Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

December 2017

Study Title:

Effects of Manual Therapy and Exercise Targeting the Hips in Patients with Low-Back Pain – A Randomized Controlled Trial


Bade M, Cobo-Estevez M, Neeley D et al.

Author's Affiliations:

University of Colorado, CO, USA; Duke University, NC, USA.

Publication Information:

Journal of Evaluation in Clinical Practice 2017; 23(4): 734-740. doi: 10.1111/jep.12705. Epub 2017 Jan 27.

Background Information:

Low back pain (LBP) is an extremely common and pervasive healthcare issue, which can cause tremendous functional limitation, disability, and economic and personal burden (1-3). Sadly, most conservative LBP treatments yield small, albeit beneficial, results (4). Hip-spine syndrome (5) is a frequently cited and increasingly common condition, which assumes two distinct disorders of the low back and hip exist together to cause greater pain at each site (particularly in elderly patients). This often presents a challenging ‘chicken-or-egg’ scenario for treating clinicians (that is, which area do we treat first?). Much of the literature on this subject has demonstrated that operative management of the overtly symptomatic hip, usually in the form of hip joint replacement, also improves symptoms associated with the coexisting lumbar spine condition (6). Other groups have advocated conservative treatment of the “asymptomatic” (non-painful) hip, in an effort to improve clinical outcomes (7, 8). These recommendations are based on the concept of regional interdependence, which assumes that anatomically proximal or even relatively disconnected regions may influence one another through unknown causes or some sort of tissue-based or biomechanical link (9).

To date, no RCT has evaluated the added benefit of hip manual therapy and exercise to standard treatment in individuals with the primary complaint of LBP. As such, the authors of this study sought to determine whether an additional hip intervention improves outcomes in patients with LBP.

Pertinent Results:

Ninety subjects were included in this study. However, only 84 subjects were included in the final analysis. On average, these subjects were 46.1 years of age (SD = 16.2), and had an average symptom duration of 18.4 weeks (SD = 40.4). Patients were treated an average of 7.90 times (SD = 4.7). The mean baseline Oswestry Disability Index Score (ODI) and Numeric Pain Rating Scores (NPRS) were 36.4 (moderate disability) and 5.3 points, respectively. There were no baseline differences between the groups.

There were no significant differences between the groups in ODI and NPRS at week 2. Also at week 2, the magnitude of effect size for the ODI (0.21) and NPRS (0.06) were small, but did trend in favour of the LBP+HIP group. Patient Satisfaction and Global Rating of Change (GRoC) measurements were significantly better in the LBP+HIP group (P = 0.02).

At discharge, the LBP+HIP group demonstrated statistically significant changes in ODI (P = 0.03), NPRS (P = 0.02), Global Rating of Change (GRoC; P < 0.01) and Patient Satisfaction (P < 0.01), compared to the LBP group. There was no statistically significant difference between the groups in the Patient Acceptable Symptom State (PASS) Score (P = 0.064). No serious adverse events were reported.

Clinical Application & Conclusions:

The goal of this RCT was to determine if hip rehabilitation and manual therapy provided additional benefit to localized low back treatment in patients with LBP. The researchers in fact did show that hip manual therapy and rehabilitation provided additional benefit to standard LBP treatment. Interestingly, the effect size magnitude was largest at discharge, indicating that the beneficial effect of hip treatment increased over the course of care. Evidence-informed clinicians should therefore consider treating the hip when encountered with a patient suffering from LBP.

Clinical Commentary: I know that many of us that work for RRS Education have been waiting for a study like this one to come out. We have been advocating this for YEARS! Concomitant low back and hip treatment is easy to perform, and can easily fit into any practitioner’s treatment toolbox and philosophy. Your assessment can be as simple as supine hip ROM testing, or as complex as analyzing specific movement patterns. Assessment and treatment of the hip in LBP patients is something you can realistically start doing tomorrow. Try it and you will see a difference!

Study Methods:

This study was a non-blinded, randomized controlled trial. Each subject was randomly assigned into one of two groups: a low back pain treatment group (LBP) or a low back pain plus prescriptive hip treatment group (LBP+HIP). Patients were seen for formalized care in an outpatient setting.

Ninety patients with a primary complaint of LBP were included. Patients were included if they were over 18 years of age, scored a minimum of 20% on the Oswestry Disability Index (ODI), had pain ratings > 2/10 on the Numeric Pain Rating Scale (NPRS), and experienced a within session change in pain ratings and/or ROM. Patients were excluded if any there were any red flags, signs of nerve root compression, if they had undergone prior low back surgery or were pregnant at the time of data collection.

The primary outcome measure was the ODI. A ≥ 50% reduction in the ODI from baseline has been considered a clinically important outcome (10). The ODI was completed at baseline, 2 weeks and upon discharge. Secondary outcome measures were the Patient Acceptable Symptom State (PASS – the state beyond which participants consider as acceptable and are unlikely to seek further treatment), NPRS, Patient Satisfaction and Global Rating of Change (GRoC). The secondary measures were collected at the same time intervals listed above.


The LBP group received low back treatment only, which included manual therapy, trunk coordination/strengthening/endurance exercise, directional preference exercise, neuromobilization, traction, education and advice on how to progressively improve general fitness. These patients did not receive any isolated hip strengthening exercise or manual therapy to the hip itself. These patients were not allowed to perform spinal exercises that involved hip motion.

The LBP+HIP group received the same treatment as described above, plus hip rehabilitation and manual therapy targeting the hip. Each subject allocated to the LBP+HIP group performed side-lying clam shells with elastic resistance, hip extension in the quadruped position, and unilateral bridge exercises (11). Subjects performed 2 sets of 12-15 repetitions, bilaterally. Hip manual therapy consisted of grade III-IV anterior-to-posterior mobilization with distraction, long axis distraction and prone posterior-to-anterior hip mobilization (12). Both groups received LBP-oriented home exercise. Subjects in the LBP+HIP group received a standardized LBP exercise program, which included 3 hip exercises. Home exercises were performed twice daily.

Analysis of covariance (ANCOVA) were used to measure differences in the ODI and NPRS. Differences in GRoC and patient satisfaction were analyzed with a Mann-Whitney U. The PASS differences were calculated with a Fisher Exact Test. Cohen d was used to analyze between-group effect sizes for NPRS and ODI. Effect sizes were classified as small = 0.20; medium = 0.50; and large 0.80. Alpha levels were set as P ≤ 0.05 for all analyses.

Study Strengths / Weaknesses:

  • Only patients that showed improvement after their initial appointment were included in the study. This is a strange case of selection bias that wasn’t really explained!
  • The researchers were not blinded – outcomes were analyzed by treating therapists.
  • There was no intermediate nor long term follow-up.
  • The standard deviation for the number of weeks suffering from back pain was EXTREMELY large. Given this information, it is uncertain whether this was a homogenous sample, which is necessary for a good RCT. Additionally, chronic LBP patients will often respond differently to traditional exercise compared to acute or subacute pain patients.
  • While the LBP+HIP treatment was more favourable and had a superior effect size, the authors did not report how well the LBP group did.
  • It is uncertain if high-velocity spinal manipulation (SMT) was used as a treatment modality in either group.
  • It is unknown what treatment was provided to the LBP patients, which limits the internal validity of the study.
  • The addition of hip treatment may have increased actual treatment time, leading to attention bias.
  • Past studies (7) required individuals that received concomitant hip and low back treatment to have a hip ROM deficit. This study did not require any hip signs or symptoms for inclusion - only 19% of included subjects in the LBP+HIP group had concomitant hip and low back pain. This indicates that in this subject cohort, targeted treatment of the hip in addition to the low back is beneficial, in spite of presenting symptomatology or clinical findings.

Additional References:

  1. Walker BF, Muller R, Grant WD. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther 2004; 27(4): 238–244.
  2. Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991; 12: 141–156.
  3. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003; 290(18): 2443–2454.
  4. Offierski CM, MacNab I. Hip‐spine syndrome. Spine 1983; 8(3): 316–321.
  5. Machado LC, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non‐specific low back pain: a meta‐analysis of placebo‐controlled randomized trials. Rheumatol Oxf Engl 2009; 48(5): 520–527.
  6. Ben‐Galim P, Ben‐Galim T, Rand N, et al. Hip‐spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine 2007; 32(19): 2099–2102.
  7. Burns SA, Mintken PE, Austin GP, Cleland J. Short‐term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. J Man Manip Ther 2011a; 19(2): 100–107.
  8. Burns SA, Mintken PE, Austin GP. Clinical decision making in a patient with secondary hip‐spine syndrome. Physiother Theory Pract 2011b; 27(5): 384–397.
  9. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther 2007; 37(11): 658–660.
  10. Fritz JM, Hebert J, Koppenhaver S, Parent E. Beyond minimally important change: defining a successful outcome of physical therapy for patients with low back pain. Spine 2009; 34(25): 2803–2809.
  11. Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine‐wire electrodes. J Orthop Sports Phys Ther 2013; 43(2): 54–64.
  12. Hando BR, Gill NW, Walker MJ, Garber M. Short‐ and long‐term clinical outcomes following a standardized protocol of orthopedic manual physical therapy and exercise in individuals with osteoarthritis of the hip: a case series. J Man Manip Ther 2012; 20(4): 192–200.