Keelan R. Enseki

Hip pain and mobility deficits--hip osteoarthritis: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association.

The Orthopaedic Section of the American Physical Therapy Association presents this third set of clinical practice guidelines on hip osteoarthritis, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders. J Orthop Sports Phys Ther 2009;39(4):A1-A25. doi:10.2519/jospt.2009.0301

Rehabilitation After Arthroscopic Decompression for Femoroacetabular Impingement

The use of arthroscopic technology to address pathologic conditions of the hip joint has become a topic of growing interest in the orthopedic community. Addressing femoroacetabular impingement through this method has generated additional attention. As surgical options evolve, rehabilitation protocols must meet the challenge of providing a safe avenue of recovery, yet meeting the goal of returning to high levels of functioning. Current rehabilitation concepts should be based on the growing body of evidence, knowledge of tissue healing properties, and clinical experience.

Post-operative guidelines following hip arthroscopy.

Rehabilitation following hip arthroscopy can vary significantly. Existing programs have been developed as a collaborative effort between physicians and rehabilitation specialists. The evolution of protocol advancement has relied upon feedback from patients, therapists and observable outcomes. Although reports of the first femoroacetabular impingement (FAI) surgeries were reported in the 1930’s, it was not until recently that more structured, physiologically based guidelines have been developed and executed. Four phases have been developed in this guideline based on functional and healing milestones achieved which allow the patient to progress to the next level of activity. The goal of Phase I, the protective phase, is to progressively regain 75% of full range of motion (ROM) and normalize gait while respecting the healing process. The primary goal of Phase II is for the patient to gain function and independence in daily activities without discomfort. Rehabilitation goals include uncompensated step up/down on an 8 inch box, as well as, adequate pelvic control during low demand exercises. Phase III goals strive to accomplish pain free, non-compensated recreational activities and higher demand work functions. Manual muscle testing (MMT) grading of 5/5 should be achieved for all hip girdle musculature and an ability to dynamically control body weight in space. Phase IV requires the patient be independent with home and gym programs and be asymptomatic and pain free following workouts. Return to running may be commenced at the 12 week mark, but the proceeding requirements must be achieved. Athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patient’s pre-operative health status and post-operative physical demands will direct both the program design and the program timetable.

Nonarthritic Hip Joint Pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to nonarthritic hip joint pain.

Postoperative Rehabilitation After Hip Arthroscopy: A Search for the Evidence

CONTEXT Hip arthroscopy has become an increasingly popular option for active individuals with recalcitrant hip pain. Conditions that may be addressed through hip arthroscopy include labral pathology, femoral acetabular impingement, capsular hyperlaxity, ligamentum teres tears, and the presence of intra-articular bodies. Although the body of literature examining operative procedures has grown, there is a paucity of evidence specifically on the efficacy of postoperative rehabilitation programs. To date, there are no systematic reviews that have evaluated the available evidence on postoperative rehabilitation. OBJECTIVE To evaluate the available evidence on postoperative rehabilitation programs after arthroscopy of the hip joint. EVIDENCE ACQUISITION A search of the PubMed, CINAHL, SPORTDiscus, ProQuest, and Google Scholar databases was conducted in January 2014 according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews. EVIDENCE SYNTHESIS Six studies met the inclusion criteria and were either case series or case reports (level 4 evidence) that described a 4- or 5-phase postoperative rehabilitation program. The available evidence supports a postoperative period of restricted weight bearing and mobility; however, the specific interventions in the postoperative phases are variable with no comparison trials. CONCLUSION This review identified a paucity of evidence on postoperative rehabilitation after hip arthroscopy. Existing reports are descriptive in nature, so the superiority of a particular approach cannot be determined. One can surmise from existing studies that a 4- to 5-stage program with an initial period of weight-bearing and mobility precautions is efficacious in regard to function, patient satisfaction, and return to competitive-level athletics. Clinicians may consider such a program as a general guideline but should individualize treatment according to the surgical procedure and surgeon guidelines. Future research should focus on comparative trials to determine the effect of specific postoperative rehabilitation designs.

Hip Pain and Mobility Deficits—Hip Osteoarthritis: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

The clinical presentation of individuals with femoral acetabular impingement and labral tears: A narrative review of the evidence

Femoral acetabular impingement (FAI) has emerged as one of the more commonly recognized intraarticular hip pathologies and is often accompanied with a labral tear. The understanding of the clinical characteristics of individuals with symptomatic FAI has evolved over the past several years due to emerging research. As research progresses, there is often a gap in translating the current evidence to clinical practice. This manuscript presents the latest evidence underpinning the clinical presentation of FAI and labral tears. Evidence is presented within the context of bridging the latest research and clinical practice.

Rehabilitation After Hip Arthroscopy

Protocols for hip arthroscopy have traditionally been based on time established criteria for tissue healing. However, there are several factors to consider beyond the surgical procedure that influence the progression of a rehabilitation program. Progression should be based on not only time frame but also objective criteria-based indicators. This chapter describes potential strategies to improve communication between the therapist and surgical team, outlines general postoperative rehabilitation guidelines related to common arthroscopic surgical procedures, defines criteria to progress a patient along various phases of a protocol, and highlights pearls and perils along the rehabilitation process.

Cost-effectiveness Analysis of Hip Arthroscopic Surgery and Structured Rehabilitation Alone in Individuals With Hip Labral Tears: Letter to the Editor:

Dear Editor: Dr Lodhia and colleagues performed a cost-effectiveness analysis (CEA) to compare hip arthroscopic surgery versus structured rehabilitation alone in individuals with labral tears and no osteoarthritis (OA). A secondary aim was to estimate the incidence of symptomatic OA and joint arthroplasty in both groups. CEAs are critically important to guiding bestpractice approaches, and we respect the authors’ attempt to address the complex issue of cost-effectiveness. However, studies evaluating the efficacy of rehabilitation in improving outcomes in individuals with nonarthritic hip pain are limited, and we are concerned that the results reported by Lodhia et al may contribute to the already escalating rates of arthroscopic surgery before rigorous investigation of treatment options has been completed. Thus, this analysis seems premature, as there simply are not enough high-quality studies available to make a valid estimate of the clinical efficacy of structured rehabilitation in this population. In fact, it could be reasonably argued that despite increased utilization of hip arthroscopy, available surgical outcome studies are also not yet of sufficient quality to make valid estimates of the long-term effects of this surgery. In a cost-utility analysis, each possible health state is assigned a utility value ranging from 0 to 1, where 0 represents death and 1.0 represents perfect health. Lodhia and colleagues report the utility value of an asymptomatic hip after arthroscopic surgery as 0.94 and the utility value of an asymptomatic hip after rehabilitation as 0.79. While the authors cite literature to support these numbers, we feel that this disparity in base case utility values underscores our argument that insufficient information is available regarding the clinical efficacy of rehabilitation for hip labral abnormality to estimate the utility value of a person’s life following a rehabilitation program. It is counterintuitive to assume that when 2 patients with asymptomatic hips are compared, the person who did not receive surgery has a substantially lower quality of life than the person who did receive surgery. While the authors used the same utility range (0.73-1.0) for both surgical and nonsurgical approaches in their sensitivity analyses, the distributions used in the probabilistic sensitivity analysis were not stated. If anything other than a uniform distribution was used, the analysis would still be substantially skewed in favor of the surgical approach. Cost-effectiveness analyses can construct models that consider all potential health states and treatment decisions. The clinical pathway of patients with symptomatic hip labral tears can include both surgery and rehabilitation, but Lodhia and colleagues constructed their Markov model in a way that did not allow for crossover from rehabilitation to surgery. Thus, it is not possible to control for the effects of rehabilitation in the arthroscopy arm of this study. Lack of improvement with rehabilitation is one of the most important indications by which surgeons determine potential candidates for hip arthroscopy. Furthermore, postoperative rehabilitation is described as ‘‘an integral component of the clinical outcome’’ of hip arthroscopy and is advocated by the senior author of this costeffectiveness analysis. It does not appear that rehabilitation costs were incorporated into the arthroscopic surgery strategy, and thus the analysis may underestimate the total costs of this treatment arm. While arthroscopic surgery may be a mitigating factor in incident hip OA, a longitudinal, randomized controlled trial design is needed to test this causal relationship. The conclusion by Lodhia and colleagues that arthroscopy results in a lower incidence of hip OA than rehabilitation alone is not supported by the methodological approach or the data presented. Additionally, whether arthroscopy alters the progression of hip OA is currently unknown. It appears that the cost of rehabilitation visits were derived from national average Medicare reimbursements for physical therapy in 2014 US dollars. However, the estimated cost of more than

An Overview of Hip Fractures in the Geriatric Population

9000 for a single episode of physical therapy care would be equated with 90 visits at approximately