Arthritis Foundation/HSS Workshop on Hip Osteoarthritis, Part 3: Rehabilitation and Exercise.

Far more publications are available for osteoarthritis of the knee than of the hip. Recognizing this research gap, the Arthritis Foundation (AF), in partnership with the Hospital for Special Surgery (HSS), convened an in-person meeting of thought leaders to review the state of the science of and clinical approaches to hip osteoarthritis. This article summarizes the recommendations gleaned from 5 presentations given on hip-related rehabilitation at the 2023 Hip Osteoarthritis Clinical Studies Conference, which took place on February 17 and 18, 2023, in New York City.

Relationship of Chronic Systemic Inflammation to Both Chronic Lifestyle-Related Diseases and Osteoarthritis: The Case for Lifestyle Medicine for Osteoarthritis.

Systemic inflammation is a root cause of lifestyle-related chronic diseases and may also play a role in the development and progression of osteoarthritis (OA). Lifestyle medicine seeks to treat, prevent, and reverse lifestyle-related chronic disease via 6 pillars: nutrition, sleep health, stress management, physical activity, social connections, and risky behavior avoidance/reduction. This article presents a review of the literature in which we assess the connections between the 6 pillars of lifestyle medicine, chronic systemic inflammation, and OA. We also discuss the whole-person approach that lifestyle medicine interventions can provide to reduce chronic systemic inflammation and affect the development or progression of OA.

Golfing after Orthopaedic Surgery: A longitudinal follow-up (GOLF) study protocol.

Aims: The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. Methods: This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites. Conclusion: The results of this prospective study will provide clinicians with accurate data to deliver to patients with regard to the likelihood of return to golf and timing of when they can expect to return to golf following their hip, knee, ankle, or shoulder arthroplasty, as well as their joint-specific functional outcomes. This will help patients to manage their postoperative expectations and plan their postoperative recovery pathway.

What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.

An audit of structure-based medical acupuncture by a single provider in patients with musculoskeletal pain using PROMIS scores as the outcome.

BACKGROUND: To assess whether structure-based medical acupuncture (SMA) can improve Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients presenting with musculoskeletal pain. METHODS: An audit was conducted of all patients presenting with musculoskeletal pain treated by a single provider with SMA in 2017. Inclusion criteria included a pre-treatment and at least one post-treatment PROMIS score. Patient demographics and previous treatments tried were recorded. Documented events other than acupuncture that were thought to interfere with PROMIS scores were recorded, and no further scores were used after these events. A maximum of nine visits after the initial visit were used. The PROMIS domains assessed included anxiety, depression, pain interference and physical function. RESULTS: Seventy-two patients who had been treated with SMA met the inclusion criteria. Sixty-five of the patients (90%) had chronic pain. For their presenting complaint, 59 (82%) had previously sought treatment from another non-operative provider, 60 (83%) had tried physical therapy, and 20 (28%) had even had surgery. Despite this, SMA appeared to be able to significantly improve PROMIS anxiety at visits 1-3 and PROMIS depression at visit 3. After just one treatment, minimal clinically important differences (MCID) were reached in 32%-44% of patients for PROMIS anxiety, 17%-36% for PROMIS depression, 28%-29% for PROMIS physical function, and 21%-36% for PROMIS pain interference, based on low and high cut-offs of a range of quoted MCID values. CONCLUSION: In a difficult patient population with musculoskeletal pain, SMA is a technique that can likely be used to improve PROMIS anxiety and depression, although no firm conclusions can be drawn from this uncontrolled clinical audit. Of note, MCIDs were sometimes obtained even after just one treatment.

Feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions in the setting of lifestyle-related chronic disease.

BACKGROUND: Lifestyle factors are associated with musculoskeletal pain and metabolic chronic diseases. To date, intensive lifestyle medicine programs have predominantly targeted metabolic rather than musculoskeletal conditions. OBJECTIVE: To assess the feasibility of an intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions. DESIGN: Prospective observational feasibility study. SETTING: Tertiary academic medical center. PATIENTS: Adults diagnosed with musculoskeletal condition(s) and lifestyle-related chronic disease(s) who previously completed standard-of-care musculoskeletal treatments, enrolled from 2018 to 2020. INTERVENTIONS: Patients enrolled in an intensive interprofessional lifestyle medicine program led by a physiatrist, with options to interface with an acupuncturist, dietician, massage therapist, psychologist, physical therapist, and smoking cessation specialist. The physiatrist engaged in shared decision making with patients to establish program goals related to function, overall health, and required lifestyle changes. Bimonthly interprofessional team conferences facilitated communication between treatment team and patients. MAIN OUTCOME MEASURES: Feasibility was measured by patient participation and goal attainment. Secondary outcomes included changes from program enrollment to discharge in patient anthropometric, metabolic lab, sleep apnea risk, and Patient-Reported Outcomes Measurement Information System (PROMIS) function, pain, and behavioral health measures. RESULTS: Twenty-six patients enrolled in the program (18 [69%] female, mean age 59 [SD 14.5] years, baseline hemoglobin A1c 6.0% [0.8%], high-sensitivity C-reactive protein 7.7 [12.1] mg/dL, 25-hydroxy vitamin D 32.0 [14.2] ng/mL). Of 21 (81%) patients who completed the program, 13/21 (62%) met their goal. On average, program completers presented for 26.2 (10.6) total visits over 191 (88) days. By discharge, program completers achieved clinically meaningful improvement in PROMIS Anxiety (mean difference -3.5 points, 95% confidence interval [-6.5 to 0.5], p = .035), whereas noncompleters did not (p > .05). CONCLUSIONS: An intensive interprofessional lifestyle medicine program for patients with musculoskeletal conditions is feasible. With training in lifestyle intervention, physiatrists are well suited to lead interprofessional teams aimed at assisting patients in making lifestyle changes to achieve personalized function- and health-related goals.

Rate of continued conservative management versus progression to surgery at minimum 1-year follow-up in patients with pre-arthritic hip pain.

BACKGROUND: Extensive literature has described surgical outcomes for pre-arthritic hip pain, but the proportion of patients who progress to surgery remains unknown. OBJECTIVE: To determine the proportion of patients who present to a tertiary referral center for pre-arthritic hip pain and progress to surgery at minimum 1-year follow-up. DESIGN: Retrospective cohort study. SETTING: Single tertiary care academic medical center. PATIENTS: Patients ages 13 to 40 years who presented for initial evaluation to a conservative or surgical orthopedic specialist and were diagnosed with pre-arthritic hip pain (n = 713 patients, 830 hips). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The primary outcome was the rate of progression to surgery at minimum 1-year follow-up for the entire cohort. Predictors of progression to surgery were determined for the entire cohort and for radiographically defined subgroups using multiple logistic regression. Candidate predictors included baseline demographic, radiographic, clinical diagnosis, and patient-reported outcome measures. RESULTS: In a cohort with a mean age of 25.4 (SD 8.1) years, 72.7% female, and mean follow-up of 2.6 (range 1.0-4.8) years, 429 of 830 hips (51.7%, 95% confidence interval [CI] 48.2% to 55.1%) progressed to surgery. Predictors of surgical progression in the entire cohort included younger age (OR 0.95/year, 95% CI 0.93 to 0.98), pain duration longer than 6 months (ORs 1.87-2.03, p ≤ .027), worse physical function (OR 0.96/Patient-Reported Outcomes Measurement Information System [PROMIS] point, 0.92 to 0.99), and a clinical diagnosis of femoroacetabular impingement (FAI) (OR 3.47, 2.05 to 5.89), acetabular dysplasia (OR 2.75, 1.73 to 4.35), and/or labral tear (OR 10.71, 6.98 to 16.47). Radiographic dysplasia (lateral center edge angle <20 degrees) increased the likelihood of surgery in all subgroups (ORs 2.05-8.47, p ≤ .008). Increasing maximum α angle increased the likelihood of surgery in patients with severe cam FAI (α > 63 degrees) (OR 1.03/degree, 1.00 to 1.06). CONCLUSION: Almost half of patients with pre-arthritic hip pain did not progress to surgery at a minimum 1-year follow-up. A trial of conservative management is likely worthwhile in most patients.

Radiation-Induced Brachial Plexopathy in Patients With Breast Cancer Treated With Comprehensive Adjuvant Radiation Therapy.

PURPOSE: Our purpose was to describe the risk of radiation-induced brachial plexopathy (RIBP) in patients with breast cancer who received comprehensive adjuvant radiation therapy (RT). METHODS AND MATERIALS: Records for 498 patients who received comprehensive adjuvant RT (treatment of any residual breast tissue, the underlying chest wall, and regional nodes) between 2004 and 2012 were retrospectively reviewed. All patients were treated with conventional 3 to 5 field technique (CRT) until 2008, after which intensity modulated RT (IMRT) was introduced. RIBP events were determined by reviewing follow-up documentation from oncologic care providers. Patients with RIBP were matched (1:2) with a control group of patients who received CRT and a group of patients who received IMRT. Dosimetric analyses were performed in these patients to determine whether there were differences in ipsilateral brachial plexus dose distribution between RIBP and control groups. RESULTS: Median study follow-up was 88 months for the overall cohort and 92 months for the IMRT cohort. RIBP occurred in 4 CRT patients (1.6%) and 1 IMRT patient (0.4%) (P = .20). All patients with RIBP in the CRT cohort received a posterior axillary boost. Maximum dose to the brachial plexus in RIBP, CRT control, and IMRT control patients had median values of 56.0 Gy (range, 49.7-65.1), 54.8 Gy (47.4-60.5), and 54.8 Gy (54.2-57.3), respectively. CONCLUSIONS: RIBP remains a rare complication of comprehensive adjuvant breast radiation and no clear dosimetric predictors for RIBP were identified in this study. The IMRT technique does not appear to adversely affect the development of this late toxicity.

Management of degenerative spondylolisthesis: development of appropriate use criteria.

BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 - 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Rate of Surgery and Baseline Characteristics Associated With Surgery Progression in Young Athletes With Prearthritic Hip Disorders.

BACKGROUND: Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes. PURPOSE: To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted variables included patients' self-reported athlete status, decision to choose surgery within 1 year of evaluation, and baseline self-reported pain and functional scores on Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score. RESULTS: Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were athletes. Athletes were no more likely to choose surgery than nonathletes (130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI, 0.78-1.25]). Among athletes, those who proceeded to surgery over conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95% CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%, RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI, 1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose surgery also reported worse baseline hip-specific symptoms on all HOOS subscales (mean difference, 10.8-17.7; P < .01 for all). CONCLUSION: Similar to nonathletes, just over half of athletes with PAHD chose surgical management within 1 year of evaluation. Many competitive athletes with PAHD continued with conservative management and deferred surgery, but more structural hip pathology and worse hip-related baseline physical impairment were associated with the choice to pursue surgery.

Short-term Clinical Outcomes of Hip Arthroscopy Versus Physical Therapy in Patients With Femoroacetabular Impingement: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results. PURPOSE/HYPOTHESIS: The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT. STUDY DESIGN: Systematic review; Level of evidence, 1. METHODS: In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)-Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool. RESULTS: The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571). CONCLUSION: In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.

Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain.

Sacroiliac joint (SIJ) pain is thought to be a component of low back pain in 20% of people who suffer with it chronically. There is no consistent objective diagnostic testing that includes SIJ pain as the diagnosis and thereby it can become a diagnosis of exclusion. Treatment of SIJ pain is variable, and no set method or protocol of treatment has been found to be efficacious or reliable. Thus, the healthcare provider is often left to create an individual treatment plan based on their own experiences and expertise. The purpose of this narrative review is to describe and discuss nonoperative treatment options for patients with SIJ pain. Further, coordination of treatment options and progression of treatment will be offered.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis.

BACKGROUND: Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia. PURPOSE: To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders. STUDY DESIGN: Systematic review and meta-analysis. METHODS: In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models. RESULTS: We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; P < .001), and they reported worse postoperative PROM scores compared with nonimpaired patients (weighted mean difference, -20.2 points; 95% CI, -32.9 to -7.5; P < .001). CONCLUSION: Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor. REGISTRATION: CRD42019124836 (PROSPERO).

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Hip Radiograph Findings in Patients Aged 40 Years and Under with Posterior Pelvic Pain.

BACKGROUND: Several sacroiliac joint (SIJ) provocative tests used to assess posterior pelvic pain involve moving and stressing the hip. It is unknown if there is a subgroup of patients with posterior pelvic pain who have underlying hip deformity that could potentially influence performance and interpretation of these tests. OBJECTIVE: To describe the prevalence of radiographic hip deformity and hip osteoarthritis in a group of adults 40 years old and under who met the clinical diagnostic criteria for treatment of posterior pelvic pain with an image guided intra-articular SIJ injection. DESIGN: Retrospective cohort study. SETTING: Tertiary university orthopedic department PATIENTS (OR PARTICIPANTS): One hundred and forty-eight patients were evaluated (83% (123/148) female; mean age 31.3 ± 6.2 years). All had completed a trial of comprehensive noninvasive treatment for posterior pelvic pain and had a minimum of three positive SIJ provocative tests on physical examination. METHODS: Retrospective review identified patients undergoing SIJ injection for pain recommended and performed by seven physiatrists between 2011 and 2017. Hip radiographs were read by a physician with expertise in hip measurements with previously demonstrated excellent intrarater reliability. MAIN OUTCOME MEASUREMENTS: Percentage of patients with hip deformity findings. RESULTS: No patients meeting the inclusion criteria had significant radiographic hip osteoarthritis (Tonnis ≥2 indicating moderate or greater radiographic hip osteoarthritis) and 4/148 (3%) were found to have mild radiographic hip osteoarthritis. Prearthritic hip disorders were identified in 123 (83%, 95% CI: 76, 89%) patients. For those patients with prearthritic hip disorders, measurements consistent with femoroacetabular impingement (FAI) were seen in 61 (41%) patients, acetabular dysplasia in 49 (33%) patients, and acetabular retroversion in 85 (57%) patients. Acetabular retroversion was identified in 43% (crossover sign) and 39% (prominent ischial spine) of patients. CONCLUSIONS: Approximately 57% of adult patients under the age of 40 years with the clinical symptom complex of SIJ pain were found to have radiographic acetabular retroversion. This is a higher percentage than the 5%-15% found in asymptomatic people in the current literature. Further study is needed to assess links between hip structure, hip motion, and links to pelvic pain including peri and intra-articular SIJ pain. LEVEL OF EVIDENCE: III.

Relative Prevalence of Anxiety and Depression in Patients With Upper Extremity Conditions.

PURPOSE: Prior research regarding the impact of mental health on upper extremity musculoskeletal function and recovery has frequently grouped catastrophizing, anxiety, and depression. This study was designed to define the relative prevalence of heightened anxiety versus depressive symptoms among a patient population seeking upper extremity care and to determine if those prevalences varied according to the symptomatic condition. METHODS: All adult patients presenting to a tertiary upper extremity orthopedic center between June 1, 2016 and November 30, 2016 (n = 3,315) completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety and Depression Computer Adaptive Tests. Descriptive statistics and multivariable linear regression assessed differences in average PROMIS scores between demographic and diagnostic groups. Patients were also analyzed according to crossing thresholds for heightened anxiety and depression scores based on established linkage tables with the Generalized Anxiety Disorder 7 and Patient Health Questionnaire-9 Depression scales, respectively. Pearson chi-square analysis and binary logistic regression were performed to determine if the proportion of patients crossing these thresholds varied according to the primary symptomatic condition while accounting for patient age, sex, and race. RESULTS: African American patients and those with carpal tunnel syndrome, trapeziometacarpal arthritis, or shoulder conditions reported significantly higher PROMIS Anxiety scores. Higher PROMIS Depression scores varied only by diagnosis. Seventeen percent of patients exceeded the Anxiety symptoms score threshold and 10% of patients exceeded the Depression symptom threshold. In logistic regression modeling, the likelihood of exceeding the Anxiety threshold varied by diagnosis and was increased in African American patients and females. African American race was associated with exceeding the Depression threshold while accounting for sex and diagnosis. CONCLUSIONS: Patients with upper extremity conditions more frequently report heightened anxiety than heightened depression. Patient race and diagnosis are independent predictors of anxiety among patients seeking care for upper extremity conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Anxiety and Insomnia in Young and Middle-Aged Adult Hip Pain Patients With and Without Femoroacetabular Impingement and Developmental Hip Dysplasia.

BACKGROUND: In young and middle-aged adults with and without hip deformity, hip pain receives treatment focused primarily related to hip structure. Because this hip pain may be chronic, these patients develop other coexisting, modifiable disorders related to pain that may go undiagnosed in this young and active population, including insomnia and anxiety. OBJECTIVE: The objective of this study was to compare assessments of insomnia and anxiety in young and middle-aged adults presenting with hip pain with no greater than minimal osteoarthritis (OA) compared to asymptomatic healthy controls. Comparisons between types of hip deformity and no hip deformity in hip pain patients were performed to assess whether patients with specific hip deformities were likely to have insomnia or anxiety as a cofounding disorder to their hip pain. DESIGN: Prospective case series with control comparison. SETTING: Two tertiary university physiatry outpatient clinics. PARTICIPANTS: A total of 50 hip pain patients aged 18-40 years and 50 gender- and age-matched healthy controls. METHODS: Patients were enrolled if 2 provocative hip tests were found on physical examination and hip radiographs had no or minimal OA. Radiographic hip deformity measurements were completed by an independent examiner. Comparisons of insomnia and anxiety were completed between 50 hip pain patients and 50 controls and between patients with different types of hip deformity. MAIN OUTCOME MEASURES: Insomnia Severity Index (ISI) and Pain Anxiety Symptoms Scale (PASS). RESULTS: A total of 50 hip pain patients (11 male and 39 female) with mean age of 31.2 ± 8.31 years enrolled. Hip pain patients slept significantly less (P = .001) per night than controls. Patients experienced significantly greater insomnia (P = .0001) and anxiety (P = .0001) compared to controls. No differences were found in insomnia and anxiety scores between hip pain patients with and without hip deformity or between different types of hip deformity. CONCLUSION: Hip pain patients with radiographs demonstrating minimal to no hip arthritis with and without hip deformity experience significant cofounding yet modifiable disorders of sleep and anxiety. If recognized early in presentation, treatment of insomnia and anxiety ultimately will improve outcomes for hip patients treated either conservatively or surgically for their hip disorder. LEVEL OF EVIDENCE: II.

Association of Hip Radiograph Findings With Pain and Function in Patients Presenting With Low Back Pain.

BACKGROUND: Relationships between low back pain (LBP) and the hip in patient cohorts have been described primarily in patients with moderate to severe hip osteoarthritis (OA). Less is known about the links of LBP with hip radiographic findings of hip deformity and minimal OA. OBJECTIVE: To describe the incidence of radiographic hip deformity or hip OA; to describe and compare spine- and hip-related pain and function in the subset of patients who were found to have radiographic hip deformity or hip OA; and to compare patients with evidence of radiographic hip deformity or hip OA to patients without hip radiographic findings. DESIGN: Prospective cohort study with cross-sectional design. SETTING: Tertiary university. PATIENTS: A total of 63 patients (40 women, 23 men) with a mean age of 48.5 ± 14 years with LBP and a minimum of one positive provocative hip test. METHODS: Hip radiographs were assessed by an independent examiner for hip OA and deformity. MAIN OUTCOME MEASUREMENTS: Comparisons of hip and lumbar spine pain and function were completed for patients with radiographic findings of hip OA or deformity. RESULTS: Moderate to severe hip OA was found in 12 of 60 patients (20.0%). At least one measurement of femoroacetabular impingement (FAI) was found in 14 of 60 patients (23.3%) to 33 of 45 patients (73.3%). At least one measurement of developmental hip dysplasia (DDH) was found in 7 of 60 patients (11.6%) to 11 of 63 patients (17.4%). Greater pain and reduced hip and lumbar spine function were found in the patients with moderate to severe hip OA. Patients with LBP and FAI were found to have significantly greater extremes of pain and reduced lumbar spine function. CONCLUSION: Links between the hip and the spine affecting pain and function may be found in patients with LBP and hip deformity and before the onset of radiographic hip OA, and may be associated with hip deformity. Further investigation is needed to better understand these links and their potential impact on prognosis and treatment of LBP. LEVEL OF EVIDENCE: II.