Acta Scientific Orthopaedics
Volume 2 Issue 4 April 2019

Mini Review

New Strategies for Development of Home Exercise toPrevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator

Kazuo Hayashi1* and Toshiharu Tsunoda2
1

Arthritis Center, Fukuoka Wajiro Hospital, Japan2

Department of Orthopedic Surgery, Asama General Hospital, Japan*Corresponding Author: Kazuo Hayashi, Arthritis Center, Fukuoka Wajiro Hospital, Japan.

E-mail: hayashis@giga.ocn.ne.jp

Received: February 13, 2019; Published: March 18, 2019

Abstract
Most patients with hip osteoarthritis complain of hip pain on standing and when taking their first few steps, with decreased hip

pain as they continue walking. On some days, they have either no pain or very slight pain. This motion pain seems to result from joint
contracture and improve with exercise therapy. Several patients complain of walking pain caused by contact with the subchondralbone secondary to loss of cartilage from the joint surface, and there are no days on which these patients have no pain or very slight

pain. Patients with this severity of walking pain require surgery. We propose that diagnosis and treatment of malalignment syndrome
should be applied in patients with motion pain.

Keywords: Hip Osteoarthritis; Home Exercise; PSTR Exercise; Postpone or Prevent Surgery; Harris Hip Score (HHS); Malalignment
Syndrome

Abbreviations
OA: Osteoarthritis; HHS: Harris Hip Score; THA: Total Hip

Arthroplasty; PSTR Exercise: Pericapsular Soft Tissue andRealignment Exercise.

Introduction

Most studies of exercise for hip osteoarthritis (OA) haveincluded participants with mild to moderate hip OA. Fernandes.,et al. [1] and Svege., et al. [2] reported that the inclusion criteria

for exercise therapy should include a Harris hip score (HHS) of 60
to 95 points, whereas they recommended total hip arthroplasty(THA) for patients with an HHS of <60 points. Bennell., et al. [3]reported that among adults with painful hip OA, physical therapy
did not result in greater improvement in pain or function comparedwith sham treatment. However, patients with an HHS of <60 points

may have a stronger desire to postpone surgery than patients withat home while continuing to work are needed. Manual therapies
that require hospital visits are not suitable as such long-term
treatments. Home exercises are suitable to postpone or prevent

surgery. From 1998 to 2006, we treated patients with hip OA using

an open kinetic chain exercise to strengthen the hip abductors of
the gluteus medius and stretching. This open kinetic chain exercise
involves raising and lowering the leg on the affected side. However,it did not alleviate symptoms or improve function in patients with

an HHS of <60 points. Most studies that have examined exercise asa nonsurgical treatment for hip OA have involved strength training,

stretching, functional training, and aerobic fitness programs [4].

Therefore, we considered the development of a new home exercise
to postpone or prevent surgery.

Discovery of different mechanisms of hip pain
In our clinical experience, many patients with hip OA, evenan HHS of >60 points. Most patients with an HHS of >60 points do

those with an HHS of <60 points, have motion pain resulting fromrearing, or caring for one’s parents. Long-term treatments thatpain seems to improve with exercise therapy, whereas pain caused

not have much disturbance in their activities of daily living. The
main reasons for avoiding or postponing surgery are work, child-can postpone or prevent surgery and allow patients to exercise

joint contracture. In these patients, pain occurs on standing andwhen taking their first steps but decreases during walking. Motion
by subchondral bone exposure on the joint surface during walking

Citation: Kazuo Hayashi. “New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator”. Acta Scientific Orthopaedics 2.4 (2019): 14-19.

New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of Pericapsular Soft
Tissue as a Pain Generator
15

may require surgical treatment. In addition, patients with motion

showed this condition in the Supplementary Information of theanalysis of the patient’s complaint is necessary to select the mostpericapsular soft tissues (joint capsule, ligaments, inner muscles),pain complain that some days they have no pain or very slight pain,
whereas patients with walking pain have no such days. Detailed
suitable treatment for each patient. To our knowledge, even mostrecent studies have not reported the detailed analysis of thepatient’s complaint [5-8].

Development of pericapsular soft tissue and realignment
exercises
Worsening hip OA results in anterior pelvic tilt, elevation of thegreater trochanter, and adduction contracture of the affected hip

Journal of Physiotherapy and Physical Rehabilitation [11]. We
considered that this instability may cause repetitive injury to theresulting in contracture of the affected hip. Thus, correction ofpelvic malalignment before a strengthening exercise is necessary

to decrease motion pain. In 2007, we introduced pericapsular soft
tissue and realignment (PSTR) exercises that Teruo Ooyati (Shiatsu

therapist, Osaka, Japan) had developed over a 20-year period
to prevent or postpone surgery for patients with an HHS of <60
points. Performance of PSTR exercise is a part of the Yuki program
developed by Teruo Ooyati [12]. Correction of apparent leg length[9,10]. Anterior pelvic tilt and elevation of the greater trochanter

difference due to pelvic malalignment on the affected hip seemed

length can result in instability while walking (Figure 1). We also

have been limited to mild to moderate cases [13].

of patients with hip OA can cause an apparent shortening of theleg length on the affected side. This apparent difference in leg

not to have been tried in the previous studies[4-6]. Therefore, theindication of exercise therapy for the patients with hip OA might

Figure 1: Pain when standing and walking is avoided by tilting the trunk forward. Release of pain generators such as
bradykinin from the damaged cartilage site may be reduced by tilting the trunk forward. The counterforce from the floor
is shifted to the posterior aspect of the acetabulum. This force causes anterior pelvic tilt and lumbar lordosis.
Dramatic effects of PSTR exercises as a new home exercise
A retrospective study of 285 patients who fulfilled the inclusion

criteria among 1077 patients who underwent PSTR exercises
showed a significant improvement in the HHS among patients witha baseline HHS of <60 points (Figure 2). We showed an illustration of
the PSTR exercises in the Supplementary Information of the Journalof Physiotherapy and Physical Rehabilitation [11]. We consider thatexercise for the lower back and correction of apparent differencesin leg lengths are the most effective exercises. Most patients withmotion pain have walking instability due to apparent shortening of

the leg length on the affected side caused by anterior pelvic tilt andelevation of the greater trochanter. This apparent shortening of theleg length causes hardening of the erector spinae on the affectedside, resulting in walking instability. This walking instability cause

repetitive pericapsular soft tissue injury to the joint capsule,ligaments, and inner muscles, resulting in contracture of theaffected hip. Most patients complain of motion pain while walking

home from work or during the night at home, whereas they have no

Citation: Kazuo Hayashi. “New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator”. Acta Scientific Orthopaedics 2.4 (2019): 14-19.

New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of Pericapsular Soft
Tissue as a Pain Generator
16

pain or very slight pain during walking to work in the morning. In

Decontracture test to differentiate between motion pain andby walking instability in the daytime. Therefore, exercise for the

motion pain and walking pain. Decontracture may be a usefuladdition to hip pain, they also sometimes experience heavy thighor calf pain at night. This motion pain is considered to be caused
lower back and correction of apparent differences in leg lengths

to increase flexibility of the erector spinae is the most effective

treatment to decrease motion pain. It appears that in many cases,
patients with motion pain are considered to have malalignment

syndrome [14] due to hip OA. Moreside., et al. [15] investigatedthe erector spinae surface electromyography on 19 individuals

with severe hip OA [SOA], 20 with moderate hip OA[MOA], and 19

asymptomatic [ASYM] individuals during treadmill walking. With

walking pain
We developed a decontracture test to differentiate between

method to ease joint stiffness. We plan to investigate the ability ofthe decontracture test to differentiate between motion pain andwalking pain and thus determine surgical indications in futurestudies. We plan to present “a decontracture test” using video slide
at the World Congress of Orthopaedics 2019 [17].

Association of hip pain with radiographic evidence of hip OA
Kim., et al. [18] reported that hip pain was discordant withincreasing OA severity, bilateral erector spinae activity increased

radiographic hip OA. In their report, pain was not present ingroups[p < 0.001]. With moderate and severe OA, sagittal and

Iidaka., et al. [19] reported that hip pain was strongly associatedduring the swing phase of gait [p < 0.001], whereas during stance,

the SOA ipsilateral erector spinae activity was higher than otherfrontal trunk motion increased during gait. We consider thatinvestigation regarding erector spinae of patients with moderate

to severe OA of the hip will be important in future. There is noconclusive evidence of the effectiveness of PSTR exercises because
the above-mentioned study was a retrospective observational

study with no controls. We have begun a multicenter prospective
single-arm study to confirm the effectiveness of this program [16].

many hips with evidence of OA on radiographs, and many painful

hips did not show radiographic evidence of hip OA. In contrast,with Kellgren Lawrence grade >3 OA. We reported that symptoms
improved markedly as a result of PSTR exercises even in patientswith loss of joint cartilage. Partial or total loss of cartilage is notdirectly related to hip pain [11]. We consider that investigationof the characteristics of hip pain (motion pin or walking pain) is
important for resolution of this problem [20]. In future, we plan toinvestigate the association between the characteristics of hip pain

and radiographic findings in addition the effect of PSTR exercises inpatients with loss of cartilage [16].We have examined MRI findingsof all patients with hip OA [11] and could not find the differenceof MRI findings between patients with motion pain and ones withwalking pain.

Basic research regarding the distribution of free nerve
ending and nociceptive receptor in subchondral bone
Witt., et al. [21] performed a review and found that in animalstudies, the subchondral bone was innervated with substanceP immunoreactive nociceptive fibers that may be involved inpain generation in OA. However, Fortier., et al. [22] reported thatthe normal subchondral bone nerve supply was obliterated inareas of advanced arthritis, with cartilage loss, bony eburnation,
Figure 2: Of 1,077 patients with hip osteoarthritis who

underwent pericapsular soft tissue and realignment exercises,
792 patients were excluded because they met the exclusion

criteria and 285 patients fulfilled the inclusion criteria. Of these285 patients, 87 had a Harris hip score of <60 points. Unilateral:

Group of patients with unilateral hip osteoarthritis (no pain in the
opposite hip). Bilateral: Group of patients with bilateral hip

osteoarthritis (pain in the opposite hip). HHS, Harris hip score.
Two-sided P<0.05 was significant.

and cyst formation. Hypercellular infiltrates in cystic cavitationsin the subchondral bone stained intensely for substance P, buttrue neurofilaments were absent in horses. We consider that therelationship between the characteristic of hip pain (motion pain orwalking pain) and the innervation of the subchondral bone should
be investigated in future basic research.
Low back pain related to hip OA

In our study, the Mental Component and Role/Social Component

summary scores on the 36-Item Short-Form Health Survey

improved in both the unilateral OA and bilateral OA groups to near

50 points according to norm-based scoring. However, the PhysicalCitation: Kazuo Hayashi. “New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator”. Acta Scientific Orthopaedics 2.4 (2019): 14-19.

New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of Pericapsular Soft
Tissue as a Pain Generator
17

Component summary score improved only slightly, remaining
below 50 points according to norm-based scoring (Figure 3 and 4).
Low back pain may have contributed to the low Physical Component
summary scores. A lumbosacral or sacroiliac disturbance may havealso been involved [9,10]. We plan to develop new exercises toaddress these issues and establish guidelines for the timing of hip
surgery based on screening involving PSTR exercises. Wang W., etal. [23] reported that the low back pain might be the most common

comorbidity of hip OA, with reported incidence of 21.2% to 100%.
Both the abnormal sagittal spine-pelvis-leg alignment and reduced
hip range of motion might be involved in the mechanism of the lowback pain, hence restoration of the alignment and improvement of
the hip range of motion should be aimed in treating hip OA. THA

is not only treating the hip pathology, but also the low back pain

without spinal disorders. Several studies reported the effect of THA
on sagittal spinal-pelvic-leg alignment and low back pain in patientswith severe hip OA [24-26]. We experienced the improvement of
the mild low back pain in patients with moderate to severe hip OA
using PSTR exercises. When low back pain becomes to be moderateor severe due to hip OA, this low back pain should be treated by

THA. However moderate to severe low back pain continues after
THA when the timing of THA is too late, resulting in disturbances in

activities of daily living even if THA improves hip pain and function.

Figure 4: 36-Item Short-Form Health Survey summary scores inaccordance with a Harris hip score of <60 points at baseline in

the bilateral osteoarthritis group. NBS, norm-based score; P<0.05
was significant. N.S., not significant.

Management of postoperative pain in the lower extremity
Many studies reported postoperative pain in a short period after

hip surgery during hospital stay [27-29]. The treatment consists of

non-steroid anti-inflammatory drugs, local infiltration analgesia,

intrathecal opioids, and lumber plexus block. Many patients who

have undergone surgery such as THA complain of postoperative
pain in the lower extremity or low back pain, especially after
discharge from the hospital. Erlenwein J., et al. [30] reported thatsix months after THA, between 26% and 58% of patients still
had hip pain. Patients with moderate to severe persistent pain

intensity(>3 on a numerical rating scale) were more restricted intheir daily life activities. Regarding persistent postoperative pain,

most patients are explained by doctors that there are no problems
about surgery even if patients complain of postoperative pain

such as pain in groin, thigh, calf, buttock, and low back. These
explanations are performed not for patient’s symptoms, but for
Figure 3: 36-Item Short-Form Health Survey summary scores inaccordance with a Harris hip score of <60 points at baseline in
the unilateral osteoarthritis group. NBS, norm-based score;Two-sided P<0.05 was significant. N.S., not significant.

only roentgenography findings. This may cause distrust of patientsto treatment. PSTR exercises can improve this type of postoperative
pain. We consider that malalignment syndromes present before
surgery were not improved by surgery alone in these cases.

Citation: Kazuo Hayashi. “New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator”. Acta Scientific Orthopaedics 2.4 (2019): 14-19.

New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of Pericapsular Soft
Tissue as a Pain Generator

Regenerative medicine of cartilage
Regenerative medicine to regenerate cartilage with induced

pluripotent stem cells or cell sheets represents a new prospect for18

4. Fransen M., et al. “Exercise for osteoarthritis of the hip”.

Cochrane Database of Systematic Reviews 22 (2014):
CD007912.

the future treatment of OA [31-34]. Nonetheless, even if cartilage

5. Uusi-Rasi K., et al. “Exercise in treatment and rehabilitationof motion is not increased. We plan to develop preoperative PSTR

6. Moseng T., et al. “The importance of dose in land-basedis regenerated, OA may recur if malalignment of the lumbar spine,
pelvis, and lower extremities is not corrected and restricted range

exercises as part of regenerative medicine. In addition, we suspectthat patients with motion pain will not achieve alleviation ofsymptoms and improvement in function if cartilage is regeneratedof hip osteoarthritis: A 12-week pilot trial”. Journal of
Osteoporosis (2017): Jan 1. Doi: (10.1155/2017/3905492).
supervised exercise for people with hip osteoarthritis. A
systematic review and meta-analysis”. Osteoarthritis andCartilage 25 (2017): 1563-1576.

without correction of malalignment of the lumbar spine, pelvis, and

7. Schiphof D., et al. “Osteoarthritis year in review 2017:

needs to be corrected before cartilage regeneration.

8. Collins NJ., et al. “Osteoarthritis year in review 2018:

lower extremities. We consider that walking instability caused bymalalignment of the lumbar spine, pelvis, and lower extremities

Conclusion

rehabilitation and outcomes”. Osteoarthritis and Cartilage 26(2018): 326-340.
rehabilitation and outcomes”. Osteoarthritis and Cartilage 27(2019): 378-391.

Pericapsular soft tissue should be considered as a pain

9. Yoshimoto H., et al. “Spinopelvic alignment in patients withanalysis of the patient’s complaint is necessary to select the most

10. Weng WJ., et al. “Characteristics of sagittal spine-pelvis-leg

Acknowledgment

11. Hayashi K., et al. “Dramatic effects of new home exercises

generator in hip OA. Diagnosis and treatment of malalignment
syndrome should be applied in patients with motion pain. Detailed

suitable treatment for each patient. Both narrative-based medicine
and evidence-based medicine are important in this setting.

We thank Angela Morben, DVM, ELS, from Edanz Group(www.edanzediting.com/ac), for editing a draft of this manuscript.

Conflict of Interest
None.

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Volume 2 Issue 4 March 2019
© All rights are reserved by Kazuo Hayashi.

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Citation: Kazuo Hayashi. “New Strategies for Development of Home Exercise to Prevent Surgery in Patients with Hip Osteoarthritis: Considerations of
Pericapsular Soft Tissue as a Pain Generator”. Acta Scientific Orthopaedics 2.4 (2019): 14-19.