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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.

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.

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.

 

 

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