Focused Neck Ultrasound and Lymph Node Sampling by Respiratory Physicians in Suspected Lung Cancer.

BACKGROUND: Malignant cervical lymphadenopathy in the setting of lung cancer represents N3 disease, and neck ultrasound (NUS) with sampling is described in the Royal College of Radiologists ultrasound training curriculum for the non-radiologists. This study reviews the incorporation of NUS +/- biopsy in the routine practice of a lung cancer fast-track clinic in the UK. METHODS: We retrospectively assessed 29 months of activity of a lung cancer fast-track clinic. Systematic focused NUS was conducted in suspected thoracic malignancy, sampling nodes with a ≥5-mm short axis, under real-time US using a linear probe (5-12 Mhz). Fine-needle aspirations (FNAs) with or without 18 Ga core biopsies were taken. RESULTS: Between August 2017 and December 2019, of 152 peripheral lymph nodes (LNs)/deposits sampled, 98 (64.5%) were supraclavicular fossa LNs with median [IQR] size 12 [8-18] mm. Core biopsies were performed in 54/98 (55%) patients, while all patients had FNAs. No complications occurred. The representative yield was 90/95 (94.7%) in cases with suspected cancer. No difference was seen between FNA versus core biopsy (p = 0.44). Of the 5 non-diagnostic samples, one was FNA only. The commonest diagnosis was lung cancer in 66/98 (67.3%). PDL-1 was sufficient in 35/36 tested (97.2%). ALK-FISH was successful in 24/25 (96%) cases. EGFR mutation analysis was successful in 28/31 (90.3%) cases. Median time from clinic to initial diagnosis was 7 [5-10] days. Computed tomography (CT) scans reported no significant lymphadenopathy in 18/96 (18.7%) cases, yet 10/18 (55.5%) cases were positive for malignancy. CONCLUSION: Neck nodal sampling by respiratory physicians was safe, timely, with a high diagnostic yield and suitability for molecular testing. Neck US can provide a timely diagnosis in cases that may be missed by CT alone.

To drain or not to drain? Abscess or empyema?

We present a case posing the clinical dilemma of differentiating a large peripheral lung abscess from an empyema, discussing the imaging and management and the clinical issues posed.

Patient- and Physical Therapist-Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain.

OBJECTIVE: To identify patient- and physical therapist-level predictors for therapeutic alliance at the end of an episode of physical therapy for knee or low back pain (LBP). DESIGN: Secondary analysis of observational cohort. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Patients receiving physical therapy for knee (n=189) or LBP (n=252) and physical therapists (n=19). Candidate predictor variables included demographics, patient clinical characteristics, and physical therapist attitudes and beliefs (Pain Attitudes and Beliefs Scale for Physical Therapists) and confidence in providing patient-centered care (Self-Efficacy in Patient-Centeredness Questionnaire). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient-reported therapeutic alliance was measured using the 12-item Work Alliance Inventory-Short Revised (WAI-SR). RESULTS: Final linear mixed models indicated different patient- and physical therapist-level factor contributions in predicting final WAI-SR scores across cohorts with knee and LBP. Female sex was a consistent patient-level predictor for both knee (estimated ß=1.57, P<.05) and LBP (ß=1.42, P<.05), with age (ß=-0.07, P<.01) and baseline function (ß=0.06, P<.01) contributing to cohorts with knee and LBP, respectively. Physical therapist-level predictors included female sex (ß=6.04, P<.05), Pain Attitudes and Beliefs Scale for Physiotherapists behavioral (ß=0.65, P<.01), and Self-Efficacy in Patient-Centeredness Questionnaire (SEPCQ) Exploring Patient Perspective (ß=-0.75, P<.01) subscale scores for LBP, with SEPCQ Sharing Information and Power subscale scores (ß=0.56, P<.05) contributing to both cohorts with knee (ß=0.56, P<.05) and LBP (ß=0.74, P<.01). Random effects for patients nested within physical therapists were observed for both cohorts. CONCLUSIONS: These findings provide preliminary evidence for inconsistent relationships among patient- and physical therapist-level factors and therapeutic alliance across cohorts with knee and LBP.

The impact of age and body mass index on a bra sizing system formed by anthropometric measurements of Sichuan Chinese females.

Existing bra sizing systems are based only on bust and underbust girths, which do not guarantee an accurate fit or comfort for consumers. This study presents a comprehensive investigation of the impact of age and body mass index (BMI) on bra sizing systems, and the distributions of band and cup sizes based on anthropometric measurement data. The first four principal components were extracted by principal component analysis, and the factor loadings of age and BMI were found to be significant determinants of bra size along with 12 other variables. Furthermore, chi-square analysis revealed that bra size allocations were significantly influenced by age and BMI. Thus, we propose that age and BMI should be considered as auxiliary criteria for the bra sizing system. Taken together, these findings will be of value to designers and bra manufacturers in developing well-fitting bras for their target consumers, and to consumers for selecting well-fitting bras with confidence. Practitioner Summary: This study contributes to an understanding of how bra sizing systems are affected by age and BMI. This understanding is valuable to bra designers, manufacturers, and retailers, as it will enable the adjustment of bra sizes for different target markets and in turn improve consumer confidence in selecting proper fitting and comfortable bras.

Endobronchial Ultrasound-guided Sampling of Centrally Located Intrapulmonary Tumors Provides Suitable Material for Diagnostic and Molecular Testing.

BACKGROUND: Curvilinear endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a key diagnostic and staging procedure for patients with suspected lung cancer. However, sampling centrally located intrapulmonary tumors is feasible but less well established. METHODS: We retrospectively evaluated the diagnostic utility of EBUS-TBNA in patients who underwent sampling of centrally located intrapulmonary tumors. Diagnostic accuracy, sample suitability for molecular testing, and complications were assessed. RESULTS: Between January 2015 and April 2021, 102 EBUS-TBNA procedures sampled centrally located intrapulmonary tumors in 99 patients. The median age was 70 [interquartile range, 63 to 75] years and 51% (51/99) were male. The commonest site was the right upper lobe (n=42/99; 42%). The median tumor size was 29 [interquartile range, 21 to 35] mm. The diagnostic yield was 88/102 (86%) with a false negative rate of 14% (14/102). In addition to intrapulmonary tumor sampling, lymph nodes were sampled in 65/102 procedures and 30/65(46%) were positive for lung cancer. Cancer was diagnosed in 87/99 (88%) cases. When requested, molecular testing was adequate in ≥94% of samples. Complications included minor bleeding in 6/102 (6%) with 2 requiring cold saline instillation, desaturation in 1/102 (1%), and tachycardia in 1/102(1%). One procedure was abandoned due to patient tachycardia. Delayed complications occurred in 1 patient who was hospitalized ≤7 days with pneumonia. CONCLUSION: EBUS-TBNA sampling of centrally located intrapulmonary tumors provides similar diagnostic accuracy to lymph node sampling, provides suitable material for molecular testing, and has a low complication rate.

Incidence of bleeding in renally impaired patients receiving incorrectly dosed eptifibatide or bivalirudin while undergoing percutaneous coronary intervention.

BACKGROUND: Limited data are available regarding adverse bleeding events associated with antithrombotic agents incorrectly dosed based on renal function in patients receiving percutaneous coronary intervention (PCI). OBJECTIVE: To compare the incidence of bleeding during their hospital stay in patients with reduced renal function receiving incorrect doses of bivalirudin or eptifibatide to the incidence of correct doses, based on manufacturer recommendations; secondary objectives were to determine the incidence of correct dosing based on manufacturer recommendations and the incidence of TIMI (Thrombolysis in Myocardial Infarction) major bleeding. METHODS: A chart review over a 32-month period showed that patients with reduced renal function who received either eptifibatide or bivalirudin during PCI were evaluated for correct dosing based on manufacturer recommendations, bleeding incidence according to the TIMI criteria, and extent of bleeding according to the TIMI and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) criteria. RESULTS: One hundred ninety patients met inclusion criteria, 56 who received eptifibatide and 134 who received bivalirudin. Eptifibatide was dosed incorrectly in 64% of the patients. Patients receiving incorrectly dosed compared to correctly dosed eptifibatide experienced significantly more bleeding (64% vs 35%, respectively, p = 0.04), a greater extent of bleeding based on the TIMI and GUSTO criteria (p = 0.03 and p = 0.009, respectively), and had more TIMI major bleeding (19% vs 5%, respectively). Bivalirudin was dosed incorrectly in 28% of the patients. Patients receiving incorrectly dosed compared to correctly dosed bivalirudin experienced a significantly greater extent of bleeding based on the GUSTO criteria (p = 0.01). There was no significant difference between the incidence of bleeding (37% vs 21%, respectively; p = 0.06), extent of bleeding based on the TIMI criteria (p = 0.058), or incidence of TIMI major bleeding (5% vs 3%). CONCLUSIONS: Patients receiving incorrectly dosed eptifibatide and bivalirudin are susceptible to adverse bleeding events. The occurrence of incorrect dosing offers an opportunity for pharmacist-driven institutional improvement.

Prevalence of Aspergillus-Derived Mycotoxins (Ochratoxin, Aflatoxin, and Gliotoxin) and Their Distribution in the Urinalysis of ME/CFS Patients.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a known complex, multi-organ system disorder with a sudden or subacute onset. ME/CFS occurs most commonly among women between 30 and 50 years of age. The current diagnostic criteria of ME/CFS, as defined by the Centers for Disease Control and Prevention, includes: profound fatigue and post-exertional malaise (>6 mo) unrelieved by rest, persistent cognitive impairment or orthostatic intolerance, and chronic unrefreshing sleep. Despite reported associations between ME/CFS onset and exposure to infectious agents (viral, bacterial, or fungal), the pathophysiology of ME/CFS remains unknown. In this prevalence study, we investigated the rates of Aspergillus-derived toxin levels, Aflatoxin (AF), Ochratoxin A (OTA), and Gliotoxin (GT), in the urinalysis of 236 ME/CFS patients with a history of chronic exposure to mold (i.e., from water-damaged buildings). Among ME/CFS patients reporting chronic exposure to mold, we found evidence of exposure in 92.4 percent of patients, with OTA being the most prevalent mycotoxin. Mold distributions (OTA, AF, and GT) in the urinalysis all demonstrated right skewness, while the distribution of age of ME/CFS patients diagnosed showed no deviation from normality. This study aims to provide preliminary, epidemiological evidence among ME/CFS patients who were diagnosed in South Florida with a history of exposure to mycotoxins. Based on these findings, we proposed how future control studies should approach investigating the association between chronic mold exposure and the diagnosis of ME/CFS.

Time between endobronchial ultrasound needle passes as a metric to monitor progress of trainees.

BACKGROUND: Methods to assess and track progress of new endobronchial ultrasound (EBUS) operators and trainees is desirable to ensure training goals and procedural competence are achieved. Relying on the diagnostic yield or on question-based assessments alone is not sufficient. This study examined the longitudinal change in times taken between needle passes (needle pass time; NPT) during EBUS lymph node sampling as a metric to monitor progress. RESEARCH DESIGN AND METHODS: :The EBUS database of a tertiary hospital was accessed to extract data on the first 50 EBUS procedures for three trainees. The NPT was derived using PACS images that are stored to document every needle pass during an EBUS procedure and an average NPT was calculated. RESULTS: Between the three trainees, 157 procedures were carried out within the study period with 302 nodal stations sampled. The mean NPT (n = 204 stations) was 2:49 ± 0:49 mins. The mean node short axis diameter was 15.5 ± 8.7 mm. There was a negative correlation between node size and time per pass (r - 0.146, p = 0.045).The average NPT showed a negative correlation with procedure order through the first 50 procedures. Less variation between procedures was noted for the three trainees from the 30th procedure onward. On multivariate regression, NPT was significantly associated with procedure order regardless of station sampled or lymph node diameter. CONCLUSION: NPT is novel, easy, and robust metric that can potentially help ensure EBUS trainees are advancing in a given training program.

Prevalence of low back pain and related disability in patients with femoroacetabular impingement syndrome.

BACKGROUND: Low back pain (LBP) has been associated with worse hip function for persons with femoroacetabular impingement syndrome (FAIS). Reports are limited to surgical populations and based on the presence or absence of LBP, regardless of pain severity. OBJECTIVES: To report the prevalence of clinically significant LBP for persons with FAIS; compare demographics, pain, and function between those with and without clinically significant LBP; and evaluate relationships between hip function and both LBP-related disability and LBP severity. We hypothesized that participants with LBP would be older, have higher body mass index (BMI), and report worse groin pain, longer symptom duration, and worse hip function. We hypothesized that worse LBP-related disability and LBP severity would be related to worse hip function. DESIGN: Observational cross-sectional study. SETTING: Hip preservation clinic. PARTICIPANTS: 158 persons with FAIS. INTERVENTIONS: n/a MAIN OUTCOME MEASURE(S): Visual analog pain scales (VAS 0-100) were used to categorize participants with (≥30) and without (<30) clinically significant LBP. Age, sex, BMI, pain severity and duration, and hip function (33-item Hip Outcome Tool [iHOT33]) were compared between those with and without clinically significant LBP. Correlations were evaluated between the modified Oswestry Disability Index (ODI) and iHOT33, ODI and groin pain severity, LBP severity and iHOT33, and LBP and groin pain severity. RESULTS: Sixty percent of participants reported clinically significant LBP (n = 95). These participants reported worse iHOT33 scores (mean difference: 10.1 points) than those without clinically significant LBP (p = .001). Worse ODI scores were associated with worse iHOT33 scores (P < .001; ρ = -0.74). Significant relationships were also observed between (1) ODI and groin pain, (2) LBP and iHOT33, and (3) LBP and groin pain, but the magnitudes of these correlations were weak (ρ ≤ 0.36). CONCLUSIONS: Clinically significant LBP is highly prevalent in persons with FAIS and is associated with worse hip function. Worse LBP-related disability, but not LBP severity, was strongly associated with worse hip function.

Treatment decisions after interdisciplinary evaluation for nonarthritic hip pain: A randomized controlled trial.

BACKGROUND: Physical therapy and hip arthroscopy are two viable treatment options for patients with nonarthritic hip pain (NAHP); however, patients may experience considerable decisional conflict when making a treatment decision. Interdisciplinary evaluation with a physical therapist and surgeon may better inform the decision-making process and reduce decisional conflict. OBJECTIVE: To identify the extent to which an interdisciplinary evaluation between a surgeon, physical therapist, and patient influences treatment plans and decisional conflict of persons with NAHP. DESIGN: Randomized controlled trial. SETTING: Hip preservation clinic. PARTICIPANTS: Adults with primary NAHP. INTERVENTIONS: Participants were randomized to receive a standard (surgeon) or interdisciplinary (surgeon+physical therapist) evaluation. Surgeon evaluations included patient interview, strength and range-of-motion examination, palpation, gross motor observation, and special testing. Interdisciplinary evaluations started with the surgeon evaluation, then a physical therapist evaluated movement impairments during sitting, sit-to-stand, standing, single-leg stance, single-leg squat, and walking. All evaluations concluded with treatment planning with the respective provider(s). OUTCOME MEASURES: Treatment plan and decisional conflict were collected pre- and postevaluation. Inclusion of physical therapy in participants' postevaluation treatment plans and postevaluation decisional conflict were compared between groups using chi-square tests and Mann-Whitney U tests, respectively. RESULTS: Seventy-eight participants (39 in each group) met all eligibility criteria and were included in all analyses. Sixty-six percent of participants who received an interdisciplinary evaluation included physical therapy in their postevaluation treatment plan, compared to 48% of participants who received a standard evaluation (p = .10). Participants who received an interdisciplinary evaluation reported 6.3 points lower decisional conflict regarding their postevaluation plan (100-point scale; p = .04). The interdisciplinary and standard groups reduced decisional conflict on average 24.8 ± 18.9 and 23.6 ± 14.6 points, respectively. CONCLUSIONS: Adding a physical therapist to a surgical clinic increased interest in physical therapy treatment, but this increase was not statistically significant. The interdisciplinary group displayed lower postevaluation decisional conflict; however, both groups displayed similar reductions in decisional conflict from pre- to postevaluation. This study also demonstrated the feasibility of an interdisciplinary evaluation in a hip preservation clinic.

Relationships between physical therapy intervention and opioid use: A scoping review.

OBJECTIVE: To synthesize available evidence that has examined the relationship between physical therapy (PT) and opioid use. TYPE: Scoping Review LITERATURE SURVEY: Data sources including Google Scholar, Embase, PubMed, Cochrane Library, and CINAHL were searched for English articles up to October 24, 2019 using terms ("physical therapy"[Title/Abstract] OR physiotherapy[Title/Abstract] OR rehabilitation[Title/Abstract]) AND (opiate*[Title/Abstract] OR opioid*[Title/Abstract]). METHODOLOGY: Included studies evaluated a PT intervention and reported an opioid-use outcome. Data were extracted to describe the PT intervention, patient sample, opioid-use measurement, and results of any time or group comparisons. Study quality was evaluated with Joanna Briggs checklists based on study design. SYNTHESIS: Thirty studies were included that evaluated PT in at least one of these seven categories: interdisciplinary program (n = 8), modalities (n = 3), treatment (n = 3), utilization (n = 2), content (n = 3), timing (n = 13), and location (n = 2). Mixed results were reported for reduced opioid-use after interdisciplinary care and after PT modalities. Utilizing PT was associated with lower odds (ranging from 0.2-0.8) of using opioid medication for persons with low back pain (LBP) and injured workers; however, guideline-adherent care did not further reduce opioid use for persons with LBP. Early PT utilization after index visit for spine or joint pain and after orthopedic surgery was also associated with lower odds of using opioid medications (ranging from 0.27-0.93). Emergency department PT care was not associated with fewer opioid prescriptions than standard emergency department care. PT in a rehabilitation center after total knee replacement was not associated with lower opioid use than inpatient PT. CONCLUSIONS: The relationship between timing of PT and opioid use was evaluated in 13 of 30 studies for a variety of patient populations. Eight of these 13 studies reported a relationship between early PT and reduced subsequent opioid use, making the largest sample of studies in this scoping review with supporting evidence. There is limited and inconclusive evidence to establish whether the content and/or location of PT interventions improves outcomes because of heterogeneity between studies.

The Relationship Between COVID-19 Infection Rates and Social Determinants of Health in Broward and Miami-Dade Counties, Florida.

Objective To determine the relationship between per capita income and COVID-19 cases in Broward and Miami-Dade Counties of Florida, USA.  Background Low socioeconomic status predisposes individuals to worse health outcomes. For example, during the 2003 SARS-CoV pandemic and the 2009 H1N1 influenza pandemic disadvantaged individuals were more likely to become infected. More recently, a study found that deaths due to COVID-19 were associated with disadvantaged areas across the United States. South Florida, in particular Broward and Miami-Dade Counties, has experienced a significant burden of coronavirus cases. Investigating the association of income on coronavirus cases in Broward and Miami-Dade Counties may aid in identifying and treating those individuals at increased risk.  Methods This retrospective cross-sectional study used data gathered by the Florida Department of Health and 2018 U.S. Census. COVID-19 cases from March 2 - November 1, 2020 were tallied by ZIP code in Florida's Broward and Miami-Dade Counties and scaled per housing unit. An exhaustive regression analysis using County "Miami-Dade" or "Broward," sex, race, ethnicity, median age, and estimated per capita income was performed for each combination of independent variables in MATLAB (MathWorks, Natick, USA). Regression models were evaluated using both adjusted R-squared and the Akaike Information Criterion, along with the number of significant predictors. The most optimal model with the highest number of significant predictors was selected. Results Among all other variables, sex, race, and ethnicity as the variables that best predicted COVID-19 cases per housing unit within a certain ZIP code. The adjusted R-squared of this optimal model was 0.5062, indicating that within each ZIP code in Broward and Miami-Dade Counties 50.62% of the variance in COVID-19 cases per housing unit can be explained by these variables. A significant relationship was found between the number of COVID-19 cases and individuals who were Black or African American (p < 0.001), individuals who were Hispanic or Latino (p < 0.001), and male to female ratio (p = 0.016). Per capita income, age, and county were not statistically significant predictors in any model tested. Conclusions Racial and gender disparities may be more significant contributors to COVID-19 cases than per capita income in housing units. Based on the results of this study, investigators may consider applying this model to similar variables in order to inform the management and prevention of cases in the present and future pandemics.

Movement Patterns and Their Associations With Pain, Function, and Hip Morphology in Individuals With Femoroacetabular Impingement Syndrome: A Scoping Review.

OBJECTIVE: The purpose of the study was to synthesize studies of movement patterns and their association with hip pain, function/activity, and morphology in individuals with femoroacetabular impingement syndrome (FAIS). METHODS: PubMed, SPORTDiscus, CINAHL, Embase, and Scopus databases were searched using predefined terms. Two authors independently reviewed abstracts and full texts. Studies were included if they enrolled individuals with FAIS, reported kinematic or kinetic data during movement tasks, and tested the data's associations with hip pain, function/activity, or morphology. Exclusion criteria were studies that did not evaluate associations between movement patters and pain, function/activity, or hip morphology. Additionally, studies with hip conditions other than FAIS, case reports, conference proceedings, review articles, and non-English studies were excluded. Descriptive consolidation and qualitative synthesis were performed for the included studies. RESULTS: Of the 1155 potential studies, 5 studies met all eligibility criteria. Movement patterns were evaluated during walking (n = 4) and squatting (n = 1). Studies reported multiple associations between variables of interest. Statistically significant associations were identified between movement patterns and hip pain (n = 2), function/activity (n = 2), or morphology (n = 3). Significant associations included increased hip flexion moment impulse during walking was associated with worse pain, increased hip flexion moment during walking was associated with worse hip function, decreased hip external rotation during gait and hip internal rotation during squat were associated with larger cam deformity, and increased hip flexion moment impulse during walking was also associated with more severe acetabular cartilage abnormalities. CONCLUSIONS: Very little current evidence has evaluated the associations between altered movement patterns and hip pain, function/activity, or morphology in individuals with FAIS, and only low-intensity tasks have been tested. These studies found some preliminary associations between altered hip biomechanics and higher hip pain, worse hip function, and specific measures of hip morphology in individuals with FAIS. IMPACT: This review is a first step in gaining a better understanding of movement patterns and their associations with hip pain, function/activity, and morphology, which could ultimately assist with the development of movement retraining interventions and potentially improve rehabilitation outcomes for those with FAIS.

Accumulation of Good Intentions: How Individual Practice Guidelines Lead to Polypharmacy in the Treatment of Patients with Polytrauma.

Polytrauma clinical triad (PCT) is the comorbid occurrence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain after trauma. No clinical practice guidelines for postacute care of patients with PCT currently exist; instead, clinical practice guidelines have been published for the three conditions (TBI, PTSD, and pain) as distinct clinical entities. Using multiple, individual practice guidelines for a patient with PCT may lead to unintended prescription of multiple and potentially adversely interacting medications (ie, polypharmacy). Polypharmacy, especially that which includes central nervous system-acting medications, may lead to overdose, suicidality, and chronic symptomatology. Current individual guidelines for each condition of PCT do not address how to coordinate care for the polytraumatic diagnosis. The purpose of this Practice Management piece is to describe the unintended consequences of polypharmacy in patients with PCT and to discuss mitigation approaches including rational prescribing, nonpharmacologic alternatives, and interdisciplinary coordination.

Associations Between Movement Impairments and Function, Treatment Recommendations, and Treatment Plans for People With Femoroacetabular Impingement Syndrome.

OBJECTIVE: The purpose of this study was to describe movement impairments for persons with femoroacetabular impingement syndrome and their association with function, treatment recommendations, and treatment plans. METHODS: This report is a secondary, observational analysis of a clinical trial dataset in which participants received an interdisciplinary evaluation from a surgeon and physical therapist. The therapist documented frontal and sagittal plane movement impairments across 6 functional tasks. Associations between number of impairments in each plane and function (33-item International Hip Outcome Tool [iHOT33]) were evaluated using Pearson or Spearman correlations. Joint provider recommendations (physical therapist and surgeon) and participant-reported treatment plans were dichotomized based on the inclusion of physical therapy or not. Logistic regressions were used to examine the effects of (1) iHOT33, total movement impairments, and previous physical therapist treatment on joint provider recommendation and (2) these same variables along with joint provider recommendation on participant treatment plan; prevalence ratios and 95% CIs were reported for significant contributors. RESULTS: Thirty-nine participants demonstrated an average iHOT33 of 35.0 (SD = 19.5) and presented with a median 5 frontal and 3 sagittal plane impairments. More frontal plane impairments were associated with worse iHOT33 scores. Twenty-seven participants received a joint provider recommendation that included physical therapy; no significant contributors to these recommendations were identified. Twenty-four of the 27 participants with a physical therapist recommendation included physical therapy in their treatment plan. Two additional participants did not receive a physical therapist recommendation but included physical therapy in their plan. Joint provider recommendation was the only significant contributor to the participant-reported plan (prevalence ratio = 7.06; 95% CI = 3.25-7.97). CONCLUSION: Persons with femoroacetabular impingement syndrome displayed clinically observable movement impairments that were associated with worse function. Joint provider recommendations strongly influenced participants' treatment plans to pursue physical therapy. IMPACT: Physical therapists contribute new information to surgical examinations regarding movement. Joint recommendations from the physical therapist and the surgeon can influence patients' decisions to pursue physical therapy.

Factors Associated with Initial Interest and Treatment Selection in Patients with Femoroacetabular Impingement Syndrome.

BACKGROUND: Outcomes for operative and nonoperative management of femoroacetabular impingement syndrome (FAIS) are variable. Understanding factors that inform patients' treatment decisions may optimize their outcomes. OBJECTIVE: To identify factors that predict which patients with FAIS proceed to surgery within 90 days of their initial evaluation by an orthopedic surgeon. The study explored potential predictors of surgical intervention, including demographic factors, activity level, symptom duration, previous treatment, hip function, pain, presence of labral tear, and patient interest in surgical and physical therapy (PT) treatment. DESIGN: Prospective cohort. SETTING: Single-site academic medical center. PATIENTS: Seventy-seven individuals with FAIS. INTERVENTION: After evaluation in a hip preservation clinic, participants reported activity level, symptom duration, treatment history, hip function [Hip Outcome Score Activities of Daily Living(HOS-ADL)], pain severity and location, and treatment interests. These variables were evaluated based on univariate analysis for entry into a multiple binomial logistic regression to identify predictors of surgery within 90 days. Adjusted marginal prevalence ratios and 95% confidence interval estimates (PR [95% CI]) were reported (P ≤ .05). MAIN OUTCOME MEASURE(S): Ninety-day treatment (surgery or not). RESULTS: Participants indicated initial interest in surgery (n = 27), PT (n = 22), both (n = 18), or neither (n = 10). Those only interested in PT had lower prevalence of diagnosed labral tear (P < .001) and previous PT for the hip (P < .001). Prevalence of previous injection was higher for those only interested in surgery than for those with any interest in PT (P < .001). Thirty-six of 77 participants (46%) underwent surgery within 90 days. Surgical interest (3.56 [1.57, 5.46]), previous hip injection (3.06 [1.73, 3.89]), younger age (0.95 [0.92, 0.98]), and worse hip function (0.97 [0.95, 0.99]) were significant (P ≤ .02) predictors of surgery. CONCLUSIONS: Treatment interest and history, patient function, and age were significantly related to participants' decision to pursue surgical intervention within 90 days. Patient engagement in the decision-making process should include considerations of patient knowledge of, and experience with, the various treatment options.

Sex-specific sagittal and frontal plane gait mechanics in persons post-hip arthroscopy for femoroacetabular impingement syndrome.

Postoperative gait mechanics in persons with femoroacetabular impingement syndrome (FAIS) remain understudied as a treatment outcome despite observed, yet inconclusive, preoperative gait abnormalities. Females with FAIS demonstrate worse preoperative patient-reported hip function and altered hip mechanics when compared with males; it is unknown whether these sex differences persist postarthroscopy. The purpose of this study was to compare sex-specific gait kinematics between persons at least 1 year postarthroscopy for FAIS and healthy comparisons. General linear models with estimating equations were used to evaluate the effect of (a) limb and sex within each group, and (b) limb and group within each sex for peak sagittal and frontal plane trunk, pelvis, and hip kinematics during stance phase of gait. Analyses were covaried by gait speed. Seventeen females and eight males an average 2.5 years postarthroscopy (1.1-7.2 year) for FAIS were compared with healthy females (n = 7) and males (n = 5). Females in the FAIS group presented with an average of 4.6° more anterior pelvic tilt, and 4.8° less hip extension compared with healthy females (P ≤ .03) and 8.6° less trunk flexion, 4.8° more anterior pelvic tilt, 3.1° more pelvic drop, and 7.5° more hip flexion than males with FAIS (P ≤ .03). Males in the FAIS group presented with 2.9° less pelvic drop, and 3.2° less hip adduction than healthy males. Preoperative gait mechanics were not collected and thus changes in mechanics could not be evaluated. This study is significant to clinicians who treat patients postarthroscopy to consider sex-specific gait impairments.

Physical Therapists and Physicians Evaluate Nonarthritic Hip Disease Differently: Results From a National Survey.

BACKGROUND: Physical therapy and surgery are viable treatment options for nonarthritic hip disease (NAHD). Interdisciplinary collaboration can help patients make informed treatment decisions. Understanding how each provider can contribute is a critical first step in developing collaborative evaluation efforts. OBJECTIVE: The objective of this study was to describe the current evaluation of NAHD by both physical therapists and physicians, and evaluate national use of expert-recommended evaluation guidelines. DESIGN: A national survey study distributed in the United States was implemented to accomplish the objective. METHODS: A survey was distributed to 25,027 potential physical therapist and physician respondents. Respondents detailed their evaluation content for patients with NAHD across the following domains: patient-reported outcomes, patient history, special tests, movement assessment, clinical tests, and imaging. Respondents ranked importance of each domain using a 5-point Likert scale (not important, slightly important, important, very important, or extremely important). Odds ratios (ORs [95% CIs]) were calculated to identify the odds that physical therapists, compared with physicians, would report each evaluation domain as at least very important. Fisher exact tests were performed to identify statistically significant ORs. RESULTS: Nine hundred and fourteen participants (3.6%) completed the survey. Physical therapists were more likely to indicate movement assessment (OR: 4.23 [2.99-6.02]) and patient-reported outcomes (OR: 2.56 [1.67-3.99]) as at least very important for determining a diagnosis and plan of care. Physical therapists had lower odds of rating imaging (OR: 0.09 [0.06-0.14]) and special tests (OR: 0.72 [0.53-0.98]) as at least very important compared with physicians. LIMITATIONS: This survey study did not include many orthopedic surgeons and thus, primarily represents evaluation practices of physical therapists and nonsurgical physicians. CONCLUSIONS: Physical therapists were more likely to consider movement assessment very important for the evaluation of patients with NAHD, whereas physicians were more likely to consider imaging and special testing very important.

Altered gait mechanics are associated with severity of chondropathy after hip arthroscopy for femoroacetabular impingement syndrome.

BACKGROUND: Suboptimal patient-reported function and movement impairments often persist after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Individuals with FAIS with preoperative cartilage pathology (ie. chondropathy) demonstrate distinct movement patterns and have worse post-operative outcomes. It is unknown whether the presence of chondropathy after surgery negatively affects movement and function. RESEARCH QUESTION: Do sagittal plane gait mechanics differ based on chondropathy severity following arthroscopy for FAIS? METHODS: A cross-sectional walking gait analysis was performed for 25 participants post-arthroscopy (2.48 ±â€¯1.38y) and 12 healthy controls (HCs). Peak total support moment (TSM) and relative contributions of the hip, knee, and ankle were calculated during loading response. The Hip Osteoarthritis MRI Scoring System was used to categorize the FAIS group into no-mild or moderate-severe chondropathy groups based on 3 T magnetic resonance imaging of their surgical hip. The interactions of group by limb were evaluated for kinetic variables, covaried by gait speed. RESULTS: Groups did not differ based on age, BMI and sex distribution (P ≥ 0.14). 13 participants with FAIS presented with moderate-severe chondropathy and 12 presented with no-mild chondropathy. Participants with moderate-severe chondropathy walked significantly slower than both other groups (P = 0.006) and demonstrated lower peak TSM than those with no-mild chondropathy (P = 0.002). Participants with no-mild chondropathy demonstrated lower hip (61.5 %) and greater ankle (17.7 %) contributions to the TSM on the involved limb compared to the moderate-severe group (hip:73.4 %, P = 0.07; ankle:10.5 %, P = 0.007). SIGNIFICANCE: Slower gait speed alone did not explain the lower TSM strategy in participants with moderate-severe chondropathy. Interestingly, the joint contribution strategy of this group was not different than HCs. Participants with no-mild chondropathy demonstrated a TSM strategy that shifted the demand away from their hip and toward their ankle. Given the small sample size, and large variability in joint strategies, future work needs to examine whether these alterations in gait strategy, with or without advanced chondropathy, impact patient function.