Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

A New Clinical Examination Algorithm to Prescribe Conservative Treatment in People with Hip-Related Pain

Hip-related pain is a common issue in active adults affecting their quality of life, mobility, and overall function, and it can lead to persistent disability. However, diagnosing hip-related pain is challenging due to the many potential sources and causes, including intra-articular and extra-articular pathology, and referred pain from other areas (lumbar or groin related pain). To address this, there is a need for a clinical algorithm based on the best available evidence and expert consensus. This algorithm could guide healthcare professionals in assessing and managing patients with hip-related pain, during the diagnosis, test selection, intervention, monitoring, and promoting collaboration among various healthcare providers. This clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. This literature review aims to establish a clinical algorithm specifically for prescribing exercise treatment to patients with hip-related pain, addressing their individual needs and enhancing their overall care.

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.

Evaluating and Characterizing the Scope of Care for Interventions Labeled as Manual Therapy in Low Back Pain Trials: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to evaluate and characterize the scope of care for low back pain that falls under the specific label of manual therapy.

METHODS

PubMed database, Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and SPORTDiscus were searched from journal inception through May 2022 for randomized controlled trials that investigated the treatment of low back pain using manual therapy. Terminology used to define manual therapy was extracted and categorized by using only the words included in the description of the intervention. An expert consultation phase was undertaken to gather feedback.

RESULTS

One hundred seventy-six trials met final inclusion criteria, and 169 unique terms labeled as manual therapy for the treatment of low back pain were found. The most frequent terms were mobilization (29.0%), manipulation (16.0%), and thrust (6.4%). Eight percent of trials did not define or specify what type of manual therapy was used in the study. After removing duplicates, 169 unique terms emerged within 18 categories.

CONCLUSIONS

Manual therapy intervention labels used in low back pain trials are highly variable. With such variation, the heterogeneity of the intervention in trials is likely large, and the likelihood that different trials are comparing the same interventions is low. Researchers should consider being more judicious with the use of the term manual therapy and provide greater detail in titles, methods, and supplementary appendices in order to improve clarity, clinical applicability, and usefulness of future research.

IMPACT

The ability to interpret and apply findings from manual therapy-related research for low back pain is challenging due to the heterogeneity of interventions under this umbrella term. A clear use of terminology and description of interventions by researchers will allow for improved understanding for the role of manual therapy in managing back pain.

Clinical Presentation Differences Among Four Subtypes of Femoroacetabular Impingement: A Case-Control Study

OBJECTIVE

The aims of this study were to assess the psychological, functional, and physical differences between patients with femoroacetabular impingement (FAI) syndrome and individuals who were asymptomatic (controls) to analyze clinical differences among 4 subtypes of FAI (cam type, cam type with labral tear, pincer type, and pincer type with labral tear), to calculate the correlations among the variables described, and to identify risk factors contributing to the hip function variance.

METHODS

A case-control study was conducted at a hospital rehabilitation unit with a cohort of individuals who were asymptomatic (controls) and a cohort of patients with FAI. Sociodemographic characteristics, pain intensity, psychological health status, hip range of motion (RoM), hip isometric strength, and hip function were assessed.

RESULTS

A total of 69 controls and 69 patients with FAI were analyzed. Although sociodemographic characteristics were comparable between samples, poorer hip RoM, strength, and psychological health were found for the cases. FAI subtypes showed no significant pain intensity, psychological health, or RoM differences (except for hip adduction), but hip strength differed among FAI subtypes. Multiple significant correlations between psychological health, pain intensity, RoM, strength, and hip function were found. The variance values of the International Hip Outcome Tool, Hip Outcome Score (HOS) for daily living activities, and HOS for sports activities were partially explained (47.6%, 36.0%, and 21.6%, respectively) on the basis of kinesiophobia, hip strength, self-efficacy, and anxiety.

CONCLUSION

Patients with FAI showed poorer psychological health, hip RoM, and strength than individuals who were asymptomatic and had similar sociodemographic characteristics. FAI subtype influenced the patients' clinical presentations. Hip strength, kinesiophobia, anxiety, and self-efficacy should be targeted for improving hip function, as they have been demonstrated to be important contributors to hip disability.

IMPACT

This study demonstrated that pain catastrophizing, hip strength, and hip adduction differed among FAI subtypes. However, hip function and pain intensity were comparable between FAI subtypes.

The addition of body weight supported treadmill training to manual therapy and exercise in the management of Hip osteoarthritis: A case series

BACKGROUND AND PURPOSE

Patients with mild-to-moderate hip OA can present with pain, a decline in function, altered gait mechanics, and pain with ambulation. Body weight supported treadmill training (BWSTT) has been utilized for patients with total hip arthroplasty, hip fracture, and lumbar spinal stenosis. The purpose of this case series was to report the outcomes of patients with hip OA that received guideline adherent physical therapy care with the addition of BWSTT. Our aim was to assess changes in pain, disability, and physical performance.

CASE DESCRIPTIONS

Seven patients participated in eight 1-h treatment sessions consisting of: manual therapy, therapeutic exercise, and BWSTT. Pre- and post-treatment outcome measures included: average pain rating via the Numeric Pain Rating Scale (NPRS), Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and the Global Rate of Change (GROC). Physical performance measures included: 6-minute walk test (6MWT), stair climbing test, and 5 time sit-stand.

OUTCOMES

The mean improvement in NPRS score for all subjects was 2.9 points. Mean improvement on the WOMAC was 18.5 + 24.8 pts, and the mean GROC score was +5.0 indicating a rating of "quite a bit better." The mean increase in 6MWT distance was 60.5 + 80.1 meters (median 39 m, range -3 to 230).

CONCLUSIONS

Though patients participating in a multimodal rehabilitation approach including manual therapy, exercise, and BWSTT demonstrated clinically important improvements in pain and function, these changes may not correspond with gait endurance improvements in the short term.

Evaluating Functional Performance Tests in those with Non-arthritic Intra-articular Hip Pain: An International Consensus Statement

Background

Non-arthritic intra-articular hip pain, caused by various pathologies, leads to impairments in range of motion, strength, balance, and neuromuscular control. Although functional performance tests offer valuable insights in evaluating these patients, no clear consensus exists regarding the optimal tests for this patient population.

Purpose

This study aimed to establish expert consensus on the application and selection of functional performance tests in individuals presenting with non-arthritic intra-articular hip pain.

Study Design

A modified Delphi technique was used with fourteen physical therapy experts, all members of the International Society for Hip Arthroscopy (ISHA). The panelists participated in three rounds of questions and related discussions to reach full consensus on the application and selection of functional performance tests.

Results

The panel agreed that functional performance tests should be utilized at initial evaluation, re-evaluations, and discharge, as well as criterion for assessing readiness for returning to sports. Tests should be as part of a multimodal assessment of neuromuscular control, strength, range of motion, and balance, applied in a graded fashion depending on the patient's characteristics. Clinicians should select functional performance tests with objective scoring criteria and prioritize the use of tests with supporting psychometric evidence. A list of recommended functional performance tests with varying intensity levels is provided. Low-intensity functional performance tests encompass controlled speed in a single plane with no impact. Medium-intensity functional performance tests involve controlled speed in multiple planes with low impact. High-intensity functional performance tests include higher speeds in multiple planes with higher impact and agility requirements. Sport-specific movement tests should mimic the patient's particular activity or sport.

Conclusion

This international consensus statement provides recommendations for clinicians regarding selection and utilization of functional performance tests for those with non-arthritic intra-articular hip pain. These recommendations will encourage greater consistency and standardization among clinicians during a physical therapy assessment.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Osteoarthritis of the hip: is radiography still needed?

Diagnosis of hip osteoarthritis (OA) is based on clinical arguments, and medical imaging is obtained to confirm the diagnosis and rule out other possible sources of pain. Conventional radiographs are recommended as the first line imaging modality to investigate chronic hip pain. They should be obtained in a rigorous technique that includes an antero-posterior (AP) radiograph of the pelvis. The choice of the appropriate lateral view depends on the clinical indication, Lequesne's false profile being valuable in the assessment of OA. Magnetic resonance imaging (MRI) is more sensitive to detect joint effusion/synovitis, cartilage, labral, and bone marrow lesions. However, structural joint changes are frequent in asymptomatic population and neither radiographs nor MRI have shown a good correlation with pain and functional impairment. MRI seems to be more suitable than radiographs as a biomarker for clinical trials addressing early OA. The absence of a validated MR biomarker of early OA, together with issues related to machine availability and MRI protocol repeatability, prevent the widespread use of MRI in clinical trials.

Non-operative Treatment Options for Osteoarthritis in the Hip

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

Changes Over Time in the Strain on the Inferior Iliofemoral Ligament During a Sustained 5-Minute High-Force Long-Axis Distraction Mobilization: A Cadaveric Study

OBJECTIVE

To analyze the changes over time in the strain on the inferior iliofemoral (IIF) ligament when a constant high-force long-axis distraction mobilization (LADM) was applied over 5 minutes.

DESIGN

A cross-sectional laboratory cadaveric study.

SETTING

Anatomy laboratory.

PARTICIPANTS

Thirteen hip joints from 9 fresh-frozen cadavers (mean age, 75.6±7.8 years; N=13).

INTERVENTIONS

High-force LADM in open-packed position was sustained for a period of 5 minutes.

MAIN OUTCOME MEASURE(S)

Strain on IFF ligament was measured over time with a microminiature differential variable reluctance transducer. Strain measurements were taken at every 15 seconds for the first 3 minutes and every 30 seconds for the next 2 minutes.

RESULTS

Major changes in strain occurred in the first minute of high-force LADM application. The greatest increase in strain on the IFF ligament occurred at the first 15 seconds (7.3±7.2%). At 30 seconds, the increase in strain was 10.1±9.6%, the half of the total increase at the end of the 5-minute high-force LADM (20.2±8.5%). Significant changes in strain measures were shown to occur at 45 seconds of high-force LADM (F=18.11; P<.001).

CONCLUSIONS

When a 5-minute high-force LADM was applied, the major changes in the strain on IIF ligament occurred in the first minute of the mobilization. A high-force LADM mobilization should be sustained at least 45 seconds to produce a significant change in the strain of capsular-ligament tissue.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Identifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines

INTRODUCTION

Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women.

METHODS

We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care.

RESULTS

We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery.

CONCLUSIONS

This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care.

PATIENT OR PUBLIC CONTRIBUTION

This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.

Quality indicators for osteoarthritis pain management in the primary care setting

BACKGROUND

Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings.

METHODS

Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs.

RESULTS

Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging.

CONCLUSION

This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.

The use of plain radiography in diagnosing osteoarthritis: A systematic review and time trend analysis

INTRODUCTION

The National Institute for Health and Care Excellence (NICE) suggest there is no role for routine radiography in the diagnosis of osteoarthritis (OA). It is not known how consistent this recommendation is across international guidelines, or the impact of UK guidance on domestic OA X-ray request rates.

METHODS

A systematic search identified guideline recommendations on the role of radiography in OA diagnosis. Full texts underwent dual screening and appraisal using the AGREE II tool. A narrative synthesis was performed. Consultation data were extracted from a UK primary care database: the Consultations in Primary Care Archives (CiPCA). The annual proportion of X-ray requests per 100 OA consulters from 2000 to 2012 were calculated. Joinpoint regression analysis examined if there were changes in the trend of X-ray request rates and compared these with the publication dates of UK guidelines.

RESULTS

Eighteen evidence-based OA guidelines were included in the review. Eleven recommended a clinical diagnosis of OA without radiographic confirmation. Seven recommended routine radiography; these guidelines were predominantly for radiologists. A mean of 17.3 X-rays per 100 patients were requested in patients consulting for OA per year between 2000 and 2012. A statistically significant reduction in X-ray request rates was seen in 2003.

CONCLUSION

Recommendations on the role of radiography in OA vary between medical specialty and countries. UK guidelines appear to have had a limited impact on X-ray request rates in OA.

Segmental bioelectrical impedance analysis can detect differences between the affected and non-affected limbs in individuals with hip osteoarthritis

OBJECTIVE

To analyze the bioelectrical impedance parameters of the lower limbs of individuals with hip osteoarthritis and healthy individuals.

DESIGN

Cross-sectional study.

SETTING

The study was carried out at the Hip Surgery Outpatient Clinic.

PARTICIPANTS

The volunteers had to be between 45 and 70 years of age, of both sexes, with a clinical and radiological diagnosis of hip osteoarthritis for at least three years, unilateral involvement, or a significant complaint in one hip.

METHODS

This was a cross-sectional study. Fifty-four individuals were recruited for the study, 31 individuals with hip osteoarthritis (OA group) and 29 healthy individuals for the control group (C group). Demographic and anthropometric data were collected and then the Numerical Pain Rating Scale, WOMAC, Harris Hip Score, and bioimpedance assessment were applied.

MAIN OUTCOME MEASURE(S)

Electrical bioimpedance parameters. Phase angle (PhA), impedance, reactance, and muscle mass.

RESULTS

There was a significant difference in phase angle (PhA), impedance, and muscle mass at 50 kHz frequency on the side affected by OA when compared to the contralateral side. In the OA group, there was a significant decrease in phase angle (PhA) -0.54 (-0.85 to -0.23) and muscle mass - 0.29 (-0.40 to -0,19), as well as an increase in impedance at the 50 kHz frequency on the side affected by OA when compared to contralateral side 21.71 (13.69 to 29.74). In the C group, there was no difference between the dominant and non-dominant sides (P > 0.05).

CONCLUSION

The segmental electrical bioimpedance equipment can detect differences between limbs affected and unaffected by hip osteoarthritis.

Care for the patient with hip pain

ABSTRACT

Hip pain is a common and sometimes disabling condition that affects adults in the primary care setting. The NP must understand the assessment, diagnosis, and treatment options for patients with hip pain. Proper care of these patients often involves conservative medical management and coordination with physical therapy.

Shoes for self-managing chronic hip Pain: the SCHIPP randomized clinical trial protocol

BACKGROUND

Chronic hip pain is common and disabling and is largely due to osteoarthritis (OA). Self-management is recommended by international OA clinical guidelines yet there are few effective treatment options. Footwear has been suggested as a self-management approach, given that foot motion influences hip forces. Currently, guidelines advocate 'stable supportive' shoes for people with OA, however this is based solely on expert opinion given no research has investigated whether these shoes are effective at reducing symptoms in people with OA-related chronic hip pain. Therefore, this randomized controlled trial (RCT) aims to determine if stable supportive footwear reduces hip pain during walking compared to flat flexible footwear in people with chronic hip pain consistent with OA.

METHODS

This trial is a 6-month, participant- and assessor-blinded, pragmatic, comparative effectiveness, superiority RCT conducted in Melbourne, Australia. We are recruiting 120 participants aged over 45 years with chronic hip pain consistent with OA from the community. Following baseline assessment, participants are randomized to receive either i) stable supportive shoes or ii) flat flexible shoes. Participants are permitted to choose two different pairs of shoes in their allocated group from a range of options that match prespecified shoe classification criteria. They are advised to wear either pair of study shoes daily for a minimum of 6 hours each day for 6 months. The primary outcome is the 6-month change in average hip pain on walking in the last week. Secondary outcomes include changes in other measures of hip pain, symptoms, function in daily living and sports and recreation, hip-related quality of life, pain at other sites, adverse events, and physical activity. Other measures include co-intervention use, adherence, shoe comfort, descriptive characteristics, footwear characteristics, and objective foot measures.

DISCUSSION

This RCT will determine whether stable supportive shoes reduce hip pain during walking more than flat flexible shoes in people with chronic hip pain. Outcomes will help to inform footwear recommendations in international clinical guidelines for OA-related chronic hip pain, which to date have been based solely on expert opinion because of an absence of RCTs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry reference: ACTRN12621001532897.

A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy

Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while "passive" therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white "sides," a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active.

Level of Evidence

5.

Psychometric properties of the Italian version of the Forgotten Joint Score in patients with total hip arthroplasty

Total hip arthroplasty (THA) surgeries are increasing; to assess quality of life after THA, an instrument that considers patient's perspective on surgical outcomes is necessary. The objective of this study is to assess the psychometric properties of the Italian version of the Forgotten Joint Score (FJS-I) in patients with THA. The FJS-I was administered to 111 patients with THA, as well as the Western Ontario and McMaster Universities (WOMAC), Numerical Pain Rating Scale (NPRS), and the EuroQol 5D-5L (EQ-5D-5L). Structural validity [confirmatory factor analysis (CFA)], internal consistency (Cronbach's alpha), test-retest reliability [intraclass correlation coefficient (ICC 2,1 )], measurement error [standard error of the measurement (SEM)], and construct validity (hypothesis testing with correlation of the WOMAC, NPRS, and EQ-5D-5L) were assessed. In addition, the minimal detectable change (MDC) was computed. The result of CFA confirmed the one-factor structure. Internal consistency was supported (α = 0.944). A high test-retest reliability (ICC = 0.958; 95% confidence interval, 0.914-0.980) was found with an SEM and an MDC of 5.3 and 16.6 points, respectively. The a-priori hypotheses were fully met, determining the construct validity to be satisfactory. Psychometric properties of the FJS-I were confirmed, and it can be used for single-person assessment. Further research is suggested to refine its structural validity.

The influence of manual therapy dosing on outcomes in patients with hip osteoarthritis: a systematic review

OBJECTIVE

To 1) Determine if specific dosing parameters of manual therapy are related to improved pain, disability, and quality of life outcomes in patients with hip osteoarthritis and 2) to provide recommendations for optimal manual therapy dosing based on our findings.

DESIGN

A systematic review of randomized controlled trials from the PubMed, CINAHL, and OVID databases that used manual therapy interventions to treat hip osteoarthritis was performed. Three reviewers assessed the risk of bias for included studies and extracted relevant outcome data based on predetermined criteria. Baseline and follow-up means and standard deviations for outcome measures were used to calculate effect sizes for within and between-group differences.

RESULTS

Ten studies were included in the final analyses totaling 768 participants, and half were graded as high risk of bias. Trends emerged: 1) large effect sizes were seen using long-axis distraction, mobilization and thrust manipulation, 2) mobilization with movement showed large effects for pain and range of motion, and (3) small effects were associated with graded mobilization. Durations of 10 to 30 minutes per session, and frequency 2-3 times per week for 2-6 weeks were the most common dosing parameters.

CONCLUSIONS

There were varied effect sizes associated with pain, function, and quality of life for both thrust and non-thrust mobilizations, and mobilization with movement into hip flexion and internal rotation. Due to the heterogeneity of MT dosage, it is difficult to recommend a specific manual therapy dosage for those with hip osteoarthritis.

Comparison of dry needling and self-stretching in muscle extensibility, pain, stiffness, and physical function in hip osteoarthritis: A randomized controlled trial

BACKGROUND AND PURPOSE

Patients with hip osteoarthritis (OA) present myofascial trigger points in the hip muscles that may reduce muscle extensibility, provoke pain and stiffness, and decrease physical function. The purpose of the study was to compare the effects of dry needling (DN) intervention with a self-stretching protocol on muscle extensibility, pain, stiffness, and physical function in patients with hip OA.

MATERIALS AND METHODS

A single-blinded randomised controlled trial was designed. Thirty-eight participants with hip OA were randomly assigned to the DN group (n = 19) or the stretching group (n = 19). The DN group received three sessions of DN, and the stretching group followed a 3-week protocol. Hip muscle extensibility was the primary outcome and was measured using the Ely test, the modified Ober test, and the Active Knee Extension test. Pain, stiffness, and physical function were the secondary outcomes measured with the WOMAC questionnaire. The variables were assessed before and after treatment by blinded examiners.

RESULTS

DN was more effective than self-stretching for improving hip flexor and abductor muscles extensibility (p < 0.05). DN and self-stretching techniques improved hip extensor muscles extensibility, pain, stiffness, and physical function in patients with hip OA (<0.05). The DN group showed large effect sizes in all the variables (d > 0.8).

CONCLUSION

Three sessions of DN were more effective than three weeks of self-stretching to improve hip muscle extensibility in patients with hip OA. DN and self-stretching techniques decreased pain and stiffness and improved physical function in patients with hip OA.

Caring for adults with hip pain

This article discusses the pathophysiology, assessment techniques, and management of hip pain in adults and the role of nurses in caring for patients with hip pain.

Effects of Hip Bracing on Gait Biomechanics, Pain and Function in Subjects With Mild to Moderate Hip Osteoarthritis

Hip Osteoarthritis (HOA) is a common joint disease with serious impact on the quality of life of the affected persons. Additionally, persons with HOA often show alterations in gait biomechanics. Developing effective conservative treatment strategies is of paramount importance, as joint replacement is only indicated for end-stage HOA. In contrast to knee osteoarthritis, little is known about the effectiveness of hip bracing for the management of HOA. Studies analysing mechanically unloading hip braces partly showed beneficial results. However, methodological limitations of these studies, such as small sample sizes or lack of control groups, limit the applicability of the results. Additionally, mechanically unloading braces might impose restrictions on motion and comfort and thus, might not be suitable for people with only mild or moderate symptoms. The aim of this study was to comprehensively quantify the effects of unilateral HOA as well as functional hip bracing on gait biomechanics, pain, proprioception and functional capacity in people with mild to moderate HOA. Hip and pelvis biomechanics during walking were analysed in 21 subjects with mild to moderate HOA under three bracing conditions: unbraced, immediately after brace application and after 1 week of brace usage. Additionally, pain, hip proprioception and functional capacity were assessed. A matched group of 21 healthy subjects was included as reference. Kinematic and kinetic data were collected using a 16-camera infrared motion capturing system and two force plates. Visual analogue scales, an angle reproduction test and a 6-min walking test were applied to measure pain, hip proprioception and functional capacity, respectively. Subjects with HOA walked slower, with reduced step length, sagittal hip range of motion and peak extension angle and had a reduced functional capacity. After 1 week of brace application step length, walking speed and functional capacity were significantly increased. Additionally, pain perception was significantly lower in the intervention period. These results encourage the application of functional hip braces in the management of mild to moderate HOA. However, as key parameters of HOA gait such as a reduced peak extension angle remained unchanged, the underlying mechanisms remain partly unclear and have to be considered in the future.

It Would Take Combat Relevance to Put a Chiropractor in Khakis— This Is Why That Has Not Happened

The purpose of this article is to challenge the premise of a recent commentary suggesting that chiropractors should become commissioned officers. An overview of the early practice guidelines and current scientific evidence for the use of spine and peripheral manipulation is provided. The Military Health System is designed to support military operations and currently includes a large contingent of active duty musculoskeletal healthcare experts to include sports medicine–trained family physicians, orthopedic surgeons, physician assistants/associates, doctors of physical therapy/physical therapists, occupational therapists, and podiatrists. The evidence is clear that it is not in the best interest of our military services to commission alternative practitioners whose practices are out of step with the rest of medicine.

Highlighting the Benefits of Rehabilitation Treatments in Hip Osteoarthritis

Background and objectives: Due to its frequency and possible complications, hip arthrosis or hip osteoarthritis (hip OA) has a high social impact, its advanced stages eventually leading to irreversible lesions involving major complications or surgery. In the early stages, conservative treatment plays a key role in the prophylaxis of complications and in slowing down the degenerative process. The association between an appropriate drug therapy (DT) and a rehabilitation treatment (RT)—including individualized physical therapy (PT) and adapted occupational therapy (OT)—provides good results. Our objective was to highlight the benefits of associating RT with DT in patients with hip OA. Materials and Methods: An observational follow-up study was conducted between 2018−2021, which included 100 patients with hip OA divided into two groups: the study group—group A (50 subjects who complied with RT) and the control group—group B (who did not comply with RT). To evaluate them, the evolution of the Lequesne hip index (LHI), Tinetti test (TT) and the hip joint mobility: flexion (FH) and abduction (AH) were monitored before the beginning of the study (T0) and after one-year (T1) for each patient. The mean values of the parameters, the standard deviations, the frequency intervals, as well as the tests of statistical significance were calculated using the Student method (t-test) and χ2, ANOVA (Bonferroni) being used to compare the means. Results: Compared to the evolution of group B, improvements were observed in group A, as follows: in LHI group A (p = 0.023) vs. group B (p = 0.650); in TT group A (p = 0.011) vs. group B (p < 0.001); in FH group A (p = 0.001) vs. group B (p = 0.025); in AH group A (p = 0.001) vs. group B (p < 0.001). BMI changes were non-significant in both groups A (p = 0.223) and B (p = 0.513). Evaluating group A, the most significant improvements of the studied parameters were observed in the age group 41−50 years. Conclusions: The study reveals the benefits of combining RT with DT in patients with especially early-stage hip OA, aged up to 50 years old.

A systematic review of clinical practice guidelines for persons with osteoarthritis. A "Best Evidence for Rehabilitation" (be4rehab) paper to develop the WHO's Package of Interventions for Rehabilitation: A systematic review of Clinical Practice Guidelines for persons with osteoarthritis for the identification of best evidence for rehabilitation

AIM

Identifying existing interventions for rehabilitation and related evidence presents a crucial step in developing the World Health Organization's (WHO) Package of Interventions for Rehabilitation. This paper reports the results of a systematic search that aimed to identify clinical practice guidelines (CPGs) relevant to the rehabilitation of people with osteoarthritis and presents the CPG recommendations and the current state of evidence available for the interventions in the CPGs.

METHODS

This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the WHO's Package of Interventions for Rehabilitation introductory paper by Rauch et al, published in 2019. It is a systematic review of the existing CPGs on osteoarthritis published between 2009 and 2019. Identified CPGs were screened taking into consideration conflict of interest, the provision of information regarding the strength of recommendation(s), and quality to be selected. Quality of CPGs was assessed using the AGREE II tool.

RESULTS

After title and abstract screening, 51 CPGs were identified. Considering the inclusion/exclusion criteria, 26 CPGs were selected. After checking for quality, comprehensiveness, multi-professionality, and publication date, five CPGs were finally included in the review. The strong recommendations for people with knee and hip osteoarthritis consistently included in all the selected CPGs, sometimes called "core treatments", were patient education, exercise training, and weight reduction if overweight or obese. Generally, recommendations overlap in the CPGs.

CONCLUSION

The systematic search revealed high-quality CPGs on osteoarthritis for the identification of "Best Evidence for Rehabilitation (be4rehab)" regarding interventions for rehabilitation of people with osteoarthritis.

Low Risk of Fracture With End-Range Movements of the Hip in People With Low Bone Mineral Density: A Narrative Review

Background: The risks of end-range movements for people with osteoporosis, specifically at the hips and shoulder, are not well understood. Objectives: To synthesize literature on the safety of stretching for people with osteoporosis by searching: 1) biomechanical literature to determine how much force results from an end-range maneuverer and is required to fracture joint components (focusing on the hip joint) and 2) clinical literature to describe techniques used, populations studied, effects, and reported adverse events. Methods: We conducted two separate search strategies in PubMed, EMBASE, and Scopus (1955-2020). Results: 16 articles described either biomechanical or clinical effects of passive and active end ranges of the hip joint. The largest load in the hip, described in the literature was in a crescent lunge during yoga. The moment produced in a crescent lunge is much smaller than that of the tensile strength of osteoporotic bone, suggesting the crescent lunge movement could be considered safe. Clinically, no adverse events were reported in exercise, stretching or yoga interventions. Conclusion: This review found no evidence that end range movements of the hip are unsafe, but there is little evidence. No studies were identified that explored the risk of humeral fracture during end range stretches.

Hip Joint Cartilage Defects in Professional Ballet Dancers: A 5-year Longitudinal Study

OBJECTIVE

A causal link between ballet, hip pain, and pathology has not been established. Change in ballet dancers' hip pain and cartilage defect scores were investigated over 5 years.

DESIGN

Longitudinal.

SETTING

Professional ballet company.

PARTICIPANTS

Twenty-one professional ballet dancers (52% men).

INDEPENDENT VARIABLES

Baseline and follow-up Copenhagen Hip and Groin Outcome Score (HAGOS-pain subscale); incidence of hip-related pain and levels of dance participation collected daily over 5 years; bony morphology measured on baseline 3T magnetic resonance imaging (MRI).

MAIN OUTCOME MEASURE

Change in cartilage defect score on MRI between baseline and 5-year follow-up.

RESULTS

Cartilage scores did not increase in 19 (90%) dancers. There was one new cartilage defect and one progressed in severity. At follow-up, all 6 dancers with cartilage defects were men. Group HAGOS pain scores were high 97.5 (7.5) and not related to cartilage defects (P = 0.12). Five (83%) dancers with baseline cartilage defects reported HAGOS pain scores <100 at follow-up. There were no time-loss hip injuries over 5 years. Two (33%) dancers with cartilage defects recorded hip-related pain (one reported minor training modification). Femoral neck-shaft angles (NSAs) were lower in men with cartilage defects [129.3 degrees (3.4 degrees)] compared with those without cartilage defects [138.4 degrees (4.5 degrees); P = 0.004].

CONCLUSIONS

Elite level ballet did not negatively affect cartilage health over 5 years. Cartilage defects were related to low femoral NSAs. Most cartilage defects did not progress and there was minimal impact on dance participation and pain levels. Longer follow-up is required to determine the long-term sequelae for those with cartilage defects.

LEVEL OF EVIDENCE

1b.

Hip Range of Motion and Strength Predict 12-Month Physical Function Outcomes in Older Adults With Chronic Low Back Pain: The Delaware Spine Studies

Objective

The objective of this study was to investigate whether poor hip range of motion (ROM) and strength predict 12‐month physical function decline among older adults with chronic low back pain (LBP) and whether hip osteoarthritis modifies those relationships.

Methods

At baseline, passive ROM and strength measurements were taken for hip flexion, extension, abduction, adduction, internal rotation, and external rotation; ultrasound images and self‐reported symptoms were used to evaluate hip osteoarthritis presence (eg, osteophytes and hip pain). At baseline and 12 months, performance‐based (repeated chair rise, self‐selected gait speed, 6‐minute walk test [6MWT]) and self‐reported (Quebec LBP Disability Questionnaire, Late‐Life Function & Disability Instrument [LLFDI] basic and advanced lower extremity scales) physical function outcomes were assessed. Regression models were constructed for each outcome predicted by baseline hip ROM and strength measures, with adjustment for potential covariates. To avoid collinearity, hip ROM and strength measures with the strongest unadjusted correlations were included in final models. The hip osteoarthritis presence by hip ROM/strength interaction was also explored.

Results

Hip abduction strength predicted repeated chair rise (β = −0.297, P < 0.001), gait speed (β = 0.160, P = 0.003), 6MWT (β = 0.159, P ≤ 0.001), Quebec LBP Disability Questionnaire (β = −0.152, P = 0.003), and LLFDI basic lower extremity scale (β = 0.171, P = 0.005) outcomes. Regarding hip ROM, extension predicted repeated chair rise (β = −0.110, P = 0.043) and LLFDI advanced lower extremity scale (β = 0.090, P = 0.007) outcomes, external rotation predicted gait speed (β = 0.122, P = 0.004) outcomes, and abduction predicted LLFDI basic lower extremity scale (β = 0.114, P = 0.026) outcomes. The hip osteoarthritis interaction was not significant for any model.

Conclusion

Reduced hip strength and ROM predict physical function decline; hip osteoarthritis presence may not modify these relationships.

The Management between Comorbidities and Pain Level with Physical Activity in Individuals with Hip Osteoarthritis with Surgical Indication: A Cross-Sectional Study

Background and Objectives: The degenerative pathology of the hip joint appears in young age groups, related to fem-oroacetabular impingement, and in advanced age, due to other inflammatory causes, with greater potential for severity in the presence of comorbidities. Objectives: To evaluate the participation of the main causes of osteoarthritis in relation to physical activities, s Body Mass Index (BMI) and television time (TV). Materials and Methods: 54 patients with surgical indication treated at an orthopedic referral university hospital were stratified into groups (Impact: I, Osteonecrosis/rheumatic: II, Infectious/traumatic: III), and the influence of comorbidities on physical activity performance, relative to BMI and TV time. Results: It was observed that the impact group was the most frequent (51.8%), with 79.6% under the age of 60 years. This group followed the general mean (p < 0.05), using the variables of comorbidity and the level of physical activity. Pain intensity, TV time, BMI showed no correlation with physical activity. Conclusion: Morphostructural changes (group I) represented the most frequent etiological group, and severe pain was common in almost the entire sample. Unlike BMI, comorbidity showed a significant relationship with the level of physical activity.

Factors associated with hip pain in end-stage renal disease patients on prevalent hemodialysis: a cross-sectional study

Background

Hemodialysis (HD) patients suffer from musculoskeletal disorders. The most reported musculoskeletal problem is arthralgia. Hip arthralgia has been commonly reported in patients undergoing HD. Hip pain can lead to a decrease in levels of physical activity, limitation in joint range of motion, and consequently difficulties in performing activities of daily living (ADL) and impair the quality of life (QoL). The aim of the study is to reveal the prevalence of hip pain and related factors in HD patients. This cross-sectional study included 73 patients on prevalent HD whose ages ranged from 25 to 65 years and who were on HD for more than 6 months. Physical examination and radiological imaging were done to every patient. Visual analog scale, Barthel Index, and Short Form-36 were used to evaluate pain, ADL, and QoL, respectively.

Results

Hip arthralgia was detected in 32 patients. Around 43% of which were diagnosed hip osteoarthritis, 34% greater trochanteric pain syndrome, 15% femoroacetabular impingement, and 6% soft tissue calcifications. Diabetes mellitus and hemodialysis duration were found to be significantly different between the groups of hip pain and without hip pain. Diabetes mellitus was identified as an independent risk factor for hip pain in hemodialysis patients. ADL and QoL were significantly lower in patients with hip pain compared to those without (p < 0.01; p < 0.05, respectively).

Conclusions

The results of our research show that HD patients should be screened for the presence of hip pain and other musculoskeletal disorders and that this is an area which requires further consideration and medical research.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.

Effectiveness of Dry Needling Therapy on Pain, Hip Muscle Strength, and Physical Function in Patients With Hip Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To investigate the short-term effects of dry needling (DN) on physical function, pain, and hip muscle strength in patients with hip osteoarthritis (OA).

DESIGN

A double-blind, placebo-control, randomized controlled trial.

SETTING

Private practice physiotherapy clinic.

PARTICIPANTS

Patients with unilateral hip OA (N=45) were randomly allocated to a DN group, sham DN group, or control group.

INTERVENTIONS

Patients in the DN and sham groups received 3 treatment sessions. Three active myofascial trigger points (MTrPs) were treated in each session with DN or a sham needle procedure. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae, and gluteus minimus muscles.

MAIN OUTCOME MEASURES

Physical function was assessed with the Western Ontario and McMaster Universities (WOMAC) physical function subscale, the timed Up and Go test, and the 40-meter self-paced walk test. Intensity of hip pain related to physical function was evaluated using the visual analog scale and WOMAC pain subscale. The maximal isometric force of hip muscles was recorded with a handheld dynamometer.

RESULTS

Significant group by time interactions were shown for physical function, pain, and hip muscle force variables. Post hoc tests revealed a significant reduction in hip pain and significant improvements in physical function and hip muscle strength in the DN group compared with the sham and control groups. The DN group showed within- and between-groups large effect sizes (d>0.8).

CONCLUSIONS

DN therapy in active MTrPs of the hip muscles reduced pain and improved hip muscle strength and physical function in patients with hip OA. DN in active MTrPs of the hip muscles should be considered for the management of hip OA.

Prolotherapy agent P2G is associated with upregulation of fibroblast growth factor-2 genetic expression in vitro

Purpose

Osteoarthritis (OA) is a prevalent, progressively degenerative disease. Researchers have rigorously documented clinical improvement in participants receiving prolotherapy for OA. The mechanism of action is unknown; therefore, basic science studies are required. One hypothesized mechanism is that prolotherapy stimulates tissue proliferation, including that of cartilage. Accordingly, this in vitro study examines whether the prolotherapy agent phenol-glycerin-glucose (P2G) is associated with upregulation of proliferation-enhancing cytokines, primarily fibroblast growth factor-2 (FGF-2).

Methods

Murine MC3T3-E1 cells were cultured in a nonconfluent state to retain an undifferentiated osteochondroprogenic status. A limitation of MC3T3-E1 cells is that they do not fully reproduce primary human chondrocyte phenotypes; however, they are useful for modeling cartilage regeneration in vitro due to their greater phenotypic stability than primary cells. Two experiments were conducted: one in duplicate and one in triplicate. Treatment consisted of phenol-glycerin-glucose (P2G, final concentration of 1.5%). The results were assessed by quantitative Reverse Transcriptase-Polymerase Chain Reaction (qRT-PCR) to detect mRNA expression of the FGF-2, IGF-1, CCND-1 (Cyclin-D), TGF-β1, AKT, STAT1, and BMP2 genes.

Results

P2G - treated preosteoblasts expressed higher levels of FGF-2 than water controls (hour 24, p < 0.001; hour 30, p < 0.05; hour 38, p < 0.01). Additionally, CCND-1 upregulation was observed (p < 0.05), possibly as a cellular response to FGF-2 upregulation.

Conclusions

The prolotherapy agent P2G appears to be associated with upregulation of the cartilage cell proliferation enhancer cytokine FGF-2, suggesting an independent effect of P2G consistent with clinical evidence. Further study investigating the effect of prolotherapy agents on cellular proliferation and cartilage regeneration is warranted.

Sex-specific Differences in Multisite Pain Presentation among Adults with Lower-Limb Loss

OBJECTIVES

Multisite pain remains significantly understudied following lower-limb loss (LLL), especially among females. This study aimed to explore sex-specific differences in the presentation of multisite pain post LLL. Hypotheses were multisite pain would be more prevalent among females post LLL as compared with males, and female sex would be significantly associated with multisite pain prevalence.

METHODS

In this cross-sectional study, participants answered standardized questions regarding the presence of amputation-specific (ie, phantom-limb, residual-limb) and secondary (ie, contralateral-limb, low-back) pain. Multisite pain was defined as pain in ≥ 2 locations. Sex-specific differences in pain prevalence were evaluated using chi-square tests (P ≤ 0.050). Using logistic regression, the association between sex and multisite pain was examined after controlling for covariates (age, body mass index, time since amputation, amputation etiology and level).

RESULTS

The sample included 303 adults (33% females) ≥ 1 year post unilateral LLL. More females than males reported pain in the residual limb (53.0% vs. 38.4%), low back (56.0% vs. 39.9%), contralateral knee (37.0% vs. 24.1%), and contralateral hip (25.0% vs. 12.3%; P < 0.050). More females than males were classified as having multisite pain (72.0% vs. 54.7%; P = 0.004). While patterns of multisite pain were similar (ie, pain affected both amputation-specific and secondary sites) between sexes, being female was independently associated with higher odds of having multisite pain (odds ratio: 2.40, 95% confidence interval: 1.40 to 4.12).

DISCUSSION

Female sex appears to be associated with multisite pain ≥ 1 year after LLL. Future work is needed to identify mechanisms underlying sex-specific differences in pain presentation and evaluate the impact of sex on pain-related outcomes post amputation.

Effects of foam rolling on hip pain in patients with hip osteoarthritis: a retrospective propensity-matched cohort study

BACKGROUND

Foam rolling is a self-applied massage using a foam roller that has gained popularity for treatment of muscle soreness. However, its efficacy for improving hip pain in patients with hip osteoarthritis remains unclear.

OBJECTIVE

To investigate the effects of foam rolling on hip pain in patients with hip osteoarthritis.

METHODS

In this retrospective propensity-matched cohort study, medical records of outpatients between January 2017 and March 2019 were reviewed. Of these, 115 patients with hip osteoarthritis were divided into foam rolling or non-foam rolling groups based on home exercises. Both groups were propensity-score matched (1:1) for age, sex, body mass index, Kellgren and Lawrence grade, and visual analog scale (VAS) of hip pain at baseline. The primary outcome was the hip pain-VAS. Effects of interventions on the hip pain-VAS were examined using a split-plot design variance analysis.

RESULTS

After matching, both groups comprised 37 patients each. No significant differences were observed in baseline characteristics and outcome measurements between the matched groups. A statistically significant interaction was seen between the effects of time and group for hip pain-VAS (F [1, 72] = 31.874, interaction: P < .001, η² = 0.307). Hip pain-VAS was improved more effectively in the foam rolling group than those in the non-foam rolling group (P < .001). Thirty-four (92%) patients in the foam rolling group, compared to 15 (41%) in the non-foam rolling group, showed a ≥ 32% (minimal clinically important difference) improvement in hip pain-VAS.

CONCLUSION

These results suggested that foam rolling was an effective intervention for improving hip pain in patients with hip osteoarthritis.

Methodological Quality of Physical Therapy Guidelines and Their Suitability for Adaptation: A Scoping Review

OBJECTIVE

Clinical practice guidelines (CPGs) can be characterized to the extent that they specifically address physical therapists and mainly contain recommendations for physical therapist interventions. The primary aim of this study was to identify existing physical therapy CPGs regardless of medical condition, with a secondary aim of assessing their methodological quality to determine whether they are potentially suitable for adaptation.

METHODS

Systematic searches of the Medline and Physiotherapy Evidence Database were performed (August 2019), and the websites of World Confederation for Physical Therapy members were screened (September 2019). Only CPGs published in German or English were included. Two independent reviewers screened records according to previously defined inclusion criteria. Information was extracted regarding country of origin, year of publication, and clinical subject area addressed. Four independent reviewers assessed the quality of physical therapy CPGs using the Appraisal of Guidelines Research and Evaluation instrument. A descriptive data analysis was performed.

RESULTS

Thirty-five CPGs met the inclusion criteria; 46% (16/35) of the included CPGs were from the United States, and 31% (11/35) were from the Netherlands. Assessment using the Appraisal of Guidelines Research and Evaluation tool resulted in the following domain scores, presented as median percentage (interquartile range): domain 1 (scope and purpose), 76 (63-92); domain 2 (stakeholder involvement), 63 (55-76); domain 3 (rigor of development), 67 (53-75); domain 4 (clarity of presentation), 74 (67-77); domain 5 (applicability), 44 (30-57); and domain 6 (editorial independence), 52 (35-66).

CONCLUSIONS

In general, the methodological quality of the included CPGs was moderate to good. Possibilities of adapting recommendations from existing CPGs should be considered with the development of new physical therapy CPGs.

IMPACT STATEMENT

This study can raise awareness of existing physical therapy CPGs and can support their application by physical therapists. Further, the study can support decisions on adapting existing CPGs with the planning of new physical therapy CPGs.

The effect of high, medium and low mobilization forces applied during a hip long-axis distraction mobilization on the strain on the inferior ilio-femoral ligament and psoas muscle: A cadaveric study

BACKGROUND

Several studies have suggested that the changes in elasticity of the joint capsule and surrounding muscles during a hip long-axis distraction mobilization (LADM) could explain the pain-relieving and mobility-improving effects of the technique.

OBJECTIVE

To compare the strain on the inferior ilio-femoral ligament and psoas muscle when applying three different magnitudes of force during LADM.

DESIGN

Repeated measures controlled laboratory cadaveric study.

METHODS

Eleven hip joints were mobilized from six fresh-frozen cadavers (mean age, 73.4 ± 5.7 years). Three magnitudes of force (low, medium and high) were applied during a hip LADM in open-packed position according to grades of joint mobilization. Strain on the inferior ilio-femoral ligament and psoas muscle were measured with strain gauges. The magnitude of the force applied during LADM was recorded.

RESULTS

Strain on the inferior ilio-femoral ligament during a high-force LADM was significantly higher than strain on the inferior ilio-femoral ligament during low (p < 0.001) and medium-force LADM (p < 0.001). The strain on the inferior ilio-femoral ligament during a medium-force LADM was significantly higher than during a low-force LADM (p = 0.004). No changes in strain on psoas muscle were observed. The magnitude of force applied during LADM showed a significant progressive increase from low to high-force LADM.

CONCLUSION

The different magnitudes of forces applied during LADM produce different strains on the inferior ilio-femoral ligament but not on the psoas muscle. The strain on the inferior ilio-femoral ligament during LADM depends on the magnitude of the mobilization force.

Rheumatoid arthritis and osteoarthritis clinical practice guidelines provide few complementary and alternative medicine therapy recommendations: a systematic review

Sixty percent of patients with arthritis have used complementary and alternative medicine (CAM) therapies at least once. The two most common types of arthritis include rheumatoid arthritis (RA) and osteoarthritis (OA). The quality and quantity of CAM recommendations for RA and OA is currently unknown. The purpose of this research was to identify the quantity and assess the quality of CAM recommendations in clinical practice guidelines (CPGs) for the treatment and/or management of RA and OA. A systematic review was conducted to identify CPGs; MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched. Three independent reviewers evaluated the quality of reporting for each guideline that provided CAM recommendations, and the specific section providing CAM recommendations, using the AGREE II instrument. From 525 unique search results, seven guidelines (3 OA, 4 RA) mentioned CAM and 5 guidelines made CAM recommendations. Scaled domain percentages from highest to lowest were (overall, CAM) as follows: clarity of presentation (92.2% vs. 94.1%), scope and purpose (90.1% vs. 87.4%), rigour of development (72.6% vs. 64.2%), stakeholder involvement (64.8% vs. 49.6%), editorial independence (61.1% vs. 60.6%), and applicability (51.4% vs. 33.3%). None of the 5 guidelines was recommended by both appraisers for either the overall guideline or CAM section. For the overall guideline, appraisers agreed in their overall recommendation for 3 of 5 guidelines, including 3 Yes with modifications; of the remaining 2 guidelines, 1 was rated by the three appraisers as 1 No and 2 Yes with modifications, while 1 guideline was rated at 2 Yes and 1 Yes with modifications. For the CAM section, appraisers agreed in their overall recommendation for all 5 guidelines including 1 No, and 4 Yes with modifications. Roughly half of arthritis CPGs found included in this review provided CAM recommendations. The quality of CAM recommendations are of lower quality than overall recommendations across the scope and purpose, stakeholder involvement, rigour of development, applicability, and editorial independence domains. Quality varied within and across guidelines.

Exercise and Osteoarthritis

Osteoarthritis (OA) is a degenerative disease of the articular cartilage with subchondral bone lesions. Osteoarthritis etiologies are mainly related to age, obesity, strain, trauma, joint congenital anomalies, joint deformities, and other factors. Osteoarthritis seriously affects the quality of life; however, there is no effective way to cure osteoarthritis. Aerobic exercise refers to a dynamic rhythmic exercise involving the large muscle groups of the body with aerobic metabolism. More and more evidence shows that exercise has become a useful tool for the treatment of osteoarthritis. This chapter will discuss the role of exercise in the prevention and treatment of osteoarthritis.

Do Geographic Region, Medicaid Status, and Academic Affiliation Affect Access to Care Among Medicaid and Privately Insured Total Hip Arthroplasty Patients?

BACKGROUND

Medicaid provides health coverage to those beneath the federal poverty line. The literature shows that patients with Medicaid experience barriers to scheduling initial and follow-up visits, although this has not been studied in patients undergoing total hip arthroplasty (THA). The purpose of this study is to assess whether insurance type, geographic location, Medicaid expansion, or academic affiliation affect access to evaluation for THA.

METHODS

The American Academy of Orthopedic Surgeons directory was used to call a total of 100 practices. Five random private and 5 random academic medical facilities were called from each of 5 Medicaid-expanded and 5 non-expanded states representing different US geographic regions. Calls were made by an investigator requesting the earliest available appointment for their fictitious parent to be evaluated for a THA. Half of the calls were made with the investigator reporting private insurance of Blue Cross Blue Shield (BCBS), and half reporting Medicaid. Appointment success rate and average time to appointment were compared. Further comparisons were drawn among Medicaid-expanded vs non-expanded states, geographic regions, and private vs academic affiliation.

RESULTS

Appointments were successful for 99 of 100 (99%) calls made with BCBS, and 72 of 100 (72%) with Medicaid (P < .001). Success rates were significantly higher for BCBS, regardless of academic vs private affiliation. In all geographic regions, appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ .01). Average time to appointment was also significantly longer for Medicaid (26 days) than private (13 days) insurance (P = .020). In the Medicaid group, appointment success rate was significantly greater for academically affiliated practices compared to private practices (84.0% vs 60.0%, respectively; P = .008).

CONCLUSION

Patients with Medicaid seeking consultation for THA experience limits in access to evaluation for THA when compared to patients with private insurance, regardless of geographic region or affiliation of the practice.

Developing core education principles for rehabilitation professionals in response to the opioid crisis: an example from physical therapy education

PURPOSE

We describe how educators in one state developed a set of core principles for the education of Doctor of Physical Therapy students in response to the opioid crisis, and we present these principles as a model for educators globally.

METHODS

In Massachusetts, a working group from the physical therapy program directors developed a model for opioid education based on a review of the literature, of curricula and of the accreditation standards.

RESULTS

The "Core Principles for the Education of Physical Therapy Professionals in the Context of the U.S. Opioid Emergency" provide a model that recognizes the profession's role in care and prevention; a role that engages the profession with patients who have painful conditions and are at risk for substance and/or opioid misuse, patients who have painful conditions and opioid use disorder, and patients who have opioid use disorder as a primary diagnosis. The principles ensure that graduates have the skills and knowledge to provide care that minimizes the social stigma and biases that individuals with opioid use disorder may face.

DISCUSSION

The Core Principles provide a roadmap for educational programs. Health professions educators can assume a role of leadership in the opioid crisis and ensure that students and clinical instructors are prepared for care provision and advocacy.IMPLICATIONS FOR REHABILITATIONIn light of the opioid crisis, students in the rehabilitation professions should have education targeted specifically to opioid use and opioid use disorder that incorporates pharmacology, pain science, behavioral and socio-political perspectives.The Core Education Principles document posits that physical therapy education around opioid use should focus on three patient populations, people who have painful conditions and are at risk for substance and/or opioid misuse, people who have painful conditions and opioid use disorder, and people who have opioid use disorder as a primary diagnosis.Within each of the patient populations there are curricular implications in terms of teaching about screening and prevention, movement system interventions, and interprofessional care activities.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

[Prescription frequency of physical therapy and analgesics before total hip and knee arthroplasy : An epidemiological analysis of routine health care data from Germany]

BACKGROUND

Osteoarthritis of the hip or knee joint is a widespread disease with a strong influence on the quality of life. At present, the extent of conservative treatment with physical therapies and analgesics before the use of a total joint arthroplasty (TJA) of the hip or knee is largely unclear in Germany.

OBJECTIVES

The aim was to analyze the prescription frequency according to regional and socio-demographic factors.

MATERIALS AND METHODS

Based on routine health care data from BARMER insurance, patients who received a TJA of the hip or knee from 2011 to 2013 were analyzed. Included were consistently insured patients with the main discharge diagnosis of osteoarthritis who did not receive any further TJA for eight quarters before and after replacement. The prescription frequency of physical therapies and analgesics, stratified according to age groups, gender, number of comorbidities and federal state was analyzed.

RESULTS

40,242 persons with hip TJA and 35,652 persons with knee TJA were included. In the year prior to surgery, 49.4% of patients (hip TJA: 49.9%; knee TJA: 48.9%) received at least one physical therapy and 81.0% were prescribed analgesics. Regionally, the prescription frequency of physical therapies for hip TJA varied between 35.7% (Bremen) and 70.6% (Saxony) and for knee TJA between 37.6% (Saarland) and 66.9% (Saxony).

CONCLUSION

The prescription frequency of physical therapy does not fully correspond to current treatment recommendations. The prescription of physical therapies in the year before the TEP shows regional differences, with fundamentally lower prescription frequencies in the former states of West Germany.