of Physiothall Rehabilitica

apy & Physer

ISSN: 2573-0312

Hayashi et al., Physiother Rehabil 2018, 3:4

Journal of

DOI: 10.4172/2573-0312.1000162

Physiotherapy & Physical Rehabilitation

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Research Article

Open AccessDramatic Effects of New Home Exercises for Patients with Osteoarthritisof the Hip: Pericapsular Soft Tissue and Realignment Exercises
Hayashi K1*, Tokunaga S2, Haruguchi K3, Nakaniwa D4, Tobo Y3 and Shimose T5
Department of Arthritis Center, Fukuoka Wajiro Hospital, Fukuoka, Japan
Department of Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
Department of Rehabilitation, Fukuoka Wajiro Hospital, Fukuoka, Japan
4
Department of Rehabilitation, Harajuku Hospital, Tokyo, Japan
5
Department of Clinical Research Support Center Kyushu, Fukuoka, Japan
1
2
3

Abstract
Objective: Many patients with hip Osteoarthritis (OA), even those with Harris Hip Scores (HHS) below 60 points,
have motion pain resulting from joint contracture. In these patients, pain occurs on standing and at first steps but
decreases during walking. Motion pain seems to improve with exercise therapy, whereas pain during walking causedby subchondral bone exposure on the joint surface may need surgery. The goal of this study was to investigate
the effectiveness of Pericapsular Soft Tissue and Realignment (PSTR) exercises for patients with OA of the hip,including those with HHS below 60 points.
Methods: This retrospective observational study included 1,077 outpatients with mild to severe symptomaticand radiographic OA of the hip who were treated with patient education and supervised PSTR exercises. Approvalof the local committee was obtained. Of the 1,077 patients who performed PSTR exercises, 792 were excluded fromanalysis. The remaining 285 participants were divided into two groups: the Unilateral OA group (no pain [HHS painscore, 44 points] in the opposite hip) and the Bilateral OA group (HHS pain score below 40 points bilaterally). HHS,
pain according to numerical rating scale, range of motion, opening angle of the hip according to modified Patrick’s
test, maximum strength of the hip abductors, and SF-36 were evaluated.
Results: Among the 285 patients, 154 had unilateral OA and 131 had bilateral OA. Both groups showed significant
HHS improvement at 3 month and 1 year follow-ups, regardless of HHS at baseline. Significant improvements inpain on the numerical rating scale, opening angle of the hip, and maximum muscle strength were noted at 3 monthfollow-up (P<0.0001-P<0.001). Among patients with HHS below 60 points at baseline, 38 had unilateral OA and 49
had bilateral OA. This study’s main limitation was that it was retrospective and uncontrolled.
Conclusions: Our results suggest that PSTR exercises may improve hip function, even in patients with an HHS
below 60 points.

Keywords: Hip osteoarthritis; Home exercise; PSTR exercise;
Postpone or prevent surgery; Harris Hip Score (HHS)Introduction
Most studies that have examined exercise as non-surgical treatment
for Oteoarthritis (OA) of the hip have involved strength training,
stretching, functional training, and aerobic fitness programs [1-5]. The
reported inclusion criteria for exercise therapy include a Harris Hip
Score (HHS) [6] between 60 and 95 points, whereas Fernandes et al.
and Svege et al. [7,8] recommend Total Hip Arthroplasty (THA) for
patients with an HHS below 60 points. Numerous studies have included
participants with mild to moderate OA of the hip [1,7-12]. However,patients with an HHS below 60 points may wish to postpone surgery
more than patients with an HHS above 60 points. Most patients with
an HHS above 60 points do not have much disturbance of Activities
of Daily Living (ADL). The main reasons for avoiding or postponing
surgery are work, child-rearing, or caring for one’s parents. Longterm treatments to postpone or prevent surgery are needed that allow
patients to exercise at home while continuing to work. Manual therapies
that require hospital visits are not suitable as long-term treatment topostpone or prevent surgery.
Several studies have reported that neuromuscular exercise was
effective at treating severe OA of the hip [13-15]. In those studies,
exercise was performed preoperatively to improve postoperative
outcomes of THA, not to postpone or prevent hip surgery. In arandomized clinical trial, Bennell et al. [16] implemented a multimodal
Physiother Rehabil, an open access journal
ISSN: 2573-0312

physical program for patients with OA of the hip. The program
consisted of manual therapy techniques (hip thrust manipulation andhip–lumbar spine mobilization), strengthening of the hip abductors
and quadriceps, stretching, Range-of-Motion (ROM) exercises,
functional balance and gait drills, and provision of a walking stick if
appropriate. Bennell et al. [16] found that the physical therapy program
conferred no additional clinical benefit over a realistic sham for 51% of
patients with moderate to severe OA of the hip; they also found that the
program was associated with relatively frequent but mild adverse effects[17]. No reported programs appear to have improved hip function inpatients with an HHS below 60 points sufficiently to allow postpone orprevention of surgery.
Worsening OA of the hip results in anterior pelvic tilt, elevation*Corresponding author: Kazuo Hayashi, Department of Arthritis Center, Fukuoka
Wajiro Hospital, Fukuoka, Japan, Tel: +8109045169461; Fax: +810926915315;
E-mail: hayashis@giga.ocn.ne.jp
Received: August 25, 2018; Accepted: October 08, 2018; Published: October
12, 2018
Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018)
Dramatic Effects of New Home Exercises for Patients with Osteoarthritis of the Hip:
Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162.
doi: 10.4172/2573-0312.1000162
Copyright: ©2018 Hayashi K, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author andsource are credited.

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 2 of 11
of the greater trochanter, and adduction contracture of the affected
hip [18-21]. When the pelvis is tilted anteriorly, muscles may follow
paths that differ from their anatomical paths. The load distribution
may also differ from physiological load distribution. Anterior pelvic
tilt and elevation of the greater trochanter cause apparent shorteningof leg length on the affected side. This apparent leg-length difference[20] may result in instability while walking. Failure to correct pelvic
malalignment before initiating strengthening exercises may cause
imbalance between the affected and nonaffected legs and exacerbate
OA of the hip. Therefore, we developed an exercise to realign the pelvis.
In our past experience, we have found that many patients with OAof the hip complained of hip pain on standing and at first steps whenstarting to walk, with decreased hip pain during walking. Many patients
have motion pain with absent or mild walking pain. Even patients with
an HHS below 60 points have this motion pain. We hypothesized that
motion pain could be caused by contracture of the hip joint, whereas
walking pain could be caused by contact with the subchondral bone
resulting from loss of cartilage from the joint surface. Motion pain
seems to improve with exercise therapy, whereas walking pain may
require surgery. Walking instability caused by anterior pelvic tilt andelevation of the greater trochanter causes repetitive Pericapsular Soft
Tissue (PST) injury to the joint capsule, ligaments, and inner muscles,
resulting in contracture of the affected hip. Therefore, correctionof pelvic malalignment before initiating strengthening exercise isnecessary to decrease motion pain, in addition to correction of apparent
leg-length differences. We hypothesized that decontracure exercise for
PST and realignment of the pelvis (PSTR exercise) may improve hipfunction for patients with OA of the hip and an HHS below 60 points.
Decontracture may provide a useful method to ease joint stiffness.
The current study investigated the effect of PSTR exercises onfunction in patients with OA of the hip; we also compared the results ofthese exercises in patients with unilateral versus bilateral OA of the hip.
It is recognized that the results of unilateral OA of the hip is better thanthat of bilateral OA of the hip for one treatment (exercise, surgery etc.).
So the result for one exercise is analyzed in unilateral versus bilateral
OA of the hip separately in general.

Methods
Participants
Inclusion criteria were as follows
1. Patients who wish to prevent surgery
2. Patients with 18-85 years at consent
3. Patients with hip pain for more than 3 months
4. Patients eligible for more than 2 of the following 1-3 criteria(ACR: American College of Rheumatology criteria [22]) or 4:4.1. ESR<20 mm/h)
4.2. Osteophytes (femoral or acetabular)
4.3. joint space narrowing
4.4. hip pain due to acetabular dysplasia
5. Patients in which the difference in the height of the tip of thegreater trochanter was 2.0 cm or less on standing full-length
radiographs of the lower extremities
Exclusion criteria were as follows
1. Patients who undergo the treatment of cardiovascular diseases
Physiother Rehabil, an open access journal
ISSN: 2573-0312

2. Patients who undergo the treatment of cancer
3. Patients who have severe osteoporosis/dysfunction in the lower
extremities due to an accident or disease besides OA of the hip(e.g. osteoarthritis with the knee above K/L grade 2)
4. Patients with pregnancy
5. All kinds of surgeries of the lower extremities
6. Patients who undergo the instruction of PSTR exercises by
therapists within one year (patients who performed exercisesby themselves according to the instruction of the book are notexcluded)
7. Patients with dementia who seem to be not eligible for exercises(Doctor's judgment e.g. patients who have difficulty withwriting the diary or understanding exercises)
8. Patients with osteonecrosis of the femoral head
9. Patients with a Subchondral Insufficiency Fracture (SIF) of thefemoral head
10. Patients with Perthes disease
11. Patients with rheumatoid arthritis
12. Patients with other rheumatic disease with spondyloarthritis
13. Patients with infection
14. Patients in which malignant diseases are suspected at the hip
joints or around the hip
15. Patients taking analgesics (even if only once)
16. Patients receiving chiropractic treatment or other hip therapy
17. Other patients in which doctor considered that they were noteligible (e.g. Dislocation of the femoral head into the buttocks)
MRI scans routinely performed during initial examination were
evaluated to rule out patients who met these exclusion criteria. In
patients with SIF of the femoral head, weight was kept off the affectedside and medication was administered to treat osteoporosis. If pain
resulting from OA of the hip remained after the SIF healed, patients
performed PSTR exercises but were excluded from this study.
The study was carried out in accordance with the Helsinki
Declaration and was approved by the Fukuoka Wajiro Hospital Medical
Research Ethics Committee. Authors obtained informed consent fromparticipants when required for protection of human subjects.
The patients were observed by one hospital and any special
recruitment such as advertisement in a local newspaper was not
performed for this study. The inclusion was performed at ArthrisCenter of Fukuoka Wajiro Hospital in Fukuoka, Japan. One orthopedic
surgeon examined all radiographs and three physical therapists of PSTR
exercise specialist rated the patient’s symptoms (HHS).

Interventions
Patient education
Precautions during everyday activities
Patients were instructed to avoid strain or impact on the hip joint
and overloading. In principle, lifting less than 5 kg was permitted; lifting
up to 10 kg was permitted for up to 15 min, if absolutely necessary.
Based on this principle, patients were also instructed regarding sports,
recreation, and other social activities.

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 3 of 11
Precautions during exercise
Patients were instructed to stop exercising if they experienced
increased pain. Patients then attempted to exercise fewer times per day.
If the pain recurred, patients were instructed to stop the program.
PSTR home exercises: Exercises 1-5 were basic exercises performedby all patients.
1.

Pelvic realignment exercise: This exercise was performed
every morning after waking and before walking. This exercise
was performed before a Closed Kinetic Chain (CKC) exercise
involving the hip abductors. Exercises ①–④ below adjusts
the anterior pelvic tilt and elevation of the greater trochanteron the affected side. Exercises were to be performed in theorder indicated. The detail of anterior pelvic tilt, elevationof the greater trochanter and each exercise were shown in
Supplementary Information.

 Exercise for the lower back: This exercise increases flexibilityof the erector spinae and the rectus abdominis.
 Exercise to correct apparent leg-length differences: Manypatients with OA of the hip have apparent leg-length differences
resulting from the posture they have adopted for a prolonged
period because of pain. Apparent leg-length differences cause
pain in the lower back and in other joints, such as the knee.
This exercise increases flexibility of the erector spinae, thetransversus abdominis, and internal oblique muscles.
 Adjustment of the greater trochanter: This exercise
strengthens the gluteus maximus and adjusts the level of thegreater trochanter.
 Adjustment of the Anterior Superior Iliac Spine (ASIS): This
exercise increases flexibility of the sartorius, hip abductors, andrectus abdominis.
2.

Back-and-forth exercise: This exercise is performed before
the CKC exercise involving the hip abductors to obtain ROM
that more closely approximates the physiological ROM.

3.

CKC exercise involving the hip abductors of the tensor fasciae
latae

4.

Correction of bowed legs

5.

Stretching of the quadratus femoris: This exercise increases
the flexibility of the Quadratus femoris and adjusts theanterior pelvic tilt on the affected side. Exercises 3, 4, and 5
can be done at any time of day after the pelvic realignment
exercise. However, the back-and-forth exercise is done before
the CKC exercise involving the hip abductors.

Patients were instructed by a physical therapist and were supervised
while exercising once every 2 weeks during the first 12 weeks. After 12
weeks, patients were instructed to perform the exercises at home as partof their daily routine.
Outcome measures: 792 patients out of 1,077ones who performed
PSTR exercise were excluded and 285 participants were analyzed.
Patients were divided into two groups: the Unilateral OA group (nopain [HHS pain score of 44 points] in opposite hip) and the Bilateral OA
group (pain in both hips, HHS pain score below 40 points bilaterally).
In the Bilateral OA group, the more painful hip joint was analyzed.

Physiother Rehabil, an open access journal
ISSN: 2573-0312

Figure 1: Modified Patrick’s test.

Measures of characteristics at baseline: age, sex, body mass index,
duration of pain, work status, and Kellgren-Lawrence (KL) arthritis
grade [23].
Measures of symptoms at baseline, 3-month, and 1-year follow-up
Month follow-up: HHS, HHS pain score, pain on a Numerical
Rating Scale (NRS) [24], ROM, opening angle of the hip (opening
angle of the hip according to a modified Patrick’s test, (Figure 1) [25],maximum strength of hip abductors (a hand-held dynamometer wasused to evaluate muscle strength), and SF-36 scores [26-28].
Year follow-up
HHS, HHS pain score, and SF-36 scores
No change in the KL grade from baseline to 1 year follow-up
was noted. None of the participants received analgesics, including
nonsteroidal anti-inflammatories, paracetamol, opioid analgesics, or
glucosamine/chondroitin products.

Statistical analyses
Only treatment teams entered and collected data from electronic
medical charts. Data scrubbing and statistical analyses were performedby the Clinical Research Support Center Kyushu.1 A paired t-test wasused for intra-personal change in endpoints between baseline and3-months later or between baseline and 1 year later. Mean difference
and its 95% confidence interval of endpoints were estimated by usingt-distribution. All analyses were performed with Stata version 13(Stata Corp., College Station, Texas). A value of p<0.05 was statisticallysignificant.

Results
Characteristics of the patients
PSTR exercises were performed by 1,077 patients with OA of the
hip who visited the Arthritis Center at Fukuoka Wajiro Hospital from
April 2011 to January 2014. Of these, 792 patients were excluded due to
The differences in the background parameters between unilateral and bilateralgroups were tested by t-test for continuous variables and Chi-square test for discrete variables.

1

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 4 of 11

Enrollment

Recruited patients assessed for eligibility (n=1077)
Patients who were excluded (n=792) any previous surgery in
the lower limbs (n=166) taking analgesics (even if only once)(n=133) received chiropractic treatment or other hip therapy(n=205) had previously undertaken this exercise program(n=173) osteoarthritis of the knee (n=73) dementia who seemto be not eligible for exercises (n=42)

Enrolment
Classification

Baseline assessment (n=285)
Patient education (n=285)
Classification (n=285)

Classified to the Bilateral OA group(n=131)

Classiﬁed to the Unilateral OA
group (n=154)

Participated in 3-month FU (n=131)
HHS, HHS pain score
NRS
ROM, Angle in Patrick’s test
Muscle strength
SF36

Follow-up (FU) and Analysis

Participated in 3-month FU (n=154)
HHS, HHS pain score
NRS
ROM, Angle in Patrick’s test
Muscle strength
SF36Participated in 1 year FU (n=39)
Reasons for lack of participation: taking
analgesics (even if only once) (n=12)
received chiropractic treatment or other hiptherapy (n=48) had not visited the clinic 2
weeks before or after the 1 year FU (n=46)
underwent surgery (THA; n=8, Osteotomy;
n=1)
HHS, HHS pain score, SF-36
SF36

Participated in 1 year FU (n=33)
Reasons for lack of participation: taking
analgesics (even if only once) (n=14)
received chiropractic treatment or other hiptherapy (n=37) had not visited the clinic 2
weeks before or after the 1 year FU (n=33)
underwent surgery (THA; n=11, Osteotomy;n=3)
HHS, HHS pain score, SF-36
SF36

Figure 2: Steps for patients participating in this study.

Variables§

Unilateral Group (n=154)

Bilateral Group (n=131)

P*

Age (years)

56.4 (14.2)

54.2 (12.8)

0.16

Women, no (%)

133 (86.4%)

123 (93.9%)

0.036

BMI (kg/m2)

22.0 (3.3)

22.1 (3.2)

0.8

HHS (0-100)

74.29 (17.76)

65.52 (17.32)<0.0001
0.024

No. (%) below 59

n=38 (25.0%)n=49 (37.4 %)

No. (%) above 60

n=114 (75.0%)n=82 (62.6%)-

Duration of pain (months)

30.8 (50.4)

55.7 (98.7)

0.007

Grade 1

57

51

0.97

Grade 232

29-

Grade 339

32-

Grade 420

16-

Lateral/concentric OA type2.10 (1.76); n=127

3.04 (1.83); n=121

0.016

Medial OA type

n=27

n=10

-

-

-

0.98

Currently employed

n=75 (49.7%)

n=63 (48.5%)-

Unable to work due to health reasons

n=2 (1.3%)

n=2 (1.5%)-

Retired, not due to health reasons

n=2 (1.3%)

n=1 (0.8%)-

Unemployed

n=22 (14.6%)

n=18 (18.9%)-n=50 (33.1%)

n=46 (35.4%)-

K/L grade

Minimal Joint Space (MJS, mm)

1)
2)
3)
4)
5)

Work status, No. (%)

Homemaker§ Mean (Standard Deviation) or frequency (percent)
No change in the K/L grade at the baseline and at the 1 year follow-up was noted†t-test for continuous variables and Chi-square test for discrete variables. P<0.05 was significant.
Table 1: Baseline characteristics.

Physiother Rehabil, an open access journal
ISSN: 2573-0312

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 5 of 11
exclusion criteria and 285 fulfilled the inclusion criteria were divided
into Unilateral Group (n=154) and Bilateral Group (N=131) (Figure2). Baseline characteristics of the patients were presented in Table 1.
Exclusion criteria from beseline to 1 year follow-up were as follows.
Patients fulfilled the following criteria were excluded as far as we
confirmed in the electronic medical charts.

3. Patients who did not visit the clinic within 2 weeks before orafter the 3 months or 1-year follow-up

eliminated because some of the data on their HHS scores were missing.
In Bilateral Group 49 patients had HHS below 59 points (37.4%) and82 patients had HHS above 60 points (62.6%) (Table 1). 115 patientswere excluded prior to 1-year follow-up in Unilateral Group (taking
analgesics: n=12, received chiropractic treatment or other hip therapy:
n=48, had not visited the clinic 2 weeks before or after 1-year followup: n=46, underwent surgery: THA; n=8, Ostoetomy; n=1). 98 patientswere excluded prior to 1-year follow-up in Bilateral Group (taking
analgesics; n=14, received chiropractic treatment or other hip therapy:
n=37, had not visited the clinic 2 weeks before or after 1-year follow-up:
n=33, underwent surgery: THA; n=11, Ostoetomy; n=3).

4. Patients who underwent surgery

Changes in outcome measures except SF-36

1. Patients taking analgesics (even if only once)
2. Patients receiving chiropractic treatment or other hip therapy

Changes from baseline to 3-month follow-up: The resultsof all included patients are shown in Tables 2a and 2b. Significant

In Unilateral Group 38 patients had HHS below 59 points (25.0%)
and 114 patients had HHS above 60 points (75.0%). Two patients were
Tests
HHS

HHS pain score

NRS

Angle in a
modified
Patrick's test
Muscle strength(Nm)

Mean (95% confidence
interval)

P value

Baseline(1 Y)

1 yearMean (95%
confidence interval)

P value

6.91(4.30 to9.52)

<0.000175.21(16.91)

87.08 (15.73)(N=38)

11.87(4.40 to19.34)

0.003

76.80 (18.65)(N=131)

11.28(8.34 to14.22)<0.000165.42(16.07)

82.06 (16.39)(N=33)

16.64(9.73 to23.55)<0.0001

26.10(14.43)31.70 (11.41)(N=154)

5.6(3.31 to
7.88)

<0.000127.44(14.28)

36.26 (10.92)(N=39)

8.82(2.93 to14.71)

0.004

19.62
(13.03)28.79 (13.29)(N=131)

9.18(6.65 to11.70)<0.000118.79(12.19)

31.70 (12.86)(N=33)

12.91(7.29 to18.52)

Unilateral

4.32 (2.22)

3.21 (2.22)(N=150)<0.0001-1.11(-1.45 to-0.77)<0.0001

-

-

-

-

-

Bilateral

4.88 (1.98)

3.61 (2.17)(N=130)-1.27(-1.66 to-0.88)<0.0001

-

-

-

-

-

Unilateral

51.44(17.51)57.30 (17.82)(N=111)

5.86(3.09 to8.63)

<0.0001

-

-

-

-

-

Bilateral

51.67(17.80)57.75 (15.26)(N=102)

6.08(3.62 to8.54)

<0.0001

-

-

-

-

-

Unilateral

41.70(18.05)48.16 (20.46)(N=132)

6.46(3.19 to9.73)

<0.001

-

-

-

-

-

Bilateral

40.56(16.82)47.36 (19.87)(N=118)6.8(4.10 to9.49)

<0.0001

-

-

-

-

-

Category

Baseline

3 months

Unilateral

74.29(17.76)81.20 (14.95)(N=152)Bilateral

65.52(17.32)

Unilateral
Bilateral

Unilateral: Group with unilateral OA of the hip (no pain in the opposite hip)Bilateral: Group with bilateral OA of the hip (pain in the opposite hip)Angle in a modified e Patrick's test: The opening angle of the hip in a modified Patrick's test
A Hand Held Dynamometer was used to evaluate muscle strength
Parenthesis were SD
Two-sided p<0.05 was significant
Table 2a: Difference in the HHS, HHS pain score, pain on an NRS, the opening angle of the hip according to Patrick's test, and muscle strength at the baseline and followup at 3 months and 1 year.
Types of Movement

Category

Baseline

3 months

flexion

Unilateral OA

109.38 (18.61)

110.49 (18.16) (N=152)

1.12(-0.44 to 2.68)

0.16

Bilatetal OA

107.50 (18.60)

110.65 (19.65) (N=130)

3.15(1.41 to 4.90)<0.001

Unilateral OA

10.93 (7.45)

11.69 (6.85) (N=151)

0.76(-0.21 to 1.73)

0.12

Bilatetal OA

10.46 (7.25)

11.38 (7.29) (N=130)

0.92(-0.31 to 2.16)

0.14

abduction

Unilateral OA

26.99 (10.38)

28.64 (9.78) (N=151)

1.66(0.41 to 2.90)

0.009

Bilatetal OA

25.08 (10.44)

27.77 (11.22) (N=130)

2.69(1.06 to 4.32)

0.001

adduction

Unilateral OA

10.20 (4.95)

11.15 (4.97) (N=152)

0.95(0.05 to 1.86)

0.04

Bilatetal OA

9.92 (4.90)

10.73 (4.41) (N=130)

0.81(-0.15 to 1.76)

0.1

Unilateral OA

34.41 (11.83)

36.45 (12.65) (N=152)

2.04(0.60 to 3.48)

0.006
0.07

extension

external rotationinternal
rotation

Mean (95% confidence interval)

P value

Bilatetal OA

35.86 (12.15)

37.30 (12.29) (N=128)

1.45(-0.13 to 3.02)

Unilateral OA

28.78 (16.21)

30.46 (17.02) (N=152)

1.68(0.05 to 3.31)

0.04

Bilatetal OA

28.57 (16.16)

32.09 (16.16) (N=129)

3.53(1.94 to 5.11)<0.0001

Parenthesis were SD
Two-sided p<0.05 was significant
Table 2b: Difference in ROM at baseline and follow-up at 3 months.

Physiother Rehabil, an open access journal
ISSN: 2573-0312

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 6 of 11
the Unilateral and Bilateral OA groups who had an HHS below 60
points at baseline (p<0.0001) (Table 2e). Table 2e shows the results ofpatients with an HHS above 60 points.

differences in HHS were noted in patients in both the Unilateral and
Bilateral OA groups (p<0.0001). Significant differences in HHS werenoted between baseline and 3 month follow-up for patients with a
KL grade of 1-3 but not for patients with a KL grade of 4 (Table 2c).
Significant differences in HHS were noted between the two time points
in patients in the Bilateral OA group who had a hip opening angle
smaller than 30° according to Patrick’s test, but not in the Unilateral
OA group. Significant differences in HHS were noted between the
two time points for patients in both the Unilateral and Bilateral OA
groups who had an opening angle of the hip greater than 30° (Table2d). Significant differences in HHS were noted in patients in both
GradesK/L grade 1
K/L grade 2
K/L grade 3
K/L grade 4

Changes from baseline to 1-year follow-up: Table 2a shows theresults of HHS and HHS pain scores. Significant differences in HHS werenoted in patients in both the Unilateral (p=0.003) and Bilateral OA groups(p<0.0001). Significant improvements in HHS were noted in both the
Unilateral (p<0.0001) and Bilateral OA groups (p<0.001) among patientswith an HHS below 60 points at baseline (Table 2e). Table 2e shows theresults of patients with a baseline HHS above 60 points.

Category

Baseline

3 months

Unilateral OA

81.58 (17.47)

87.93 (11.08) (N=57)

6.35

Mean (95% confidence interval)(2.20 to 10.50)

P value
0.003

Bilateral OA

71.73 (15.37)

84.22 (14.34) (N=51)

12.49(8.39 to 16.59)<0.0001

Unilateral OA

75.28 (17.19)

84.97 (12.2) (N=32)

9.69(3.31 to 16.06)

0.004

Bilateral OA

64.59 (17.54)

80.52 (15.37) (N=29)

15.93(9.00 to 22.86)<0.0001

Unilateral OA

67.64 (15.31)

74.05 (14.45) (N=39)

6.41(0.68 to 12.14)

0.03

Bilateral OA

60.13 (17.21)

69.50 (17.90) (N=32)

9.38(3.88 to 14.87)

0.002

Unilateral OA

66.60 (16.50)

69.15 (17.47) (N=20)2.55(-2.00 to 7.10)

0.26

Bilateral OA

55.25 (17.11)

58.25 (21.62) (N=16)3(-8.96 to 14.96)

0.6

No change in the KL grade at the baseline and at the 3 months follow-up was noted
Parenthesis were SD
Two-sided P<0.05 was significant
Table 2c: HHS in accordance with the K/L grade.
Tests

Category

Baseline

3 months

Angle<30° in a modified
Patrick's test

Unilateral OA

76.67 (18.97)

82.67 (12.72) (N=15)

Mean (95% confidence interval)
6(-3.12 to 15.12)

P value
0.18

Bilateral OA

67.13 (17.32)

74.40 (20.74) (N=15)

7.27(2.25 to 12.28)

0.008

Angle 30°-50° in a modified
Patrick's test

Unilateral OA

67.19 (18.13)

73.11 (17.52) (N=37)

5.92(0.26 to 11.58)

0.04

Bilateral OA

56.81 (18.85)

70.06 (18.36) (N=31)

13.26(4.78 to 21.74)

0.003

Angle>50° in a modified Patrick's
test

Unilateral OA

76.17 (17.29)

84.55 (13.77) (N=58)

8.38(4.18 to 12.57)<0.001

Bilateral OA

70.85 (14.43)

81.95 (14.55) (N=55)

11.09(7.23 to 14.95)<0.0001

Mean (95%
confidence interval)

P value

42.75(31.21 to
54.29)<0.0001

Angle in a modified Patrick's test: The opening angle of the hip in a modified Patrick's test
Parenthesis were SD
Two sided P<0.05 was significant
Table 2d: HHS in accordance with the opening angle of the hip in a modified Patrick's test.
HHS at different
Points
HHS<60 points
at baseline

HHS≥60 points
at baseline

Category

Mean (95% confidence
interval)

P value

Baseline(1 Y)(16.07 to 28.79)<0.0001

90.00 (12.04)
47.25 (4.98)
(N=8)

20.89

(15.48 to 26.31)<0.0001

48.58(10.34)78.17 (19.20)(N=12)

29.58(17.42 to41.75)<0.00184.60 (12.06)(N=114)1.83(-0.26 to 3.92)

0.08

82.67 (9.26)

86.30 (16.66)(N=30)

3.63(-2.61 to
9.88)

0.24

82.43 (15.33)(N=82)

5.77(2.87 to 8.66)<0.00175.05 (9.33)

84.29 (14.58)(N=21)

9.24(2.07 to16.41)

0.01

Baseline

3 months

Unilateral

48.38 (7.35)

70.81 (18.04)(N=38)

22.43

Bilateral

46.09 (8.98)

66.98 (19.98)(N=49)

Unilateral

82.77(10.38)Bilateral

76.66 (9.13)

1 year

HHS<60 points at baseline
Unilateral: K/L grade1(N=10), K/L grade2 (N=8), K/L grade 3 (N=11), K/L grade 4 (N=8)
Angle in a modified Patrick's test: <30° (N=2, ≥30° (N=30)
Bilateral: K/L grade1 (N=11), K/L grade 2 (N=13), K/L grade 3 (N=15), K/L grade 4 (N=8)
Angle in a modified Patrick's test: <30° (N=3, ≥30° (N=32)
HHS≥60 points at baseline
Unilateral: K/L grade 1 (N=47), K/L grade 2 (N=24 ), K/L grade 3 (N=29), K/L grade 4 (N=13)
Angle in a modified Patrick's test: <30° (N=7), ≥30° (N=71)
Bilateral: K/L grade 1 (N=40), K/L grade 2 (N=16), K/L grade 3 (N=18), K/L grade 4 (N=8)
Angle in a modified Patrick's test: <30° (N=5), ≥30° (N=60)
Parenthesis were SD
Two sided p<0.05 was significant
Table 2e: HHS in accordance with HHS<60 points or HHS ≥ 60points at baseline p<0.05.

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Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 7 of 11

Changes in SF-36 scores
Changes from baseline to 3 months follow-up: The results of all
investigated patients are shown in Tables 2f and 2g. In the Unilateral
OA group, patients with an HHS below 60 points at baseline hadsignificant improvements in their Mental Component summary score.
In the Bilateral OA group, patients with an HHS below 60 points atbaseline had significant improvements in their Mental Component andRole/Social Component summary scores (Tables 2h and 2i). Tables 2hand 2i show the results of patients with a baseline HHS above 60 points.

Changes from baseline to 1-year follow-up: The results of all
investigated patients are shown in Tables 2f and 2g. Patients in the Unilateral
OA and Bilateral OA groups with an HHS below 60 points at baseline hadno significant changes in any of the component summary scores between
baseline and 1-year follow-up (Tables 2h and 2i). Tables 2h and 2i show theresults of patients with a baseline HHS above 60 points.

Discussion
Pelvic malalignment must be corrected and decontracture of the

Mean (95% confidence
interval)

P value

Baseline (1year)

1 year0.13

35.80(11.08)38.12 (11.80)(n=28)

Baseline

3 months

33.83 (15.93)

35.52 (14.71)(n=114)

Role Physical (NBS)

39.01 (14.26)

41.42 (14.12)(n=113)2.41(-0.19 to 5.01)

0.07

Bodily Pain (NBS)

38.07 (8.67)

42.49 (8.40)(n=113)4.42(2.75 to 6.09)<0.0001

39.37(10.01)

General Health (NBS)

45.69 (10.25)

47.47 (9.44)(n=114)1.78(0.36 to 3.20)

0.01

Vitality (NBS)

45.98 (11.00)

49.24 (9.48)(n=114)

3.26(1.61 to 4.91)

Social Functioning (NBS)

45.59 (12.39)

47.96 (11.48)(n=114)2.38(0.18 to 4.58)

Role Emotional (NBS)

43.78 (14.03)

46.42 (13.13)(n=112)2.64

Mental Health (NBS)

47.74 (10.78)

50.51 (9.80)(n=114)

Physical Component
summary score34.18 (13.14)

Mental Component summary
50.64 (10.12)
score

Physical Functioning (NBS)

Role-Social Component
summary score46.46 (15.56)

Mean (95%
confidence interval)

P value

2.32(-2.28 to
6.93)

0.31

1.67

(-3.22 to
6.56)

0.49

44.85 (7.54)(n=27)

5.48(1.29 to
9.66)

0.01

46.30 (9.28)

47.69 (8.52)(n=28)

1.39(-1.27 to
4.05)

0.29

<0.00148.10(13.07)49.26 (9.66)(n=28)

1.16(-1.95 to
4.26)

0.45

0.03

45.96
(11.21)49.87 (9.34)(n=28)

3.91(-0.13 to
7.96)

0.06

(0.11 to 5.17)

0.04

46.06
(11.92)48.23 (11.28)(n=27)

2.16(-1.36 to
5.69)

0.22

2.77

(1.08 to 4.47)

0.002

49.61
(11.22)52.12 (10.02)(n=28)

2.51(-1.27 to
6.30)

0.18

35.58 (11.59)(n=110)1.4(-0.59 to 3.40)

0.1735.64 (9.52)

36.43 (11.15)(n=26)

0.8(-3.14 to
4.73)

0.68

53.51 (8.50)(n=110)2.87(1.47 to 4.28)<0.0001

51.67(11.93)53.72 (10.52)(n=26)

2.04(-1.09 to
5.17)

0.19

47.84 (13.84)(n=110)1.37(-1.33 to 4.08)

0.32

47.99
(12.76)49.59 (13.68)(n=26)

1.6(-2.77 to
5.98)

0.46

1.68

(-0.49 to 3.85)

42.31 (13.81)
40.64 (12.7)(n=28)

Parenthesis were SD
Two-sided p<0.05 was siginificant
Table 2f: Difference in SF-36 scores at baseline and follow-up at 3 months and 1 year (Unilateral OA group, NBS; Norm-Based Scoring).

Baseline

3 months

Mean (95%
confidence interval)

Physical Functioning (NBS)

29.32(15.17)33.13 (15.91(n=103)

3.81

Role Physical (NBS)

34.87(14.16)38.79 (14.33(n=102)

Bodily Pain (NBS)

35.70 (7.70)

General Health (NBS)

Mean (95%
confidence
interval)

P value

Baseline (1 year)

1 year

(1.66 to5.96)

<0.00131.92 (11.04)

36.45 (12.56)(n=28)

4.52(1.19 to
7.86)

0.01

3.93

(1.52 to
6.34)

0.002

37.08 (14.17)

41.48 (13.41)(n=28)

4.4(-0.41 to
9.20)

0.07

41.14 (7.71(n=102)

5.44(3.87 to7.01)

<0.0001

34.97 (7.55)

42.00 (6.48)(n=28)

7.03(3.29 to10.77)<0.00144.59 (8.72)

46.71 (8.87(n=102)2.13(0.97 to3.28)

<0.00144.71 (9.95)

48.51 (10.42)(n=28)

3.8(1.32 to
6.28)

0.004

Vitality (NBS)

44.23 (9.11)

46.81 (9.83(n=102)2.58(0.77 to
4.40)

0.006

44.90 (8.62)

49.49 (8.63)(n=28)

4.59(0.43 to
8.75)

0.03

Social Functioning (NBS)

42.41(13.68)45.51 (12.09(n=102)

3.09(1.04 to
5.15)

0.004

44.34 (13.30)

48.95 (11.18)(n=28)

4.6(-0.48 to
9.69)

0.07

Role Emotional (NBS)

40.99(14.23)45.32 (12.57(n=101)

4.33(1.96 to6.70)

<0.00140.46 (15.15)

47.16 (13.83)(n=28)

6.7(1.59 to11.81)

0.01

Mental Health (NBS)

46.38(10.48)50.78 (9.21(n=102)4.4(2.58 to
6.21)

<0.000147.42 (9.07)

52.50 (7.59)(n=28)

5.08(1.43 to
8.72)

0.008

Physical Component
summary score

30.95(11.51)33.91 (12.92(n=101)

2.97(1.10 to
4.83)

0.002

31.68 (9.78)

35.31 (10.70)(n=28)

3.63(0.89 to
6.37)

0.01

53.03 (8.12(n=101)2.24(0.64 to
3.83)

0.006

50.81 (8.74)

54.66 (8.75)(n=28)

3.85(0.24 to
7.47)

0.04

46.52 (14.15(n=101)

3.38(0.91 to
5.85)

0.008

44.43 (17.13)

48.76 (14.95)(n=28)

4.34(-1.38 to
10.06)

0.13

Mental Component summary
50.79 (8.63)
score
Role-Social Component
summary score

43.14(16.07)

P value

Parenthesis were SD
Two-sided p<0.05 was siginificant
Table 2g: Difference in SF-36 scores at baseline and follow-up at 3 months and 1 year (Bilateral OA group, NBS; Norm-Based Scoring).

Physiother Rehabil, an open access journal
ISSN: 2573-0312

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 8 of 11

HHS<60pointsat baseline

HHS≥60pointsat baseline

Mean (95%
confidence
interval)

P value

Baseline (1year)

1 year

(-0.69 to
4.97)

0.13

37.43 (8.21)

33.73 (10.55)
(N=6)

-3.70

(-12.03 to
4.63)

0.31

3.13

(0.57 to
5.70)

0.02

46.42 (5.19)

49.13 (8.32)
(N=6)

2.72

(-2.67 to
8.10)

0.25

1.70

(-3.29 to
6.69)

0.49

50.30 (14.22)

59.87 (6.05)
(N=6)

9.57

(-6.59 to
25.72)

0.19

0.93(-1.71 to
3.56)

0.49

37.25 (11.46)
35.10 (10.01)(N=20)

2.15(-2.54 to
6.83)

0.35

54.02 (8.81)(N=77)

2.67(0.92 to
4.43)

0.003

53.25 (13.00)

55.09 (10.89)(N=20)

1.84(-2.13 to
5.81)

0.34

49.09 (12.84)(N=77)

1.40(-1.96 to
4.76)

0.41

47.29 (12.60)

46.51 (13.90)(N=20)-0.79(-4.59 to
3.02)

0.67

Baseline

3 months

Physical Component
summary score30.56 (9.88)

32.70 (11.64)(N=31)

2.14

Mental Component
summary score48.63 (8.47)

51.76 (7.57)(N=31)

Role-Social Component
summary score

44.84(15.54)46.53 (14.59)(N=31)

Physical Component
summary score36.55(12.84)37.48 (10.50)(N=77)

Mental Component
summary score51.35(10.74)Role-Social Component
summary score

47.69(15.21)

Mean (95%
confidence interval)

P value

Parenthesis were SD
Two-sided p<0.05 was significant
Table 2h: SF-36 scores in accordance with HHS<60 points or HHS≥60points at baseline (Unilateral OA group, NBS; Norm-Based Scoring).

HHS<60pointsat baseline

HHS≥60pointsat baseline

Mean (95% confidence
interval)

P value

Baseline (1year)

1 year(-2.90 to 3.97)

0.75

29.81
(10.07)31.77 (13.60)(N=10)

1.96(-3.53 to
7.45)

0.44

(0.92 to 5.68)

0.008

50.56 (6.27)

54.66 (9.07)(N=10)

4.10(-2.53 to10.73)

0.2(2.42 to 12.85)

0.006

39.64
(18.13)44.31 (11.71)(N=10)

4.67(-7.30 to
16.64)

0.4

4.04(1.82 to 6.27)<0.00132.71 (9.75)

37.27 (8.51)(N=18)

4.56(1.20 to
7.92)

0.01

52.91 (7.67)(N=70)

1.77(-0.30 to 3.84)

0.09

50.94
(10.02)54.66 (8.83)(N=18)

3.72(-1.06 to
8.49)

0.12

47.82 (14.61)(N=70)

1.49(-1.20 to 4.19)

0.27

47.09
(16.46)51.24 (16.26)(N=18)

4.15(-2.84 to
11.14)

0.23

Baseline

3 months

Physical Component
summary score28.39(10.48)28.93 (11.30)(N=31)

0.54

Mental Component
summary score50.02 (7.98)

53.32 (9.21)(N=31)

3.30

Role-Social Component
summary score

35.94(16.50)43.57 (12.79)(N=31)

7.64

Physical Component
summary score32.08(11.84)36.12 (13.05)(N=70)

Mental Component
summary score51.14 (8.94)

Role-Social Component
summary score46.33(14.90)Mean (95%
P valueconfidence interval)

Parenthesis were SD
Two-sided p<0.05 was siginificant
Table 2i: SF-36 scores in accordance with HHS<60 points or HHS≥60points at baseline (Bilateral OA group, NBS; Norm-Based Scoring).

affected hip must be performed to decrease motion pain, thus improving
function in patients with OA of the hip and an HHS below 60 points.
In this study, PSTR exercises were not indicated for patients with a KL
grade of 4 and an opening angle of the hip smaller than 30° according toa modified Patrick’s test. Patient education including ADL instruction
is essential for PSTR exercises to be effective and to maintain adequate
function and QOL over the long term [29-32].

Continuation of exercises
Once symptoms improved, patients had difficulty continuing allof the PSTR exercises daily as preventive treatment. Even if pelvic
balance was restored, once patients with prolonged symptoms stopped
performing the pelvic realignment exercise, the anterior pelvic tilt andelevation of the greater trochanter on the affected side tended to recur
within a few days. Therefore, the following treatment program was
implemented after the first 3 months of PSTR exercises.
Three months from baseline
If anterior pelvic tilt and elevation of the greater trochanter were
alleviated and symptoms improved
1. Patients temporarily stopped performing the pelvic alignment
exercise. If the anterior pelvic tilt and elevation of the greater
trochanter were absent for 2 weeks, patients discontinued thepelvic realignment exercise. Patients continued to performthe exercise to correct apparent leg-length differences and the
back-and-forth exercise. Instructors followed patients for up to

Physiother Rehabil, an open access journal
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1 year from baseline.
2. If anterior pelvic tilt and elevation of the greater trochanterrecurred within 2 weeks, patients continued to perform thepelvic alignment exercise for 3 more months.
If anterior pelvic tilt and elevation of the greater trochanter were
alleviated but symptoms did not improve: Instructors re-evaluated theprogram and re-educated the patient regarding ADL. If the patient had a
KL grade of 4 and an opening angle of the hip smaller than 30° according toa modified Patrick’s test, instructors considered THA in consultation withan orthopedic surgeon. A SIF of the femoral head or massive tearing of thecapsule, labrum, and pericapsular ligaments may be present in these cases.
If the anterior pelvic tilt and elevation of the greater trochanterremained and symptoms did not improve: Patients continued toperform the pelvic realignment exercise. If the patient had a KL gradeof 4 and an opening angle of the hip smaller than 30° according to amodified Patrick’s test, instructors considered THA in consultation
with an orthopedic surgeon.
If the anterior pelvic tilt and elevation of the greater trochanterremained but symptoms improved: Patients continued to performthe pelvic realignment exercise. Symptoms could readily recur; surgery(osteotomy, THA, etc.) was considered when symptoms recurred if theanterior pelvic tilt and elevation of the greater trochanter remained.
THA was considered for patients with a KL grade of 4 and an opening
angle of the hip smaller than 30° according to a modified Patrick’s test.

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 9 of 11
Six months from baseline
If anterior pelvic tilt and elevation of the greater trochanter
were alleviated and symptoms improved: After performing the pelvic
realignment exercise for 6 months, almost all patients had improvementof anterior pelvic tilt and greater trochanter elevation, with alleviationof symptoms. Patients stopped performing the pelvic realignment
exercise but continued to perform the exercise to correct apparent
leg-length differences and the back-and-forth exercises. Instructors
followed patients for up to 1 year from baseline.
Patients performed PSTR exercises only as home exercises;
instruction during clinic visits stopped. Patients who determinedthat elevation of the greater trochanter had recurred visited theclinic for reevaluation by instructors. Therefore, instruction in selfevaluation of the greater trochanter on the affected side was important(Supplementary Information). When the greater trochanter was
difficult to locate, the position of the medial malleolus of the ankles wascompared [20]. The medial malleolus of the ankle on the affected side
is often elevated proximally in patients with hip pain. Patients cannot
compare the position of the medial malleolus of their own ankles, sofamily members were taught this technique.
If anterior pelvic tilt and elevation of the greater trochanter were
alleviated but symptoms did not improve: Instructors re-evaluatedthe program and reeducated the patient regarding ADL. THA wasconsidered in patients with a KL grade of 4 and an opening angle of the
hip smaller than 30° according to a modified Patrick’s test.
If anterior pelvic tilt and elevation of the greater trochanterremained and symptoms did not improve: Instructors re-evaluatedthe program and patients continued to perform the pelvic realignment
exercise for 6 more months. THA was considered in patients with a KL
grade of 4 and an opening angle of the hip smaller than 30° according
to a modified Patrick’s test.
If the anterior pelvic tilt and elevation of the greater trochanterremained and symptoms did improve: Patients continued to performthe pelvic realignment exercise. Symptoms could readily recur; surgery(osteotomy, THA, etc.) was considered when symptoms recurred andthe anterior pelvic tilt and elevation of the greater trochanter remained.
THA was considered for patients with a KL grade of 4 and an opening
angle of the hip smaller than 30° according to a modified Patrick’s test.
One year from baseline
If symptoms improved: Patients continued to perform the backand-forth exercise.
If symptoms did not improve: Surgery (osteotomy, THA, etc.) was
considered. If patients wanted to continue performing the exercises,
instructors reevaluated the program and re-educated the patient
regarding ADL for up to 2 years from baseline.
Two years from baseline
If symptoms improved
Patients continued to perform the back-and-forth exercise.
If symptoms did not improve: Surgery (osteotomy, THA, etc.) was
considered.
The Mental Component and Role/Social Component summaryscores on the SF-36 improved in both the Unilateral OA and Bilateral
OA groups to near 50 points according to norm-based scoring.
However, the Physical Component summary score improved only
slightly, remaining below 50 points according to norm-based scoring(Tables 2f and 2g).
Low back pain may have contributed to the low Physical Component
summary scores. A lumbosacral disturbance or a sacroiliac disturbance
may have been involved [18,21]. The current authors plan to develop
new exercises to address these issues and to establish guidelines for thetiming of hip surgery based on screening involving PSTR exercises.

Damage to and loss of cartilage→Cartilage damage (genetic factors, cartilage metabolism, malalignment, etc.)↓
Synovitis causes hip pain→Pain generators are released into the joint from the site of cartilage damage.
Pain generators stimulate nociceptors of the synovium, resulting in pain.

↓
Transition from original weight-bearing site to new site with healthy cartilage. (Pain when walking is avoided by tilting
the trunk forward→Release of pain generators may be reduced by tilting the trunk forward.)↓
Thrusting force from the foot to the sacrum causes a slight anterior tilt of the affected pelvis and subjects the
lumbosacral joint to abnormal loads and forces, resulting in low back pain.

↓
Increased pain results from increased strain and loading of the capsule and ligaments. Decreased ROM results from anterior
tilt of the affected pelvis. Anterior pelvic tilt and elevation of the greater trochanter causes apparent shortening of the leg
length on the affected side.

↓
Instability while walking occurs. This instability causes repetitive injury of capsule andligaments, resulting in joint contracture. Motion pain results from joint contracture.
Figure 3: Discussion of the development of pain in patients with osteoarthritis of the hip.

Physiother Rehabil, an open access journal
ISSN: 2573-0312

Volume 3 • Issue 4 • 1000162

Citation: Hayashi K, Tokunaga S, Haruguchi K, Nakaniwa D, Tobo Y, et al. (2018) Dramatic Effects of New Home Exercises for Patients with
Osteoarthritis of the Hip: Pericapsular Soft Tissue and Realignment Exercises. Physiother Rehabil 3: 162. doi: 10.4172/2573-0312.1000162

Page 10 of 11

Motion pain as mechanism for hip pain
In many of the current patients, symptoms improved markedly asa result of PSTR exercises, even in patients with loss of joint cartilage.
Partial or total loss of cartilage is not directly related to hip pain, but it
can trigger that pain. Excessive strain on or overloading of the synovium,
periosteum, capsule, ligaments, and labrum may cause hip pain via themechanism shown in Figure 3 [33]. Anterior pelvic tilt and elevation of
the greater trochanter may cause an apparent leg-length difference in theaffected hip, resulting in instability while walking. This instability may
cause repetitive PST injury, resulting in joint contracture. According toseveral studies, the main cause of joint contracture is skeletal muscle,
followed by the joint capsule; other studies have also mentioned
ligament contracture [34-38]. Therefore, performing PSTR exercises
early to improve apparent leg-length differences and contracture of thejoint capsule and ligaments is crucial to alleviate hip pain in motion andto prevent progression of OA. Ligament contracture needs to be studied
in the future. In this new perspective, pericapsular soft tissue must be
considered a pain generator in OA of the hip that can be addressed withnew home exercises to prevent surgery [39].
This retrospective study revealed that a new home exercise program
may improve hip function for patients with OA of the hip and an HHS
below 60 points. We have begun a multicenter prospective single-arm
study to confirm the effectiveness of this program [40]. In addition weplan studies to investigate the decontracture test to differentiate between
motion pain and walking pain to determine surgical indications [39].

Strengths and Limitations
This study appears to be the first to describe an attempt to develop
effective physical therapy for patients with severe OA of the hip(including those with an HHS below 60 points) who wish to postpone
or avoid surgery for a prolonged period. However, there is no conclusive
evidence of the effectiveness of PSTR exercises because this was a
retrospective observational study with no controls.
Patients who took analgesics (even if only once) were excluded
because this was a retrospective observational study. However,including patients who took analgesics with no change in type or dosewould result in fewer drop-outs 1 year from baseline. The current
authors plan to design a prospective comparative study that includes
patients who take analgesics with no change in type or dose. Patients
who received chiropractic treatment or other hip therapy at baseline
were also excluded because this was a retrospective observational
study. Patients had difficulty continuing to perform PSTR exercises forlonger than 1 year. As mentioned in the discussion, the current authors
plan to create a greatly reduced exercise program for patients whose
symptoms improve (alleviation of anterior pelvic tilt and elevation of
the greater trochanter) and to establish an exercise program to prevent
surgery. Patients who were excluded from this study as described in thesteps for patient enrollment in Figure 3 were determined based on aretrospective analysis of interviews in which a patient met two or moreof the exclusion criteria. In Table 1, the Unilateral OA group at baseline
consisted of 154 patients; however, two patients were eliminatedbecause some of the data on their HHS scores were missing.

Comparison to Other Studies
To our knowledge, the current study is the first to analyze theeffectiveness of exercise therapy to postpone or prevent surgery for a
prolonged period in patients with severe symptoms of OA, including
those with an HHS below 60 points. According to the latest Cochranereview, patients generally perform land-based exercise programs
Physiother Rehabil, an open access journal
ISSN: 2573-0312

consisting of traditional muscle strength training, functional training,or an aerobic fitness program [1], except for one study in which
participants were enrolled in a tai chi program [3]. The current study isthe first to investigate the effectiveness of a pelvic realignment exercise
before muscle exercises to improve function in patients with OA of thehip. We plan to conduct a prospective comparative study to investigate
the relationship between the effect of PSTR exercises and changes inpelvic malalignment over time.
Author Contributions
K. Hayashi contributed to study design, collection, analysis, and interpretationof data, and drafting and revising of the manuscript. S. Tokunaga contributed toanalysis and interpretation of data, use of statistics, and critical revising of themanuscript. K. Haruguchi, D. Nakaniwa, and Y. Tobo contributed to the explanationsof PSTR exercises, the discussion, and analysis of patient characteristics atbaseline (Table 1). T Shimose contributed to analysis and interpretation of data
and use of statistics. All authors approved the final version of the manuscript.

Ethical Considerations and Study Approval
The study was carried out in accordance with the Helsinki Declaration and
was approved by the Fukuoka Wajiro Hospital medical research ethics committee.

Earlier Publication
Some of the results of this study were prepared as an abstract and poster atthe 2015 OARSI World Congress, April 30-May 3, 2015 in Seattle, WA, USA [41].

Conflict of Interest
None

Acknowledgments
PSTR exercise is a part of the Yuki program developed by Teruo Ooyati(Osaka, Japan) [41]. K. Hayashi treated patients with OA of the hip using an open
kinetic chain exercise to strengthen the hip abductors of the gluteus medius andstretching from 1998 to 2006. This open kinetic chain exercise involves raising andlowering the leg and stretching on the affected side but did not alleviate symptoms
or improve function in patients with an HHS below 60 points. In 2007, K. Hayashi
introduced PSTR exercises that T. Ooyati had developed over a 20 year period,
and achieved alleviation of symptoms and improvement in function. The authors
wish to thank the exercise developer T Ooyati as well as the staff of Yuki Shiatsu
for their contributions. The authors wish to thank the staff of the Department of
Rehabilitation of Fukuoka Wajiro Hospital in addition to K Haruguchi, D Nakaniwa,
and Y Tobo for the contributions to the explanation and discussion of PSTR
exercises and analysis of patient characteristics at baseline. Ken Toyota, directorof the Clinical Research Support Center Kyushu, helped with supervisory advice
regarding statistical analysis. The authors also wish to thank all 1,077 patients who
participated in this study. We thank Rebecca Tollefson, DVM, from Edanz Group(www.edanzediting.com/ac) for editing a draft of this manuscript.

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