Author Names
Hicks, G. E., George, S. Z., Pugliese, J. M., Coyle, P. C., Sions, J. M., Piva, S., Simon, C. B., Kakyomya, J., & Patterson, C. G.
Reviewer Name
Ciara Roche, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background
Previously, we identified a population of older adults with chronic low back pain, hip pain, and hip muscle weakness who had worse 12-month low back pain and functional outcomes than age-matched adults with only low back pain, indicating an increased risk for future mobility decline. We sought to determine whether tailored, hip-focused physical therapy reduced pain and functional limitations in this high-risk population compared with non-tailored, spine-focused physical therapy.
Methods
We did a multicentre, single-masked, randomised controlled trial at three research-based sites in the USA. We recruited older adults (aged 60–85 years) with hip pain and weakness who reported moderate low back pain intensity at least half the days in the last 6 months. Patients were randomly assigned to hip-focused physical therapy or spine-focused physical therapy using permuted blocks with random block size, stratified by site and sex (ie, male or female). The primary outcomes were self-reported disability using the Quebec Back Pain Disability Scale (QBPDS) and performance-based 10-Meter Walk Test (10MWT) at 8 weeks. All analyses were done in the intention-to-treat population. Adverse events were collected by study staff via a possible adverse event reporting form and then adjudicated by site investigators. This trial was registered with ClinicalTrials.gov, NCT04009837.
Findings
Between Nov 1, 2019, and April 30, 2022, 184 participants were randomly assigned to receive hip-focused (n=91) or spine-focused physical therapy (n=93) interventions. The mean age was 70·7 (SD 6·2) years. 121 (66%) of 184 participants were women, 63 (34%) were men, and 149 (81%) were White. At 8 weeks, the mean between-group difference on the QBPDS was 4·0 (95% CI 0·5 to 7·5), favouring hip-focused physical therapy. Both groups had similar, clinically meaningful gait speed improvements (10MWT) at 8 weeks (mean difference 0·004 m/s [95% CI –0·044 to 0·052]). No serious adverse events were related to study participation.
Interpretation
Tailored hip-focused physical therapy demonstrated greater improvements in low back pain-related disability at 8 weeks. However, both hip-focused physical therapy and spine-focused physical therapy produced clinically meaningful improvements in disability and function for this high-risk population at 6 months. These findings warrant further investigation before clinical implementation.
Funding
US National Institute on Aging of the National Institutes of Health.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
Hip-focused interventions may be more beneficial for short-term pain improvement in older adults with chronic low back pain.
Key Finding #2
Hip-focused interventions may be more beneficial in improving lower extremity strength and endurance in older adults with chronic low back pain.
Key Finding #3
Both hip- and spine-focused interventions may be beneficial in improving functioning of older adults with chronic low back pain.
Key Finding #4
Hip-focused interventions may be more beneficial for short-term improvement in low back pain related disability in older adults with chronic low back pain.
Please provide your summary of the paper
This study aimed to investigate how older adults with chronic low back pain who are at risk for functional decline respond to different physical therapy interventions. This study was significant because much of the existing research on low back pain interventions studies the adult population, not older adults. Older adults are at a higher risk of chronic pain and subsequent decrease in function, therefore it is important for physical therapists to identify and implement the treatment strategy with the greatest improvement in outcomes. This randomized controlled trial compared hip-focused interventions with spine-focused interventions including a combination of manual therapy and exercise. Men and women aged 60-85 years with chronic moderate low back pain, hip pain, and hip weakness were included. The primary outcomes assessed were Quebec Back Pain Disability Scale and 10-Meter Walk Test, and they were assessed at baseline, 8 weeks, and 6 months. All participants were seen for intervention sessions 2 times per week for 8 weeks. The hip-intervention group received manual therapy to each hip including long axis distraction, mobilizations in all directions, and manual stretching to the hip flexors and hamstrings. They participated in functional hip exercises including partial wall squats, hip abduction with elastic band, forward step-ups, wall squats, side-stepping with band, and lateral step-ups. Finally, their home exercise program consisted of hip strengthening in abduction, extension, internal rotation and external rotation with an elastic band, and trunk muscle training exercises such as bracing, curl-ups, side bridges, and alternating arm lifts in quadruped. The spine-intervention group received manual therapy to the lumbar spine including P-A mobilizations and effleurage. They participated in trunk muscle training exercises such as bracing, curl-ups, alternating arm lifts in quadruped, and stationary cycling without resistance. Their home exercise program consisted of general lumbar flexibility stretches, bracing, curl-ups, and alternating arm lifts in quadruped. Both groups received moist heat during HEP education at the end of each session. Secondary physical performance measures including 6-Minute Walk Test, 30-Second Chair Stand Test, and Timed Up and Go were also assessed at baseline and the two follow-up assessments. Self-report questionnaires, Low Back Activity Confidence Scale, the Pain Catastrophizing Scale, hip isometric strength, and Quantitative Sensory Testing were also collected at each assessment. At 8 weeks, the hip-intervention group had statistically significantly higher improvements in self-reported disability and 6-MWT distance than the spine-intervention group. At 6 months, the hip-intervention group had statistically significantly higher improvements in 6-MWT and 30SCST than the spine-intervention group. The hip-intervention group also had higher improvements in self-reported pain and pain interference measures at 8 weeks.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Although many of the outcomes favored the hip-focused intervention group at the 8-week follow up assessment but not at the 6-month follow up assessment, both groups continued to improve from 8-weeks to 6-months, indicating that both hip- and spine-focused interventions may produce favorable outcomes in the population that was studied. Hip-focused interventions may provide quicker short-term improvements, but more research is necessary to determine if clinically significant improvements are made earlier than the 8-week timepoint. The results of this study can guide physical therapists in treating this population: a combination of manual therapy and exercise during a plan of care 2 times per week for 8 weeks should result in improved pain, self-selected gait speed, strength and functioning at 6 months from baseline. These findings cannot be extrapolated to individuals with cognitive impairment, rheumatoid arthritis, artificial hip joint, or red flag symptoms, or who are wheelchair users, as they were excluded from the study.
