Test-retest. The therapist can perform test: retest procedures throughout the treatment session as required.

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1 HIP TREATMENT PROTOCOL Manual Therapy General Guidelines The goal of manual therapy: For this study, manipulative therapy includes specific manipulations (lowamplitude, high-velocity thrust techniques) and specific mobilizations (low-velocity, oscillatory movements) intended to modify the quality and range of motion of the target joint and soft tissue structures. To reflect actual clinical practice, the clinician will be allowed to select which thrust or non-thrust manipulation procedure they feel is most beneficial to their patient targeting the comparable site that reproduces the patient s chief complaint. Patient feedback following the selected technique will be used to modify position, angle, force, or rate based on patient response. At least 1 manual therapy technique is required each visit. Joint position. The therapist may select a joint position for treatment based on their assessment of the irritability of the patient s condition. Joint position can be altered in response to patient reporting or test: re-test findings. Patient position. The therapist may modify the patient s starting position for treatment based on the patient s condition. Patient position can be altered in response to patient inability to achieve the standard position or reporting discomfort. Dose: At least 1 manual therapy technique is required each visit. To reflect actual clinical practice, the clinician may alter or abandon a specific technique once they feel the patient has met their maximal improvement within or between treatment sessions based on patient response resulting in decreased pain or improved movement. Test-retest. The therapist can perform test: retest procedures throughout the treatment session as required. Addition/dropping of techniques. At least 1 joint MT techniques should be performed at every visit. Some techniques may be dropped at follow up sessions if goals have been reached Absolute and Relative Contraindications to Manipulation/Mobilization Absolute Malignancy of the targeted physiological region Cauda equina lesions producing disturbance of bowel or bladder Red flags including signs of neoplasm, fracture, or systemic disturbance Rheumatoid collagen necrosis Coronary artery dysfunction Unstable upper cervical spine Practitioner lack of ability Spondylolisthesis Gross foraminal encroachment Children Pregnancy Fusions Psyhogenic disorders Immediately postpartum Relative Active, acute inflammatory conditions

2 Significant segmental stiffness Systemic diseases Neurological deterioration Irritability Osteoporosis (depending on the intent and direction of movement) Condition is worsening with present treatment Acute nerve root irritation (radiculopathy) When subjective and objective symptoms don t add up Any patient condition (handled well) that is worsening Use of oral contraceptives Blood-clotting disorder Exercise General Guidelines The goal of exercise: The exercise program is tailored to the individual patient needs as discerned by the therapist. There are 4 main treatment goals on which exercise therapy focuses: 1) increase of muscle function, including endurance, strength, and coordination; 2) improvement of range of motion; 3) decrease of pain; 4) and improvement of functional ability. To reflect actual clinical practice, the clinician will be allowed to select which exercise(s) are most beneficial to their patient targeting identified weaknesses based upon the initial clinical examination. At least 1 exercise technique is required each visit. Dose: Each strengthening exercise will be performed at 3 sets of 10 or until fatigue. Patient will be progressed to the next level of strengthening when the exercise is no longer challenging and the patient can perform activity with ease and good form.

3 Section 1: Primary Manual Therapy Techniques. One of the following techniques must be chosen as part of the manual therapy component of the treatment protocol. Long axis distraction with thrust: This technique is the only MT technique that has been demonstrated to be effective for hip OA. This technique has not been studied in this patient population. It has been evaluated in a randomized, controlled trial. It was found to be safe and effective in older adults with moderate to severe hip OA. The trial reported that 90% of patients received this intervention on every visit, with no adverse events reported. Caudal glide or distraction mobilizations, with the hip flexed: Ensure the belt is placed firmly in the patient s crease. Flex the patient s hip to the first point of pain or restriction and use your body to impart a caudally directed, passive accessory glide to the proximal hip. The joint position (amount of hip flexion, rotation, add/abduction) and the direction of force (caudal, lateral, inferio-lateral) can be varied at the discretion of the therapist to address movement restriction. E.g. For hip flexion: hip flexed; distraction +/- caudal glide For hip external rotation: hip externally rotated, lateral distraction For hip internal rotation: hip internally rotated, lateral distraction +/- posterior glide Antero-Posterior Progression (Posterior glide): to improve adduction and flexion by stretching the posterolateral capsule. With the patient supine, place the foot of the affected hip on the table across the opposite knee. A mobilizing force is imparted through the long axis of the femur to the postero-lateral hip capsule using passive accessory glides. The amount of hip flexion may be adjusted to find the position that most effectively stretches the hip Postero-Anterior Progression (Anterior glide): to improve extension by stretching the anterior capsule. With the patient prone and the knee flexed, the therapist supports the lower extremity of the patients affected hip. A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from posterior to anterior. The amount of internal/external rotation is varied to find the position that most effectively stretches the hip. Postero-Anterior glide with flexion, abduction, and external rotation (Figure 4): With the patient prone, position the affected hip on the table using a combination of flexion, abduction, and external rotation; adjust the preceding motions to optimize the amount of stretch felt by the patient. A pillow may be placed under the subject s abdomen if the position is not initially tolerated. Contact the femur just distal to the greater trochanter. A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from posterior to anterior. Lateral glide: to improve adduction and flexion by stretching the lateral capsule. Internal Rotation in Prone: to improve internal rotation and extension of the hip by stretching the anterolateral capsule. Acceptable variations include: Patient position (supine/sitting/weight bearing, with or without seat belt) Med/lat glides of tib/fem jt, with/without seatbelt Varus/valgus stresses, internal/external rots of tibia, for accessory and physiological movements Combining movements and accessories Manual stretches to stretch Quad/ hip flexors, hamstrings, adductors, gluteus/ internal rotators, external rotators. These can be discontinued when ROM goals are reached (refer to protocol for details).

4 Section 2: Primary Exercise Techniques Strengthening: Exercises consist of muscle strengthening exercises with the use of weight or strengthening equipment. All exercises performed as 3 sets of 10 or until fatigue. Hip Abduction: To improve weak hip abduction strength. Begin with standing hip abduction against resistance with progression to sidestepping with theraband and single limb squat. Hip Extension: To improve weak hip extension strength. Begin with standing hip extension against resistance with progression to supine bridging, quadruped hip extension, or single leg bridging over theraball Hip External Rotation: To improve weak hip external rotation strength. Begin with sidelying clams against resistance and progress to seated hip ER against resistance. Knee Extension: To improve weak knee extension strength. Begin with Shuttle machine (progressive load), 3 x 10 reps, 70% MR, Knee flexion-extension on chair (progressive load), 3 x 10 reps, 70% MR, Mini wall sits, Squats, lunges, step ups Abdominal Bracing: To improve decreased core stability. Begin with Transversus abdominus and multifidus isolated contraction and associated light exercises, such as bridging and crouching, Progress to lateral bridge, mini squat, Progress to swiss ball exercises (core stabilization with perturbation forward, backward, side to side; sitting on swiss ball performing isometric hip adduction and ball toss; movements with lower limbs holding a swiss ball between legs) Stretching: Stretches consist of muscle lengthening exercises. Hold for 30 seconds and repeat. Hip Flexor: To improve decreased hip flexor length. Performed as ½ kneeling hip flexor stretch Hamstring stretch: To improve decreased hamstring length. Performed in standing or sitting leaning forward from the pelvis keeping the back straight. FABER Figure 4 stretch: To improve decreased external rotation muscle length. Performed in supine with one leg crossed over the other just above the knee. Gently pull on the back of the thigh bringing the leg toward you until a stretch is felt. Neuromuscular control: Coordination is trained through balancing exercises with increasing complexity. Can be a combination of techniques including: Balance, balance board, vibration plate, dynadisc, slide board Progress to combine exercises with sports movements (kicking and throwing)

5 Impairment Decreased hip motion Long axis Distraction / thrust Seatbelt Glide or Distraction Techniques: Caudal/Lateral Glide Progression Antero-Posterior Progression (Posterior glide) Postero-Anterior Progression (Anterior glide) Postero-anterior glide with flexion, abduction, and lateral rotation The patient is positioned supine. The therapist grasps involved leg, above malleoli. The patient s hip is placed at the point of restriction per the therapist s discretion. The therapist performs an oscillatory passive accessory mobilization force inferiorly feeling for the restrictive barrier and imparts a thrust in an inferior direction. Progression of the distraction position into more abduction to gain further ROM. Repeated as necessary The therapist uses a mobilization belt placed firmly in the patient s hip crease. The therapist flexes the patient s hip to the restrictive barrier. The therapist uses their body to apply a caudally/laterally directed force to the proximal thigh and performs an oscillatory passive accessory mobilization force. The amount of hip flexion, rotation, & add/abduction can be varied to find the position of optimal mobilization. The therapist places the patient s lower extremity with the hip in a position of flexion and adduction. The therapist uses his body to impart an oscillatory, passive mobilizing force to the postero-lateral hip capsule through the long axis of the femur. The technique is progressed by adding more flexion, adduction, & / or internal rotation. With the patient in prone the therapist grasps and supports the patient s lower extremity with his arm. The therapist places either the 1st web space, thenar eminence, or hypothenar eminence of his hand just inferior and medial to the greater trochanter. The therapist brings the patient s hip into varying degrees of flexion/extension, abduction/ adduction, and internal/ external rotation to find the vector of force that most effectively stretches the hip. The therapist imparts an oscillatory, passive mobilizing force through the proximal femur in a posterior to anterior direction. The stretch should be felt by the patient in the anterior hip region Tip: To progress the technique the therapist increases the amount of extension, adduction, and internal rotation. Can also modify by progressing into FABER position. With the patient in prone the therapist brings the patient s hip into varying degrees of flexion, abduction and external rotation. If the patient is extremely stiff, start with patient s lower extremity on a stool. Progress to lying flat on the table when able. With the patient positioned prone, the therapist positions the affected hip on the table using a combination of flexion, abduction, and lateral rotation; this can be adjusted to find the position that the therapist believes most effectively stretches the hip joint and is tolerated by the patient. A pillow may be placed under the patient s abdomen if the position is not tolerated initially. The therapist contacts the femur just distal to the greater trochanter. A mobilizing force is imparted to the hip through the proximal femur using passive accessory glides from posterior to anterior.

6 Internal Rotation in Prone Quadrant Manual Quad stretch/ hip flexor Manual hamstring stretch Manual gluteus/ external rotator stretch The therapist flexes the patient s knee to 90 degrees and ensures that the hip is in neutral or slight adduction. The hip is internally rotated until the contralateral ilium raises approximately 1-2 inches from the table. The therapist stabilizes the lower leg and imparts an oscillatory, passive mobilizing force through the contralateral pelvis Note: If the patient experiences knee discomfort, grasp the distal thigh and place your forearm along the medial aspect of the patient s tibia Combined hip movements of flexion, adduction, and rotation as needed are added. The therapist drapes hands and arms over the knee and thigh and imparts an oscillatory, passive mobilizing force in the direction of flexion, adduction, internal rotation. This technique is effective for treating stiffness through combined movements. The patient is positioned prone with the involved LE dangling over the edge of the plinth. The therapist sits alongside the involved LE and flexes the knee just before the point of patient reported stretch 2 reps x 60 sec 4 reps x 30 sec 6 reps x 20 sec Alternate position prone knee flexion with pelvis stabilized. NB: Can be done along with STM Quads (above) The patient is positioned supine with knee extended. The therapist grasps the involved LE and flexes the hip while maintaining knee extension to the point of stretch. 2 reps x 60 sec 4 reps x 30 sec The patient is positioned supine. The therapist flexes the patient s knee to 90, flexes and externally rotates the hip to the point of stretch. 2 reps x 60 sec 4 reps x 30 sec

7 Hip internal rotator stretch The patient is positioned prone. The therapist flexes the patient s knee to 90 degrees and ensures that the hip is in neutral or slight adduction. The hip is internally rotated until a stretch is felt at the anterior hip. 2 reps x 60 sec 4 reps x 30 sec

8 Impairment Decreased hip abduction strength Decreased hip external rotation strength Decreased hip flexor strength Decreased hip extension strength Decreased knee extension strength Decreased core stability Intervention Hip abduction progression Hip external rotation progression Hip flexion progression with increased resistance Hip extension progression with increased resistance Knee extension progression with increased resistance/difficulty Core lumbopelvic stabilization exercises Details Standing hip abduction/adduction (progressive load), 3 x 10 reps Progress to Sidestepping gait with elastic band over midfeet, 3 x 1 min Progress to Dynamic valgus control with single limb squat, 3 x 1 min Progress to side plank with hip abduction, 1 x 30 sec Sidelying clam exercises (progressive resistance), 3 x 10 reps Seated ER (progressive resistance), 3 x 10 reps Progress to dynamic valgus control with single leg stance and eccentric external rotation control Supine straight leg raise (add cuff weights as needed) Standing hip flexion (add resistance as needed) Standing hip flexion with cable machine (progressive load), 3 x 10 reps Standing hip extension (progressive load), 3 x 10 reps Supine bridging Supine unilateral bridge Quadruped hip extension with knee bent or leg straight Supine unilateral bridge over swiss ball Kneeling gluteal squeeze against resistance Shuttle machine (progressive load), 3 x 10 reps, 70% MR Knee flexion-extension on chair (progressive load), 3 x 10 reps, 70% MR Mini wall sits Squats Lunges Step-ups Transversus abdominus and multifidus isolated contraction and associated light exercises, such as bridging and crouching Progress to lateral bridge, mini squat Progress to swiss ball exercises (core stabilization with perturbation forward, backward, side to side; sitting on swiss ball performing isometric hip adduction and ball toss; movements with lower limbs holding a swiss ball between legs)

9 Decreased hamstring muscle length Decreased iliopsoas muscle length Decreased external rotation muscle length Decreased neuromuscular control Hamstring stretch Hip flexor/quad stretch Hip external rotator stretch Sensory motor training Can be performed manually by the treating therapist or patient can assume standing or seated position Can be performed manually by the treating therapist or in ½ kneeling hip flexor stretch/ Runner s stretch Can be performed manually by the treating therapist or patient can assume supine position and perform Figure 4 stretch Balance, balance board, vibration plate, dynadisc, slide board Progress to combine exercises with sports movements (kicking and throwing)