The NAT Hip Protocol: A Case Study

This case study was designed to test the Stuart Hinds NAT Hip Protocol technique. It was carried out by soft-tissue therapist, Marty Fry (Tasmania).

OBJECTIVE:

To treat using only the ARI (Altered Reciprocal Inhibition) High-Performance Hip Technique Protocol on the dysfunctional hip of a client with a long-term condition.

RESEARCH:

In 2001, 32% (6 million) of the population reported having a disease of the musculoskeletal system and connective tissue as a long-term condition, where the condition lasted, or was expected to last, six months or more.( Musculoskeletal Conditions in Australia: A Snapshot, 2001- Australian Bureau of Statistics)(.1)

In 2003, 6.8% of the whole population had a disability related to diseases of the musculoskeletal system or connective tissue, more than any other medical condition (ABS 2004a).(.2)

Of those persons who reported a physical disability in 2003, 41% reported their main condition as a disease of the musculoskeletal system or connective tissue (ABS 2004a). (.2) 

14 years after these statistics Lower back and Hip pain are still some of Australia’s leading musculoskeletal problems.

The ARI High-Performance Hip Technique was developed by Stuart Hinds. The “treatment concept has been borne out of the principles which are quite akin to those of the Neil Asher Technique applied in case of shoulder dysfunction. He was prompted to try out this after a question on whether it would be possible to apply the NAT shoulder Treatment principles to treat the hip joint problems crossed his mind.”(.3)

The technique follows a 3 Step Treatment Sequence: 1 Hip Extension 2 Hip Abduction 3 Internal Rotation (.3)

PATIENT:

The client is a 67-year-old male of athletic build. He has suffered (L) hip pain for the past year. He keeps active with daily walking up to 5 kms. He has been active all his life playing football, sprint running and has played tennis and been a professional coach for the past 30 plus years. He is a (R) handed tennis player. He has no previous hip related history. He has previously had occasional lower back tightness in line with a person of this age and level of activity

SYMPTOMS:

Hip: (L) anterior /posterior hip tightness. He feels tightness over TFL and GMIN.  He also noted he felt tightness in (L) REC FEM. He has felt his step shortens on that side but has made a focused effort on his gait whilst walking

Back: he can often feel lower back/QL tightness and often feels stuck @ (R) SIJ. He can also feel lower back tightness when awakening of a morning or during a walk.

Glutes: Pain can feel deep on (L) side. He feels stretching piriformis is required

ASSESSMENT:

Orthopedic / Range of Motion Testing:

Initial Assessment @ Treatment 1 (This assessment is performed before every treatment)

STANDING FLEXION = (R) SIJ UPSLIP

FAIR TEST= +ve pain in (L) Piriformis

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) hip reduced 30deg with Thoracolumbar fascia tightness, (L) QL pain and Rec Fem pain

HIP ABDUCTION = (L) @30deg he feels a tightness/stretch

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL ,10 deg ROM

LATERAL FLEXION=  Reduced (L) and (R) with a strong tissue stretch feel

PAIN SCALE= (L) hip discomfort not painful

OBSERVATION: (L) Lower limb external rotation when lying in supine – suggesting piriformis hypertonicity, Mortons foot structure

DIFFERENTIAL DIAGNOSIS:

• Lower crossed syndrome
• Glute weakness
• Osteoarthristis
• Tissue/muscle overload
• Piriformis syndrome
• Sacroiliac joint dysfunction
• General lower back pain
• Femoro-Acetabular Impingement (FAI) syndrome

TREATMENT PLAN:

The treatment plan is to follow the ARI High-Performance Hip technique 3 Step Treatment Sequence: 1 Hip Extension 2 Hip Abduction 3 Internal Rotation

Client will keep a daily symptom diary.

TREATMENT 1

PRE-TREATMENT ASSESSMENT:

STANDING FLEXION = (R) SIJ UPSLIP

SEATED FLEXION =

FAIR TEST= +ve pain in (L) Piriformis

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) hip30deg with Thoracolumbar fascia tightness, (L)QL pain and Rec Fem pain

HIP ABDUCTION = (L) @30deg he feels a tightness/stretch

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL , 10 deg ROM

LATERAL FLEXION=  Reduced (L) and (R) with a strong tissue stretch feel

PAIN SCALE= (L) hip discomfort not painful

TREATMENT: 3-Step Treatment Sequence: 1) Hip Extension, 2) Hip Abduction, 3) Internal Rotation

Correct (R) up-slip

Hip Extension: Release (L) iliopsoas TP @ lesser trochanter and (L) Rec fem TP

(L) Rec fem Myofascial Tension Technique and soft tissue release

Hip Abduction: Release (L)  Adductors passively with hip abducted and knee flexed with the client's foot resting on my hip using soft tissue release and Myofascial Tension Techniques 

Release (L)adductor Longus/Magnus TP

(L)Passive Hip abduction with client contracting Glutes @ end of range x 30

Internal Rotation: Chased the tissue restriction @ TFL released with TP and Myofascial Tension Techniques

Released Thoracolumbar fascia tightness with TP @ T11/12

Released (R)/(L)  QL TPs

Released (L) Piriformis TP

POST-TREATMENT :

Felt reduced muscle tension, he noted some mild soreness at iliopsoas TP at lesser trochanter

Recommend stretching: Psoas, illiacus, Adductors to his comfort level twice daily

TREATMENT 2 (12 days after 1^st treatment)

PRE-TREATMENT:

Felt some back stiffness when getting out of bed for 4 days after treatment but then it reduced to only feeling some mild occasional stiffness. (L) hip felt smooth and had felt ease of movement whilst walking( walking x2 daily AM and PM)

He performed daily stretching: Psoas, illiacus, Adductors to his comfort level twice daily

ASSESSMENT:

STANDING FLEXION = (R) SIJ UPSLIP

SEATED FLEXION =

FAIR TEST= +ve pain in (R)/(L) Piriformis

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) hip 30deg with Thoracolumbar fascia tightness, (L)QL pain and Rec Fem pain

HIP ABDUCTION = (L) @35deg he feels a tightness/stretch

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL , 10 deg ROM

LATERAL FLEXION=  Reduced (L) and (R)with a strong tissue stretch feel

PAIN SCALE= (L) hip discomfort not painful

TREATMENT: 3-Step Treatment Sequence: 1) Hip Extension, 2) Hip Abduction, 3) Internal Rotation

Correct (R) up-slip

Hip Extension: Release (L) iliopsoas TP @ lesser trochanter and (L) Rec fem TP (L) Rec fem Myofascial Tension Technique and soft tissue release

Hip Abduction: Release (L) Adductors passively with hip abducted and knee flexed with the clients foot resting on my hip using soft tissue release and Myofascial Tension Techniques 

Release (L)adductor Longus/Magnus TP

(L)Passive Hip abduction with client contracting Glutes @ end of range x 30

Internal Rotation: Chased the tissue restriction @ TFL released with TP and Myofascial Tension Techniques

Released Thoracolumbar fascia tightness with TP @ T11/12

Released (R)/(L)  QL TPs

Released (L) Piriformis TP

POST-TREATMENT :

Felt reduced muscle tension, he noted some mild soreness at iliopsoas TP at lesser trochanter

Recommend stretching: Psoas, illiacus, Adductors to his comfort level twice daily

TREATMENT 3 (16 days after 2^nd treatment)

PRE TREATMENT:

(L) hip felt smooth and had felt ease of movement whilst walking( walking x2 daily AM and PM). Has some (L) hip stiffness after 4 hour car trip having been seated  in the flexed position. Some mild lower back stiffness

He performed daily stretching: Psoas, illiacus, Adductors to his comfort level twice daily

ASSESSMENT:

STANDING FLEXION = (R) SIJ UPSLIP

SEATED FLEXION =

FAIR TEST= no real noted pain or discomfort

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) hip 30deg with Thoracolumbar fascia tightness, (L)QL pain and Rec Fem pain

HIP ABDUCTION = (L) @35deg he feels a tightness/stretch

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL , 20 deg ROM

LATERAL FLEXION= Reduced (L) and (R) with a tissue stretch end feel

PAIN SCALE= (L) hip discomfort not painful

TREATMENT: 3-Step Treatment Sequence: 1) Hip Extension, 2) Hip Abduction, 3) Internal Rotation

Correct (R) up-slip

Hip Extension: Release (L) iliopsoas TP @ lesser trochanter and (L) Rec fem TP (L) Rec fem Myofascial Tension Technique and soft tissue release

Hip Abduction: Release (L) Adductors passively with hip abducted and knee flexed with the client's foot resting on my hip using soft tissue release and Myofascial Tension Techniques 

Release (L) adductor Longus/Magnus TP

(L) Passive Hip abduction with client contracting Glutes @ end of range x 30

Internal Rotation: Chased the tissue restriction @ TFL released with TP and Myofascial Tension Techniques

Released Thoracolumbar fascia tightness with TP @ T11/12

Released (R)/(L)  QL TPs

Released (L) Piriformis TP

POST-TREATMENT :

Felt reduced muscle tension, he noted some mild soreness at iliopsoas TP at lesser trochanter, He feels reduced tone in (L) REC FEM / TFL

Recommend stretching: Psoas, illiacus, Adductors to his comfort level twice daily

TREATMENT 4 (12 days after 3rd treatment)

PRE-TREATMENT:

(L) hip felt smooth and had felt ease of movement whilst walking( walking x2 daily AM and PM). Has some mild (L) hip stiffness. Some mild lower back stiffness

He performed daily stretching: Psoas, illiacus, Adductors to his comfort level twice daily

ASSESSMENT:

STANDING FLEXION = (R) SIJ UPSLIP

SEATED FLEXION =

FAIR TEST= no real noted pain or discomfort

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) hip 35deg with Thoracolumbar fascia tightness

HIP ABDUCTION = (L) @40deg he feels a tightness/stretch

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL , 25 deg ROM

LATERAL FLEXION=  Reduced (L) and (R)

PAIN SCALE= (L) hip discomfort not painful

TREATMENT: 3-Step Treatment Sequence: 1) Hip Extension, 2) Hip Abduction, 3) Internal Rotation

Correct (R) up-slip

Hip Extension: Release (L) iliopsoas TP @ lesser trochanter and (L) Rec fem TP

(L) Rec fem Myofascial Tension Technique and soft tissue release

Hip Abduction: Release (L) Adductors passively with hip abducted and knee flexed with the client's foot resting on my hip using soft tissue release and Myofascial Tension Techniques 

Release (L) adductor Longus/Magnus TP

(L) Passive Hip abduction with client contracting Glutes @ end of range x 30

Internal Rotation: Chased the tissue restriction @ TFL released with TP and Myofascial Tension Techniques

Released Thoracolumbar fascia tightness with TP @ T11/12

Released (R)/(L)  QL TPs

Released (L) Piriformis TP

POST TREATMENT :

Felt reduced muscle tension, he noted some mild soreness at iliopsoas TP at lesser trochanter, he feels reduced tone in (L) REC FEM

Recommend stretching: Psoas, illiacus, Adductors to his comfort level twice daily

TREATMENT 5 (12 days after 4th treatment)

PRE-TREATMENT: 

(L) hip felt smooth and had felt ease of movement whilst walking( walking x2 daily AM and PM). Has some mild (L) hip stiffness. Some mild lower back stiffness

He performed daily stretching: Psoas, illiacus, Adductors to his comfort level twice daily

ASSESSMENT:

STANDING FLEXION = 

SEATED FLEXION =

FAIR TEST= no real noted pain or discomfort

FABERS TEST= no real noted pain or discomfort

HIP EXTENSION= (L) 35deg with Thoracolumbar fascia tightness

HIP ABDUCTION = (L) @45deg he feels a tissue stretch feel

INTERNAL HIP ROTATION= (L) reduced with tightness felt @ TFL , 35 deg ROM

LATERAL FLEXION=  Normal ROM with a mild tissue stretch end feel

PAIN SCALE= (L) hip discomfort not painful

TREATMENT: 3-Step Treatment Sequence: 1) Hip Extension, 2) Hip Abduction, 3) Internal Rotation

Hip Extension: Release (L) iliopsoas TP @ lesser trochanter and (L) Rec fem TP (L) Rec fem Myofascial Tension Technique and soft tissue release

Hip Abduction: Release (L) Adductors passively with hip abducted and knee flexed with the clients foot resting on my hip using soft tissue release and Myofascial Tension Techniques 

Release (L) adductor Longus/Magnus TP

(L) Passive Hip abduction with client contracting Glutes @ end of range x 30

Internal Rotation: Chased the tissue restriction @ TFL released with TP and Myofascial Tension Techniques

Released Thoracolumbar fascia tightness with TP @ T11/12

Released (R)/(L)  QL TPs

Released (L) Piriformis TP

POST-TREATMENT:

Felt reduced muscle tension, he noted some mild soreness at iliopsoas TP at lesser trochanter

Recommend stretching: Psoas, illiacus, Adductors to his comfort level twice daily

SUMMARY:

Treatments occurred over the period of mid-December 2016 – February 2017 using the treatment plans listed. The client noted increased ROM after the 5 treatments and greater ease of movement. He noted reduced muscle tightness in (L) TFL, GMIN and REC FEM. The discomfort level had reduced and he found that he could walk a greater distance before any onset of symptoms occurred. He also noted that his stride length returned to what he felt as normal. He also noted that discomfort was not felt daily as it previously was prior to the first treatment. After all treatments, some corrective stretching was recommended and he performed them as instructed whilst also maintaining his normal work and exercise.

Table of Changes in ROM and Testing:

 OUTCOME:

Treatments occurred over the period of mid-December 2016 – February 2017 using the treatment plans listed. There was a positive increase in all testing performed after 5 treatments and noted ease and increase of ROM (above table shows results). The client felt that the treatments provided where tolerable and isolated to his condition. He did note some mild post-treatment soreness at the iliopsoas TP at the lesser trochanter but felt it only for around 24 hours post-treatment. He described it as more of an awareness that the area had been treated more so then a pain or discomfort.

The initial tightness he experienced at the first assessment around the (L) TFL/GMIN had subsided after the 5 treatments as had the deep (L) piriformis tightness. He also noted reduced tone in (L) Rec Fem. He only occasionally felt any (R) SIJ discomfort but occasionally had some general Thoracolumbar fascial tightness around T11/T12.

As of June 2017 he has had ongoing maintenance treatments every 2-3 weeks including using some of the ARI High-Performance Hip Technique but by no means having a strong focus on using this as in the first five treatments, as listed in this case study. He has maintained daily stretching.

CONSENT:

Client consent has been given to provide the above information for the purpose of a case study on the ARI (Altered Reciprocal Inhibition) High-Performance Hip Technique Protocol.

KEY

Abbreviations:

(L): Left

(R): Right

ARI: Altered Reciprocal Inhibition

+ve : positive

-ve: negative

TP: Trigger Point

ROM: Range of Motion

Definitions:

Trigger Point: A highly irritable localizes spot of exquisite tenderness in a nodule in a palpable taut band of (skeletal) muscle (.4)

REFERENCES:

(.2) 2003 ABS Survey of Disability, Ageing and Carers, and other ABS and non-ABS sources.
(.1) Musculoskeletal Conditions in Australia: A Snapshot, 2001- Australian Bureau of Statistics)

(.3) High-Performance Hip: Treatment of Altered Reciprocal Inhibition of the HIP – Stuart Hinds

(.4) Drs Janet Travell and David Simons(1992)

Treating Hip Pain & Dysfunction Master Course

About Marty Fry

Dip Remedial Massage, Cert Orthopedic Massage, Cert Advanced Orthopedic Massage, Certified Neil Asher Technique – Level 3

Massage and Myotherapy Australia Member, Sports Medicine Australia Soft Tissue Therapist Member

About Stuart Hinds

Stuart Hinds is one of Australia’s leading soft tissue therapists, with over 27 years of experience as a practitioner, working with elite sports athletes, supporting Olympic teams, educating and mentoring others as well as running a highly successful clinic in Geelong.

Stuart has a strong following of practitioners across Australia and globally who tap into his expertise as a soft-tissue specialist. He delivers a range of highly sought after seminars across Australia, supported by online videos, webinars and one-on-one mentoring to help support his colleagues to build successful businesses.

In 2016, Stuart was awarded a lifetime membership to Massage & Myotherapy Australia for his significant support and contribution to the industry.

 This trigger point therapy blog is intended to be used for information purposes only and is not intended to be used for medical diagnosis or treatment or to substitute for a medical diagnosis and/or treatment rendered or prescribed by a physician or competent healthcare professional. This information is designed as educational material, but should not be taken as a recommendation for treatment of any particular person or patient. Always consult your physician if you think you need treatment or if you feel unwell.