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9/2/16 Disclosures Hip Rehabilitation for Men and Women: Strategic Treatment Recommendations • • No personal disclosures/conflicts No institutional disclosures/conflicts ISHA 2016 – Advanced Hip Rehabilitation Symposium Keelan R. Enseki, MS,PT,OCS,SCS,ATC,CSCS Hip Rehabilitation Strategies for Men and Women Hip Rehabilitation Strategies for Men and Women • Majority of research pertains to hip kinematics and recruitment as it pertains to sex-differences for rehabilitation in the knee injury population • Minimal data available for sex-differences specific to the pathological hip population • Trends that have been observed in the non-arthritic hip pain population (Harris-Hayes et al., 2014) have not been well-delineated between males and females • Concern for conditions that have higher incidence in one sex • Factors to consider o Anatomical variation • Bony o Pelvis o Femur • Pelvic musculature o Kinematic differences o Muscle recruitment differences o Pelvic floor conditions • Male/Female o Urinary & bowel o Sexual dysfunction • Postpartum o Dysplasia (F>M) o Pelvic floor dysfunction (different underlying causes in women vs. men) o Birth related/post-partum Kinematic Differences Anatomical Variations • Adult pelvic structure variation to accommodate delivery for females o Relatively wider o Structurally more round • Morphological differences(Köhnlein W et al., 2009; Nakahara et al., 2011) o Acetabular surface area • Women < Men o Acetabular anteversion • Women > Men o Femoral anteversion • Women > Men o Q Angle • Women > Men • Rehabilitation implications • Although anatomical trends have been described, the observed differences currently have minimal impact on specific rehabilitation considerations when considered in isolation • Overall, female athletes moved into greater hip internal rotation and used less sagittal plane hip motion during the early deceleration phase of a cutting maneuver (Pollard et al., 2007) • Women had larger peak extension angles across numerous single leg exercises and smaller peak hip flexion angles with single leg squat tasks (Dwyer et al., 2010) • Rehabilitation implications o Males and females appear to have different hip kinematics with various exercise tasks o The utility of available information is limited due to testing of uninjured subjects and/or original intention to apply majority of data to knee population o Expansion of testing to subjects with hip injuries is necessary 1 9/2/16 Strength and EMG Data • Mean root-mean-square amplitudes for gluteus maximus and rectus femoris muscles in both the concentric and eccentric phases of 3 exercises were greater for women than for men (Dwyer et al., 2010) • “Trunk and hip electromyographic activity during single leg squat exercises do sex differences exist?”(Bolgla et al., IJSPT, 2014) o Females generated moderate (39% greater MVIC vs. males) EMG activity (neuromuscular education/ endurance) o Males generated low EMG activity (likely no therapeutic effect) • Rehabilitation implications o Healthy females and males appear to recruit differently o Injured population? o External resistance may be necessary for progressive gluteus medius strengthening, particularly in males Pelvic Floor Concerns • Male or females o Female cases better and more frequently described in the literature • Unique conditions/events o o o o o Pregnancy/delivery Urinary & bowel issues Sexual dysfunction Organ prolapse Hypertonicity • Pelvic floor rehabilitation specialists • Rehabilitation implications o Concurrent or primary pelvic floor rehabilitation can play an important role in treating individuals with hip pain o Screening is integral • Internal examination? Summary of Rehabilitation Recommendations Interaction of Hip Strength and Joint Kinematics • Men demonstrated greater hip abductor peak torque when landing from a jump (Jacobs et al., 2007) • Correlations between hip abductor strength and landing kinematics were generally larger for women than for men (Jacobs et al. 2007) • Rehabilitation implications o Consider the potential effect of decreased hip abductor strength on single leg landing tasks o Consider strength testing as part of advancement criteria Postpartum Considerations • Points of Consideration o Hormonal changes • Increased joint laxity • Breastfeeding may extend this period of induced mobility o Anthropometric changes that occurred during and after pregnancy o Deconditioning o Compromise of lumbopelvic muscle integrity through delivery or c-section • Clinical Recommendations o o o o o Focus on proximal strength Lumbopelvic/core stabilization Neuromuscular re-education General endurance Pelvic floor specialty consultation if indicated • Rehabilitation implications o The presence of joint pathology (labral,capsular,etc.) and physiological/ structural changes associated with childbirth create a unique rehabilitation challenge o Integrated treatment approach should be considered Thank You • The general approach to strengthening and other rehabilitation activities (volume, frequency, etc.) should not be prescribed differently based upon sex • Specific recommendations (exercise selection) may be made based upon limited movement and recruitment data • Kinematic data may indicate sex-specific usefulness of specific exercises o Consider incorporating single-leg squat, lunge, and step-up-and-over exercises in rehabilitation program to enhance pelvic control o Hip abductor strength is important for men and women; however, deficits may result in more significant kinematic differences for females • Other associated factors may be considered: specific pathology/conditions, pre-injury physical status, patientgoals, etc. • Further study and clarification required 2 9/2/16 • • • • • • • • Bolgla L, Cook N, Hogarth K, Scott J, West C. Trunk and hip electromyographic activity during single leg squat exercises do sex differences exist? Int J Sports Phys Ther. 2014 Nov;9(6):756-764. Dwyer MK, Boudreau SN, Mattacola CG, Uhl TL, Lattermann C. Comparison of Lower Extremity Kinematics and Hip Muscle Activation During Rehabilitation Tasks Between Sexes. Journal of Athletic Training. 2010;45(2):181-190. Harris-Hayes M, Mueller MJ, Sahrmann SA, et al. Persons with Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength. The Journal of Orthopaedic and Sports Physical Therapy. 2014;44(11):890-898. Howard JS, Fazio MA, Mattacola CG, Uhl TL, Jacobs CA. Structure, Sex, and Strength and Knee and Hip Kinematics During Landing. Journal of Athletic Training. 2011;46(4):376-385. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip Abductor Function and Lower Extremity Landing Kinematics: Sex Differences. Journal of Athletic Training. 2007;42(1):76-83. Köhnlein W, Ganz R, Impellizzeri FM, Leunig M. Acetabular Morphology: Implications for Joint-preserving Surgery. Clinical Orthopaedics and Related Research. 2009;467(3):682-691. Nakahara I, Takao M, Sakai T, Nishii T, Yoshikawa H, Sugano N. Gender differences in 3D morphology and bony impingement of human hips. J Orthop Res. 2011 Mar; 29(3):333-339. Pollard CD, Sigward SM, Powers CM. Gender differences in hip joint kinematics and kinetics during side-step cutting maneuver. Clin J Sport Med. 2007 Jan;17(1):38-42. 3