Low back pain (LBP) is one of the most challenging musculoskeletal conditions that lead to long-term functional limitations. In addition, there are some assumptions that a limited hip range of motion plays a role in LBP by resulting in compensatory motions of the lumbopelvic region, more specifically in the lumbar spine and the pelvis, which may contribute to the onset of LBP and its severity. The authors of this article review current studies on the im-portance of considering hip joint movement in the treatment of LBP.
Authors: Kati Simon & Aki Rintala
The societal and individual impact of LBP
LBP places a heavy direct and indirect burden on individuals, their families, and societies (Sadeghisani et al. 2015), as it brings challenges to society and the individual in terms of increased medical costs, use of medical services, and reduced working days (Miyachi et al. 2022). The majority of the world’s population will experience some level of LBP at some point of time in their lifespan (Hlaing et al. 2021), and its exacerbation can contribute to a decrease in productivity at work and also in employment (Nishimura & Miyachi 2020). In particular, an individual suffering from LBP can experience psychological distress if LBP develops into a chronic stage (Sadeghisani et al. 2015). People exposed to high levels of sedentary work are at higher risk of developing LBP and most cases of LBP are categorised as non-specific LBP with no identifiable cause or pathology. One key factor that decreases daily functional activities in patients with LBP is a reduced ability to maintain postural control (Hlaing et al. 2021), i.e., the ability to maintain a controlled upright posture.
Why should we focus on hip joint movement in LBP?
The lumbar spine and hip range of motion are closely related, and when hip joint motion occurs, lumbar spine motion also occurs via the pelvis (Miyachi et al. 2022). This article presents a few current studies that have assessed whether focusing only on the hip joint can prevent or alleviate LBP. The common conclusion of these studies is that hip-strengthening exercises alone are not effective in the prevention and rehabilitation of LBP, but such exercises are recommended to be part of the LBP rehabilitation programme.
One randomised controlled trial involved 70 persons with chronic non-specific LBP. Participants were randomly assigned into two groups for an exercise programme twice a week for five weeks. The experimental group received manual therapy and lumbar segmental stabilisation (e.g., joint mobilisation and myofascial treatment aimed at reducing joint stiffness and muscle overactivity) supplemented with hip-strengthening exercises (using elastic bands and weights). The control group received the same treatments without the hip-strengthening exercises. The authors reported that adding specific hip-strengthening exercises did not provide additional benefits to clinical outcomes in patients with chronic non-specific LBP, which may indicate that solely concentrating on hip-strengthening exercises may not be effective in treating LBP (Fukuda et al. 2021). Furthermore, one systematic review including 309 patients with LBP (five studies) concluded that hip strengthening may be an essential adjunct to trunk muscle-strength training, which could also be supported for persons with LBP. Hip-strengthening exercises were mostly employed from one to seven times per week for six weeks. Therefore, specific hip-strengthening exercises alongside conventional therapy may be beneficial for improving pain and disability in persons with LBP, however, it has not been shown whether strengthening the muscles around the hip joint alone reduces LBP (de Jesus et al. 2020).
A recent cohort study investigated whether an abnormal range of motion in the hip joint pre-disposes LBP among elite inline hockey players. The findings indicated that LBP was expe-rienced more often in hockey players with excessive external hip rotation and total rotation. Moreover, inline hockey incorporates the technical features of skating, which requires a wide range of hip joint movements, especially on the rotation side. As a result, the authors concluded that hip muscle-strengthening exercises are a common intervention to prevent and treat LBP. In the case of excessive hip joint movement, a mixed exercise programme (including back stretching, hip stretching, core/gluteus strength, and muscle relaxation exercises) could reduce the risk of recurrent LBP in the future (Cejudo et al. 2020).
When viewing the topic from regular sedentary workers, one study showed that persons who have sedentary work and LBP are also exposed to a lower range of hip joint movement. This can be assumed, as sitting with the trunk flexed for a long period may cause thinning of the lumbar soft tissues and a prolonged sitting position may impair the stability of the spine support mechanism and decrease the lumbar spine’s rigidity. However, the authors were not able to determine whether decreased mobility of the hip joint was caused by LBP, or whether LBP was caused by decrement mobility of the hip joint. Therefore, it is necessary to examine the causal relationship between LBP and decreased mobility of the hip joint in the future (Nishimura & Miyachi 2020).
Recommended exercises in clinical practice
Based on the aforementioned studies, additional hip-strengthening exercises may be a part of the prevention and treatment of LBP regardless of the study population. Therefore, the therapists are also encouraged to examine hip joint movement, muscle strength around the hip joint region, and the patient’s ability to stabilise hip joint movement if they experience LBP. Strengthening the muscles that facilitate the movements around the hip joints with elastic bands and weights could be a good addition to the treatment plan, and keeping hip region exercises as a part of the overall LBP treatment. All the treatments of LBP which incorporated any type of hip-strengthening exercises were designed for 5-6 weeks, which indicates that incorporating such exercises for persons with LBP requires a personalised approach, while the frequency of the exercises was diverse and varied. The question remains concerning when such exercises can be beneficial to examine and guide patients when they are experiencing LBP.
The hip joint is connected to our spine, so if one component is damaged, it can cause a domino effect on other regions of the body via compensatory strategies. These compensations can lead to the development and exacerbation of LBP. Therefore, it is important to note that in the prevention, treatment, and post-rehabilitation of LBP, it may be important to focus on the surrounding formations such as hip strength and movement.
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Sadeghisani, M., Manshadi, F. D., Kalantari, K. K., Rahimi, A., Namnik, N., Karimi, M. T., & Oskouei, A. E. 2015. Correlation between hip rotation range-of-motion impairment and low back pain. A literature review. Ortopedia, traumatologia, rehabilitacja. Vol. 17 (5), 455–462. Cited 4 Apr 2023. Available at https://doi.org/10.5604/15093492.1186813
Kati Simon is a physiotherapy student in the Faculty of Health Sciences at the University of Pécs, and is currently studying as an Erasmus exchange student at LAB University of Applied Sciences in Lappeenranta, Finland.
Aki Rintala is working as a principal lecturer in physiotherapy in the Faculty of Social Sciences and Health Care at LAB University of Applied Sciences in Lahti, Finland.
Illustration: https://pxhere.com/en/photo/1629726 (CC0)
Reference to this article
Simon, K. & Rintala, A. 2023. The role of the hip joint in low back pain treatment. LAB Pro. Cited and date of citation. Available at https://www.labopen.fi/lab-pro/the-role-of-the-hip-joint-in-low-back-pain-treatment/