COMPARISON OF EFFECT OF HIP JOINT MOBILIZATION AND HIP JOINT MUSCLE STRENGTHENING EXERCISES WITH KNEE OSTEOARTHRITIS

*A. Tanvi, **R. Amrita, ***R. Deepak, ****P. Kopal

ABSTRACT Purpose- The purpose of pre and post experimental study was to determine whether hip joint mobilization and hip joint muscle strengthening of the hip muscles in patients with knee osteoarthritis are effective in comparison to the conventional therapy in treatment of knee osteoarthritis. Background- Osteoarthritis is a chronic, degenerative joint disease mainly affecting weight-bearing joint such as knee. Exercise programs for knee OA have been described such as general aerobic exercise programs like walking or cycling as well as more specific programs involving strengthening of particular muscle groups and/or flexibility exercises of lower limb muscle groups. Method- A total of 30 patients were taken on the basis of inclusion (Kellgren grade 2 or 3) and exclusion criteria and divided into two groups via convenient sampling. Group A (n=15) received conventional treatment i.e.US+TENS, Knee range of motion strengthening and stretching exercises and Group B (n=15) received conventional + hip joint mobilization and hip joint muscle strengthening exercise for six weeks. All the outcome variables i.e .knee range of motion, pain and functional disability were measured at 0 (pre-test), 10th and 21st sitting. Result- t-test indicated that Group B (experimental group) demonstrated significant improvements in knee ROM, pain and functional disability, measurements. Within group analysis was found to be significantly different. Conclusion- The results of the study suggest that hip joint mobilization and hip joint muscle strengthening exercises are beneficial in improving knee ROM and functional disability and in reducing pain. Keywords: osteoarthritis, hip joint mobilization and hip joint muscle strengthening exercises, WOMAC, knee
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ROM.

INTRODUCTION

on improving quadriceps strength. However, little attention has been paid to improving the strength of other lower limb muscle groups such as the hip abductors and adductors.1 Reduced hip abductor strength has also been shown in people with knee pathology and is most likely to be a consequence of altered loading during gait to rapidly move body weight onto the unaffected limb. In contrast, medial knee OA progressed more slowly in people with stronger ipsilateral hip abductors because adequate hip abductor strength may control weight shift and maintain lateral pelvic stability during the single-leg stance phase of gait. Mobilization is one of the most commonly recommended treatments for this condition. The goal of mobilization is to restore the normal arthro-kinematics of a joint, including spins, rolls and glides, by improving the extensibility of the ligamento-capsular tissue. Mobilizations well.11 Impaired hip mechanics have been associated with increased medial compartment knee loads.6 Less is known about the hip adductor muscles in relation to knee OA but they may also help reduce the knee adduction moment, particularly in a varus malaligned knee. By virtue of their attachment to the distal medial femoral condyle, the adductors could are often combined with

Osteoarthritis (OA) is a degenerative condition of articular/hyaline cartilage of synovial joints and is a chronic, localized joint disease affecting approximately one third if adults with the diseases predominately affecting the medial compartment of the tibio-femoral joint. Patients with knee OA frequently report symptoms of knee pain and stiffness as well as difficulty with activities of daily living such as walking, stair-climbing and housekeeping. Ultimately, pain and disability associated with the disease lead to a loss of functional independence and a profound reduction in quality-of-life.1

Osteoarthritis of the knee, defined as a Kellgren and Lawrence grade of two or higher in either knee, was found in 121 women, a prevalence of 12.5%.2 Prevalence of OA increases with age and aging is associated with decreasing physiological functions.3 General health status instruments measure multiple aspects of health, including, specifically, physical function, social function, and pain, and are suitable for comparison of health status between diseases.5 A variety of exercise programs for knee OA have been described in the literature. These have included general aerobic exercise

traditional physical therapy modalities as

programs such as walking or cycling as well as more specific programs involving

strengthening of particular muscle groups and/or flexibility exercises. Studies

investigating the effects of strengthening in patients with knee OA have generally focused
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eccentrically restrain the tendency of the femur to move further into varus. Yamada et al. found

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that patients with knee OA demonstrated stronger hip adductors compared with agematched controls, and that those with more severe OA had even stronger adductors than their less severe counterparts. They

variable that improve their performance. A written consent form was taken from the patients who volunteered for the study and fulfilled the inclusion and exclusion criteria of the study. Outcome measures Demographic variables of all subjects, such as age, height, and weight were recorded. All subjects underwent a detailed orthopaedic assessment. dependent goniometer, A baseline measurement taken and of

hypothesized that this increased strength may be due to greater use of the hip adductors in an attempt to lower the knee adduction moment. The purpose of this study was to analyze the efficacy of hip joint mobilization and hip joint muscle strengthening exercise to improve knee ROM, functional disability and improve pain in knee OA. METHODOLOGY

variables WOMAC

were score

using visual

analogue scale. Knee Range of Motion measured using Subjects criteria This study was carried out on 34 patients, out of which 30 continued the study and other drop out in between the study and the patient was collected from R K physiotherapy clinic Khanpur, Delhi. Their ages ranged from 40-75 years old, according to Kellgren grade 1 or 2 radiologically, predominance of pain over medial region of knee as well as hip pain, clinical criteria described by Attman et al for knee OA, VAS more than 5 on 10cm scale were included6,7,8 and was excluded if history of trauma, surgery of hip, knee and ankle joint, and peripheral vascular diseases, any Functional disability was assessed using WOMAC questionnaire which consists of 3 sections A,B,C i.e. section A for pain and section B for stiffness and section C for functional difficulty. Patient is asked to rate each question out of five grades of severity. the testretest reliability of the WOMAC was 0.74, 0.58, and 0.92 (ICC) for the pain, stiffness, and Patients were informed that results drawn out of study will facilitate them to measure their performance and help in further enhancing the
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universal goniometer which is a commonly used method for the clinical assessment of

range of motion. The intraclass correlation coefficients (ICCs) for intratester reliability of measurements obtained with a goniometer were .99 for flexion and .98 for extension. Intertester reliability for measurements obtained with a goniometer was .90 for flexion and .86 for extension10.

neurological or cardiovascular pathology and systemic diseases1,4,8.

physical function subscales.20 Pain was assessed using VAS (visual analogue

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scale), used to measure the average intensity of pain. In this patient is asked to mark their pain on a 10 cm line marked with 0 marked on one side and 10 on other end, where 0 indicated no pain and 10 indicates maximum pain. The ICC for all paired VAS scores was 0.97.9 Treatment Both the groups received US and TENS at a set dosage used for pain relief.32 Group A received set of knee range of motion exercises, strengthening and stretching

squeezes ( 3 sets of 10 with 5 second hold). Data was collected prior to start of treatment program 0 sitting, at 10th sitting and after the end of treatment session i.e. at 21st sitting. DATA ANALYSIS The mean and standard deviation of all the variables were analysed. Data analysis was done with the help of SPSS for windows in order to verify the investigations of the study. Independent t-test was used to compare between group difference and repeated

exercises which includes knee in mid flexion to full extension, knee in mid extension to full flexion(two 30 s bouts with 3 sec hold), knee strengthening exercises includes static quad sets in knee extension (6 sec hold with 10 sec rest for 10 repetitions), standing terminal extension (hold for 3 sec for 10

ANOVA measures was used to analyze within group difference for all the dependent

variables. The significance level set for this study was 95% (p<0.05). The significance of mean difference within and between the groups was done by Newman-Keuls post hoc test after ascertaining normality by Shapiro-Wilks test and homogeneity of variances by Levenes test. RESULTS The age of two groups i.e. Group A who received conventional treatment along with US and TENS and Group B who received hip joint mobilization and hip joint muscle strengthening are summarized graphically in Fig. 1.1. The age of Group A and Group B knee OA patients ranged from 41-70 yrs and 44-68 yrs, respectively with mean ( SD) 53.93 8.85 yrs and 57.47 7.46 yrs, respectively. The mean age of Group B was comparatively higher than Group A. Comparing the mean age of two groups, t test revealed similar (p>0.05) age between the two groups (53.93 8.85 vs. 57.47
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repetitions),seated leg presses(hold for 3 sec and repeat for 30 sec bouts), knee stretching exercises includes standing calf stretch ,supine hamstring stretch, prone quadriceps femoris

stretch (hold for 30 sec and repeat for 3). Group B received all the exercises in group A as well as additional exercises for hip joint which includes all the glides in different planes (caudal glide, anteriorposterior glide,

posterior anterior glide, posterior to anterior mobilization in flexion, abduction and external rotation) and hip muscle strengthening

exercises include abduction and adduction in side lying, abduction and adduction in standing, standing wall hip isometric abduction, towel

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7.46, t=1.18, p=0.247). In other words, patients of two groups were age matched and therefore age may not influence the outcome measures. Fig. 1.1 Mean age of two groups
Age (yrs)
70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 Group A Groups Group B

Outcome variables I. ROM

The pre and post treatments ROM levels (degree) of two groups are summarized in Table 1.1. which shows that the mean ROM levels in both groups increased (improved) after the treatments and at the end of the treatments, the increase (improvement) was found higher in Group B than Group A.

Mean

Table 1.1: Pre and post treatments ROM levels (Mean SD) of two groups 0 sitting (n=15) 99.20 9.66 94.60 9.75 0.194 10th sitting (n=15) 104.87 10.37 101.53 8.94 0.344 21st sitting (n=15) 111.60 10.52 112.00 7.43 0.909

Groups Group A Group B p value

Fig. 1.2. Comparative mean ROM levels within the groups.

Fig. 1.3. Comparative mean ROM levels between the groups.

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Comparing the mean ROM levels within the groups (Fig.1.2 and Fig. 1.3), the ROM levels in both groups increased (improved)

II.

WOMAC

The pre and post treatments WOMAC scores of two groups are summarized in Table 1.3. which shows that the mean WOMAC scores in both groups decreased (improved) after the

significantly (p<0.001) at both 10th and 21st sittings (post treatment) as compared to 0 sitting (pre-treatment). Further, the mean ROM levels in both groups also increased significantly (p<0.001) at 21st sitting as compared to 10th sitting.

treatments and at the end of the treatments, the decrease (improvement) was found higher in Group B than Group A.

Table 1.3: Pre and post treatments WOMAC scores (Mean SD) of two groups 0 sitting (n=15) 65.47 13.26 64.27 11.60 0.813 10th sitting (n=15) 48.40 14.11 48.07 15.25 0.948 21st sitting (n=15) 37.80 14.62 31.07 13.37 0.189

Groups

Group A Group B p value

Fig. 1.5. Comparative mean WOMAC scores within the groups

Fig. 1.6 Comparative mean WOMAC scores between the groups

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Comparing the mean WOMAC scores between the groups (Fig 1.5 and Fig. 1.6), the WOMAC scores of two groups did not differed (p>0.05) at 0 sitting i.e. found to be statistically the same. In others words, WOMAC scores of two groups were comparable. Further, the mean WOMAC scores of two groups also not differed (p>0.05) at 10th sitting and 21st sitting,

III.

VAS

The pre and post treatments VAS scores of two groups are summarized in Table 1.5 shows that the mean VAS scores in both groups decreased (improved) after the treatments and at the end of the treatments, the decrease (improvement) was found higher in Group B than Group A.

Table 1.5: Pre and post treatments VAS scores (Mean SD) of two groups 0 sitting (n=15) 7.47 0.83 7.33 0.98 0.745 10th sitting (n=15) 6.07 1.10 5.33 0.98 0.078 21st sitting (n=15) 4.67 1.59 3.60 1.06 0.012

Groups

Group A Group B p value

Comparing the mean VAS scores within the groups (Table 1.6), the VAS scores in both groups decreased (improved) significantly (p<0.001) at both 10th and 21stsittings (post treatment) as compared to 0 sitting (pretreatment). Further, the mean VAS scores in both groups also decreased significantly Fig. 1.7. Comparative mean VAS scores within the groups. (p<0.001) at 21st sitting as compared to 10th sitting. The comparisons concluded that both treatments are effective for improving VAS in patients with knee OA.

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(Cliborne, et al. 2004)22 and hip muscle strengthening on knee load, pain, and function in people with knee osteoarthritis (Kim L Bennell, et al. 2007)33. It appears that hip joint mobilization and strengthening exercises are effective in reducing pain and stiffness, and in improving knee ROM and physical function in patients with OA of the knee than conventional Fig. 1.8. Comparative mean VAS scores between the groups. Comparing the mean VAS scores between the groups (Fig 1.7 and Fig. 1.8), the VAS scores of two groups did not differed (p>0.05) at 0 sitting i.e. found to be statistically the same. The mean VAS scores of two groups also not differed (p>0.05) at 10th sitting. However, the mean VAS score of Group B at 21st sitting was found significantly (p<0.05) different and lower as compared to Group A, indicating treatment. This finding is in agreement with Cliborne, et al. (2004)22 who stated that short term response of hip mobilization on Knee OA and of Bennell, et al. (2007) the hip strengthening exercises were effective on OA of the knee33. The present study while demonstrating significant difference in the effect of conventional treatment and hip joint mobilization and hip joint strengthening

exercises on the selected clinical features of OA have however shown that the hip joint mobilization and hip joint strengthening

Group B is more effective than Group A for improving VAS in patients with knee OA. DISCUSSION The aim of the study was to compare the effectiveness of hip joint mobilization and hip joint strengthening of the hip muscles with conventional therapy in the treatment of patients with knee osteoarthritis. The result of the study suggested that hip joint mobilization and hip joint strengthening exercises are significantly more effective than conventional treatment. This finding supports the view that there are the positive effects of hip joint mobilization
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exercises affected greater pain relief as well as gains in ROM and improves function. Pain is a major contributory factor to the disability in the patient with Knee OA hence it is

understandable that experimental group which effected greater pain reduction in this study brought about greater functional improvement. Among subjects who completed the study, those in the experimental group had a greater improvement in WOMAC scores over the 6week period (P<.001) than those in the conventional treatment group. Impaired hip muscle performance can render the hip joint susceptible to dysfunction in all planes. Abnormal motion of the femur can have

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a direct effect on tibiofemoral joint kinematics and strain the soft tissue restraints that bind the tibia to the distal end of the femur. Chang and colleagues, who reported that the ability to generate greater hip abductor moments during walking was protective against ipsilateral medial compartment osteoarthritis progression in older adults.29 Altered knee function as a result of knee OA may affect the hip and result in painful impairments.24 The faulty

thought to reduce joint pain through the stimulation of afferent nerve receptors or by improving joint lubrication. Mobilization of the hip is also used to help restore joint mobility.28 Since serotonin and noradrenaline releasing neurons in the spinal cord originate in supraspinal sites in the brainstem, these data support a role for descending inhibitory pathways in the hypoalgesia produced by joint mobilization. It has been hypothesized that mobilization may activate descending pain inhibitory systems, mediated supraspinally (Wright, 2002; Souvlis et al., 2004).31 During mobilization/manipulation, the

biomechanical knee position can be a result of a tight posterior and posteriorlateral hip complex, causing the femur to not flex, adduct, and internally rotate during the loading phase of gait. This causes the knee to remain relatively extended, abducted, and externally rotated, and could lead to medial joint overload over time.23 Mechanoreceptors that provide proprioceptive function are located at the tendons, ligaments, meniscus, joint capsule and muscle. Pain may be a factor affecting the evaluation of muscle strength and proprioceptive acuity. mobilization which involves
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capsuloligamentous tissues of a joint are mechanically stretched. One primary goal of mobilization is to improve extensibility of restricted secondarily, capsuloligamentous articular tissue;

mechanoreceptor

activation level is affected. Joint mobilization has been demonstrated to improve physiologic and accessory motions to hypomobile

Joint

structures. This in turn causes an alteration in the articular mechanoreceptor resulting by way of arthrokinetic reflex activity in enhanced muscle strength.26 Joint mobilization also causes physical loading and unloading of joint cartilage to facilitate the flow of synovial fluid within the joint. This flow of fliud ensures adequate nutrition to the articular cartilage. When compression is combined with

low-velocity

passive movements within or at the limit of joint range of motion reduces pain by modulating the nervous tissues and increases joint motion
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(Maitland

2005;

Vicenzino

2001). Joint mobilization has been shown to induce immediate hypoalgesia in individuals with knee OA with a concurrent improvement in function. The positive hypoalgesic affects are believed to occur through stimulation of mechanoreceptors and activation
30

mobilization, there is thought to be even greater stimulation of synovial fluid flow. 11 Other proposed benefits of manual therapy
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of pain

inhibitory cortical systems.

Mobilization is

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include

mechanical

alteration

of

tissue,

biomechanics of the joint. Strength training is presumed to protect the joint from pathologic stress and loading. 14 People with knee OA demonstrate significant weakness of the hip musculature compared with asymptomatic controls.17 Hip abduction (HA) exercises have important functional implications because they enable patients to regain the muscle strength needed for

neurophysiologic effects, and psychological influence.30 Joint mobilization not only has an impact on the motor unit activity in muscles functioning over the joint, but it also has been shown to affect more remote muscles as well, including muscles on the contralateral side of the body.26 Hip mobilizations are a

noninvasive,

relatively

inexpensive

intervention that appears to provide short-term benefit in patients with knee pain and clinical evidence of knee OA who present any combination of 2 CPR variables. 24 Chang and colleagues postulated that hip abductor weakness may result in additional contralateral pelvic drop, shifting the centre of mass toward the swing extremity, which therefore increases forces across the medial compartment of the stance extremity and hastens disease progression.17 The aim of strengthening exercises in people with OA is primarily to improve control and stability of the joint during movement and thus maintain functional ability. More recent reviews also indicated a strong evidence base for the efficacy of strengthening exercises in managing OA.13 The beneficial effects of resistive

performing activities of daily living and sports.15 Since muscle strengthening improves pain and function in knee OA, strengthening exercise is widely recommended for the condition.17 Lower limb strengthening

exercises are an important component of the treatment for knee osteoarthritis (OA).

Strengthening the hip abductor and adductor muscles may influence joint loading and/or OA-related symptoms, but no study has compared these hypotheses directly.1 The hip muscles, particularly the abductors, play an important role in stabilization of the pelvis and trunk. Indeed, movement of the contra lateral pelvis or lateral leaning of the trunk over the stance limb, which may occur as a result of hip muscle weakness, has been suggested to adversely influence the magnitude of the knee adduction moment. Thus, hip muscle activity appears to be an important, yet understudied, contributor to knee joint load.1 The exercises focus on strengthening the hip abductor muscles, such as the gluteus medius, a broad, thick, radiating muscle that helps to

exercise for individuals with OA may be attributed to several associated factors such as: facilitation of endogenous opiates which

creates an analgesic effect to improve a persons tolerance to pain, decrease in

depression coupled with perceived level of disability, through associated weight loss, or mechanically through alteration of the
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stabilize the pelvis during ambulation. In patients with osteoarthritis in the knees, these muscles tend to be weak, causing the pelvis to tilt toward the side of the swing leg when walking, instead of remaining level with the ground, which increases the load on the knee joints. Strengthening these muscles helps the pelvis and the knee remain in better alignment, and thereby lessens the load.
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provided

positive

outcome

of

the

experimental method conducted in order to treat the proposed condition; still it provides us with a chance to further modify the

methodology. Relevance to Clinical Practice Hip joint mobilization and hip joint muscle strengthening exercises shows better

Hip muscles

may stabilize the pelvis during gait in ways to maintain the center of mass in alignment, which may have an effect on frontal plane knee moments as suggested by Bennell.
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improvement in muscle strength and function and reduction in pain in comparison to conventional therapy in the patients with knee osteoarthritis. So Hip joint mobilization and hip joint muscle strengthening exercises can be use as clinical practice in the treatment of knee joint osteoarthritis. Conclusion The study concludes by stating that null hypothesis is rejected as the result of the study suggests that the hip joint mobilization and hip joint muscle strengthening exercises are more effective in decreasing pain and in improving functional ability and increasing knee ROM in patients with knee osteoarthritis.

In this

study, as reduction in pain brought significant improvement in health and physical function that contribute in improving WOMAC score, and thus helps in reducing knee disability by minimizing the load on knee joint during ambulation and so intervention of the hip may be indicated in the treatment of patients with knee OA. Future Research can be done by extending the duration of the study or including other exercise protocols. The future study can be done by using another electrotherapeutic modality with same protocol. This study has
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27. Howard Makofsky Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abductor Torque: A Pilot Study J Man Manip Ther. 2007; 15(2): 103110. 28. Elizabeth A. Sled et al. Effect of a Home Program of Hip Abductor Exercises on Knee Joint Loading, Strength, Function, and Pain in People With Knee Osteoarthritis: A Clinical Trial Phys Ther.2010;90:895904. 29. Michael T. Cibulka and Anthony Delitto, A Comparison of Two Different Methods to Treat Hip Pain in Runners JOSPT Volume 17 Number 4 April 1993 30. Christopher M. Powers, The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective J Orthop Sports Phys Ther 2010;40(2):42-51. 31. Thomas Adams et al. Physical Therapy Management of Knee Osteoarthritis in the Middle-aged Athlete Sports Med Arthrosc Rev 2013;21:210 32. Penny Moss et al. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia Manual Therapy 12 (2007) 109118. 33. Naryana C Mascarinet al. Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial BMC Musculoskeletal Disorders 2012, 13:182 34. Kim L Bennell, et al. Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol BMC Musculoskeletal Disorders 2011, 12:276

CORRESPONDENCE *MPT (Musculoskeletal), Assistant professor, Santosh Medical and Dental, college of physiotherapy. **MPT (Musculoskeletal), Student, Santosh Medical and Dental, college of physiotherapy. ***MPT (Musculoskeletal), Principal, Associate professor, Santosh Medical and Dental, college of physiotherapy. ****MPT (Sports), Assistant professor, Santosh Medical and Dental, college of physiotherapy. Corresponding author: Dr. Tanvi Agarwal, MPT (MUSCULOSKELETAL), A48 A- ASHOK NAGAR GHAZIABAD, drtanviagg@gmail.com

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