4 Instant Ways To Assess And Move For OA Of The Hip

Over the past couple of weeks we’ve been discussing different ways we can help patients who are dealing with OA of the hip.

Here are some relatively simple assessments you can do, which will also be great as homecare exercises!

When looking at all of these movements/tests it is recommended that you demonstrate it once to the patient, then have them do a practice run before the actual test takes place.

Sit To Stand Test

You start this with just a chair placed with the back of it against a wall. The patient sits with feet shoulder width apart and arms crossed at the chest.

You then have them rise to a standing position, then return to seated position for as many times possible for a 30 second duration.

Doing this can help give us an idea of some activity limitations the person may have. 1

 

4 Square Step Test

The literature recommends using four canes spread out with the handles at 90°, but I didn’t have any canes, so I just used tape on the floor.

Start the person in square 1 (whichever one you dictate that is) then in a clockwise direction stepping forward into square 2, side stepping to square 3, reverse step to square 4, then side step back into square 1.

Once the person is back in square 1, you reverse the direction going counterclockwise, side step to square 4, forward step to square 3, side step to square 2, reverse step to square 1.

This is timed to see how the person can do as quickly as possible to give us an indication of how well a person can move in different directions.1

Step Test

This one is a great way to assess a persons balance.

The literature recommends a 15cm step, but I didn’t have one, so I’m just demonstrating with a platform we have at the clinic.

Have the person stand on the affected, or the test hip. With the opposite leg step up onto your elevated surface until the foot is flat on the step, then return it back down to the floor. The painful side is always the “stance” side and doesn’t move up onto the step.

See how many times the person can do this for 15 seconds.1

 

Timed Single Leg Stance

This is another one for assessing a persons balance.

Hands are placed on the hip. Testing side is the “stance” side, opposite leg is put into a flexion position so that hip is neutral.

Then time the person for a maximum of 30 seconds. The test stops if the hands come off the hips, they touch the stance leg with their hands, or the stance leg touches the non-stance leg.1

What I really like about all of these, is that while their intent is an assessment, each one of these could easily be a homecare exercise you recommend to anyone with hip issues. You can easily do any of these in your treatment room and it can give you a great indication of a patients progression or digression. As always don’t just give them this with no reasoning behind it, make it meaningful to the person, find out their goals and explain how these or any other exercise can help them attain that goal. Make it about them!

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 orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.

Proven Ways To Increase Strength, Endurance, And Flexibility Of The Hip

Last week we had a post all about helping patients with OA of the hip.

One of the big recommendations was doing exercises that would help with strength, endurance, and flexibility of the hip. 

Here’s a series of exercises I learned back in college (from a pretty great instructor) that I believe would help with all of those goals.

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.

 

 

How Changing Our Habits Can Change Our Practice

Change can be difficult. Like, REALLY difficult.

In fact, we’ve written posts on here a few times regarding different ways therapists are stuck (or refuse to change) the way they practice. Quite often because of not wanting to include research in their practice, or committing to the new narratives around pain science etc.

If we did change, it often feels like a daunting task where the things we have been doing for so long have to change, and in turn there is sometimes fear around how our patients would react when this change occurs.

In the past, I’ve often chalked this up to the methods we use, or techniques we love become part of our identity and thus we don’t want to change.

While I still believe this to be true, it can’t be the only reason.

While reading a book recently, it dawned on me there could be another reason, which most of us probably don’t even realize. Mainly because this occurs subconsciously, it happens routinely, is performed regularly, and most of the time just happens automatically.

What I’m referring to a simple word that most of us don’t realize we are doing with every patient who comes in to see us.

Habits!

Little Seeds Of Change

Quite often when teaching or discussing different concepts around manual therapy with other practitioners, inevitably the topic always comes up “how do I incorporate this in practice”?

I’d say this is especially true with Massage Therapists and discussing how to begin including movement and exercise into treatments (this is just my take on discussions I’ve had with therapists, not the general rule).

There is usually a concern where the patient comes in and just wants to get on the table and get their treatment going. Even to the point of looking at their watch in an attempt to make sure they get their full hour on the table.

This was also true as I started getting interested in pain science and while learning along the way had to change my narrative with patients. I was genuinely worried (also due to my lack of confidence) that patients would think I sounded like I was out to lunch and start seeing a different therapist.

Well, the reality is, when I started doing more of both, not one of my patients ever looked at me and refused to do a movement, or told me they thought I was out to lunch (they may have thought it but never said it to me), and they very well could have because I’m sure it sounded like I was vomiting all this new information at them.

However, there is a way to do this in a much better way than I did when I first started trying to incorporate these things into my practice.

When we are trying to create change with a patient it’s usually about planting little seeds of information and playing the long game. It’s not always about making huge, grand changes all in one session. It’s about incorporating small changes over a longer period.

Perhaps it’s making one small change in an activity of daily living until eventually several changes are made and your patient adapts to a new routine or exercise until it becomes a habit.

So, if this approach can and does work for our patients, what if we took the same approach with our practice?

Changing Our Habits

In his book “Atomic Habits” James Clear breaks down how to build good habits and break bad ones.

One of the things I found really interesting was a quote from the book talking about habit change, I couldn’t help but relate it to how so often our techniques become part of our identity in our practice:

“The real reason habits stick is that it becomes part of your identity, improvements are only temporary until they become part of who you are”

“When you have repeated a story to yourself for years, it is easy to slide into these mental grooves and accept them as a fact. In time, you begin to resist certain actions because “that’s not who I am”. There is internal pressure to maintain your self image and behave in a way that is consistent with your beliefs. You find whatever you can to avoid contradicting yourself”

Just about everything we do in our clinic is a habit without even realizing it.

The way we greet a patient when they come in, the way we sit in our clinic room with them when they first arrive, the way our hands make initial contact with them when they’re on our table…all habits. We’re probably more likely to call it a routine, but these are all habits we’ve created, which is also part of the reason you’re successful.

Your patients REALLY like this routine.

And the thing is, so do we! It’s comfortable and familiar, which makes change all that much harder.

However, if we truly want to grow in our practice, it’s a matter of us deciding we will change, not making the patient change (although this will happen gradually).

This can also be daunting because it can feel like we’ll get left behind (making it all that much easier to stay in our groove), which is overwhelming, I mean, it takes 17 years before research is actually implemented in most medical practices, so it’s not like we’re going to get left behind by attempting to change what we do in our practice.

In this book, James talks about how to create new habits by doing something called “habit stacking”. To do this you identify a current habit you already do each day and then stack your new behaviour on top of the current one. As you begin to master the structure of doing this, you create larger change by incorporating more of these small changes until these new habits are formed.

Could we just start by asking one new question during our intake and do it with each patient one day, then the next, until it becomes part of our normal conversation with a patient? Once this becomes our new normal, we could include one graded exposure movement before each treatment? When this becomes part of the routine, start to incorporate movement into a treatment, then homecare, etc. Even if all we do is just change by a small fraction each day or week, this can have a profound change in our practice and our patients over the long term. As this adds up you can have some breakthrough moments that not only make you a better therapist but can enhance your career. And the best part is, while you gradually make this change, your patients will change with you without them realizing it. These changes will become an expected part of your treatment and hopefully, they won’t be checking their watch at the start of the treatment.

If you’re curious or want to know more about habit change and how it can help you and your patients, I highly recommend “Atomic Habits” which you can get HERE.

 

 

Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

Crossed Arm Syndrome

 

I understand the trend toward patient-empowerment, trying to build self-efficacy without risking dependency on the clinician. This has elevated the interventions of education and exercise over manual therapy in terms of best-practice recommendations for physical therapists.

As a long-term PT, I can understand this movement, but the trend comes at a price.

First off is the belief that manual therapy, viewed as a passive intervention, should be dosed sparingly as to not encourage dependency. In contrast, I contend that if manual therapy allows movement with less fear, pain, and caution, this, in itself, builds independence.

I do accept that more common view of PT is the exercise-based model, though I have HUGE issues with intellectual lazy PTs who blame weakness on pain. What I don’t and will not accept is an apparent lack of engagement on the part of my profession.

I have great respect for the time, patience, money, and emotional investment that a budding PT student makes to become a DPT, as it is not an easy path. But what are we building?

Recently I had dropped my car off for a service at a local repair facility. Rather than join the squad impatient chair-sitters, waiting for word of the bill in need of payment, I chose instead to take a long walk. This walk afforded me an opportunity to cruise through the nearby picturesque village, able to see the sights while getting my exercise. My walk took me past the village PT clinic…twice, once on my outbound journey, and again on my way back to the garage.

On my first pass, I was easily able to view a good handful of patients dutifully working out on at their respective stations, all seeming to be completely engaged in their tasks. But at the center of the facility, I viewed two individuals who I am assuming where the resident PTs. How did I know this?

Apparel, for one. They were the only ones NOT engaged.

Instead, they stood side by side, talking with each other, in the dreaded arms-crossed posture. Argh! OK, I thought, as I passed, maybe I caught them at a bad moment. Maybe it was a fluke. I’ll take a look on my way back, hoping that they would not be caught in such a compromising position.

The walk took me through the rest of the village and, with a bit of a divergence, along a roaring creek. Quite lovely. But as I again approached the PT clinic my suspicions rose and, sure enough, there they stood. Maybe they have moved and returned to the exact same spot to converse again…or maybe not. But there they stood, arms-crossed and conversing, while their patients dutifully went through their paces.

A PT may argue that those patients were engaged in self-helping behaviors, learning self-reliance, and building upon their own potential. Quite possibly.

But why did the PTs need to be standing there so unengaged? We can be more than arm crossers, we can be cheerleaders, encouragers, coaches, teachers, and, yes, occasionally, applying manual interventions. Self-reliance is key, but what has the PT profession become; a bunch of arm crossers? Manual therapy PT has its own skulls in the closet, but that’s not what this post is about. It’s about arm crossing.

My bias is toward using manual therapy as a primary intervention and evidence exists for this as a viable treatment strategy. I strongly discourage dependency of any sort and abhor it in other professionals. My work is set up to empower my patient to feel like they can move and with less fear. I teach them to self-treat, based on my examples, and make it a strong encouragement to engage in the movement of their choosing. I recognize that a good majority of patients seen for exercise-based PT improve, though those that don’t often come through my door.

As a profession, PT and other similar professions, the view of us by the public matters. Arm-crossing and spending a good amount of your time conversing with your peer instead of your patient is simply a lame way to spend medical dollars, not to mention a very expensive education.

Next time I make that walk, my hope is to see PTs engaged with their patient. They may not be touching, using manual therapy as I do, but I hope to see them spending time speaking to their patients, coaching and encouraging, aiding and correcting, prescribing, and adapting. I hope to see them doing the things our profession(s) are capable of and not resorting to the stereotypes that pockmark our profession.

BAN ARM-CROSSING