Division of Geriatrics and Gerontology黃柏誠

Effect of Physical Therapy on Pain and Function in Patients With Hip

OsteoarthritisA Randomized Clinical Trial

JAMA. 2014 May 21;311(19):1987-97.

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Hip osteoarthritis

• Guideline

– for symptomatic hip osteoarthritis

• conservative non-pharmacological physiotherapy

• irrespective of severity, pain levels, and functional

status

Introduction

OARSI recommendations for the management of hip and knee osteoarthritisOsteoarthritis Cartilage. 2010;18(4):476-499.

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Importance

• Physical therapy for hip osteoarthritis

– limited evidence of RCT

Introduction

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ObjectiveIntroduction

Hip osteoarthritis

Pain Function

12-wks multimodal physical therapy

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Design

• A randomized, participant- and assessor

blinded, parallel-group, placebo-controlled

trial

Methods

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Setting

• Intervention: 12 wks

• Follow-up: 24 wks

Methods

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Participants

• 102 volunteers recruited from the community

– May 2010 ~ April 2012

Methods

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Participants

• Inclusion

– ≧50 y/o

– hip osteoarthritis confirmed by radiograph#

– hip pain for ≧3 months

– average pain intensity in past week ≧40/100mm

(VAS)

– moderate difficulty with daily activities

Methods

# The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34(5):505-514.

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Participants

• Exclusion

– Regular structured exercise or walking

– Physical therapy, chiropractic treatment in

past 6 mo

– Hip surgery in past 6 mo or waiting list for hip

surgery

– Hip or knee replacement

– Corticosteroid use

– Inability to walk unaided

Methods

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FlowchartMethods

1441 patients with hip OA

203 for X-ray

111 for physical screening

102 randomized

1238 Excluded　 212 Did not meet inclusion criteria　 982 Met exclusion criteria　 44 Did not undergo X-ray

92 Excluded　 51 Did not meet inclusion criteria　 6 No longer interested　 35 No longer eligible

9 Could not reproduce hip pain

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RandomizationMethods

5349

102 randomized

Active Placebo

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Schedule

• intervention: 10 sessions over 12 weeks

Methods

intervention

60min

30-45min

12

3 4 5 6 7 8 9 10

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Active treatment (12 wks)

• manual therapy

– hip thrust manipulation

– hip lumbar spine mobilization

– deep tissue massage

– muscle stretches

Methods

12

3 4 5 6 7 8 9 10 intervention

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Active treatment (12 wks)

• home exercise (4 times/wk)

– strengthening of the hip abductors and quadriceps

– stretching and range of motion

– functional balance and gait drills

Methods

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3 4 5 6 7 8 9 10 intervention

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Active treatment (12 wks)

• education and advice

– osteoarthritis

– response to exercise and daily physical activity

– activity-rest cycle versus over-activity cycle

– joint protection advice

Methods

12

3 4 5 6 7 8 9 10 intervention

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Active treatment (12 wks)

• Prescription of a single walking stick

– only if it will enable the patient to improve their

gait pattern and increase their daily physical

activity

Methods

12

3 4 5 6 7 8 9 10 intervention

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Placebo (12 wks)

• inactive ultrasound

• inert gel

Methods

12

3 4 5 6 7 8 9 10 intervention

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Schedule

• intervention: 10 sessions over 12 weeks

Methods

12

3 4 5 6 7 8 9 10 intervention

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Schedule

• intervention: 10 sessions over 12 weeks

• follow up: 24 weeks

Methods

follow up

12

3 4 5 6 7 8 9 10 intervention

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Follow up (24 wks)

• active group

– home exercise (3 times/wk)

Methods

follow up

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Follow up (24 wks)

• placebo group

– self-applied gel (3 times/wk)

Methods

follow up

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OutcomesMethods

blinded assessor questionnaire

s

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Primary outcomesResults

PrimaryPain

Function

Pain: VAS (0-100mm) (0: best)

Function: WOMAC (0-68) (0: best)Western Ontario and McMaster Universities Osteoarthritis Index Likert version 3.1

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OutcomesMethods

SecondaryPrimary

Impairments

Physical performance

Global change

Psychological status

Quality of life

Pain

Function

Pain

Function

Impairments

Physical performance

Global change

Psychological status

Quality of life

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FlowchartResults

44

50

53

1441 patients with hip OA 1339

Excluded

96 (94%)

83 (81%)

49

46

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102 randomized

Active Placebo

13 wk

36 wk

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Characteristics

• similar at baseline

Results

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Primary outcomesResults

PrimaryPain

Function

Pain: VAS (0-100mm) (0: best)

Function: WOMAC (0-68) (0: best)Western Ontario and McMaster Universities Osteoarthritis Index Likert version 3.1

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Pain: within-group

• both groups

– statistically significant improvements

Primary Outcome

Activemean [ 95% CI ] mm

Placebomean [ 95% CI ] mm

13 week−17.8 [−26.2,

−9.3]−23.6 [−31.4, −15.9]

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Pain: between-groups

• not significantly different

– mean difference of 6.9 [−3.9, 17.7] in favor of

placebo

Primary Outcome

Activemean(SD) mm

Placebomean(SD) mm

Baseline 58.8 (13.3) 58.0 (11.6)

13 week 40.1 (24.6) 35.2 (21.4)

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Function: within-group

• both groups

– statistically significant improvements

Primary Outcome

Activemean [ 95% CI ]

Placebomean [ 95% CI ]

13 week−4.5 [−8.5,

−0.4]−5.7 [−9.1,

−2.3]

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Function: between-groups

• not significantly different

– mean difference of 1.4 [−3.8, 6.5] in favor of

placebo

Primary Outcome

Activemean(SD)

Placebomean(SD)

Baseline 32.3 (9.2) 32.4 (8.4)

13 week 27.5 (12.9) 26.4 (11.3)

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Secondary outcomes

• no between-group differences

– except balance step test

Results

…

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Adverse effects

• Significantly more participants in the active

group reported adverse events (p=0.003)

Results

Active Placebo

Participants 19 (41%) 7 (14%)

Eventsincreased hip painback painpain in other regionincreased stiffness

2615010802

96021

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No additional benefits

• Both groups showed significant

improvements in pain and function following

treatment.

Discussion

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Exercise & manual therapy

• Two randomized controlled trials in hip OA

– combining exercise and manual therapy

• does not confer additional benefits

• may have an adverse interaction effect

Discussion

Osteoarthritis Cartilage. 2013;21(4):525-534.Arch Phys Med Rehabil. 2013;94(2):302-314.

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Strength

• minimized potential for bias

– a credible sham treatment

– concealing treatment allocation

– blinding (participants, assessor, biostatistician)

Discussion

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Limitation

• lack of therapist blinding

• the absence of more blinding than expected

at the final follow-up assessment

• not all participants adhered fully to treatment

Discussion

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Limitation

• the results cannot necessarily be generalized

– to different physical therapy programs

– to cohorts of younger patients

– to those with milder symptoms

Discussion

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ConclusionSummary

Hip osteoarthritis

Pain Function

12-wks multimodal physical therapy

1) no additional benefit2) more adverse effects

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