Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Objective and importance

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.

Clinical presentation

A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.

Intervention

The patient received seven manual physical therapy sessions over the course of one month.

Conclusion

During this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Effects of non-pharmacological conservative treatment on pain,range of motion and physical function in patients with mild to moderate hip osteoarthritis. A systematic review

ObjectiveThe purpose of this review was to identify the effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis.DesignA systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.SettingWe searched MEDLINE, PEDro, Scopus and the Cochrane Library databases for randomized controlled trials related to non-pharmacological conservative treatments for hip osteoarthritis with the following keywords: “hip osteoarthritis,” “therapeutics,” “physical therapy modalities,” and “combined physical therapy”. The PEDro scale was used for methodological quality assessment and the Oxford Centre of Evidence-Based Medicine scale was used to assess the level of evidence. Outcomes measures related to pain, hip range of motion and physical function were extracted from these studies.ResultsTwelve studies met the inclusion criteria. Most of the studies showed high level of evidence and only two showed low level of evidence. High quality of evidence showed that manual therapy and exercise therapy are effective in improving pain, hip range of motion and physical function. However, high quality studies based on combined therapies showed controversy in their effects on pain, hip range of motion and physical function.ConclusionsExercise therapy and manual therapy and its combination with patient education provides benefits in pain and improvement in physical function. The effects of combined therapies remain unclear. Further investigation is necessary to improve the knowledge about the effects of non-pharmacological conservative treatments on pain, hip range of motion and physical function.     

Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

Abstracts: AAOMPT Conference, 2002

Abstract

Background/Purpose: The purpose of this case report is to describe the clinical management of a patient with sacroiliac joint dysfunction (SIJD) and a concomitant asymmetrical hip-joint rotation range of motion. The patient was a 53-year-old male whose chief complaint was right low back pain (LBP) that interfered with work and leisure activities. Physical therapy consisted of manual therapy, stretching, and postural education to address SIJ and hip motion abnormalities. At the conclusion of 6 visits, the hip-joint rotation range of motion was more symmetrical. The patient reported self-correction of unilateral standing and sitting postures. He returned to full-time work and to playing golf, and he rated pain at 0-1/10. This patient's asymmetrical hip-joint rotation range of motion may have been associated with SIJD, either as a result of trauma or subsequent habitual postural adjustments. Clinician awareness of the possible relationship between SIJD and asymmetrical hip joint rotation range of motion is recommended.     

Aims and Objectives of IFOMT Educational Standards

Abstract

The interacting systems of the entire spine make the diagnosis and treatment of lumbar spinal stenosis a difficult and challenging condition for the manual therapist. Not only is the aged population of patients with symptomatic spinal stenosis increasing, so is the number of younger males 30–40 years with a history of untreated sports trauma in their formative teenage years. With advanced knowledge of the condition, sophisticated investigations and skilled manual therapy techniques conservative treatment will often afford the patient great relief from symptoms.     

The effectiveness of manual physical therapy interventions in pediatric patients with anterior hip pain: a retrospective study

Objectives: The purposes of this study were to: (1) assess the benefit of adding manual therapy (MT) to physical therapy care in pediatric patients with anterior hip pain; (2) assess the relative risk of adverse reactions when MT is used; and (3) report the types of MT used.

Methods: This study was a retrospective chart review of patients treated in a hospital-based sports medicine clinic. The charts of 201 patients (mean age = 14.23?±?2.15 years) met the inclusion criteria and were reviewed. Patients were grouped into those who received MT during their episode of care, and those who did not. Pain efficiency (change in pain/number of visits), number and type of adverse reactions, as well as frequency and type of manual therapy interventions used, were the outcomes of interest.

Results: The mean pain efficiency was significantly less if manual therapy was performed (MT = 0.60 [95% CI 0.47–0.72], no MT = 0.80 [95% CI 0.71–0.90] p = 0.01). There was no significant difference between groups in risk of adverse reactions (MT = 5, no MT = 5). The number of visits was significantly different between groups (MT = 9.43?±?3.9 sessions, and no MT = 7.6?±?5.2 sessions).

Discussion: MT did not increase the risk of an adverse reaction in pediatric patients with anterior hip pain. While it appears to be a safe intervention, it did not improve pain efficiency or patient adherence. Future research should be performed to assess the effectiveness of MT, when performed by skilled therapists, in pediatric patients with hip pain in a controlled manner.

Level of Evidence: 3b.     

Manual therapy and exercise for impingementrelated shoulder pain

Abstract

Background: Shoulder complaints are among the commonest causes of musculoskeletal pain. They are potentially disabling and frequently cause absenteeism from work and claims for sickness benefits. One of the most prevalent subtypes of shoulder pain is impingement. This is often managed physiotherapeutically, with 'hands-on' manual therapy and exercises being mainstays.

Objectives: To assess the effectiveness of manual therapy and exercises to improve pain, disability and function in people with shoulder impingement.

Methods: A systematic review was conducted including systematic reviews, quasi-randomized trials and randomized controlled trials published up to October 2008. Searches included the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, Cinahl and PEDro. Methodological quality and risk of bias were assessed with appropriate instruments. All findings were critically analysed and discussed, and summary conclusions formulated.

Results: Eight systematic reviews and six randomized controlled trials were included. Methodological quality and risk of bias as well as population and treatment parameters varied. Clinical heterogeneity prevented meta-analysis, thus all findings were synthesized narratively. The included research provides limited evidence to support the use of manual therapy and exercise interventions for shoulder impingement. This primarily relates to subacute and chronic conditions and short to medium-term effectiveness.

Conclusions: Manual therapy and exercise seem effective for shoulder impingement, but varying methodological quality and risk of bias in reviews and trials warrant caution in the interpretation of the results. There is a need for further good-quality primary research.     

The ability of a sustained within-session finding of pain reduction during traction to dictate improved outcomes from a manual therapy approach on patients with osteoarthritis of the hip

Abstract

Objectives: The objectives of this study were to: (1) determine the association of a within-session finding after traction of the hip with self-report of well-being, pain, and self-report of function at 9 weeks; and (2) to determine if the interactions between the within-session finding and the outcome measure are different between groups of patients with hip OA who receive and who do not receive manual therapy.

Methods: Data were retrospectively analysed in 70 subjects who were part of a randomized control trial. Correlation analyses of within-session findings from the initial visit after traction of a concordantly painful hip were compared to self-report measures for function, pain, and well-being at 9 weeks. A comparison of slope coefficients between manual therapy and non-manual therapy groups was performed to determine the interactive aspects of the within-session finding.

Results: Although the correlations for the manual therapy group were higher than for the supervised neglect group, none of the correlational analyses for both groups was strong or significant. Significant differences in the slope coefficients for well-being and pain were found, suggesting that the interactions between the within-session findings and the targeted outcomes were different in the manual therapy group versus supervised neglect group.

Discussion: These findings suggest that within-session findings during the initial evaluation are not strongly related to a positive outcome after manual therapy, although the interaction of the finding of a within-session change and the use of manual therapy is more compelling than the finding in a sample of patients who did not receive manual therapy.     

The Effect of Manual Therapy on Lower Extremity Joint Kinematics during Running: A single-subject case study

BackgroundWhile there is scarcity of current literature to support the effectiveness of muscle energy techniques (MET) with musculoskeletal injuries, the overall impact on gait kinematics necessitates investigation. This case study involved a 48-year-old male runner and aimed to determine the effect of manual therapy, including joint mobilization and MET, on lower extremity (LE) kinematics. The subject had a medical history that included: Achilles tendonitis, low back pain, and iliotibial band syndrome.MethodsA clinical exam and Xsens motion capture were performed on the subject prior to treatment and at the conclusion of the 6 weeks of treatment. Motion capture was used to examine bilateral foot contact time, hip transverse plane motion and ankle sagittal plane motion. Pre-treatment and post-treatment ipsilateral and bilateral differences between groups were analyzed.ResultsChanges were noted between ipsilateral and bilateral pre- and post-treatment contact times; right foot sagittal plane joint angle at foot off; left hip transverse plane joint angle at foot contact and foot off, all bilateral pre- and post-treatment hip angles at foot contact and foot off, all bilateral pre- and post-treatment ankle angles at foot contact and foot off.ConclusionsClinical exams paralleled the change in hip external rotation bringing the hips to a more neutral position. In addition, the final clinical exam noted a decrease in subtalar eversion bilaterally, which may relate to the improved pelvic symmetry and biomechanical compensation pattern. Clinically, these findings may coincide with improving proximal lumbopelvic symmetry assisting with normalizing distal mobility by using manual therapy.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Diagnosis and laparoscopic excision of accessory cavitated uterine mass in a young woman: A case report

BACKGROUNDAccessory and cavitated uterine mass (ACUM) is an uncommon form of connate Müllerian anomaly seen in young and nulliparous women, which presents as chronic periodic pelvic pain and severe dysmenorrhea. The entity is often underdiagnosed due to a broad differential diagnosis, including rudimentary uterine horn, true cavitated adenomyosis and degenerating fibroids.CASE SUMMARYA 22-year-old woman who presented with severe dysmenorrhea and was initially misdiagnosed with cystic adenomyosis. Gynecological examination and ultrasonography were performed. The patient underwent laparoscopic excision of the mass and histopathological examination confirmed the diagnosis. Postoperatively, the patient did well, with no further dysmenorrhea.CONCLUSIONACUM is difficult to diagnose. A correct diagnosis can be made only after excision and histopathological evaluation. Surgical excision is necessary and can be carried out by laparoscopy.     

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners

Aim: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners’ perspectives on the practices that constitute high quality hip fracture rehabilitation.

Methods: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners’ perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.

Results: Seven themes emerged: objectives of care; first 72?h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.

Conclusions: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners’ perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes.

• Implications for Rehabilitation

• This study highlights occupational and physiotherapy therapy practitioners’ perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation.

• While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers.

• Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

     

Formative Dynamics: The Pelvic Girdle

Abstract

Altered mechanics and/or forces related to the lumbar/pelvic/hip regions may result in pelvic-girdle dysfunction and or instability, which then may contribute to the development, persistence, or reoccurrence of low back pain (LBP). This series of three case studies outlines an integrated biomechanical clinical evaluation and treatment approach utilizing manual care, education, and exercise in the treatment of patients with chronic pelvic-girdle dysfunction and/or instability.

This integrated approach was used on three patients with a primary diagnosis of sacroiliac joint (SIJ) dysfunction. These patients had similar patterns of altered mechanics, movement patterns, and muscle imbalances. The treatment they received was an integration of three components: 1) restoration of optimal soft tissue/joint mechanics to the thoracic/lumbar/pelvic region and lower quarters; 2) patient education in specific self-stretching/mobilization exercises, spinal/pelvic stabilization exercises, and body mechanics training; 3) pelvic external bracing and/or prolotherapy injections (sclerosing) for those patients with hypermobile/unstable, chronic and recurring pelvic girdle dysfunction. Treatment varied from 24 to 35 visits over a 3-4 month period. The treatment outcomes demonstrated a correlation between improved patient function and pain reduction after restoring optimal mobility, functional strength, and movement patterns. These benefits lasted well beyond the course of treatment. Further research is needed to determine whether patients with chronic pelvic-girdle dysfunction and/or instability who receive this integrated approach will consistently achieve lasting pain relief and restoration of function when compared with no treatment or other treatment approaches.     

The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports

Abstract

Peripartum posterior pelvic pain is a clinical enigma commonly encountered by physical therapists. It is hypothesized that the release of relaxin hormone during pregnancy may result in ligament laxity, which could lead to sacroiliac instability resulting in pain and decreased function. The purpose of these case reports was to describe the effects of manual physical therapy and therapeutic exercise on a peripartum patient with reports of posterior pelvic pain. Two patients referred to physical therapy by their obstetrician during their pregnancy were recruited for these case reports. During the initial examination, both patients completed a number of self-report measures including the Oswestry Disability Index, a body diagram, and the Numeric Pain Rating Scale. Both patients were treated with muscle energy techniques directed at pelvic and sacral positional faults and therapeutic exercise consisting of transverse abdominis and multifidus neuromuscular re-education; isometric hip abduction and external rotation; and a force closure sacroiliac stabilization program directed at neuromuscular re-education of the anterior and posterior oblique sling systems (hip adductors-contralateral obliques and gluteus maximus-contralateral latissimus dorsi combinations). At the time of discharge, both patients again completed the self-report outcome measures as well as a global rating of change. Both patients demonstrated a clinically meaningful improvement in their pain levels as well as perceived disability. In addition, both rated their global rating of change as "a great deal better." These case reports provide preliminary evidence suggesting that manual physical therapy and therapeutic exercise may be an effective intervention strategy for peripartum patients reporting posterior pelvic pain.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

Patellofemoral Malalignment

Abstract

This 27 year old male has had increasing bilateral medial knee pain over the last two years with the right knee being worse than the left. After a comprehensive physical therapy examination which included a motion analysis assessment, it was determined that the patient had bilateral patellofemoral malalignment. Customized orthotics which used both rearfoot and forefoot posting allowed this patient to resume his running program.     

The fidelity of comparison intervention in manual therapy trial for patients with low back pain: a systematic review

Abstract

Background: Comparison interventions for low back pain are described in the literature utilizing different treatment interventions with various terminology. The effectiveness of these comparison groups is not well defined.

Objectives: The objective of this systematic review is to assess the fidelity of comparison interventions within randomized controlled trials assessing the effect of manual therapy on low back pain.

Methods: This systematic review utilized PubMed, CINAHL, Scopus, Cochrane, and Pedro databases. Articles were screened by two authors for eligibility criteria and then extracted, reviewed, and cross-checked for data that included sample size, patient demographics, manual therapy intervention, the control group protocol, and outcomes. The Cochrane Risk of Bias tool was used to determine disagreement among authors. A qualitative synthesis of the evidence was completed.

Results: A total of 20 articles were included in this systematic review. The comparison interventions were categorized into themes based on the terminology used by the various studies. The themes consisted of “standard care”, “sham treatment”, “control groups”, and unnamed comparison interventions. These themes were then compared to the CPG based on the interventions utilized in each study.

Conclusions: There appears to be significant variability in comparison interventions within randomized controlled trials assessing manual therapy effects on patients with low back pain. This variability may lead to inconsistent published effect sizes. It is imperative to correctly follow evidence-based practice from resources, such as the CPG, to determine the effectiveness of treatment interventions.