Science in Conflict Hip Versus Spine in Low Back Pain

Amazingly, despite mountains of research, there is still no consensus on the musculoskeletal contributors.2 In some quarters, the musculoskeletal-treatment professions have divided into camps regarding the role of hip versus spine treatment. Physiotherapists may treat hip first, spine first, or both simultaneously. Referring patients to the right treatment could accelerate recovery, improve patient adherence, and cut costs.

Last month, The Lancet published the latest evidence-based instalment in this debate, which may have tipped the scales.3 Experts have long hypothesised the role of limited range of motion (ROM) in the hips as a contributor to LBP. Prather et al. reported 80% of LBP cases presented with limited hip ROM, and the systematic review by Avman et al. finds that limited hip flexion specifically (as opposed to other ranges of motion) tends to be associated with non-specific low back pain.4,5 Before 2024, two noteworthy, randomised, controlled trials (RCTs) gave us conflicting evidence.

Most recently, Burns et al. published the boldly titled RCT, “When Treating Coexisting Low Back Pain and Hip Impairments, Focus on the Back: Adding Specific Hip Treatment Does Not Yield Additional Benefits.” Their RCT, published in 2021, included 68 patients.6 Leading up to that, in 2017, Bade et al. randomised 84 subjects to spine-focused treatment or that plus hip-focused treatment. They found that adding hip-focused treatments was associated with small to moderate gains over the spine-only treatments.7 In January, The Lancet published Hicks et al., who randomised 184 participants to either hip -only focus or spine-only focus. They found that, while both approaches were effective, the hip-focus produced greater reductions of disability.3 With this new evidence, we have 268 RCT subjects with outcomes suggesting the efficacy of hip therapy in LBP, and 68 RCT subjects with outcomes trending to the contrary. Additionally, another study finds that 25 consecutive patients receiving total hip replacements experienced noteworthy improvements in LBP following surgery.8 The preponderance of the evidence now suggests that hip dysfunction, especially limited flexion, contributes to low back pain, and that treatments for such improve LBP outcomes. More evidence is needed to refine this observation. For instance, would a hip-first treatment plan be more cost-efficient than leading with a hip & spine plan, in some presentations? Currently, physiotherapists should include hip assessment and treatment in management of LBP. While this can increase treatment, the evidence suggests it also improves outcomes. To maximise each patient’s return on time investment, treatment plans should be individually tailored to address specific deficits discovered in assessment.

References

1. Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, Carter A, Casey DC, Charlson FJ, Chen AZ, Coggeshall M. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016 Oct 8;388(10053):1545-602.

2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ. What low back pain is and why we need to pay attention. The Lancet. 2018 Jun 9;391(10137):2356-67.

3. Hicks GE, George SZ, Pugliese JM, Coyle PC, Sions JM, Piva S, Simon CB, Kakyomya J, Patterson CG. Hip -focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial. The Lancet Rheumatology. 2024 Jan 1;6(1):e10-20.

4. Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. Journal of Orthopaedic & Sports Physical Therapy. 2017 Mar;47(3):163-72.

5. Avman MA, Osmotherly PG, Snodgrass S, Rivett DA. Is there an association between hip range of motion and nonspecific low back pain? A systematic review. Musculoskelet Sci Pract. 2019; 42: 38–51.

6. Burns SA, Cleland JA, Rivett DA, O'Hara MC, Egan W, Pandya J, Snodgrass SJ. When treating coexisting low back pain and hip impairments, focus on the back: adding specific hip treatment does not yield additional benefits—a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy. 2021 Dec;51(12):581-601.

7. Bade M, Cobo‐Estevez M, Neeley D, Pandya J, Gunderson T, Cook C. Effects of manual therapy and exercise targeting the hips in patients with low‐back pain—A randomized controlled trial. Journal of Evaluation In Clinical Practice. 2017 Aug;23(4):734-40.

8. Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel S, Floman Y. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine. 2007 Sep 1;32 (19):2099-102.