Physical therapy doesn’t help hip osteoarthritis?

Right off the bat here, we need to say,

• This study potentially makes physical therapists *not* look good, at least not the ones used in the study.
• There is a lot going on here. The conclusion is not as clear cut as made out to be. (By the authors, nor those who’ve written about it.)

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Issues with methodology

Even the authors go (bolding is always mine),

“The rigorous methodology is a strength of our study. We minimized potential for bias by including a credible sham treatment, concealing treatment allocation, and blinding the participants, outcome assessor, and biostatistician.”

Talk about some confidence! The hallmark of research is a randomized, double blinded study. This study is not double blinded. It ain’t that rigorous. The physical therapists knew what therapy they were giving, as the sham treatment was “inactive ultrasound.” Plus, you know whether you’re exercising someone or rubbing gel on them.

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Is this really a sham?

The exercise group received manual therapy, where the sham group did not. It’s not tough to make a case that rubbing a gel on someone’s hip, which is what was done in the “ultrasound,” is a form of manual therapy, as that’s essentially massage therapy.

We need more sham trial research, but a true sham trial, in certain arenas, is hard to pull off. If someone gently rubbed an area that had been bothering you for a while, that constitutes a treatment, and is often what any massage or manual therapy is. While not every therapist, many are rubbing around aimlessly.

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Lots of variability

An odd exclusion

“Major exclusions were hip or knee joint replacements or both, planned lower limb surgery, physical therapy, chiropractic treatment or prescribed exercises for hip, lumbar spine, or both in past 6 months, walking continuously more than 30 minutes daily, and regular structured exercise more than once weekly.”

I understand excluding those who are already exercising to some degree, but I’m not sure about excluding even walking for 30 minutes a day. Being inactive in itself isn’t great for pain, or practically any health measure. I wonder if the results would have been better (for both groups) if general activity wasn’t excluded and or encouraged.

Furthermore, even though the study went after pretty sedentary people, the average step count per day was about 7500 for all subjects. That’s pretty damn active for people who are doing zero exercise, and don’t walk more than 30 minutes at a time.

Even weirder, after implementing exercise for 13 weeks, both groups had less steps per day than when they started out.

But after the 13 weeks, after the intervention, the active group got more steps again.

Meaning the exercise group appeared to have compensated for a benefit of exercising -more movement- by generating…less movement. From a pure sedentary perspective, the exercise group didn’t get any benefit, which is important because you tend to find more active people are healthier all around, pain and function included.

This may be more strange than anything, but we’ll come back to it.

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That said,

The above doesn’t necessarily cancel out some things this study found.

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The point of exercise is to…

Improve on some measure. Often, this is strength and endurance. Pain is another common measure.

The subjects were one on one with the therapists on average 10 times in 12 weeks. Less than once per week. This isn’t much feedback. My experience with new clients is most need feedback a minimum of once per week. And that once per week clients very, very rarely do as well as twice or three time per week clients.  This is irrespective of how long I’ve had the client. The study started out with patients twice per week for a week, then tapered that down, averaging out to 10 over 12 weeks. But what I’m saying is it doesn’t matter if I’ve had you for four years, if you move down to once per week, you typically don’t do as well.

1. Adherence goes down, no matter what the person says. (This study asked people to report their adherence. I’ve talked about issues with asking people about their behavior before.)
2. Effort goes down. People aren’t as diligent nor do they work as hard when someone is not regularly working with them.

-> I find this happens sometimes even if I’m in the gym with the client! The moment I don’t look at them for a couple minutes, form may fall off.

But let’s get away from the methodology. One way we can tell whether this was enough feedback is to look at the improvements the subjects had. Pain wise, per the conclusion, we know the sham group did just as well. How about strength wise though? Or endurance wise? A fake ultrasound shouldn’t be comparable in these regards, right?

Looking at quadricep strength-

• Exercise group went from 1.29 to 1.41, a ~9% improvement.
• Sham group went from 1.32 to 1.37, a ~4% improvement.

Hamstring strength-

• Exercise 0.70 to 0.73, a 4% improvement.
• Sham had 0% improvement.

More specifically at the hip, hip flexion strength-

• Exercise 0.98 to 0.99, a 1% improvement.
• Sham 1.01 to 1.03, a 2% improvement.

Sit to stand test (how many times can you sit up and down in 30 seconds)-

• Exercise 9.4 to 10.7, ~12% improvement.
• Sham 9.8 to 10.7, ~8% improvement.

Timed stair climb-

• Exercise 8.6 to 7.9, ~8% improvement.
• Sham 8.2 to 7.4, ~10% improvement.

This is three months of exercise we’re talking about here. Compared to doing no exercise, the exercise group often only improved by ~4%? Hip flexion strength, something that often should be significantly worked on in hip pain, improved by 1%? In some cases the exercise group did worse than the sham group? On an exercise measure???

We either have,

1) Adherence must not have been very good.

My experience is exactly the above. For in person clients on a once per week session basis, new ones often only exercise once a week, despite what they tell you, and once a week exercise is a recipe for exercise measurements improving marginally, if at all.

Or,

2) What in the world were these physical therapists doing?

If you take someone who is sedentary, and have them start doing damn near anything on a regular basis, they’ll get better. It doesn’t matter how terrible the program is, strength and endurance tend to improve, because the baseline is so low.

Putting this another way. Your first day you come in and bench press 100lbs. Three months later you’re able to bench press, maybe, 104lbs. What kind of progress would you consider that??? How would you feel if three months later someone who did zero exercise also improved that amount? Usually you can progress someone, a minimum, of 5 pounds a week the first few months. Meaning by week two someone should be able to bench press 105lbs! (Improve 5%.)

Or here is a random study I found:

–Effects of Maximal Isometric and Isokinetic Resistance Training on Strength and Functional Mobility in Older Adults

Three months of training in older people.

Those numbers are all a lot bigger than the ones in this current study. Plus, the above subjects average age was about 72, where the ones in the hip study are about 63. If anything, improvement should be worse with the 70+ crowd.

Which is why I lean towards adherence likely being way worse than the authors believe. They remark adherence reported as 85%. If that’s truly the case, then this is an incredibly poor exercise program. The therapists were instructed to progress exercise difficulty, but this clearly couldn’t have been done. Three months of exercise and you do worse than someone who didn’t exercise, on an exercise test? And these are basic exercise tests. We’re talking getting out of a chair or going up a flight of stairs. It’s not like you could say, “Well, these people were also marathon running, which could negatively impact maximal strength.” We’re nowhere near that type of discussion.

To be fair, maybe it was the people who designed the exercise program, opposed to those who carried it out. There were only two mandatory strengthening exercises. A hip abduction exercise and a quadricep exercise. All others were optional.

When only 27% of people are performing gluteal exercise for a hip issue, we have a problem. If anything, the glutes should have been mandatory and the quadriceps optional. Why would strengthening the quads be a primary focus in a hip issue? The quads don’t even connect to the femoral head.

Not many did any of the optional strengthening work. For that, the blame is on the therapists. Thinking 3 sets of 10 of hip abduction and quadricep work is going to do much for hip pain is on them.

By the way, I’m not sure we have any idea how often the optional exercises were done. One time? Ten times? Every session? One week but not the other 13? When the patient wanted?

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Pain outcomes

One reason this is important is because exercising only once a week or less is a good way to have exercise cause pain. After you exercise you have about about 48 hours you’re typically weaker. From there, it’s about another 72 hours you’re stronger than that first session. After this, you start getting weaker again.

• Squat on Monday.
• Tuesday and Wednesday you’re weaker than you were on Monday (if you tried to squat again).
• Thursday, Friday, Saturday, maybe Sunday, you’ll be stronger than you were Monday (if you try to squat again).
• ~Sunday / Monday; you’re just as strong as you were last Monday (if you haven’t squatted since).

This is why the optimal training frequency per body part is about once every five days. Or twice a week for practical purposes. It’s why you see optimal training splits be something like (as one example),

• Monday / Thursday legs
• Tuesday / Friday upper body

If you wait and only do things once a week, well, we all know what exercising after not exercising for a while feels like. Painful. This is one reason we shouldn’t be surprised by this,

“19 of 46 (41%) in the active group reported 26 adverse events vs 7 of 49 (14%) in the sham treatment group reported 9 adverse events. All were mild and transient, comprising increased hip pain or stiffness or pain in the back or in other regions.”

People did improve

It’s important to note whether it was exercising or the sham group, people did get better. Quite a bit better. So, it’s not that exercise did not improve things. It’s that it didn’t offer an additional benefit compared to the sham group.

But that’s not typically how exercising goes. Not only did these people exercise for three months with sporadic therapist interaction, they exercised a total of nine months. No extra benefits from nine months of exercise?

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Why did they improve?

It’s tough to know. Both groups involved some form of another person rubbing on their body. The sham group had the fake ultrasound; the active group had various manual therapy techniques.

Both groups also had interaction with a presumably understanding therapist. How you interact with people is very important. But,

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A minor hit to pain science?

“Treatment credibility ratings after the first treatment sessions were significantly higher in the active group than in the sham treatment group, indicating greater participant confidence in his/her treatment and its effectiveness but were not different after the last session.”

The pain science lords will gladly glug a gallon of water and piss on everyone with showers of “how much one believes in the treatment matters; relationship with the therapist matters.” That we can’t only look at the “damage” element. Well, you can’t only look at the brain element either. The belief element either. The therapist interaction element either.

Credibility was higher in the exercise group to start, but this eventually waned. Why did it wane? I don’t think it’s tough to imagine because results were not different. That as the treatments progressed, and the results were similar, the minds started to match the results. That the results dictated the thinking. The behavior dictated the attitudes. Because it clearly didn’t happen the other way around!

-> This is a hallmark of cutting edge 21st century behavioral change, by the way. (See BJ Fogg at Stanford.) It’s where the obsession pain science has with education is misguided. Just look at weight-loss as a prime example. Educate people all you want about nutrition, carbs, protein, how many calories are in something by placing calories numbers in all restaurants, how being overweight is bad for heart disease, diabetes, even fertility, and you get a country that’s still getting fatter. Knowledge does not equal behavioral change. It can help as a factor, but as one factor.

How you feel about your pain is one element. Just like biomechanics, just like alignment, just like an abnormal MRI, just like “joint damage,” just like whether you suffer from depression or not.

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A minor hit to manual therapy (and subsequently pain science again)?

After 13 weeks, subjects were left on their own. For those exercising, they were instructed to keep up with their routine on their own. For those in the sham group, they continued to rub some gel on themselves, to simulate the ultrasound.

What happened after 13 weeks?

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The overall conclusion isn’t quite correct

“A multimodal physical therapy program conferred no additional clinical benefit over a realistic sham for people with hip osteoarthritis…”

I’ve used the following rationale two years ago. It bears repeating:

Let’s say exercise truly doesn’t offer any extra benefit for hip osteoarthritis related pain. You exercise to get rid of your hip pain, but your pain doesn’t dissipate more than fake ultrasound with a therapist. All you get is,

• Improves your chances of living longer and living healthier
• Helps protect you from developing heart disease and stroke or its precursors, high blood pressure and undesirable blood lipid patterns
• Helps protect you from developing certain cancers, including colon and breast cancer, and possibly lung and endometrial (uterine lining) cancer
• Helps prevent type 2 diabetes (what was once called adult-onset diabetes) and metabolic syndrome (a constellation of risk factors that increases the chances of developing heart disease and diabetes; read more about simple steps to prevent diabetes)
• Helps prevent the insidious loss of bone known as osteoporosis
• Reduces the risk of falling and improves cognitive function among older adults
• Relieves symptoms of depression and anxiety and improves mood
• Prevents weight gain, promotes weight loss (when combined with a lower-calorie diet), and helps keep weight off after weight loss
• Improves heart-lung and muscle fitness
• Improves sleep
• Helps with dementia
• Helps with parkinson’s disease
• Benefits fibromyalgia patients
• Improves self-esteem
• Strengthens immune system
• Reduces inflammation
• Impacts basic cognitive function, such as learning and memory.
• Decrease macular degeneration (helps with eyesight)

By the way, you still get a pain reduction. What if you exercise and all you get is [list of endless benefits]?

This is where the “no additional clinical benefit” over fake ultrasound isn’t exactly accurate. I think the authors may have given themselves an out with the “clinical benefit” remark, but you can’t discount what exercise can do in other respects.

We looked at this earlier. While the numbers at 13 weeks are odd, the numbers at 36 weeks may have some significance. In the least, the active group is more active than the beginning of the trial, where the sham group is a thousand less steps active, and seemingly trending downwards.

Is reduced risk of heart disease not a “clinical benefit?” The authors looked at osteoporosis / osteopenia rates between groups, exercise can help that, is that not a clinical benefit? Reduced risk of diabetes? Possible weight loss? Strength? Endurance?

Which is again why the lack of and or marginal improvement in practically every exercise oriented element is disturbing in this study. It means you can’t say much about the exercise program’s benefits other than it offered barely any. (If the exercise did offer some significant benefit, those who exercised may have gotten a greater pain reduction.) In the least, if people are exercising, particularly when compared to people who aren’t, they should clearly be getting more steps per day, getting stronger, getting more endurance, it should be easier to go up and down a flight of stairs, easier to get up and down out of chair. For a sedentary person, after months of exercise, these things should all improve demonstrably. Something didn’t go right with this study’s exercise program.

-Effect of Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis

A better title for the study,

-Effect of Nearly Futile Physical Therapy on Pain and Function in Patients With Hip Osteoarthritis

Giving us the conclusion of,

“A minimally effective multimodal physical therapy program conferred no additional clinical benefit over a realistic sham for people with hip osteoarthritis…”

I’m not sure how many people would even click that link?

“…Interacting with a therapist can give pain reduction in itself, particularly when the therapist is touching you.”

Sooo, people like to be rubbed and have conversations?

“Furthermore, in our first group, interacting with a therapist who touched the subjects offered the same benefit as in our second group, who interacted with a therapist touching them.”

Hot damn, this really is the golden age of understanding the human brain.