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Bennell: Physiotherapy management of hip osteoarthritis

Physiotherapy management of hip osteoarthritis


Kim Bennell
Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Australia

Key words: Hip, Osteoarthritis, Exercise therapy, Physiotherapy

Introduction becoming persistent and more limiting as disease


progresses. Patients with hip osteoarthritis also report
Hip osteoarthritis is a chronic disease affecting the joint difculty with functional activities such as walking,
and surrounding musculature resulting in structural and driving, stair-climbing, gardening, and housekeeping
functional failure of the joint and causing pain, disability, (Guccione et al 1994) as well as higher levels of anxiety
and reduced quality of life. This narrative review outlines and depression (Murphy et al 2012). Work productivity is
the prevalence and burden of hip osteoarthritis followed affected with greater absenteeism, while fatigue and sleep
by its natural history and risk factors. Considerations for problems are common (Murphy et al 2011). Furthermore,
diagnosis and assessment are then covered. An overview of people with osteoarthritis typically suffer from a range of
the principles of hip osteoarthritis management is presented co-morbid diseases that further increases their likelihood of
together with specic physiotherapy interventions and poor physical function (Guh et al 2009).
evidence for their effectiveness. It is important to note,
however, that the bulk of research regarding conservative Hip osteoarthritis imposes a substantial economic burden,
management relates to osteoarthritis at the knee or mixed with most costs related to a range of conservative and
osteoarthritis populations rather than hip osteoarthritis surgical treatments, lost productivity, and substantial loss
specically, and that results cannot necessarily be of quality of life (Dibonaventura et al 2011). In particular,
generalised from the knee to the hip given differences in rates of costly hip joint replacement surgery for advanced
biomechanics, presentation, and risk factors. There is also disease are increasing including a shift in the demographic
a paucity of research in many areas. The recommendations of recipients to younger patients (Australian Orthopaedic
of clinical guidelines are therefore emphasised. The review Association National Joint Replacement Registry 2012,
concludes with potential directions for research to advance Ravi et al 2012). Clearly hip osteoarthritis is associated with
the eld. considerable individual and societal burden and, given that
there is currently no cure for the disease, treatments that
Prevalence of hip osteoarthritis reduce symptoms and slow functional decline are needed.
Hip osteoarthritis is a common condition worldwide,
particularly in older individuals. The reported prevalence Risk factors and natural history
of hip osteoarthritis varies greatly due to differences in the The development of hip osteoarthritis results from a
denition of osteoarthritis used (radiographic, symptomatic, combination of local joint-specic factors that increase
or self-reported) and the characteristics of the sample. A 2011 load across the joint acting in the context of factors that
meta-analysis found 27 studies of generally good quality increase systemic susceptibility (Figure 1). Age is a
reporting hip osteoarthritis prevalence rates from a range well-established risk factor for hip osteoarthritis as are
of countries (Pereira et al 2011). The rates varied from 0.9% developmental disorders such as congenital hip dislocation,
to 45% with radiographic rates higher than those using self- slipped capital femoral epiphysis, Perthes disease, and hip
reported or symptomatic osteoarthritis denitions. Men and dysplasia (Harris-Hayes and Royer 2011). More recently,
women showed similar overall prevalence: 11.5% for men femoroacetabular impingement, which refers to friction
and 11.6% for women. This differs from knee osteoarthritis between the proximal femur and acetabular rim due to
where the disease is signicantly more prevalent in women abnormal hip morphology and is seen in younger active
(Pereira et al 2011). In contrast to prevalence, information individuals, has been implicated as increasing the risk of hip
on the incidence of hip osteoarthritis is limited, reecting osteoarthritis (Harris-Hayes and Royer 2011). Caucasians
greater methodological challenges. The meta-analysis appear to have a higher prevalence of hip osteoarthritis
reported only four cohort studies from the USA, Netherlands, compared to Asian, African, and East Indian populations.
and Norway, with cumulative incidence rates varying from Albeit based on limited or inconsistent evidence, hip
3.8% over 10 years to 33% over 8 years (Pereira et al 2011). osteoarthritis also appears to be associated with obesity,
Despite the variation in reported rates, it is apparent that hip occupations involving heavy lifting and farming, high
osteoarthritis is a major public health problem, and one that volume and intensity of training particularly in impact
is likely to worsen with the ageing of the population. sports, and leg length discrepancy (Suri et al 2012).
The burden of hip osteoarthritis The natural history of hip osteoarthritis shows that
Osteoarthritis is a leading cause of musculoskeletal pain radiographic deterioration over time is common although
and disability. The most recent Global Burden of Diseases the rate of progression varies from person to person. Risk
study, published in The Lancet in 2012, found that, of the factors for disease progression can differ from those of
musculoskeletal conditions, the burden associated with disease onset. A 2009 systematic review summarising
osteoarthritis is amongst the most rapidly increasing (Vos the results of 18 prospective cohort studies found
et al 2012). Hip osteoarthritis is extremely debilitating strong evidence that age, baseline hip pain, and several
for affected individuals. Pain is a dominant symptom, radiographic features were predictive of the progression

Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 145
Invited topical review

Joint shape Joint Predisposition Gender


biomechanics to OA
Joint injury Age

Overload Biomechanical pathways Race

Neuromuscular Genetics
function
Hip osteoarthritis Systemic
factors

Age Pain and disability Obesity

Medical and
Physical Psychological Neuromuscular
psychological
activity factors function
co-morbidity

Figure 1. Aetiology of and risk factors for hip osteoarthritis, adapted from Lohmander et al
(2007) and Suri et al (2012). Disease initiation and progression are caused by a combination
of local factors and systemic factors that vary between individuals.

of hip osteoarthritis, while there was weak evidence of no Diagnosis


association with body mass index (Wright et al 2009). The Hip osteoarthritis can generally be diagnosed by a
role of modiable biomechanical and neuromuscular factors combination of history and physical examination ndings
such as muscle weakness in predisposing to development of without the need for an X-ray and exposing the patient to
hip osteoarthritis has not been investigated. unnecessary radiation. The most commonly used clinical
A limited number of studies have evaluated the course of criteria for diagnosing hip osteoarthritis are those from the
functional status over time in people with hip osteoarthritis. American College of Rheumatology (Altman et al 1991),
For studies with follow-up durations of three years or less, which include either of two sets of clinical features (Box 1).
pain and functional status appear to be relatively stable Moderate-to-severe hip osteoarthritis can be conrmed on
on a population level although considerable individual radiographs with ndings including joint space narrowing,
variation occurs. With follow-up of longer than three years, marginal osteophytes, subchondral sclerosis, and bone
deterioration has been noted (van Dijk et al 2006, van Dijk et cysts. Magnetic resonance imaging is more useful than
al 2010). There is little research on predictors of functional radiographs in detecting early structural changes such
decline. A longitudinal cohort study of 123 people with as focal cartilage defects and bone marrow lesions in
hip osteoarthritis found that several factors predicted the subchondral bone. Hip osteoarthritis has different
3-year worsening of function including range of motion, radiological presentations based on the pattern of migration
pain severity, cognitive impairment and co-morbidities of the femoral head within the acetabulum. Superolateral
(van Dijk et al 2010). Therefore, while progression of hip femoral migration is more common in men while women
osteoarthritis can occur, it is not necessarily inevitable and have more superomedial migration (Ledingham et al 1992).
for many people osteoarthritis may remain stable or even There is strong evidence that greater hip osteoarthritis
improve. disease progression is associated with certain structural
features on radiographs including joint space narrowing,
femoral osteophytes, bony sclerosis, and superolateral
femoral migration (Wright et al 2009).
Box 1. American College of Rheumatology clinical criteria
for the diagnosis of hip osteoarthritis (Altman et al 1991). Assessment
Either set of criteria can be used. The sensitivity and
In a subjective assessment, pain is a consistent nding,
specicity of these clinical criteria are 86% and 75% with
a positive likelihood ratio of 3.44 and a negative likelihood usually related to a particular movement or sustained
ratio of 0.19. position. Stiffness following rest can often be more
problematic than pain (Sims 1999). An important part
Clinical Set A Clinical Set B of the subjective assessment is to gain an understanding
of the impact of psychosocial factors including mood
% Age > 50 years % Age > 50 years disorders (eg, depression and anxiety) and sleep, social
% Hip pain % Hip pain support, ability to cope, social wellbeing and participation
% Hip internal rotation * % Hip internal rotation in leisure, relationships, community, and employment.
15 deg < 15 deg Exploring patient knowledge, expectations, and goals
% Pain with hip internal % Hip exion ) 115 deg facilitates a patient-centred approach to communication and
rotation management.
% Morning stiffness of the A key part of the physical examination is to identify what
hip ) 60 min
adverse mechanical conditions the hip is being subjected
to and what local and global factors are causing the

146 Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Bennell: Physiotherapy management of hip osteoarthritis

adverse conditions (Sims 1999). Reductions in all hip and location and degree of structural damage (Zhang et al
ranges of motion (Arokoski et al 2004) and weakness of 2005).
the hip and thigh muscles, especially the hip abductor and
quadriceps muscles, have been reported in people with hip Given the broad impact of osteoarthritis and in accordance
osteoarthritis (Loureiro et al 2013). The weakness appears with a biopsychosocial approach to the management
to be due primarily to a reduction in muscle size (atrophy) of chronic pain, it is logical that both biological and
rather than inhibition (Loureiro et al 2013). Biomechanical psychosocial factors should be addressed in people with
studies have detected altered gait patterns that may be hip osteoarthritis. For hip osteoarthritis, core conservative
compensatory in nature to reduce loading on the painful treatments for all patients should include education and
hip or as a consequence of other impairments (Eitzen et al exercise. In addition, weight loss is also recommended for
2012). In addition, balance impairments and reduced lower those with lower limb osteoarthritis who are overweight/
limb proprioception, which are linked to higher rates of obese (Conaghan et al 2008, Hochberg et al 2012, Zhang et
falling, have been demonstrated among people with lower al 2005, Zhang et al 2008). It is apparent that the treatments
limb arthritis (Sturnieks et al 2004). of exercise and weight loss for osteoarthritis require
behavioural changes and it is well known that these changes
Therapists should use validated outcome measures are difcult to initiate and maintain. Therapists therefore
including self-report measures of pain (such as a visual need to assist the patient in formulating achievable short-
analogue scale or numeric rating scale), physical function, and long-term goals and specic action plans.
and patient global rating of change, as well as physical
performance measures. Clinical practice guidelines from the Education
American Physical Therapy Association, specically for hip Patient education is a core component of hip osteoarthritis
osteoarthritis, recommend functional outcome measures, treatment as it is an indispensable element in promoting
such as the Western Ontario and McMaster Universities adequate self-management. Education delivery modes vary
(WOMAC) Osteoarthritis Index, the Lower Extremity and can include informal discussion with the health care
Functional Scale, and the Harris Hip Score, based on strong provider, provision of written materials, support groups,
evidence (Cibulka et al 2009). The Osteoarthritis Research websites, and structured self-management programs. Self-
Society International (OARSI) has recently recommended a management programs can also take various forms with
core set of physical performance measures for hip and knee differences in the content, mode of delivery (individual,
osteoarthritis (Dobson et al 2013). The set comprises the group-based, telephone, internet), program length, and
30-second chair stand test, a 40 m fast-paced walk test, and expertise of those delivering the material (lay leaders,
a stair climb test with additional tests including the Timed health care professionals). Self-management programs
Up and Go test and the 6-minute Walk test. typically include coping with behavioral change,
educational information, and self-management techniques.
Principles of management of hip Topics should cover: knowledge and understanding of
osteoarthritis osteoarthritis; the consequences of osteoarthritis on
function, activities, and participation; the pain experience;
Clinical guidelines advocate a combination of conservative the role of psychological factors; ways to deal with
non-drug and drug therapies for optimal hip osteoarthritis complaints caused by osteoarthritis; the importance of an
management (Zhang et al 2005). However, the vast majority active and healthy lifestyle including exercise, weight loss
of treatments currently available for osteoarthritis are and sleep; joint protection strategies; communicating with
drugs and/or surgery, and the current body of knowledge health providers; and stress management and relaxation.
reects this bias. A review of studies of hip osteoarthritis
treatment showed that 74% assessed surgical procedures, In general, however, the reported effects of isolated self-
19% evaluated drug therapies, with only 7% evaluating management programs for osteoarthritis have often been
conservative non-drug interventions (Zhang et al 2005). small or non-signicant. A meta-analysis published in 2003
Whilst drugs may relieve symptoms, effect sizes are involving 17 trials of all types of arthritis found an effect
small to modest at best and their toxicity/adverse event size of only 0.12 for pain and 0.07 for disability (Warsi et al
prole is unfavourable compared to conservative non- 2003). A more recent systematic review found ve studies
drug interventions (Zhang et al 2007). Indeed, all clinical specically involving people with hip or knee osteoarthritis
guidelines advocate conservative non-drug strategies for hip (Iversen et al 2010). The programs and outcome measures
osteoarthritis (Conaghan et al 2008, Hochberg et al 2012, were variable and the results generally showed no or modest
Zhang et al 2008). In particular, guidelines recommend benets. A large randomised trial in the UK primary
a focus on self-help and patient-driven treatments rather care setting involving 812 participants with hip or knee
than on passive therapies delivered by health professionals osteoarthritis found no difference in pain or function, but
(Zhang et al 2008). Treatment should be individualised reduced anxiety and improved self efcacy to manage
and patient-centered, involving shared decision making symptoms, between a 6-session self-management course
between the patient and physiotherapist taking into account including an educational booklet compared to administration
the patients preferences and wishes. Two recent systematic of the educational booklet alone (Buszewicz et al 2006). In
reviews have found that such patient-centred interaction another study, a telephone-based self-management program
enhances the therapeutic alliance (Pinto et al 2012a) and delivered via 12 monthly telephone calls to people with hip
improves patient satisfaction with care (Oliveira et al 2012). or knee osteoarthritis produced moderate improvements in
Other aspects to consider in guiding treatment include: pain compared to a health education control group (Allen et
hip factors (adverse mechanical factors, impairments, al 2010). A 24-month randomised trial in people awaiting
obesity, physical activity, dysplasia); general factors (age, total hip joint replacement found that a group who received
sex, co-morbidity); level of pain intensity and disability; a multidisciplinary information session 2 to 6 weeks before

Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 147
Invited topical review
Table 1. Summary of randomised controlled trials evaluating land-based and aquatic exercise for the management of hip osteoarthritis.
148

Reference Population Groups Follow-up Outcomes Results

Van Baar Hip OA (n = 71) 


 XFFLT oXFFL NJOTFTTJPO Baseline t VAS pain Exercise therapy associated with reduced pain
(1998) Knee OA (n = muscle strength, mobility, movement, 12 weeks t Observed disability and disability. Effect sizes were medium (0.58)
119) locomotion, and co-ordination and small (0.28), respectively
Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.

t Medication use
Both (n = 10) 2) Usual care by general practitioner

Hopman- Hip OA and knee 


 XFFLTPGIPNFCBTFEXL NJO Baseline t Pain Benets found for pain, quality of life,
Rock OA (n = 120 in session strengthening exercises for 6 weeks t Quality of life quadriceps strength, knowledge, self-efcacy,
(2000) total) IJQLOFF IFBMUIFEVDBUJPOQSPHSBN
t Muscle strength BMI, physically active lifestyle, and visits to
6 months t Range of motion physical therapist. Most effects moderate at
2) No treatment
t Activity restrictions post-test assessment and smaller at follow-up.
t Body mass index No effects found for range of motion and
t Knowledge of OA and functional tasks
self efcacy
t Health care usage

Foley Hip OA and knee 


 XFFLTPGXL NJOTFTTJPOoHZN Baseline t WOMAC In combined hip and knee OA group, gym
(2003) OA (n = 105 in program of strengthening exercises 6 weeks t Quadriceps strength program improved quads strength, walking
total) 
 XFFLTPGXL NJOTFTTJPOo t 6-minute walk test speed and self efcacy compared to control.
aquatic exercises t Adelaide Activities Aquatic exercise group was signicantly
Prole different from controls in 6-min walk test,
3) Fortnightly telephone calls t SF-12 physical component of the SF-12 and left
t Arthritis Self Efcacy quadriceps strength only.
t Drug use No program improved pain

Ravaud Hip OA (n = 741) 


 oXFFLTPGBUMFBTUXL NJO Baseline t VAS pain Home exercise did not lead to signicantly
(2004) Knee OA (n = sessions unsupervised home-based 24 weeks t WOMAC physical greater benets than usual care after 6 months
2216) exercise program to improve muscle function in pain or function in patients with hip OA
strength and range of motion t Global rating of status receiving concomitant nonsteroidal anti-
2) Usual medical care inammatory drugs

Tak (2005) Hip OA (n = 109) 


 XFFLTPGXL NJOTFTTJPOo Baseline t VAS pain Exercise had positive effect on pain (moderate
strengthening exercises, treadmill 8 weeks t Harris Hip Score effect at post-test and small effect at follow-
2) Usual care t Sickness Impact Prole up), hip function (small effect at post-test), self-
12 weeks t Groningen Activity reported disability (small effect at follow-up),
Restriction Scale BOEUJNFE6Q(PUFTU TNBMMFGGFDUBUGPMMPX
t Timed functional tests up)
t Quality of life

Cochrane Hip OA (n = 54) 


 XFFLTPGXL NJOTFTTJPOo Baseline t WOMAC *OUIFDPNCJOFEIJQLOFF0"HSPVQ UIFSF
(2005) Knee OA (n = aquatic exercise 52 weeks t SF-36 were small signicant benets of aquatic
258) 2) Usual care t EuroQol exercise on pain and physical function at one
18 months t Muscle strength year but these were not signicant at 18
t 8-foot walk months. There was a favourable cost-benet
t 4UBJSBTDFOUEFTDFOU outcome
t Heath care usage
Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.

Table 1. Summary of randomised controlled trials evaluating land-based and aquatic exercise for the management of hip osteoarthritis continued

Reference Population Groups Follow-up Outcomes Results

Rooks Hip OA (n = 63) 


 XFFLTPGXL oNJOTFTTJPO Baseline t WOMAC For the hip OA group, exercise signicantly
(2006) Knee OA (n = 45) aquatic, strengthening and exibility 6 weeks t SF-36 improved WOMAC physical function, SF-36
exercise t 1 rep max leg press scores and muscle strength compared with
8 weeks t Functional reach test controls pre-operatively but were not different
2) Control education via 2 mail outs and 3 post op
telephone calls t Timed Up and Go post-operatively
26 weeks
post op

Hinman Hip OA (n = 16) 


 XFFLTPGXL oNJOTFTTJPO Baseline t VAS movement pain *OUIFDPNCJOFEIJQLOFF0"HSPVQ BRVBUJD
(2007) Knee OA (n = 55) aquatic exercise 6 weeks t WOMAC exercise resulted in signicantly reduced pain
2) Control no aquatic exercise t AQoL and stiffness and improved physical function,
12 weeks t Physical activity hip muscle strength and quality of life with
t Muscle strength benets sustained at 12 weeks in the
t Timed Up and Go combined hip and knee OA group. However,
t 6-minute walk test the effect sizes were small
t Step test
t Patient global rating

Fransen Hip OA (n = 20) 


 XFFLTPGXL IPVSTFTTJPOT
 Baseline t WOMAC *OUIFDPNCJOFEIJQLOFF0"HSPVQ CPUI5BJ
(2007) Knee OA (n = 77) class-based Sun style Tai Chi 12 weeks t SF-12 Chi and aquatic exercise resulted in signicant

 XFFLTPGXL IPVSTFTTJPOT
 t DASS21 improvements in function with moderate effect
24 weeks t Patient global rating sizes (0.63 and 0.62) compared with control.
class-based aquatic exercise
t Timed Up and Go Aquatic exercise resulted in signicant
3) Wait list control t Stair climb test improvement in pain. Benets were generally
t 50-foot walk test sustained at follow-up. Aquatic exercise

Bennell: Physiotherapy management of hip osteoarthritis


improved in most other measures while Tai Chi
only improved in stair climb test

Fernandes Hip OA (n = 109) 


 XFFLTPGXLTVQFSWJTFETFTTJPOT Baseline t WOMAC No difference was found for pain at any time
(2010) plus access to gym strengthening, 16 weeks t SF-36 point. WOMAC physical function improved
functional and exibility exercises. Also t Physical activity signicantly at 40 weeks and 64 weeks
patient education 40 weeks compared to control
2) Patient education 3 group sessions 16 months
and one individual physiotherapy visit

Juhakoski Hip OA (n = 120) 


 XFFLTPGXL NJO Baseline t WOMAC No signicant effect of exercise on WOMAC
(2011) physiotherapist supervised group 12 weeks t SF-36 pain at any time point. Signicant improvement
session and 4 additional booster t Range of motion in WOMAC physical function at 6 and 18
sessions one year later as well as home 24 weeks t Extensor power months although size of effect may not be
FYFSDJTFTXLGPSZFBSTo 52 weeks t 6-minute walk test clinically meaningful. No difference in
strengthening and stretching exercises 18 months t 10-meter walk performance-based measures nor in total
plus usual care 24 months t Timed Up and Go health care system costs between groups
2) Usual care by general practitioner t Sock test
t Body mass index
t Direct healthcare costs
149
Invited topical review

surgery had less preoperative anxiety and pain compared

OA = osteoarthritis, VAS = visual analogue scale, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index, SF-36 = Short-form 36, DASS21 = Depression, Anxiety and Stress
to those receiving usual information in an information

affected joint added into the statistical model).

physical performance measures compared to


in WOMAC physical function, range of motion
Exercise group had signicant improvements

and patient global rating of change but not in

No signicant difference in primary outcome


leaet (Giraudet-Le Quintrec et al 2003). Nevertheless, the

total WOMAC between exercise and control


group in intention-to-treat analysis (or when

Exercise led to signicant improvements in


relatively small effect sizes of self-management programs
and patient education in isolation highlight that these should
form one component of an overall treatment plan.
Exercise
Exercise is an integral component of conservative non-
pharmacological management of osteoarthritis and is
pain or other outcomes

advised by clinical guidelines for all patients, irrespective


Table 1. Summary of randomised controlled trials evaluating land-based and aquatic exercise for the management of hip osteoarthritis continued

of disease severity, age, co-morbidity, pain severity, or


disability (Conaghan et al 2008, Hochberg et al 2012,
Zhang et al 2008). Among the limited randomised trials,
however, few have exclusively recruited people with
hip osteoarthritis. The details of the relevant trials are
Results

control
presented in Table 1. The studies vary particularly with
regard to the type, dosage, mode of delivery, and duration of
the exercise program. Most include strengthening exercises
alone or in combination with other types of exercise such
as those targetting range of motion or balance. One study
40 m self paced walk
Patient global rating

Patient global rating

investigated Tai Chi and ve investigated aquatic exercise.


30-sit to stand test

OMERACT-OARSI
Timed Up and Go
Range of motion

Although effective in people with knee osteoarthritis,


50-foot walk test

Pain medication
Sit-to-stand test

aerobic land-based exercise such as walking has not been


Scale, NRS = numeric rating scale, HADS = Hospital Anxiety and Depression Scale, AQoL = Assessment of Quality of Life

investigated in people with hip osteoarthritis. In most


responder
Pain NRS
WOMAC

WOMAC

studies the participants exercised under the supervision of


Outcomes

HADS
SF-36

a physiotherapist. The duration of the interventions ranged


Pain

from 6 to 12 weeks, except in two studies where it was 24


and 52 weeks.
t
t
t
t
t
t
t
t
t

t
t
t
t
t
t
t

Results of the studies to date suggest that treatment effects


Follow-up

26 weeks
52 weeks
18 weeks
Baseline

Baseline

of exercise are generally small, as presented in Figure 2.


9 weeks

9 weeks

A 2009 Cochrane review of land-based exercise for hip


osteoarthritis, combining the results of ve clinical trials,
demonstrated a small treatment effect for pain but no
benet in terms of improved self-reported physical function
1) 9 physiotherapist-supervised sessions, 7
1) 68 individual 30 min physio supervised

2) Usual care by a general practitioner and


in rst 9 weeks then 2 booster sessions

(Fransen et al 2009). The authors concluded that the


BUXFFLQMVTIPNFQSPHSBNXL
QMVTNJO XLBFSPCJDFYFSDJTFo
exercise exibility and strengthening

limited number and small sample sizes of the trials restricts


sessions over 8 weeks, daily home

the condence that can be attributed to these results and


neuromuscular control exercises
strengthening, stretching and

that further clinical trials with larger sample sizes and


walking, swimming or cycling

exercise programs specically designed for people with


other health care providers

symptomatic hip osteoarthritis need to be conducted.


Similar conclusions were reached by the authors of another
2009 systematic review where it was stated that there was
insufcient evidence to suggest that exercise therapy alone
2) Wait list control

can be an effective short-term management approach with


respect to pain, function, and quality of life (McNair et
al 2009). Conversely, the results of a 2008 meta-analysis
were more favourable in terms of the benets of exercise
Groups

for pain relief in hip osteoarthritis but studies using aquatic


programs were also included in the analysis as well as
specic hip data obtained from the authors of the studies
(Hernandez-Molina et al 2008). The review concluded that
Hip OA (n = 131)

Hip OA (n = 90)

therapeutic exercise, especially with specialised hands-on


Knee OA (n =

exercise training and an element of strengthening, is an


Population

efcacious treatment for hip osteoarthritis.


Since these systematic reviews, four additional high-
116)

quality, large, randomised trials of exercise have provided


data specic to hip osteoarthritis (Abbott et al 2013,
Fernandes et al 2010, French et al 2013, Juhakoski et al
Reference

2011), as presented in Table 1. In general these trials found


French

Abbott
(2013)

(2013)

non-signicant mean improvements in pain with various


types of exercise that are well short of the benchmark
minimum clinically important difference. When combined

150 Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Bennell: Physiotherapy management of hip osteoarthritis

A Pain

Study Standardised difference Weight Standardised difference


in means (95% CI) % in means (95% CI)
Van Barr 1998 1.04 (1.55 to 0.53) 12
Hopman-Rock 2000 0.14 (0.67 to 0.94) 6
Foley 2003 0.56 (1.56 to 0.43) 4
Tak 2005 0.07 (0.52 to 0.39) 14
Fransen 2007a 0.03 (0.98 to 1.04) 4
Fernandes 2010 0.19 (0.57 to 0.18) 18
Juhakoski 2011 0.26 (0.62 to 0.10) 18
French 2013 0.30 (0.69 to 0.08) 17
Abbott 2013b 0.21 (0.91 to 0.49) 7
Pooled 0.30 (0.51 to 0.09) 100
3.0 1.5 0 1.5 3.0
Favours exercise Favours control

B Physical Function

Study Standardised difference Weight Standardised difference


in means (95% CI) % in means (95% CI)
Van Barr 1998 0.36 (0.12 to 0.84) 13
Hopman-Rock 2000 0.25 (1.09 to 0.59) 6
Foley 2003 0.06 (0.67 to 0.79) 8
Tak 2005 0.18 (0.74 to 0.39) 11
Fransen 2007a 1.21 (2.29 to 0.13) 4
Fernandes 2010 0.13 (0.51 to 0.24) 17
Juhakoski 2011 0.41 (0.77 to 0.04) 18
French 2013 0.49 (0.91 to 0.07) 15
Abbott 2013b 0.35 (1.05 to 0.36) 8
Pooled 0.23 (0.45 to 0.00) 100
3.0 1.5 0 1.5 3.0
Favours exercise Favours control

Figure 2. Mean difference in change between land-based exercise and control groups with 95% CIs in studies
where this could be calculated specically for hip osteoarthritis patients for (A) pain and (B) physical function.
a
Although this trial also contained a hydrotherapy group, the data shown here represent only the comparison of
Tai Chi versus control. bCalculated using a subset of only hip osteoarthritis patients from a combined hip and
knee osteoarthritis trial.

with the earlier studies in a meta-analysis, an overall Aquatic exercise has been recommended as an exercise
treatment effect on pain was signicant but small (SMD option for people with hip osteoarthritis by the American
0.30, 95% CI 0.51 to 0.09) as presented in Figure 2a. In College of Rheumatology with the choice of land- or water-
contrast to pain, exercise appeared to have greater effects based exercise dependent on patient preference and ability
on physical function in the recent studies. With all studies to perform the exercises (Hochberg et al 2012). While
combined, the overall treatment effect on function was there are several randomised trials of aquatic exercise, it is
again signicant but small (SMD 0.23, 95% CI 0.45 to difcult to draw conclusions from these given their mixed
0.002) as presented in Figure 2b. In the study by Abbott hip and knee osteoarthritis samples.
et al (2013), a multimodal exercise program with initial
physiotherapist-supervised sessions and home exercises In addition to structured exercise, there is some evidence that
thrice weekly led to statistically and clinically signicant behavioural graded activity, an operant treatment approach,
improvements in physical function at 2 years (p = 0.005), may be effective in improving physical activity levels and
but with suboptimal, non-signicant effects on pain. Indeed reducing need for joint replacement in people with hip
the effect size for physical function was double that of pain osteoarthritis. The operant principles include reinforcement
(0.67 vs 0.33) (Abbott personal communication). Therefore, of healthy behaviors and withdrawal of attention to pain
evidence to date suggests that exercise has only modest behaviors to increase the time of performance of daily
benets that, in more recent studies, appear greater for activities. This approach has been evaluated in a Dutch
function than pain. cluster-randomised trial (Veenhof et al 2006). In this
study, 200 people with hip and knee osteoarthritis were

Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 151
Invited topical review

randomised into a behavioural graded activity program or in Figure 3. Numerous strategies have been suggested to
usual exercise therapy, delivered by physiotherapists. Both improve adherence to exercise in people with osteoarthritis
treatments consisted of a maximum of 18 sessions over including individualising and supervising the program,
12 weeks while the behavioural graded activity program educating patients about the disease process and the benets
also involved 5 to 7 booster periods. The results showed of exercise, regular monitoring and booster sessions, and
similar benets for pain and functional status from both use of behavioural principles (eg, goal setting, reinforcing
treatments at 23, 39, and 65 weeks as well as at 5 years appropriate behaviours, feedback, rewards, use of written
(Pisters et al 2010b). However, in participants with hip contracts, and motivational interviewing). However, a
osteoarthritis, signicantly fewer hip replacement surgeries relatively recent systematic review found few clinical trials
were performed in the behavioural graded activity group investigating the effectiveness of adherence strategies
compared with the usual exercise therapy group. A further in people with chronic musculoskeletal pain including
benet of the behavioural graded activity program was that osteoarthritis (Jordan et al 2010).
participants had signicantly better exercise adherence
and higher physical activity levels than those in the usual Manual therapy
exercise therapy group (Pisters et al 2010a). Given this Manual therapy is commonly used in clinical practice for
and the fact that it was no more costly than usual exercise hip osteoarthritis with surveys revealing that 96% of Irish
therapy (Coupe et al 2007), behavioural graded activity physiotherapists (French 2007) and over 80% of Australian
may be a useful treatment for people with osteoarthritis, physiotherapists (Cowan et al 2010) include it in their usual
particularly those with a relatively low level of physical management of this patient group. While UK clinical
function in whom greater benets were found (Veenhof et osteoarthritis guidelines (Conaghan et al 2008) and those
al 2007). from the American Physical Therapy Association (Cibulka
et al 2009) recommended manual therapy as an adjunctive
Adherence is a key factor inuencing the longer-term treatment for hip osteoarthritis, to date only three
effectiveness of exercise in people with osteoarthritis. randomised trials have evaluated the efcacy of manual
Although adherence to exercise is often good when therapy for this patient group (Abbott et al 2013, French
commencing a program, it typically declines over time. et al 2013, Hoeksma et al 2004), with two providing high
A complex array of factors can inuence adherence to quality evidence of benecial effects (Abbott et al 2013,
exercise programs in people with osteoarthritis including Hoeksma et al 2004).
intrinsic factors such as personal experience and individual
attributes and extrinsic factors such as the physical and One study involving 109 participants with hip osteoarthritis
social environment (Petursdottir et al 2010), as presented compared a 5-week manual therapy program with a

Extrinsic
Social environment
Social support
Socioeconomic status
Time
Social/cultural context
Provider beliefs
Patient-provider
relationship

Personal experience
Symptoms Physical environment
Perceived benefit of Weather
Exercise
exercising Availability of facilities
Quality of sleep Behaviour Access to care
Mental status Transportation
Exercise experience

Individual attributes
Motivation
Personality
Self-image
Knowledge
Exercise history
Physical capacity
Intrinsic

'JHVSF. Factors inuencing exercise adherence for people with osteoarthritis.

152 Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Bennell: Physiotherapy management of hip osteoarthritis

10 Usual care
(13.2 to 26.4)
5 Manual therapy Exercise Combined
(43.3 to 2.6) (27.1 to 2.3) (30.9 to 15.3)
Change in
WOMAC score 0

10

15

20

25

Figure 4. Mean (95% CI) change in WOMAC score from baseline to 1-year follow-up for
participants with hip osteoarthritis (n = 61) who did not have joint replacement surgery
during the randomised controlled trial by Abbott et al (2013). Positive scores indicate
worsening while negative scores indicate improvement. WOMAC = Western Ontario
and McMaster Universities Osteoarthritis Index.

therapist-supervised exercise program (Hoeksma et al While manual therapy appears to be benecial, there may
2004). The manual therapy comprised traction and high be specic subgroups of people with hip osteoarthritis who
velocity thrust traction manipulation of the hip joint as respond best to the intervention. Post hoc evaluation of the
well as muscle stretches of iliopsoas, quadriceps, tensor Hoeksma (2004) trial showed that the response to manual
fascia latae, gracilis, sartorius, and the hip adductors. The therapy was not inuenced by baseline levels of hip function,
exercise program aimed to improve hip range of motion, pain, and range of motion. However, participants with mild
muscle length, muscle strength, and walking endurance. or moderate hip osteoarthritis assessede radiographically
While both groups improved following treatment, the had better range of motion outcomes with manual therapy
success rate (dened as improved, much improved or than did those with severe osteoarthritis.
free of complaints) in the manual therapy group (81%) was
signicantly better than that in the exercise group (50%), From a clinical perspective, a range of manual therapy
(OR = 1.92, 95% CI 1.30 to 2.60). These benets in favour techniques can be used to treat people with hip osteoarthritis.
of manual therapy were maintained at a 29-week follow-up. These include soft tissue techniques and stretches,
mobilisation of accessory and physiological movements and
A more recent factorial study comparing the effects of manipulation. In addition, given the close link between the
manual therapy and exercise, alone or combined, against hip, lumbar spine, and sacroiliac joints, as well as the kinetic
usual care in 206 people with hip or knee osteoarthritis link with more peripheral joints, manual therapy to these
also conrmed the benets of manual therapy (Abbott et other joints is often applied to people with hip osteoarthritis
al 2013). The manual therapy was delivered in 9 sessions (7 (Abbott et al 2013). However, a chiropractic study in people
visits in the rst 9 weeks with 2 booster sessions at Week with mild to moderate hip osteoarthritis found no difference
16) and consisted of techniques to modify the quality and comparing a treatment regimen (9 treatments over a
range of motion together with a home program of up to six 5-week period) involving full kinetic chain manual and
joint range-of-motion exercises. Overall, and among the manipulative therapy plus exercise to that of one involving
participants with hip osteoarthritis only, manual therapy targeted hip manual and manipulative therapy plus exercise
alone resulted in greater reductions in pain and disability (Brantingham et al 2012). While there have been no reports
immediately after the treatment (effect size = 0.74) that of serious adverse events associated with the use of manual
were maintained at 1-year follow-up (Figure 4). However, therapy in patients with hip osteoarthritis, therapists should
the combination of exercise with manual therapy did not advise patients about the possibility of self-limiting post-
confer additional benets (effect size = 0.36) and in fact, treatment soreness.
the combination was generally less effective or at best no
more effective than either treatment alone. These results Hip joint protection strategies
are supported by those of another recent study that found While there are no clinical trials, interventions that reduce
no additive benet of combining manual therapy (involving adverse mechanical forces across a compromised hip joint
6 to 8 sessions over an 8-week period with up to 5 non- have face validity (Zhang et al 2005). The patient should
manipulative lower grade mobilisation techniques per be given appropriate joint protection advice guided by their
session) with exercise, except for patients satisfaction aggravating factors and functional problems. The main
with their clinical outcome (French et al 2013). It has been advice is to avoid prolonged postures and activities that
postulated that those in the combined therapy group might overload the joint.
spend less time on each intervention than do those who
receive only one intervention, which subsequently decreases Gait aids. During walking and stair ascent/descent, the
the effectiveness of both modalities (Abbott et al 2013). hip joint is subjected to considerable loading with data
from instrumented hip prostheses revealing hip loads of
approximately 250% of body weight (Bergmann et al

Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license. 153
Invited topical review

2001). Biomechanical studies demonstrate that use of a backward sloping seat. For sleeping in side lying, a pillow
cane in the contralateral hand signicantly reduces the load may be used between the legs and limiting the amount of
on the affected hip but increases load on the ipsilateral hip hip exion can be helpful. In supine, a pillow can be placed
(Ajemian et al 2004). Thus therapists should be mindful of under the knees. Prolonged standing should be avoided, as
the effects of cane use on the ipsilateral side particularly should standing in positions whereby weight is taken mostly
if the patient has bilateral symptoms. A recent case series on the affected side.
found that although initial use of a cane led to decreased
gait velocity and cadence in people with hip osteoarthritis Footwear and heel raises. Clinical guidelines recommend
compared to walking unaided, these were restored after that people with hip and knee osteoarthritis wear
practice. However, there was no signicant improvement in appropriate footwear (Zhang et al 2008). However, due to
hip pain and function with four weeks of cane use, although limited research, this recommendation is based solely on
inconsistent use may have contributed to this lack of benet expert opinion and what constitutes appropriate footwear
(Fang et al 2012). Patient education pointing out the value has not been specically dened for hip osteoarthritis.
of a gait aid in improving function and reducing load at the Intuitively, shoes with high heels should be discouraged
hip joint may assist with adherence. given evidence of higher hip joint moments associated with
walking in high heels (Simonsen et al 2012). Clinically,
Weight loss. Being overweight or obese may be a risk heel raises can be used to achieve pelvic obliquity and
factor for hip osteoarthritis (Jiang et al 2011). Greater body improve joint congruence in the setting of a functional
weight could have detrimental effects on joint structure by leg-length discrepancy. When pelvic obliquity is improved
placing additional loads on the lower limb during walking with adduction of the hip, a heel raise can be applied on
and other daily activities as well as via general increases in the affected leg while abduction of the hip can be achieved
substances that can directly degrade the joint or increase with a heel raise on the unaffected side. In an uncontrolled
joint inammation (Vincent et al 2012). Weight loss is study, use of a heel raise (maximum of 1.5 cm in height) for
recommended for those with lower limb osteoarthritis an average of 23 months was associated with substantial
who are overweight or obese, generally dened as a body decreases in pain in 33 people with hip osteoarthritis
mass index > 25 kg/m2 (Hochberg et al 2012, Zhang et (Ohsawa and Ueno 1997). While there is no evidence from
al 2005). There are no randomised trials of weight loss randomised trials supporting their use, heel raises are a
interventions in people with hip osteoarthritis. However, simple inexpensive self-management option that can be
a recent prospective cohort study found that an 8-month trialled for their effects in individual patients.
combined intervention of exercise and dietary weight loss
resulted in a 33% improvement in self-reported physical Electrotherapy
function as well as reduced pain (Paans et al 2013). This
The use of ultrasound, electromagnetic elds, and low-
provides preliminary evidence that exercise and weight loss
level laser therapy in clinical practice varies between
combined are effective in people with hip osteoarthritis.
countries. For example, surveys of physiotherapy practice
While the amount of weight loss needed for clinical benets
found that Irish therapists reported frequent use of thermal
is unknown, based on a limited number of trials in knee
agents and electrotherapy (French 2007), while Australian
osteoarthritis, patients should reduce body weight by at least
therapists reported infrequent use of these (Cowan et
5% using a combination of diet and exercise (Christensen
al 2010). Based on equivocal evidence or evidence of no
et al 2007). The Ottawa Panel guidelines specically
benet, electrotherapy is generally not recommended for
recommend reducing weight prior to the implementation of
weight-bearing exercise in order to maintain joint integrity the management of hip and knee osteoarthritis (Peter et al
and to avoid joint dysfunction (Brosseau et al 2011). 2011). However, instructing patients in the use of thermal
Incorporating weight management interventions into the agents has been recommended by the recent American
management of osteoarthritis is challenging as it requires College of Rheumatology clinical guidelines as a self-
considerable time and effort on behalf of both the patient management strategy (Hochberg et al 2012).
and the health provider. Furthermore, to be effective,
the health provider needs to be cognisant of behavioural Future directions
change techniques. Given the complexity of weight loss, Despite the relatively large amount of research into therapies
physiotherapists should work with an interdisciplinary team for hip osteoarthritis compared to many other areas of
including dietitians who have expertise in this area. physiotherapy, some questions remain unanswered and
Load carriage. Carrying loads increases the demands on clinical guidelines still resort to expert opinion for some
the hip abductor muscles and consequently increases hip recommendations. Evidence is required to guide some key
joint loading. Minimising the amount to be carried reduces areas of physiotherapy management. The role of exercise in
load on the hip, as does carrying the item in the ipsilateral managing hip osteoarthritis should be claried including
arm relative to the affected hip (Neumann 1999). Patients comparisons of the effects of different exercise modalities
should be given specic advice for daily activities such as (land-based, aquatic) and dosages. Manual therapy requires
using a shopping trolley rather than carrying a basket. further investigation given the seemingly different results
when it is delivered in isolation versus in combination with
Postural advice. People with hip osteoarthritis should exercise. Randomised controlled trials are also needed
be given advice about postures for sitting, sleeping and to evaluate other interventions such as gait aids, heel
standing. Chairs should be rm and of appropriate height wedges, and self-management programs. In parallel with
so that the patient sits without pain with the hip higher than this, investigation into the biomechanical, neuromuscular,
the knee. Pillows, cushions or folded towels can be used to and psychological mechanisms underpinning treatment
alter the chair height. Crossing the legs should be avoided. effects will help to better understand outcomes and rene
In the car, patients may sit on a folded towel to correct a treatments.

154 Journal of Physiotherapy 2013 Vol. 59 Australian Physiotherapy Association 2013. Open access under CC BY-NC-ND license.
Bennell: Physiotherapy management of hip osteoarthritis

In addition to assessing clinical effectiveness, economic Altman R, Alarcon G, Appelrouth D, Bloch D, Borenstein D,
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criteria for the classication and reporting of osteoarthritis
effectiveness of treatments. This is important in todays
of the hip. Arthritis & Rheumatism 34: 505514.
health care landscape to assist health policy makers in their
decision-making regarding funding. A recent systematic Arokoski MH, Haara M, Helminen HJ, Arokoski JP (2004)
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Acknowledgements: Kim Bennell is partly supported by Assessment 9: 114.
an Australian Research Council Future Fellowship. The Conaghan PG, Dickson J, Grant RL (2008) Care and
contribution of A/Professor Haxby Abbott and Dr Fiona management of osteoarthritis in adults: summary of NICE
Dobson in assisting with the exercise study data extraction guidance. BMJ 336: 502503.
is gratefully appreciated. Coupe VM, Veenhof C, van Tulder MW, Dekker J, Bijlsma
JW, Van den Ende CH (2007) The cost effectiveness of
Correspondence: Professor Kim Bennell. Centre for behavioural graded activity in patients with osteoarthritis
Health, Exercise and Sports Medicine, Department of PG IJQ BOEPS LOFF Annals of the Rheumatic Diseases 66:
Physiotherapy, The University of Melbourne, Australia. 215221.
Email: k.bennell@unimelb.edu.au Cowan SM, Blackburn MS, McMahon K, Bennell KL (2010)
Current Australian physiotherapy management of hip
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