Manual Therapy in the Management of the Older Adult with Hip Osteoarthritis
1. Manual Therapy in the
Management of the Older Adult
with Hip Osteoarthritis
Alexander Ohmes
July 13, 2016
Individual Practice Analysis
2. 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.”
3. 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
4. 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 ✓
5. 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: (+)
6. 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
7. 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
8. 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?
9. 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=JmRiPWFwaCZjbGkwPUZUJmNs
djA9WSZjbGkxPVJWJmNsdjE9WSZ0eXBlPTEmc2l0ZT1laG9zdC1saXZlJnNjb3BlPXNpdGU%
3d
10. • 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
11. • 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
12. 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).
13. Have you been paying attention?
• What are the “ABCS” for reading a radiograph?
• Alignment
• Bone density
• Cartilage space
• Soft tissue
15. 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
16. 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 0
10
20
30
40
50
60
70
80
90
100
Flexion Extension Abduction Adduction IR ER
Changes in Hip ROM
Initial Eval 5/2/16 Re-eval 6/9/16
17. 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
18. 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.”
19. Patient’s Healthcare Timeline
10/21/13
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
5/2/16
PT Eval
***Strongest single predictor of success with PT
is symptom duration of less than 1 year9
20. 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.
Notas del editor
I saw this patient on my first day of clinical.
My CI performed the evaluation; I observed.
My patient fit all 3 of Birrell’s criteria.
My patient fit 4/5 criteria from Sutlive.
Even without radiograph, I would have concluded hip OA from my evaluation.
I rewrote my CI’s diagnosis to include all levels of the ICF.
Pant & socks:
Currently had to sit down to put on pants and sock.
Could not balance on one leg
Did not have enough hip flexion to put on sock normally, so he had to improvise.
- Since Medicare pt, had to establish G-code
Throughout my search, I used combinations of these 5 MESH terms.
LEFS being my outcome measure
Jumped to this article b/c high level of evidence and recent publication
Total of 19 RCTs reviewed
5 that included manual therapy
Conclusions on manual therapy were not what I was hoping
Only used pain as outcome
Hip Harris Score – functional
SF-36 – health-related quality of life
Methods:
Each treatment began with stretching
Followed with hip distraction
Then long-axis manipulation (5 max) each successive manipulation performed in limited position.
Used “end-feel” to assess effectiveness of manipulation
Deemed successful when end-feel of the treated hip was similar to that of the contralateral hip
Exercise group:
Exercises for muscle functions, muscle length, joint mobility, pain relief, and walking ability
Likert scale: ranges from “much worse” to “complete recovery”
The higher improvement in the manual therapy group compared with the exercise therapy group endured for most measures after 17 and 29 weeks.
An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure.
P&W: Odd ratio – estimate of relative risk in a case-control study
OR=1 Exposure does not affect odds of outcome
OR>1 Exposure associated with higher odds of outcome
OR<1 Exposure associated with lower odds of outcome
95% CI = precision of the OR
A large CI indicates a low level of precision of the OR, whereas a small CI indicates a higher precision of the OR.
Perform at each session with patient.
Prescribe these exercise and variations over the course of my treatment sessions.
Focused on strengthening proximal hip musculature with some balance, motor control, and hip mobility.
Began with open chain exercises. Progress to closed chain.
Extremely compliant with HEP.
So, at our 4th session, pt came in discouraged. Was not seeing significant improvements.
Thought this would be a good time to re-eval.
Articulated to him the significant improvements in strength and gait.
Spent time educating pt on progressive nature of OA and principles of conservative treatment.
Did not get LEFS at initial evaluation – explain Kaiser e-mailing outcome measures
Got LEFS score at second visit
6/23/16 = discharge visit
Pt felt like PT and HEP was consuming his life.
Wanted to try a few weeks of self-management.
Try to get back to normal gym routine; see if he could tolerate it.
Would reach out to us if needed.
Things I learned:
-It is important to share improvements that we as PTs are seeing, because the patient may not be seeing them.
-They may not notice changes in ROM or strength.
-They are going to notice more functional things.
They are going to notice changes that are meaningful to them.
Maybe I should’ve focused more on functional training of putting on his sock.
I learned the challenge behind managing highly-active patients who want to return to a high-level of activity, when it may not be possible.
Wife extremely involved, trying to learn anatomy meticulous about form, would make corrections when unwarranted
Time management skills challenged with these pts b/c they wanted to talk so much.
Wanted detailed explanation about his condition, the manual therapy, and the exercises.
Wright (2011):
Unilateral hip pain
Age </ 58 years old
Pain >/ 6/10
40m self-paced walk test </ 25.9 seconds
Duration of sxs </ 1 year
2/5 criteria, +LR = 3.99
3/5: posttest probability of success to 99% or higher
Could patient have had better outcomes had PT seen him sooner??
Given that the strongest single predictor of success with physical therapy was symptom duration of less than 1 year, patients are encouraged to seek physical therapy treatment early in the disease process rather than waiting until it has reached more advanced stages, when the disease may be less responsive to conservative treatments (Wright 2011).
Who is to blame?
