Clinical Practice Update: The Hip
In case you could not tell, we read a lot of research here at Perfect Stride. If you have missed out on our Perfect Pearl series, we post a new research article with description and break down every Wednesday on our Instagram account which you can follow here.
In one of the most recent JOSPT from June 2017, we were greeted with an update to the Hip Clinical Practice Guidelines which originally came out in 2009. Sir William Osler, one of the fathers of modern medicine, was famously quoted as saying, "Osteoarthritis is an easy disease to treat, when the patient walks in the front door, I walk out the back door."
Yes, osteoarthritis can be a complicated subject matter, but we have made some strides in research that have given us insight into how we should be organizing our treatments, recommendations, and aligning our thought process. More recent research has highlighted the fact that most patients are not receiving appropriate care. The most underutilized areas? Lifestyle and behavioral management, particularly with implementation of exercise and weight loss. The current approach of medication followed by joint replacement needs to change, as 1 in 4 people who undergo arthroplasty are not satisfied with the result.
Furthermore, treatments that seemingly have no clinical benefit, are harmful, or not cost effective such as glucosamine, opiods, viscosupplements and arthroscopy should not be considered as treatment in management of hip OA.
The following list is a recommendation of care for Hip OA that had "Strong Evidence."
(*Note much more was recommended, however the highlight of this blog was to give the reader a "Best Practice" approach.)
- Classifying adults over the age of 50 with hip OA should be made with criteria including anterior or lateral hip pain with weightbearing, morning stiffness of less then 1 hour, hip IR less then 24 degrees, and hip flexion 15 degrees less then the non-painful side, as well as increased pain with hip IR.
- As clinicians we should be using validated outcome measures including WOMAC, BPI, PPT, HOOS, LEFS and HHS
- Physical performance measures should be assessed utilizing 6 minute walk, 30 second chair stand, timed up and go, 4 square test as well as balance assessments such as the Berg Balance Scale
- Examination of ROM should also document strength as well as FABER and Patrick Assessment
- Manual therapy should be implemented with patients who display signs and symptoms of hip OA. Therapy may include thrust, non-thrust and soft tissue mobilization 3 times per week for 6-12 weeks
- Exercises focusing on flexibility, endurance and strength should be tailored to specific needs of the patient and implemented 1-5 times per week for 6 to 12 weeks.
When will we know it is time for something else? Non-surgical treatment will have "failed" if a patient does not demonstrate 20-25% improvement on a WOMAC pain subscale and has progressive loss of joint space between 0.3 and 0.7 mm per year as seen on radiographs.
In conjunction with clinical decision making and staying up to date on research recommensations, we can make positive impacts on this subgroup of patients and not have to worry if we can make it to the "back door."