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Corresponding author: Helen P. French, PhD, Lecturer in Physiotherapy, School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
To determine the effectiveness of exercise therapy (ET) compared with ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention.
Design
Assessor-blind randomized controlled trial with a 9-week and 18-week follow-up.
Setting
Four academic teaching hospitals in Dublin, Ireland.
Participants
Patients (N=131) with hip OA recruited from general practitioners, rheumatologists, orthopedic surgeons, and other hospital consultants were randomized to 1 of 3 groups: ET (n=45), ET+MT (n=43), and waitlist controls (n=43).
Interventions
Participants in both the ET and ET+MT groups received up to 8 treatments over 8 weeks. Control group participants were rerandomized into either ET or ET+MT groups after 9 week follow-up. Their data were pooled with original treatment group data: ET (n=66) and ET+MT (n=65).
Main Outcome Measures
The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function (PF) subscale. Secondary outcomes included physical performance, pain severity, hip range of motion (ROM), anxiety/depression, quality of life, medication usage, patient-perceived change, and patient satisfaction.
Results
There was no significant difference in WOMAC PF between the ET (n=66) and ET+MT (n=65) groups at 9 weeks (mean difference, .09; 95% confidence interval [CI] −2.93 to 3.11) or 18 weeks (mean difference, .42; 95% CI, −4.41 to 5.25), or between other outcomes, except patient satisfaction with outcomes, which was higher in the ET+MT group (P=.02). Improvements in WOMAC, hip ROM, and patient-perceived change occurred in both treatment groups compared with the control group.
Conclusions
Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.
Physiotherapy management of osteoarthritis of the hip: a survey of current practice in acute hospitals and private practice in the Republic of Ireland.
Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis. Consensus development at OMERACT III.
in the short and medium term, results for changes in physical function (PF) are conflicting. A number of randomized controlled trials (RCTs), some of which have included participants with hip or knee OA, have found functional benefits with exercise,
Does hydrotherapy improve strength and physical function in patients with osteoarthritis–a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme.
The small number of participants (n = 204) and interstudy heterogeneity may have influenced this finding. Long-term (>6mo) follow-ups of exercise-based RCTs have found that posttreatment improvements in pain and function were not maintained,
but it is unclear at what point benefits dissipate after treatment and long-term follow-up.
There is, therefore, a need to identify the medium-term effects of physiotherapy for hip OA. MT, which is the use of hands-on techniques delivered to the joint or soft tissues to modulate pain and improve joint mobility,
Physiotherapy management of osteoarthritis of the hip: a survey of current practice in acute hospitals and private practice in the Republic of Ireland.
the scientific evidence supporting this recommendation is based on 1 RCT, which compared MT head to head with ET, rather than as an adjunct, and found that MT was superior in pain, function, and PGA outcomes.
A more recent RCT found no difference in outcomes between targeted hip MT with exercise and full kinetic chain MT with exercise delivered by chiropractors.
Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: a randomized controlled trial.
Neither of these trials included a control group. The aim of this RCT was to determine if the addition of MT to an 8-week program of ET for hip OA improved function and other clinical outcomes more than ET alone at 9 and 18 weeks. A secondary aim was to ascertain if immediate commencement of treatment (ET or ET+MT) resulted in better outcomes compared with a 9-week waiting period for either intervention.
Methods
Design
The Exercise and Manual Physiotherapy Arthritis Research Trial (EMPART) multicenter RCT was conducted in 4 academic teaching hospitals in an urban area in Ireland.
The study was approved by each of the hospital's research committees. An initial 3 group parallel arm trial (allocation ratio 1:1:1) was used, with a modified cross-over design, whereby control group participants were crossed over to 1 of 2 intervention arms after a 9-week period, thereby ensuring sufficient power to test the primary trial hypothesis. Details of EMPART protocol are published elsewhere.
The principal investigator (H.P.F.) screened all patients for trial eligibility and enrolled participants after receipt of written informed consent.
Participants referred from rheumatologists, orthopedic surgeons, other hospital consultants, and general practitioners were recruited from physiotherapy waitlists. Waiting times for physiotherapy varied from 6 weeks to 6 months across the 4 trial sites. Participants were included if they had OA of the hip according to the American College of Rheumatology clinical and radiographic criteria
and were aged 40 to 80 years. Exclusion criteria included previous hip arthroplasty, congenital or adolescent hip disease, clinical signs of lumbar spine disease, physiotherapy in the previous 6 months for hip symptoms, pregnancy, hip fracture, contraindications to ET,
inflammatory arthritis, on the waitlist for hip joint replacement within the next 7 months, intra-articular hip corticosteroid injection in the previous 30 days, or insufficient understanding of the English language to complete questionnaires.
Randomization
Two computer generated randomization lists were compiled by an independent statistician. The first list randomized participants into 1 of 3 arms: ET, ET+MT, or a waitlist control group. The second list rerandomized control group participants into 1 of 2 intervention groups (ET or ET+MT) after the 9-week follow-up assessment. Both lists were maintained by a member of the research team (T.C.), who was located offsite from the 4 trial centers and was not involved in participant assessment or treatment. Simple randomization was conducted after email notification of patient recruitment by the principal investigator. Group allocation was communicated via email by the independent randomizer to the treating therapists in each treatment site.
Blinding
A single assessor (H.P.F.), blinded to group allocation and measurement data from previous assessment points, carried out all outcome assessments. Patients were requested not to divulge information regarding allocated treatment. Disclosure of group allocation was recorded prospectively by the blinded assessor.
Interventions
The ET and ET+MT interventions were administered by senior grade or clinical specialist physiotherapists (n=23) in the 4 participating hospitals. Training in the 2 treatment protocols was provided by the principal investigator (H.P.F.) along with a comprehensive written manual in order to ensure a standardized approach to treatment across the trial centers.
All therapists at all sites provided either ET or ET+MT interventions.
All participants were treated according to the protocol detailed in appendix 1.
Exercise therapy
Participants attended 6 to 8 individual 30-minute physiotherapy sessions over 8 weeks, which included flexibility and strengthening exercises delivered using a semi-structured protocol. The protocol provided guidance on exercise prescription and progression, but could be tailored to individual patient physical assessment findings.
Strengthening focused on low-load exercise, commencing in nonweight-bearing positions, and progressing to functional positions. The key target muscles were the gluteal muscles, which are commonly atrophied in hip OA.
American College of Sports Medicine ACSM guidelines for exercise prescription in OA.
in: Whaley M.H. Brubaker P.H. Otto R.M. ACSM's guidelines for exercise testing and prescription. 7th edition. Lippincott, Williams and Wilkins,
Baltimore2006: 50
and were given written and verbal information on the principles of aerobic conditioning, such as pacing, gradually progressing intensity and time of exercise, and incorporating exercise into daily life.
Exercise therapy and manual therapy
Participants attended 6 to 8 individual 45-minute physiotherapy sessions over an 8-week period, which included 30 minutes of ET, as previously described, and up to 15 minutes of MT in line with current clinical practice at participating sites. A choice of nonmanipulative MT techniques based on pain/stiffness relations
and movement restrictions of the affected hip was available, with no more than 5 MT techniques allowed during an individual session.
Control group
Participants in the control group remained on the physiotherapy waitlist and completed a follow-up assessment with the blinded outcome assessor at 9 weeks, after which they were rerandomized into either the ET or ET+MT group.
All 3 groups received standardized written information on hip OA.
All nonconsenting and excluded participants were treated as usual by the physiotherapy department in each trial center. Participants were asked to avoid all other interventions for the duration of the RCT, apart from routine doctor care and analgesics. Participants with bilateral hip OA received clinic-based treatment for the more symptomatic hip only, but were provided with an HEP for both hips.
Outcomes
Outcomes were chosen according to internationally recommended core outcomes for hip or knee OA.
Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis. Consensus development at OMERACT III.
The primary outcome was self-reported PF, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, Likert version) PF subscale for hip OA.
Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
ROM and physical performance procedures demonstrated excellent test-retest reliability (intraclass correlation coefficient >.90) in a subgroup of people with and without hip OA.
Pain severity (with activity and at night) was measured using a Numerical Rating Scale, and pain medication usage was quantified using the Medication Quantification Scale.
Other outcomes included general health status (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) and psychological well-being (Hospital Anxiety and Depression Scale [HADS]).
PGA of change was assessed using a 7-point scale (very much worse to very much better), and the Physiotherapy Outpatient Survey assessed patient satisfaction.
The WOMAC PF subscale was used to estimate the sample size required. Using a previously ascertained minimal clinically important difference (MCID) ± SD of 5.4 ± 11 on the WOMAC Likert scale,
with a significance level of .05 (2-tailed) and a power of 80%, 67 patients were required per group, based on the final group allocation to ET or ET+MT. This was increased to 74 patients per group to allow for 10% attrition at the 18-week follow-up, thus requiring a total sample of 148 participants.
Statistical analysis
Analyses were conducted on an intention-to-treat basis. Missing data were replaced using multivariate multiple imputation (Stata version 12a). Twenty imputed datasets were generated using a model whereby data were considered missing at random. Imputations were based on baseline demographic variables (age, sex, occupation, and body mass index) and predictor variables, such as symptom duration, baseline pain, PF, psychological health, and general health status. An overall significance level of P=.05 was set. To address the primary study aim, comparisons were made between the ET and ET+MT groups at baseline, 9 weeks, and 18 weeks, and participants in the control group were analyzed according to the intervention received after the 9-week follow-up. Comparisons were made between the control group and the 2 treatment groups combined (ET and ET+MT) at baseline and 9 weeks in order to address the secondary study aim. Linear regression modeling was used to examine between-group differences, with adjustment for baseline levels of the outcome. For the 2 group analysis, baseline WOMAC PF and aggregate ROM were included as covariates because of baseline differences. Pain medication usage, aggregate ROM, sit-to-stand, and WOMAC PF subscale were added as covariates for the 3 group analysis because of baseline differences in these variables.
Quantile regression was used for nonnormally distributed outcomes. PGA ratings were dichotomized as improved (very much better, much better, somewhat better), no change, and worse (very much worse, much worse, and somewhat worse), and chi-square analysis was used to test for differences between the groups.
Results
Participants
One hundred and thirty-one patients were recruited across the 4 sites between May 2008 and February 2010. In the initial 3 group allocation, 43 patients were randomized each to the ET+MT and control groups, and 45 were randomized to the ET group. Figure 1 shows participant flow through the trial. Eight patients (6.1%) withdrew from the trial at 9 weeks: 4 declined continuation, 1 had hip surgery, 1 developed cardiac symptoms, 1 could not be contacted by the researcher, and 1 withdrew for family reasons. By 18 weeks, a further 11 (8.4%) withdrew: 5 underwent hip surgery, 1 could not be contacted, and 5 declined follow-up for personal reasons. This resulted in an overall dropout rate of 14.5%. Table 1 shows the baseline characteristics as determined by the 2 group (ET and ET+MT) allocation. Baseline characteristics for the 3 groups are shown in table 2.
Fig 1Flow of participants through the trial. *Missing data were imputed using multiple imputation methods.
Group assignment was disclosed to the outcome assessor by 5 participants, who were all in the control group. No treatment disclosure occurred in the 2 intervention groups.
Outcomes
Two group analysis (ET and ET+MT)
At both the 9- and 18-week time points, there was no significant difference between the ET and ET+MT groups for any outcomes (table 3), with the exception of patient satisfaction with outcome, which was higher for the ET+MT group (table 4).
Table 3Primary and secondary outcomes for ET and ET+MT groups at baseline, 9 weeks, and 18 weeks
At 9 weeks, analysis of data from the initial 3 group randomization (table 5) demonstrated significant improvements in the treatment groups compared with the control group in WOMAC PF, aggregate ROM, and PGA. There was no significant difference between the control and 2 treatment groups in the remaining outcomes.
Table 5Outcomes for ET, ET+MT, and control groups at 9 weeks
Twenty-two physiotherapists treated the patients in EMPART. The mean number of treatments ± SD for the ET group was 5.62 ± 1.99 and for the ET+MT group was 5.22 ± 2.31. Fifty-two (78.8%) participants of the ET group and 50 (76.9%) participants of the ET+MT group received at least 4 of their planned treatments. A total of 38 that completed HEP diaries were available for analysis: 22 (40.7%) in the ET+MT group and 16 (28.1%) in the ET group. Mean duration of aerobic exercise ± SD per week undertaken by the ET group was 4.62 ± .91 hours and for the ET+MT group was 4.1 ± 0.6 hours. Mean duration ± SD of the HEP per week was 2.97 ± .49 hours for the ET group and 3.57 ± .31 hours for the ET+MT group.
Discussion
Primary research aim
This assessor-blinded multicenter RCT assessed the effectiveness of the addition of MT to an 8-week ET program for the treatment of hip OA. There was no significant difference between the ET and ET+MT groups in the majority of outcomes at 9 or 18 weeks, except patient satisfaction with outcome. Because of the number of outcomes assessed in this study, this significant finding of satisfaction may have occurred by chance. Patients reported higher satisfaction with outcome for the ET+MT group, as in other trials of MT intervention for musculoskeletal disorders.
Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program.
This coincides with the higher (although not statistically significant) proportion of participants who reported improvement with ET+MT compared with ET (see table 3). Satisfaction with other aspects of the physiotherapy interactions was comparable, possibly because both interventions were delivered by the same physiotherapists at the same locations.
Comparison with other similar studies is limited, because no known studies have evaluated ET with or without MT for hip OA, although a similar trial is underway in New Zealand.
Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: a randomized controlled trial.
who compared MT head to head rather than as an adjunct to ET, found that MT alone had a superior effect on pain, function, and PGA compared with ET. Reasons for these somewhat incongruous results may relate to the dosage of MT provided; Hoeksma
in EMPART. The setting in which our RCT was located may affect external validity of these findings. The heterogeneity in clinical severity of the sample may have attenuated the treatment effect, and the more severely affected patients may not be representative of those seen in a primary care setting. Heterogeneity may also have been because of the broad age profile of the participants, which was chosen in line with other studies.
Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: a randomized controlled trial.
Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: a single blind randomized clinical trial.
Although it is possible that treatment effects may differ for patients with varying OA severity, this trial was not powered to examine subgroup effects. Larger multicenter studies are required to identify if effects of ET and MT differ depending on OA severity.
Secondary aim
Both groups improved in self-reported PF, aggregate ROM, and patient-perceived improvement relative to the control group in the short term (9wk). These results conflict with a meta-analysis, which found no significant short-term benefit of exercise on PF for hip OA, despite a moderate treatment effect for pain.7 Their result was considered inconclusive because of the intertrial heterogeneity and small sample size (N=205). In our study, the deterioration in WOMAC scores in the control group along with improved scores in the intervention groups accounts for the significant results obtained (see table 5). This deterioration in the control group over such a short timeframe was a surprising outcome. The unblinded status of participants may have influenced these results, introducing a cognitive measurement bias, which can occur with subjective patient-reported outcomes, where control group participants report negative outcomes because of disappointment at not receiving the target intervention.
The participants in this trial were recruited in a hospital setting, where the majority of patients were initially referred from primary care physicians to rheumatology and orthopedic specialists, and onward to physiotherapy. This care pathway increases the waiting time for patients to receive rehabilitation from the time of onset of symptoms.
Other studies, which showed positive effects for exercise over no treatment, included a variety of exercise types, such as graded behavioral exercise,
Exposing people with hip or knee OA to similar interventions in the same trial may result in undetected joint-specific effects. To date, the optimal exercise approach for hip OA alone has yet to be identified.
In our trial, the mean improvement at 9 weeks was 6.25 for ET+MT and 4.21 for ET (see table 5), which suggests that the clinical significance of the improvement in EMPART is borderline.
The influence of the therapist-patient interaction cannot be eliminated as a reason for improvements in the 2 intervention groups compared with the control group. It has been shown that interventions that include a specific therapeutic relation may contribute to the treatment effect.
In EMPART, although self-reported PF improved as a result of both ET and ET+MT interventions, there was no change in physical performance tests. The 50-foot walk test may have been too short in distance to detect change, because longer walk tests have been shown to be more responsive to change in people with OA,
Neither intervention in this RCT had a significant impact on psychological status or general health, even though reduced quality of life and depression prevail in OA.
and suggests that exercise on its own does not impact the wider psychosocial manifestations of OA.
Although the exercise program in this trial provided information on self-management principles, it did not use behavioral or cognitive approaches to empower participants. Lack of significant change may also have been limited by the outcomes used (SF-36 and HADS), because both have previously demonstrated lower responsiveness to change than OA-specific measures.
Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.
This study used a rigorous methodology, such as blinding of the outcome assessor, independent central randomization, allocation concealment, validated outcome measures, highly reliable physical measures, and intention-to-treat analysis using multiple imputation.
Simple randomization was used over block randomization, because the recruitment locations (acute teaching hospitals in an urban area) were comparable. The principal investigator who screened all participants was an experienced musculoskeletal physiotherapist and was able to effectively and systematically screen patients for suitability and ensure that patients with primary lumbar spine pathology were excluded.
Study limitations
A type II error may have occurred in relation to the 2 group analysis because of failure to reach the target sample size. Post hoc power analysis based on the 131 recruited patients and accounting for the dropout rate provided a power of 73.8%, at a significance level of .05, resulting in a loss of power of <7%. Attrition rate at the 18-week follow-up was higher than the a priori estimated rate of 10%. No long-term follow-up data are presented, thus limiting the interpretation of the results. The lack of blinding of both patients and physiotherapists can also be considered a limitation, although it is well recognized that blinding is virtually impossible to achieve in nonpharmacologic trials.
The low return of the completed HEP diaries is also worth noting but may be related to the study design. Participants were asked to return diaries to the treating therapists in order to maintain assessor blinding. Because of the high number of treating therapists, this proved difficult to implement successfully.
Conclusions
This RCT demonstrated that an 8-week program of ET, with and without adjunctive MT, for people with hip OA, showed similar improvements in self-report function, ROM, and PGA at 9 weeks, which were maintained at 18 weeks. However, the clinical meaningfulness of these changes is questionable. Patient satisfaction was higher for those who received adjunctive MT. These findings highlight the benefit of physiotherapy-based exercise for those with hip OA, but no additive benefit from the use of additional MT. More research is required to identify the optimal components of rehabilitation required to target the multifaceted elements of hip OA.
Supplier
a.
Statacorp, 4905 Lakeway Dr, College Station, TX 77845.
Acknowledgments
We thank the treating physiotherapists in this trial: Claire Gilsenan, MSc, Aisling Brennan, MSc, Vanessa Cuddy, BSc, Breon White, MSc, Martina Fitzpatrick, MSc, Aoife Caffrey, MSc, Jennifer Eadie, MSc, Fiona Lenehan, MSc, Rachel Egginton, BSc, Fiachra McLeid, MPhySt, Donal Scanlon, MManTher, Yvette Harte, BSc, Maire-Brid Casey, MManTher, Maura O'Rahilly, BSc, Ruth McCollum, BSc, Mary Cassells, MPhysio, Grainne Quinn, BSc, Fiona Cahill, BSc, Sarah O'Driscoll, MSc, Sheila McDermott, MManTher, Julie Sugrue, MManTher, Mairead Dockery, MManTher, Sarianne Farrell, MSc, and Mhairi Claire Burke, BSc.
Appendix 1. EMPART: Exercise and Manual Physiotherapy Arthritis Research Trial treatment protocols
Exercise therapy protocol
The primary objective of the exercise program is to increase hip ROM to optimize hip stability and gluteal muscle strength for function.
Warm up: Each exercise session will consist of a warm-up exercise; 5min cycling on a static bicycle (or pedals). Patients will be positioned to maximize hip ROM without resistance or excessive discomfort.
Stretching: Muscle balance between tight hip flexors and weak hip extensors is restored through appropriate stretching exercises. Weeks 1–8, 30-s hold, 5 repetitions, 3 times a day
Patients can be given stretches of the 2 most restricted movements, as indicated by the baseline assessment. In total, up to 5 exercises can be given as part of the HEP, including 2 stretches. Exercises can be chosen from the list below with progression from weeks 1–8, depending on patient's severity and progression in strength.
List of exercises
(Extensive description and photographs of each exercise provided in protocol for treating physiotherapists)
Stretches (weeks 1–8)
1.
Hip extension in supine
2.
Hip extension/abduction in supine
3.
Hamstrings stretch in sitting or supine
4.
Flexion, abduction, external rotation stretch
5.
Hip flexion in 4 point kneel
6.
Hip flexion in supine
7.
Internal rotation in 4 point kneel
8.
Internal rotation in prone
Strengthening
Week 1
9.
Activation of psoas major in side-lying
10.
Activation of psoas major in supine
11.
Bent knee fall outs (external rotation control)
12.
Isometric gluteus maximus in supine
13.
Isometric gluteus medius supine—knee flexed
14.
Isometric gluteus medius supine—knee extended
15.
Isometric gluteus maximus in prone
Week 2
16.
Gluteus maximus prone with knee flexion
17.
Isometric hip lateral rotation prone in knee flexion
18.
Bridging in supine
19.
Gluteus maximus prone preparation for hip extension
Week 3
20.
Walk stance level 1
21.
Gluteus medius hip extension in prone
Week 4
22.
Gluteus medius turn out in side-lying
23.
Walk stance level 2
24.
Gluteus medius abduction in side-lying
25.
Gluteus medius in standing side-on at wall
26.
Double-leg wall squat
Weeks 5–8
27.
Pelvic lowering in standing
28.
Lateral step-up
29.
Step-ups
30.
Step-downs
31.
Double-leg squat
32.
Lunge
Manual therapy protocol
All treatments start with general mobilization. Choose the top 2 most restricted movements from the assessment data. Determine treatment approach on each session based on direction of restriction and pain/stiffness relation. For patients with a combined pain/stiffness pattern, determine which is the predominant feature.
This information will be given by the outcome assessor for the first treatment. For all other treatments, this can be re-evaluated by the treating therapist. Treatment approaches chosen can vary from treatment to treatment as directions of restriction, pain, and stiffness change.
Between 2–5 treatment techniques may be used in any 1 session for an approximate total treatment time of no more than 15min. Manual therapy must be used in at least 4 treatment sessions.
Tabled
1
Pain>Stiffness
Pain=Stiffness
Stiffness>Pain
General Mobilization (all treatments start with general mobilization)
Femoral shaft rotations Long Caud Gr II Lateral belt traction Gr II Long Caud Gr II AP supine Gr II
Femoral shaft rotations Long Caud Gr II/III Lateral belt traction Gr II/III Long Caud Gr II AP supine Gr II
Femoral shaft rotations Long Caud Gr III Lateral belt traction Gr III Long Caud Gr III AP supine Gr III
Flexion-related symptoms
APs Gr II MWM into flexion with belt Flex/Add Gr II Physiol Flex Gr II AP supine Gr II
MWM into flexion with belt Flex/Add Gr II/III Contract/hold relax flexion AP supine Gr II/III
MWM into flexion with belt Flex/Add Gr III/IV Cyriax B mobilization AP supine Gr III
Extension-related symptoms
PA in prone Gr II PA Side-lying Gr I/II Hip flexor stretch (mild/moderate) Long Caud prone Gr II
PA Gr II or III Hip flexor stretch Contract relax prone, then hip extension Long Caud prone Gr II
PA Gr III/IV Contract/hold relax extension MWM lateral glide in standing Long Caud prone Gr III
Abduction-related symptoms
MWM lateral traction in standing Physiol Abd with distraction Gr II
MWM lateral traction in standing Contract/hold relax abduction Physiol Abd with distraction Gr II/III
MWM lateral traction in standing Contract/hold relax Abduction Cyriax B mobilization Abd
IR-related symptoms
Physiol IR Gr II in supine MWM in hip flexion
Physiol IR Gr II/III in supine MWM in hip flexion
Physiol IR Gr III in supine Physiol IR Gr III in supine MWM in hip flexion MWM in 4 point kneel
ER-related symptoms
MWM in supine Physiol ER Gr II in supine
MWM in supine Physiol ER Gr II/III supine/prone FABER stretch Contract/hold relax ER
MWM in supine Physiol ER Gr III in supine FABER stretch MWM in 4 point kneel Contract/hold relax ER
At the beginning of each session, establish how the patient's status has changed since the last visit from the following, as appropriate:
Pain status after previous treatment: How the pain was posttreatment (if increased or decreased)? How long did the change last? Numerical Rating Scale can be used.
Changes in functional activities (eg, walking, stairs, sit to stand).
Medication status: Any change since last treatment?
ROM in supine (including endfeel): Flexion/abduction/external rotation/internal rotation/extension/flexion, abduction, external rotation (FABER).
If pain worsens for more than 24h after treatment (treatment soreness), then the intensity of the mobilization techniques should be decreased in the next session, for example, from stiffness to pain and stiffness.
References
Dominick K.L.
Ahern F.M.
Gold C.H.
Heller D.A.
Health-related quality of life and health service use among older adults with osteoarthritis.
Physiotherapy management of osteoarthritis of the hip: a survey of current practice in acute hospitals and private practice in the Republic of Ireland.
Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis. Consensus development at OMERACT III.
Does hydrotherapy improve strength and physical function in patients with osteoarthritis–a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme.
Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: a randomized controlled trial.
in: Whaley M.H. Brubaker P.H. Otto R.M. ACSM's guidelines for exercise testing and prescription. 7th edition. Lippincott, Williams and Wilkins,
Baltimore2006: 50
Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program.
Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: a single blind randomized clinical trial.
Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.
Supported by a Fellowship for the Therapy Professions from the Health Research Board , Ireland (grant no. CTPF-06-12 ).
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
In the article French HP, Cusack T, Brennan A, et al, Exercise and Manual Physiotherapy Arthritis Research Trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial, Arch Phys Med Rehabil 2013;94:302-14, an author was inadvertently omitted from the final manuscript.
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