Manual Therapy in the Management of the Older

Adult with Hip Osteoarthritis Alexander Ohmes

July 13, 2016Individual Practice Analysis

What do you see? • ABCS:• Alignment ✓• Bone density ?

• SCLEROSIS• Cartilage Space ?

• NARROW • Soft tissues ✓

• “There is moderate right hip osteoarthritis and severe left hip osteoarthritis. No bony abnormalities are seen.”

Learning Objectives • By the end of this presentation, my colleagues will be able to: • Recognize osteoarthritic changes on a radiograph image using the ABCS

method. • Recall special tests & CPRs to perform for hip OA during a PT evaluation• Apply appropriate treatment strategies to a patient with hip OA• Cite literature describing effective treatments of patients with hip OA

Initial Evaluation – History & Review of Systems• Patient history

• 74 year old male• Constant L hip pain

• NPRS: 0/10 – 8/10• Started 2 years ago training for Boulder/Boulder• Pain in backside of butt and lateral hip• Denies N/T• Wants to run again• Does not want surgery• Worse: walking, prolonged sitting• Better: Heat, quad stretch• Meds: none• Sleep: disturbed, need pillow between knees • Activities: 4-5x/week 30 minutes elliptical,

upright bike, walk at fast pace• Occupation: retired

• Review of Systems• Cardiopulmonary ✓• Integumentary ✓• Musculoskeletal – hip OA• Neurological ✓• Cognitive ✓

Initial Evaluation – Systems Review and Tests & Measures • Gait analysis: limited time in SLS on L, L hip

elevation• Movement analysis: poor squat mechanics• AROM:

• Flexion – 90 (painful)• Extension – 10• Adduction – neutral• Abduction – 30 • IR – neutral• ER – 15

• PROM = AROM• Strength:

• 3/5 glut med bilaterally• 3/5 R iliopsoas (painful)• 4/5 glut max bilaterally

• Palpation: ttp glut med and upper glut max at L ilium, L SIJ pain

• Muscle Length:• Ober’s: (+)• Thomas: (+)

• Special Tests:• SLR: (-)• SI provocation: (+)• FABER: (+)• FADIR: (+)• Circumduction/scour test: (+)

Initial Evaluation – Interpretation • Do you remember Summer ‘15?:

• Hip ER < 23, IR < 23, Flexion < 94• Birrell et al. (2001) • +LR 4.4-5

• Self-reported squatting as aggravating• Active hip flexion causing lateral

hip pain• Scour test causing lateral hip or

groin pain• Active hip extension causing pain• Passive IR < 25• Sutlive et al. (2008)• 4/5 +LR 24.3

HIP OA

Diagnosis, Prognosis, Goals • Patient presents with signs and

sxs consistent with L hip OA causing pain and limited ROM which prevents him from running for exercise and participating in 5k/10k races. • Rehab Potential: Fair

• Age (-)• Progressive condition (-)• Family support (+)• Motivated (+)

• Patient Goals:• Run again• Put on pants and socks normally

• PT Goals:• Independent HEP/self management in 8

weeks.• Decrease pain 80% in 2-3 weeks.• Normal gait in 4 weeks • 5/5 hip girdle strength in 6 weeks.• Walk for exercise in 8 weeks

• G Codes:• Initial eval: 60-79% impaired• D/c goal: 1-19% impaired

PICO Question • P - For male patients with hip osteoarthritis greater than 70 years of

age • I - is manual therapy with exercise• C – more effective than exercise only• O– in decreasing hip pain and increasing function?

Literature Review• EBSCOhost• “hip osteoarthritis,” “manual therapy,” “exercise,” “LEFS,” “manipulation”• “hip osteoarthritis” AND “manual therapy” AND “exercise” 13 results

• http://web.b.ebscohost.com.dml.regis.edu/ehost/resultsadvanced?sid=df63bc08-39f8-431f-951c-7b6ed3b30fcf%40sessionmgr106&vid=5&hid=124&bquery=((hip+AND+osteoarthritis))+AND+((manual+AND+therapy))+AND+(exercise)&bdata=JmRiPWFwaCZjbGkwPUZUJmNsdjA9WSZjbGkxPVJWJmNsdjE9WSZ0eXBlPTEmc2l0ZT1laG9zdC1saXZlJnNjb3BlPXNpdGU%3d

• British Journal Of Sports Medicine, 2016• Level 1A• From 5 reviewed studies, failed to find positive benefit of manual therapy (with or

without exercise) when compared to exercise alone or a minimal control. • • Limitations:

• Did not explore effect of manual therapy on function (only VAS)• Heterogeneity between populations and interventions • Small sample size (n < 15) in many of the studies

• Arthritis & Rheumatism, 2004• Level 2b• 2 groups: 1) manual therapy, 2) exercise therapy • Biweekly treatment for 5 weeks (9 treatments total) • Follow-up at 3 months & 6 months

• Outcome measures: 6-point Likert scale, Hip Harris Score, SF-36, VAS, ROM

Hoeksma et al. (2004)• After week 5, the success rate of manual therapy was 81% versus 50%

for exercise therapy (OR 1.92, 95% CI 1.30, 2.60).

Have you been paying attention? • What are the “ABCS” for reading a radiograph? • Alignment• Bone density• Cartilage space• Soft tissue

Intervention – manual therapy Manual therapy technique (grades III & IV) Dosage

Long axis distraction 5 bouts, 30 seconds

Lateral glides (w/ belt) 5 bouts, 30 seconds

Inferior glides (w/ belt) 5 bouts, 30 seconds

• Loose pack position of hip?• 30 flexion• 30 abduction• 5-10 ER

6 6

Intervention – exercise therapy Exercise Dosage Goal

Clamshells 3 sets, 15 reps, 3x/week Muscle strength

Glute bridge w/ band around knees 3 sets, 15 reps, 3x/week Muscle strength

Thomas stretch @ EOB 3 sets, 60 sec holds, 5x/week Muscle lengthening

Glute bridge w/ marching 3 sets, 12 reps, 3x/week Motor control

Hip 4-way (flex, ext, abd – yellow TB)

2 sets, 10 reps, 3x/week Muscle strength, coordination, balance

Side stepping w/ resistance at ankles

2 sets, 12 reps, 3x/week Muscle strength

Single leg bridge 2 sets, 12 reps, 3x/week Muscle strength, motor control

Supine single knee to chest 2 sets, 15 reps, 3x/week Mobility

Long sitting hamstring stretch 3 sets, 60 sec holds, 5x/week Muscle lengthening

• Extremely compliant with HEP

Outcomes • Significant improvements in

strength & gait:• 5/2/16

• 3/5 glute med bilaterally• 4/5 glute max bilaterally

• 6/9/16• 5/5 glute med bilaterally• 4+/5 glute max bilaterally

• Small improvements in ROM

Flexion Extension Abduction Adduction IR ER0

10

20

30

40

50

60

70

80

90

100

Changes in Hip ROM

Initial Eval 5/2/16 Re-eval 6/9/16

Outcomes – LEFS • Questionnaire containing 20

questions about a person’s ability to perform everyday tasks. • 0-80 scale • Max score of 4 for each item • Pt indicates current level of difficulty

with each activity • Lower score = higher disability

• 45/80 – 5/20/16• 49/80 – 6/23/16

• SEM = 5.367 • MDC = 9.9 points7 • MCID = 6 points or 11.3%8

• Not OA specific, ”hip impairment”

• Excellent test-retest reliability (r = 0.86)7

• Excellent interrater reliability (r = 0.84)7

• Criterion validity: not established • Construct validity: Pearson coefficients and

one way analysis of variance, compared with SF-36, showed to be more sensitive to change7

• Responsiveness: not established

Discussion/Conclusion • Did I help this patient?

• LEFS? No. • ROM? Barely. • Strength? Sure. • Pt perception?

• Managing highly-active and extremely compliant patients• Limited literature strongly supporting the

use of manual therapy in tx of hip OA • Hoeksma (2004)• MacDonald (2006) – case series • French (2011) – systematic review • Wright (2011) – CPR attempt

• Patient e-mail:• Able to find comfortable sleeping

position most nights• Using upright bike & elliptical has

improved significantly• Better posture and balance• Less limping with gait• “So, at this point I’m very happy

with my progress.”

Patient’s Healthcare Timeline10/21/13 Radiograph

Radiologist’s report: “There is moderate right hip osteoarthritis and severe left hip osteoarthritis. No bony abnormalities are seen.”

11/18/13 Ortho Eval

POC: glucosamine, chondroitin, Aleve, baby aspirin. “Candidate for THA when pt is ready.”

4/12/16 Internal Medicine

Suggested PT for ongoing hip problem

5/2/16PT Eval

***Strongest single predictor of success with PT is symptom duration of less than 1 year9

References 1. Birrell F, Croft P, Cooper C, Hosie G, Macfarlane G, Silman A. Predicting radiographic hip osteoarthritis from range of movement. Rheumatology

(Oxford, England) [serial online]. May 2001;40(5):506-512. Available from: MEDLINE, Ipswich, MA. Accessed July 6, 2016.2. Sutlive T, Lopez H, Childs J, et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip

pain. The Journal Of Orthopaedic And Sports Physical Therapy [serial online]. September 2008;38(9):542-550. Available from: MEDLINE, Ipswich, MA. Accessed July 6, 2016.

3. Altman R, Alarcón G, et. a, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis And Rheumatism [serial online]. May 1991;34(5):505-514. Available from: MEDLINE, Ipswich, MA. Accessed July 6, 2016

4. Beumer L, Jennie W, Wong J, et al. Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. British Journal Of Sports Medicine [serial online]. April 15, 2016;50(8):1-7. Available from: Academic Search Premier, Ipswich, MA. Accessed June 28, 2016.

5. Hoeksma, HL, Dekker J, Ronday HK, et al. Comparison of Manual Therapy in Osteoarthritis of the Hip: A Randomized Controlled Trial. Arthritis and Rheumatism. 2004;51(5):722-729. doi: 10.1002/art.20685.

6. MacDonald C, Whitman J, Cleland J, Smith M, Hoeksma H. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series. The Journal Of Orthopaedic And Sports Physical Therapy [serial online]. August 2006;36(8):588-599. Available from: MEDLINE, Ipswich, MA. Accessed July 9, 2016.

7. Pua, Y. H., Cowan, S. M., et al. (2009). "The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale." J Clin Epidemiol 62(10): 1103-1111.

8. Wang, Y. C., Hart, D. L., et al. (2009). "Clinical interpretation of a lower-extremity functional scale-derived computerized adaptive test." Phys Ther 89(9): 957-968

9. French H, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee - a systematic review. Manual Therapy [serial online]. April 2011;16(2):109-117. Available from: MEDLINE, Ipswich, MA. Accessed July 9, 2016.

10. Wright A, Cook C, Flynn T, Baxter G, Abbott J. Predictors of Response to Physical Therapy Intervention in Patients With Primary Hip Osteoarthritis. Physical Therapy [serial online]. April 2011;91(4):510-524. Available from: Academic Search Premier, Ipswich, MA. Accessed July 9, 2016.