Hip osteoarthritis: clinical advice and treatment options from a musculoskeletal and chiropractic perspective
Matthew Barks is a chiropractor who qualified in 2012 and practises in the north-east of Scotland. He has a keen interest in the management of patients affected by chronic musculoskeletal pain. He completed a Master’s in Pain Management in 2018 and is a fellow of the Royal College of Chiropractors’ Pain Faculty. A core component of his practice is providing strategies to support patient self-management.
Musculoskeletal (MSK) complaints can cause a significant burden on a person’s life, and chronic pain arising from the hip can be a prime example of this. It is no secret that this burden has been made ever heavier due to COVID19 and the significant pressures put on MSK services, leading to longer waiting times and difficulties accessing services.
Pain arising from the hip and the surrounding tissues can limited a person’s ability to undertake and enjoy their normal activities of daily living, including being able to work, spend time with their loved ones or to have a good night’s sleep. In fact, MSK complaints are one of the most common causes for GP appointments, accounting for around 30% of GP consultations in England [i].
Hip osteoarthritis specifically is most common in men under the age of 50 and in women over the age of 50. Pain is typically reported into the groin and lateral hip; however, pain can also be present into the lower back and the knee. Patients can report stiffness in the morning that normally settles within 30-minutes, however advanced stages can lead to discomfort with general activity and sleeping at night.
Evidence based care
Osteoarthritis of the hip is a common complaint that can lead to a patient attending a healthcare professional. The evidence for the current National Institute for Health and Care Excellence (NICE) guidelines [ii] for osteoarthritis (NG226) from 2022 focus primarily on knee osteoarthritis and to a lesser extent, the hip. Their recommendations can still form a very strong base for managing hip osteoarthritis, with a key component of these guidelines being to promote weight loss by ensuring that patients remain active and undertake prescribed exercises.
There is currently limited high-quality evidence that weight loss can decrease levels of hip pain, however, professional consensus does recommend that overweight patients may benefit from losing weight to increase mobility and relieve pressure on joints.
Managing patients with manual therapy techniques
Patients who have or are more likely to have osteoarthritis are often managed with manual therapy by chiropractors and other healthcare professionals. It is important to emphasise to patients the importance of remaining active when providing any manual therapy, and to combine this treatment with physical exercise. These treatments can vary from focusing on the mobilisation of the hip joint, to soft tissue techniques such a as massage and ensuring that other joints within the kinematic chain (i.e., knee, ankle, lower back) are able to function appropriately.
Manual therapy techniques can be appropriate for almost all patients, although care needs to be taken to ensure that a patient’s medical status and history is considered. Patients who are osteoporotic should be managed with techniques using less pressure or force. This patient-centred approach is essential when treating MSK issues; everyone’s pain and presentation is unique and must be treated as such.
Putting the patient first
It is very common for fear avoidance behaviours to have a detrimental effect on a patient’s activity levels. If a patient has not been physically active for a period of time, returning to any form of exercise can lead to short term tenderness afterwards. This can create a negative feedback cycle, with some patients believing that exercise is actively making their complaint worse, limiting motivation to engage with an exercise programme. Having a phased plan of exercise, made in conjunction with the patient, and educating the patient can be an effective strategy to help them better engage with physical exercise.
When introducing exercise, activity advice and goal setting, identifying what patients would prefer to undertake can be very important with improving compliance. It is easy for clinicians get tunnel vision and prescribe the same types of exercises to their patients, without taking into account a patient’s preferences. A patient might not feel comfortable or confident to undertake isotonic exercises at home using a resistance band, for example, but would happily undertake exercises at a swimming pool. These interventions can then be linked to goals such as being able to walk further, getting dressed easier or engaging with social activities. In this way even if a patient’s improvement is not only tied to pain levels but their ability to improve their function and activities of daily living. Personalising treatment plans from patient to patient in this way is key to increasing their effectiveness.
Clear communication to patients
The manner and context in which healthcare professionals communicate with patients is becoming much more crucial within clinical management. The way in which information is communicated to patients can be equally as important as other aspects of care. It is common for patients to grasp onto ‘soundbites’ such as wear and tear or osteoarthritic changes, especially if being read from a radiographic report. As an example, if a clinician informs a patient that they have mild osteoarthritic changes of the hip, it can be easy for the patient to then understand this as having arthritis in their hip leading them to be doomed to a lifetime of pain or imminent hip replacement surgery. This can lead to patients being ‘resigned to their fate’ and being less likely to engage with important self-managements strategies such as losing excess weight or performing prescribed exercises. For this reason, context is key, and it is vital that the appropriate time is taken to explain what any findings mean, such as radiographic findings being age related, and their relevance and future implications.
Referring to GP for orthopaedic consultation
Patients who are not responding to care and are experiencing a substantial impact on their quality of life should be referred to their GP. This could be due to pain, stiffness, reduced function or progressive joint deformity.
Patients should ideally have been offered a package of care incorporating exercise, with the lack of response to conservative management triggering a referral.
Osteoarthritis of the hip can be extremely debilitating, however there are a number of ways in which a Chiropractor can support in relieving the painful symptoms of this. Typical treatment can vary from the mobilisation of the hip joint to soft tissue techniques, and this should be combined with physical activity and prescribed exercise. Despite there being recommended guidance, treatment plans for patients with osteoarthritis of the hip should be bespoke and personalised. Patients will yield better results from a treatment plan tailored to them and with their medical history and exercise and treatment preference in mind. Therefore, comprehensive understanding of patient’s goals and needs is essential. In addition to this, the way in which patients are communicated with can have a direct effect on their willingness to engage with their treatment plan. Medical professionals must be conscious of the language that they use, understanding that the words they use can have a last negative or positive impact on a patient. Finally, and most importantly, patients must always be aware of all treatment options available; informed consent must be obtained at all times throughout a patient’s care.