[Physio Discussed] Exercise as medicine: tackling hip pain and OA effectively with Dr Jo Kemp and Dr Josh Heerey

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What are the current treatment options for osteoarthritis of the hip?
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How does exercise differ between a young patient and an older patient?
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And how does hip morphology fit into the mix?
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We explore all of these things and much more in today's episode with two amazing guests we are very lucky to have on, Dr.
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Josh Heery and Dr.
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Joanne Kemp.
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Dr.
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Josh Heery is a physiotherapist and hip osteoarthritis research and development lead at La Trobe University's Sport and Exercise Medicine Research Centre.
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Josh is recognised internationally as an expert in the diagnosis and management of hip and groin conditions.
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Dr Joanne Kemp is a sports physiotherapist and senior research fellow at La Trobe Sport and Exercise Medicine Research Centre in Australia.
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Jo is also recognised internationally as an expert on hip pain including FAI, and early onset hip OA in young and middle-aged adults and its impact on activity, function and quality of life.
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You'll learn so much about the hip in today's episode, leaving you far more confident to tackle the next hip that comes into clinic.
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So let's get into it.
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This is Physio Discussed and I'm Sarah Yule.
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Well, welcome Josh and Jo to the podcast.
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It's great to have you both on.
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Thanks, Sarah, for the invitation.
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Great to be here.
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Great to be here, Sarah.
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Thank you.
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Well, let's dive straight into it.
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Jo, as you've explored in a previous PhysioNetwork Masterclass, hip OA is not just chondral loss at the joint, but it's a disease of the whole joint.
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And I'm keen on both of your thoughts in the context of hip OA.
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What's the evidence for exercise and does the type of exercise matter?
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Yeah, no, it's a really good question.
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So there is some good evidence for exercise in advanced HICOase.
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We published a systematic review on that a few years ago now in BJSM that showed that both land-based and water-based exercise is good in the short term, so up to three months.
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Once you push out from three months, the evidence is a little bit less strong, but there is still evidence for land-based and water-based exercises.
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And then there was a big clinical trial that was done in Norway.
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It was probably actually done around 10 years ago, and then they published the longer-term follow-up a few years ago on that trial, and they used a combination of strengthening type exercises, physical activity, and what they called flexibility or range of motion exercises.
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And that RCT, and they compared it to usual care.
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And what they showed in that RCT was that the group that did the exercises, it was a three-month intervention of exercise.
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For up to six years, the risk of having a hip replacement was reduced by about 40%.
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And the time difference between when each group had hip replacement was almost two years.
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So there is some good evidence for exercising in advanced HIPAA.
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The problem we find clinically, and I might hand over to Josh on this in a minute as well, is that what I see in my clinic and not sure about you, Josh, is that often those people with HIPAA, by the time they present, you can try exercise with them, but they often have almost fallen off the cliff where it's almost too late.
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So I know Josh has done a quite a bit of work in the early OA space and probably has thoughts on the timing of exercise and that sort of thing for people with OA.
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Yeah, thanks, Jo.
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That's a good probably point to make because often with the keep OA, people don't always respond to exercise.
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And I think we need to obviously be open to other treatment options.
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And we could probably talk about those later in the podcast, but I think exercise is one option in those people.
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But I think it's important that we remember that not every person that we see in our clinical practice will actually respond to exercise.
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And then we need to obviously be aware what other treatment options we can access to improve their pain and their quality of life and their function.
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And it sounds like effectively, as with many things, the moral of the story is keeping people moving.
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So in the situations where you've got people that just aren't able to exercise as the solo form of treatment, what would you typically pair it with?
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There's a couple of things there.
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So Often we talk about this treatment pyramid where we think about first-line treatment options.
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So that's obviously exercise sits within that first-line treatment option.
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And within that is obviously education as well around the condition, what they can do for their lifestyle, what choice they might be able to make with their occupation, for example.
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And then there's obviously consideration of weight loss as well within that first-line treatment.
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I suppose the options that we have access to.
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And then beyond that, then we're thinking second-line interventions, which often includes things like manual therapy, but also pharmacological treatments.
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So anti-inflammatories, paracetamol, but also consideration around intra-articular injection.
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And I know there's obviously a lot of controversy around what those injections do for the joint in the long term, but I think it's in the right person at the right time, it can be a very valid treatment option to improve their pain and their function, but also enable them actually to exercise and undertake the program that you want to deliver with them as well.
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Absolutely.
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And from memory, that's the diagram that almost looks like a food pyramid where you've got the bulk of what should be happening with education, exercise and weight control at the bottom.
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Do you think there's a bit of a mismatch in what we're delivering clinically with what that pyramid actually suggests we should be doing?
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Absolutely.
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So, when we look at OA generally and bearing in mind most of the research has been done more in knee than hip, but there are some studies that have looked at hip and knee OA that what is happening in the real world is quite different to what that pyramid recommends.
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So, There was a nice study that looked at the habits of Australian GPs.
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It was published around about 10 years ago now.
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And what they found is that around about a quarter of patients with DOA who present to their GP are referred for either imaging or to an orthopaedic surgeon.
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probably around a third of them referred for NSAIDs, et cetera, or even opioids, but only 3% were referred for any sort of exercise-based treatment, which include physio-based exercise treatment.
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So there is a real inversion of that pyramid where what should be happening to a few is probably happening to too many and not enough people are being referred to exercise.
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And there's lots of reasons for that.
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I think there's perceptions on the whole bone-on-bone concept and that pure relationship between what you see imaging-wise structurally versus symptoms.
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And we know from a lot of Josh's work and others' work that not just in our way, but in the earlier way, young people with hip pain, that that correlation is actually really, really poor.
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And so I think if we can try and change some of those perceptions, maybe more people would be referred for exercise because exercise does have the capacity to address all of the other things that we know cause pain beyond structure, but even does have the potential to affect structure as well.
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I think that's a great point.
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What are both of your thoughts on if you've got a clinician seeing a patient and the patient is really keen on getting imaging as a form of diagnosis, how do we go about conveying that likely or perhaps unlikely diagnosis without necessarily going straight to imaging and really addressing the bottom bit of that pyramid?
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Yeah, great question.
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I think that's something which often we face in our clinical practice on a daily basis.
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Probably if we consider imaging a patient, and we can talk about the different reasons why we may consider imaging, but I think if we're thinking it might be appropriate, then I think it's really important to send them away understanding that they're probably going to find things on imaging, whether that be x-ray, MRI scan, or CT, or ultrasound.
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So they are aware that it's very normal to have changes in tendon joint cartilage on imaging, and the fact that they're not always related to their symptoms.
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I think that's a good starting point.
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So, then they're sort of coming to you with the results, understanding that, okay, these things are often seen in people without pain.
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That's often something which I do, even sending someone to imaging, let them know that these things are probably going to be there.
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And then it's my job to work out what's relevant on that imaging scan or the report.
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Fantastic.
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And you're right, it always comes back to giving context to the patient, whether it's exercise and that second line of treatment with injections or NSAIDs or any of those forms of management and the same thing will go for imaging as well.
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Context is king.
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Indeed.
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Josh, perhaps you can answer this one.
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Going back to the role of evidence with exercise, in terms of exercise management for treating hip pain in younger people when the source of symptoms might be labral or cartilage tears, how does that differ from the later stages?
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Yeah, so I think, look, there's definitely evidence to support the role of exercise therapy in someone with early hip OA, so probably in their, say, maybe 30s, 40s and 50s, that shows that they can have beneficial effects for pain reduction, improvement of function, getting back to sport, quality of life, all of those sort of important patient parameters.
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But I think it's important to flag also that A recent systematic review found that around half people may actually not respond to exercise therapy.
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So again, it's this idea that it's a really important treatment option and something that we can use, but to also be aware that your patient may not respond as well to that approach.
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And then again, you need to be aware of other treatment options, like we mentioned earlier, that might be really valid to your patient and actually may help them and also improve in addition to their exercise therapy.
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In clinic then?
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What sort of timeframes would you be looking at if you've had a younger person present with hip pain that's not responding to exercise as well?
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What sort of timeframes would you be looking at to pair it with or refer on?
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Yeah, that's a good question.
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I think it's very individual.
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I suppose one thing that's always important to consider is what treatment they had before they have come to see you.
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So if they've undergone three to four, five months of good quality exercise therapy, then it's unlikely they're going to probably respond to another sort of three to four months of exercise therapy with you.
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But again, I suppose it's important to understand what they actually have done with their previous clinicians.
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In the patient that may have not tried exercise therapy, then the recommendations say that we should consider 12 weeks of exercise as an appropriate timeframe to see a response.
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But if your patient's really despondent, they're not having improvement they want to seek another opinion or consider another treatment option, then you've got to consider that as part of your treatment.
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For sure.
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That's a fantastic point as well.
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And I'm sure you'd both often see the second and third and fourth clinical opinions with people being sent to you.
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In the context of having seen what the previous clinicians might have prescribed, Is there any consistencies that either of you see in how exercise is being prescribed and is sort of 90% of the program right, but 10% might be a bit off, like they might be overloaded or underloaded?
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Is there anything that you find yourself consistently going, it's nearly there, but just tweak this?
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Yeah, that's a
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good question.
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And I think we're interested to see what Josh, whether we see similar things in our clinic or not.
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But if I think of some things that I see that are perhaps not quite there consistently, Physios are getting better and better at prescribing joint-specific rehab for people with hip pain, young people with hip pain.
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I think that's really improved over the last five years.
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I think the knowledge out there is a lot better.
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What I think is missing is that recognition of the importance of general physical activity.
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So if we could call it non-joint-specific physical activity in addition to the joint-specific rehab program.
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So really encouraging all patients to be trying to meet the physical activity guidelines.
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And also that recognition that physical activity can be done even in a state of pain.
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You just don't want it to be too much pain.
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That often when you sit down with patients and tease it out, they'll say, I've stopped doing any physical activity because I didn't want to stir up my pain.
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But what I found is I'm no better now that I've stopped.
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In fact, I'm worse.
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I feel better when I am doing some sort of general fitness.
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So it's really trying to find what type of physical activity patients can do in a way that doesn't stir up their pain too much, but still enables them to meet the physical activity guidelines and the importance of that for all patients.
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I think that's something as physios we do need to get better at.
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It's interesting.
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We have just recently completed a large clinical trial in people with FAI syndrome And we presented this at the SMA conference last year and at some other conferences.
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So the abstract is being published, but the main trial hasn't been published yet.
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But what we found in that trial is we compared a targeted sort of strengthening intervention that was three months of supervised exercise and then gave them a three-month gym membership with sort of maintenance sessions with the physio.
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We compared like an individualized targeted strength program to a stretching-based program.
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And what we found is that actually both interventions, the patients improved quite dramatically by about 22 points out of 100.
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So bigger than the minimal important change for the measures that we use and also bigger than what the previous surgical RCTs had found.
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And we were not surprised, we were pleased that the targeted individualized strengthening group got a lot better, but we were a little bit surprised that the stretching group also got improved just as much.
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And so what the stretching group had is they got some standardized stretching sort of flexibility exercises, but also general physical activity education and guidance.
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And sort of our, I guess our take home from that is that actually just getting people to exercise and be active might be as important as the specific targeted exercise that address their impairments.
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We've always pushed a very much an impairment-based approach.
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focus.
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So, you know, assess someone's impairments and then give them interventions to try and improve those impairments.
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But the non-specific exercise group also improved.
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Interestingly though, the group that got the targeted individualized strengthening got more strong than the non-specific stretching group.
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So, their strength measures actually got better.
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So, if someone needs weight, give them strength because that will make them stronger.
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And when we look at their perceived pain, Do you feel like your perceived pain improved or not?
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A statistically significantly larger group of the targeted strengthening group felt their perceived pain had improved than the stretching group.
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So around about three quarters of the targeted group felt like their perceived pain had improved compared to about half of the stretching group.
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So even though their overall quality of life improved in both groups by 22 points, the targeted strengthening group probably when you looked at drill down a little bit more into the subtleties probably improved by more than the stretching group.
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But in saying that, if someone comes to you and they love yoga, they love flexibility and they love physical activity, that's probably going to be good for them.
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And they hate weights and they hate strengthening, like don't ram strengthening down their throat because they'll probably still get some benefit from doing something other than, you know, would be very focused on strengthening.
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Strengthening is very important, but you can also introduce other types of exercise as well.
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Fantastic.
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Josh, did you have any thoughts on that one as well?
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What are your low-hanging fruits?
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Just picking up what Jo said about the strength element, I think our first job is to identify that.
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And often I think that's probably something that we don't do well enough in our clinical practice.
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So often, and many of those may see this, is the use of objective measures to assess hip strength is not often done in our patients.
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So I think we need to be able to identify those impairments and are they actually impairments, and that will help you decide on what treatment you're going to deliver to your patient.
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I think that's a really critical point because if your patient's really strong, there's probably no point delivering a strengthening intervention to them or they may not benefit as much as someone who may be very weak, for example, in particular hip muscles.
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I think that's a really important point.
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And then as Joe sort of mentioned, I think there's obviously people getting improvement from a whole series of different interventions and we see that in obviously in Joe's studies and a few other studies have looked at something similar.
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So I think this idea that we can tailor a program that suits our patients, that means they're going to be compliant with what we're giving them is really important.
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And there's been studies in people with more advanced HIPAA that have shown that both high intensity and low intensity exercise is equally as effective in pain reduction.
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So I think asking your patients what they prefer and then developing a program around that is probably pretty important for compliance because if you've only got one option for every patient, then you're probably not going to be successful in a lot of patients that you see.
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We also just recently published a study just a couple of weeks ago in the Brazilian Journal of Physio where we actually asked patients with FAI syndrome what they wanted from their physio treatment.
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And the really key things that they said they wanted to get were they wanted to be able to return to physical activity and return to sports.
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So, one of their main reasons for seeking out physio treatment was to be able to get back to activity and sports.
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So, really keeping that at the front of our mind and planning for that right from the start.
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But the other thing they really wanted was to know what's this going to cost them in terms of time and also money.
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So rather than just having your patient coming in and you say, I'll see you next week, you'll see you next week, give them a plan right up front that, look, this is going to take you, like Josh said earlier, this is probably going to take you at least three months, but it could be up to six months before you really get the full benefit of this.
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And you hopefully will see improvements along the way sooner than that.
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So that they're prepared for that and that they're also prepared that exercise is a key thing.
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So like Josh said, you could start to talk to them about their preferences.
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Like, do you like the gym?
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Do you want to get a gym membership?
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How much is that going to cost you?
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You know, you're going to need to go two to three times a week.
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How are you going to build that into your schedule?
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And just being really clear and explicit with them of what the overall program is going to look like right from the start, because they don't like it when they're just told to come back each week without actually having a clearer longer term plan as well.
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That's a pretty powerful point.
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I think it's probably one of the most important questions we can ask patients is what are your expectations from the session?
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And then, as you've both said, you can have the ability to create a really patient-centered program that's addressing their needs.
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And Josh, as you said before, I feel like you're right.
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We actually have so much technology now to be able to be really objective than just relying on manual muscle testing.
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There's the dynamometry cost has come down.
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You've got force machines like active force that might be a couple of hundred dollars that mean that we can be really objective.
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And I'd imagine it's a pretty good selling point, or in my experience anyway, it's a good selling point to patients when you're actually looking at either a side-to-side difference or a reduction in strength relative to their body weight.
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That's a pretty powerful measure.
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Yeah, I think so.
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And as with all the treatments we have, it's important to acknowledge the limitations of the assessment method.
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But I think as a starting point, that's a really good foundation to your assessment and often it hasn't been done and the patient doesn't really understand why you're giving them a particular exercise.
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So, if you can put two and two together for them, that probably is going to improve their compliance, what you're asking them to do.
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Take them on the journey.
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Exactly,
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yeah.
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So, you measure strength and then, Joe, I know you spoke about this in your masterclass.
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In terms of re-measuring strength, range of the hip as you're treating hip OA and that presentation.
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What do you reassess and what do you tend to use as a measure less frequently?
00:19:44.295 --> 00:19:57.913
It's interesting because probably for the last 10 years, I've been measuring as the measure that I will use before and after the start and at the finish of treatment, I've been measuring hip flexion range with an inclinometer as a way of measuring change.
00:19:58.114 --> 00:20:11.093
And the reason for that is probably about almost 10 years ago now, we published a paper from my PhD was in people who had undergone hip arthroscopy, but we found that hip flexion range was the thing that was most closely associated with their outcomes.
00:20:11.292 --> 00:20:13.957
And so that's why I've been doing that myself and still do that.
00:20:14.136 --> 00:20:26.009
And Josh was part of a consensus paper that was published a few years ago where it found that the evidence for what range is important was probably a little bit light on the ground and not as strong as it could be.
00:20:26.049 --> 00:20:40.570
But we have a fantastic PhD student called Diogo Gomez, who's looking at that at the moment, and he'll have some really interesting findings that'll hopefully confirm what the best range of motion measure is in people who haven't had surgery.
00:20:41.092 --> 00:20:45.057
But yes, I tend to measure flexion range as a changeable range of motion measure.
00:20:45.377 --> 00:20:51.388
Some of the rotation ranges that we measure are perhaps are less relevant in that they don't tend to change as much.
00:20:51.429 --> 00:20:59.778
They might be a little bit more related to the morphology that we can't change and perhaps less related to some of the patient reported outcomes.
00:20:59.917 --> 00:21:07.065
I don't know, Josh, what you do in your practice in terms of that objective measure, you can see a quick change from before to after treatment.
00:21:07.786 --> 00:21:10.387
Yeah, I think flexion is probably the one that you will see the most.
00:21:10.608 --> 00:21:19.171
And I think, as you mentioned, the rotational range that someone has is heavily influenced by their acetabulum and also their femoral morphology.
00:21:19.211 --> 00:21:38.301
So I think we want to be really careful about trying to improve those because we may be intervening on something that actually can't be changed and there's only to jump on social media and you'll see people doing all sorts of stretches to try and improve hip mobility or hip rotation range and they're essentially probably stretching something that can't be stretched.
00:21:38.321 --> 00:21:40.625
So I think it needs to be considered properly.
00:22:08.483 --> 00:22:14.798
And when you think about the functional movements that people lose when they have hip pain or hip OAS, those movements that require flexion.
00:22:14.897 --> 00:22:22.814
So putting on shoes and socks is the classic one, sitting in low chairs, getting in and out of the car where you need a lot of flexion range to get in and out of those positions.
00:22:22.855 --> 00:22:28.827
So I think that also just logically makes the most sense from a functional point of view.
00:22:28.847 --> 00:22:28.927
Yeah.
00:22:29.315 --> 00:22:29.515
Yeah.
00:22:29.535 --> 00:22:33.800
And I think you can use those measures as well to help with their treatment as well.
00:22:33.820 --> 00:22:49.357
Like if someone has limited hip flexion range, then using something like a wedge cushion for them at work may really improve their hip pain considerably or getting a higher seat in their car or reducing their squat depth or all those things can be used to inform the treatment you're going to deliver them.
00:22:49.798 --> 00:22:50.057
Yeah.
00:22:50.438 --> 00:22:58.426
And I suppose also going even further back, those sorts of questions of, are you having difficulty tying your shoes, manipulating shoelaces?
00:22:58.446 --> 00:23:05.686
Are you having back pain, hip pain, what sort of functional activities are you finding challenging might aid in the diagnosis?
00:23:06.211 --> 00:23:11.996
Coming back to one of your original questions, Sarah, was how do you, you know, do you need imaging to diagnose somebody with HIPAA?
00:23:12.436 --> 00:23:24.067
When you look at the diagnostic criteria for HIPAA, it is pain in the area, reduced range of motion and reduced ability to do functional tasks and pain with functional tasks.
00:23:24.127 --> 00:23:27.630
And they're sort of the clinical diagnostic criteria and being over 45.
00:23:28.070 --> 00:23:37.298
So if someone comes to you over 45 and has those criteria, you can potentially make a clinical diagnosis of OA without having imaging to for that diagnosis.
00:23:38.400 --> 00:23:38.461
And
00:23:38.500 --> 00:23:45.307
that's pretty powerful as a clinician educating a patient that we can just reframe what imaging actually means.
00:23:45.348 --> 00:23:48.731
It's not necessarily the diagnostic source.
00:23:48.812 --> 00:23:52.135
It's in our effectiveness of subjective.
00:23:52.817 --> 00:23:53.637
Yeah, absolutely.
00:23:54.618 --> 00:24:01.706
On hip morphology then, I suppose, what role does hip morphology play when considering treatment options?
00:24:02.167 --> 00:24:05.692
And on that, probably education, Josh, as you say, I couldn't agree more.
00:24:06.019 --> 00:24:14.994
There's so many exercises on social media to unlock hips and people are probably pushing through FAIs and retroversion and whatnot.
00:24:15.836 --> 00:24:17.019
Yeah, I think that's a good question.
00:24:17.399 --> 00:24:20.484
Is this part of the profile for your patient?
00:24:20.524 --> 00:24:26.274
So obviously, particular morphologies, if we think about surgery, for example, the treatment options are different.
00:24:26.334 --> 00:24:31.403
Like we think about dysplasia, often it's a reorientation of the socket and or maybe femoral neck or head.
00:24:31.779 --> 00:24:40.611
Whereas like FAI syndrome, CAM morphology, PITS morphology, there's obviously arthroscopic techniques to improve the shape or the morphologies that are associated with that condition.
00:24:40.631 --> 00:24:42.173
So I think there's the surgical side.
00:24:42.213 --> 00:24:52.627
Probably the physiotherapy treatment side, there's things that we as clinicians see and think that maybe we change our treatment approaches for different conditions.
00:24:52.748 --> 00:25:00.919
But I think if you look at empirical evidence, we probably don't know enough in terms of specific treatment regimes for different conditions.
00:25:01.507 --> 00:25:03.230
Often there's a lot of overlap.
00:25:03.250 --> 00:25:10.424
So there's obviously muscle strengthening, there's physical activity, there's trunk strength, trunk endurance, functional strengthening.
00:25:10.925 --> 00:25:12.750
All of the principles are largely the same.
00:25:12.789 --> 00:25:15.895
But is this probably because we just don't know enough in that space at this point?
00:25:16.076 --> 00:25:17.357
I don't know what you think about that, Jo.
00:25:17.838 --> 00:25:18.800
Yeah, no, I totally agree.
00:25:18.880 --> 00:25:22.147
And probably really the only condition...
00:25:22.500 --> 00:25:38.551
Morphology-wise, where I'll really think about specific exercises is with hip dysplasia that we know from Julie Jacobson's work that they are generally weak and sore in their hip flexors and hip abductors.
00:25:38.591 --> 00:25:44.263
And when you think about what happens in dysplasia at the socket, you lose acetabular coverage at the side.
00:25:44.515 --> 00:25:45.577
and also at the front.
00:25:45.877 --> 00:25:47.600
So that's where most of the coverage is lost.
00:25:47.621 --> 00:26:01.346
Then it makes sense that in those patients, their abductors at the side and their hip flexors at the front are going to be trying to provide some sort of muscular additional coverage or stability to the joint that you won't get because of the shallow acetabulum.
00:26:01.385 --> 00:26:18.709
So probably in those patients, I do really make sure that almost regardless of what my dynamometry findings are that I really make sure I include targeted exercises for hip flexor strength and hip abductor strength, even if my dynamometry suggests that that's perhaps less important.
00:26:18.889 --> 00:26:20.251
But otherwise, yeah, absolutely.
00:26:20.291 --> 00:26:25.680
I agree with Josh that we don't, in saying that, even though I include that, we don't have evidence to say that that is the best thing to do.
00:26:25.760 --> 00:26:30.828
I'm just basing that off the knowledge that we have of what those patients present like.
00:26:30.868 --> 00:26:44.803
But I agree with Josh that generally speaking, those general exercise principles of hip muscle strengthening, functional strengthening, trunk muscle strengthening, general physical activity, maybe some mobility exercise as well, is the most important thing for those patients.
00:26:46.728 --> 00:26:49.814
In that, what about the role of your deep hip rotators?
00:26:49.894 --> 00:26:54.543
Is that effectively similar to your role of your hip abductors and your hip flexors?
00:26:55.264 --> 00:26:57.829
Are we undercooking or overcooking the hip rotators?
00:26:58.430 --> 00:26:59.011
Yeah, that's
00:26:59.111 --> 00:27:00.334
such a good question, Sarah.
00:27:00.375 --> 00:27:06.024
And look, over the last decade, I think there has been so much discussion around the role of hip rotators.
00:27:06.866 --> 00:27:13.759
Generally speaking, I won't prioritize that over other muscles in patients for a couple of reasons.
00:27:14.083 --> 00:27:26.723
Firstly, the evidence that we have up till now doesn't really suggest that they play a more important role in your larger hip stabilizing group, so your hip extensors, your hip flexors, adductors.
00:27:26.823 --> 00:27:49.044
However, in some patients, if they are particularly weak in those rotator muscles or if they have functional requirements where they do need a lot of rotational control, I will have a focus on the hip rotator muscles, but often I'll do that perhaps in a more functional way rather than a specific open chain rotation exercise against band.
00:27:49.064 --> 00:28:02.963
One of the reasons for that is that what I've found in my clinical practice and interest to see what Josh says about this as well, is that doing a lot of rotational movement backwards and forwards and backwards and forwards and backwards and forwards under load aggravates pain.
00:28:03.491 --> 00:28:10.201
These patients, particularly when they're in that acute painful stage, don't like a lot of excessive rotational movement.
00:28:10.300 --> 00:28:17.809
So trying to get rotator muscle activity without doing a lot of open chain, I find tends to work better.
00:28:17.869 --> 00:28:21.855
And it's also about people have only got so much time in their day to commit to exercises.
00:28:21.895 --> 00:28:24.197
Do we want to be giving them eight different exercises to do?
00:28:24.217 --> 00:28:28.384
Or do we want to really prioritize the two or three key ones that are most important for them?
00:28:28.740 --> 00:28:35.529
And I find that from a priority point of view, the rotation exercises for most people are less important.
00:28:36.050 --> 00:28:38.153
Not to say they're not important for some people though.
00:28:38.994 --> 00:28:40.557
Yeah, I tend to agree with Joan.
00:28:40.576 --> 00:28:45.703
There's probably a couple of things I'll add is obviously firstly about how we assess the deficit there.
00:28:46.044 --> 00:28:56.299
So I understand the concept broadly and I can see how it may work, but then it's how we actually assess the deficit in those muscle groups is probably one thing to think about.
00:28:56.803 --> 00:29:02.953
And then if we can do that, do we have exercise that actually target those specific muscle groups consistently?
00:29:02.973 --> 00:29:05.759
And again, I just don't know whether we do at this point.
00:29:06.339 --> 00:29:12.490
So yeah, I think it's part of, again, part of your treatment consideration, but I personally focus a lot on it myself.
00:29:13.192 --> 00:29:18.921
The other thing to remember is that the same muscles that do the rotation movement of the hip do up the movements of the hip.
00:29:19.021 --> 00:29:26.309
So if you think about the biggest contributor to external rotation, the hip is actually your inferior glute max and then your biceps femoris.
00:29:26.350 --> 00:29:28.958
So if you're targeting those muscles.
00:29:29.411 --> 00:29:41.204
perhaps through hip extension exercises or whatever, you're going to get an element of improvement in the muscles that do the external rotation movement, even if you're not training them into external rotation.
00:29:41.264 --> 00:29:48.933
So, you may well get hypertrophy of that muscle if that's what you're trying to achieve without necessarily going into the external rotation movement.
00:29:48.973 --> 00:29:57.803
So, it's about prioritizing and choosing exercises where you might get more bang for your buck, potentially, just knowing that not everyone has time to do 10 different exercises.
00:29:58.371 --> 00:30:15.411
Yeah, probably the only thing I'll add to what Jay just said is that, and again, to my point before, is that there's no studies to say that a particular exercise regime like that is going to be superior to a general exercise program where they might be doing, say, a bridge or a split squat or something like that.
00:30:15.531 --> 00:30:56.854
So I think it's important for clinicians to remember that often we get bogged down with the specific movements and they're activating a particular muscle, but there's just not the studies to support or to show that that's any more effective than a simplified approach in a patient.
00:30:56.894 --> 00:31:06.710
And often simplified approach means that they can actually do it at home in their own time and not get confused and get sufficient doses of exercise and they understand.
00:31:06.750 --> 00:31:13.221
So I think there's merits to both options, but I think a simplified approach is often easier for our patients.
00:31:14.102 --> 00:31:15.885
I think those are great points.
00:31:16.186 --> 00:31:23.448
And it sounds like you both strike the balance between It's a simplified approach whilst also addressing impairments.
00:31:23.810 --> 00:31:26.382
So it's equally not a general approach.
00:31:27.151 --> 00:31:38.647
Just to your point before, Josh, when you said, I think, identify where the impairment is with respect to internal and external rotators, there's so many ways that we can assess that, isn't it?
00:31:38.827 --> 00:31:52.506
I mean, I've seen we do it in seated or we do it in prone or we do it in the 90-90 position and that has implications for what the femoral neck or the femoral head coverage looks like with relation to the acetabulum.
00:31:52.587 --> 00:31:58.067
So, as you say, keeping it functional and closed chain probably makes far more sense for the patient.
00:31:58.808 --> 00:31:59.569
I think so.
00:31:59.729 --> 00:32:08.583
And any of the listeners that have completed those assessments with the dynamometer know that it's often a tricky movement for your patients to actually reproduce.
00:32:09.364 --> 00:32:15.313
So, what are we actually getting from the testing of those muscles and those different angles is probably the next question you want to ask yourself as well.
00:32:15.854 --> 00:32:16.395
Yeah.
00:32:16.879 --> 00:32:22.348
Talking about prioritizing time, like as therapists, a lot of physios may only have a 20-minute appointment.
00:32:22.408 --> 00:32:30.381
So do you want to spend your whole time doing a million dynamometry measures or really hone in on the ones that are most important as well?
00:32:30.421 --> 00:32:38.273
So I think for therapists, we have to be time efficient as much as we have to expect our patients to be time efficient with the exercises that we're giving them as well.
00:32:39.896 --> 00:32:41.158
That's a fantastic point.
00:32:41.478 --> 00:32:46.393
You can almost take that back to the asterisk measure as well.
00:32:46.533 --> 00:32:53.661
If they're having trouble tying their shoes, that might become your asterisk gun, which might lead into whether you assess flexion.
00:32:54.322 --> 00:32:54.983
Yeah, exactly.
00:32:55.303 --> 00:32:55.523
Totally.
00:32:55.583 --> 00:32:57.025
It holds relevant for the patient.
00:32:58.146 --> 00:33:21.772
If you've got a fine-up period of time, which everyone does with their patients, and, for example, your patient is held up on imaging findings that they're worried about being really severe and related to their pain, I would probably prioritise those measures Those things are often going to be barriers to your patient engagement exercise over a particular exercise that targets a particular muscle group, I think.
00:33:21.832 --> 00:33:27.081
There's bigger picture things that you want to get right with your patient initially, and then you can finesse those things maybe down the track.
00:33:27.101 --> 00:33:30.907
But without addressing those bigger things, I think you can often fall down with your treatment.
00:33:31.568 --> 00:33:32.089
Very true.
00:33:32.269 --> 00:33:38.900
It's the zoom out so we can zoom in, get the education right and get the expectations set, and then we can move forward.
00:33:39.461 --> 00:33:40.263
Great points.
00:33:40.719 --> 00:33:52.796
So going back to hip morphology, in the context of your patients with FAI and hip dysplasia, of those, who goes on to develop hip osteoarthritis?
00:33:53.718 --> 00:34:04.473
So obviously, we have a lot of large-scale studies that show that both morphologies are, I suppose, risk factors for hip osteoarthritis development.
00:34:04.573 --> 00:34:12.023
So if you have that Morphology, for example, you're going to be at greater risk of developing hip osteoarthritis than the person that doesn't have the morphology.
00:34:12.983 --> 00:34:18.090
But in saying that, not everyone with the morphology will go on and develop osteoarthritis.
00:34:18.130 --> 00:34:25.578
So, there's a relative risk, which is essentially comparing the person with morphology to the person without, and then it's the absolute risk.
00:34:25.598 --> 00:34:32.567
So, how many of those people will actually go on and develop osteoarthritis if you have the particular dysplasia or ham morphology?
00:34:32.587 --> 00:34:37.009
So, I think it's important for patients to remember because they often get told the relative risk.
00:34:37.229 --> 00:34:46.119
So they have a higher odds to the person without, but they actually don't get told the absolute risk that even though you have that, you're not guaranteed to go and develop osteoarthritis.
00:34:46.798 --> 00:34:49.843
So I think they're two important points you need to share with your patient.
00:34:50.724 --> 00:34:57.010
And in terms of the risk, it really varies between studies and across different populations that you look at.
00:34:57.071 --> 00:35:04.778
But I think the main take-home would be that it does increase the risk, but it's not guaranteed that your patient will go and develop osteoarthritis.
00:35:04.938 --> 00:35:05.639
It's not that simple.
00:35:06.255 --> 00:35:13.182
I think that's really important because that understanding of the risk can really influence people's decision making around what treatment is best.
00:35:13.222 --> 00:35:23.333
Like if they're told, you've got a 10 times higher risk of getting arthritis because you've got this bump on your hip, the patient will immediately jump to, well, I have to get rid of this bump.
00:35:24.094 --> 00:35:26.376
And so that can really drive treatment decisions.
00:35:26.516 --> 00:35:30.420
But then that's, as Josh shared, the absolute risk is still low.
00:35:30.440 --> 00:35:33.121
It's still only a small number who will go on to develop arthritis.
00:35:33.182 --> 00:35:38.322
And we don't have the evidence yet that Changing that risk factor will actually change whether or not you get arthritis.
00:35:38.382 --> 00:35:45.456
So absolutely important to not catastrophize things and not put fear, to just be very sensible in how you describe it.
00:35:45.516 --> 00:35:47.079
And Josh described it perfectly.
00:35:47.298 --> 00:35:47.338
I
00:35:48.101 --> 00:35:51.606
suppose for some context, Sarah, if you think there's one, like some of...
00:35:52.304 --> 00:35:54.847
curricular's work, who's a Dutch orthopedic surgeon.
00:35:55.146 --> 00:36:00.813
He's done a lot of longitudinal studies looking at the importance of cam morphology and dysplasia and PITS morphology, for example.
00:36:00.874 --> 00:36:12.126
And I think in one of his studies, he found that even if you have a large cam morphology, so I think they define that by an alpha angle of maybe 83, I think, or greater than 83 degrees and reduced internal rotation.
00:36:12.186 --> 00:36:14.269
So, a restricted joint range.
00:36:15.070 --> 00:36:19.996
Still only half of those people actually developed osteoarthritis in a five-year time period.
00:36:20.076 --> 00:36:30.990
So, Again, even when you see those more extreme cases in clinic, only half of those, if we look at the work by Rinche, actually developed osteoarthritis in a five-year time period.
00:36:31.010 --> 00:36:38.804
So again, this highlights that, I suppose, that important distinguish between the relative and absolute risk and educate your patient about that.
00:36:39.280 --> 00:36:43.385
And there's a lot of other intersecting factors too that we don't fully understand in those patients.
00:36:43.585 --> 00:36:53.856
And Josh is leading some interesting work in this space that looks at, we know that there is an increased risk of developing hip arthritis if you have a manual occupation.
00:36:54.237 --> 00:36:56.380
So farming, factory working and that sort of thing.
00:36:56.720 --> 00:37:07.954
There is also an increased risk if you play elite sport where you are playing a lot of sport, but what we don't understand as well is the risk If you're sedentary, we think there's probably a risk in being sedentary as well.
00:37:08.034 --> 00:37:16.728
So there's a lot of intersecting factors beyond just the shape of the hip that will, I think, contribute to whether someone is going to develop arthritis or not.
00:37:16.869 --> 00:37:27.668
And then there's all the other non-mechanical factors like body mass and inflammatory diets and all sorts of other things that we haven't even looked at that I think can contribute to that risk as well.
00:37:28.112 --> 00:37:29.474
It's fascinating, isn't it?
00:37:29.514 --> 00:37:42.972
It's always finding that Goldilocks zone of knowing that something like a physically demanding job increases the risk of developing hip OA whilst also strengthening can equally help delay the need for a hip replacement.
00:37:43.572 --> 00:37:58.072
So it's like I do wonder your thoughts on where the sweet spot is and I wonder what factors might play a role in driving hip pathology in a physically demanding job that a strength program suitably mitigates given both involve load.
00:37:58.672 --> 00:38:01.175
As Joe mentioned, most studies have looked at them separately.
00:38:01.195 --> 00:38:09.487
So some of the work that we've been doing is looked at a cohort of football players and essentially divided the football players up into those with high and low occupational load.
00:38:10.188 --> 00:38:21.503
And what we found is the symptom presentation is worse in the combination, so the high occupational load and football dissipation, but when you actually look at MRI findings and morphology, it's actually the same.
00:38:21.967 --> 00:38:32.182
Our take of that is maybe it's the morphology is the same and MRI findings are the same, but they're becoming sensitized because of the occupational load that that person is undertaking on a daily basis.
00:38:32.744 --> 00:38:38.753
But again, I suppose speaks to that, the intricacies of the morphology and MRI findings.
00:38:38.813 --> 00:38:49.068
And again, we just need to know more in that space and how they relate to the, I suppose, progression of disease, but also the symptom presentation that we see in our clinical practice.
00:38:49.487 --> 00:38:56.717
And then there's also all the other kind of confounding things that contribute for someone perhaps who is in a more manual job.
00:38:56.938 --> 00:39:01.124
There may be differences in other lifestyle factors as well that sit alongside that.
00:39:01.164 --> 00:39:09.936
And it might be those other lifestyle factors that are increasing the risk just as much as the actual manual job, you know, things like socioeconomic status, sex or gender.
00:39:09.976 --> 00:39:15.583
Like there's so many other things that can influence things that relate to the type of work that you do.
00:39:16.079 --> 00:39:19.967
that it might not just be the work, the mechanical elements of the work that you do.
00:39:20.387 --> 00:39:22.851
And then there's all the psychological elements of work as well.
00:39:22.952 --> 00:39:28.041
So I think there's lots of different contributing factors of what we really just don't understand at all.
00:39:28.641 --> 00:39:32.750
All the factors that make an RCT fun to design and plan, I'd imagine.
00:39:33.550 --> 00:39:33.972
Exactly.
00:39:33.992 --> 00:39:47.269
And I suppose on what you've both said, as you say, sometimes there's not an alignment with what Imaging might say what the symptoms are or a person may have FAI and their symptoms may fluctuate.
00:39:47.329 --> 00:39:59.507
So in that, I'd imagine you'd both find yourself outlining the possible other symptom sources that might be intra-articular and extra-articular that do have the capacity to be calmed down during the treatment.
00:40:00.175 --> 00:40:00.757
No, definitely.
00:40:00.817 --> 00:40:04.302
I think a lot of the extra articular soft tissues can contribute to pain.
00:40:04.822 --> 00:40:10.550
There's always the possibility that there's potentially referred pain from other structures like lumbar spine and pelvis.
00:40:10.610 --> 00:40:19.083
I think in women, we have to be really aware of the potential gynecological sources of pain as well that can often be overlooked.
00:40:19.163 --> 00:40:20.945
So yeah, absolutely.
00:40:20.965 --> 00:40:30.670
There's many things beyond the hip joint itself that can contribute to pain that if we don't address, then I think we won't fully be able to help people manage their pain.
00:40:31.409 --> 00:40:32.050
Absolutely.
00:40:32.952 --> 00:40:36.795
I think the lumbar spine and the hip is probably a whole podcast in itself.
00:40:37.757 --> 00:40:38.298
Yeah, I reckon.
00:40:39.298 --> 00:40:39.818
Fabulous.
00:40:40.320 --> 00:40:43.222
Well, thank you both so much for your time today.
00:40:43.262 --> 00:40:47.648
And I think, I really do think listeners can come away with some fantastic clinical pearls.
00:40:47.688 --> 00:41:06.195
And we've seen that a comprehensive, subjective evaluation and Imaging when needed and indicated and the right assessment tools and procedures that we can all hopefully diagnose well and develop some really effective treatment plans for our patients and work towards improving quality of life.
00:41:06.235 --> 00:41:08.018
So thank you both very, very much.
00:41:08.057 --> 00:41:09.599
Thanks for having us, Sarah.
00:41:10.119 --> 00:41:10.900
Been a pleasure, Sarah.
00:41:10.920 --> 00:41:11.101
Thank you.
00:41:11.541 --> 00:41:11.942
Thank you.
00:41:11.981 --> 00:41:20.452
Hopefully you enjoyed today's episode of Physio Discussed.
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If you did, please do subscribe and feel free to leave us a rating.
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Josh and Jo can both be found on Instagram, Jo on at Joanne L Kemp and Josh on at Jay Heery.
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I'm Sarah Yule.
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Thank you for listening.
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And this is Physio Discussed.