Moving Towards Physical Therapy and Pre-habilitation as Standard Management for Hip OA

Changes in our healthcare system come slowly

Nothing changes quickly in our healthcare system; change is a marathon, not a sprint. Now that we've finally recognized the opioid epidemic, individual states are taking steps to stem their overuse. Patients with chronic pain – and their doctors – are looking for other ways to deal with their pain, and one of those ways is physical therapy.

In fact, one of the most common sources of chronic pain is hip osteoarthritis, a degenerative disease that strikes more than 1 out of every 5 Americans. But not many primary care doctors are aware that physical therapy can relieve the pain and other symptoms of hip OA – before surgery becomes an option. And not many payers support physical therapy as an early course of treatment for hip OA.

Pre-habilitation should be prescribed, performed and paid for before surgery, just as re-habilitation is after total hip replacement surgery.

Rehabilitation accepted as part of THR

Further down the road, as the osteoarthritis progresses and surgery is warranted, everyone – patients, providers and payers – recognizes that physical therapy for rehabilitation is expected. It is expected, prescribed, performed and paid for without question following total hip replacement surgery.

Over the past year, we've seen the beginning of a movement to make "pre-habilitation" a must before surgery. Therapy before surgery can improve patients' physical condition and familiarize them with the exercises and movements that are part of post-surgical rehab. More surgeons now recognize that this approach results in faster recovery and better overall outcomes.

Pre-habilitation should start early

In the best of all worlds, pre-habilitation begins at diagnosis of hip osteoarthritis or at the time the symptoms – pain and increasing tightness – manifest themselves and begin to impact the patient's activities. Starting physical therapy early returns the best results. And that therapy would continue – first in clinic, then after discharge from clinic, at home. Continuing therapeutic exercises that can be performed in the home, and periodic checkups with a physical therapist, can eliminate the use of opioids during the period of time between diagnosis and hip replacement surgery. This is significant, as that period averages multiple years – as many as six – for some patients. Further, surgery is not an option for some patients, either by choice or other limiting medical factors. For those patients, continuing physical therapy can enable them to stay active and functional.

Physical therapy can address the joint capsule

Physical therapy is effective because it directly addresses the cause of the pain and tightness that increase as hip osteoarthritis advances and eventually become disabling. That cause is the progressive capsular pattern of restriction that develops around the degenerative hip. The hip joint is surrounded by a deep connective tissue called the joint capsule. The joint capsule, in addition to ligaments, helps to stabilize and control the range of motion of the hip joint. As the disease progresses, the joint capsule becomes inflamed and progressively tighter, causing the femoral head to migrate superiorly and severely restrict normal movement of the hip. This capsular tightening, inflammatory reaction and loss of range of motion increases pressure within the joint which causes immediate increased pain.

Manual therapy, therapeutic exercise and education can treat the signs and symptoms

Physical therapy does not "cure" osteoarthritis, but it can greatly improve the signs and symptoms with a combination of manual therapy, therapeutic exercise and education. The most common technique in manual therapy is long axis traction (LAT). It is particularly effective with hip osteoarthritis because it can stretch and distract the hip joint and provide a great deal of pain relief. This mobilizes the joint capsule and other tissue around the hip joint, and bathes the joint in the nutrient-rich synovial fluid. The result is pain relief and improved mobility. Like antibiotics, the benefits of LAT are cumulative, and last longer with consistent use.

Continuing treatment at home

Physical therapists use therapeutic exercises in combination with LAT and other manual therapies. Patients learn to perform these exercises by themselves at home so that they can continue their own treatmentafter their discharge from the clinic. This home therapy enables patients to continue or resume their social activities and many forms of exercise, despite their hip OA. Periodic checkups with their physical therapists provide a chance to adjust exercises appropriately and monitor progress. Such patients will be in better physical condition when they have THR surgery, whether that is two years or ten years later. That improved physical condition translates to better patient outcomes - better quality of life before surgery, and faster recovery from surgery. And in a win-win, that faster recovery yields reduced costs for the heathcare system overall.