it also has been

shown to affect more remote muscles as well,

including muscles on the contralateral side of

the body.26 Hip mobilizations are a

noninvasive, relatively inexpensive

intervention that appears to provide short-term

benefit in patients with knee pain and clinical

evidence of knee OA who present any

combination of 2 CPR variables. 24

Chang and colleagues postulated that hip

abductor weakness may result in additional

contralateral pelvic drop, shifting the centre of

mass toward the swing extremity, which

therefore increases forces across the medial

compartment of the stance extremity and

hastens disease progression.17 The aim of

strengthening exercises in people with OA is

primarily to improve control and stability of the

joint during movement and thus maintain

functional ability. More recent reviews also

indicated a strong evidence base for the

efficacy of strengthening exercises in managing

OA.13 The beneficial effects of resistive

exercise for individuals with OA may be

attributed to several associated factors such as:

facilitation of endogenous opiates which

creates an analgesic effect to improve a

person’s tolerance to pain, decrease in

depression coupled with perceived level of

disability, through associated weight loss, or

mechanically through alteration of the

biomechanics of the joint. Strength training is

presumed to protect the joint from pathologic

stress and loading. 14

People with knee OA demonstrate significant

weakness of the hip musculature compared

with asymptomatic controls.17 Hip abduction

(HA) exercises have important functional

implications because they enable patients to

regain the muscle strength needed for

performing activities of daily living and

sports.15 Since muscle strengthening improves

pain and function in knee OA, strengthening

exercise is widely recommended for the

condition.17 Lower limb strengthening

exercises are an important component of the

treatment for knee osteoarthritis (OA).

Strengthening the hip abductor and adductor

muscles may influence joint loading and/or

OA-related symptoms, but no study has

compared these hypotheses directly.1

The hip muscles, particularly the abductors,

play an important role in stabilization of the

pelvis and trunk. Indeed, movement of the

contra lateral pelvis or lateral leaning of the

trunk over the stance limb, which may occur as

a result of hip muscle weakness, has been

suggested to adversely influence the magnitude

of the knee adduction moment. Thus, hip

muscle activity appears to be an important, yet

understudied, contributor to knee joint load.1

The exercises focus on strengthening the hip

abductor muscles, such as the gluteus medius, a

broad, thick, radiating muscle that helps to


25

stabilize the pelvis during ambulation. In

patients with osteoarthritis in the knees, these

muscles tend to be weak, causing the pelvis to

tilt toward the side of the swing leg when

walking, instead of remaining level with the

ground, which increases the load on the knee

joints. Strengthening these muscles helps the

pelvis and the knee remain in better alignment,

and thereby lessens the load.25 Hip muscles

may stabilize the pelvis during gait in ways to

maintain the center of mass in alignment,

which may have an effect on frontal plane knee

moments as suggested by Bennell.14 In this

study, as reduction in pain brought significant

improvement in health and physical function

that contribute in improving WOMAC score,

and thus helps in reducing knee disability by

minimizing the load on knee joint during

ambulation and so intervention of the hip may

be indicated in the treatment of patients with

knee OA. Future Research can be done by

extending the duration of the study or including

other exercise protocols. The future study can

be done by using another electrotherapeutic

modality with same protocol. This study has

provided a positive outcome of the

experimental method conducted in order to

treat the proposed condition; still it provides us

with a chance to further modify the

methodology.

Relevance to Clinical Practice

Hip joint mobilization and hip joint muscle

strengthening exercises shows better

improvement in muscle strength and function

and reduction in pain in comparison to

conventional therapy in the patients with knee

osteoarthritis. So Hip joint mobilization and hip

joint muscle strengthening exercises can be use

as clinical practice in the treatment of knee

joint osteoarthritis.

Conclusion

The study concludes by stating that null

hypothesis is rejected as the result of the study

suggests that the hip joint mobilization and hip

joint muscle strengthening exercises are more

effective in decreasing pain and in improving

functional ability and increasing knee ROM in

patients with knee osteoarthritis.

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CORRESPONDENCE

*MPT (Musculoskeletal), Assistant professor, Santosh Medical and Dental, college of physiotherapy.

**MPT (Musculoskeletal), Student, Santosh Medical and Dental, college of physiotherapy.

***MPT (Musculoskeletal), Principal, Associate professor, Santosh Medical and Dental, college of

physiotherapy.

****MPT (Sports), Assistant professor, Santosh Medical and Dental, college of physiotherapy.

Corresponding author: Dr. Tanvi Agarwal, MPT (MUSCULOSKELETAL), A48 A- ASHOK NAGAR

GHAZIABAD, [email protected]

Documents

Comparison of Effect of Hip Joint Mobilization and Hip Joint Muscle Strengthening Exercises With Knee Osteoarthritis a. Tanvi, r. Amrita, r. Deepak, p. Kopal Srji Vol 3-Issue 1 Year