PHYSICAL THERAPY AS CONSERVATIVE TREATMENT

The strength of recommendation was downgraded to moderate for several reasons including heterogeneity in the types of modalities and interventions provided in intervention groups and heterogeneity in the frequency, duration, and intensity of interventions.

Fifteen articles (thirteen high-quality, one moderate-quality, and one low-quality) disagreed whether physical therapy in patients with osteoarthritis of the hip (OAH) had statistically significant positive outcomes when compared to a control group. Eight articles concluded there was either no significant difference in primary outcomes, or slight non-significant improvements in the intervention group (mainly with patient reported outcomes) (Bennell 2014, Beselga 2016, Pisters 2010, Steinhilber 2017, Svege 2016, Teirlinck 2016, Thompson 2020) while the other seven articles concluded that physical therapy significantly improved outcomes when compared to a control group (Fernandez 2010, French 2013, Koybasi 2010, Olsen 2022, Poulsen 2013, Svege 2015, Tak 2005).

In the high and moderate quality studies that found physical therapy was beneficial, there were significant improvements in hip flexion, Patient Global Assessment, Visual Analogue Scale (VAS) Pain, and Western Ontario McMaster Arthritis Index (WOMAC) in more than one article. There were also improvements to 5m Walking Test, range of motion (ROM), Balance Step Test, Body Awareness Rating Scale Movement Quality and Experience (BARS-MQE), Chair Stand Test, 15m Walking Test, Harris Hip Score (HHS), Hip Abduction, Hip Adduction, Hip Extension, Hip Internal Rotation, Hip Disability and Osteoarthritis Outcome Score (HOOS), Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP), Patient-Oriented Physical Function McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR), Physiotherapy Outpatient Survey, Reported Recovery, Self-Paced 40m Walk, Sickness Impact Profile, and Timed-Up-and-Go-Test were illustrated in at least one of the articles.

While there was disagreement among the studies as to whether supervised physical therapy was superior to control groups, there were no studies that found that physical therapy resulted in worse outcomes.

Most studies failed to stratify results or subject selection based on osteoarthritis severity, which may have contributed to the overall disagreement among studies as to whether physical therapy was effective. Few studies compared a comprehensive physical therapy program to a placebo group, instead many studies focused on a singular intervention (e.g., core strengthening, ultrasound, mobilizations, etc.).

Benefits/Harms of Implementation
Patients who are candidates for conservative treatment may benefit from physical therapy to improve range of motion, reduce pain, and improve function. Most studies did not stratify participants based on Kellgren-Lawrence grade or structural severity of osteoarthritis, making it unclear if physical therapy is beneficial for all patients, or just those earlier in the course of osteoarthritis. It is possible that patients with end-stage disease may not receive functional benefit from physical therapy, despite the cost and time associated with rehabilitation.

Outcome Importance
Participation in physical therapy may improve a wide range of outcomes, including range of motion, pain, functional performance, walking speed, and self-reported functional ability.

Cost Effectiveness/Resource Utilization
There is limited comparative data on the cost effectiveness of physical therapy for patients with osteoarthritis of the hip as part of conservative management.

Acceptability
This recommendation should be readily implemented as it does not reflect a major change in clinical practice. Physical therapy is commonly recommended for patients with mild to moderate hip osteoarthritis and physical therapists should be familiar with the condition and appropriate interventions to address physical impairments and functional deficits associated with hip OA.

Feasibility
Physical therapy as an option for conservative management should be feasible for most stakeholders.

Future Research
Future research is necessary to draw stronger conclusions about the benefit of physical therapy for patients with hip osteoarthritis. Future studies should stratify results based on osteoarthritis. Future studies also need to compare comprehensive physical therapy programs that include a formal evaluation and individualized treatment plan to a placebo group.