Everything You Wanted To Know About OA Of The Hip

I wrote a post a few years back about a mistake I made helping someone who had osteoporosis in their hip and how to avoid my mistake.

We’ve also been posting lots around different hip pathologies lately.

It can be confusing, to say the least, trying to determine exactly what is going on with a patient experiencing hip pain. Coming up with what we “think” is a diagnosis, then attempting to differentiate which pathology they are experiencing if there even is one.

Then, of course, using our clinical decision making to develop a treatment plan and homecare.

But, are we really sure we’re doing the right thing for each pathology?

Well since we’ve already done posts on the SI joint and Femoroacetabular Impingement, I figured it was time to take a look at the research on Osteoarthritis and what we can do to help.

Finding A Diagnosis

Yes, I know…we’re not allowed to diagnose.

But!, that doesn’t mean we shouldn’t have some knowledge around how this is diagnosed so we can better educate our patients on what they are dealing with.

OA of the hip is usually seen in middle-aged and elderly people, most often over the age of 601, with men having a higher prevalence.

It affects the joint capsule (as well as other structures around the joint) which in turn causes some muscle weakness and limits the range of motion1, mostly with internal rotation and flexion.

When we look at the clinical guidelines around OA of the hip1 there is a list of things used in the diagnosis:

  • Moderate anterior or lateral hip pain during weight-bearing activities.
  • Morning stiffness less than one hour in duration after waking.
  • Hip internal rotation of less than 24°, or internal rotation and hip flexion 15° less than the non-painful side.
  • Increased hip pain with passive internal rotation.
  • Above the age of 50.

So if we are seeing someone and we suspect possible OA, or we are unsure of the diagnosis and their symptoms aren’t matching up to the above, this would be a good opportunity for us to refer out to get a possible differential diagnosis.1

Part of what we should assess is also what the daily function looks like for the patient sitting in front of us. What activities would they normally be doing that are being hindered because of the pain associated with this?

Also extremely important to take into account are: What are their goals? What are they hoping to get out of the treatment? What would a successful treatment look like to them?

The cited paper 1 gives four different activity tests which could be useful for you in your practice:

  • 30 Second Chair Stand Test
    • Seated on a chair, feet shoulder-width apart, arms crossed, patient stands up and repeats this as many times as possible for 30 seconds
  • 4-Square Step Test
    • Four canes placed with handles out at 90° angles to form four squares. The patient stands in square 1, steps forward with both feet into square 2, then steps right into square 3, then steps back into square 4. Sequence is then done in reverse and is timed.
  • Step Test
    • Patient steps on and off a 15cm step maintaining stance on the painful leg, both feet are placed on the step, then down to the floor on the opposite side. This is done for 15 seconds with the full number of steps counted.
  • Timed Single Leg Stance
    • The patient places hands on their hips and stands on the affected leg, with the knee of non-stance leg flexed so the foot is behind. The patient stands on 1 leg for as long as possible up to 30 seconds.
  • Six Minute Walk Test 2
    • You guessed it! Go for a walk with your patient. See how far they can go on a flat surface for 6 minutes in duration.

What I love about these assessments is how they all help to measure strength, balance, endurance, and flexibility…which are also the recommendations for exercise or homecare interventions for people with OA of the hip. So these could easily be part of homecare instructions to increase strength, balance, endurance, and flexibility (and I’ve got another exercise routine coming at you soon).

In addition to these active assessments it is also important to document 1 flexion, abduction, and external rotation (FABER test) along with passive hip ROM and strength (which might be tough to do via special testing), which is where the above activities will help.

Now that you have an understanding of how individuals are diagnosed, and how we can do some assessment, it’s important to know what the research says on treatment.

The biggest recommendations are patient education, exercise, and manual therapy1.

Now, I’m not about to lecture you on the manual therapy end of things. You all have your favourite techniques and your patients come and see you because of what you do, so keep it up! When it comes to education, we aren’t so much educating patients on OA itself (we can leave that to the doctors and rheumatologists) but we can teach them some activity modifications and…you guessed it again…exercise. If the work you’re doing or if the guideline recommendations aren’t helping the patient see some improvement, this would also be a good time to refer out.

So let’s look at what the evidence says on exercise!

Exercise For Hip OA

Now it’s important to mention that weight loss is one of the main recommendations to help OA of the hip, however, counseling a patient on this is well out of our scope. Also, as Greg Lehman puts it, losing weight is really hard!

So let’s focus on what we can do (which in turn may help with a bit of weight loss), EXERCISE!

When reading over the research on this, the first statement that popped out to me was:

Pain is the dominant symptom although it is important to note that the severity of pain and the extent of changes on x-ray are not well correlated 3

This is crucially important as quite often people will get the x-ray to confirm a diagnosis and take this as an indication they shouldn’t exercise or can catastrophize over this, thinking they are so damaged exercise isn’t an option.

Pain along with joint stiffness, instability, swelling, and muscle weakness can lead to not only physical but psychological changes and impaired quality of life. However, when we look at the benefits of exercise it can not only improve physical activities but can also help to improve a wide range of other functions including social, domestic, occupational, and recreation activities.

It can also help with fall risk, which is not only an immediate benefit but also a very long term benefit in preventing traumatic injuries due to fall accidents.

When looking at the type of exercise that would be most useful, it was determined that using supervised therapeutic exercise for strengthening the area is most beneficial and surprisingly (at least I was surprised) water-based exercise wasn’t as effective, nor was there as much research done in that area. Part of why this is not as effective is due to less of a load on the joint which does not correlate to walking ability or an increase in joint ROM. Also access to facilities is harder to come by compared to just being able to go for a walk outside.

However, it is suggested that for obese patients (I’m not about to make that assessment, this would be better coming from a doctor), or those who have more severe changes, aquatic exercise would probably be more beneficial until more load could be tolerated.

So, digging deeper into the research it goes back and forth as to what is more effective strengthening, or aerobic. However, the reason it seems to go back and forth is because it always comes down to what is most important, and or, more effective for the patient sitting in front of you. This way there is no “one” recommendation as far as exercise goes. To provide a good exercise recommendation is to look at what is affecting the patient more. Is it more important to strengthen the area according to the person’s daily needs? Or is aerobic exercise more important? What are the patients goals? Is going for a daily walk more important, or is being able to do a squat, climb a flight of stairs, or playing a game of tennis the top priorities.

I love these two quotes from our friend Bronnie Lennox Thompson:

Whatever the reason, tapping into that is more important than the form of the exercise.

and

Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time.

Now don’t get me wrong, exercise is never a waste of time and the evidence shows us, in this case, it can assist with daily function and help with pain (it will never completely get rid of pain). However, if we aren’t making the exercise applicable to, and enjoyable for the person, the likeliness they will do it is low. We also have to take into account they will likely have some discomfort with exercise but we must educate them on how this is not correlated to the condition getting worse. If we recommend an activity and 48 hours later there is some swelling, or the pain worsens this demonstrates that we have overdone it a bit and may have to back off the homecare dosage we have given them. We must use our clinical decision making not only in our dosage but also in what’s important to the person sitting in front of us.

References

 

1. Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.
2. American College Of Rheumatology. Six Minute Walk Test. https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Six-Minute-Walk-Test-SMWT.[August 10, 2020]
3. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal of Science and Medicine in Sport. 2011 Jan 1;14(1):4-9.

The First Breathing Strategy You Should Be Teaching

We’ve done several interviews with our friend Keith Meldrum who deals with persistent pain. One of the things he says really helps is just simply breathing.

Some patients are very sensitized, in severe pain, unable to move and/or have extremely high anxiety. These are not people who generally respond to repeated motions, mobilization/manipulation or other go to treatments.

Diaphragmatic breathing is a great strategy to tune down the nervous system and desensitize it. However, fear avoidance often prevents people from taking a good deep exhale. In this video, I go over the importance of teaching exhalation.

 

 

 

Articles Of The Week August 16, 2020

You know how we feel about exercise around here, so we had to share this one as it is FULL of good advice regarding the good, the bad, and the ugly about exercise for patients (and I have to say my respect for her just increased one hundred fold since she used a hockey stick as a kid).

“Is Exercise The New Snake Oil? Or Just A Dirty Word?” – Bronnie Thompson

Mental health is extremely important for us to recognize in our patients. But, what about when it’s us who needs the help? While this article is directed toward personal trainers, it could be applicable to any of us who work with people and it has some great advice.

“Training Through the Struggle” – Chris Cooper

We quite often talk about the importance of “soft skills” when we’re communicating with patients. What about using some soft skills outside the clinic room to be successful in our business and our life? Here’s some great ones.

“25 Soft Skills You Need to Be Successful in Life” – Jeremy Diamond

Whether it’s a manual therapy conference, a pain conference, or something for sport we would all probably be better off collaborating with mental health professionals to enhance our practice. This is a great example of how a sport psychology doctor brought awareness around the psychosocial factors of return to sport for other sport med professionals.

“Why Should Sport Psychology Practitioners Attend Sports Medicine Conferences?” – Kelly Butterworth

This is both a podcast you can listen to, or just text to read, but either way when David Butler speaks, you should listen. Check out his thoughts on nerve root pain.

“Talking Nerve Root Pain With David Butler” – Tom Jesson

10 Tips For The Practical Application Of Pain Science

 

Knowledge about pain science is rapidly growing with articles and blogs aimed at everybody from personal trainers to doctors and surgeons springing up on the topic. It could be argued that anyone who deals with the body should have a basic understanding of how pain works.

We have criticism that we still have not gone far enough in this field and others seeing the pendulum as having swung far to far already!

Whilst it is important to digest this barrage of information, we also need to think about the real world application of the academia to the end user, e.g. the person you are trying to help understand all this information, and often this is the bit people find hard.

1. Pain Science Can Help Us To Understand What Not Ts Say, But Not What To Say

 

At the very LEAST a better understanding of pain science should influence us to know that what we say can have a profound affect on the way someone perceives themselves and their current state. Unfortunately words that hinder rather than help can often easily trip off the tongue as they have been used so many times before!

Just staying away from certain words may help to not create detrimental nocibo effects.

• Rip
• Tear
• Instability
• Damage
• Degeneration
• Chronic
• Out of place

These words have the potential to alter people’s perceptions of their capabilities, beliefs and expectations for recovery. ‘Thought viruses’ is a catchy term regarding negative beliefs and how they can be generated and passed between people.

What should we say? Well that is an infinitely harder question to answer and will vary between individuals, there are certainly are no recipes here.

Hence why learning what NOT to say is often a great start!

2. Learn More About The Subject!

 

A criticism of our current educational processes is that they do not teach much about the mechanisms behind the experience of pain at undergraduate level or in many courses that deal with injury.

While it is a start to watch a few videos or read a few blogs, using the concepts of modern pain science should be underpinned by a good working knowledge of how pain works. A few buzz words or analogies probably aren’t quite enough to get it across to the target audience, especially when they have a habit of asking tricky questions.

Here are some questions it may just be worth knowing the answer to or how to explain:

What is pain?
How does nociception work?
What is central sensitisation?
What is peripheral sensitisation?
What are the supra spinal mechanisms involved in the pain experience?
What are descending inhibition & facilitation?
Why do stress, context & emotion have an effect on the pain experience?

3. Explanation Of A Complex Subject Like Pain Takes Practice

 

Everything is hard before it is easy - motivational slogan on a clipboard with a cup of coffee

People can feel under pressure to be able to ‘explain pain’ like an expert. Firstly you need the basic science then you need to learn how to articulate it and this does not happen over night.

As Einstein says, “If you can’t explain it simply you don’t know it well enough”.

Complexity and confusion during an explanation may lead to confusion and uncertainty in someone’s understanding and actually increase rather than dampen down someone’s pain experience.

Perhaps it is something that should be practiced away from a ‘live’ environment to build your own confidence and communication skills? Fuck it up a few times, learn from this and be ready to roll it out when you need it.

All the best presenters practice after all!

4. You May Need More Than One Analogy

 

Analogies have been promoted as a great way to get across complex subjects such as pain. As we use analogy so much in everyday life this makes a lot of sense but it is good to keep in mind always that these things depend on the person receiving the analogies previous experiences, cultural factors and education level.

SO if it ain’t working then switch it up.

5. Challenge Concepts And Not People

 

A great way to ruin rapport, which can be vital to the success of what you are trying to achieve, is to tell people they are wrong or make them feel stupid. Beliefs can be like superglue and adding confrontation into the mix can make things go downhill quickly. If it is not working STOP, maybe you can come back to it later or drip feed in over time.

6. Always Find Out How Someone Has Perceived What You Have Told Them

 

This is vital, it maybe the information you have presented is perceived in precisely the way that you did not mean it to be! Prof Kieran O’Sullivan promotes a most sensible course of action by asking “What would you tell your friends and family about what I have told you”.

This means any miscommunications can be (hopefully) remedied before they turn into ‘thought viruses’ such as “they told me the pain was all in my head”.

7. There Are No Recipes Or Protocols – It Is About The Individual

 

What works for one person may not work for another. Perhaps a plus for pain science is it points towards being person centred rather than having a specific protocol across humans such as more protocol based approaches do.

Strategies that have been promoted from the fields of psychology involve techniques such as exposure therapy and expectancy violation. We have to be careful that the patient/client identifies the specific fears and beliefs to be addressed, and hopefully inhibited, and this is not seen as a general concept.

8. Changing Beliefs Is Not An Instantaneous Process, An Exact Science Or Even Always Possible

 

As discussed in point 5, beliefs can be sticky and contagious between friends, family and work colleagues (even more so with Dr Google!). Rarely do people walk out from chatting with their therapist or trainer and suddenly change their outlook and opinion on themselves or beliefs they hold.

It could be a slow and laborious process (likely!) or in fact never happen at all!

9. People Often Have Their Own Epiphanies Away From You

 

Reconceptualizing can happen in mysterious ways with mysterious triggers, a bit like an apple falling on your head! You may have to wait for someone to come to their own realizations about the information you are giving them rather than expecting an epiphany in front of your eyes.

10. You Can’t Talk Tolerance Into A Tissue

 

One of the major parts of the BPS model is the B for biological. Just because you can help someone understand they are not fragile does not mean they suddenly develop an enhanced capacity for moving. The less you move the less likely you are to be robust at moving, that’s the SAID principle in action.

Someone once said “you can’t talk tolerance into a tissue” a very true statement. But you may have to talk to someone first to get them to do that work and get the tolerance!

11. BPS Model Is Still In The Minority Away From Social Media

 

For the eagle eyed yes it did say 10 and this is number 11!

It may feel like social media is awash with pain science from every angle to the delight of some and not to others! Go out into the wider world of the internet and shock, horror the actual real world and it feels like the information being delivered in the medical and training world regarding pain is still pretty traditional with structural and biomechanical factors being promoted.

Articles Of The Week August 9, 2020

If you’ve been following this blog for any length of time, you know I love this guy. Here’s another great video on being a movement optimist when it comes to the low back and spinal flexion.

“Do You Need To Worry About Spine Flexion And Low Back Pain?” – Greg Lehman

Some new updates on helping people with persistent pain…however, patient centred care remains at the centre of our focus.

“Commonly Used Treatments For Chronic Pain Can Do More Harm Than Good And Should Not Be Used, Says NICE In Draft Guidance” – National Institute For Health And Care Excellence

When we look at some of the causes and issues around pain and specifically low back pain, things can seem fairly complicated. However, when we look at the modern research around this, it really doesn’t have to be.

“Simplifying The Treatment And Management For Low Back Pain– Eric Purves

Inevitably we’ve all had a patient come in asking for “deep tissue massage”. But, what is this really?, it can mean different things to different people. Well, this is a great description and a modern narrative we can use when discussing this with patients.

“What Is A Deep Tissue Massage? A Modern Narrative” – Heather Thuessen

Do you have patients who are regular gym-goers, or athletes who come in for treatment because they’re sore after a hard workout? Well, there may be a dangerous condition result if they push too hard.

“High-Intensity Workouts May Put Regular Gym Goers At Risk Of Rhabdomyolysis, A Rare But Dangerous Condition” – Christopher Gaffney

 

Making Movement More About The Person, Not The Exercise

So I was on Facebook the other day.

And I saw somebody trying to make the argument that this exercise with a Theraband should be retired from anybody’s rehab toolkit.

And their argument was that there’s far better exercises for a rotator cuff injury.

And I’m sure there are, and I’m sure that you could even use this in different planes and do different things in order to help a rotator cuff injury.

But what we have to understand is that it’s not necessarily about the exercise itself.

It’s about the person who’s standing in front of us and we have to make that exercise meaningful to them.

Because maybe their biggest goal is to just be able to put their groceries away pain free, or maybe it’s to pick their child up and if this becomes a meaningful exercise to them that helps build capacity, build resilience and makes it so that they can do those activities we just talked about, then this is just fine as an exercise.