Knee OA: CPR for Hip Mobs

Original Editor - Andrew Klaehn

Top Contributors - Laura Ritchie, Andrew Klaehn, Dan Rhon and Evan Thomas

Purpose

Knee osteoarthritis xray.jpg

Clinical prediction rules (CPRs) are certain signs and symptoms that can be combined to help clinicians narrow down the likelihood of a specific diagnosis or classification so that appropriate treatment may be directed to facilitate a timely and effective outcome.  Currier et al [1] presented a level IV study in 2007 that favors at least a short term decrease in pain in people that have knee osteoarthritis after they undergone 4 different hip mobilizations.

Clinical Prediction Rule Variables

1. Hip or groin pain or parasthesias

2. Ipsilateral anterior thigh pain

3. Passive knee flexion < 122 deg

4. Passive hip internal rotation < 17 deg

5. Pain with hip distraction

Evidence

      Variable
 Sensitivity (95% CI)
 Specificity (95% CI)
 + Likelihood Ratio
 - Likelihood Ratio
  Hip/groin pain/numbness
          0.15
         0.98
         6.19
       0.87
  Anterior thigh pain
          0.27
         0.95
          5.1
       0.77
 PROM <122 deg knee flex
          0.32
          0.95
          6.02
       0.72
  PROM < 17 deg hip IR
          0.32
          0.95
          6.02
       0.72
  Pain with hip distraction
          0.13
          0.98
          5.24
       0.89


Based on the pretest probability of success, which was 68%, the presence of one variable being present  increased a successful response to 92%.  If 2 variables were present, the probability of success increased to 97%. It is interesting to note that in the 60 subjects that were involved in this study, none had more than 3 variables that were positive. [1]

Measuring Techniques

Measuring knee flexion- The patient is in the hooklying position and their knee is flexed up by the therapist to the point where resistance is first met. This is measured with a standard goniometer

Measuring Hip Internal Rotation-The patient is prone with knees flexed to 90 degrees.  A gravity goniometer is then placed over the lateral malleolus and the lower leg is rolled outward

Hip Distraction- The patient is lying in supine. The intended lower extremity is grasped by the examiner above the ankle and put in ~30 degrees of hip flexion and 20 degrees of hip abduction.  A traction force is then applied inferiorly to the point of resistance.

[2]

[3]

[4]

Hip Mobilization Treatment Techniques

(each mobilization is held 3 times for 30 seconds)

1. Caudal Glides- The patient is supine. The affected hip is flexed past 90 degrees until resistance is felt.  A mobilization belt is place around the patient's proximal thigh and fastened down around the therapist's gluteal region.  The therapist gives a counter force with his hands behind the patient's knees while he sits back into the mobilzation belt, giving the patient a caudally directed force through the hip joint.

2. Anterior-Posterior Glides- The patient is supine.  The affected lower extremity is put into the FADIR position with the foot on the affected side placed on the lateral side of the other knee.  A posterior force through the hip is imparted through the long axis of the femur by the therapist.

3. Posterior-Anterior Glides- The patient is prone.  The affected hip is pulled into extension with the knee flexed with one hand by the therapist. The other hand provides an anterior force through the proximal femur at approximately the gluteal fold.  The amount of hip internal or external rotation can be varied according to the point of most restriction.

4. Posterior-anterior Glides in the FABER position- The patient is prone.The affected lower extremity is put into the FABER position with the affected foot resting on the back of the opposite knee. An anterior force is applied through the proximal femur at approximately the gluteal fold. A pillow may be needed at the patient's abdomen or between the affected foot and the opposite leg for comfort.


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[6]

[7]

[8]

Conclusion

An important thing to keep in mind with this particular clinical prediction rule is that the results were seen very short-term. Effect size of almost any intervention will be significant in the short-term..[9]  It is important to keep the results of this Level IV evidence study within that perspective.[1] These 4 hip mobilizations have shown to provide short-term benefit with patients that present with knee pain from osteoarthritis and at least 1 of the above named variables. This is in the first step of a 3 step process that is recommended when formulating a CPR- CPR development.  The next two steps need to be completed to apply this CPR with great confidence. These are: 1. completing a validation study and then 2. completing an impact analysis which would  assess whether clinicians and patients benefit from the CPR.

Resources

  1. Childs JD, Cleland JA. Development and Application of Clinical Prediction Rules to Improve Clinical Decision Making in Physical Therapist Practice. Physical Therapy 2006; 122-131.
  2. Jaeschke R, Guyatt G, Sackett D. User's Guide to the Medical Literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994; 271:703-707.
  3. Randolph et al, cited in: Beattie P and Nelson R. Clinical prediction rules--what are they and what do they tell us? Australian J of Physiotherapy 2006;52:157-163.

Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 Currier L, Froehlich P, Carow S, McAndrew R, Cliborne A, Boyles R, Mansfield L, Wainner R. Development of a Clinical Prediction Rule to Identify Patients with Knee OA and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-term Response to Hip Mobilization. Physical Therapy 2007; 1106-1119.
  2. Chad Schneider. Goniometry: Knee Extension & Knee Flexion ROM. Available from: http://www.youtube.com/watch?v=tHzkTnzbhH4 [last accessed 24/09/14]
  3. SCOFPTA2013. GONI Hip Internal & External Rotation. Available from: http://www.youtube.com/watch?v=qlfbE0sa9XU [last accessed 24/09/14]
  4. everydayPT. Hip Distraction. Available from: http://www.youtube.com/watch?v=TmmsCf5qxOo [last accessed 24/09/14]
  5. Physical Therapy Nation. Hip Inferior Glide Mobilization (With and Without Foot on Table). Available from: http://www.youtube.com/watch?v=8b4rAWwxtIk [last accessed 24/09/14]
  6. tsudpt11's channel. Posterior glide (supine). Available from: http://www.youtube.com/watch?v=SissDOXYC7A [last accessed 24/09/14]
  7. tsudpt11's channel. Anterior glide (prone). Available from: http://www.youtube.com/watch?v=ZE0ZsV0JvqU [last accessed 24/09/14]
  8. RFUMS DPT Ortho Review. Joint Mob Hip Modified Anterior Glide Student. Available from: http://www.youtube.com/watch?v=lqCPLN_m0WI [last accessed 24/09/14]
  9. Cook, JMMT, 2011 http://www.ingentaconnect.com/content/maney/jmt/2011/00000019/00000001/art00001