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 short version

This clinical trial focused on a specific, higher-risk group of older adults with chronic low back pain (LBP): those who also have hip pain and weak hip muscles, a combination the researchers had previously linked to worse pain and disability outcomes over time. Older adults are usually left out of low-back-pain research entirely, so there has been little evidence to guide their care. This trial, called MASH, asked whether physical therapy specifically targeting the hips would work better for this subgroup than standard physical therapy focused on the spine. 184 adults aged 60 to 85 (average age 70) with this hip-and-back pattern were randomly assigned to one of two physical therapy programs, delivered twice a week for eight weeks by trained therapists at three US research sites. One group received hands-on therapy and stretching for the hips plus hip-strengthening and core exercises (hip-focused); the other received hands-on therapy for the lower back plus some of the same core exercises and gentle stationary cycling (spine-focused). Both groups also did home exercises. The two main measures tracked were self-reported back-pain disability (using a standard 0-100 scale) and walking speed, checked at 8 weeks (the main comparison point) and again at 6 months. At 8 weeks, people who got the hip-focused therapy reported meaningfully less disability than those who got spine-focused therapy, though this difference faded by 6 months - not because the hip-focused group got worse, but because the spine-focused group kept catching up. Walking speed improved similarly in both groups the whole time. However, several other measures did favor hip-focused therapy throughout the study: people in that group walked farther in a 6-minute walk test, stood up from a chair more times in 30 seconds by 6 months, and reported less pain and better physical function, mood, and quality of life at 8 weeks. Both treatments were about equally safe, with mostly mild, expected muscle soreness; a small number of more serious health events occurred in each group, but none were linked to the therapy itself. The researchers see this as encouraging evidence that matching physical therapy to a person's specific pattern of hip and back impairments, rather than giving everyone the same generic back-focused program, can produce faster improvement, especially in physical performance. Both approaches were active, hands-on treatments (there was no do-nothing comparison group), participants obviously knew which type of therapy they were receiving, and the 16-session program is a substantial time commitment, so the researchers say more work is needed on cost and on whether a shorter or more flexible version could achieve similar results before this approach could be widely recommended.

Key findings

• In a trial of 184 older adults (average age 70) with chronic low back pain plus weak, painful hips, physical therapy specifically targeting the hips reduced self-reported disability significantly faster than standard spine-focused physical therapy, at the 8-week primary endpoint.
• This disability advantage did not persist at 6 months, not because the hip-focused group got worse, but because the spine-focused group continued to catch up over time.
• Walking speed improved similarly in both groups throughout the study, but the hip-focused group walked farther on a 6-minute walk test and performed better on a chair-stand strength test, both at 8 weeks and 6 months.
• The hip-focused group also reported less pain, better physical function, and better mood at 8 weeks than the spine-focused group.
• Both treatments were about equally safe; a small number of unrelated serious health events occurred in each group, and there was no drug-free or no-treatment comparison group in this trial, so it cannot say how much of either group's improvement reflects the passage of time alone.

Common questions