Joanne L Kemp

Patient-Reported Outcome (PRO) questionnaires for young-aged to middle-aged adults with hip and groin disability: a systematic review of the clinimetric evidence

Background/aim To recommend Patient-Reported Outcome (PRO) questionnaires to measure hip and groin disability in young-aged to middle-aged adults. Methods A systematic review was performed in June 2014. The methodological quality of the studies included was determined using the COnsensus-based Standards for the selection of health Measurement INstruments list (COSMIN) together with standardised evaluations of measurement properties of each PRO. Results Twenty studies were included. Nine different questionnaires for patients with hip disability, and one for hip and groin disability, were identified. Hip And Groin Outcome Score (HAGOS), Hip Outcome Score (HOS), International Hip Outcome Tool-12 (IHOT-12) and IHOT-33 were the most thoroughly investigated PROs and studies including these PROs reported key aspects of the COSMIN checklist. HAGOS and IHOT-12 were based on studies with the least ratings of poor study methodology (23% and 31%, respectively), whereas IHOT-33 and HOS had a somewhat larger distribution (46%). These PROs all contain adequate measurement qualities for content validity (except HOS), test–retest reliability, construct validity, responsiveness and interpretability. No information or poor quality rating on methodological aspects made it impossible to fully evaluate the remaining PROs at present. Conclusions HAGOS, HOS, IHOT-12 and IHOT-33 can be recommended for assessment of young-aged to middle-aged adults with pain related to the hip joint, undergoing non-surgical treatment or hip arthroscopy. At present, HAGOS is the only PRO also aimed for young-aged to middle-aged adults presenting with groin pain and is recommended for use in this population. Trial registration number CRD42014009995.

Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence

Background Femoroacetabular impingement (FAI) and associated pathologies are associated with pain and reduced quality of life. Physical impairments can be associated with worse symptoms and may be an important target of rehabilitation programmes in this patient group. Knowledge regarding physical impairments in people with symptomatic FAI is limited. Hypothesis In adults aged 18–50 years with symptomatic FAI: (1) to identify physical impairments in range of motion (ROM), hip muscle function and functional tasks; (2) to compare physical impairments with healthy controls; and (3) to evaluate the effects of interventions targeting physical impairments. Study design Systematic review. Methods A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The modified Downs and Black checklist was used for quality appraisal. Studies of adults aged 18–50 years with symptomatic FAI that examined ROM, hip muscle function and functional tasks were included. Standardised mean differences were calculated where possible or best evidence synthesis and study conclusions were presented. Results Twenty-two studies fulfilled all inclusion criteria. Methodological quality was varied. Results for hip joint ROM differences between people with symptomatic FAI compared and control subjects were varied. People with symptomatic FAI demonstrated some deficits in hip muscle strength and reduced balance on one leg when compared with control subjects. For hip joint ROM and hip muscle strength results for within-group differences between preintervention and postintervention time points were limited and inconclusive. No randomised controlled trials evaluated the effect of different types of interventions for symptomatic patients with symptomatic FAI. Conclusions People with symptomatic FAI demonstrate impairments in some hip muscle strength and single leg balance. This information may assist therapists in providing targeted rehabilitation programmes for people with FAI and associated pathology. Further research is needed to determine whether symptomatic FAI affects other aspects of functional performance; and to evaluate whether targeted interventions are effective in symptomatic FAI. Clinical relevance This information may assist therapists in providing targeted rehabilitation programmes for people with symptomatic FAI.

Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis

Aim To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). Methods A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0–3 months=short term; 4–12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. Results 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD −0.53, 95% CI −0.96 to −0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD −0.49, 95% CI −0.70 to −0.29). There were no medium (SMD −0.23, 95% CI −0.48 to 0.03) or long (SMD −0.22, 95% CI −0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD −0.38, 95% CI −0.88 to 0.13) when compared to minimal control. Conclusions Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary prevention of osteoarthritis by joint injury prevention in sport and recreation.

The risk of post-traumatic osteoarthritis (PTOA) substantially increases following joint injury. Research efforts should focus on investigating the efficacy of preventative strategies in high quality randomized controlled trials (RCT). The objective of these OARSI RCT recommendations is to inform the design, conduct and analytical approaches to RCTs evaluating the preventative effect of joint injury prevention strategies. Recommendations regarding the design, conduct, and reporting of RCTs evaluating injury prevention interventions were established based on the consensus of nine researchers internationally with expertise in epidemiology, injury prevention and/or osteoarthritis (OA). Input and resultant consensus was established through teleconference, face to face and email correspondence over a 1 year period. Recommendations for injury prevention RCTs include context specific considerations regarding the research question, research design, study participants, randomization, baseline characteristics, intervention, outcome measurement, analysis, implementation, cost evaluation, reporting and future considerations including the impact on development of PTOA. Methodological recommendations for injury prevention RCTs are critical to informing evidence-based practice and policy decisions in health care, public health and the community. Recommendations regarding the interpretation and conduct of injury prevention RCTs will inform the highest level of evidence in the field. These recommendations will facilitate between study comparisons to inform best practice in injury prevention that will have the greatest public health impact.

Hip and Knee Osteoarthritis Affects Younger People, Too

Synopsis Although osteoarthritis (OA) has traditionally been considered a disease of older age, hip and knee OA can and does affect younger adults, with a profound impact on psychosocial well-being and work capacity. Obesity and a history of traumatic knee injury (eg, anterior cruciate ligament rupture and/or meniscal tear) are key risk factors for the accelerated development of knee OA, while structural hip deformities (including those contributing to femoroacetabular impingement syndrome) are strong predictors of early-onset hip OA. In view of these associations, rising rates of obesity and sports injuries are concerning, and may signal a future surge in OA incidence among younger people. Assessment of hip and knee OA in younger people should focus on a patient-centered history, comprehensive physical examination, performance-based measures, and patient-reported outcome measures to enable monitoring of symptoms and function over time. Referral for imaging should be reserved for people presenting with atypical signs or symptoms that may indicate diagnoses other than OA. Nonpharmacological approaches are core strategies for the management of hip and knee OA in younger people, and these include appropriate disease-related education, activity modification (including for work-related tasks), physical therapist- prescribed exercise programs to address identified physical impairments, and weight control or weight loss. High-quality evidence has shown no benefit of arthroscopy for knee OA, and there are no published clinical trials to support the use of hip arthroscopy for OA. Referral for joint-conserving or joint replacement surgery should be considered when nonpharmacological and pharmacological management strategies are no longer effective. J Orthop Sports Phys Ther 2017;47(2):67-79. doi:10.2519/jospt.2017.7286.

What fooled us in the knee may trip us up in the hip: lessons from arthroscopy

“The only good thing about repeating your mistakes is you know when to cringe.” Aleksandr Solzhenitsyn Those old enough to remember when knee arthroscopy revolutionised treatment of the injured meniscus several decades back might be forgiven if a sense of deja vu is emerging from the hip. Hip labral tears are increasingly seen on imaging and at hip arthroscopy in people with hip and groin pain, which coincides with improved diagnostic techniques and the rapid growth of arthroscopic surgery.1 The number of hip arthroscopies have increased 1800% in the USA over the past 5–10 years,2 with dramatic increases also reported in the UK, Australia and elsewhere worldwide. The similarities between the meniscus and labrum are striking on several fronts. The knee meniscus and acetabular labrum are comprised of fibrocartilage that has a partially innervated peripheral vascular red zone.3 …

Implementation of concussion guidelines in community Australian Football and Rugby League: the experiences and challenges faced by coaches and sports trainers

OBJECTIVES While guidelines outlining the appropriate management of sport-related concussion have been developed and adapted for use within community sport, it remains unknown how they are experienced by those responsible for implementing them. DESIGN Longitudinal study. METHODS 111 coaches and sports trainers from community-level Australian Football and Rugby League teams completed pre- and post-season surveys assessing their attitudes towards using concussion guidelines. Participants also provided post-season feedback regarding their experiences in using the guidelines. RESULTS 71% of participants reported using the guidelines in the preceding season. Post-season attitude was related to pre-season attitude (p=0.002), football code (p=0.015), and team role (p=0.045). An interaction between team role and guideline use (p=0.012) was also found, with coaches who had used the guidelines, and sports trainers who had not, reporting more positive post-season attitudes towards using the concussion guidelines. Implementation challenges included disputing of decisions about return-to-play by players, parents, and coaches, and a perceived lack of time. Recommendations for improved guideline materials included using larger fonts and providing for witnessing of advice given to players. CONCLUSIONS This is the first study to examine the implementation of concussion guidelines in community sport. Training of coaches/sports trainers needs enhancement. In addition, new education should be developed for parents/players about the importance of the return-to-play advice given to them by those who follow these guidelines. Information provided by those who attempted to use the guidelines will assist the refinement of implementation and dissemination processes around concussion guidelines across sports.

2016 international consensus on femoroacetabular impingement syndrome: the Warwick Agreement-why does it matter?

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain in young and middle-aged adults. It is one of the hot topics in sports medicine, and debate among surgeons, sports physicians and physiotherapists is ongoing. The rate of diagnosis and treatment of FAIS has exploded in the past decade, with rates of hip arthroscopy increasing by almost 400% over this time.1 ,2 Such a rapid increase in diagnosis and treatment can inevitably lead to a backlash, with claims by sceptics of overdiagnosis, over treatment and a lack of evidence. While there may be some truth in these claims, such scepticism can cause people to question whether FAIS exists. Given this, it is important to understand what FAIS is, whether it is a problem and why we need a consensus statement. FAIS refers to the intra-articular pathology and subsequent symptoms and signs that develop in susceptible individuals when the femoral and acetabular components of the hip repetitively and prematurely abut against each other.3 ,4 Typically, …

We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine

In 2015, a website (www.allmalepanels.tumblr.com/) began documenting instances of all-male panels (colloquially known as a ‘manel’). This, along with the Twitter hashtag #manel, has helped drive recognition of the persistent and pervasive gender bias in the composition of experts assembled to present at conferences and other events. Recent social media discussions have similarly highlighted the prevalence of all-male panels in Sport and Exercise Medicine (SEM). While, to our knowledge, all-male panel trends in SEM have not yet formally been documented or published, one need look no further than SEM conference committees, keynote speaker lists, panels and other events to see that it exists in practice. Why, in 2018, is SEM and its related disciplines still failing to identify and acknowledge the role that implicit bias plays in the very structure of our own research, practice and education? SEM is, after all, a profession that contains experts, and serves populations, of all genders. This editorial will introduce the definition, implications and manifestations of implicit gender bias and then explore how the SEM community can begin to address this issue, advance the discussion and develop a more equitable global community. Social cognitive theory describes ‘implicit bias’ as the unconscious …

What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis

Background Intra-articular hip pathologies are thought to be associated with the development of hip and groin pain. A better understanding of the relationship between symptoms and imaging findings may improve the management of individuals with intra-articular hip pathologies. Objective To undertake a systematic review and meta-analysis to determine the prevalence of intra-articular hip pathologies in individuals with and without pain. Methods Seven electronic databases were searched in February 2017 for studies investigating the prevalence of intra-articular hip pathologies using MRI, MRA or CT. Two independent reviewers conducted the search, study selection, quality appraisal and data extraction. Meta-analysis was performed when studies were deemed homogenous, with a strength of evidence assigned to pooled results. Results In general, studies were moderate to high risk of bias, with only five studies adjudged to be low risk of bias. The 29 studies reporting on the prevalence of intra-articular hip pathologies identified limited evidence of a labral tear prevalence of 62% (95% CI 47% to 75%) in symptomatic individuals, with moderate evidence identifying a labral tear prevalence of 54% (95% CI 41% to 66%) in asymptomatic individuals. Limited evidence demonstrated a cartilage defect prevalence of 64% (95% CI 25% to 91%) in symptomatic individuals, compared with moderate evidence of a cartilage defect prevalence of 12% (95% CI 7% to 21%) in asymptomatic individuals. Conclusion The prevalence of intra-articular hip pathologies is highly variable in both symptomatic and asymptomatic populations. The prevalence of intra-articular hip pathologies appears to be higher in symptomatic individuals. However, imaging-defined intra-articular hip pathologies are also frequently seen in asymptomatic individuals, highlighting a potential discordant relationship between imaging pathology and pain. PROSPERO registration number CRD42016035444.