Вы находитесь на странице: 1из 11

Clinical Hip Tests and a Functional Squat Test in Patients With Knee Osteoarthritis: Reliability, Prevalence of Positive Test

Findings, and Short-Term Response to Hip Mobilization


Amy V. Cliborne, MPT 1 Robert S. Wainner, PT, PhD, OCS, ECS, FAAOMPT 2 Dan I. Rhon, MPT 1 Coy D. Judd, MPT, ATC 1 Terrance T. Fee, MPT 1 Robert L. Matekel, PT, DSc, OCS, FAAOMPT 3 Julie M. Whitman, PT, DScPT, OCS, FAAOMPT 4

Study Design: One group pretest-posttest exploratory design. Objectives: Primary purposes of this study were to examine the short-term effect of hip mobilizations on pain and range of motion (ROM) measurements in patients with knee osteoarthritis (OA) and to determine the prevalence of painful hip and squat test findings in both patients with knee OA and asymptomatic subjects. The secondary purposes were to assess intrarater reliability and to determine whether fewer subjects experienced painful test findings following hip mobilization. Background: Conservative intervention, including manual physical therapy applied to the lower extremity, has been shown to reduce impairments associated with knee OA. Methods and Measures: One rater pair administered 4 clinical hip tests to 22 patients with knee OA (mean age, 61.2 years; SD, 6.1 years) and 17 subjects without lower extremity symptoms or known pathology (mean age, 64.0 years; SD, 7.9 years). Intrarater reliability was examined for each clinical test. Patients with knee OA and painful-hip and squat test findings received hip mobilizations. Pain and ROM responses for each test were dependent variables. Results: Intraclass correlation coefficients for all tests were greater than 0.87. Composite and individual test pain scores and ROM scores improved significantly following hip mobilization. All clinical test findings were more frequent in the group with knee OA, except for those of the FABER test, and the number of subjects with painful test findings following hip mobilization was reduced for all tests except the hip flexion test.
1 Student (at the time of the study), US Army-Baylor Graduate Program in Physical Therapy, Fort Sam Houston, TX. 2 Director of Research, US Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston, TX. 3 Assistant Chief, Physical Therapy, Madigan Army Medical Center, Fort Sam Houston, TX. 4 Affiliate Faculty, Department of Physical Therapy, Regis University, Denver, CO. The Institutional Review Board of Brooke Army Medical Center, Fort Sam Houston, TX, approved this study. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Air Force, US Department of the Army, or the US Department of Defense. Address correspondence to LtCol Robert S. Wainner, US Army-Baylor Graduate Program in Physical Therapy, 3151 Scott Road, Room 1303, Fort Sam Houston, TX 78234. E-mail: Robert.Wainner@cen. amedd.army.mil

Conclusions: Patients experienced increases in ROM, decreased pain, and fewer subjects had painful test findings immediately following a single session of hip mobilizations. Examination and intervention of the hip may be indicated in patients with knee OA. J Orthop Sports Phys Ther 2004;34:676-685.

Key Words: arthritis, lower extremity, manual therapy, provocation

steoarthritis (OA) is a disease process that causes progressive hyaline articular cartilage loss and may cause underlying bone to develop outgrowths, osteophytes, and bony sclerosis.8 OA is the most common joint disease reported worldwide, currently affecting over 21 million Americans, and is predicted to have the largest increase in new patient numbers of any disease in the United States by the year 2020.10,17,23 Prevalence estimates vary. Most individuals have some degree of OA

676

Journal of Orthopaedic & Sports Physical Therapy

by age 65, and approximately 80% have radiographic evidence of OA by age 75.3,22 The associated social and economic costs of OA are staggering. In 1994, the US Bureau of Labor Statistics and the US National Center for Health Statistics reported medical expenses and job-related OA costs to be between $3.4 to $13.2 billion per year.14 OA most commonly affects the knee, and mild to moderate disability affects up to 10% of adults over the age of 55.3,19 OA can be managed conservatively or surgically. Conservative intervention is primarily geared toward pain relief, improvement of function, and minimization of deformity.14 Manual physical therapy and exercise have been shown to decrease pain, improve function, and delay or eliminate the need for total knee arthroplasty.7,18 In a recent randomized clinical trial, Deyle et al7 assessed the effect of a multimodal intervention program for patients with knee OA, which included manual therapy interventions to the lumbopelvic region and lower extremity, in addition to exercise and a walking program. Manual therapy procedures included joint manipulation and mobilization techniques administered to the spine, mobilization techniques to the joints of the lower extremities, and manual and assisted stretching to both the trunk and lower extremities. Those patients treated with manual physical therapy and exercise had significant improvements in both the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and in the 6-minute walk distance test, and fewer performed or requested total knee arthroplasties at a 1-year follow-up, than those in a control group receiving placebo ultrasound intervention and a walking program. Because this multimodal intervention approach is efficacious and involves minimal risk (no complications were reported in the Deyle et al7 study), manual therapy and exercise should be strongly considered as components of an intervention program for this patient population. Knee pain has been reported to arise from the hip and/or lumbar spine regions in a number of different conditions.5,15 Given the relationship between the more proximal joints of the hip and spine and knee symptoms, it is feasible that hip impairments may be associated with the symptoms experienced by patients with knee OA. In addition, gait alterations due to knee pain may result in painful impairments and functional limitations of the hip. Indeed, hip joint impairments were among those treated in the Deyle et al7 study, but the relative contribution of hip joint mobilization to the observed intervention effect was not quantified. However, based on our clinical observations, hip joint impairments are frequently present in patients with knee OA. Understanding the relationship between hip joint impairments and knee OA could help to focus therapists manual therapy and exercise interventions and thereby potentially in-

crease intervention effectiveness and reduce the overall cost associated with the management of patients with knee OA. For this study, selected tests of the clinical examination used to identify hip impairments were the FABER (flexion, abduction, external rotation), hip scour, hip flexion, and functional squat tests.4,11,13,24 However, the measurement properties of these tests have not been well studied or studied at all. Hip flexion range of motion (ROM) and pain with hip flexion were reported by Altman et al1 to be sensitive (sensitivity, 0.96 and 0.80, respectively) for hip arthrosis. The FABER test has been shown to be reliable for assessing sacroiliac dysfunction.13 In a study that correlated radiographic changes of the hip and clinical examination findings, Theiler24 measured the distance between the knee and table when performing the FABER test and reported a correlation of 0.54, which was higher than the correlation obtained for any other ROM variable except hip extension. No information was located describing the measurement properties of the FABER test in patients with hip or knee pain. The functional squat test has been advocated as a useful method for assessing knee pain and function, but its value for assessing hip impairments has not been studied.4,11 Reliability and validity information is not available for the hip scour test. Primary purposes of this study were to examine the short-term effect of hip mobilizations on pain and ROM measurements in patients with knee OA, and to determine the prevalence of painful hip and squat test findings in both patients with knee OA and asymptomatic subjects. The secondary purposes were to assess intrarater reliability and whether fewer subjects experienced painful test findings following hip mobilization.

RESEARCH REPORT

METHODS Subjects
Patients with knee OA and subjects without knee OA or lower extremity complaints were recruited from a convenience sample at the Physical Therapy clinic at Brooke Army Medical Center (BAMC). Twenty-two patients with knee OA (mean age, 61.2 years; SD, 6.1 years), and 17 subjects without lower extremity symptoms or known pathology (mean age, 64.1 years; SD, 7.9 years) were enrolled. Demographics of each group are listed in Table 1. An attempt was made to match asymptomatic subjects to the subjects with knee OA for age and gender as closely as possible. Patients with knee OA were referred for participation by physical therapists from BAMC, Fort Sam Houston, TX, and Wilford Hall Medical Center, Lackland Air Force Base, TX. Inclusion criteria for
677

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

TABLE 1. Descriptive data on patients with knee osteoarthritis (OA) and the asymptomatic group. Knee OA Group Males (11) Age Age Age Age (y)* 50-59 (n) 60-69 (n) 70-79 (n) 61.8 7.5 (51-75) 4 5 2 Females (11) 60.9 4.6 (52-66) 3 8 0 Asymptomatic Group Males (12) 65.6 7.1 (51-75) 2 7 3 Females (5) 60.4 9.4 (51-73) 3 1 1

* Mean SD and range in parentheses.

patients with knee OA were based on the presence of the following clinical criteria described by Altman et al,2 which are sensitive (sensitivity, 0.84) and specific (specificity, 0.89) for knee OA: (1) knee pain, (2) greater than 50 years of age, (3) palpable bony enlargement, (4) morning stiffness less than 30 minutes. Asymptomatic subjects were also recruited from BAMC and a local assisted-living facility by means of flyers and word of mouth. Knee pain or pain in any of the other lower extremity joints was an exclusion criterion. Patients with knee OA and asymptomatic subjects were excluded from the study if they had: (1) a hip arthroplasty, (2) a cortisone injection to the hip or knee within the previous 30 days, (3) low back pain as a primary complaint or low back pain radiating to or below the knee, or (4) any lower extremity condition that prevented the patient from performing a one-quarter squat. Patients were required to be eligible for military health care and have sufficient English language skills to comprehend all explanations of the study. The Institutional Review Board of BAMC approved the study protocol. All patients gave informed consent prior to participating in the study. No external funding was received for this study.

Procedure
Prior to data collection, 4 student therapists responsible for data collection underwent two 1-hour training and practice sessions for administering the clinical tests and measures used in this study, and two 2-hour training and practice sessions for administering the hip mobilization interventions. A faculty investigator determined when the student therapists performance of all study procedures satisfactorily met the operational definition of each procedure as defined in Appendices A and B. Two student physical therapists administered all test procedures. The examiners were not blinded to the subjects respective groups. The more involved or painful lower extremity was tested in patients with knee OA, while the dominant lower extremity (that used to kick a ball) of asymptomatic subjects was tested. Pain levels and ROM were assessed for each test procedure. A gravity inclinometer (CE 0120; MIE Medical Research, Ltd, Leeds, UK) was used to
678

measure ROM for the functional squat, FABER, and hip flexion tests. The reliability of these measurements using a gravity inclinometer for hip ROM and the FABER and squat test has not been reported. All study participants were asked to rate the amount of pain experienced with each test by marking an 11-point numeric pain rating scale (NPRS). The NPRS was anchored by 0 (no pain) and 10 (worst pain imaginable). This scale has been demonstrated to be reliable, generalizable, and internally consistent in measures of clinical and experimental pain sensation intensity.12,21 Pain measurements were recorded for each test immediately following test termination. The functional squat, FABER, hip flexion, and hip scour tests have been operationally defined in Appendix A. Both pain and ROM measurements were obtained for all tests except the hip scour test, for which only pain ratings were obtained. The primary examiner (examiner 1) performed all of the tests in a random order and was blinded to all goniometric measurements and NPRS ratings. Examiner 1 positioned the gravity inclinometer in the appropriate position for each applicable test, with the face of the inclinometer toward examiner 2. Examiner 2 zeroed the inclinometer, recorded inclinometer measurements, gave the patient an NPRS scale to record their pain rating after each test procedure, and documented the location of pain, if applicable. Patients were given a 2-minute rest period after the 4 test procedures were completed. All 4 tests were then readministered in the identical order, as performed the first time. After this portion of testing, any patients with knee OA who did not have 1 or more painful test findings and all subjects in the asymptomatic group were considered to have completed the study. A painful test finding in this study was defined as pain experienced during the test, as rated by the patient on the NPRS scale to be equal to or greater than 1. Patients with knee OA who had 1 or more painful test findings were treated with a series of hip oscillatory mobilizations based on test findings and location of pain. Patients received a combination of mobilizations from the following techniques: caudal glide (CG), anterior-posterior (AP) glide, posterior-anterior (PA) glide, and PA glide with the hip in flexion, abduction, and external rotation (FAE). Hip mobilizations procedures were administered using grade III

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

and IV movements, with the procedure intensity dictated by patient response.16 Mobilization procedures are depicted and operationally defined in Appendix B. If a subject with knee OA felt pain in the anterior hip or groin area with any of the tests, the subject received both PA and FAE mobilizations. Conversely, if pain was present in the hip or buttock posteriorly, then CG and AP mobilizations were administered. Patients with knee OA experiencing hip pain both anteriorly and posteriorly received two 30-second bouts of all 4 mobilization procedures. For patients receiving only 2 mobilization procedures, four 30second bouts were administered. All patients, therefore, received 2 minutes of hip mobilization. Following the 2 minutes of hip mobilizations, the patient was immediately retested on all 4 test procedures by the same examiner, as previously described. The examiner remained blind to the initial measurements. If the patient documented no pain on the NPRS scale for any procedure, that subjects participation in the study was complete after documenting the ROM for each test. If the patient documented pain for any of the tests, the mobilization techniques were administered again, based on the criteria previously described. Following the second iteration of mobilizations, the 4 test procedures were repeated, pain and ROM measurements were again obtained in the same manner as previously described, and the subjects participation in the study was complete, regardless of the presence or absence of pain.

tion, ROM measurements and NPRS ratings for all 4 test procedures were summed, respectively, for each patient to yield composite pain and ROM scores. Preintervention and postintervention composite scores were then analyzed using a 1-way repeatedmeasures multivariate analysis of variance (MANOVA). Subsequent post hoc univariate 1-way repeated-measures analysis of variance procedures were performed for composite pain and ROM scores. Differences in pain and ROM for individual tests before and after mobilization were analyzed using 2-tailed paired t tests. Because clinicians frequently make dichotomous judgments regarding test results based on the presence or absence of pain, a McNemars analysis was performed for each test to determine if a reduction of painful findings (presence or absence of pain) occurred in patients with knee OA following hip joint mobilizations. An alpha level of .05 was used in all analyses.

RESULTS
Baseline pain and ROM values for each group are listed in Table 2. Of the 22 patients with knee OA, 1 had negative findings for all 4 hip tests and was included in analyses of prevalence and reliability only.
TABLE 2. Baseline pain (mean SD) and range of motion (ROM) values by group. Group OA (n = 22) Asymptomatic (n = 17) 0.2 0.4 26.1 5.2 0.8 1.1 71.7 8.9 0.1 0.2 37.4 11.2 0.6 .09

RESEARCH REPORT

Data Analysis
Data were analyzed using SPSS for Windows, Version 10.1 (SPSS, Inc, Chicago, IL). Descriptive statistics were computed for subject demographics, as well as pain and ROM results for individual tests. Intrarater reliability of pain and ROM measurements for each of the 4 tests was calculated using an intraclass correlation coefficient (ICC3,1). The difference in the prevalence of painful test findings between patients with knee OA and asymptomatic subjects was analyzed using a Pearsons chi-square analysis. To assess the overall effect of hip mobiliza-

Functional squat Pain* ROM FABER Pain* ROM Hip flexion Pain* ROM Hip scour Pain*

1.7 2.0 25.8 7.8 2.1 2.1 72.1 10.7 1.6 2.5 34.8 14.1 2.9 1.6

* Pain was measured with an 11-point numeric pain rating scale. Hip flexion ROM measurements were taken from starting position of 90 hip flexion.

TABLE 3. Intraclass correlation coefficients (ICC3,1), and their 95% confidence interval (95% CI) and standard error of measurement (SEM) for pain and range of motion associated with each of the clinical tests. Pain (NPRS)* Test Functional squat FABER Hip scour Hip flexion ICC3,1 0.90 0.87 0.87 0.87 95% CI 0.81-0.95 0.78-0.94 0.76-0.93 0.75-0.93 SEM 0.48 0.58 0.57 0.43 ICC3,1 0.92 0.96 0.94 Range of Motion 95% CI 0.84-0.96 0.92-0.98 0.89-0.97 SEM 1.9 2.9 1.9

* Measured using an 11-point numeric pain rating scale. Range of motion was not obtained for the hip scour test. In degrees.

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

679

100% 90% 80% 70% 60% 50% 40% 40% 30% 30% 20% 10% 0% Functional Squat FABER Hip Flexion Hip Scour 15% 10% 55% 45% 68% Asymptomatic Symptomatic 91%

FIGURE 1. Comparison of prevalence of positive painful hip tests between groups. A significant difference (P .05) is found between groups for all tests except the FABER test.

Intrarater Reliability of Clinical Hip Tests and the Functional Squat Test
Intrarater reliability was determined from 35 of the 39 participants who completed the study. An alternate examiner performed the procedures on 4 subjects; therefore, data for these subjects was not included in the analysis. Reliability of ROM measurements was excellent for the functional squat (ICC, 0.92), FABER (ICC, 0.96), and hip flexion (ICC, 0.94) tests. Good intrarater reliability was demonstrated with NPRS ratings of pain with the functional squat (ICC, 0.90), FABER (ICC, 0.87), hip scour (ICC, 0.87), and hip flexion (ICC, 0.87) tests. ICCs, along with their 95% confidence intervals (95% CI) and the standard error of measurements (SEM), for each test are listed in Table 3.

Percentage of Individuals With Positive Tests

The Effect of Hip Mobilizations on Composite Pain and ROM


A significant difference in preintervention to postintervention pain and ROM was found (Wilks lambda = 0.368, F = 16.31, P .001). For both subsequent univariate ANOVA procedures, Mauchleys test was significant, indicating the assumption of sphericity was violated. Therefore, Greenhouse-Geisser corrected P values were used to determine significance. Univariate analyses revealed that both changes in composite pain ratings (F = 13.5, P = .002) and composite ROM measurements (F = 11.5, P = .003) were significant. Preintervention and postintervention mean composite ROM and pain data are shown in Figure 2. The mean change in composite pain rating for patients with knee OA with initial painful test ratings was a decrease of 5.1 points (SD, 4.8 points) and the mean change in composite ROM was an increase of 12.4 (SD, 17.0).

Prevalence of Painful Test Findings in Patients With Knee OA and Asymptomatic Subjects
Significant differences were detected in the prevalence of painful test findings in patients with knee OA versus asymptomatic subjects for the scour test (P .001), squat test (P = .01), and hip flexion test (P = .02). There was no difference in the prevalence of painful findings on the FABER test between the groups (P = .13). Results are depicted graphically in Figure 1.
680

Changes in Individual Test Findings Before and After Intervention


Preintervention and postintervention differences in pain and ROM for individual tests are listed in Table 4. The NPRS scores for all tests were significantly reduced following mobilization, with the largest mean reduction occurring in the functional squat test (2.1

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

160 150 140 130 120 110 100 0

25 20 15 10 5 0

Mean Composite Pain (NPRS)

Mean Composite ROM (deg)

points). A significant increase in ROM was found for the functional squat and hip flexion tests but not for the FABER test. The presence of painful findings during testing was significantly reduced in patients receiving hip joint mobilizations for all tests except for the hip flexion test, in which 10 of 21 patients (48%) had pain before intervention, compared with 6 (29%) after intervention (P = .22). One patient who did not have pain with the hip flexion test before intervention experienced pain after intervention. During the functional squat test, 12 of 21 patients (57%) experienced pain before intervention; 4 (19%) had pain after intervention (P = .008). Unfortunately, the location of pain with the functional squat test was not documented, so it is unclear whether the origin of this pain was from the hip region, arthritic knee, or other location. With the FABER test, 15 of 21 patients (71%) had pain before and 8 (38%) had pain after intervention (P = .016). With the hip scour test, 20 of 21 patients (95%) had pain before intervention compared with 10 (48%) after intervention (P = .002). These results are depicted in Figure 3.

hip region, which could be a contributing source of symptoms and may need to be considered in intervention strategies. The hip mobilization procedures in this study were administered based on the presence of painful hip test findings. The largest mean reduction in pain following mobilization occurred in the squat test (2.1 points) and the largest mean increase in ROM occurred in hip flexion (8.2). The number of patients with painful findings following a single intervention session of hip mobilizations was significantly reduced for all tests except the hip flexion test. A possible explanation why a significant reduction in the number of individuals with painful hip test findings was not observed may be due to the fact
170 ROM Pain 30

RESEARCH

DISCUSSION
The intrarater reliability of the functional squat, hip scour, FABER, and hip flexion tests were excellent (ICC, 0.91) for ROM and good (ICC, 0.87) for assessing pain in all tests. The hip tests, as operationally defined in this study, appear to be reliable methods for assessing the hip by a single examiner. Comparison of our results with those of previous authors is difficult due to the differences in test operational definitions24 or patient population.4,11,13 Significantly more patients with knee OA had pain with the clinical tests, as compared to the asymptomatic subjects for all tests except the FABER test (64% in patients with knee OA versus 40% in asymptomatic subjects). It appears that the FABER test is positive in a large percentage of asymptomatic subjects and may not be associated with knee OA. Given the association between painful test findings of the hip joint and the presence of knee OA, further work is necessary to assess the diagnostic measurement properties of these tests and to determine which tests may be useful in the differential diagnosis of pain-generating structures in patients with knee OA. It is not known whether hip impairments in patients with knee OA are independent from, or a result of, gait alterations and altered knee function. Given the increased prevalence of painful hip test findings in patients with knee OA, it follows that evaluation of the hip joint may be beneficial in this patient population. The results of a hip examination in this population may identify impairments of the

Preintervention

Postintervention

REPORT

FIGURE 2. Effect of hip mobilization on mean composite range of motion (ROM) and pain. Pain was measured using an 11-point numeric pain rating scale for each test. A significant decrease in pain and a significant increase in ROM is noted post intervention.

TABLE 4. Premobilization and postmobilization numeric pain rating scale (NPRS)* and ROM measurements (mean SD) in patients with knee osteoarthritis Premobilization Functional squat Mean NPRS (n = 12) Mean ROM (n = 21) FABER Mean NPRS (n = 15) Mean ROM (n = 21) Hip flexion Mean NPRS (n = 10) Mean ROM (n = 21) Hip scour Mean NPRS (n = 20) 2.9 1.8 25.8 7.8 3.0 1.9 72.1 10.7 3.1 2.7 34.8 14.1 2.6 3.8 Postmobilization 0.8 1.4 28.2 7.3 1.8 1.2 75.7 8.6 1.3 1.5 43.0 12.8 1.7 2.0

* Pain was measured with an 11-point numeric pain rating scale. Only patients with initial pain scores 1 for the respective test procedures were included; ROM not assessed for hip scour test. Indicates a significant difference between pre and post intervention P .01. Indicates a significant difference between pre and post intervention P .05.

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

681

100% Percentage of Individuals With Positive Tests 90% 80% 71% 70% 60% 50% 40% 30% 20% 10% 0% Functional Squat FABER Hip Flexion 19% 38% 29% 57% 48% Before mobilization After mobilization

95%

48%

Hip Scour

FIGURE 3. Comparison of prevalence of positive provocative hip tests before and after intervention with hip mobilizations. All after mobilization values are significantly lower (P .05) except for hip flexion.

that, although a significant reduction in pain was experienced, hip ROM also increased and could have resulted in additional joint stress that prevented the abolition of a pain response. It is unknown whether this short-term reduction in pain and impairment corresponds to an improvement in function or disability. Further research should address the cause and effect relationship of hip mobilization and changes in long-term function and disability. This study used a single-group, pretest-posttest design, which has several inherent limitations and threats to internal validity. Our study had no comparison group, so a cause-and-effect relationship between hip mobilization and pain and ROM outcomes cannot be made. We focused on the short-term change in impairments in this study. Although our short follow-up time guards against maturation and history effects, it limits any generalizations of outcome to meaningful time frames beyond the immediate postmobilization period. Because of the uncertain relationships between impairments and functional limitations, it is unknown whether our results would affect more patient-oriented outcomes such as those of the WOMAC or timed walking tests. Another limitation to this study was its lack of examiner blinding to subject categor y (knee OA or asymptomatic), which could have biased the examiners testing and measurement. In addition, we were unable to adequately match the knee OA and asymptomatic groups for age or sex, and the patients with knee OA in our study appeared to have a mild
682

degree of OA, based on their ROM and pain ratings. Due to the relatively low pain scores and minimally impaired ROM of patients in our study, there may be a substantial floor effect present that could have minimized the effect size of hip mobilizations. However, our findings do suggest that patients with knee OA may benefit from examination and intervention of the hip. In patients with knee OA, hip ROM improved, pain decreased, and fewer patients had painful hip test findings following hip mobilization. This suggests that hip mobilization may be a helpful adjunct to more traditional approaches to management of knee OA. The results of this study are consistent with those reported by Deyle et al,7 who found that manual physical therapy (including mobilizations to the ankle, knee, hip, and back), in addition to exercise, improved WOMAC scores and 6-minute walk time more than a placebo ultrasound intervention over an 8-week period. It was observed in this study that some patients responded dramatically to hip mobilization, while others did not, which indicates that a subgroup of patients who respond favorably to mobilization might exist. A next logical step would be to develop a clinical prediction rule to determine which patients with knee OA respond best to hip mobilization, as has been recently described for manipulative intervention in patients with low back pain.9 A subsequent randomized controlled clinical trial would include patients with knee OA likely to benefit from hip mobilization and would compare a multimodal inter-

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

vention regimen, which would include hip mobilization, to competing interventions. Given the results of this study and the reported association between hip dysfunction and low back pain, it would also be of interest to replicate this study using patients who have low back pain as the condition of interest.6,20

CONCLUSIONS
The clinical hip tests as operationally defined in this study appear to have acceptable intrarater reliability for obtaining pain and ROM measurements. Examination of the hip in patients with knee OA may be indicated, based on the increased prevalence of painful clinical hip test findings in this study. The improvements in both composite and individual pain and ROM scores, as well as a reduction in the number of patients with painful hip test findings, suggest that hip mobilization may be a beneficial component of intervention for patients with knee OA who have positive hip clinical tests.

REFERENCES
1. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514. 2. Altman R, Asch E, Bloch D, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee.Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29:1039-1049. 3. Birchfield PC. Osteoarthritis overview. Geriatr Nurs. 2001;22:124-130; quiz 130-121. 4. Bockrath K, Wooden C, Worrell T, Ingersoll CD, Farr J. Effects of patella taping on patella position and perceived pain. Med Sci Sports Exerc. 1993;25:989-992. 5. Chang WS, Zuckerman JD. Geriatric knee disorders, Part II: Differential diagnosis and treatment. Geriatrics. 1988;43:39-42, 44, 46 passim. 6. Cibulka MT. Low back pain and its relation to the hip and foot. J Orthop Sports Phys Ther. 1999;29:595-601. 7. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-181.

8. Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med. 2000;133:635-646. 9. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843. 10. Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ. Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med. 2000;133:321-328. 11. Gerrard B. The patello-femoral pain syndrome: a clinical trial of the McConnell programme. Aust J Physiother. 1989;35:71-80. 12. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994;58:387-392. 13. Kenna C, Murtagh J. Patrick or fabere test to test hip and sacroiliac joint disorders. Aust Fam Physician. 1989;18:375. 14. Leigh JP, Seavey W, Leistikow B. Estimating the costs of job related arthritis. J Rheumatol. 2001;28:1647-1654. 15. Magee DJ. Orthopedic Physical Assessment. Philadelphia, PA: W.B. Saunders Company; 1997. 16. Maitland G. Peripheral Manipulation. London, UK: Butterworth & Co; 1986. 17. March LM, Bachmeier CJ. Economics of osteoarthritis: a global perspective. Baillieres Clin Rheumatol. 1997;11:817-834. 18. Marks R, Cantin D. Symptomatic osteo-arthritis of the knee: the efficacy of physiotherapy. Physiother. 1997;83:306-312. 19. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis. 2001;60:91-97. 20. Porter JL, Wilkinson A. Lumbar-hip flexion motion. A comparative study between asymptomatic and chronic low back pain in 18- to 36-year-old men. Spine. 1997;22:1508-1513; discussion 1513-1504. 21. Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain. 1994;56:217-226. 22. Schlesinger N. Osteoarthritis: pathology, epidemiology, and risk factors. Phys Med Rehabil. 2001;15:1-9. 23. Simon LS. Osteoarthritis: a review. Clin Cornerstone. 1999;2:26-37. 24. Theiler R, Stucki G, Schutz R, et al. Parametric and non-parametric measures in the assessment of knee and hip osteoarthritis: interobserver reliability and correlation with radiology. Osteoarthritis Cartilage. 1996;4:3542. 25. Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine. 1992;17:617-628.

RESEARCH REPORT

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

683

Appendix
A

APPENDIX A Operationally Defined Test Procedures


For each test described below, a positive test was considered to have occurred if subjects experienced pain (numeric pain rating scale 1) associated with their condition during the test. Hip Flexion Test With the subject in the supine position, the primary examiner passively flexed the hip to 90 and zeroed the inclinometer at the apex of the knee. The hip was then flexed until the opposite thigh began to rise off of the table (Figure 4A). Hip Scour Test The hip scour test was performed with the patient lying in the supine position while the primary examiner flexed and adducted the hip until resistance to the movement was detected. The examiner then maintained flexion into resistance and moved the hip into abduction, then brought the hip through 2 full arcs of motion. If the patient reported no pain, then the examiner repeated the test while applying long-axis compression through the femur (Figure 4B). Range of motion was not assessed with this test. FABER Test The FABER test was administered with the subject in supine, the heel of the lower extremity to be tested placed over the opposite knee. The hip joint was passively externally rotated and abducted by placing pressure over the ipsilateral knee, while stabilizing the contralateral innominate. After being zeroed against a wall, the inclinometer was placed on the medial tibia of the lower extremity to be tested, just distal to the medial tibial condyle (Figure 4C). The range of motion measurement was taken at the point of maximal passive resistance or at the point where the subject stopped the test secondary to pain. Functional Squat Test This test was considered to be a provocative test that also served as a measure of function. To perform the functional squat test, patients were asked to stand with their feet pointed forward at a comfortable distance apart. The inclinometer was placed on the tibia of the lower extremity to be tested just distal to the tibial tuberosity and zeroed. The subjects were then asked to bend the knees and bring the buttocks straight toward the heels without bending forward or lifting their heels off the ground (Figure 4D). The range of motion measurement was taken at the greatest range of motion at which the subject was able to maintain the proper form, or at the point where the subject stopped the test secondary to pain.
684

FIGURE 4. (A) Hip flexion test, (B) hip scour test, (C) FABER test, (D) functional squat test.

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

APPENDIX B Operationally Defined Hip Mobilization Procedures


Caudal Glide With the patient supine a mobilization belt is placed as proximally along the thigh as possible. The patients affected hip is flexed slightly past 90 until slight resistance is felt. The therapist imparts a caudally directed, passive accessory glide force to the proximal hip. The amount of hip flexion, rotation, and abduction or adduction may be adjusted to find the position that most effectively stretches the hip joint (Figure 5A). Anterior-Posterior Glide With the patient supine, the foot on the side of the affected hip is brought across midline to the lateral side of the opposite knee. A mobilizing force is imparted through the long axis of the femur using passive accessory glides. The amount of hip flexion may be adjusted to find the position that most effectively stretches the hip (Figure 5B). Posterior-Anterior Glide With the patient prone and the knee flexed, the therapist supports the patients thigh as illustrated. A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from posterior to anterior. The amount of internal and external rotation is varied to find the position that most effectively stretches the hip (Figure 5C). Posterior to Anterior Mobilization in Flexion, Abduction, and External Rotation With the patient prone, the affected hip is positioned using a combination of flexion, abduction, and external rotation. The position is adjusted to optimize the stretch felt by the patient. The therapist contacts the femur just distal to the greater trochanter. A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from posterior to anterior. A pillow may be placed under the subjects abdomen if the position is not initially tolerated (Figure 5D).

RESEARCH

REPORT

FIGURE 5. (A) Caudal glide, (B) anterior-posterior glide, (C) posterior-anterior glide, (D) posterior to anterior mobilization in flexion, abduction, and external rotation.

J Orthop Sports Phys Ther Volume 34 Number 11 November 2004

685

ERRATA
CORRECTION: ALTMANS CRITERIA FOR OSTEOARTHRITIS OF THE HIP AND KNEE
n 1991, Altman and colleagues1 published criteria for classification of osteoarthritis of the hip, of which one criterion was less than or equal to 60 minutes of morning stiffness. This criterion was erroneously published by the JOSPT as greater than 60 minutes in TABLE 3 of the article by Cibulka and Threlkeld3 (August 2004) and in TABLE 1 of the article by MacDonald et al5 (August 2006). Also, one of the criteria for classification of idiopathic osteoarthritis of the knee, as published by Altman et al2 in 1986, was less than 30 minutes of stiffness. This was incorrectly published as stiffness greater than 30 minutes in the text of the article by Cliborne et al,4 in the November 2004 issue of the JOSPT. We apologize for these errors and have corrected reprints of the articles, which are available to members and subscribers for download on the JOSPT web site (www.jospt.org).
ment of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29:1039-1049. 3. Cibulka, MT, Threlkeld, J. The early clinical diagnosis of osteoarthritis of the hip. J Orthop Sports Phys Ther. 2004;34(8):461-467. 4. Cliborne AV, Wainner RS, Rhon DI. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test ndings, and short-term response to hip mobilization. J Orthop Sports Phys Ther. 2004. 34(11):676-685. 5. MacDonald CW, Whitman JM, Cleland JA, Smith M, Hoeksma HL. Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: a case series. J Orthop Sports Phys Ther. 2006;36(8):588-599.

REFERENCES
1. Altman R, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classication and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:505-514. 2. Altman R, Asch E, Bloch D, et al. Develop-

journal of orthopaedic & sports physical therapy | volume 37 | number 9 | september 2007 |

573

Вам также может понравиться