ARTICLE REVIEW by Tyler Tice PT, DPT, ATC
It is common for individuals with low back pain to also have associated hip pain and is often times challenging to determine the primary source of the pain. This article, which was recently published in the Journal of Orthopaedic and Sports Physical Therapy in December 2021, suggests the focus of rehab for concomitant hip and low back pain should be to the low back. Below is a review of the article.
Introduction: The cause of low back pain is not always clear and for individuals with hip AND low back pain makes the cause even harder to find. Clinicians will often perform interventions to both hip and back without knowing which treatment interventions are truly helping. This has potential to prolong symptoms and increase health care costs. The goal of this study was to determine the short term and long term effects of low back only treatments compared to low back and hip specific treatments.
Methods:
- Participants randomized to 1 of 2 groups: low back treatment only; low back and hip treatments
- Participants and therapists not blinded due to nature of the study
- Inclusion criteria: >/= 18 years old; low back pain 2/10 or more, self reported disability >20% on ODI, and concurrent hip impairment (groin pain, reproducible hip pain, limited hip ROM and/or strength, or positive special test for hip pathology)
- Exclusion criteria: contraindications to manual therapy, recent trauma to low back, positive neurological findings, recent spine surgery, hip replacement
- 76 total participants – 39 low back only, 37 low back and hip treatment
- 11 physical therapists provided treatments with each given a video training for this study
- Primary outcome measures: ODI (Oswestry Disability Index – a patient questionnaire that measures function), NPRS pain rating scale from 0-10.
- Secondary outcome measures: Fear Avoidance Beliefs Questionnaire, Global Rating of Change, Patient Acceptable Symptoms State
- Outcomes were assessed at baseline, 2 weeks, discharge, 6 months, and 12 months (please refer to article for more information on each measure)
- Treatments: all in person sessions, frequency/duration varied with recommendation of 2-3x/week for 45-60 minute sessions
- Low back only group received treatment based on therapist discretion
- Low back and hip treatment group received additional hip treatments including 2 manual therapy interventions and 2 exercise interventions based on a predetermined set of treatments
Results:
- 8 participants lost at discharge; additional 15 participants lost at 6 months; additional 5 lost at 12 months (Coronavirus played a role on this)
- Baseline characteristics and number of visits between the two groups were similar
- Disability and Pain: no significant difference on ODI and pain scores between groups at ANY time point. Both groups pain and disability improved at time of discharge and maintained at 6 and 12 month follow up
- Fear Avoidance Beliefs Questionnaire: For WORK subscale: better scores for low back group at discharge and long term follow up; For PHYSICAL ACTIVITY: no significant difference between groups
- Global Rating of Change: Slightly better for low back only group at 2 weeks and discharge; similar between groups at 6 months and 12 months; both groups improved
- Patient Acceptable Symptom Scale: no statistically significant differences between groups at ANY time; majority of patients reported an acceptable symptom state at discharge and 6 months, which reduced in both groups at 12 months
Discussion:
Based on these results, adding hip interventions for people with low back and hip pain did not improve functional disability or pain outcomes. There were some significant differences in the secondary outcome measures that favored low back only treatments. These findings suggest that adding hip treatments may not be necessary and to focus the interventions to the low back.
Limitations for this study include small sample size, missing data at long term follow ups, wide confidence intervals, and therapists and participants were not blinded. Therapists were also allowed to choose treatments per their discretion which is reflective of real world clinical practice, however can cause certain biases and non-compliance in eh research setting.
Conclusion:
“Adding treatment directed at the hips to usual low back pain care for individuals with low back pain and concurrent hip impairment did not improve disability and pain in the short or long term”
This is a well designed randomization control trial with its obvious limitations, however these limitations were hard to control for given the timing and nature of study. Based on these results, it is not necessarily a BAD thing or WRONG to perform hip interventions for these individuals with both low back and hip pain. If one of my patients have a clinical finding of a hip impairment, I think I will still address it using specific hip interventions. With saying that, we can not exclude interventions for the low back and by focusing on the low back in a rehab program may help the patient progress along more quickly. I also think this can have clinical significance when giving patients home exercise programs (HEP). Using these findings, it will be better to provide patients with 1-2 low back exercises to manage their back and hip pain instead of additional hip exercises. Patients typically have poor adherence to a HEP so it is better to consolidate their HEP to the most effective interventions using the best evidence.
If you’re one of these individuals having both low back pain with a hip impairment, give Physical Therapy First a call and we can help you out!
Reference:
Burns SA, Cleland JA, Rivett DA, et al. When treating coexisting low back pain and hip impairments, focus on the back: Adding specific hip treatment does not yield additional benefits—a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(12):581-601. doi:10.2519/jospt.2021.10593