Hayashi, J Physiother Rehabil 2019, 3:2
DOI: 10.4172/jptr.1000122

Journal of Physiotherapy
and Rehabilitation

Short Communication

A SCITECHNOL JOURNAL

Narrative-based Medicine forDevelopment of Home Exercise toPrevent Surgery in Hip
Osteoarthritis: Consideration ofPericapsular Soft Tissue as a Pain
Generator
Kazuo Hayashi1* and Toshiharu Tsunoda2
1Arthritis Center, Fukuoka Wajiro Hospital, Fukuoka, Japan
2Department of Orthopedic Surgery, Asama General Hospital, Nagano, Japan*Corresponding author: Kazuo Hayashi, Department of Arthritis Center, Fukuoka
Wajiro Hospital, Fukuoka, Japan, Tel: +8109045169461; Fax: +810926915315; Email: hayashis@giga.ocn.ne.jp

Received Date: 13 May, 2019; Accepted Date: 30 May, 2019; Published Date: 5June, 2019

Abstract
In many cases of hip osteoarthritis (OA), patients exhibit
symptoms that are discordant with radiography and magnetic
resonance imaging findings. We have observed two distinct
types of pain in hip OA: motion pain and walking pain. Motion
pain typically improves with exercise therapy, whereas walking
pain may require surgery. Many patients with motion pain haveKellgren-Lawrence grade 3 or 4 findings. Therefore, thecombination of narrative-based medicine and evidence-based
medicine is important for selecting the most suitable treatment
for patients with hip OA.
Keywords: Hip osteoarthritis; Home exercise; PSTR exercise;
Harris Hip Score (HHS)

Limitations of Evidence-based Medicine in hip OA
A major problem at our clinic during patients’ first visit is theirunderstanding of the explanation of their hip pain received at hospitals
they have visited previously. Most patients with hip osteoarthritis (OA)
have received advice from doctors explaining that the exposed
subchondral bone secondary to loss of cartilage from the joint surface
is contacted, causing hip pain that can only be relieved by surgery. We
always consider whether this is indeed the case, because we haveobserved many cases of patients with contact of the subchondral bonesecondary to complete loss of cartilage who report no hip pain and nolimitations in activities of daily living. In addition, we observed apatient with hip OA in which radiographic findings at first visit
indicated Kellgren-Lawrence (K/L) Grade 2 [1], with preservedcartilage (Figure 1A).

Figure 1: (A) Radiographic findings of a patient at first visit with
Kellgren-Lawrence (K/L) grade 2 and preserved cartilage. The
patient had a Harris Hip Score (HHS) of 49 points, as well as severe
hip pain and limping with a walking stick. (B) Pericapsular soft
tissue and realignment (PSTR) exercise [3] was begun. One year
later, hip pain and function were improved, with HHS of 80 points,and walking without a stick. However, the K/L grade of radiographyhad worsened to K/L grade 4. Magnetic resonance imaging could
not explain the relationship between symptoms and radiographic
findings in this case.
This patient had a Harris Hip Score (HHS) [2] of 49 points, andexhibited severe hip pain and limping with a walking stick.
Pericapsular soft tissue and realignment (PSTR) exercise [3] wasbegun. One year later, hip pain and function were improved, resultingin HHS of 80 points, and walking without a stick. However, the K/Lgrade based on radiography had worsened to Grade 4 (complete loss ofcartilage, Figure 1B). Magnetic resonance imaging findings were notable to explain the relationship between symptoms and radiographic
findings in these cases. Overall, we have found that many patients’problems cannot be explained by evidence-based medicine in hip OA.

Narrative-based Medicine in Hip OA
We have analyzed the details of patients’ complaints over 12 years,
revealing the following mechanisms of hip pain:

A: Motion pain
1: Patients have either no pain or very slight pain on some days.
2: Patients complain of hip pain while standing and when taking thefirst few steps, with decreased hip pain as they continue walking.
3: Patients who walk for more than 20 minutes each way for work,in addition to bus, subway, or train travel, either have no pain or veryslight pain during walking to work in the morning. However, they
complain of hip pain while walking home from work or during theevening at home, and sometimes experience intense thigh pain or calf
pain at night.
4: Motion pain appears to result from joint contracture. Anterior
pelvic tilt and elevation of the greater trochanter in patients withpainful hip OA causes apparent shortening of the leg on the side of theAll articles published in Journal of Physiotherapy and Rehabilitation are the property of SciTechnol and is protected bycopyright laws. Copyright © 2019, SciTechnol, All Rights Reserved.

Citation:

Hayashi and Tsunoda (2019) Narrative-based Medicine for Development of Home Exercise to Prevent Surgery in Hip Osteoarthritis: Considerationof Pericapsular Soft Tissue as a Pain Generator. J Physiother Rehabil 3:2.

doi: 10.4172/jptr.1000122
affected hip. This apparent shortening of leg length causes hardening of
the erector spinae on the affected side, resulting in instability while
walking (Figure 2). This walking instability causes repetitive injury ofpericapsular soft tissue (joint capsule, ligaments, inner muscles),resulting in joint contracture. Moreside et al. reported the effects of theerector spinae in patients with moderate to severe hip OA [4].

Figure 2: Anterior pelvic tilt and elevation of the greater trochanter in patients with painful hip OA caused apparent shortening of the leg on
the side of the affected hip. This apparent shortening of the leg length caused hardening of the erector spinae on the affected side, resulting inwalking instability. This walking instability caused repetitive injury of the pericapsular soft tissue (joint capsule, ligaments, inner muscles),resulting in joint contracture.

B: Walking pain
1: There are no days on which patients have no pain or very slightpain.
2: Patients complain of more intense hip pain during walking thanpain while standing and when taking the first few steps.
3: Patients who walk for more than 20 minutes each way for work inaddition to bus, subway, or train travel, have moderate to severe
walking pain while walking to work in the morning. Sometimes thesepatients need a stick, or to rest while walking. They have walking pain
for most of the day.
4: Walking pain is caused by contact with the subchondral bonesecondary to loss of cartilage from the joint surface. Patients withsevere walking pain may require surgery.

Volume 3 • Issue 2 • 1000122

PSTR exercise can improve pain and functioning in patients withmotion pain, whereas patients with walking pain typically requiresurgery. Many patients with motion pain have radiographic findings ofK/L Grade 3 or 4. We have reported that symptoms improved
markedly as a result of PSTR exercises in patients with K/L Grade 3 or
4 in which joint cartilage was lost [3]. Radiographic findings areunable to determine the indication for exercise therapy or surgery. In aprevious study, we reported that a narrative-based approach withpatients is necessary for determining an indication for exercise therapy
or surgical treatment [5]. In another study, we found no difference inmagnetic resonance imaging findings between patients with motion
pain and those with walking pain in a sample of 1077 patients [3].

• Page 2 of 3 •Citation:

Hayashi and Tsunoda (2019) Narrative-based Medicine for Development of Home Exercise to Prevent Surgery in Hip Osteoarthritis: Considerationof Pericapsular Soft Tissue as a Pain Generator. J Physiother Rehabil 3:2.

doi: 10.4172/jptr.1000122

Consideration of Pain Generators in OA

References

Previous studies reported that bone-related causes of pain in OA
include subchondral microfracture, bone stretching with elevation ofthe periosteum due to osteophyte growth, bone remodeling and repair,bone marrow lesion, and bone angina caused by decreased blood flow
and increased intra-osseous pressure [6]. The subchondral bone andsynovium may be responsible for nociceptive stimulation, andperipheral neuronal sensitization is an important feature, resulting inpain during daily activities such as walking [7]. Witt et al. [8]conducted a review, reporting that, in animal studies, the subchondralbone was innervated with substance P immunoreactive nociceptive
fibers that may be involved in pain generation in OA. However, Fortieret al. [9] reported that the normal subchondral bone nerve supply wasobliterated in areas of advanced arthritis, with cartilage loss, bony
eburnation, and cyst formation. In addition, hypercellular infiltrates incystic cavitations in the subchondral bone stained intensely for
substance P, but true neurofilaments were found to be absent in horses.

1.

We propose that further investigation regarding potential
differences in the mechanisms between motion pain and walking pain
will be important for determining the most suitable treatment for eachpatient. The relationship between the characteristics of hip pain
(motion pain or walking pain) and innervation of the subchondralbone should be investigated in future studies.

Conclusion
The combination of narrative-based medicine and evidence-based
medicine is important for selecting the most suitable treatment foreach patient with hip OA.

2.

3.
4.
5.

6.
7.
8.
9.

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AcknowledgmentThe PSTR exercises were ones in books published by Teruo Ooyati(Osaka, Japan). We thank Benjamin Knight, MSc., from Edanz Groupfor editing a draft of this manuscript.

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