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Yonsei University College of Medicine, Seoul, Korea, Department of Rehabilitation Medicine and Research Institute1, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea, Department of Rehabilitation Medicine2 |
Objective
Spondyloarthritis (SpA) is a group of diseases, characterized by the chronic inflammatory reaction of the axial skeleton or peripheral joint. There are several previous reports that the concomitant bilateral hip joint arthritis deteriorates the quality of life in ankylosing spondylitis (AS) patients. This is the first report of rapid functional enhancement that the range of motion (ROM) of hip joints doubled, which were severely limited within 2 weeks by multimodal therapies.
Methods
1. Patient
A 20-year-old young man visited the Department of Orthopedic Surgery of a tertiary hospital for limitation of ROM and pain (Numeric Rating Scale, NRS 4) in bilateral hip joints, and gait disturbance. He was diagnosed as AS by 5 years of low back pain, grade III sacroiliitis by simple plain images, and positive HLA B27. MRI confirmed synovitis in bilateral hip joints, inflammatory changes in right gluteus minimus, medius, and maximus muscles. Even after 6 months of pharmacologic treatment, the ROM still severely limited to use bilateral crutches, where NRS was 0. On the day of admission to the Department of Rehabilitation Medicine, total ROM of the bilateral hip joints was 140°. Bath Ankylosing Spondylitis Metrology Index (BASMI) score was 2.2 (maximal intermalleolar distance; 7.0 cm). Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score was 7.0.
2. Procedure
First, to resolve the synovitis, ultrasonography-guided intra-articular injection on each hip joint was done with corticosteroid (20 mg) and hyaluronic acid (20 mg). Second, to release the tight gluteal muscles, multimodal therapy was done including 10 sessions of manual therapy (soft tissue technique, articulatory treatment, direct myofascial release), 2 session of electrical twitch obtaining intramuscular stimulation on bilateral gluteus maximus, gluteus medius, quadratus lumborom, and lower lumbar multifidus (L4-S1) muscles, 1 sessions of extracorporeal shock wave therapy on gluteus maximus and medius muscles, ICT, ultrasound, and hot pack were applied on quadratus lumborum, multifidus (L4-S1) muscles (Table 1).
Results
By 10 days of multimodal rehabilitation program, the total ROM of bilateral hip joints was doubled to 280° (Figure 1). BASMI score was 1.8 (maximal intermalleolar distance has increased to 31.0 cm, a 443% improvement) (Figure 2). BASDAI score was improved to 3.2. Finally, he came to be able to walk independently.
Conclusion
In this case, as peri-articular inflammatory process, the shortened and tight hip girdle muscles also caused functional decrement. The management should focus on the muscle relaxation as well as the direct control of intra-articular or inflammation. Even in short period, rapid functional regain is possible by enhancing the ROM of hip joints by multimodal therapy.
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