Regis Carpenter Aaompt Poster 2008

The Effects of Hip Mobilization and Mobilization with Movement in the Physical Therapy Management of a Person with Lateral Hip Pain: A Case Report. Gray Carpenter PT, DPT, OCS Fellow - Regis University Manual Physical Therapy Fellowship Program Physical Therapist, Alamance Regional Medical Center

Manual Therapy Fellowship

Assistant Professor, Elon University Methods

PURPOSE •The purpose of this case report is to describe the use of hip joint mobilization, hip mobilization with movement and therapeutic exercise in a patient with lateral hip pain. (2,3,4) •Mulligan’s Mobilization with Movement is a commonly used technique in the clinical setting but there is little evidence to support the effectiveness of this technique. (1)

Case Report Subject

Subjective Exam •Patient Profile: Patient is a 53 year old female secretary. •Chief Complaint: L hip pain. •Symptoms: Patient reported 4/10 deep ache pain at lateral hip now and at best, 6/10 at worst. •Present History: Patient reported a 3 month history of unchanging hip pain. She was unable to state how the pain started. She had received cortisone shot in hip without change. Imaging of hip was unremarkable. •Past History: She reported no prior hip, ankle, and knee pain but did have a prior episode of low back pain with repeated bending forward. •Aggravating Factors: Bringing leg up to tie shoes but decreases immediately when bring leg down, walking > 5 minutes that decreased with sitting, riding a motorcycle with husband > 15 minutes, swimming, and unstable with going down steps. •Easing Factors: Immediately with getting out of provocative positions. •PMH: High Blood Pressure, Migraine Headaches, sleep apnea. •Outcome Measures: Harris Hip Scale 64/100, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) 43/115, Lower Extremity Functional Scale (LEFS) 51/80 Physical Exam •AROM/PROM: L hip was minimally limited in all areas with capsular end feel compared to the R. •Strength: Grossly 5/5 in all areas without pain. Able to stand on heels and toes without compensation or discomfort. •Gait: No significant deviations. •Neurodynamic testing: Negative bilateral SLR and slump test. •Passive Accessory Testing: Hypomobility in L hip for inferior, lateral, AP, PA, and PA in “frog leg” position. No hypomobility in R hip. •Palpation: Tenderness along L lateral hip near greater trochanter. •Lumbopelvic Exam: Presented with full lumbar AROM with no pain with movement. PA glides to lumbar area exhibit no hypomobility or hypermobility. Negative pelvic compression, pelvic distraction, thigh thrust, and sacral compression. •Special Tests: Negative bilateral Ober’s Test, Scour Test, and Ely’s Test. •Muscle Length: Reported a stretch feeling and increased pain with piriformis less than 90 degrees in L hip. Reported no change with piriformis testing greater than 90 degrees. No difficulties noted in R hip. •Functional Tests: Independent with squat without pain. Had pain with L leg crossing right with a slight pull in left posterior hip.

Meth

Day

Assessment

Visit 1 Day 1 Initial Visit

See Initial Visit

Visit 2 Day6

Visit 3 Day 14

Reports difficulty with crossing legs but better overall. Reports pain with tying shoe. +L FABER Reports able to ride motorcycle 45 minutes without pain. 0/10 L Hip Pain

0/10 pain with occasional lateral hip pain at 5/10. No hip pain with swimming, walking, riding motorcycle with husband. R=L hip passive accessory for PA and inferior. L
Intervention

Response to Treatment

Home Program of sitting hip rotation, standing hip extension, sitting hip flex PA glides to L hip 30 second X 3

No change

Hip flex MWM with lateral glide, hip adduction MWM with lateral glide X 30 each.

Able to cross leg without pain

Grade 3-4 hip PA glide in neutral and progressed to full extension 30 second X 3 Grade 3-4 hip PA frog leg glide 30 sec X 3. Grade 3-4 AP glide 30 seconds X 3. Hip MWM with lateral glide for flex, adduction and IR/ER X 10 X 3.

R =L FABER at end of treatment

Hip AROM for adduction/ abduction X 10

GROC +4 “Moderately Better” for overall treatment Pain in L hip piriformis >90° but no pain with piriformis <90°. Low Back pain increase with treatment. FABER painful but decreased since first day.

Grade 3-4 AP in neutral and frog leg position 30 seconds X3

L hip MWM with lateral glide for flex, adduction, IR/ER X 10 3 each

Report decreased pain with crossing leg. Had increased pain with piriformis stretch less than 90°

“Twinge “ pain with piriformis >90° and FABER. R =L hip PA and frog leg No pain after treatment

Acknowledgements Acknowledgements Special Thanks to Dr. Deborah Stetts PT,DPT,OCS, FAAOMPT Special thanks to Dr. Deborah Stetts PT, DPT, OCS, FAAOMPT and and the staff at ARMC the staff at ARMC

Conclusion •This case study suggests that hip mobilizations combined with MWM and therapeutic exercise may reduce pain and improve function for patients with lateral hip pain. •Further research is needed to investigate the effectiveness of MWM as a component of manual therapy intervention and the particular patients that it would provide the most benefit.

References

Results

•Mulligan, B. Manual Therapy: NAGs, SNAGs, MWMs, etc. Plane View Services, Ltd. 4th Edition. 1999 •MacDonald, CW et al. Clinical Outcomes Following Manual Physical Therapy and Exercise for Hip Osteoarthritis: A Case Series. J Orthop Sports Phys Ther 2006; 36(8): 588- 599. •Hoeksma, HL et al. Comparison of Manual Therapy and Exercise Therapy in Osteoarthritis of the Hip: A Randomized Clinical Trial. Arth Rhuematism 2004; 5(15):722-729. •Cliborne AV et al. Clinical Hip Tests and a Functional Squat Test in Patients with Knee Osteoarthritis: Reliability, Prevalence of Position Test Findings, and Short Term Response to Hip Mobilization. J Orthop Sports Phys Ther 2004;34: 676 – 685.

•Discharged 3 visits •Reported no pain for the last two visits. Pain decreased from 4/10 to 0/10. •Was able to tying her shoes, swim, walk, and riding motorcycles with her husband without pain or difficulty. •The LEFS improved 11 points and the Harris Hip Scale improved 24 points. •Reported that she was “a great deal better” on the Global Rating of Change. • The left hip joint mobility was equal to the right with passive accessory motion. •Had no pain with piriformis muscle length below 90° and a small twinge of pain with piriformis muscle length testing greater that 90°. •Reported greater ease with crossing her legs.

Figure A

Figure B

Figure C

Figures represent hip Mobilization with Movement used in the case presentation. The arrows represent the movement performed. The figures represents hip flexion (figure A), hip rotation (figure B) and hip adduction ( figure C).