Clinical decision making in a patient with secondary hip-spine syndrome.

Abstract

The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved, highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is to describe the clinical decision making in the examination and treatment of an individual with secondary hip-spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain. His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution. Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.

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Physiotherapy Theory and Practice, 2010, Early Online, 1–14
Copyright & Informa Healthcare
ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2010.509382
RESEARCH ARTICLE
Clinical decision making in a patient with secondary
hip-spine syndrome
Scott A Burns, PT, DPT, OCS, FAAOMPT,1Paul E Mintken PT, DPT, OCS, FAAOMPT,2
and Gary P Austin, PT, PhD, OCS, FAAOMPT3
1Assistant Professor, Department of Physical Therapy, Temple University, College of Health Professions and Social Work,
Philadelphia, Pennsylvania, USA
2Assistant Professor, Department of Physical Therapy, University of Colorado Denver, School of Medicine, Aurora,
Colorado, USA
3Associate Professor, Department of Physical Therapy and Human Movement Science, Sacred Heart University,
Fairfield, Connecticut, USA
ABSTRACT
The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved,
highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is
to describe the clinical decision making in the examination and treatment of an individual with secondary hip-
spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain.
His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance
beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient
specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary
hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening
exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution.
Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown
that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting
regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary
complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.
INTRODUCTION AND BACKGROUND
Low back pain (LBP) and hip pain are common
conditions managed by physical therapists. Clinical
decision making in the presence of pathology in both
regions can be challenging (Fogel and Esses, 2003),
leading to inefficient care and increased costs
(Offierski and McNab, 1983). Emerging research
suggests that hip impairments may contribute to LBP
(Offierski and McNab, 1983; Reiman, Weisbach, and
Glynn, 2009). Identifying primary and secondary
impairments is critical in the development of an
appropriate physical therapy plan (APTA, 2001;
Offierski and McNab, 1983).
Offierski and McNab (1983) originally described
coexisting lumbar spine and hip pathologies and labeled
this conditionhip-spine
described four categories of hip-spine syndrome,
including simple (primary), secondary, complex, and
misdiagnosed. Simple hip-spine syndrome (HSS)
occurs when pathological changes are present in both
the lumbar spine and hip; however, the primary source
of symptoms is clear. Secondary HSS is when the hip
and spine pain are ‘‘interdependent’’ and the symptoms
in one joint are ‘‘secondary’’ to a deformity or pathology
in the other joint. Complex HSS was defined as a
pathological change in each region that yields no clear
primary source despite a careful physical examination.
syndrome. Theauthors
Address correspondence to Dr. Scott A Burns, PT, DPT, OCS,
FAAOMPT, 3307 North Broad St, Jones Hall Room 618, Philadelphia,
PA 19140.
E-mail: scott.burns@temple.edu
Accepted for publication 13 July 2010.
1
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Typically, individuals classified with complex HSS
undergo nerve root blocks or joint injections in an
attemptto confirmthe
Misdiagnosed HSS occurs when the primary source of
symptoms is incorrectly diagnosed, leading to erroneous
or inappropriate treatment and unnecessary cost to the
individual and the health care system. These categories
epitomize theinherent
individual’s with concurrent pathology. Traditionally,
diagnostic imaging has been used to determine the
pathoanatomic source of the symptoms, but this
approach has produced suboptimal outcomes in the
treatment of spinal disorders (Waddell, 2006). Dagenais,
Garbedian, and Wai (2009) concluded that there is 1) a
lack of consensus regarding the radiographic diagnosis of
hip osteoarthritis and 2) no clear association between the
presence of radiographic hip osteoarthritis and the
indication for surgical management. In lieu of these
deficiencies, the concept of regional interdependence
has gained popularity in the physical therapy literature.
Wainner, Whitman, Cleland, and Flynn, (2007) defined
thetermregional interdependence
unrelated impairments in a remote anatomical region
that may contribute to, or be associated with, the
patient’s primary complaint.’’ The literature supports
the validity of this concept in multiple regions of the
body (Boyles et al, 2008; Cleland et al, 2007; Whitman
et al, 2006). For example, intervention directed at the
thoracic spine has been shown to be effective for
shoulder pain (Boyles et al, 2008) and mechanical neck
pain (Cleland et al, 2007). Manual therapy and exercise
targeting the spine and lower extremities has been shown
to be effective for patients with lumbar spinal stenosis
(Whitman et al, 2006).
Given the anatomic proximity and shared soft
tissue connections, an interaction between the lumbar
spine and hip joint seems biologically plausible. Hip
range of motion (ROM) measurements have been
implicated in studies with interventions targeting the
lumbar spine (Flynn et al, 2002; Hicks, Fritz, Delitto,
and McGill, 2005). A study examining the hip ROM in
subjects with LBP and/or sacroiliac dysfunction showed
asymmetries in bilateral hip internal rotation (Cibulka,
Sinacore, Cromer, and Delitto, 1998). Although some
radiographic studies looking at patients with LBP and
hip complaints have failed to show a clear connection
between the two regions (Matsuyama, Hasegawa, and
Yoshihara, 2004; Yoshimoto, Sato, and Masuda, 2005),
Ben-Galim, Ben-Galim, and Rand (2007) reported on
25 patients with pain and impairments in both regions
who had significant reductions in LBP and disability
scoresfollowingtotal hip
Weisbach, and Glynn (2009) provide a detailed
overview of the evidence supporting the potential
interactions between the lumbar spine and hip joint.
primarypain generator.
complexityof managing
as ‘‘seemingly
arthroplasty. Reiman,
Despite an
lumbar spine and the hips, there is limited evidence
to guide the therapist in selecting the region to initiate
treatment. The purpose of this case report is to
describe the clinical decision making in the exami-
nation and treatment of an individual with secondary
hip-spine syndrome.
apparentconnectionbetween the
CASE DESCRIPTION
History
A 62-year-old male, employed as a claims supervisor,
was referred to physical therapy with a chief presenting
complaint of right-sided LBP with concomitant right
hip pain. He had no previous injury to his lumbar
spine or lower extremities,and denied any significant
medical history. No red flags were identified during
the systems review and physical examination/symptom
investigation. The individual reported that his symp-
toms began approximately 5 and a half months prior,
following a weight-training session for his lower extre-
mities. He was performing an inverted leg press
exercise when he felt the initial onset of right-sided
LBP with an aching sensation along the right lateral
hip region. Following the onset of this pain, he dis-
continued his lower extremity weight-training sessions
for 2 weeks. His symptoms progressed until he was
unable to drive for greater than 60 minutes and had
lumbar discomfort while sitting at work. Two weeks
after initial onset, he sought medical treatment from
his primary care physician and was initially managed
with a nonsteroidal anti-inflammatory drug (NSAID)
and rest. After 4 weeks with no improvement in his
symptoms, he returned to his physician and was
referred to an orthopedic surgeon. The orthopedic
surgeon ordered magnetic resonance imaging (MRI)
of the right thigh to rule out a suspected femoral stress
fracture due to his high level of activity. The MRI
results were unremarkable except for age-related
degenerative changes in the hip joint. He was then
referred to a physiatrist for further medical manage-
ment. The physiatrist referred him to physical therapy
for evaluation for symptoms of a musculoskeletal
origin with a referral for ‘‘LBP Evaluate and Treat.’’
The subject in this case gave consent to use his medical
information and images as part of this publication.
Five and a half months after the initial injury,
he presented to physical therapy with the following
baseline outcome measurements: Oswestry Disability
Index (ODI) of 18%; average Numeric Pain Rating
Scale (NPRS) of 4/10 in the lumbopelvic-hip region;
Fear Avoidance Beliefs Questionnaire (FABQ) work
subscale score of 0; FABQ physical activity subscale
2Burns et al.
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score of 18; a Lower Extremity Functional Scale
(LEFS) score of 74/80; and a Patient Specific
Functional Scale (PSFS) score of 7.33. The three
activities he reported as problems on the PSFS
included 1) running, 2) lower extremity weight
training, and 3) sitting greater than 60 minutes.
Table 1 provides a brief description of each outcome
measure, including their
properties. Additional functional limitations included
squatting, crossing his right leg over his left, ascending
stairs, and driving. He also reported an intermittent
aching sensation in the right calf that extended into his
first and second toes typically associated with driving
andprolongedsitting.
infrequent and resolved in less than 24 hours.
Finally, he reported mild morning stiffness in the
back and hip region that lasted less than 30 minutes.
The patient made it clear that he was distressed about
his inability to maintain his exercise regimen due to his
pain and that he was anxious to return to activity. Prior
to the incident, he was participating in weight training,
racquetball, and running five to six times per week. His
main goal was to return to his previous exercise
regimen. At the time, he was working full-time with a
majority of his day spent in a seated position.
respective psychometric
Thesesymptomswere
Tests and measures
The physical examination began with observation and
postural screening in standing, sitting, and supine as
described by Kendall, McCreary, and Provance
(1993). Remarkable findings included decreased lum-
bar lordosis and increased thoracic kyphosis. Range of
motion (ROM) was assessed by using a bubble
inclinometer (Fritz, Piva, and Childs, 2005) and
revealed hip and lumbar ROM impairments. Lumbar
ROM was limited to 428 flexion and 188 extension with
increased LBP with each movement. Prone hip
internal rotation (IR) was limited to 188 on the right
and produced concordant lumbar spine pain and right
hip pain at end range. In this case, concordant
symptom reproduction is defined as reproduction of
the ‘‘exact’’ symptoms for which the individual was
seeking treatment. Manual muscle testing revealed
normal strength in the lower extremities with the
exception of the gluteus maximus and gluteus medius
on the right, which were graded as 41/5 on the right
(Kendall, McCreary, and Provance, 1993). Resisted
testing of the gluteus maximus and medius also
increased his LBP symptoms. The results of the
ROM and strength testing are outlined in Table 2.
He did not demonstrate a directional preference for
lumbarflexion orextension
Cleland, and Fritz 2007). Abdominal strength was
normal (Kendall, McCreary, and Provance, 1993).
Popliteal angle was limited bilaterally to 65 degrees in
the supine 90 degree hip flexed position. Slump testing
and straight leg raise testing were negative for
symptom reproduction and ROM asymmetry. No
abnormalities were noted in the lower extremities for
(Browder, Childs,
TABLE 1 Description and psychometric properties of outcome measures
Outcome measure DescriptionReliability Minimum detectable change and
minimal clinical important difference
Modified Oswestry
Disability Index
10 question condition-specific
measurement for individuals with
LBP. Involves questions relating to
pain and functional limitations.
ICC 5 0.90 (Fritz & Irrgang,
2001)
MDC 5 4–10 pts (Tacci, Webster,
Hashemi, & Christiani, 1999)
MCID 5 6 pts or 12% (Cleland &
Netter, 2005; Fritz & Irrgang, 2001)
Patient Specific
Functional Scale
A patient-centered questionnaire in
which the patient writes his or her
own limitations due to the
condition.
0.82–0.97 (Chatman, Hyams, &
Neel, 1997; Grotle, Brox, &
Vollestad, 2006; Tacci, Webster,
Hashemi, & Christiani, 1999;
Whitman et al, 2006)
0.77 (back pain) (Cleland,
Childs, & Whitman, 2008)
MCID 2.0 (Cleland, Fritz, &
Whitman, 2006)
MDC 5 1.88–3.00 (Cleland, Fritz, &
Whitman, 2006; Fritz & Irrgang, 2001)
Fear Avoidance
Beliefs
Questionnaire
Questionnaire designed to assess
beliefs regarding movement and its
effects on LBP. Two subscales:
work and physical activity.
11-point scale asking the individual
to rate his or her pain level based on
severity.
MDC (Grotle et al, 2006)
Work 5 12 pts
Physical Activity 5 9 pts
Numeric Pain
Rating Scale
0.76 (Cleland, Childs, &
Whitman, 2008)
MCID 5 2 pts (Childs, Pica, & Fritz,
2005; Cleland, Childs, & Whitman,
2008; Grotle, Brox, & Vollestad, 2006)
Global Rating of
Change
Retrospective 15-point scale asking
the individual to rate their
perceived level of change (1 or 2)
Not reported
66 or 75large changes (Jaeschke,
Singer, & Guyatt, 1989)
64 or 55moderate (Jaeschke, Singer,
& Guyatt, 1989)61 to 35small
(Jaeschke, Singer, & Guyatt, 1989)
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sensation, muscle stretch reflexes, or pathological
reflexes.
Posterior to anterior passive mobility assessment
of the thoracic and lumbar spine was unremarkable
for symptom reproduction, however, all segments
were deemed to be hypomobile (Maher, Latimer,
and Adams, 1998; Maitland, 1986; Maitland, 1991).
Posterior to anterior passive mobility testing (Maitland,
1991) of the hip was deemed to be hypomobile in
inferior and anterior glides with a firm end-feel, but these
motions did not reproduce symptoms. Supine anterior-
posterior hip accessory motion testing reproduced his
concordant* symptoms. Palpation of the soft tissue
structures in the spine and hip regions did not reveal
any focal tender points. Ober’s test was positive for ilio-
tibial band shortness. Nonconcordant hip pain was
produced with the hip quadrant and FABER tests.
In this case, nonconcordant symptom reproduction is
defined as reproduction of symptoms not associated
with a patient’s primary complaint and/or a therapist
identified physical impairment (i.e., impairments in joint
mobility or ROM). Mechanical testing of the sacro-
iliac joint, soft tissue and neural structures of the
lower extremity were not provocative. See Table 3 for
description and psychometric properties of special tests
performed with this patient.
Diagnosis
The first step in the clinical decision-making process is
to determine if the patient is an appropriate candidate
for physical therapy services. Delitto, Erhard, and
Bowling (1995) in their treatment-based classification
(TBC) system, outlined this initial step in the patient-
therapist interaction. Three options are described,
including 1) patient is appropriate to be managed by
physical therapy, 2) patient is appropriate for physical
therapybut may require consultation
health care provider, and 3) patient is not appropriate
for physical therapy and needs to be referred to
appropriate healthcare provider (Delitto, Erhard, and
Bowling, 1995). The clinician determined that no red
flags were present that would necessitate referral, and
the patient did not present with any signs/symptoms
that would require further consultation (Delitto,
Erhard, and Bowling, 1995). Although the FABQ
physical activity subscale score of 18 may warrant
consideration for consultation due to elevated fear
avoidance beliefs, in the absence of additional psycho-
social yellow flags, the clinician opted to initiate treat-
ment without referring to another health care provider
(Delitto, Erhard, and Bowling, 1995).
After determining that the individual was appropriate
for physical therapy management, the second step in a
classification-based approach is to place the individual
into a stage, based on functional limitations and symp-
tom severity (Delitto, Erhard, and Bowling, 1995).
Stage I includes those patients with higher ODI scores
who are unable to perform basic mechanical functions
(i.e., sit .30min, stand .15min, and walk .¼ mile).
Stage II includes those patients who are able to perform
basic activities adequately but are unable to perform
more functional activities. Stage III includes patients
who are unable to perform demanding or sustained
activities. The clinician determined that this individual
was best suited to the stage II of the TBC because his
ODI was on the border of Stage II and III and he was
able to perform basic activities but had difficulty with
more functional activities. Treatment goals for patients
in stage II include reducing disability, correcting
physical impairments, and improving the patient’s
ability to perform complex (functional) tasks. The
clinician opted to use a response-driven, impairment-
based approach to treatment.
In a response-driven, impairment-based approach,
the clinician looks for movements, positions, or
impairments that reproduce a patient’s concordant
symptoms. Concordant symptom reproduction was
achieved with prone passive right hip internal rotation
and anterior-posterior passive accessory motion of the
right hip (Appendix A). It is unlikely that these tests
isolate movement at the hip joint, but care was taken
by the clinician to minimize lumbar spine movement
while performing these tests/measures. During prone
passive hip IR, the pelvis was stabilized via manual
pressure directed in a posterior to anterior direction
over the sacrum and contralateral ilium. Anterior-
posterior passive accessory motion of the right hip was
performed in a position of hip and knee flexion, hip
by other
TABLE 2 Significant examination findings
RightLeft
Gluteus Maximus41/5*
5/5
Gluteus Medius41/5*
5/5
Hip External Rotation (prone; passive) 338
318
Hip Internal Rotation (prone; passive)188***
278
Hip Extension (sidelying; passive)08
68
Hip Flexion (supine; passive)1088
1108
Ober’s Test
12
Hip Quadrant
1**
2
FABER
1**
2
Lumbar Flexion428*
Lumbar Extension 188*
*Denotes nonconcordant production of low back pain.
**Denotes nonconcordant production of hip pain.
***Denotes concordant symptom reproduction.
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TABLE 3 Description and psychometric properties of tests/measures performedTest/Measure
Description
Reliability
Range of Motion (ROM)
Lumbar ROM using single inclinometer
Hip ROM using standard goniometer
ICC 5 0.60–0.61(Fritz, Piva, & Childs, 2005)
ICC 5 0.58–0.94 (Holm et al, 2000)
Manual Muscle Testing
Gradation of strength using manual resistance
Inter-examiner
ICC 5 0.82–0.97 (Cuthbert & Goodheart, 2007)
Deep Tendon Reflexes
Using single reflex hammer
Intra-examiner
ICC 5 0.68–0.91 (Litvan et al, 1996)
Inter-examinerICC 50.50–0.64 (Litvan et al, 1996)
Sensory Testing
Identification of sensation differences.
Not reported
Posterior-Anterior Segmental
Mobility Testing
Patient in prone. Examiner exerts a posterior-to-anterior force through the lumbar vertebrae.
Assessment for mobility, end-feel and symptoms.
ICC 5 0.55–0.72 (Maher, Latimer, & Adams,
1998)
Ober’s Test
Patient sidelying. On the side being examined the knee is flexed to 908 and is abducted/extended
until it is in line with the trunk. The examiner guides the extremity as gravity adducts the hip.
Positive test result includes asymmetry in adduction ROM of greater than 108.
Intra-examiner 0.90 (Reese & Bandy, 2003)
FABER (Flexion/
Abduction/ExternalRotation)
Begin with patient in sidelying. Place LE in hip flexion/abducted with the ipsilateral foot resting
on the opposite knee (Figure 4). Stabilize the contralateral ASIS and apply an ER and posterior
force on the ipsilateral knee. Positive test result for SI dysfunction includes symptom/pain
reproduction over the ipsilateral SI region. Positive test result for hip pathology includes
symptom/pain reproduction over the anterior hip or groin region (Troelsen et al, 2009).
K 5 0.60–0.96 (Cliborne et al, 2004; Kokmeyer,
van der Wuff, Aufdemkampe, and Fickenscher
et al, 2002; Martin & Sekiya, 2008)
FAIR (Piriformis) Test
Begin with the patient in sidelying with the test LE being upward. Passively flex, adduct and IR
the tested LE. Positive test result includes pain/symptom reproduction.
Not reported
Gaenslen’s Test
Begin with patient in supine. Test LE is brought into full hip and knee flexion. The opposite LE
stays in extension. Pressure is applied to the flexed extremity. Positive test result includes
reproduction of pain/symptom over the SI region.
Inter-examiner
K 5 0.54–0.76 (Cliborne et al, 2004; Laslett &
Williams, 2004; Martin & Sekiya, 2008)
Thigh Thrust
Begin with patient in supine. Examiner passively flexes and adducts the hip to 908. A long-axis
compressive force is applied through the femur. Can repeat in varying angles of adduction/
abduction. Positive test result includes pain/symptom reproduction over the ipsilateral SI region.
Inter-examiner
K 5 0.67–0.88 (Cliborne et al, 2004; Laslett &
Williams, 2004; Martin & Sekiya, 2008)
Sacral Thrust
Begin with patient in prone. Examine applies a thrust in the anterior direction over the sacrum.
Positive test result includes pain/symptom reproduction over the involved SI region.
Inter-examiner
K 5 0.41–0.56 (Cliborne et al, 2004; Laslett &
Williams, 2004; Martin & Sekiya, 2008)
Compression Test
Begin with patient in sidelying. Examiner applies compressive force over the iliac crest directed
toward the opposite iliac crest. Positive test result includes pain/symptom reproduction over
involved SI region.
Inter-examiner
K 5 0.26–0.73 (Cliborne et al, 2004; Laslett &
Williams, 2004; Martin & Sekiya, 2008)
Distraction Test
Begin with patient in supine. Apply pressure to both ASIS in a posterolateral direction. Positive
test result includes pain/symptom reproduction over involved SI region.
Inter-examiner
K 5 0.26–0.69 (Cliborne et al, 2004; Laslett &
Williams, 2004; Martin & Sekiya, 2008)
IR-Flexion-Axial
Compression
Begin with patient in supine. Passively flex and IR the hip. Apply an axial compressive load
through the femur. Positive test result includes pain/symptom reproduction in the groin region.
Not reported
Anterior Labral
Tear Test
Patient supine, take hip into full flexion, external rotation and full abduction. Extend the hip
combined with medial rotation and adduction. Positive test result includes groin pain reproduction.
Not reported
Posterior Labral
Tear Test
Patient supine, take hip into full flexion, adduction and internal rotation. Extend the hip with
combined abduction and external rotation. Positive test result includes groin/hip pain reproduction.
Not reported
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adduction and slight hip IR, and care was taken to not
introduce movement of the lumbar spine and pelvis.
Nonconcordant symptom reproduction was achieved
with strength testing of gluteus medius and maximus,
active lumbar flexion and extension, hip quadrant and
FABER tests. Additional nonconcordant findings
included lumbar and hip joint hypomobility. Table 2
outlines the impairments found in the physical exami-
nation. The concurrent and apparently interrelated hip
and spine impairments suggest a secondary hip-spine
syndrome, in which the primary complaint of LBP is
considered secondary to concurrent pathology in the
hip. Given this information, initial physical therapy
interventions were targeted at the hip joint.
Prognosis
The initial prognosis was guarded due to the persistent
nature of his symptoms and previous recalcitrance
to rest, self-management, and previous medical care.
The clinician was optimistic that physical therapy
interventions directed at hips would result in a success-
ful outcome as this patient had never received treat-
ment directed at the hip joints.
Intervention
The clinician utilized a combination of manual therapy
and therapeutic exercises directed at the hip. The
manual therapy techniques included thrust and non-
thrust long axis distraction manipulation of the right
hip, supine anterior-posterior nonthrust mobilization,
and prone posterior-anterior nonthrust mobilization in
flexion, abduction, and external rotation (Appendix A).
Nonthrust mobilizations were performed for three
bouts of 30 repetitions on the right side at a grade III
or IV, as described by Maitland (Maitland, 1986;
Maitland, 1991). The selected thrust and nonthrust
manipulations were utilized in this case to address the
hypomobility of the hip joint identified in the physical
examination.
The patient was instructed in a home exercise
program and was required to demonstrate competence
at subsequent visits (Appendix B). His therapeutic
exercise regimen consisted of: stretching exercises
for the piriformis and hamstrings; self-mobilization
techniques directed at the postero-inferior hip capsule;
and strengthening exercises for hip extension and
sidelying hip abduction/external rotation. The supine
piriformis stretch was prescribed on the basis of the
reduction of symptoms rather than the presence of
muscle shortness. The stretching was prescribed for
20–30 seconds holds and repeated two tor three times
(Decoster, Cleland, Altieri, and Russell, 2005).
The self-mobilization techniques were performed
for two to three bouts of 30 repetitions (Maitland,
1991). The hip extension and sidelying hip abduction/
external rotation exercises were prescribed to be
performed for 15–20 repetitions (Mascal, Landel,
and Powers 2003). The exercises listed above were
selected to address the impairments of joint mobility
and muscle performance identified at the hip in the
physical examination.
The episode of care consisted of one session
per week for 3 weeks and then a final session at the
5th week, for a total of four visits. His home exercise
program was to be performed two times per day.
Phone follow-ups regarding current symptoms and
functional status were performed at 3 months and
6 months after last treatment session. Written outcome
measures were obtained via facsimile at the same time
points.
Outcomes
Outcome measures were collected at the first, third, and
fourth visits as well as follow-up sessions at 3 months
and 6 months. By the third visit, the patient had an ODI
of 0%, an average NPRS 0/10, FABQ work and
physical activity subscales scores of 0, PSFS score of
10, and an LEFS score 80/80. In addition, a global
rating of change score of 17 was obtained, indicating
a large shift in perceived recovery. See Table 1 for
psychometric properties of all standardized outcome
assessments. All outcomes remained unchanged at
the 3- and 6-month follow-up. More importantly, his
functional limitations of squatting, crossing his right leg
over his left, ascending stairs, running and lower
extremity weight lifting, and driving/sitting for longer
than 1 hour had all resolved. He was able to participate
without limitation in his activities of daily living,
as well as all his occupational and recreational activities.
The results are highlighted in Table 4.
TABLE 4 Outcome measure values throughout course of
treatment
Initial visit 3rd visit Discharge
(4th visit)
3 Month 6 Month
ODI18% 0% 0%0%0%
Avg. NPRS4/10 0/100/10 0/100/10
PSFS 7.33101010 10
FABQ-W00000
FABQ-PA180000
GROC n/a7777
6Burns et al.
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DISCUSSION
The clinical decision-making process in patients with
concurrent impairments in the lumbar spine and hip
can be complex, and the evidence describing the
interaction between the lumbar spine and hip joint is
limited. With the exception of lumbar spinal stenosis
(Whitman et al, 2006), the hip is rarely treated in
patients with LBP. The hip joint has been implicated
in studies identifying predictor variables of patients
who will respond to specific lumbar interventions
(Browder, Childs, Cleland, and Fritz, 2007; Flynn et al,
2002). There is also low level evidence suggesting
potential relationships between LBP and hip strength
(Nadler, Malanga, and Feinberg, 2001) and hip ROM
(Cibulka, Sinacore, Cromer, and Delitto, 1998).
Although the direct relationship between the hip and
lumbar spine is unknown, there is an apparent
interaction between the two regions.
Given this unclear relationship, the focus of this
case report was to describe the clinical decision-
making process taken in the presence of concurrent
impairments of the hip joint and lumbar spine.
The concept of regional interdependence, which has
some face validity based on previous research, was
considered important in this patient In this case,
examination of regions surrounding the area of pri-
mary complaint afforded the clinician the opportunity
to reproduce the concordant symptoms with tests
directed at the hip joint. This allowed for the
appropriate categorization of this individual as having
a secondary hip-spine syndrome. In secondary hip-
spine syndrome, the hip is deemed to be the primary
contributor to a patient’s LBP. Concordant symptom
reproduction was critical in this case to allow for
appropriateclinicaldecision
intervention. Had the clinician not implemented a
regional interdependence approach and reproduced
the concordant symptoms, there is a possibility that
inappropriate interventions may have been imple-
mented, resulting in increased health care costs and
prolonged disability. Finally, the treatment-based
classification for LBP allowed the clinician to syste-
matically triage and stage the patient in an efficient and
effective manner.
Previous literature has shown that individuals with
lumbar spinal stenosis may respond favorably to
mobilization of regions remote to the lumbar spine,
including the hips. The findings of this case report
suggestthatsome individuals
complaint of LBP may benefit from manual therapy
and exercise targeted at the hip. In this case, it is likely
that the primary contributor to the clinical presen-
tation was the hip joint despite a primary complaint
of LBP. Proper identification of the region that is
making andinitial
withaprimary
primarily responsible for symptom production may
have resulted in faster recovery for this individual.
We would argue that the successful outcome was
achieved because of interventions being applied to the
correct, symptom-provoking region.
CONCLUSION
Appropriate clinical decision making in cases that
have concurrent lumbar and hip pathology is often
challenging. Concordant symptom reproduction using
a response-driven, impairment-based approach may
allow clinicians to correctly identify the symptom-
generating region and deliver effective interventions
to reduce pain and disability. Finally, utilizing the
concept of regional interdependence, clinicians may
improve the likelihood that they correctly identify
impairments that are causing or contributing to a
patient’s symptoms.
ACKNOWLEDGMENTS
All photos were graciously taken by Mr David Weil
from the University of Colorado Denver Physical
Therapy Program. All photos are of a model demon-
strating the movements.
Declaration of Interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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Appendix A. Manual therapy interventions.
Long-axis Distraction Manipulation
(High-velocity, end-range, longitudinal traction force to the lower extremity on the acetabulum in supine with the
hip in slight flexion, abduction and varying degrees of internal and external rotation of the lower extremity)
5
>
Grasp the patient’s ankle proximal to the malleoli with both
hands in a grip comfortable for the patient
Raise the leg to approximately 10–308 of hip flexion and
15–308 of abduction, slight external rotation
Gently distract the hip and perform oscillations
Once the hip is felt to relax, apply a high velocity, small
amplitude thrust
>
10
>
>
15
20
25
Anterior-posterior Hip Mobilization Progression
(Low-velocity, mid end-range, anteromedial to posterolateral oscillatory force to the femur in a supine position,
with hip flexion, adduction and external rotation)
>
30
Position the lower extremity with the hip in a position of
flexion, adduction and internal rotation
Use your body to impart an oscillatory, passive mobilizing
force directed at the postero-lateral hip capsule through the
long axis of the femur
Progress the technique by adding more flexion, adduction
and/or internal rotation
>
35
>
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40
Posterior-Anterior Mobilization in Flexion, Abduction, External Rotation
(Low velocity, end-range, posterior to anterior oscillatory force to the proximal femur in a prone position, with hip
flexion, abduction and external rotation).
45
>
Place the patient in prone
Bring the hip into varying degrees of flexion, abduction and
external rotation
Contact the proximal hip and use your body to impart an
oscillatory, passive mobilizing force in a posterior to anterior
direction
Vary the vector of your mobilizing force dependent on the
patient’s symptoms and joint stiffness
If extremely stiff, start with a pillow under the patient’s left
trunk to decrease the amount of hip abduction required.
Progress to lying flat on the table when it is tolerated by the
patient.
>
50
>
>
55
>
60
Appendix B. Specific home exercise program.
65
SUPINE PIRIFORMIS STRETCH
Grasp your right leg with your hands.
Bring your right leg up toward your left shoulder. You should feel a stretch in your right buttocks.
70
Hold this stretch for _____ seconds and repeat _____ times.
10Burns et al.
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Self Mobilizations of the Hip Joint
>
75
Place ankle on a chair.
Place both hands in the crease of the groin.
Use hands to apply a force into the hip joint that is directed toward the floor.
Vary your angle of force to find the area with most stiffness.
Repeat 30 times for 2–3 bouts.
>
>
80
>
>
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85
HAMSTRING STRETCH
Place a towel roll under your lower back. Tighten the muscles of your left leg to keep it straight and on the ground.
Grasp the lower right thigh with both hands and bring it up until it is perpendicular to your body (straight up).
Keep your elbows straight and straighten your leg until you feel a stretch behind your right thigh.
90
Hold for _____ seconds and repeat ______ times.
Note: You should not feel lower back pain or pain in the calf with this exercise.
12Burns et al.
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PRONE HIP EXTENSION
95
Lay on your stomach at the end of a table with your left foot on the floor.
Tighten your deep abdominal muscles and hold a ‘‘neutral’’ pelvis position. Lift and straighten your right leg as
though you were to kick someone positioned straight behind you.
100
Ensure that the motion is all coming from your hip and leg. Do not allow your lower back or upper body
to move. Do not lose the ‘‘neutral’’ pelvis position.
Squeeze your
buttocks.
Straighten
your knee
while
bringing your
foot straight
back.
Tighten your
abdominals.
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‘‘THE CLAM’’ HIP ABDUCTION/EXTERNAL ROTATION IN SIDE LYING
Lay on your right side. Your shoulders, trunk, and hips should remain stationary and perpendicular to the floor
throughout this exercise.
105
Keep your knees together and lift your top knee toward the ceiling.
DO NOT let the pelvis roll backward. Concentrate on having all of the motion come from the left hip.
110
NOTE: If you have difficulty keeping the pelvis and trunk from rolling backward, start the exercise with your back,
buttocks, and feet up against a wall. As you get stronger, move away from the wall.
Perform this exercise ______ times per session, ______ sessions per day.
14 Burns et al.
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