Clinical Outcomes Following Manual
Physical Therapy and Exercise for Hip
Osteoarthritis: A Case Series
Cameron W. MacDonald, PT, DPT, GCS, OCS, FAAOMPT 1
Julie M. Whitman, PT, DSc, OCS, FAAOMPT 2
Joshua A. Cleland, PT, DPT, PhD, OCS, FAAOMPT 3
Marcia Smith, PT, PhD 4
Hugo L. Hoeksma, PT, PhD, MSc, MT 5
Study Design: Case series describing the outcomes of individual patients with hip osteoarthritis
treated with manual physical therapy and exercise.
Case Description: Seven patients referred to physical therapy with hip osteoarthritis and/or hip
pain were included in this case series. All patients were treated with manual physical therapy
followed by exercises to maximize strength and range of motion. Six of 7 patients completed a
Harris Hip Score at initial examination and discharge from physical therapy, and 1 patient
completed a Global Rating of Change Scale at discharge.
Outcomes: Three males and 4 females with a median age of 62 years (range, 52-80 years) and
median duration of symptoms of 9 months (range, 2-60 months) participated in this case series.
The median number of physical therapy sessions attended was 5 (range, 4-12). The median
increase in total passive range of motion of the hip was 82° (range, 70°-86°). The median
improvement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient who
completed the Global Rating of Change Scale at discharge reported being ‘‘a great deal better.’’
Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-point
scale.
Discussion: All patients exhibited reductions in pain and increases in passive range of motion, as
well as a clinically meaningful improvement in function. Although we cannot infer a cause and
effect relationship from a case series, the outcomes with these patients are similar to others
reported in the literature that have demonstrated superior clinical outcomes associated with
manual physical therapy and exercise for hip osteoarthritis compared to exercise alone. J Orthop
Sports Phys Ther 2006;36(8):588-599. doi:10.2519/jospt.2006.2233
Key Words: arthritis, Harris Hip Score, manipulation, mobilization, passive
range of motion
1
Physical Therapist, Centennial Physical Therapy, Colorado Sport and Spine Centers, Colorado Springs,
CO; Fellow, Manual Physical Therapy Fellowship Program, Regis University, Denver, CO.
2
Assistant Professor, Department of Physical Therapy, Regis University, Denver, CO; Faculty, Manual
Physical Therapy Fellowship Program, Regis University, Denver, CO.
3
Assistant Professor, Department of Physical Therapy, Franklin Pierce College, Concord, NH; Physical
Therapist, Rehabilitation Services, Concord NH; Fellow, Manual Physical Therapy Fellowship Program,
Regis University, Denver, CO.
4
Associate Professor, Department of Physical Therapy, Regis University, Denver, CO.
5
Professor, Department of Rehabilitation and Health Services, St Antonius Hospital, Nieuwegein, The
Netherlands; Physical Therapist, Clinical Epidemiologist, Manual Therapy Certified, Netherlands Institute
for Health Services Research, Utrecht, The Netherlands.
This project is attributed to Centennial Physical Therapy, CSSC and the Regis University Fellowship
Program in Orthopedic Manual Physical Therapy, Denver, CO, and received approval from the
Institutional Review Board at Regis University, Denver, CO.
Address correspondence to Dr Cameron MacDonald, Centennial Physical Therapy, Colorado Sport and
Spine Centers, 5731 Silverstone Terrace #120, Colorado Springs, CO 80919. E-mail:
physiocam@adelphia.net
588
O
steoarthritis (OA)
of the hip is described as a progressive loss of
hyaline cartilage
within the hip joint, sclerosis of
subchondral bone, and the formation of bone spurs at the joint
margins.2,18,34 Hip OA has been
identified as a major cause of disability, with a prevalence of 10% to
20% in the aging population.20,52
When viewed as a predictor of
functional disability, the overall
condition of OA ranks fourth
among women, and eighth among
men.7,20,52 In addition to the personal disability associated with the
disorder, OA also has a significant
economic
impact
on
the
healthcare system. In the United
States it is estimated that the number of people with OA in any
region of the body will increase
from 43 to 60 million by 2020,
resulting in an estimated cost of
over 100 billion healthcare dollars
per year.20 Considering the personal and economic impact of OA,
and the currently accepted ‘‘standard of care’’ for hip OA reported
as joint replacement surgery,46 interventions with the potential to
limit the disability and/or slow the
progression of hip OA, potentially
Journal of Orthopaedic & Sports Physical Therapy
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
TABLE 1. American College of Rheumatology criteria for classification of hip osteoarthritis. Referenced from Altman R et al.1
Cluster 1 used in this case series.
Test Cluster 1
All 3 findings need to be present for diagnosis of patient with
hip osteoarthritis
• Pain reported in the hip
• 115° hip flexion
• 15° hip internal rotation
CASE REPORT
delaying or decreasing the number of joint replacements, demand further attention.
Hip OA typically presents clinically as pain in the
groin, lateral hip, and the medial thigh regions,
sometimes extending distally to the knee.43 Patients
with OA of the hip often experience morning stiffness, loss of motion, and pain with weight bearing on
the affected limb.40,72 These impairments are often
correlated with a loss of function, such as difficulty
raising from a low chair, bathing, dressing the lower
extremities, and ascending and descending stairs.47
The current American College of Rheumatology
(ACR) guidelines for hip OA focus on pharmacological and surgical management.30 The role of exercise
therapy is acknowledged, 3 but manual physical
therapy (MPT) is not recognized in the most recently
updated guidelines.29 Systematic reviews have concluded that exercise reduces pain and disability in
patients with hip OA,59,68 but these benefits have
been shown to yield only a moderate effect that
typically regresses by 24 to 52 weeks following cessation of exercise therapy.70,71 With the side effects
associated with medications prescribed for patients
with hip OA (nonsteroidal anti-inflammatory medications), including gastrointestinal bleeds and cardiovascular disease,6,22,73 it seems reasonable to conclude
that the roles of nonpharmocologic and noninvasive
therapies, such as MPT, should be further explored.
Research on the use of MPT in the treatment of
hip OA is limited. In a recent literature search of
electronic databases using Medline, OVID and Pedro,
we identified only 2 references reporting the use of
MPT techniques for patients with hip OA.34,48 First,
Loudon48 reported on the use of MPT and exercise
to treat a patient with hip OA. The author proposed
that the benefits of the mobilization/manipulation
(thrust and nonthrust) facilitated a return of function, which potentially could have prevented the
need for a total hip arthroplasty (THA). The inherent limitations of a case report, however, do not allow
for the identification of a cause-and-effect relationship. More recently, Hoeksma et al34 published the
results of a randomized clinical trial comparing the
effectiveness of 2 different therapy programs in a
group of patients with hip OA. The results of this
trial demonstrated the superiority of MPT plus exercise over exercise alone for improving pain and range
of motion (ROM). A clinically meaningful difference
was also found in favor of the MPT-plus-exercise
group in function, as measured on the Harris Hip
Score (HHS).34 In addition, these improvements were
maintained at the time of the 6-month follow-up.
Recently the Ottawa Panel for evidence-based clinical
practice reviewed the role of exercise and MPT in the
treatment of OA in general (not joint specific), and
found that further research is needed on the individual effects of MPT for patients with OA.54
Test Cluster 2
Alternate cluster for diagnosis if all 3 findings are present
• Pain with hip internal rotation
• 60 minutes morning stiffness
• 50 years of age
Considering the limited published reports investigating the effectiveness of MPT in the management
of hip OA, and the findings of the Ottawa Panel,54 a
case series reporting clinical decision making and
outcomes of patients treated with MPT and exercise
is of value to the research literature. In particular, a
case series allows for the presentation of the clinical
decision-making process based on the best available
evidence for treatment selection, rather than a stringent, predetermined protocol of interventions often
used in large clinical trials. The purpose of this case
series is to describe the clinical decision making used
to treat a series of patients with hip OA, to report the
clinical outcomes achieved by these patients, and to
demonstrate the implementation of evidence-based
practice into clinical patient care.34,61
CASE DESCRIPTIONS
Patients referred to physical therapy with a diagnosis of hip OA or a primary report of hip pain,
meeting the ACR classification for hip OA (Table 1),1
were screened to determine eligibility for participation in this case series. Satisfaction of the ACR
guidelines, which are considered the diagnostic standard for hip OA in rheumatologic medicine, yields a
positive likelihood ratio of 4.4 to 5.0, indicating a
moderate shift in probability that the patient presents
with hip OA.1,5,11,13 Further inclusion and exclusion
criteria for this case series are listed in Table 2. A
total of 7 patients satisfying all inclusion and exclusion criteria participated in this case series. Five were
treated at Centennial Physical Therapy, Colorado
Springs, CO, 1 patient was treated in The Hague,
The Netherlands, and 1 in Concord, NH.
This study was approved by the Institutional Review
Board at Regis University, Denver, CO. Patient privacy, patient consent, and compliance with Health
Insurance Portability and Accountability Act (HIPAA)
guidelines was maintained through the course of this
case series for patients treated in the United States,
58 9
TABLE 2. Inclusion and exclusion criteria.
Inclusion Criteria
•
•
•
Referral to physical therapy with a diagnosis of hip pain or
hip osteoarthritis
50-90 years of age
Meet ACR classification for hip osteoarthritis
Exclusion Criteria
•
Prior hip surgery
•
•
Patient refusal of mobilization/manipulation techniques
Clinical exam consistent with nonmusculoskeletal etiology
of symptoms (malignancy, infection, etc)
Rheumatoid arthritis
Severe low back pain
Recent spinal or knee orthopedic surgery
Radicular pain below the knee*
Osteoporosis
•
•
•
•
•
Abbreviation: ACR, American College of Rheumatology.
*Radicular pain was defined as presenting with radiating pain into
the lower extremity, in a recognized dermatomal path, consistent
with pain primarily of spinal origin and not from the hip.
TABLE 3. Patient demographics and outcomes at baseline.
Patient
Age (y)
Sex
Involved
Hip
1
2
3
4
5
6
7
53
52
66
62
59
80
76
M
M
F
F
F
M
F
Right
Left
Right
Left
Left
Right
Left
Symptom
Duration
(mo)
60
9
36
9
3
2
9
with appropriate patient privacy maintained per institutional standards in The Netherlands.
Examination
have been shown to be reliable, and the summation
of hip PROM (including flexion, extension, abduction, and internal and external rotation) has been
shown to be valid in comparing total hip PROM
between subjects.36
Because a loss of strength is purported to be a
consequence of hip OA, and a potential cause of
functional impairments, we believe that addressing
strength deficits may be an important component of
a rehabilitation program for this population.1,16,19,59,62 MMT was utilized to assess the major
muscle groups of the hip. MMT has been reported to
have good reliability (82% interrater agreement,55 ␬
= 0.6757) and validity for assessment of the hip
extensors and flexors; however, no reliability data for
measurements of hip abduction or rotation have
been reported in the literature. The specific techniques for MMT of the hip are consistent with those
reported in Magee.49
Techniques used to determine joint impairments
included the assessment of hip joint end feels and
evaluation of hip joint accessory motion.38,49,50 The
interexaminer reliability of hip joint mobility through
manual assessment has been reported to be good to
excellent for pain provocation in flexion and internal
rotation (␬ = 0.88 and 0.74), and fair to good without
pain provocation, but the reliability of specific assessment of passive accessory mobility of the hip joint is
unknown.8
Gait assessment was also included in this case
series, with visual observation of the trunk, pelvis,
and lower extremities during ambulation on a level
surface. Deviations from normal hip and pelvic motion were recorded individually, with attention to a
visible Trendelenburg sign, antalgic gait, or an altered step length.9,66
Outcome Measures
Patients completed a number of baseline self-report
questionnaires, followed by a comprehensive history
and physical examination. The historical examination
included patient age, sex, duration of symptoms,
location and nature of symptoms, aggravating and
easing positions or activities, occupation, symptom
irritability, recreational and leisure activities, patient
goals, medical history, and past surgical history.
Baseline variables for all patients are shown in Table
3.
The physical examination included a postural assessment,42 neurological assessment,44 hip passive
range of motion (PROM) measurements, manual
muscle testing (MMT) of the lumbopelvic, gluteal,
and hip musculature,42,53 and assessment of passive
accessory mobility of the hip joint.8,45,50 PROM was
assessed using a standard dual-arm goniometer for
hip flexion, abduction, internal/external rotation,
and extension. Goniometric measures of hip PROM
PROM, numeric pain rating score (NPRS), and a
measure of disability (HHS) was collected at baseline.
PROM and pain scores were included because these
factors have been shown to be significantly associated
with the disability experienced by those with hip
OA.69 The NPRS was collected at the baseline examination and weekly thereafter until discharge. Patients
were asked to report the highest level of pain
experienced over the last 24 hours on a 0-to-10 scale,
with 0 representing no pain and 10 the worst pain
imaginable. Previous studies have demonstrated adequate reliability and validity for this type of NPRS,
and a 2-point change has been reported to represent
clinically meaningful change.10,23 Patient-perceived
levels of disability were measured with the HHS
(Table 4). The HHS is a 10-item functional assessment tool yielding a score of up to 100, with lower
scores representing greater amounts of disability and
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TABLE 4. Outcome measure: Harris Hip Score. Referenced from
Harris.28
Category
Points
44
40
30
20
10
0
Case Presentations
a 4-point change indicating clinically meaningful
change.28,32 This questionnaire has been shown to be
reliable in a patient population with hip OA and is
All 7 patients included in this case series exhibited
a loss of both passive hip flexion and internal
rotation.45 Table 5 presents the initial PROM and
NPRS and lists the initial examination ACR classification1 for each patient. Every patient presented with
weakness of the hip external rotators and hip abductors on the affected side. Variable muscle weakness
between patients was also identified in the ipsilateral
hamstrings, hip extensors, and quadriceps. Muscle
performance of the trunk and core (including the
deep abdominal muscles) was examined to identify
any primary control or muscle capacity deficits that
may have indicated the need for interventions targeting these impairments.31 Specific individual examination findings for each patient participating in this
case series are described in detail below.
Patient 1 A 53-year-old, 100-kg male with a diagnosis
of right hip pain and a 5-year history of pain and
mobility limitations reported a progressive decrease
in the ability to participate in bike riding and golf. In
addition to the common findings for all patients
previously described, this patient’s pain was reproduced with passive internal rotation of the right hip.
Additionally, the patient exhibited an antalgic gait
pattern and decreased step length on the right side.
Patient 2 A 52-year-old, 83-kg male with a 9-month
history of left hip pain reported increasing difficulty
ascending and descending stairs, walking, and getting
into and out of his car. The patient demonstrated a
Trendelenburg gait pattern on the left side, indicating weakness of the left gluteus medius muscle.56
Additionally, he reported pain in the left hip region
with a full squat and exhibited strength deficits in the
left hamstrings (4/5) and gluteus medius (4/5)
muscles.
Patient 3 A 66-year-old female (body mass not
reported) diagnosed with right hip OA and a progressive loss of functional status, reported that she had
previously completed a bout of physical therapy (PT),
which included functional and active exercises. According to the patient, this type of treatment was not
beneficial in improving her function or disability
level. She did not recall receiving any MPT. This
patient exhibited decreased right hip extension during gait and reported being unable to ascend stairs
comfortably.
Patient 4 A 62-year-old, 73-kg female with a diagnosis of left hip pain reported a 9-month history of
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
591
5
4
2
11
8
5
0
11
7
5
4
2
0
11
8
5
2
0
4
2
1
0
4
2
0
5
3
0
1
0
4
0
Total score:
/100
*ROM: no specific instructions for definition of partial ROM were
available at the time of this case series for the HHS. For the purposes
of this study, partial ROM was when either hip flexion was ⬍115° or
internal rotation was ⬍15°. If both limitations were present this was
scored as limited ROM.
†
Deformity: the presence of 1 of the following 4 deformities led to a
0 score in this category: less than 10° abduction, leg length
discrepancy ⬎3.18 cm, flexion contracture ⬎30°, or leg fixed in
⬎10° internal rotation in extension.
CASE REPORT
Pain
None
Slight, occasional
Mild, normal activity
Moderate, activity concessions
Marked, severe concessions
Totally disabled
Range of motion (ROM)
Full
Partial*
Limited*
Gait/limp
None
Slight
Moderate
Unable to walk
Gait/support
None
Cane for long walks
Cane, full time
Crutch
Two canes
Unable to walk
Gait/distance
Unlimited
6 blocks
2 or 3 blocks
Indoors only
Bed and chair
Function/stairs
Normal
Normal with banister
Any method
Unable
Socks and shoes
Easy
With difficulty
Unable
Sitting
Any chair 1 hour
High chair 1⁄2 hour
Unable to sit 1⁄2 hour
Public transport
Able
Not able to use
Deformity†
Absence of all 4
Presence of 1
utilized as a primary outcomes tool for clinical
research involving patients with hip OA.32,34,35,65 Radiographs were not used to guide clinical decision
making in this study, as the relationship between
radiographic presentation and disability from hip OA
is variable and has not been shown to be predictive of
response to MPT interventions.15,33,40,58
TABLE 5. Baseline measurements and ACR classification. From Altman et al.1
Patient
1
2
3
4
5
6
7
PROM Flex (deg)
PROM IR (deg)
NPRS Score*
Meet ACR Hip
Classification?
95
89
100
80
90
98
95
0
12
0
0
2
12
2
6
8
6
7
9
5
6
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Abbreviation: ACR, American College of Rheumatology; IR, internal rotation; NPRS, numeric pain rating scores; PROM, passive range of motion.
*Pain was reported verbally by the patient on a 10-point NPRS, recording the worst pain felt over the last 24 hours. Zero represents no pain, with
10 as the worst pain imaginable
progressive pain and dysfunction in the left hip. She
reported sharp pain upon upright stance that radiated into the anterior left thigh and difficulty with
functional and recreational tasks, including driving
and skiing. The patient exhibited a left antalgic gait
with decreased step length and no extension beyond
15° of flexion of the left hip. She reported that pain
was most severe with supine passive left hip flexion.
Patient 5 A 59-year-old, 70-kg female with a diagnosis of left hip OA reported left hip pain, with
radiation down the medial thigh to the knee. A prior
history of left buttock and low back pain was treated
with chiropractic care, which resulted in mild improvements in these symptoms. Through observation
of the patient’s gait, the therapist visually noted
excessive pronation of the left midfoot. A valgus
deformity was also noted at the left knee. Pain was
most severe with passive left hip internal rotation.
Patient 6 This patient was an 80-year-old, 75-kg male
with a 10-week history of right hip and leg pain and a
diagnosis of right hip OA. He reported difficulty with
walking, pain on weight bearing, and loss of function.
A hip scour test was positive for primary pain in the
right hip.38,49
Patient 7 A 76-year-old, 61-kg female referred to PT
with a diagnosis of bilateral hip degenerative joint
disease greater in the left than the right hip. The
patient reported the left hip pain resulted in a loss of
function, as she was unable to complete gardening
and was restricted in daily activities due to the left
hip. Weakness was present bilaterally, but greater in
the left abductors and external rotators (3+/5) compared to 4+/5 on the right side. No specific treatment was completed on the right hip.
TABLE 6. Hip mobilization/manipulation techniques.
Supine
•
•
•
•
•
•
•
Long-axis nonthrust oscillations in slight abduction
Progression of above into abduction
Nonthrust lateral glides of femur with a belt
Lateral glides with combined rotations
Long-axis thrust mobilization/manipulation in a loosepacked position
Thrust mobilization/manipulation in less abduction (⬎15°)
Hip flexion nonthrust inferior glides
Sidelying
•
•
•
Anterior femoral nonthrust mobilization/manipulation
Hip distraction with nonthrust medial femoral glide
Hip distraction nonthrust medial glide plus abduction
Prone
•
•
Anterior nonthrust femoral glides
Anterior nonthrust glides in figure-four position
Three physical therapists completed all examinations and patient interventions in this case series. Five
patients were treated by the primary author (C.M.), a
physical therapist with over 10 years of clinical
practice, 1 patient by a physical therapist (J.C.) with
more than 5 years of clinical practice, and the final
patient by a physical therapist (H.H.) with more than
10 years clinical practice. A summary of the techniques used in this case series is presented in Table 6.
The MPT methods for addressing joint mobility were
determined by the treating therapist and based on
the clinical examination of each respective patient.
We recognize that there is no reported reliability or
validity of these techniques that might assist in
selecting particular treatment interventions in MPT;
however, each clinician used these techniques to
guide the clinical decision making regarding the
direction and magnitude of joint mobilization/
manipulation in each patient case, and whether to
use thrust or nonthrust mobilization/manipulation
techniques.4,38,49,50,63 Thrust mobilization/manipulation techniques were performed where a significant
restriction in capsular end feel was identified in
comparison to the contralateral side or where, in the
judgment of the treating PT, there was an abnormally
hypomobile ‘‘capsular’’ end feel when bilateral hip
involvement was present. Thrust mobilization/
manipulation was not performed in the presence of a
normal end feel when the hip was tested with a
caudal distraction.14,38 Mobilization/manipulations
were performed in the direction of identified restric-
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Interventions
Description/Rationale of Selected Techniques
The following techniques are described as they
were most frequently implemented in this case series,
along with the clinical decision making for their
utilization.
Nonthrust Long-Axis Oscillation Mobilization/
Manipulation This technique was used with the intent
of encouraging relaxation of the muscles of the hip,
decreasing tension in the soft tissues of the hip, and
improving the elasticity of the joint capsule.18,51 This
technique was utilized on all subjects at the beginning of treatment. A failure of this technique to
restore capsular mobility was an indication to use
thrust mobilization/manipulation techniques for patients treated in this case series.
For this technique, the patient was supine, with the
contralateral limb flat and slightly abducted or flexed
at the hip and knee, based on patient comfort.
Gentle and progressive long-axis distraction oscillations were performed by the therapist, with a
2-handed hold at the ankle as shown in Figure 1.
Oscillations in this case series were repeated grade II
or III nonthrust mobilization/manipulations with a
progressive increase in intensity.50 Every attempt was
made to ensure patient comfort and, if needed, the
therapist performed the same technique with the
hands above the knee. Progression of the distraction
position into more abduction was utilized as motion
improved to gain further ROM.
Hip Joint Thrust Mobilization/Manipulation This technique was used with the intent of creating temporary
relaxation of the muscles of the hip, decreasing
tension in the soft tissues of the hip, and improving
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
the elasticity of the joint capsule, allowing for progression of mobility with other techniques.18,51 Thrust
mobilization/manipulation was utilized on every patient in this case series.
The thrust mobilization/manipulation of the hip
joint was performed in a manner very similar to the
techniques described by Hoeksma et al.34 It was
initially performed in a position of approximately 30°
abduction and slight flexion, and was progressed into
less abduction (not less than 15°) and internal
rotation of the hip to gain further capsular flexibility
and to potentially decrease intra-articular pressure.18,51 Patient positioning was the same as for
long-axis nonthrust mobilization/manipulations (Figure 1) and the technique was adjusted to address the
direction of restriction identified by the treating
therapist for each individual patient’s hip. In this case
series, no specific number of thrust mobilization/
manipulations was utilized during each session, but
clinical
assessment
following
each
thrust
mobilization/manipulation was utilized to determine
a change in joint end feel, and thrust mobilization/
manipulations were repeated based on the judgment
of the treating physical therapist with consideration
to the success of intervention and patient comfort.
Sidelying Nonthrust Medial Mobilization/Manipulation
This technique was intended to promote medial and
inferior articular mobility of the femoral head in the
acetabulum, with the ultimate goal of improving hip
abduction and internal rotation. This technique was
utilized by the primary author (C.M.) on 5 patients
in this case series. Lateral nonthrust mobilization/
manipulation of the hip joint with a belt, as shown in
Figure 2, was also used for the intent to improve hip
abduction and internal rotation.
As shown in Figure 3, a 2-person sidelying medial
nonthrust mobilization/manipulation combined with
distraction was utilized. The distraction force was first
FIGURE 1. Long-axis nonthrust mobilization/manipulation of the
hip in 15° to 30° abduction and 15° to 30° flexion.
593
CASE REPORT
tions, with immediate reassessment of PROM and
joint mobility to determine changes occurring after
administration of the interventions. This was performed based on the clinician’s belief that intrasession changes would be predictive of a positive overall
outcome given the recent reports on the positive
predictive value of intersession changes for MPT
interventions to the spine.26,67
Nonthrust mobilization/manipulations in this case
series are defined as repetitive passive movement of
varying amplitudes and of low velocity, applied at
different points through the range of motion, depending on the effect desired.25 Thrust mobilization/
manipulation is defined as small-amplitude, highvelocity therapeutic movements of a joint.4 We are
unaware of any reported adverse effects associated
with hip nonthrust and thrust mobilization/
manipulation. However, Hoeksma et al34 reported
that if osteophytes were noted on radiographs of the
hip, they performed hip thrust mobilization/
manipulations with the hip in greater than 15° of
abduction, theoretically to avoid acetabular impaction.34
active contraction by the patient of the external
rotators of the hip, with the intent of increasing the
anterior glide of the femur through the contraction
of the muscles across the posterior aspect of the hip
joint (Figure 5). The combination of nonthrust
mobilization/manipulation with active contraction by
the patient was also used on a limited basis for the
lateral gapping mobilization/manipulation combined
with internal rotation in this case series (Figure 2).
Treatment progression for each patient focused on
frequent reassessment (both intrasession and at the
end of each session of MPT) of joint accessory
motion and PROM by the treating clinician.24,38,39,64,74 Where a restriction in hip joint mobility was still perceived by the treating therapist,
FIGURE 2. Lateral nonthrust mobilization/manipulation of the hip
with a belt, combining a lateral femoral glide with internal rotation.
FIGURE 3. Two therapist caudal hip nonthrust mobilization/
manipulation with combined medial and inferior glide. One therapist (not visualized here) distracts the hip while the other therapist
provides a medial glide to the hip.
FIGURE 4. Anterior hip nonthrust mobilization/manipulation in
modified figure-four position, allowing for less available abduction
(knee on stool).
applied, then a medial and inferior translation of the
femoral head was provided by the second therapist,
individualized to each patient based upon restrictions
in motion detected by the examiner and progression
of the treatment program. The technique was most
often an oscillatory glide at the middle to end of
range of osteokinematic motion, with the end range
being the passive limit of available hip motion in a
given direction at the point of first restriction.14
Prone Figure-Four Nonthrust Mobilization/Manipulation
With Knee off Table We used this technique with the
intent to improve anterior femoral glide, ultimately
with the goal of improving physiologic hip extension
and external rotation. This technique was utilized for
5 of 7 patients in this case series.
Figure 4 shows the patient positioning and therapist hand placement for a prone anterior glide of the
femoral head. The knee was placed off the table to
allow for the technique to be completed where there
was a restriction in abduction of the involved hip.
This technique was also used in conjunction with an
FIGURE 5. Anterior hip nonthrust mobilization/manipulation, using
an active contraction of the hip external rotators to assist with the
anterior glide. The patient actively pushes the knee into the
therapist’s hand, facilitating a contraction, as the therapist mobilizes
the femur anteriorly with the proximal hand (dashed line represents
direction of push from patient’s muscle contraction).
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J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
appropriate nonthrust and thrust mobilization/
manipulative interventions were continued. Joint
MPT interventions were ceased once assessed joint
end feel was considered normal, PROM equaled the
contralateral side, no further progression could be
made secondary to patient complaint of pain, or
there was no noted progression following repeated
mobilization/manipulations (3 sessions without
change). Following mobilization/manipulation, patients were prescribed exercises, which were determined individually based upon the outcomes of their
evaluation. Exercises were chosen primarily to
strengthen the hip external rotator and abductor
musculature, given the examination findings of consistent lateral hip weakness in these muscles for each
patient. A home exercise program was established for
each patient, with the most frequently prescribed
exercises and hip stretches listed in Table 7. In
general, exercises were completed in 3 sets of 10
repetitions without weight, then progressed with the
addition of weight up to 4 kg as a maximum for
gluteus medius training in hip abduction and external rotation with the knee flexed to 90° and the hip
flexed to 45°.
Patients were discharged from PT care if there was
a plateau in improvements in pain and PROM, or
once the patient reported 0/10 NPRS with an ability
to continue home exercises independently. One patient did not complete the HHS at the initial evaluation; therefore, he was asked to complete a Global
Rating of Change (GROC) at the time of discharge.10
This scale is a 15-point Likert scale ranging from a
very great deal worse (–7), to no change (0), to a
very great deal better (+7), with changes greater than
+3 indicating a moderate change in patient status.37
OUTCOMES
Hip flexion: baseline
Hip flexion: discharge
130
120
Degrees
•
•
•
•
Upright bicycle: 10 min
Gluteus medius clamshell exercises: 3 sets of 12
Hip abduction in sidelying: 3 sets of 12
Core transverse abdominus: 2 sets of 20 in supine with hips
flexed to 45°
Bridge with straight leg raise: 3 sets of 10
Hip flexor stretch kneeling or sidelying: 30 sec × 3
Single leg balance: up to 60 sec
Tandem stance eyes open or closed: up to 60 sec
110
100
90
80
70
60
1
2
3
4
Patient
5
6
7
FIGURE 6. Patients’ hip flexion passive range of motion as measured at baseline and at discharge.
Hip IR: Baseline
Hip IR: Discharge
30
25
20
15
10
5
0
The total number of PT visits ranged from 4 to 12,
with a median number of 5 visits over a 2- to 5-week
period. All 7 patients demonstrated and reported
improvements in pain, hip mobility, and disability
status over the course of PT care. The specific
changes in patient hip flexion PROM, hip internal
FIGURE 7. Patients’ hip internal rotation (IR) passive range of
motion at baseline and discharge. Note: patients 1 and 3 had 0° hip
IR at baseline.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
595
1
2
3
4
Patient
5
6
7
CASE REPORT
•
•
•
•
rotation PROM, total joint PROM, HHS, and NPRS
are shown in Figures 6 through 10. The median
improvement in total hip ROM was 82° (range,
70°-86°), the median improvement in pain on the
NPRS was 5 points (range, 2-7 points), and the
median improvement in disability on the HHS was 25
points (range, 15-38 points).
Each patient in this case series progressed from
meeting the ACR classification criteria for hip OA at
examination, to not having the identified impairments for classification at discharge. Each patient
registered clinically meaningful changes in hip ROM,
hip pain, and hip function. Individual significant
functional changes were a return to golf for patient
1, an ability to return to skiing by patient 4 immediately following participation in this case series, and a
return to gardening by patient 7.
Although long-term outcomes were not collected
formally, the primary author of this study (C.M.)
contacted 5 of the patients in this case series. Patient
1 reported no change in discharge (DC) status at 6
months post-DC, but sought further MPT care 15
Degrees
TABLE 7. Home exercises. Exercises were commenced following manual physical therapy in the clinic, and progressed into
home programs individualized to each patient. Completed 1 to
2 times per day.
not require further care at 6 months post-DC. Two of
these patients reported 100% function at 6 months,
and one 80% improvement at 3 months and again at
6 months post-DC. Patient 4 continued to receive
intermittent private care for hip MPT and was discharged from all PT care 6 months post-DC from this
case series, with further functional gains in PROM
and activity levels.
Total Hip PROM: Baseline
Total Hip PROM: Discharge
300
Degrees
250
200
150
100
DISCUSSION
50
1
2
3
4
5
Patient
6
7
months post-DC for symptoms at a lower intensity
than those present initially (NPRS score, 2/10; initial
was 6/10 with 0/10 at DC). Patients 5, 6, and 7 did
This case series describes the rationale and clinical
decision making regarding the incorporation of MPT
and exercise into the treatment of hip OA. Patients
receiving MPT interventions based upon the clinical
examination, including directional nonthrust
mobilization/manipulations and thrust mobilization/
manipulations of the hip demonstrated similar outcomes to the patients of the Hoeksma et al34
randomized clinical trial who received MPT and
exercise. Significant changes in function as measured
through the HHS and decreases in pain as recorded
in the MPT group of the Hoeksma et al34 trial were
also noted in this case series. This case series demonstrates the incorporation of the best available evidence into clinical practice for the use of MPT and
exercise in the treatment of patients with hip OA.
The fact that each patient satisfied the ACR classification for hip OA at initial examination, but not at
discharge, also suggests a positive outcome for the
patients in this case series. The primary impairments
identified in the ACR guidelines may have been
influenced by MPT.1 Improvements in PROM in
flexion and internal rotation were the primary outcomes that changed the diagnostic classification of
the patients in this case series. The specific MPT
techniques described in this case series serve to
illustrate potential primary interventions for patients
with hip OA.
The treatments in this case series were not based
on a specific predetermined set of planned interventions or protocol but, rather, on the clinicians’
individual patient assessment of deficits in PROM,
end feel, and loss of joint motion as perceived
through manual joint assessment. The apparent success of manual interventions for hip OA promotes
the potential of a decreased reliance on pharmaceutical management, improved quality of life, decreased
pain, and decreased personal and community costs
associated with hip OA.7,41,52 Medication usage was
not recorded in this case series, and was not noted to
be recorded in previous reported studies of MPT
involving the hip.12,34
The rationale for this type of treatment approach
in the management of hip OA is to restore functional
motion to the hip, allowing for an increase in
exercise participation and to potentially improve the
nutrition and tissue health of the hip joint.18,35,39,51
596
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
FIGURE 8. Patients total hip passive range of motion (PROM) at
baseline and discharge. PROM includes flexion, extension, internal
rotation, external rotation, and abduction.
Baseline
Discharge
Harris Hip Scores
(Range 0-100)
100
80
60
40
20
0
1
2
3
4
5
Patient
6
7
FIGURE 9. Harris Hip Scores (HHS) from evaluation and discharge,
0 represents total disability, 100 represents normal hip function and
mobility. Minimum clinically important difference (MCID) for the
HHS is 4 points (Hoeksma et al35). Patient 2 did not complete a
HHS.
Baseline
Discharge
NPRS (Range 0-10)
10
8
6
4
2
0
1
2
3
4
Patient
5
6
7
FIGURE 10. Patients reported maximal pain levels in the previous
24 hours, using a numeric pain rating scale (NPRS) where 0
represents no pain and 10 the worst pain imaginable. The minimum
clinically important difference (MCID) for patients with low back
pain is 2 points (Childs10). Patients 1 and 3 reported a 0 score on
the NPRS at discharge.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
and whether specific joint testing is necessary to
guide mobilizations, or if general application of
mobilization/manipulation to the hip will provide
benefits in pain and disability for patients with hip
OA. Future studies should also inquire into the usage
of medications following MPT interventions for hip
OA and identify the duration of long-term benefit
following MPT for hip OA.
CONCLUSIONS
This case series highlights the use of nonthrust and
thrust mobilization/manipulative techniques and exercise in the treatment of hip OA from an
impairment-based MPT approach. Loss of PROM and
pain in the hip formed the basis of the medical
diagnosis in this case series, while restrictions in
PROM, joint end feels, functional decline in mobility,
and pain guided the MPT interventions. The utilization of specific techniques to increase joint mobility
with complementary exercises appears to have contributed to gains in PROM, decreases in pain, and
increased functional activity in this case series. Because a case series cannot establish a cause-and-effect
relationship, further research, including randomized
clinical trials, is necessary to uncover the exact effects
of MPT and exercise for the treatment of hip OA.
ACKNOWLEDGEMENTS
We would like to graciously thank the faculty of
Regis University, Denver Colorado, for their ongoing
support of clinical research.
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The actual pathophysiology behind the success of
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activity, as causality can not be determined from a
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As previously mentioned, we cannot infer a causeand-effect relationship from a case series. Further
limitations include the fact that no intrarater or
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examination tests and measures and the MPT techniques utilized. No blinding occurred as the treating
physical therapists completed all of the patient examinations in this case series. A directional causal effect
cannot be extrapolated for specific MPT techniques
as multiple techniques were used. The influence of
the Hawthorne effect, which is the tendency of
individuals to perform better in a research setting as
they are being assessed,60 can not be ignored, as each
therapist in this case series was aware that individual
patient outcomes were being measured, but no subjects were excluded from outcomes reporting. However, despite the limitations of the case series, the
outcomes presented are encouraging for the clinical
utilization of MPT techniques and exercise in the
treatment of hip OA and patients with primary hip
pain satisfying the ACR classification for hip OA.
Future studies should investigate the physiological
mechanism that promotes improved joint function
following nonthrust and thrust mobilization/
manipulation for hip OA. Research assessing the
appropriateness of including MPT into the ACR
guidelines for the treatment of hip OA, given the
outcomes of the Hoeksma et al34 trial and this case
series, is warranted. Studies should investigate
whether thrust mobilization/manipulation generates
a different clinical outcome than nonthrust
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ERRATA
CORRECTION: ALTMAN’S CRITERIA
FOR OSTEOARTHRITIS OF THE HIP
AND KNEE
I
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). T
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.
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Sports Phys Ther. 2004;34(8):461-467.
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tests and a functional squat test in patients
with knee osteoarthritis: reliability, prevalence
of positive test findings, and short-term response to hip mobilization. J Orthop Sports
Phys Ther. 2004. 34(11):676-685.
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M, Hoeksma HL. Clinical outcomes following
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Phys Ther. 2006;36(8):588-599.
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