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steoarthritis is a com- It is important that we have information on the role of physical therapists in the treatment of
mon problem treated patients with osteoarthritis of the hip prior to total hip arthroplasty. This article describes the
by physical therapists. management of a patient with limited range of motion of the right hip due to osteoarthritis. The
This is a disease char- patient made a significant improvement with decreased pain, increased range of motion of the right
acterized by the dete- hip, increased periarticular muscle strength, improved gait, and improved mobility. One year later,
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rioration of the cartilaginous weight- the patient had a right total hip arthroplasty. The rationale of the management of patients with
bearing surfaces of joints, sclerosis of osteoarthritis of the hip is discussed. In addition, the role of physical therapists in the management
subchondral bone, and proliferation and treatment of patients with osteoarthritis prior to total hip arthroplasty is discussed.
of new bone at the joint margins (2). Key Words: osteoarthritis, hip arthroplasty, joint mobilization
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(lo), decreased flexibility, and de- outcome following physical therapy. unable to recall any specific mecha-
creased aerobic capacity (2), which A year later, the patient had an unce- nism of injury. The patient attempted
leads to decreased mobility and de- mented total hip arthroplasty. This to continue aerobic exercise classes
creased activities of daily living (15). was due to occasional hip pain and and running during the subsequent 2
Goals of physical therapy manage- also to the change in the patient's months and the pain worsened. The
ment of patients with osteoarthritis gait pattern which was unacceptable patient followed up with an orthopae-
include control of pain, prevention to this relatively young patient with dic consultation, X-rays were taken,
of strain or further damage to the an active lifestyle. This poses two and a diagnosis of early osteoarthritis
affected joints, improved range of questions: I) Was the outcome of was made. The patient was immedi-
motion and muscle strength, and physical therapy successful? and ately referred to physical therapy.
maintenance of or improvement in 2) What is the role of the physical The patient described the area of
functional independence (14). This therapist in the treatment of patients pain as the right groin area, radiating
is achieved by the use of stretching with osteoarthritis prior to total hip into the right anterior thigh. She also
and flexibility exercises, strengthen- arthroplasty? complained of right posterior low
ing exercises, aerobic conditioning, back pain. The pain was of a variable,
and education on joint protection. intermittent-type ache, aggravated by
History
When conservative treatment of walking and eased by rest in the su-
the patient with osteoarthritis is not The patient was a 51-year-old pine position. On waking, the patient
successful, then total hip arthroplasty woman employed as an administrator felt no pain. The pain was reduced
is the standard surgical intervention who presented with a diagnosis of on rising compared with the pain
for selected patients with advanced early osteoarthritis in the right hip. following prolonged weight bearing.
degenerative arthritis. Total hip ar- The operational definition of early During the day, the patient's job in-
.
JOSFT Volume 26. Number 1 * July 1997
CASE STUDY
decreased weight bearing through knees appeared normal. creased heel strike in an attempt to
the right leg with a slight shift in the On examination of the sacroiliac avoid weight bearing. There was an
lumbar spine toward the left. There joints, there appeared to be less m e increased lumbar lordosis during
appeared to be a flattening of the tion of the right posterior superior midstance and push-off. The patient
right gluteal musculature. On palpa- iliac spine compared with the left. ambulated with a cane.
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tion of the pelvic levels in standing, This was significant compared with
the right posterior inferior iliac spine forward bending and marching tests. Treatment
Provocation tests of the sacroiliac
joints include iliac compression and The patient was seen three times
distraction. The importance of these per week over the 7-week course of
Change in the patient's tests is their usefulness in excluding treatment. To increase range of mo-
gait pattern was joint irritability, hypermobility, and tion, treatment initially consisted of
serious disease (6). There was no re- hip mobilizations, stretches, hold re-
unacceptable. production of pain with these tests. lax, and range of motion exercises.
Journal of Orthopaedic & Sports Physical Therapy®
progressed to resisted exercises with treat the loss of hip range of motion creasing the range of motion of the
a 31b weight. Functional exercises and flexibility. hip. This patient had an abnormal
were added, including sitting-to- Overall, the patient's status capsular end-feel of the hip which
standing, weight-bearing exercises, changed from ambulating with signif- Cyriax described as suggestive of non-
for example, contralateral hip exten- icant right groin pain with a cane to acute arthritis (4). End-feel is the
Copyright © 1997 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
sion and abduction, and gait reedu- being able to ambulate pain free sensation imparted to the examiner's
cation. The patient was instructed in without an assistive device. On initial hand at the extreme of the possible
a home exercise program, which was evaluation, the patient ambulated by passive range of motion of the joint
the exercises previously described. increasing the weight through the (4). There did not appear to be any
The patient was instructed in am- left lower extremity because it was change in the end-feel of the pa-
bulation with a cane at the beginning too painful to weight bear through tient's hip joint.
of treatment and had progressed to the right hip. She had a poor heel By using prolonged stretching,
ambulating without an assistive device strike and toe-off and increased lum- joint mobilizations, proprioceptive
by week 3. bar lordosis from midstance to toe- neuromuscular facilitation, strength-
Journal of Orthopaedic & Sports Physical Therapy®
off. At the end of the physical ther- ening, and aerobic exercises, this pa-
RESULTS apy program, the patient had no pain tient had a significant decrease in
on walking. However, the gait pattern pain, an increase in range of motion
The patient's chief complaint was had not returned to normal. She of the hip, increased strength of the
pain. Subjectively, the patient re- continued to walk with a decreased periarticular hip musculature, im-
ported a gradual decrease in pain heel strike and increased lumbar lor- proved mobility, and functional abili-
intensity over the first 5 weeks. By dosis. The speed of walking and agil- ties. The patient was seen three times
week 6, the patient reported no groin ity continued to be less than her pre- per week, which did appear to be the
or thigh pain, with only minimal pain exacerbation normal. optimum frequency for treatment.
in the posterior superior iliac spine Again, a pain scale was not used
area. In the management of a patient DISCUSSION with this patient but would have p r e
with a painful arthritic hip, this a p vided documentation of a measurable
peared to be an important outcome The use of strengthening exer- outcome.
measure. Another factor affecting the cises for patient5 with osteoarthritis is This patient had an uncemented
patient's function was limited range well documented (2,8,10,12). These total hip arthroplasty 1 year following
of motion. This was measured twice patients have Type I1 fiber atrophy in the completion of her physical ther-
weekly using a goniometer. The muscles supporting the joints ( 12). apy program. During that period, she
change in range of motion over the Strengthening exercises are used to had continued on a home exercise
course of treatment is shown in Table gain increased muscle strength in program. The patient reported that
3. Muscle strength is another factor order to provide better shock-absorb the main reason for her choice to
which was addressed. This improved ing capabilities to the joints and have surgery was her inability to walk
in all of the periarticular hip but did maintain and improve the use of the long distances comfortably. The walk-
ing efficiency of patients with osteoar- subsequent years (5). Perhaps the patients with rheumatoid and osteoarthri-
thritis of the hip is less than normal role of the physical therapist is to tis. 1 Rheumatol 12:458-46 1, 1985
3. Brown M, Hislop HI, Water RL, Pore11
and this improves following total hip help extend the time before total hip D: Walking efficiency before and after
arthroplasty (3). This patient was very arthroplasty and assist the patient in total hip replacement. Phys Ther 60:
satisfied with the outcome of her sur- maintaining his/her optimum func- 1249-1253, 1980
gery and felt she could now walk tional level. In this way, if the patient 4. Cyriax I : Textbook of Orthopaedic
much better. does require a total hip arthroplasty, Medicine (Volume I), Diagnosis of Soh
Tissue Lesions, London: Balliere Tin-
he/she will be starting the process at dall, 1978
their highest achievable functional 5. Efltekhar NS: Total Hip Arthroplasty, St.
level. Louis, MO: Mosby-Year Book, Inc.,
1993
Perhaps the role of the 6. Grieve GP: Common Vertebral loint
Problems, Edinburgh: Churchill Living-
physical therapist is SUMMARY AND CONCLUSIONS stone, 1988
7. Kendall FP, McCreary EK, Provance
to help extend the The management of a patient PC: Muscles: Testing and Function,
with limited hip motion due to osteo- Baltimore, MD: Williams & Wilkins,
t h e before total arthritis has been described. Despite 1993
8. Lawrence RC, Hochberg MC, Kelsey lL,
hip arthroplasty. significant functional improvements,
the patient went on to have a right McDuffie CF, Medsger TA, Felts WR,
Shulman LE: Estimates of the preva-
total hip arthroplasty the following
Downloaded from www.jospt.org at on June 15, 2022. For personal use only. No other uses without permission.
have a successful outcome following stretching, and proprioceptive neuro- Anderson SK, Kay OR: Efficiency of
physical therapy. The role of physical muscular facilitation to increase hip physical conditioning exercises in pa-
therapists in the treatment of patients range of motion are necessary as tients with rhematoid arthritis and os-
with a diagnosis of osteoarthritis of these treatment techniques are com- teoarthritis. Arthritis Rheum 32:1369-
the hip is to assist in achieving the monly used in the clinic. JOSPT 1405, 1989
1 1. Paris SV, Patla CE: Extremity evaluation
highest functional outcome possible,
and manipulation, El course notes, The
irrespective of whether they will even- Institute of Physical Therapy, St. Augus-
tually have a total hip arthroplasty. ACKNOWLEDGMENTS tine, FL, 1993
The outcome of this patient indicates 12. Semble EL, Loeser RF, Wise CM: Ther-
apeutic exercise for rheumatoid arthri-
Journal of Orthopaedic & Sports Physical Therapy®