Physical Therapy Management Of Hip OA

Hip Osteoarthritis

Osteoarthritis is a chronic degenerative joint disease that originates in the cartilage and affects underlying bone, soft tissues, and synovial fluid. Osteoarthritis commonly affects the knee and hip. Symptomatic OA is associated with pain, stiffness, swelling, joint instability, muscle weakness, and poor health status. Hip OA is typically treated conservatively, through rest, analgesics and physical therapy, before a surgical approach is considered.

Goals ¹

The goals of physical therapy include:

• The reduction of pain and muscle spasm
• Therapeutic exercises to: Maintain or improve range of motion, correct muscle imbalances, strengthen, improve flexibility, and improve ambulation
• Provide assisted devices as needed (canes, walkers, orthotics, reachers, etc.)
• Aerobic conditioning using low to nonimpact exercises (walking, pool program)
• Provide patient education
• Promote healthy lifestyle and reduce risk factors for OA

Physical Therapy Intervention ^2,3,4,5

A physical therapist will often work with the patient throughout all of the conservative goals, including patient education. Patient education is important to aide in the self management of arthritic changes. Proper education may lead to decreases in pain, improved function, and reduction in stiffness and fatigue. With education, patients will learn the importance of preserving hip ROM and muscle function, they will understand proper therapies, and when surgery may be likely. Education may also include joint protection, proper posture, and orthotic use.

Physical therapy is often prescribed to optimize joint function and ADL's. The therapist will work with the patient to prevent further injury through gait and balance training. Function gait and balance training may also include education and strength training during exercises such as rising from a chair, reaching, stepping, or squatting down. This training may reduce the risk of falls associated with OA. Exercise programs can improve function without exacerbating symptoms and without the risks associated with pharmacologic use. Specific exercise training will be used to reduce the stress placed on the joint and to help with shock absorption. Excercises may include aqua therapy, which has been shown to have equal benefits to the land based exercise programs. Maximizing adherence to a home exercise program (HEP) is a key element to the success of exercise therapy. Manual therapy may be used to increase hip joint range of motion and to reduce pain.

Adjunctive interventions, physical agents and electro-therapeutic modalities, can be incorporated during the treatment to help reduce the symptoms of hip OA. Possible modalities can include:

• Cryotherapy - to help reduce pain and inflammation, and to prevent muscle guarding during ROM exercises
  • Contraindications to cryotherapy:
    • Open wound
    • Poor Circulation (peripheral vascular disease)
    • Cryoglobinemia
    • Paroxysmal cold hemoglobinuria
    • Raynaud's phenomenon
    • Infection
• Thermotherapy - to help to reduce pain and muscle guarding
  • Contraindications include contraindications for cryotherapy and:
    • Acute injury/inflammation
    • Cardiac insufficiency
    • Malignancy
    • Edema
    • Hemophilia
• Electrical stimulation - to aid in pain modulation (TENS) and muscle reeducation (NMES)
  • Contraindications for electrical stimulation
    • Electronic implants close to treatment area
    • Seizure disorders
    • Phlebitis
    • Malignancy
    • Cardiac arrhythmia
    • Osteomylitis

Tests for differential diagnosis ³

• The Scour test for labral tears

• FABER (Patrick’s) test for labral tears

• Fitzgerald’s test for labral tears

• Flexion-adduction internal rotation tests for labral tears
• Sacroiliac joint provocation tests for sacroiliac joint pain
• Femoral nerve stretch test for L2-3 radiculopathy

Guide to Physical Therapist Practice

The guide is used to give policy makers, patients, and PT's a clear consensus of the physical therapist's role in patient care throughout various physical therapy appropriate medial diagnosis. The PT diagnosis focuses on the specific impairments that makes the patient a candidate for physical therapy. In this case hip osteoarthritis is the medical diagnosis and Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation is the physical therapy diagnosis.
According to the guide, "over the course of 2 to 4 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments." The guide goes on to state that the anticipated goals will be achieved during the episode of care which was quoted at 6-24 visits.
Guide to PT Practice Pattern 4E

Bibliography

1. Dutton M. McGraw-hill's NPTE (National Physical Therapy Examination). Second ed. McGraw-Hill; 2012.

2. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport. 2011;14(1):4-9. doi: 10.1016/j.jsams.2010.08.002.

3. Cibulka MT, White DM, Woehrle J, et al. Hip pain and mobility deficits—hip osteoarthritis: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the american physical therapy association. J Orthop Sports Phys Ther. 2009;39(4):A1-25. doi: 10.2519/jospt.2009.0301.

4. Goodman CG, Fuller KS. Pathophysiology: Implications for the physical therapist, 3rd edition. St Louis, MO: Saunders Elsevier; 2009.

5. Wandel S, Juni P, Tendal B, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: Network meta-analysis. BMJ. 2010;341:c4675. doi: 10.1136/bmj.c4675.

6. Guide to Physical Therapist Practice. American Physical Therapy Association. 2012. Accessed March 10, 2012.