Katie de Luca, M Chiro, Henry Pollard, PhD, James Brantingham, PhD,
Gary Globe, DC, PhD, Tammy Cassa, DC
32 Elizabeth St,
Parramatta NSW 2150, Australia.
OBJECTIVE: Osteoarthritis is the most common musculoskeletal disorder, estimated to affect 3 million Australians. Previous studies support structured exercise programs and manipulation for hip osteoarthritis; however, no trials have examined treatment of the lower limb kinetic chain. The purpose of this case series was to report hip range of motion and pain scale outcomes in 4 patients diagnosed with hip osteoarthritis who were treated with chiropractic management of the lower limb kinetic chain.
METHODS: Four subjects (mean age 59.5; SD +/- 6.7) were provided with 9 sessions of chiropractic treatment. This included long-axis traction pulls and pre/post adjustment stretching of the symptomatic hip, with additional manipulation and mobilization of the lumbar spine, sacroiliac, knee, and ankle joints. Outcome measures included range of motion as measured and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
RESULTS: All 4 subjects had improvements in WOMAC scores, with a mean group reduction of 382.5 (SD +/- 115.8) and overall improvement of 68.1%. As a group, there were improvements in internal rotation (51.7%, mean 7.3 degrees; SD +/- 6.2 degrees), adduction (26.7%, mean 5.3 degrees; SD +/- 5.0 degrees), abduction (21.1%, mean 6.8 degrees; SD +/- 5.4 degrees), flexion (15.3%, mean 15 degrees; SD +/- 4.8 degrees) and external rotation (8.5%, mean 8.5 degrees; SD +/- 6.0 degrees).
CONCLUSIONS: Four patients diagnosed with hip osteoarthritis had decreases in WOMAC scores and increases in hip range of motion after chiropractic management. Further research in the form of large scale randomized controlled trials is needed to investigate the effectiveness and clinical significance of chiropractic management for hip osteoarthritis.
From the Full-Text Article:
Osteoarthritic conditions, especially hip and knee OA, affect a large proportion of the population; yet, there is little research into conservative care, particularly those associated with manual therapy. Anecdotally, many patients with OA report that the options for nonsurgical treatment are limited; the basic notion is “put up with the pain until surgery is required.”
The effectiveness of exercise programs and conservative care in HOA has been demonstrated by previous studies. [9-11] However, protocols assessing the entire lower limb kinetic chain have not been reported. Therefore, this case series presents results which demonstrate observations of how subjects responded to chiropractic management of the full lower limb kinetic chain. We found that providing manipulation and mobilizations to the lumbar spine, sacroiliac, knee, and ankle joints, performed with lengthening and stretching exercises collectively increased range of motion of the symptomatic hip and reduced individual WOMAC scores after 9 treatment sessions. The overall change in the WOMAC score of 69% is far above that which is required for a Minimally Clinically Important Improvement,  in pain (32.0%), global assessment (32.6%), and WOMAC physical function (21.1%),  as well as the Minimum Clinically Important Difference for pain (47%) and WOMAC physical function (28%). [23, 24] An increase in flexion greater than 10° (we had an increase of 15°) also suggests that treating the lower limb kinetic chain may cause a clinically meaningful increase in hip flexion, as it is reported that a loss of hip flexion is a significant indicator of increased disability.  As there is evidence HOA disability is significantly worsened with decreases in hip extension, hip external rotation and knee flexion, a broader protocol that emphasizes the restoration of hip and knee range of motion using supplementary stretching and soft tissue techniques would make clinical sense. [11, 14, 17]
It conceptually makes sense to chiropractors that take a biomechanical approach that manipulation and an exercise program go hand in hand, particularly in conditions such as OA which affect joint function. The nervous system relationship between diminished articular mechanoreceptor and proprioceptive function, may exacerbate further cycles of joint degenerative effects on tissues and muscle function and has been previously investigated. [26-28] It is important to consider that patients with degenerative joint disease may require much longer treatment to initially restore function and that they may also require periodic care to restore/maintain joint movement as a part of any ongoing management of OA. It is a consideration that the location of a patient’s pathology (pain, inflammation, subsequent degenerative changes) may actually represent compensation for dysfunction of another joint, proximal and/or distal to the area of complaint.  As early as the 1960s, the concept of treating joint dysfunction (hypokinesia) within the full kinetic chain of the human locomotive system has been promoted by many within the chiropractic profession.  This case series supports the theory that a biomechanical approach to treating HOA can produce outcomes which decrease pain and increase function. If the observations found in this case series are able to be replicated in a large scale, randomized controlled trial format, and the continuation of minimal adverse outcomes is reported, this form of therapy may be an important intervention in the management of HOA in the future. It is recommended that future studies report any adverse effects, as there is no current surveillance literature on the treatment of osteoarthritis with chiropractic management.
Osteoarthritis carries a significant economic burden on the Australian population. The Australian Institute of Health and Welfare estimates medical costs related to OA attributed to $624 million in 1994. Major components were hospitalizations, visits to general practitioners, prescription and over the counter medicine and allied health care. More recently, figures show that OA has become the leading source of Australian government health expenditure with $2.03 billion dollars allocated in 2007—just under half the total expenditure for arthritis.  Valid and reliable studies of chiropractic management of HOA may broaden the scope of treatment options for patients diagnosed with HOA. Evidence for chiropractic management may bridge the gap between medication, exercise prescription and surgery. It is reasonable to suggest that if the symptomatology of HOA is reduced with conservative options, the need for surgical intervention may be lessened or at least delayed. By providing evidence that supports nonsurgical management of HOA, the economic impact of OA may be reduced.
Pain and the loss of mobility are common symptoms of OA which patients control with analgesics and NSAIDs. In 2004, the World Health Organization consensus statement, based upon an extensive meta-analysis that included 32 randomized control trials and 13 major cohort studies, concluded that after 1 month of exposure to NSAIDs, there was a 50% increase in risk of a gastrointestinal complication compared to nonusers.  In addition, long-term use of NSAIDs has been associated with adverse effects such as renal insufficiency, hypersensitivity and gastrointestinal toxicity causing pronounced morbidity due to NSAID use particularly after long term use.  As our study found that all 4 subjects had decreases in WOMAC scores and a group improvement of 68.1%, the need for analgesics and NSAIDs may be reduced and the detrimental effects of pharmacological treatments on the body is lessened. Reducing the long-term dependency on medications has great implications not only for the cost of OA management, but also the ageing population. Further studies should examine the use of medications and whether dosage changes after chiropractic management. If studies can provide evidence on reporting the decrease in medication use, the strength of support for conservative care should be reinforced in treatment guidelines. Finally, governmental bodies looking to decrease the burden of an ageing population should take into consideration current research activities which look to efficiently manage osteoarthritic conditions.
Treatment was delivered by senior chiropractic interns. Different outcomes may be gained by more experienced and clinically sound practitioners, or alternative therapists. This is a case series, thus is only a small sample with no clinical control or natural history group and only short term outcomes. Hence, it is necessary to be cautious in the interpretation of these results. Case series which are prepared properly and follow a checklist as provided by Green and Johnson  are important contributions to literature, however larger randomized controlled trials are needed to support preliminary findings and provide evidence, as indicated, for guidelines of conservative care in the treatment of osteoarthritis of the hip.
This case series presents 4 participants diagnosed with hip osteoarthritis who had increases in hip range of motion and reductions in pain and disability scores (WOMAC scores) of approximately 69% after 9 sessions of chiropractic management of the lower limb kinetic chain. This case series provides the observations of assessing and treating the entire lower limb kinetic chain (through hip and full kinetic chain manipulative therapy combined with passive and active-assisted stretching) for HOA. However, further research in the form of large scale randomized controlled trials is needed to investigate the effectiveness and clinical significance of chiropractic management of the lower limb for hip osteoarthritis.