December 11, 2018 at 3:53 pm #7198
Hey everyone – since we did not get through the second hip case this weekend – we post a few articles from the case and facilitate some clinically related hip discussion.
Here’s the first: Gluteal Tendinopthy from JOSPT/Alison Grimaldi.
Have a read – post some patient/clinical thoughts
December 13, 2018 at 10:17 am #7203
This was a great review article for all things gluteal tendinopathy. I appreciate that they included the stats (sens/spec) on the diagnostic tests for confirmation of pathology. I’ve been thinking more about streamlining my clinical exam after our discussions about exam efficiency last weekend. While I still want to be thorough in my exam, it seems that the subjective and objective findings consistent with this condition would allow us to rule in/out fairly easily (knowing it’s the most common condition associated with lateral hip pain).
The discussion on isometrics for their analgesic effect is interesting. I’ve utilized isometrics for patella tendon, RTC tendons, and achilles tendon pain fairly regularly. I haven’t thought of using it for gluteal tendon pain, but it makes complete sense. For someone that is very painful and cannot tolerate isotonic exercise, this is a great option that I’m definitely going to start trying. I’m curious if anyone has tried this before and what volume/intensity they choose? AKA 25% vs 70% contraction // 30 vs 45 vs 60 second holds. I would assume start light and assess response but if someone has some clinical in regards to this that would be great!
Also, I like the suggestions for sleeping positions to avoid irritation during the evening. I’m going to start suggesting the supine position with pillows under knees for those who have a lot of night pain. Again, this is intuitive, but I haven’t consistently made this suggestion to all of my patient’s in the past.
December 14, 2018 at 12:53 pm #7205
Jon, it seems like the painful side sleeping may be mechanically driven with regards to the tendon insertion and/or bursa. With this in mind, it’d make sense to me that a method to soften the pressure on the area would provide most relief. (Though I’d be interested in other folks’ thoughts).
I really appreciated the article’s likening of the gluteal tendinopathy to that of a RTC, and I could see patients appreciating this anatomic parallel to help them better understand what kind of pathology they’re experiencing.
My biggest takeaway is how mechanically driven the pathology is, and with this in mind I feel as though I can be more creative to provide useful tx exercises that most mimic a patient’s environment.
December 14, 2018 at 8:07 pm #7206
In the past, I generally have people perform as strong of a contraction as they can without causing any pain (or increase in pain). I usually say 5 sec holds. However after reading this article, I think I am definitely going to start with much lighter contractions (25-50%) and longer holds. This was something I found very valuable from this article.
In regards to sleeping positions, I have been using this advice in clinic, with moderate success at best. Many of my patient say that either they can’t lay in supine, or that the pillows move when in sidelying with pillows inbtn knees and shins, or that they toss and turn too often. Some patients say that sleeping on the couch helps, because it forces them into a supine position. I never thought about sitting/standing position before – that will be another useful piece of advice I can offer my patients who tend to stay in hip ADD positions.
December 14, 2018 at 8:18 pm #7207
I really enjoyed this article, and am now kicking myself for discharging my patient with glut tendinopathy just last week (who only got mod pain relief from PT).
My biggest takeaway from this article is the importance of keeping the hips in neutral of a hip ABD position throughout their exercises. Simply adding a pillow inbtn knees for clamshells or sidelying hip ABD is very important yet simple change to be made to these basic exercises. Ensuring patients don’t go into hip ADD during lateral side-steps with TB is another good tip. I may start to give monster walks instead of side-steps for these patients, as I think this exercise promotes a more hip ABD posiiton throughout the movement.
The educational advice in this article is really key, and if patients are able to make modifications, I would imagine this would lead to much less compression of the glut tendons throughout their every day lives.
One last takeaway from this article is when prescribing exercises that are supposed to promote muscle hypertrophy, they should only be performed 3x/week to allow for increased soft tissue healing and adaptation. I have almost never advised someone to do exercises at this low of a frequency, however this makes perfect sense. When I go to the gym, I don’t do chest day every single day (although my PT school classmates may argue this), so why would I prescribe this to my patients? This is another example of how I believe our profession tends to treat patients very different from a healthy population, sometimes for the worse.
December 16, 2018 at 9:51 am #7208
This article was an awesome resource for a recent evaluation I had this past week for lateral hip pain. Her subjective and objective presentation matched those mentioned in this article almost exactly. I have a better understanding of how mechanically driven this pathology is and the importance of educating our patients on neutral hip positioning during functional tasks, sleep, and exercise. I will definitely start implementing some of the isometric strategies proposed by the article, now knowing some of the analgesic effects it has on the body. For example with my patient she was unable perform an isotonic sidelying clamshell against gravity due to pain, most likely due to her hip resting in an ADD position. This upcoming week I will definitely see how she responds to an isometric clamshell with a pillow between her knees.
Jon to your questions about volume/intensity of isometric contraction I typically educate my patients that less is more in the beginning, with and pain free/ low pain levels being the key during the exercise. I will typically start with ~50% contraction for 5-10s holds and modify from there based on their tolerance, but now after reading the article I will considering starting with even less intensity.
December 17, 2018 at 9:06 am #7209
I have to agree with you guys. One thing this article (and VOMPTI) has really made a difference in my treatment approach is to bolster my educational component. Eric really laid it out there simply in the last VOMPTI course that as PTs we have 3 tools: manual, exercise, and education. I lacked so badly the educational component, and it’s super obvious now that it’s arguably the most powerful tool in our toolbox. If a patient for instance isn’t aware of simple do’s and don’ts (and WHY to/not to) related to their pathology, such as hip ADD during glute tendinopathy, then they’re more likely to feel helpless or passive in their treatment. Patients desire to understand. They want to feel in control. We can make a difference in their prognosis just by improving their outlook of their case.
December 17, 2018 at 2:28 pm #7210
Good discussion – another point I try and emphasize in this OA case; especially in the patients with Gluteal Tendinopathy is understanding how to use the evidence to make clinical decisions.
Here is a Gluteal/EMG article systematic review.
How do you use this info to prescribe exercise for this population (gluteal tendinopathy)?
Progressive tendon loading is the hallmark of tendonopathy management.
I.e. – if someone has glute medius tendinopathy how would you use this research conclusions for treatment decision making (versus clamshells to death)
Please post thoughts/discussion
December 17, 2018 at 8:17 pm #7212
These two articles are great because of their clinically relevance and applicability. About two months ago, I evaluated 30 y/o male with lateral hip pain who presented with symptoms most consistent with gluteal tendinopathy. I was not sure what to do after the evaluation, so I did some research and actually found this JOSPT article which helped me tremendously. On my initial objective exam, the main objective findings for me were the pain with palpation, resisted abduction, and ober’s test – yet this was not very provocative. I did some single leg assessment (single limb stance for 10 seconds and single leg squat – only looking for pain). Both of which were negative on the exam. But after reading the article I realized I need to be more specific with my single leg tests. The first follow up session, I tested single leg stance for 30 seconds and single leg squat looking for pain and deviation – which the pt had positives with pain and deviations that worsened with increased repetitions. That follow up session I cut and pasted the pictures from this article about positions of compression and gave it to him, which really helped him because he slept in the side lying position with weight over the greater trochanter. We talked about positions to avoid while at work or home.
Treatment wise, the isometrics made the biggest change in my opinion, mostly with pain. I do not think I gave enough reps based on what the article recommended, but it still had some good changes (4×45 sec, 2x day, SL clamshell isometric with band at different hip flexion angles). I struggled with managing exercises between the isometric phase and single leg phase. The second article would have been really nice for developing a better treatment progression. I tended to go too fast too soon with single leg activities which would increase the pt’s hip pain days following. But overall, this JOSPT article was great and super helpful. I feel like I would have spent too much time trying to massage the glute med/min region and clam-shelled him to death with reps versus managing this like other tendon pathologies, with isometrics and gradually progressing load.
December 18, 2018 at 9:03 am #7213
I like the second article quite a bit. It was one that I read in school after we discussed it during class. I think it puts a lot of the “strengthening” exercises that we prescribe into perspective. The side plank has the highest activation, but this is not necessarily appropriate for someone with irritable glute med tendonopathy. Similar to what Cam was saying, single leg activities have a lot of activation (via EMG), but this might not be where to start for those with higher levels of pain/irritability. I like how the article goes into some detail regarding the lowest EMG level that has been shown to “strengthen” muscles (40%). Knowing this and what we took from the 1st article, we could start somebody with isometrics for pain relief, then progress them to an exercise within the 41-60% MVIC category to begin tendon loading. Of course, each pt would be more appropriate for different exercises (e.g. lateral step up vs pelvic drop), but this is how I would interpret the findings of this study. Additionally, certain patient’s would not be appropriate to jump right into “high-level activation” exercises after isometrics, but this would be up to clinical judgement of course. My goal would be to progressively load their glute med tendon, similar to what Eric was saying, by moving them into either higher volume or greater activation levels. I think I’ll try to take this approach more directly for the next patient I have with glute tendonopathy.
December 20, 2018 at 6:58 am #7214
I agree, two great articles. I the gluteal tendinopathy article has helped me so much be more efficient and effective with my differential diagnosis. I also really love the visuals that are provided. I have used those exact pictures to show my patients for patient education. Commenting on Jon’s post of not thinking of isometrics for gluteal tendinopathy had not occurred to me. I actually have a patient with a pretty irritable and severe gluteal tendinopathy and I was thinking any activation of that muscle was going to make her hate me and never come back. I have her the supine isometric hip abduction with the thigh supported and she absolutely loved this exercise! This is when I decided to bring up this article and show her the varying degrees of compression based on position. Found myself another highly visual learning, I felt like this helped more than anything I was going to do or teach her. Total light bulb moment for her!
The second article is also very helpful for therex prescription. It really highlights to me the importance and finesse to prescription if done correctly. For example, with my patient I described above with gluteal tendinopathy and potentially a gluteal tear, I want to find the most appropriate exercise to improve her glut max strength while minimize the amount of compression and tensile load on the gluteal tendons all the while trying to make it functional as possible. We have been doing mini squats however once irritability improves, I was wondering where I would progress with her exercises, especially since she doesn’t tolerate side-lying or even quadruped on elbows stabilizing with her involved LE for glute max strengthening. This article will help me immensely to prescribe appropriately going forward. Finding that sweet spot of highest Gmax activation while minimizing the amount of tensile load on Gmed will be my biggest challenge. I think retro step ups are in this lady’s future. Reiman’s EMG study will definitely give me a nice linear progression and resource to draw from for therapeutic exercises to load the tissues/tendons appropriately while respecting the amount of tension/compression of the tendon that has been driving her lateral hip pain. Oh and by the way, this lady was clamshelled to death prior to coming to PT if anyone cared. Really rocking the PT community with taking away the clamshells heal all mantra!
December 20, 2018 at 9:45 pm #7215
I really enjoyed this second article and how it applies to everyday practice. As a new clinician it’s easy to fall into prescribing clamshells for glute strengthening exercises for each patient. We need to take into consideration all the functions of the Glute max and med have outside of just lateral rotation/abd. I found it very helpful how the article highlights and differentiates exercises into low, mod, high, and very high level activation. While it would be amazing to prescribe each patient with glute med weakness slide planks, single leg squat and single leg deadlift these may not be the most appropriate exercise for the patient based on their symptom presentation.
This article will definitely be a resource I turn to for my patient that I am seeing for glute med tendinopathy as we progress from isometrics to more functional based exercises that focus on progressively loading her glute medius tendon.
December 21, 2018 at 7:29 am #7216
I have 2 big take-aways from the second article. The first being that it’s important to circle back to the anatomy. The GMax and GMed muscles each have varying fiber direction, influencing their action. This means that we can provide a base exercise, such as a lunge, and alter it slightly (maybe with a forward or backward lean) to more specifically engage these portions of the muscle belly. I love this reality for its clinical applicability, as it allows me as a clinician to broaden my perspective for the bank of exercises that are useful. Likewise, specifically engaging a portion of the muscle belly may aide in overall muscle activation, whereas focusing on a single exercise (such as using clamshells at 30deg hip flexion but not also including 60deg hip flexion) may bypass a portion of the target muscle.
My second take-away is how functionally eye opening this article can be. By realizing the broad variety of postures that are proven to engage GMax and GMed, I can more specifically provide graded progression to my patient’s goal task. We may start with sidelying clamshells or supine bridges, progress to quadraped or planks, and end with variable stair climbing (lateral, forward, retro). I think this can also generate better patient buy-in, if they can see the natural progression of exercise from sidelying to actually using a stair (rather than progressing from yellow theraband clamshells to black theraband clamshells).
Love the post, Eric.
December 22, 2018 at 8:54 am #7217
My takeaway from the second article is how small changes in exercises greatly affects the GMax and GMed activity. In general, I try to be particular about my patient’s form when prescribing exercises, but this article showed me the importance of really being a stickler, as small changes in trunk position and depth of squat can make big differences in strength gains.
I think this article will help increase my exercise bank for glute exercises, but also make my exercise prescription for specific to where my patient is in the rehab process. If a patient has never activated their GMed in her life (every older patient I see), I may want to start with exercises under that 40% MVIC mark, because I need to teach the muscles how to fire neuromuscularly, before they can tolerate exercises for muscle hypertrophy. In general, both GMax and GMed had higher activity in standing positions, so I may want to include these later on the rehab process when they are less irritable and demonstrate improved stabilization and strength. Similar to some of the above posts, if a patient still demonstrates weakness or irritability, having patients in WB positions may be too quick of a progression.
December 26, 2018 at 8:55 pm #7219
Happy Holidays – Another hip article to read/discuss clinical implications.
This is one of my favorites – even though apparently only I treat this patient population.
Have a read, stick it in your library; post some thoughts about the article, specifically the clinical reasoning/differential diagnosis; treatment decision making.
December 29, 2018 at 11:12 am #7221
As I have never treated an athlete with AP, this article gives me a good framework for DD and intervention when I eventually come across this diagnosis. I think the red flag pathologies is an important reminder of what to keep in the back of my mind, and gives me a better idea of what questions to ask about in my subjective exam, that I never really ask patients (burning with urination, any pain in testes area, etc). The “typical” subjective findings are helpful as well, and it was a good reminder that this does not only affect men.
One question I had was why the authors emphasized doing a neuro screen for these patients (dermatomes, myotomes, reflexes, UMN testing – table 2). Does anyone have a good explanation for this? Is this part of the author’s lower quarter exam for every patient they see?
I like the advice to rule out red-flags, then the the LS region and the hip, before continuing with the exam. As AP is a diagnosis of exclusion, it makes sense to ensure these are all negative before assigning them a diagnosis of AP. I also like that instead of suggesting to treat all patients with AP similarly, it is most helpful to categorize them and treat their primary impairments first. Especially since most of these patients are highly competitive athletes, it is imperative to treat the local impairment, and then treat regionally/globally, so that the athletes can move properly and dynamically for their sport, without adding unnecessary loads/stress.
December 30, 2018 at 3:22 pm #7222
Jeff- To answer your question, my guess would be because its a syndrome and a diagnosis of exclusion, like you pointed out, they are stressing the emphasize on the neurological exam to screen out for more serious pathology with objective measures. I think they want us to ask ourselves do we have enough information to treat this patient and using a neuro exam with the addition of using highly sensitive tests should be carried out during the evaluation process. And your question of do they do this on every patient? I would say its definitely a possibility. One of my previous CI’s did a neurological exam on every patient she evaluated, she felt it was important to always be suspicious of neurological dysfunction. She followed Naber’s orthopedic examination process, which in his work he stresses that the “neurological examination has the greatest significance on treatment planning”.
I currently am treating a young man who has a history of athletic pubalgia, who I evaluated about 8 weeks ago after getting a “core muscle repair” or sports hernia repair. He had bilateral rectus abdominis, adductor longus/brevis and pectineus compartment decompression and repairs. This is a surgery I have never seen or treated before so this article has assisted me in progressing his rehab appropriately which has been rather challenging for me. The protocol that was sent to me via the Vincera Institue in PA, where he had his surgery, is rather aggressive allowing the patient to initiate running 8 days post-op. The patients protocol also indicates agility, plyometrics and sport specific activities being incorporated at week 3. Does anyone else find that surprising, because I sure did?
This article has been and is going to be helpful for me to progress this patient appropriately using the different stages of intervention starting with Stage I: addressing pain control, motion, and strength and stability, to then progress to the stage addressing the regional interdependence (stage II) to stage III which is much more sport specific. I like having these guidelines instead of this trash protocol given to me because it addresses the need for a restoration stage, appropriate tendon loading and allows me to use it as a means to educate my patient why we are progressing slower then what is indicated on his rehab protocol.
I also think this article does a great job of highlighting the importance of regional interdependence, which is where I feel my patients impairments current lie and are requiring a more conservative progression. This patient has had bilateral lower leg fasciotomies (4 compartments) and strayer procedures 2 years ago and has had compensatory patterns with his ADL and sport activities for years. This article has heightened my awareness of why I need to step back and get a bigger picture of the kinetic chain as we progress, because its clear (at least to me) that the forces applied distally have had a impact to the proximal structures which may have led to this surgery. The suggested exercises will be very helpful for me to prescribe appropriately knowing where his deficits lie and knowing I need to educate and incorporate appropriate rest in order to assess response to tendon loading.
There is also a really interesting podcast on clinical edge: https://www.clinicaledge.co/podcast episode 85 which is called “How to rehab groin and lower abdominal pain in running and gym junkies with Andrew Wallis”
January 2, 2019 at 3:39 pm #7227
Casey – I’m actually working with a gentleman with a B rectus femoris, B adductor, B pectineus release, pelvic floor repair, and R THR (all performed on the same day). He was also seen at Vincera in Phili…makes me wonder if that’s a common sx that they perform there. He had a different protocol than the one you described. He is not cleared to return to sport-like activity (running, agility drills, advanced plyometrics, etc) until 14 weeks post-op. He’s a recreational weight lifter and works as an X-ray tech so has to push patients on stretchers up to 400# on his own. It’s interesting how different the post-op protocol was despite similar sx. Of course, the additions of the pelvic floor repair and R THR likely play a factor, but running at 8 days post op is drastically different than 14 weeks. I’m curious how their presentations would differ at IE and d/c.
December 31, 2018 at 12:02 pm #7223
I have not encountered anyone thus far presenting with this condition. However this article gives a nice framework of examination and treatment of an individual presenting with these symptoms. The diagnosis of “athletic pubalgia” has a fairly broad definition: “pain in the groin, medial thigh, lower abdomen, or public region that presents in athletes.” Much like many syndrome diagnoses in physical therapy, this is a diagnosis of exclusion and has a broad presentation. A recent JOSPT article (attached below), may help improve the specificity for groin related pain through examination and evaluation by breaking it down into (adductor, iliopsoas, inguinal, pubic, hip, FAI, or other related groin pain). Although, athletic pubalgia seems to have a specific population associated with the diagnosis (young males involved in high intensity running/cutting sports). The most prevalent theory is a biomechanical imbalance between the structures that attach to the pubic bone in combination with playing a sport that involves these particular structures. A study that the authors reported found that an athlete is 17x more likely to experience an adductor muscle strain if there adductor strength is < 80% of hip abductor strength. Other studies they reported on found that rectus abdominus strength or delayed contraction of transverse abdominus resulted in increased risk of injury in this region. I like how the authors propose an intervention sequence and categorize individuals based on pain, ROM, and strength initially, then gradually progressing to address local, then regional contributing factors. Overall, this is a very helpful clinically based article to help diagnose and treat athletic pubalgia.
Jeff – I think the main reason they perform at neuro exam, is because this is a diagnosis of exclusion. It also helps to take off anything scary on your differential list. Interestingly, the authors state that “the patient with AP will most often report insidious onset or non-contact related unilateral pain in the adductor region and/or lower abdominals.” An insidious onset would also make me want to fully rule out neuro.
Casey – yes, that seems surprising how early your patient is returning to running / agilities. Did you find any strength or ROM imbalances in your patient that was consistent with what the article stated for this patient population (i.e. hip abductor vs adductor strength)?
January 1, 2019 at 6:10 pm #7225
Casey, I raised an eyebrow at that protocol (thinking back to my experience receiving a hernia repair surgery, having a hard time just climbing stairs). Cam, I wonder what’s a smart way to test the ratio? 1RM?
I appreciated how the article suggested we begin the exam with a global attempt to rule OUT involvement from other structures, followed by an attempt to rule IN local involvement that may indicate AP. It’s cool to think about different approaches to an exam, especially when you’re in an area that lacks research for guidance. Further, I appreciated its attempt to simplify a really muddy area, and really it just recommends we stick to our roots. Figure out what it’s not… do your best to find a supporting argument for what it most likely is… then place the patient into treatment “buckets”… pain / ROM / strength and go from there. That’s a really applicable framework that I know I often get lost from when I’m in the moment attempting to find the most important information for this evaluation.
January 3, 2019 at 8:08 pm #7233
Erik in regards to the best way to test ratio I think it depends on the patient in front of you. For example if you have ruled out all other differentials and you are attempting to rule in AP for a patient who is coming in w/ c/o inc pain levels, >7/10 I’d probably lean towards a 1RM to determine ABD:ADD ratio. As compared to another individual presenting with lower pain levels who may be in a sub-acute or chronic stage a 1RM may not reveal underlying fatigable weakness. I believe that the key is to be consistent with how we perform these test and measures as the article mentions, but I would typically lean towards a 3RM so that an average can be taken and fatigable weakness can be identified.
I also appreciated the fact that this article brought us back to the basics and did not try to overcomplicate the evaluation and examination of AP. Sometimes I find myself trying to group patients in categories when they don’t belong in one. As long as I am diligent in ruling out red flags, identify impairments that can be addressed and progressing/regressing patients appropriately they will often times get better.
January 1, 2019 at 6:31 pm #7226
Erik – My clinic has a hip ABD/ADD machine, that I think it used too often, however I think this would be a good way to test the strength ratio of ADD:ABD. I have no research-supported rationale, but I tend to have patients do an 8RM when trying to quantify their strength. I think with many injured patients, placing the increased load of a max contraction, or 1RM, puts the muscle under a lot of stress. Especially if I am dealing with something like a strain, I wouldn’t want to re-injure or flare up the patient. I also think that a 1RM is not as helpful, as it doesn’t capture any possible fatiguing issue in the muscle. Does anyone else have any thoughts on this?
Casey – That seems pretty crazy. Especially since he has an extensive surgical history, I would definitely err on the side of caution.
January 2, 2019 at 8:40 pm #7228
Here’s one more Hip article to read/discuss.
How do you take this evidence into your clinical decision making?
Well done study (feel free to critique methods); well authored clinical researchers, in a HIGH Impact journal, with very specific conclusions.
Does this make you change what you do, or how does this change with this population?
Happy New Years
January 2, 2019 at 10:54 pm #7230
Very interesting article. “PT does not result in greater improvement in pain or function compared to sham treatment, raising questions about its value for these patients” – pretty strong statement, and in JAMA of all places.
The conclusion from this study was very frustrating. I then became very biased and tried to find how this article could be wrong about PT.
My first thought was to compare our clinical practice guideline for hip OA to their protocol. The JOSPT CPG revision of hip pain and mobility deficits – hip OA came out in 2017, while the JAMA article was posted in 2014. Keeping the time difference in mind, the JAMA article used interventions that were similar to the revised hip OA CPG. For example, the CPG has strong evidence supporting manual therapy, and flexibility/strengthening/endurance exercises; moderate evidence for patient education, functional/gait/balance training, and modalities (ultrasound/heat). The JAMA PT group focused on manual therapy, flexibility/strengthening, and education while the sham group had inactive ultrasound…So that didn’t work.
Although, the JAMA article focused on research supported areas (i.e manual/exercise/education), the way they carried it out was different than I would have expected. I thought the manual approach was appropriate which included mandatory techniques of long axis distraction with thrust, seat belt mobilizations, IR in prone, and soft tissue massage. This not including other optional manual hip glides, distraction in prone, manual stretching, and lumbar spine mobilization. The interesting part was their exercise portion. All exercises were instructed to be performed as a home exercise program. The target muscle groups were appropriate, but the exercises were not really performed in clinic but rather to be performed at home. We all know patient compliance is very hard to achieve. How they measured adherence was through self-reported measures such as a “log book” and “mailed questionnaires asking participants how many days in the past week had they performed their HEP.” Seems very trusting for a study that states, “the rigorous methodology is a strength of our study.” That would be like a teacher asking you to write down if you did your homework without actually checking to see if you completed your homework at all, but that is just my opinion.
Overall, this article does not really change my practice towards hip OA management. I would be interested to see if they changed their exercise implementation to a more supervised approach, would the results still be the same.
January 3, 2019 at 10:08 am #7231
Cameron – I agree with you, I was sad by the results of this article, and definitely tried to think of reasons why they were wrong as I was reading it. I agree with you that their methodology for assessment of HEP adherence is iffy. However, the article reports that both groups had similar adherence, so I don’t think we can say that this favors either group more than the other.
What I was surprised mostly about was that there were so little improvements in strength and ROM of the PT group. I could see how the PT group doesn’t have significant differences when it comes to pain and physical function. But if the PTs are working at exercises and manual techniques to gain ROM, how did this not show in the results? In some categories, patients had less strength or ROM than when they began. My thought is that with hip OA, it is a joint issue, and it is tough to work on joint mobs in an HEP. Does anyone know if the patients were at least using bands and MWM techniques for their HEP? If the patients are only being seen once a week to once every two weeks for the last 10 weeks of the study, maybe this wasn’t enough frequency to make these changes (especially when it comes to improving accessory motion). I wonder if 2x/week for the entire duration of the study would have been enough frequency to notice a change.
My last attempt of reasoning through why this study is maybe wrong, is that the exclusion criteria consisted of participants who did NOT participate in more than 1x/week of structured physical activity. Maybe the participants are used to being sedentary, and so laying down and rubbing gel on their leg suits their bias better? Maybe the adverse effects, likely mild increases in pain, were just soreness, and these patients did not know the difference between pain and soreness? Maybe the patients in the PT group were performing their HEPs, but doing a shitty job with their form because they have poor motor control/body awareness, or just not challenging themselves enough – because they are not used to exercise? Again, these are just possibilities and me trying to rationalize the findings of this article.
January 3, 2019 at 11:20 am #7232
As expected – young enthusiastic clinicians biased against any clinical findings that contradict what you have learned/practice.
What kind of bias’ are we looking at here, and how can we critically reason our individual treatment decisions/clinical practice based on these findings versus just look for anything to contradict a well done study in a high impact journal.
January 4, 2019 at 7:42 am #7234
I too was surprised at the outcomes and conclusion of this study. It definitely contradicts my beliefs and my outlook on PT’s role in the management of hip OA. As new clinicians it is important to keep an open mind and critically appraise arguments and articles that that may challenge our beliefs. With that being said I still believe that PT is superior to sham treatment for the best outcomes for our patients.
The wording of their conclusion will make many therapists turn an eye to this article. Looking at the results and outcomes, both groups made improvements from baseline in self-perceived pain levels. I was more surprised at the extent at which the sham group improved. Jeff I too found it interesting at the lack of improvements made in jt ROM and strength in the PT group. I think frequency of visits could have been increased especially in the earlier phases of rehab to review HEP and ensure that it was performed correctly. I feel that this article shines a bigger light on the effect of the placebo effect as opposed to the lack of efficacy of PT for patients with hip OA. As we talked about earlier this year, placebo is a powerful tool that can be utilized in the right situation.
Cam & Jeff- I agree that there were limitations and a few things I would change in the methods in regards to how to quantify compliance with HEP and how to determine if the prescribed was performed correctly. I definitely think this article can be beneficial for the right patient who is not improving and may benefit from an alternative approach to treatment.
January 6, 2019 at 6:21 pm #7272
Wow, I’ve really enjoyed the discussion on the hip articles so far. I agree, it can be easy to beat around the pinata a bit when it comes to critically evaluating a study. Cam, I’m 100% with you that it seems unlikely to say that the participants actually adhered to the HEP as well as they did (85% compliance). It’s even more strange this is considered “excellent” when this is supposed to be the main bulk of their rehabilitation focus (since the participants are cumulatively receiving 6hrs of in-tx care over the course of 3months with hands-on care that gradually tapers away to just 30minute sessions received every 2 weeks).
My biggest takeaway here is the real benefit of the placebo effect. One group was seriously regulated to not even exercise during the 3month period and solely received inactive ultrasound from an experienced clinician and yet both groups showed significant improvements in both pain and function. This makes me revisit my tx frequency and duration expectations and wonder if weighing education higher than manual or perhaps exercise can be more appropriate for some patients.. How would you guys weigh the value of these approaches for this patient pop?
January 6, 2019 at 8:53 pm #7273
There was one line from the results section that stuck out to me that I wanted to bring up in this discussion board: “Treatment credibility ratings after the first treatment sessions were significantly higher in the active group than in the sham treatment group, indicating greater participant confidence in his/her treatment and its effectiveness but were not different after the last session”. Anybody else wonder why that would be? It had me questioning what about the subsequent visits that lost the patients confidence and effectiveness?
I would consider that it may be because the physical therapist was evaluating, assessing, and educating them on their specific physical impairments like joint and soft tissue restrictions and relating these finding to their pain and/or functional mobility. If their confidence in their treatment and its effectiveness continued with treatment sessions less driven by physical impairments (PT goals) but by addressing their participation restrictions and functional limitations specific to them would the outcomes have been the same?
This study used a multimodal approach (“semi-standardized” aka as semi cookie cutter) with the active group interventions being sound clinical and pragmatic plans of care for patients with hip OA. It could possible that the active group intervention just missed the mark on where their emphasize should lie when providing individualized care?
I’d like to think that if visits weren’t about getting more hip extension, but about using interventions and treatments to then reinforce its usefulness with a patient specific goal, like getting down on the ground to play with their grandkids or to garden results may have tipped in favor of the active group. We as physical therapist need to maximize the benefits of physical therapy through a patient-centered approach to be more effective with emphasize on communication and treatments geared towards specific tasks required to achieve treatment goals.
But again I am young enthusiastic PT so what do I know! #pumpuptheplacebo
January 8, 2019 at 10:31 am #7277
I think that’s a great point, Casey. To be honest, my time in Los Angeles was a great period where I could work on my manual and prescribed exercise skills, but my patient education skills suffered. A strong portion of my daily patient pop was from Mexico, so in addition to a language barrier the patients also had strong reverence for any medical professional and embodied a “whatever you say, doc” attitude minimizing my need to justify my plan. I felt this contrast now working in a suburb of Richmond, and I know I missed the mark with a few patients simply because I didn’t draw the connection between the patients’ impairments, my plan, and their goals and values. I can definitely say this super simple shift in my prioritizing has improved patients’ outlooks on their prognosis, objective outcomes, and their senses of self efficacy.
January 8, 2019 at 12:32 pm #7279
Casey – I agree that making the patient’s treatment more specific to function and less about changing their ROM (which didn’t work anyways) may have been helpful and more individualized for the patient. This makes the patient feel more like an individual and less than just a diagnosis. Like the article stated, the placebo group likely had more patient-PT interaction and therefore felt like they were listened to.
Another thought I have is that I think its so important to give the patient SOMETHING to go home with. I have had evals where at the end, I don’t know exactly what is going. Even if I don’t have time to test/treat/re-test, or don’t know exactly the best exercise to give the patient, I should give the patient something to do that I can be 99% certain at least won’t increase their symptoms. That way they feel like they are working on improving their problem and have some sort of control. I think that is why the US group got better too – because they were at least doing something at home to control their pain.
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