Evidence-Based Approach

Introduction

Clinical practice guidelines are patient care recommendations systematically formulated based on scientific research data or evidence to guide health care decisions for specific clinical conditions or specific situations (Segen’s Medical Dictionary. 2011.). [1]

When using clinical practice guidelines to guide interventions, clinicians must understand that they are not fixed protocols that must be followed. They are recommendations only and are not a substitute for clinical judgment. [2] Clinical practice guidelines establish standards of care supported by Scientific evidence and its purpose is to allow clinicians to consider recommended interventions to enhance decision-making. [3] These evidence-based tools were developed using well-defined methods and based on a systematic review of the evidence. [2][4] Because clinical practice guidelines Establishing standards of care, they can assist clinicians in decision making. [3]

The American Physical Therapy Association (APTA), which represents physical therapists, physical therapist assistants, and physical therapy students in the United States, has published a systematic review of the evidence in the form of Clinical Practice Guidelines (CPGs). [5] CPG by The APTA section is provided to assist clinicians in selecting treatment options for optimal outcomes. [2]

Quality of Evidence

APTA uses six levels of recommendations based on strength of evidence. Each level represents the quality of evidence supporting a particular action:

• A or Strong: Based on Level 1 research. Level I studies included systematic reviews or meta-analyses of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on RCT systematic reviews, or 3 or more high-quality RCTs with similar characteristics result. [6][7]
• B or Moderate: Based on Level II studies. Level II studies included at least one well-designed RCT. [6][7]
• C or Weak: Based on a single Level II study or Levels III and IV studies. Level III studies are well-designed controlled trials without randomization. Level IV evidence comes from well-designed case-control or cohort studies. [6] [7]
• D or Conflicting Evidence: High-quality studies on the topic disagree with their conclusions. The recommendation is based on these conflicting studies. [8]
• E or Theoretical/Basic Evidence: Evidence from animal or cadaveric studies based on conceptual models/principles or basic science/benchmark studies that support the conclusion. [8]
• F or Expert opinion: Best practice based on the clinical experience of the guideline development team.[8]

RCTs are the gold standard for research. The researchers randomly divide the participants into experimental and placebo groups to remove any selection bias from the analysis. Selection bias can alter results in a way that benefits researchers or the body funding the research to the detriment of science loyalty.[9]

X-ray: Hip OA (advanced)

Hip Osteoarthritis

Hip osteoarthritis (OA) is a degenerative joint disease that primarily affects the tendons and surrounding tissues.[10] Primary hip OA is of idiopathic origin while secondary hip OA results from a joint articular surface disorder.[10]

Guidelines for the Clinical Management of Hip Osteoarthritis

The following are hip osteoarthritis practice guidelines developed by the APTA[11][12] and various specialty medical groups including:

• American College of Rheumatology 2012 recommendations [13]
• EULAR evidence-based recommendations were developed by a panel of 18 rheumatologists, 4 orthopedic surgeons, and 1 epidemiologist representing 14 European countries [14]
• A recent review of hip osteoarthritis by orthopedic surgeons, rheumatologists, and immunologists from the Cleveland Clinic and Boston Medical Center, USA [10]

Risk Factors

• Age: Over 50 years old [12] (Level A)
• Gender: Higher in men under 50 and women over 50 [10]
• Obesity:[10] For every 10 pounds (4.5 kg) of body weight gained, each step puts an additional 60 pounds (27 kg) of stress on the hips[10][15]
• Genetics: Relatives who have had total hip replacement increase a person’s risk of having the same procedure [10]
• Occupation: Engaging in high-intensity physical activity, repetitive stress, and biomechanical overload (eg, farmer) [10]

Clinical presentation and level of evidence

The most common symptoms of hip osteoarthritis include:

• Anterior or lateral hip pain, especially during weight bearing, including walking, sitting-to-standing transition, and stair climbing [12] (Grade A)
• Pain can be progressive or sudden onset [10]
• Morning stiffness [12] (Grade A) or stiffness after sitting or resting [10]
• Stiffness lasts for a few minutes and decreases within 30 minutes [10]
• Hip rotation limitation and hip extension[12] (Grade A) .
• Static cyclic hip pain[12] (Grade A) .
• It is difficult to wear shoes and socks[12].

Examination

Physiotherapy Assessment

Osteoarthritis of the hip can be diagnosed based on its clinical presentation. The objective test should include:

• Lower extremities inspection
• Leg length discrepancy measurement
• Evaluation of hip joint weakness and stability
• Bony prominence palpation for tenderness
• Passive and active range of motion assessment for flexion extension adduction abduction internal rotation and external rotation[11][12].
• Neurovascular assessment
• FABER test (Grade A)[12]

[16]

Outcome Measures

Outcome measures in hip osteoarthritis have grade A evidence and may include:[11][12]

• Western Ontario WOMAC
• Brief Pain Inventory
• Pain Pressure Threshold
• Visual Analogue Scale
• Lower Extremity Functional Scale
• Harris Hip Score

Physical Performance Measures

The Grade A evidence includes a standardized balance test: the Berg Balance four-square-foot test and the timed single-leg stand to assess balance in patients with longstanding hip osteoarthritis and falls.

Other Physical Functioning Measures indicated in hip osteoarthritis are:

• Six-minute walk test (6MWT)
• 30-second chair stand
• Timed up and go test (TUG)
• Self-paced walk

[17]

Physiotherapy Intervention

Patient Education

• Patient education (Grade B). Research suggests that patient education should include information about regular reductions in physical activity and appropriate functional modifications.[11] [12] When assessing functional variables, environmental variables should be considered including, for example, seat height or the bed from which the patient rises.[11][12]
• Education reduces pain[14]
• Weight loss education has some value (Grade C)[14]
• Weight loss (strongly recommended)[13]

Example: hip strengthening exercises

Example: hip strengthening exercises

Example: balance exercises

Physiotherapy Treatment

Exercise provides significant benefits in the early stages of hip osteoarthritis. However, little or no benefit was observed from physical therapy interventions in late hip osteoarthritis.[14] The following activities are recommended:

• Functional training based impairment gait training and balance training (Grade C)[11][12].
• Balance exercises (conditional recommendations)[13] .
• Personalized exercise therapy based on the individual’s daily life participation and functional activity needs (Grade C)[11][12].
• Tai Chi (strong recommendation)[13] .
• Manual therapy including thrust or non thrust manipulation and soft tissue releases performed two to three times per week for over six to twelve weeks (Grade A)[11][12].
• Manual therapy with or without exercise (contraindicated recommendation) [13].
• Massage therapy (recommended for conditional use)[13].
• Flexibility and endurance exercise (Grade A)[12] are the least impactful activities.[10] It can be slow yoga cycling or swimming.[10]
• Group-based therapy should be conducted one to five times per week for six to 12 weeks[12].

Modalities

• Ultrasound: One Megahertz at One Watt per hundred per cent squared five minutes in all directions 10 treatments performed for two weeks (Grade B)[11][12].
• Acupuncture (recommended under certain circumstances)[13] .
• Burn exposure (conditional recommendations)[13]
• Transcutaneous Electrical Nerve Stimulation (TENS) (strongly recommended against) [13]

Orthotics

• Use of walking sticks as needed (strongly recommended) [13]
• Lateral and medial wedge insoles (conditional advice against)[13]

Hip Fracture

An Evidence-Based Approach to Rehabilitation After a Hip Fracture

Examination

Physiotherapy Assessment

Outcome Measures

• McDonough et al [8] recommend assessing and recording the following body functions, body structures, and activities in all settings (acute and postacute):
  • Knee extension strength (Grade A).
  • Verbal Rating Scale (VRS) for monitoring pain levels (Level A)
  • A gait speed test when the patient can walk without human assistance. Documentation should include comfort or maximum speed and use of walking aids (Level A).
  • Basic Mobility Assessment Using Cumulative Walk Score (CAS) (Level A)

Physical Property Measurements/Patient Reported Outcome Measurements

• According to McDonough et al. [8] the following tests and patient-reported outcome measures should be considered in all settings (acute and post-acute):
  • Timed-Up-And-Go test (TUG)(Grade A)
  • Short Body Energy Scale (Level C)
  • New Mobility Score (Grade B)
  • Falls Efficacy Scale – International (Level B)
  • Level 3 version of the EuroQol-5 scale (Level C)
  • Medical Outcomes Study 36-Item Short-Term Health Survey (SF-36) 10-Item Physical Function Scale (Level C)

[18][19]

Progressive Resistance Training – Hip Extension

Progressive Resistance Training – Hip Adduction

Weight bearing activities

Physiotherapy Intervention

• According to NICE guidelines [20], the management of hip fractures in adults should be on the day of surgery unless there are medical or surgical contraindications. Mobilization should continue at least once a day after regular physical therapy review. [20]
• Ftouh et al. [21] and Handoll et al. [22] found that progressive resistance training after hip fracture showed substantial improvement in mobility. [12] (high to moderate evidence). However, Handoll et al. [22] concluded that there was insufficient evidence from randomized trials to determine the best Strategies to enhance mobility after hip fracture surgery. [22] According to both authors, there is no evidence that specific treadmill training is better than controlling walking speed or pain. [12] (high evidence).
• Treadmill training did not change length of hospital stay or patients’ pain. [12] (high evidence).
• The strength training proposed by Sylliaas et al. [23] consisted of three sets of 15 repetitions, each exercise was increased from 70% to 80% of the patient’s 1-RM, and the number of repetitions was reduced from 12 to 10 every three weeks. times while maintaining at least 8 repetitions. [23] (Strong evidence).
• There was no statistically significant evidence that strength training compared with exercise training at 3 months postoperatively showed greater improvements in ADL gait and balance tests. [12]
• McDonough et al. [8] suggested that physical therapists must provide structured exercise based on progressive high-intensity resistance strength balancing weight bearing and functional movement training (Level A). Patients with mild to moderate dementia should receive similar interventions and prescriptions Same as people without dementia (Grade B). During hospitalization after hip fracture surgery, physical therapy interventions should be frequent (daily), of tolerable duration, and must include guidance in a family program (Grade B). Early post-acute physiotherapy care Should include upper body aerobic training progressive resistance training balance and flexibility training (Grade C). [8]
• According to Karlsson et al [24] patients living at home and admitted for hip surgery showed better and improved outcomes compared to patients admitted from an assisted living facility or nursing facility or dementia care. [12] Patients receiving geriatric treatment Interdisciplinary home rehabilitation showed similar ambulation to patients receiving traditional aged care and rehabilitation. [twenty four]
• Latham et al [25] found that a home-based, function-oriented exercise program improved physical function over six to nine months [12] (moderate evidence).
• Diong et al [26] recommend extending an exercise program up to 12 months after surgery to improve certain outcome measures: Knee extension balance TUG “fast” gait speed [12] (moderate recommendation).
• Auais et al. [27] suggested a community-based program for better adherence to the program, resulting in improvements in key areas [27] (strong evidence).

Modalities

• Dry needling was not found to be more effective than functional movement and functional acclimatization to the environment in recovery after hip surgery. [12] (moderate to low evidence)
• McDonough et al. [8] recommend the use of electrical stimulation to strengthen the quadriceps if other methods fail (Grade C). In addition, physical therapists may use electrical stimulation to relieve pain if other strategies are ineffective [8] (Grade C).

Discharge and Post-Hospital Care

• Ftouh et al [21] recommended discharge home after a review of discharge destinations after hip fracture. According to Ftouh et al. Home-based care resulted in significant increases in measures of functional independence. [12] (strongly recommended).
• Izzaguire et al [28] concluded that specialized physical therapy appeared to be important in the first few months after surgery and became less so after four months. A review of the literature supports the claim that there is no difference in the type of physical therapy offered to help Patients are able to perform daily activities and become independent after a hip fracture. [28] (strong evidence).
• Ftouh et al. [21] concluded that the first few weeks after hip fracture are critical for recovery. [twenty one]
• McDonough et al. [8] stated that if strength balance and functional deficits persist 8 to 16 weeks after the fracture, clinicians must provide additional treatment. Additional treatment should focus on strength, balance, functional training and gait training to address mobility impairments Limitations and risk of falls. These services can be delivered in an outpatient setting at home or as an evidence-based community-based exercise program. (Grade A).

In Summary

Physiotherapists treating patients with hip osteoarthritis should consider the following interventions:

• Low-impact endurance and flexibility exercises
• Group-based therapy
• Tai-Chi
• Patient education
• walking with assistive devices when needed

Physical therapy interventions for the treatment of hip fractures should include:

• Early mobilisation
• Progressive resistive training
• Strength training
• Community-based programme
• Home-Based Functional Exercise Program

Resources

1. Hip Osteoarthritis: 2017 Revision. Clinical practice guidelines related to the American Physical Therapy Association Orthopedic Division’s International Classification of Disability and Health
2. Treatment of hip fractures in adults. OK.
3. Physiotherapy management of hip fractures in older adults. Clinical practice guidelines related to the American Physical Therapy Association Orthopedic Physical Therapy Society and Geriatric Physical Therapy Society International Classification of Disability and Health association.