Posts in hip osteoarthritis
Does Physical Activity Improve after a Total Knee or Hip Replacement?

Total knee and hip replacements are among the fastest growing surgeries in our country.  Physical Therapy remains the first line treatment for patients with knee and hip arthritis, but in patients with severe osteoarthritic pain and loss of function joint replacement remains a good surgical option.  In prior research among patients undergoing these procedures there is often a disconnect between subjective reporting of pain and function and the objective testing of a patient's function.  For example, a patient may report great outcomes and an ability to walk long distances without fatigue or pain, but objective testing in Physical Therapy often reveals residual endurance, strength, and balance impairments.  

In addition to severe pain, one of the most important indications for a total joint procedure is loss of function.   After the surgery patients are expected to increase their activity levels due to reduced pain, but new research is questioning this assumption.  A recent review article in the Journal of Orthopedic and Sports Physical Therapy examined if physical activity levels increased after these procedures (Arnold et al. 2016).  Authors reviewed the available data and found 8 studies of 373 patients who underwent a total joint replacement.  

These studies objectively tracked a patients physical activity levels up to 1 year after the procedure to see if levels had increased compared to pre operative levels.  The authors reported negligible improvements at 6 months and limited evidence to support increases in activity levels at 1 year.  At one year, patients with total joint replacements were significantly less active than their peers.  This study indicates the importance of post operative Physical Therapy to effectively improve strength, endurance, and balance allowing patients to resume an active lifestyle.  

Physical Therapy Reduces Need for Total Hip Replacement

Over 200,000 Americans undergo a total hip replacement often as a result of severe hip osteoarthritis.  Patients who enter the surgery in a weakened, less functional state have worse outcomes up to 2 years post operatively compared to their higher functioning peers (Fortin et al. 1999, 2002).  This is concerning because the most rapid recovery after surgery occurs in the first 3 months with slower recovery up to 1 year.  A patient with more difficulty entering surgery would have limited success in this crucial window in their recovery.  Conversely, pre operative Physical Therapy for patients with limited flexibility, strength, balance, and endurance can improve surgical outcomes, but similar to research in knee osteoarthritis may delay or prevent the need for the surgery.  

A recent study was conducted to determine the long term impact of PT interventions on patients with hip osteoarthritis (Svege et al. Ann Rheum Dis. 2015).  Patients were randomized to either an education or PT group and followed up to 6 years after the treatment.  The authors reported the average time to a total hip replacement was 5 and a half years in the Physical Therapy group compared to 3 and a half years in the education group.  In addition, twice as many patients in the Physical Therapy group did not require surgery reducing the need for surgery by 44%.  

This evidence adds to our knowledge on the beneficial effects of Physical Therapy on patients with hip osteoarthritis.  Patients with hip pain are advised to see a Physical Therapist to postpone or prevent the need for a total hip replacement. 

Hip Osteoarthritis and the Impact of Exercise

Currently, in the state of Colorado patients can access their Physical Therapist without a referral from another healthcare provider such as primary care physician.  This model of care has been utilized since the 1950's throughout the country and is most notable in our military where our soldiers have direct access to their Physical Therapists.  In both the civilian and military worlds seeing a Physical Therapist first is both clinically and cost effective for patients, saving an average of $1000 per plan of care.  For the majority of musculoskeletal conditions exercise is the key intervention to reduce pain and improve function.  There is no better healthcare profession than Physical Therapy for the design and implementation of an exercise program for patient's in pain.  A new research paper was released demonstrating the importance of exercise in the management of hip osteoarthritis.

Hip osteoarthritis is a common condition leading to pain, loss of motion, weakness and loss of function in many middle to older aged adults.  Prior research has shown exercise therapy's ability to reduce pain and improve function in patients with hip osteoarthritis.  A recent study compared the cost of exercise therapy and primary care to primary care interventions alone (Tan et al. Osteoarthritis Cartilage. 2015).  Over 200 patients were followed over the course of a year and their medical expenses were collected.  The authors reported exercise therapy was a less costly treatment option compared to primary care alone.  

To learn more on how Physical Therapy and exercise can save you money and improve your quality of life contact your local Physical Therapist.    

Hip Pain and the Role of Diagnostic Imaging

Often in Physical Therapy we are asked if an image would help in our diagnosis or treatment of a patient's symptoms.  The answer is very dependent on the individual patient's case but in most cases imaging has not been shown to improve outcomes.  In prior posts we have discussed the strengths and limitations of diagnostic imaging such as MRI or x rays for musculoskeletal pain.  One of the main limitations of these tests is the presence of both false negatives, the absence of pathology in those who have symptoms, or the more risky false positives, the presence of pathology in those who do not have symptoms.  As our technology has improved we are able to view body structures in greater detail leading to "positive" findings even in asymptomatic people.  These false positives may lead to unnecessary tests, medications, or procedures if they are not balanced by thorough clinical exam.  

Recently researchers in the British Medical Journal published a study on the relationship between hip pain and x ray evidence of hip arthritis (OA) (Kim et al. 2015).  The authors performed x rays on subjects and then interviewed these individuals for the presence of pain in the hip, groin, or low back.  In one cohort of the study of >900 participants only 16% of painful hips showed evidence of OA (false negative) and only 21% of hips with the presence of OA were painful (false positive).  Similarly, in a second cohort of >4300 patients the authors found only 9% of frequently painful hips showed signs of OA and 24% of hips with OA were painful.  

The authors concluded that hip pain was not present in many hips with OA and many hips with pain did not not show signs of hip OA.  The authors recommend utilization of a strong clinical examination prior to diagnosis based on diagnostic imaging alone.  Visit your local Physical Therapist to assist in your evaluation and treatment of hip pain.