Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series

Abstract

Study design: A case series of consecutive patients with chronic low back pain.

Background and purpose: In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints.

Methods: EIGHT CONSECUTIVE PATIENTS (MEAN AGE: 43·9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC).

Results: Five of the eight (62·5%) patients reported 'moderately better' or higher (>+4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24·4% reduction in ODI scores.

Discussion: This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.

Keywords: Chronic low back pain; Hip; Impairment; Lumbar; Manipulation; Manual therapy.

Figures

Figure 1

Long-axis distraction manipulation is a high-velocity, end-range, longitudinal traction force to the lower extremity on the acetabulum in supine with the hip in slight flexion, abduction, and varying degrees of internal and external rotation of the lower extremity. Step 1: grasp the patient’s ankle proximal to the malleoli with both hands in a grip comfortable for the patient. Step 2: position the leg in approximately 10–30° of hip flexion and 15–30° of abduction, with slight external rotation. Step 3: gently distract the hip and perform oscillations. Step 4: once the hip is felt to relax, apply a high-velocity, small-amplitude thrust.

Figure 2

Caudal non-thrust manipulation is a low-velocity, mid-end-range, superior-to-inferior oscillatory force to the femur in a supine position, with hip flexed to 90–100°. Step 1: position the patient in supine and passively flex the hip to 90–100° with neutral rotation. Step 2: place your hands on the anterior aspect of the femur near the joint line of the hip. Step 3: gently distract the femur from the acetabulum in the caudal direction and perform oscillations.

Figure 3

Anterior–posterior hip mobilization progression is a low-velocity, mid-end-range, anteromedial-to-posterolateral oscillatory force to the femur in a supine position, with hip flexion, adduction, and external rotation. Step 1: position the lower extremity with the hip in a position of flexion, adduction, and internal rotation. Step 2: use your body to impart an oscillatory, passive mobilizing force in a posterolateral direction through the long axis of the femur. Step 3: progress the technique by increasing flexion, adduction, and/or internal rotation.

Figure 4

Posterior-to-anterior non-thrust manipulation in neutral is a low-velocity, mid-end-range, posterior-to-anterior oscillatory force to the femur in a prone position. Step 1: position the patient in prone with the knee flexed to 90–100° in neutral abduction and rotation. Step 2: passively extend the hip slightly and apply a posterior to anterior force thru the posterior aspect of the femur slightly distal to the hip.

Figure 5

Posterior-anterior mobilization in flexion, abduction, external rotation is a low-velocity, end-range, posterior-to-anterior oscillatory force to the proximal femur in a prone position, with hip flexion, abduction, and external rotation. Step 1: place the patient in prone. Step 2: bring the hip into varying degrees of flexion, abduction, and external rotation. Step 3: contact the proximal hip and use your body to impart an oscillatory, passive mobilizing force in a posterior-to-anterior direction. Step 4: vary the vector of your mobilizing force dependent on the patient’s symptoms and joint stiffness. Step 5: if extremely stiff, start with a pillow under the patient’s left trunk to decrease the amount of hip abduction required: progress to lying flat on the table when it is tolerated by the patient.