9. The effectiveness of exercise is independent of the presence or severity of radiographic findings. 10. Improvement in muscle strength and proprioception gained from exercise programs may reduce the progression of knee and hip OA. In addition to exercise, manual therapy is an important evidence-based component of management of the patient with hip OA. When comparing manual therapy and exercise in isolation against each other, patients receiving manual therapy alone demonstrated significantly better outcomes on pain, stiffness, hip function, and range of motion, with effects lasting 6 months following treatment compared with patients receiving exercise therapy alone. The manual therapy techniques found to be beneficial in this study included manual stretching of shortened muscles, traction of the hip joint, and manipulation in each direction of limited motion (Hoeksma et al., 2004). When patients are placed in subcategories based on severity of symptoms (mild, moderate, or severe), patients with severe hip OA demonstrate less progress in range of motion following manual therapy than patients with mild or moderate symptoms (Hoeksma et al., 2005). Furthermore, MacDonald et al. (2006) conducted a case series in which they analyzed the effects of exercise and manual therapy on patients with hip OA; patients in this study receiving both exercise and manual therapy demonstrated increases in passive range of motion in addition to clinically meaningful improvements in functional abilities according to their Harris Hip scores. Aquatic therapy has been shown to have short-term positive effects on patients with hip OA, however long-term studies have yet to be conducted. When compared with no intervention, aquatic therapy has been shown to improve strength, mobility, functional capability, pain, and quality of life at 6-week follow-up. Patients who do not progress with land-based physical therapy may be considered candidates for aquatic therapy (Cibulka et al., 2009). Other treatments may include gait training, education, recommendation for assistive devices such as a cane or walker to decrease pain and pressure on the hip joint, and balance training to promote functional capabilities of the patient (Cibulka et al., 2009). It is important to consider that following radiograph findings of OA, a patient may have been told by a health care provider that the condition is permanent, thus bestowing a hopeless outlook. Evidence for the role of physical therapy suggests that reversal of loss of range of motion and stiffness is possible, with subsequent decrease in pain and improved quality of life. Patient education is important for maintaining activity and the positive outcomes of manual therapy can motivate the patient and instill a more hopeful outlook. pertinent, and an abduction pillow to prevent the impaired lower extremity from adducting is advised. A THA administered surgically through the anterolateral approach generally results in fewer dislocations postoperatively, however, post-op restrictions are still recommended. A study by Peak, et al. (2005) demonstrated low dislocation rate (0.33%) in patients who underwent anterolateral approach with uncemented hip components when they were given post-op restrictions. Patients were advised to limit hip flexion to less than 90°, restricted to 45° of internal and external hip rotation, and limited adduction of the hip was advised with instructions to sleep on their backs with an abduction pillow in place to prevent passive adduction during sleep.
2. Osteophytes on plain film radiograph (x-ray) examination. 3. Obliteration of the joint space. (Altman et al., 1991) A large proportion of persons with hip complaints not fulfilling the ACR criteria at baseline develop hip OA after 2 and 5 years of follow up (Damen, 2019). Once the diagnosis of hip arthritis has been made, perhaps the most important aspect of treatment is to encourage the patient to remain active. The American College of Rheumatology’s general recommendations for management of knee and hip OA include exercise, weight loss in patients who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal anti- inflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations are made for balance exercises, yoga, cognitive behavioral therapy, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol (Kolasinski 2020). In 2005, a multidisciplinary group of health care practitioners established the MOVE consensus, a set of guidelines for the management of hip and knee OA based on evidence (Grades 1A through 4). The group established 10 propositions to manage patients based on the evidence in literature (Roddy et al., 2005): 1. Both strengthening and aerobic exercise can reduce pain and improve function and health status in individuals with hip and knee OA. 2. Few contraindications exist to the prescription of strengthening or aerobic exercise in individuals with hip and knee OA. 3. Prescription of both general aerobic fitness training and local strengthening exercises is an essential aspect of management of hip or knee OA. 4. Exercise therapy for OA of the hip or knee should be individualized and patient-centered, taking into account age, comorbidity, and overall mobility. 5. To be effective, exercise programs should include advice and education to promote a positive lifestyle change with an increase in physical activity. 6. Group exercise and home exercise are equally effective and patient preference should be considered. 7. Adherence is the principle predictor of long-term outcome from exercise in patients with hip or knee OA. 8. Strategies to improve and maintain adherence should be adopted including long-term monitoring, review by patient and health care provider, and inclusion of spouse and/or family in the exercise program. Total hip arthroplasty As previously mentioned, when conservative measures for hip OA fail, total hip arthroplasty (THA) may be indicated. Other pathologies that may lead to THA include avascular necrosis and fracture. On the basis of data from 2000 to 2014, primary total hip arthroplasty (THA) is projected to grow 71%, to 635,000 procedures, by 2030 (Sloan, 2018). Though rehabilitation protocols may vary by operating physician, it is common to see physical therapy orders for weight bearing as tolerated (WBAT) following a cemented THA and toe-touch weight bearing (TTWB) for uncemented THA. Additionally, it is necessary to verify the approach the operating physician used to perform the THA. A posterolateral approach commonly requires avoidance of hip adduction, internal rotation, and flexion beyond 90° to prevent dislocation of the femoral head. Patient education is
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