Table 2

Details of the Physiotherapy Treatment

Manual Therapy Techniques

Description

Dosage


Mandatory techniques:


Long axis distraction with thrust

Supine. The hip is in 15-30° flexion, 15-30 ° AB, slight ER. Preferably use seat belt. Perform 3-6 thrusts at the beginning of the first set then perform oscillations in the remaining sets.

3-6 sets of 30 secs

Seatbelt glide, or distraction mobilisations, with the hip flexed

Supine with hip flexed and using a seatbelt, oscillatory passive accessory mobilisation forces applied caudally or laterally to the proximal thigh.

3-6 sets of 30 secs

Internal rotation in prone

Prone with knee flexed. IR until contralateral pelvis rises, apply oscillatory force downwards to contralateral pelvis.

3-6 sets of 30 secs

Soft-tissue or deep-tissue massage of quads, adductors, hamstrings, psoas, lateral hip muscles and/or posterior hip muscles and associated fascia

Firm effleurage stroke, deep frictions or sustained pressure trigger point release with the muscle on stretch.

2-5 mins


Optional techniques:


Long axis distraction in prone

Prone. The hip is in 10-15 ° AB. Preferably use seat belt. Perform caudally directed oscillations. May perform 3-6 thrusts at the beginning of the first set.

3-6 sets of 30 secs

Antero-posterior progression (posterior glide)

Supine with hip in flexion and adduction. Use body weight to impart passive oscillations to the postero-lateral hip capsule through the long axis of the femur. Add more flexion, adduction, &/or internal rotation to progress.

3-6 sets of 30 secs

Postero-anterior progression (anterior glide)

Prone with knee bent. Leg supported at knee (may use seatbelt). Pressure applied inferior and medial to greater trochanter in posterior to anterior direction. Vary amount of hip flexion/extension, AB/AD, IR/ER. Modify to use figure-4 position and apply pressure through sacrum.

3-6 sets of 30 secs

Manual stretches to one joint knee extensors, rectus femoris, hip flexors, hamstrings, hip internal rotators, hip external rotators, or hip adductors

Stretch should be felt in target muscle. Manual stretches should match the soft or deep tissue massage technique selected.

6 reps × 20 secs or 4 × 30 secs or 2 × 60 secs

Lumbar spine mobilisation

- Unilateral postero-anterior accessory glides

- Passive physiological lumbar spine rotation

- Lumbar spine manipulation (supine)

- Lumbar spine manipulation (side lying with affected hip up)

3-6 sets of 30 secs


Home exercises

Description

Dosage


Mandatory techniques:

[Exercise difficulty must be progressed]


Hip abductor strengthening

Progressed through supine, standing, side lying and standing wall press.

3 × 10 repetitions

Quads strengthening exercise

Progressed through sitting elastic band press or knee extension, partial squats, partial wall squats*, sit-to stand* and split sit to stand.

3 × 10 repetitions

Muscle stretch (should match with the soft tissue/deep tissue massage technique chosen in the manual therapy section

- Hip extension

- Hip flextion

- Hip abduction and external rotation

- Hip internal rotation

2 mins total with 20-60 sec hold times

Challenging functional neuromuscular balance/gait drills set

- standing weight shifting forwards#, lateral# and tandem stance#

- standing hip control progressing to eccentric hip abductor exercise

- balance in double leg stance on foam# or single leg stance#

- side stepping progressing to 'carioca' (or braiding)

- shuttle walking

- stairs

1-2 exercises (4 minutes total time)



Optional techniques:

[Maximum of two]


Strengthening exercise(s)

- hip extensors progressed through gluteal sets, bridging* and unilateral bridging

- hip external rotators progressed through clamshells (or sitting or 4-point kneeling internal rotation), resisted clamshells (or sitting internal rotation) and standing wall press

- hip internal rotators progressed through 4-point kneeling, sitting and bottom-leg clamshells

3 × 10 repetitions

Additional stretches(s)

(as above)

Lumbopelvic control exercise

Supine pelvic tilt with progressions

10 repetitions


* Option to add elastic band resistance around both knees.

# Option to close eyes.


Patient education


- About osteoarthritis

- Response to exercise and daily physical activity

- Activity-rest cycle versus over-activity cycle

- Joint protection advice


Prescription of a single walking stick

Only if it will enable the patient to improve their gait pattern and increase their daily physical activity.


Stationary cycling

Up to 10 minutes at a moderate level of intensity (rated as "hard" up to "very hard" - level 5-8 on the Modified Borg Rating Scale of Perceived Exertion achieved within 2 minutes of activity if possible) after each treatment session while at the physiotherapy clinic.


The treatment program was structured to include a number of mandatory components plus some optional components. Individual technique selection was guided by assessment findings and radiological presentation.

AB = abduction, AD = adduction, ER = external rotation, IR = internal rotation

Bennell et al. BMC Musculoskeletal Disorders 2010 11:238   doi:10.1186/1471-2474-11-238

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