March Journal Club Case

[Justin Bittner]

Referring diagnosis: Low Back Pain, Scoliosis
Outcome Measures: ODI – 38% (discharge score = 8%)

Subjective: Pt is a 66 y/o female librarian. Reports standing and walking most of the day throughout the library with intermittent sitting breaks.

Pt reports primary hip pain that can be both achy (when sitting) and sharp (when ambulating). The pain is primarily anterior and lateral hip pain. Reports she can have posterior hip pain when back pain is present. She reports the back pain is a secondary complaint, and with questioning, reports that the back pain is only present when the hip pain is increased (with prolonged standing or ambulating). The back pain is descibed to be a deep ache and is intermittent based on activity. Back pain is described to be a 4/10 when worst and hip pain is described as 7/10 at worst.

Has not had previous tx.

During subjective questioning she reported that she had hip surgery a long time ago when she was 16. With questioning, she reported that the hip surgery was for congenital hip dislocation. This spiked my curiosity since this is dx in infants. She reported that the dx was missed at birth and she had been living with it for 16 years. The pain and discomfort she was having, her parents correlated with “growing pains”. She reported that her acetabulum and femoral head/neck had not developed properly due to lack of proper forces with ambulation. When asked details of the surgery, she reported the MD took bone from her iliac crest and reshaped her femoral head/neck and acetabulum. She reported she was in a cast from abdomen to below knee for a time she could not remember (it was 50 years ago).

Description of symptoms, Agg/Ease
Lumbar: Achy, deep, intermittent, variable. Agg: Generally with increased ambulation and standing >2 hours. Only is present with increased hip pain. Pain can be relieved within minutes of sitting.

anterior/lateral hip: Achy/sharp, deep and superficial, intermittent, variable. Agg: Putting on R sock/shoe, bending to pick object off floor, getting up from squatting, standing >30 minutes, walking >1 hour, sitting >2 hours. Pain can last all day once intensity is high enough.

PMH: X-ray 1 week ago from PCP, Does not know the results at this time. (By 3 week of tx, image results were received and showed severe hip OA in R hip)

Primary Hypothesis after subjective: Primary R hip OA, Secondary R L5-S1

Objective:
Lumbar
-Flexion= 50% limited (produces all hip pain) (increased with R foot on stool)
-RSB= 25% limited (produces all hip pain)
-Front R quadrant= most provocative position (hip pain only) (increased with LE slightly internally rotated)**
-Sustained back R quadrant with OP produces lumbar/buttock pain
-Other lumbar ROM full and painfree

Neuro screen: 2+ patellar and achilles reflexes bilaterally, 1 beat clonus bilateral, negative babinski, negative hoffmans
Myotomes (-)

Slump: negative bilaterally

Hip:
R Hip ROM:
Flexion = 85 (hip pain)
IR at 90 flexion = 10 (hip pain)
ER at 90 flexion = 5 (hip pain)
Extension = 5 (hip pain)
Limited glides in all directions
L Hip ROM:
Flexion = 110
IR at 90 flexion = 20
ER at 90 flexion = 50
Extension = 15
Glides limited but significantly less than R

R Hip special tests:
(+) FABER
(+) FADDIR
(+) Scour
(-) on L

PA provocation testing:
Only (+) for back/buttock pain with UPA to R L5-S1

Severity: Mod – difficulty completing full work day without pain; Pain 7/10
Irritability: Mod – when pain is increased it can last the remainder of the day (occasionally into following day); easily provoked in clinic
Stage: Chronic (3-5 years)
Stability: Worsening

Pt was discharged 1.5 wks ago with no complaints of pain. No pain with ADLs. Reported she had resumed walking with her granddaughter in the evening after work.

Primary tx performed over 6 week period:
– Belted hip mobilizations all directions
– Belted hip mobilizations with movement
– Lower lumbar PA mobilizations
– Education on self hip mobilizations at home with a band and with a towel
– Hip LE ROM and strengthening exercises

Article for discussion:
Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis
A Randomized Clinical Trial

Discussion Questions:

1. What are you thoughts on her living with a dislocated hip for 16 years?

2. What other things would you have measured/assessed? What did I leave out?

3. Additional treatment you thought of or may have performed.

Questions regarding article:

1. What do you think about the tx frequency & tx time for the “active tx” group? (30 minute manual therapy and an HEP with 4-6 exercises. Performing 3 sets of 10 reps.)

2. Thoughts on not performing therex in the clinic and relying on HEP as exercise?

3. Thoughts on only 22% in active group receiving PA mobs and only 16% in active group receiving AP mobs when usually most limitation with hip OA is in hip extension and hip IR.

4. Have you had success treating hip OA with ultrasound?

We will hopefully have time to discuss some of these points in addition to others during Journal Club this month. Such as, how can we combat this article when explaining the benefit of manual therapy and exercise for pts with hip OA.

Cheers.

Attachments:

You must be logged in to view attached files.

[August Winter]

Articles like these are always fun to discuss so thanks for posting Justin. I seem to remember an article from a few years ago (maybe from JAMA?) that had similar findings that produced some interesting discussion among some of my classmates.

1. I’m not quiet sure what to think. My understanding is that these issues would be caught early because of obvious differences in static hip positioning in the infant, in addition to continued pain and dysfunction. It almost makes me wonder if this truly was a dislocated hip or some other congenital anomaly that would require surgical intervention? Either way I think even though this is much later into the future I would have concerns about of the blood supply and bone quality around that joint, especially for a a post-menopausal woman.

2.
– Anything noteworthy about her gait, squat form?
– Since you did a slump, it might have been good to try some of the anterior hip femoral neural provocation tests that we talked through in the past course weekend.
– For someone with both lumbar and hip pain, I think it can be helpful to perform combined rotation and then differentiate which is most limited or painful. I’d assume the hip would be most limited here, but maybe if you can improve the small amount of rotation at the lumbar spine you can take pressure off the hip during functional motions.

3. A few points on treatment:
– What was your thought process for the lumbar PA mobilizations? How often did you treat her low back?
– Education: What were her thoughts on conservative versus surgical management? What was your education on the natural course of OA, the role of continued conservative management, leisure time PA?
– What did her home program involve?

[Justin Bittner]

I did some research and apparently this was “somewhat” common back in the day. The body creates a “false joint” after soft tissue invades the acetabulum. Good thought about the post menopause and blood supply. I hadn’t thought of that.

She had decreased standing time on R and demonstrated a compensatory trendelenberg. Also lacked hip extension at terminal stance. During squat she compensated by wt shifting onto her unaffected side loading that hip more and increasing hip flexion on that side. She did not demonstrate posterior pelvic translation either with squat. I had not thought of during femoral nerve tests, mainly because she had no radicular sx or neurogenic type sx. But since I did a slump, I could see why that would be beneficial. I did a standing rotation test but did not mention it above. I find it useful as well.

I primarily treated her hip, however, she had low back complaints. Although the hip was the driving factor I felt it was worth addressing her back as well. Treating proximally potentially to provide positive neural input. Similar to the article Eric posted about the hip and back complaints being intimately related. I gave her exercises such as self mobilizations to improve hip mobility. I gave her hip strengthening exercises in modified WB or open chain to reduce compressive force (since she was on her feet all day with compression).

[Erik Lineberry]

1. That must have hurt. I’m sure she had some type of dysplasia, I really hope she didn’t have to live with a constantly subluxing and/or dislocated hip that long. It would be interesting to know more details about the procedure, since it seems to have lasted a fairly long time without symptoms returning.
2. I wouldn’t change much. Thorough lumbar screen, I liked the added R hip flexion with use of a step for AROM. I’m not sur I would have gone through all of the provoking positions with OP, but if she was having mild symptoms and you wanted more info why not right.
3. I was helping treat one of Kristin’s patients with LBP yesterday that had significant hip mobility deficits. He has been responding well to lumbopelvic dissociation intervention in supine, quadruped, and functional positions. He really wanted to get back to golf, so it made sense to focus on golfing type activities and gaining rotational control through the low back and hip. I’m not sure your patient would have needed all of those interventions, but maybe something to try with a similar presentation in the future.

1. 3×10 lol – more in answer 2
2. I feel like this only works with a small highly motivated and high level patient population. Most folks are doing to either not perform their exercises or perform them in a way that is not optimal. At a minimal checking the patient’s HEP performance once every 1-2 weeks to tweak it seems necessary to me. However, for most patients the more we interact with them the better off they’re going to be.
3. This is a tough call due to how the treatment selection was structured. The way I read this was that the treating therapists were able to select 2 additional techniques after long axis distraction with thrust, Distraction in hip flexion, IR in prone, and STM. So then you have to decide what would be most effective for the subject after that. It just isn’t clinically applicable. In the clinic we would chose whatever is best for the patient and if they are lacking extension for example and have OA I would want to perform some distraction techniques, possibly some manual stretching if indicated, PA mobs, and lumbar spine intervention if the patient has limitations there. This article shows the difficulty in creating a well-designed study and retaining clinical applicability.
4. I hardly ever use US and I do not know what it could offer a patient with hip OA. The provoking area would be so deep I could not see US providing any effect at all. I would love to hear what others think about US for this patient and patients in general. It is just something I rarely break out in clinic.

[nhoover17]

1. My initial question would be about her activity level as a child. If she wasn’t moderately active I guess I can see how it went undiagnosed or untreated. I think “false joint” evidence is intriguing, but I wonder just how much activity that kind of thing can handle.

2. I would have looked more at functional testing. The OA findings are not a surprise with her history and the lumbar findings seem to coincide with having bad hip mechanics for that long. Obviously her body learned how to adapt so I would have looked more into the adaptations via functional screening and see what you can find. Also hip AROM and strength. I think there may be some info there to guide your treatment.

3. I know you probably did this, but I think more info regarding her functional activity or recreational hobbies to help with specific therex. Thats the only thing I would have included that wasnt described in your post.

Article questions
1. I think the treatment plan is quite generic and I did not see anything that discussed progressions. There has to be a ceiling effect on the benefit of 4-6 exercises of 3×10 reps that were performed only at home.

2. I think they identify the benefits of pt/therapist interaction in their discussion as a point of possible error. They discredit other articles based on subjective reporting but then the prescribed therex program and adherence to it is based soley on subjective report.

3. I think Erik makes a great point about the pt specific treatment model and clinical applicability of a treatment program from this article. The MT skills are generic and performing 4 techniques plus 2 additional “most effective” techniques in only 30 mins is spreading things a bit thin.

4. Obviously pt body type has to be considered but, for the most part, I believe current evidence shows that US does not reach the tissue depth to have treatment effect on the hip joint. Erik, I have only used US in combination w/ tacking and stretching on an acute hamstring strain under the guidance/recommendation of a past CI. It was effective there for reducing pain to allow the pt to perform his exercises, but we only used it for the first 2-3 visits.

[Michael McMurray]

Discussion questions:
1. As you were, I would have been very curious with her mentioning congenital hip dislocation. Along the similar lines of Nic’s questions, I would have been interested in her activity level as a child and if her hip was some hindrance. It’s hard to speculate but I would imagine if she had dislocations or severe difficulty, she might not remember with what exactly, but that she did; more so during her teenage years than younger. Did this ever spark curiosity with her to look into the procedure she had or discuss this with family members? Also, I’m with August in regards to concerns for blood supply; she may be someone who would benefit from some education with regards to degeneration/ femoral head avascular necrosis.
2. It sounds like you performed everything necessary to confirm your primary and secondary diagnosis. Like Nic and August alluded to, functional tests may tell you more about how she moves which may guide treatment.
3. Like Nic mentioned, prescribing exercises that are specifically functional for her. With lower extremity strengthening did you include balance/proprioception exercises, I might include those as well.

Article Questions:
1. I agree with Nic and Erik, the intervention group was generic. They mention that the “active physical therapy program may not adequately target and change physical impairment.” For a very hypomobile hip, 30 minutes a week does not seem like an adequate amount of time to address restrictions. Additionally, when not following up with exercise you could potentially lose the range you gain. The exercise prescription is non-specific, and I would speculate that this article may be something to spin in positive light as to why individualized physical therapy treatment with personalized function exercise is the way to go.
2. Similar to answer one, if you are not following up mobilization with exercise, you may not see as great gains in range of motion. Also, there may be a ceiling effect or participants may start out without compensation but develop this overtime.
3. It doesn’t surprise me given the time constraints of therapy. Again, the provides an argument why specific treatment and manual therapy may be beneficial if provided in a different treatment model.
4. I have utilized ultrasound a handful of times, but I do not see the applicability to this patient population. Others have mentioned tissue depth but I believe ultrasound is more affective for soft tissue injuries.

[Author]

Posts