Physical Therapy Failed to Improve Hip OA

Abstract

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online in JAMA. The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. “These results question the benefits of such a physical therapy program for this patient population,” said Kim L. Bennell, PhD, foundation director and professor, center for health, exercise, and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates. Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend “conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status,” the investigators noted. To test the efficacy of physical therapy for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics. The therapy included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region. At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test. Nineteen of 46 patients (41%) who received active physical therapy reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014;311[19]:1987-97). The “benefits” in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in “10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch,” which, together with patient confidence in their therapy, “are known to contribute to an effective placebo response,” Dr. Bennell and her associates said. This study was supported by Australia's National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.