Physical Therapists as Advocates and Educators

Like most physical therapists, I’m constantly playing the role of educator and advocate. This oftentimes occurs while working with patients diagnosed with early-onset hip osteoarthritis. Individuals may not realize how much modern conservative care can help them during the months and years they may have to wait until they are candidates for THR surgery.

Every day in this country thousands of individuals visit their physicians to find answers to their hip pain. Many of these individuals are referred to a surgeon, and an increasing number of them are relatively young and active individuals. During the visit with the surgeon, many patients find out that they have hip osteoarthritis and will likely need a hip replacement. However, oftentimes the patient is not bad enough to warrant immediate hip replacement and the surgeon may recommend the patient go on their own to exercise to lose weight, use painkillers (opioids) to reduce pain, and wait for it to get bad enough for surgery.

Exercise and weight loss will help and should be recommended, but for many of these individuals, with joint mobility limitations due to a progressive capsular pattern of restriction, exercise can increase their subjective hip pain. And when they are on their own and it starts to hurt more, they naturally stop. The result? They feel defeated, discouraged, and in more pain as their condition progresses. Now that they are becoming inactive and not exercising at least 30 minutes a day, they also have significantly more risk for co-morbidities such as heart disease, stroke, diabetes, cancer, depression, obesity, and addiction.

In many progressive parts of the country, that initial conversation between the surgeon and the patient is and should be going a bit differently:

Surgeon: Mr. Johnson, the x-rays show that you have moderate osteoarthritis of your hip joint and well, you’re going to need a hip replacement. The good news is that you’re not bad enough to have surgery yet and it could be 5-10 years. A hip replacement will typically only last about 20-25 years with today’s technology, so it's better if you wait as long as possible so you'll hopefully only need one in your lifetime.

Patient: Ok, that makes sense. So, I’ll try to put it off for about 5-10 years, and then we can do it. In the meantime, what do we do now to help me feel better because it really hurts and I’m finding myself becoming less and less active? I have two small children and I need to keep working.

Surgeon: Well, there is no cure for arthritis and it will continue to progress. However, we also know that when people with arthritis can exercise, lose weight and increase their strength, two things happen:

First, it may decrease your pain and increase your activity level while you are waiting for surgery. And if you stay active, modify some of your activities, decrease your pain and improve your strength and conditioning, you might even be able to delay that surgery even longer.

Second, regardless of whether you can delay the surgery longer or not, you still win because you will be more prepared, stronger, and in better shape going into that surgery. Studies show that individuals that are in better strength and conditioning going into surgery do better recovering from that surgery.

As the next step, I want you to find a physical therapist who can evaluate and direct your program between now and surgery. Even if you are currently active, there is still something you need to learn about what is happening around your hip joint. You know how it’s hard to cross your legs to put on socks and difficult to walk without a limp? Well, that's because a soft tissue called the joint capsule, which is the connective tissue around your hip joint is getting tighter and more restricted as your arthritis progresses. As the joint capsule gets more restricted, you will feel increased pressure and pain around the hip, more pain around your lower back, increasing tightness and proper exercise can really hurt.

Physical therapists have advanced training in hands-on techniques called joint capsule mobilization that will help to decrease this tightness and restriction around the arthritic hip joint. Then they can instruct you in a specific exercise program that you'll be able to complete on your own to promote this new mobility while building strength and function around it.

So here is a prescription for physical therapy and a list of the PTs who specialize in hip joint problems such as this. Not all physical therapists have special experience working with hip osteoarthritis so I want you to start with this list.

To sum up, although we cannot change arthritis and it will get worse over time, if you can improve your mobility, strength, and activity tolerance while decreasing your pain levels, you will either be more comfortable, take fewer medications overall and have a more active lifestyle before surgery OR be in better strength and conditioning going into that surgery. It’s a win-win situation!

This is the conversation we wish patients could and will have with their physicians and surgeons in the future.

As physical therapists, we have a responsibility to educate both patients and other health care providers with whom we work on the role we can play. The surgeons are continually improving their techniques, surgical instruments, and implants. They cannot possibly keep up on how physical therapy is progressing in the management and treatment of hip osteoarthritis, biomechanics, manual therapy, or durable medical equipment. The same is true of all medical providers – they each have their own areas of expertise that are changing, and it is up to us as physical therapists to keep them updated on ours.

By providing manual therapy techniques initially when needed, then progressing through proper biomechanics and exercise, patients may have a much higher rate of compliance, tolerance, and success. The surgeons I work with absolutely understand that the physical therapists are not treating the osteoarthritis but the secondary changes around the joint. These surgeons appreciate the value of having a strong physical therapist on their team to assist in their patient's overall care, both for “pre-habilitation and for re-habilitation.”

Each of us needs to reach out to the physicians and surgeons we work with as advocates and educators so that they know the modern treatment options available to patients with hip osteoarthritis before surgical intervention. This yields the best results for the patients, providers, and ultimately, the healthcare system as a whole.