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Thread: Physiotherapy in Coxarthrosis

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    Default Physiotherapy in Coxarthrosis

    Physiotherapy in Coxarthrosis

    Physical therapy is essential to the treatment, rehabilitation, and prevention of many of the conditions that affect the hip and its surrounding supporting structures. By treating arthritis early and following a well-designed treatment plan, you can reduce your symptoms, increase joint movement, lessen joint-damaging effects... Osteoarthritic joints are not always painful, and when pain is present, it can vary in intensity. In some people severe osteoarthritis is completely pain-free, whereas in others even minor joint changes are quite painful. The response to arthritis pain is broad and very personal. Because of this, it is important to have an individually designed treatment program. What works for one person may not necessarily work for another, even if both have osteoarthritis of the same joint.

    Patients with hip arthritis should avoid the extremes of hip motion and should minimize jarring and high impact activities: contact sports such as football, rugby, and wrestling, and stop-and-go sports such as basketball, tennis, and racquetball should be limited or avoided, at least temporarily. The rapid changes in position and/or the impact and jarring of these activities can cause flares of arthritis and worsen arthritic damage. Avoid running, jumping and positions that cause wide spreading of the legs.
    Patient education and, where appropriate, education of the patient's family, friends, or caregivers is an integral part of the treatment plan for patients with OA of the hip. Patients should be encouraged to participate in self-management programs, such as the Arthritis Self-Help Course. Individuals who attend these programs report decreased pain, decreased frequency of physician visits, and overall improvement in quality of life. Additional educational materials, including videos, pamphlets, and newsletters, are available from the Arthritis Foundation.
    Another cost-effective nonpharmacologic approach for patients with OA is provision of social support via routine telephone contact. Studies of monthly telephone contact by trained nonmedical personnel to discuss such issues as joint pain, medications and treatment compliance, drug toxicities, date of next scheduled visit, and barriers to keeping clinic appointments, found moderate-to-large degrees of improvement in pain and functional status, and did not significantly increase costs. These studies underscore the concept that improved communication and education are important factors in decreasing pain and increasing function in patients with OA.
    Individuals with OA of the hip may have limitations that impair their ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). These may include difficulties in walking, bathing, dressing, toileting, and performing household chores. Physical and occupational therapists play a crucial role in the management of patients with functional limitations. The physical therapist assesses muscle strength, mobility, and ambulation; may recommend the use of modalities such as heat (especially useful just prior to exercise); instructs patients in an exercise program to maintain or improve joint range of motion and periarticular muscle strength; and provides assistive devices, such as canes, crutches, or walkers to improve ambulation.
    The role of exercise in the management of OA of the hip has been reviewed recently. The goals of an exercise program are to preserve at least 30[degree] of flexion and full extension of the hip, and to strengthen the hip abductors and extensors. Proper use of a cane (in the hand contralateral to the affected hip) reduces the loading forces on the joint and is associated with decreased pain and improved function. The cane should also be of proper height: when the subject is standing erect, with arms to the sides, the top (if a curved handle) or the level part (if a straight handle) of the handle should come to the level of the proximal wrist crease. Although no trial data are available to support this, patients may benefit from using shoe orthoses to correct abnormal biomechanics due to leg length inequality, as well as wearing shoes with viscoelastic insoles to decrease shock of impact loading.
    The occupational therapist evaluates the patient's ability to perform ADLs and IADLs, and provides assistive devices as needed. The patient may be taught principles of joint protection and energy conservation.
    For example, selected patients might be advised to live on one floor of their homes and to avoid painful step climbing, when possible.
    Assistive devices, including raised toilet seats, dressing sticks for putting on socks and hose, and wall bars for getting in and out of the bathtub, can be provided. For patients with OA of the hip who have pain and/or difficulty with sexual activities, sexual counseling can be provided.
    Aerobic conditioning exercises have been found to be feasible and efficacious in some patients with OA of the hip. Minor and colleagues found that patients with lower extremity OA (feet, hip, and/or knee) who were randomized into an exercise program of aerobic walking or aerobic aquatics for 12 weeks showed significant improvement in aerobic capacity, 50-foot walking time, depression, anxiety, and physical activity compared with a control group who performed only range of motion exercises. To improve functional status and reduce pain, a program of aerobic activity, particularly an aquatic program such as that sponsored by the Arthritis Foundation, should be suggested to all patients with OA of the hip. These exercise programs, however, require a commitment of time and effort on the part of the patient.
    Finally, epidemiologic studies have found that obesity is associated with an increased prevalence of hip OA; however, it is not known whether weight loss will slow the progression of existing OA or alleviate symptoms. Overweight patients with OA of the hip should be encouraged to participate in a comprehensive weight management program that includes dietary counseling and aerobic exercise. Specific dietary therapy and other unproven therapies are not recommended in the management of patients with OA of the hip.

    While you can't reverse the effects of osteoarthritis, early treatment may help you avoid pain and disability and slow progression of the disease. Surgery may help if your condition is already severe.

    If you have early stages of osteoarthritis of the hip, the first treatments may include:
    1. Resting your hip from overuse
    2. Following a physical therapy program of gentle, regular exercise like swimming, water aerobics or cycling to keep your joint functioning and improve its strength and range of motion
    3. Using nonsteroidal anti-inflammatory medications like ibuprofen for pain
    4. Getting enough sleep each night

    In later stages of osteoarthritis, your hip joint hurts when you rest at night or your hip may be severely deformed. Your doctor may recommend total hip replacement surgery or arthroplasty. A two-piece ball and socket will replace your hip joint. This will cure your pain and improve your ability to walk. You may need crutches or a walker for a time after surgery. Rehabilitation is important to restore your hip's flexibility and to work your muscles back into shape.

    Treatments may include:

    Weight Control

    Weight control is important to successful arthritis management. Research suggests that:
    - Being overweight is a risk factor for osteoarthritis
    - Overweight young adults are likely to develop osteoarthritis of the knee as they age
    Controlling your weight can:
    -Lessen pain by reducing stress on the weight-bearing joints (hips, knees, back, feet)
    -Increase self-esteem and avoid the risk of psychological suffering and/or depression that can affect overweight individuals
    Weight loss should be coupled with a regimen of more physical activity. A productive goal is a total of 30 minutes of daily exercise. Exercise may need to be altered in the presence of OA, but most can exercise.


    Regular exercise is very important for successful control of osteoarthritis.
    Strengthening and stretching exercises can help by:
    - Relieving pain and improving joint movement
    - Building up the muscles around the joint, making the joint more stable and resisting further damage.
    Specific exercises may be prescribed to improve strength and range of motion in particular joints and muscles. Three types of exercise are used to treat osteoarthritis:
    1. Stretching exercise. Also called range-of-motion (ROM) exercise, it helps to maintain joint flexibility and reach. It includes anything that puts a joint through its fullest range of motion (for example, stretching the shoulder joint by holding the arms out at the sides and circling them in a windmill fashion). Stretching exercise often is more easily performed if the person takes a pain reliever or applies heat to the joint before starting to exercise.
    2. Isometric exercise. This is exercise in which muscles are tensed for a period without actually moving them. It can be performed without actually bending a painful joint. As muscles are exercised against resistance, their size and power will increase.
    3. Aerobic exercise. This is endurance-building exercise that improves cardiopulmonary (heart/lung) fitness. For most individuals with osteoarthritis, the best aerobic exercises are:
    - Swimming (especially in a heated pool)
    - Walking on level ground
    Such gentle exercises are less stressful on the joints. Water exercise is especially recommended for people who have osteoarthritis of the large joints (hips, knees). The buoyancy of the water makes it possible to exercise while the body weight is supported.
    Since pain may worsen with increased activity, people with advanced osteoarthritis may need to take several rest periods during the day. On the other hand, too much inactivity can worsen osteoarthritis by causing increasing stiffness. An optimal treatment plan should achieve a balance between daily exercise and adequate rest.

    Heat And Cold Therapy

    Heat and cold treatments are well-known to reduce the pain, stiffness, and occasional swelling associated with osteoarthritis. But this is generally temporary. There is no 'set' formula for therapy. Heat works better for some individuals, whereas others favor cold.
    Heat often is used to relieve pain or relax muscles before the start of exercise.
    - Heating pads or hot packs can be positioned over stiff joints. Some people prefer "moist heat" in the form of warm towels, a warm shower or bath, or a heated whirlpool or hot tub.
    - Other heat treatments include ultrasound and immersion of painful hands into warm wax. All are able to bring soothing heat to sore joints.
    - Heat should be applied at a comfortable temperature and seems to be most beneficial when used over the muscles adjacent to the joint.
    Cold can lessen pain in a sore joint by numbing the local tissues.
    - It may be applied in the form of a reusable pack or ice.
    - Ice and cold packs never should be placed directly on the skin, as they are likely to cause skin damage. Instead, ice and cold packs should be wrapped in a towel before they are applied.

    Pain Medication

    Medicines to control OA pain must be pain-specific, since osteoarthritis can cause both sudden and chronic pain.
    - If a person experiences unexpected, severe pain from a damaged joint, he or she might benefit from strong pain relievers and muscle relaxants.
    - By contrast, such medications usually are not useful or appropriate for chronic pain, which is more effectively treated by self-management techniques such as proper joint use, joint protection, exercise, medication scheduling, and weight control.
    Many medications are used to treat arthritis. Some must be prescribed by a physician, whereas other "over-the-counter" (OTC) products can be bought without a prescription.

    Other Pain Relief Options

    - Transcutaneous electrical nerve stimulation (TENS) is a technique that directs small pulses of electricity to specific nerves. The aim is to reduce the sensitivity of nerve endings in the spinal cord, thereby closing the pain "gates." Although TENS is not effective in all arthritis sufferers, some people find it to be a practical means of pain control. The procedure, which produces a tingling sensation at the site of the electrical pads, has few side effects (some people have reported allergic reactions to the jelly used to apply the pads). TENS instruction usually is provided by a physiotherapist, who can explain how to position the pads, select the correct electrical frequency and pulse strength, and time how long the treatment should last.
    - Acupuncture may provide short-term relief of pain. If performed properly with sterile needles, acupuncture can do no harm. Acupuncture therapy is believed to work by stimulating the body's own pain-relieving hormones. However, acupuncture cannot "cure" arthritis; its effects are temporary.
    - Therapeutic massage
    - Yoga

    - Physical therapy

    Stress Control

    Emotional stress sometimes causes arthritic symptoms to worsen. Repeated daily stresses - such as money problems, traffic jams, or shopping difficulties - may increase joint discomfort.
    Although emotional anxiety does not appear to be as important a factor in osteoarthritis as it is in rheumatoid arthritis, osteoarthritic pain may develop after stressful life events, like the loss of a loved one or separation from a spouse.
    Arthritis itself is a source of stress.
    - Individuals may feel trapped in a vicious cycle in which arthritic pain causes stress and stress causes more pain.
    - In addition, they may have a low self esteem and feel a loss of control because of arthritis-related concerns such as pharmaceutical bills, side effects from medicines, limited mobility, or unwelcome physical changes.
    Stress management techniques are especially significant, because they can help people to regain a sense of control while relieving their arthritic pain.
    Proven techniques for stress management include:
    1. Muscle relaxation
    2. Controlled breathing
    3. Biofeedback
    4. Self-hypnosis
    5. Time management
    6. Social support
    7. Assertiveness training
    8. Coping skills training

    Injections Into The Joint

    Corticosteroids, such as prednisone, are medications that lessen inflammation, swelling, and pain. These medicines generally are not used for OA; however, the direct injection of corticosteroids into an inflamed joint can markedly reduce the swelling of soft tissues and relieve pain.
    Injectable hyaluronic acid - which currently is marketed under the brand names Hyalgan® and Synvisc® - is a new FDA-approved treatment for osteoarthritis of the knee. This form of therapy, known as "visco-supplementation," involves the injection of hyaluronic acid into the joint once a week for three to five weeks, depending on the product brand.


    Although recent advances in joint surgery have improved the lives of millions of people throughout the world, surgery is NOT the first line of treatment for osteoarthritis.

    Of course, as a physiotherapysts, we have a great job and after surgery!

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    Therapy for osteoarthritis of the hip has two major objectives: to relieve pain and to preserve function. Few randomized trials have evaluated pharmacologic and nonpharmacologic treatments specifically in patients with osteoarthritis of the hip.

    Lifestyle Interventions

    Self-help education classes inform patients about the disease and how exercise and other lifestyle modifications can result in improvements in pain and function (Table). However, in controlled trials, such improvements have tended to be modest. Educational materials may be useful in informing patients about how to deal with pain and disability. Periodic telephone-support interventions by lay personnel may also promote self-care in patients with osteoarthritis. Exercise interventions have proved effective for osteoarthritis of the knee but have been less well improved quality-of-life scores by 30 to 50% for the 3-month treatment period, as compared with the outcomes in an untreated control group; the benefit was maintained after 3 months of follow-up. Patients with osteoarthritis of the hip report an improvement in balance when walking with a cane, although this benefit has not been carefully studied. In addition, the use of insoles has been suggested to limit disease progression by reducing forces across the hip joint; however, supporting data are lacking.

    Hip pain that develops gradually and is initially associated primarily with weight-bearing activity, as described by the patient in the vignette, is characteristic of osteoarthritis. A physical examination should be performed to rule out other causes of hip pain, and radiography should be performed to confirm the diagnosis. I would initially recommend treatment with acetaminophen (up to 4 g daily) in lieu of ibuprofen. If his hip pain and function do not improve with this treatment, I would recommend the initiation of treatment with an NSAID at the lowest effective dose. Given the patient’s age, I would add a proton-pump inhibitor to reduce the risk of gastrointestinal side effects. If the pain is not relieved with these medications and awakens him at night, I would consider the use of a narcotic such as codeine or tramadol.
    The patient should be referred to an arthritiseducation class in his community and to an exercise program of water aerobics or to a physical therapist at a frequency of twice a week for at least 2 months to improve muscle strength in his legs and the range of hip motion. A physical therapist should also evaluate him for the presence of an inequality in leg length and provide him with a shoe lift if necessary. Although data from randomized trials are lacking, I would encourage weight reduction if the patient is overweight and would suggest that he use a cane while walking, since it might improve his sense of balance and confidence in performing his daily activities.

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