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The association between hip joint pathology and patient reported outcomes prior to hip arthroscopy
Abstracts / Journal of Science and Medicine in Sport 20S (2017) 48–51
activities—lying on the affected hip, ascending or descending stairs/slopes/ramps, and pain moving from a sitting to standing position. A blinded physiotherapist performed 10 pain provocation tests potentially diagnostic for GTPS—palpation of the greater trochanter, resisted external derotation test, modified resisted external derotation test, standard and modified Ober’s tests, FABER (flexion, abduction, external rotation) test, resisted hip abduction, single-leg stance test, and the resisted hip internal rotation test. Diagnostic test accuracy was determined by calculating sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and odds ratio. A sample of 16 symptomatic and 17 asymptomatic women undertook a hip MRI scan. Gluteal tendons were evaluated and categorized as no pathology, mild tendinosis, moderate tendinosis/partial tear, or full thickness tear. Results: Clinical test analyses showed FABER test, palpation of the greater trochanter, resisted hip abduction, and the resisted external derotation test have the highest diagnostic test accuracy for greater trochanteric pain syndrome. All symptomatic and 88% of asymptomatic participants had pathological gluteal tendon changes on MRI, from mild tendinosis to full-thickness tear. Discussion: Undertaking of a series of pain provocation tests could be useful for diagnosing GTPS. Radiological investigation with a MRI scan, may be of little value to the management of this condition, however, is an important tool to rule out more sinister pathologies and other potential causes of hip pain (e.g., lumbosacral spine and sacroiliac joint pathology). Future research may consider investigating clinical prediction rules, whereby a selected number of tests must be positive before diagnosis of the condition can be made. https://doi.org/10.1016/j.jsams.2017.09.290 96 Inducing slight hip discomfort reduces hip extension in gait T. Pizzari 1,∗ , J. McClelland 1 , A. Semciw 1,2 1
La Trobe University Sport and Exercise Medicine Research Centre, Australia 2 The University of Queensland, Australia Background: Recent developments in the measurement of electromyographic (EMG) activity of the deep gluteal muscles has advanced knowledge of the role of these muscles in hip function and dysfunction. The EMG techniques require the insertion, via needles, of intramuscular electrodes into the gluteus minimus (GMin) and the gluteus medius (GMed). It is not known if this somewhat invasive technique alters the kinematics of movement that could, in turn, alter EMG activity. Therefore, the aim of this study was to compare trunk and lower limb kinematics before and after the insertion of intramuscular electrodes into the deep gluteal muscles. Methods: Ten healthy individuals (6 men, 4 women; mean age 23.8 years, SD = 1.6) were included in this study. Participants performed six walking trials at a self-selected speed before and after EMG electrode insertion into their stance leg. A 10 camera Vicon motion analysis system was used to analyse lower limb and trunk biomechanics during walking and an embedded force platform allowed the calculation of lower limb joint moments. Following the initial kinematic testing, five intramuscular electrodes were inserted under ultrasound guidance; three into the segments of GMed and two into GMin. Kinematic testing was repeated following the insertions. All biomechanical characteristics were compared before and after electrode insertions using paired t-tests. Level of discomfort was recorded during gait trials using a visual analogue scale (VAS: 0–10 cm), with 10 representing extreme discomfort.
49
Results: Post electrode insertion, participants walked with reduced hip extension (p < 0.02) and a reduced hip extension moment (p < 0.03). There was no change in walking speed or cadence and no other kinematic differences in the trunk or lower limb following electrode insertion. The mean VAS discomfort score post insertion was 2.4 cm (SD = 1.9). Discussion: Inducing slight hip discomfort resulted in an immediate reduction in hip extension which could have implications particularly for anterior GMin EMG activity. This finding adds to current evidence of the sequelae of the anterior GMin in hip dysfunction. Consistent deficits have been identified in the anterior GMin muscle structure and function in the presence of painful pathology. It has been proposed that shorter strides, evident in a number of painful hip conditions, reduces the stimulus to the anterior GMin since it is not required to stabilise the front of the hip in terminal stance when the hip would normally reach full extension. In combination, this emerging evidence highlights the potential role for gait re-education in hip rehabilitation. https://doi.org/10.1016/j.jsams.2017.09.291 97 The association between hip joint pathology and patient reported outcomes prior to hip arthroscopy M. Freke 1 , K. Crossley 2 , T. Russell 1 , K. Sims 1 , A. Semciw 1,∗ 1
The University of Queensland, Australia La Trobe University, Australia Background: Hip arthroscopy has been used to manage symptoms associated with femoroacetabular impingement (FAI), acetabular and femoral head chondropathy (indicative of early osteoarthritis) and labral tears. While patient reported outcomes (PROs) following hip arthroscopy have significantly improved for a number of pathological conditions; those with advanced osteoarthritic signs, or severe chondropathy tend to have less benefit, or deteriorate following arthroscopy. It may be important to understand how pathology diagnosed at arthroscopy relates to PROs before hip arthroscopy. This may inform clinicians and patients about the appropriateness and potential benefit of hip arthroscopy. Therefore the aim of this study was to; (i) describe the prevalence of chondral and labral pathology at arthroscopy in people with hip and groin pain; (ii) describe the association between pathology and patient reported outcome (PRO) scores in a pre-hip arthroscopy population. Methods: 67 participants (22 female) aged 31 (18–48) years scheduled for hip arthroscopy completed a series of PROs prior to surgery. The PROs included: Hip osteoarthritis outcome score (HOOS); international Hip Outcome Tool (iHOT33); Pain on Activity visual analogue scale (POA). Pathology during arthroscopy was described as: acetabular or femoral chondropathy (mild, severe); cam or pincer morphology (FAI); ligamentum teres tear; labral tear (mild, severe). Univariate linear regression models were used to establish the relationship between individual PRO items (dependent variable) and diagnosis at pathology (independent variable), as well as potential covariates (e.g. age, height, gender, BMI). Separate backwards step-wise multivariate linear regression models were built for each PRO subscale, by entering independent variables or covariates that trended to significance (p < 0.10). Results: 91% of participants had labral pathology; 76% had acetabular chondropathy; 31% had femoral head chondropathy. Across the ten PRO subscales, severe femoral head chondropathy and severe labral tears had the greatest number of significant associations with PRO scores. The strongest association was with ‘HOOS 2
50
Abstracts / Journal of Science and Medicine in Sport 20S (2017) 48–51
symptoms and stiffness’ subscale, where severe femoral head chondropathy explained 26% of variability in symptoms and stiffness, when adjusted for BMI and presence of pincer FAI morphology (p = 0.002). Discussion: There is a high prevalence of labral pathology and acetabular chondropathy in people with hip and groin pain requiring arthroscopy. Severe femoral head chondropathy and severe labral tears are most associated with pre-arthroscopy PROs, however, at best only explain 26% of variability in PROs. Further investigation regarding pre-operative physical function and radiological examination may help to refine clinical decision-making with regards to the appropriateness and likely benefit of hip arthroscopy.
cohort of chronic groin pain patients, we observed remarkable outcomes, offering hope to patients and practitioners alike. https://doi.org/10.1016/j.jsams.2017.09.293 99 Education with exercise improves pain and dysfunction in post-menopausal women with greater trochanteric pain syndrome C. Ganderton 1,∗ , A. Semciw 1,2 , J. Cook 1 , E. Moreira 3 , T. Pizzari 1 1
La Trobe University, Australia The University of Queensland, Australia 3 Federal University of Minas Gerais, Brazil Introduction: The conservative management of greater trochanteric pain syndrome (GTPS) is poorly described as there have been few studies evaluating conservative management for GTPS. The aim of this study was to determine the effects of education and exercise on pain and function in post-menopausal women with GTPS. Methods: 95 post-menopausal women were recruited and randomised to receive one of two 12-week exercise programs (sham or targeted exercise intervention). All participants received education on avoiding tendon compression with appropriate activity modification. The Victorian Institute of Sport Assessment–gluteal tendon (VISA-G) was examined at baseline, 12-weeks and 52-weeks, with 12-weeks being the primary outcome point. Secondary outcomes included hip pain and function questionnaires (hip dysfunction and osteoarthritis outcome score, Oxford hip score, lateral hip pain questionnaire), a global rating of change in symptom questionnaire, and a quality of life measure (AQoL-8D questionnaire). Differences between groups were analysed using intention to treat with analysis of covariance. Per-protocol analysis and responder analysis were also undertaken. Results: Intention to treat analyses and the per-protocol analysis showed no between-group differences for the targeted intervention and sham exercise groups. Significant within-group improvements in VISA-G score was found for both exercise programs at 12 and 52-week time-points (p < 0.001). Responders to the targeted intervention had significantly better VISA-G, hip dysfunction and osteoarthritis outcome score, Oxford hip score, and lateral hip pain questionnaire scores when compared to responders in the sham group. Discussion: Improvements in both groups reflect the importance of education in the management of GTPS. Education focused on decreasing compression of the gluteal tendons over the greater trochanter. Combined compressive and tensile load cause adaptive changes in the tendon matrix and associated pain and dysfunction. Therefore, a reduction in these loads should result in pain relief and increased function. Some women randomised to the targeted exercise group had better outcomes than others within the group. This suggests that this exercise program may have additional benefit for some women, however, further research to identify the characteristics of this group is necessary. Education on postural strategies and functional activities could be the most important element in the management of GTPS in post-menopausal women. 2
https://doi.org/10.1016/j.jsams.2017.09.292 98 Dorsal root ganglion stimulation as a treatment for intractable groin pain Bruce Mitchell 1,3,∗ , Paul Verrills 1 , David Vivian 1 , Chantelle Sinclair 2 1
Metro Pain Clinic, Monash House, Australia Monash Clinical Research, Monash House, Australia 3 Metro Pain Group, Australia Introduction: Neuromodulation is an effective and safe treatment option for chronic neuropathic pain, especially for low back pain and predominant limb pain1 . The majority of patients with chronic pain experience sustained and significant pain relief with SCS treatment. However, the anatomical pain distributions of some presentations, such as neuropathic pain of the extremities, are not well covered with conventional SCS induced paraesthesias. Groin pain is one of these distributions. Fortunately, a recent iteration of neuromodulation pain therapies is the stimulation of the dorsal root ganglion (DRG). DRG stimulation therapy uses an innovative lead configuration and delivery system around the dorsal root ganglion allowing more effective and individualised treatment of patients, particularly those with persistent focal pain, including areas that are difficult to treat with conventional SCS. A brief overview of the DRG SCS technique as well as the outcome results from a prospective series of patients who presented with groin pain and were implanted with DRG SCS. Methodology: Since 2014, twelve consecutive groin pain patients were prospectively recruited, trialled and implanted with DRG stimulation systems for groin pain. Specifically designed leads were implanted to target the DRGs between T11 and L2. VAS pain scores were recorded at baseline and at 1, 3, 6 and 12 month follow-ups. The technical aspects specific to this procedure will be presented alongside outcome data. Treatment outcome was assessed with the numerical pain rating scale (NPRS). Assessments were made at baseline and at end of trial (EOT), 6 and 12 month follow-ups. Study was HREC approved. Results: The mean baseline VAS was 81.6/100 (SD 14.6). One month after implant, the mean VAS dropped to 19.2/100 (SD 12.9). At 3 months the mean VAS of 17.5/100 (SD 11.9, n = 12 to date) was observed. Pain relief was maintained; at 12 months a mean VAS of 17.8/100 (SD 9.7, n = 9 to date) was observed. All patients had reduced their pain by ≥ 50% at their most recent follow-up visit. Conclusions: DRG stimulation is an exciting evolution in the treatment options for chronic, non-responsive groin pain. It offers compelling therapeutic benefits compared with traditional neuromodulation therapies2 . Indeed in this small but difficult to treat 2
https://doi.org/10.1016/j.jsams.2017.09.294
activities—lying on the affected hip, ascending or descending stairs/slopes/ramps, and pain moving from a sitting to standing position. A blinded physiotherapist performed 10 pain provocation tests potentially diagnostic for GTPS—palpation of the greater trochanter, resisted external derotation test, modified resisted external derotation test, standard and modified Ober’s tests, FABER (flexion, abduction, external rotation) test, resisted hip abduction, single-leg stance test, and the resisted hip internal rotation test. Diagnostic test accuracy was determined by calculating sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and odds ratio. A sample of 16 symptomatic and 17 asymptomatic women undertook a hip MRI scan. Gluteal tendons were evaluated and categorized as no pathology, mild tendinosis, moderate tendinosis/partial tear, or full thickness tear. Results: Clinical test analyses showed FABER test, palpation of the greater trochanter, resisted hip abduction, and the resisted external derotation test have the highest diagnostic test accuracy for greater trochanteric pain syndrome. All symptomatic and 88% of asymptomatic participants had pathological gluteal tendon changes on MRI, from mild tendinosis to full-thickness tear. Discussion: Undertaking of a series of pain provocation tests could be useful for diagnosing GTPS. Radiological investigation with a MRI scan, may be of little value to the management of this condition, however, is an important tool to rule out more sinister pathologies and other potential causes of hip pain (e.g., lumbosacral spine and sacroiliac joint pathology). Future research may consider investigating clinical prediction rules, whereby a selected number of tests must be positive before diagnosis of the condition can be made. https://doi.org/10.1016/j.jsams.2017.09.290 96 Inducing slight hip discomfort reduces hip extension in gait T. Pizzari 1,∗ , J. McClelland 1 , A. Semciw 1,2 1
La Trobe University Sport and Exercise Medicine Research Centre, Australia 2 The University of Queensland, Australia Background: Recent developments in the measurement of electromyographic (EMG) activity of the deep gluteal muscles has advanced knowledge of the role of these muscles in hip function and dysfunction. The EMG techniques require the insertion, via needles, of intramuscular electrodes into the gluteus minimus (GMin) and the gluteus medius (GMed). It is not known if this somewhat invasive technique alters the kinematics of movement that could, in turn, alter EMG activity. Therefore, the aim of this study was to compare trunk and lower limb kinematics before and after the insertion of intramuscular electrodes into the deep gluteal muscles. Methods: Ten healthy individuals (6 men, 4 women; mean age 23.8 years, SD = 1.6) were included in this study. Participants performed six walking trials at a self-selected speed before and after EMG electrode insertion into their stance leg. A 10 camera Vicon motion analysis system was used to analyse lower limb and trunk biomechanics during walking and an embedded force platform allowed the calculation of lower limb joint moments. Following the initial kinematic testing, five intramuscular electrodes were inserted under ultrasound guidance; three into the segments of GMed and two into GMin. Kinematic testing was repeated following the insertions. All biomechanical characteristics were compared before and after electrode insertions using paired t-tests. Level of discomfort was recorded during gait trials using a visual analogue scale (VAS: 0–10 cm), with 10 representing extreme discomfort.
49
Results: Post electrode insertion, participants walked with reduced hip extension (p < 0.02) and a reduced hip extension moment (p < 0.03). There was no change in walking speed or cadence and no other kinematic differences in the trunk or lower limb following electrode insertion. The mean VAS discomfort score post insertion was 2.4 cm (SD = 1.9). Discussion: Inducing slight hip discomfort resulted in an immediate reduction in hip extension which could have implications particularly for anterior GMin EMG activity. This finding adds to current evidence of the sequelae of the anterior GMin in hip dysfunction. Consistent deficits have been identified in the anterior GMin muscle structure and function in the presence of painful pathology. It has been proposed that shorter strides, evident in a number of painful hip conditions, reduces the stimulus to the anterior GMin since it is not required to stabilise the front of the hip in terminal stance when the hip would normally reach full extension. In combination, this emerging evidence highlights the potential role for gait re-education in hip rehabilitation. https://doi.org/10.1016/j.jsams.2017.09.291 97 The association between hip joint pathology and patient reported outcomes prior to hip arthroscopy M. Freke 1 , K. Crossley 2 , T. Russell 1 , K. Sims 1 , A. Semciw 1,∗ 1
The University of Queensland, Australia La Trobe University, Australia Background: Hip arthroscopy has been used to manage symptoms associated with femoroacetabular impingement (FAI), acetabular and femoral head chondropathy (indicative of early osteoarthritis) and labral tears. While patient reported outcomes (PROs) following hip arthroscopy have significantly improved for a number of pathological conditions; those with advanced osteoarthritic signs, or severe chondropathy tend to have less benefit, or deteriorate following arthroscopy. It may be important to understand how pathology diagnosed at arthroscopy relates to PROs before hip arthroscopy. This may inform clinicians and patients about the appropriateness and potential benefit of hip arthroscopy. Therefore the aim of this study was to; (i) describe the prevalence of chondral and labral pathology at arthroscopy in people with hip and groin pain; (ii) describe the association between pathology and patient reported outcome (PRO) scores in a pre-hip arthroscopy population. Methods: 67 participants (22 female) aged 31 (18–48) years scheduled for hip arthroscopy completed a series of PROs prior to surgery. The PROs included: Hip osteoarthritis outcome score (HOOS); international Hip Outcome Tool (iHOT33); Pain on Activity visual analogue scale (POA). Pathology during arthroscopy was described as: acetabular or femoral chondropathy (mild, severe); cam or pincer morphology (FAI); ligamentum teres tear; labral tear (mild, severe). Univariate linear regression models were used to establish the relationship between individual PRO items (dependent variable) and diagnosis at pathology (independent variable), as well as potential covariates (e.g. age, height, gender, BMI). Separate backwards step-wise multivariate linear regression models were built for each PRO subscale, by entering independent variables or covariates that trended to significance (p < 0.10). Results: 91% of participants had labral pathology; 76% had acetabular chondropathy; 31% had femoral head chondropathy. Across the ten PRO subscales, severe femoral head chondropathy and severe labral tears had the greatest number of significant associations with PRO scores. The strongest association was with ‘HOOS 2
50
Abstracts / Journal of Science and Medicine in Sport 20S (2017) 48–51
symptoms and stiffness’ subscale, where severe femoral head chondropathy explained 26% of variability in symptoms and stiffness, when adjusted for BMI and presence of pincer FAI morphology (p = 0.002). Discussion: There is a high prevalence of labral pathology and acetabular chondropathy in people with hip and groin pain requiring arthroscopy. Severe femoral head chondropathy and severe labral tears are most associated with pre-arthroscopy PROs, however, at best only explain 26% of variability in PROs. Further investigation regarding pre-operative physical function and radiological examination may help to refine clinical decision-making with regards to the appropriateness and likely benefit of hip arthroscopy.
cohort of chronic groin pain patients, we observed remarkable outcomes, offering hope to patients and practitioners alike. https://doi.org/10.1016/j.jsams.2017.09.293 99 Education with exercise improves pain and dysfunction in post-menopausal women with greater trochanteric pain syndrome C. Ganderton 1,∗ , A. Semciw 1,2 , J. Cook 1 , E. Moreira 3 , T. Pizzari 1 1
La Trobe University, Australia The University of Queensland, Australia 3 Federal University of Minas Gerais, Brazil Introduction: The conservative management of greater trochanteric pain syndrome (GTPS) is poorly described as there have been few studies evaluating conservative management for GTPS. The aim of this study was to determine the effects of education and exercise on pain and function in post-menopausal women with GTPS. Methods: 95 post-menopausal women were recruited and randomised to receive one of two 12-week exercise programs (sham or targeted exercise intervention). All participants received education on avoiding tendon compression with appropriate activity modification. The Victorian Institute of Sport Assessment–gluteal tendon (VISA-G) was examined at baseline, 12-weeks and 52-weeks, with 12-weeks being the primary outcome point. Secondary outcomes included hip pain and function questionnaires (hip dysfunction and osteoarthritis outcome score, Oxford hip score, lateral hip pain questionnaire), a global rating of change in symptom questionnaire, and a quality of life measure (AQoL-8D questionnaire). Differences between groups were analysed using intention to treat with analysis of covariance. Per-protocol analysis and responder analysis were also undertaken. Results: Intention to treat analyses and the per-protocol analysis showed no between-group differences for the targeted intervention and sham exercise groups. Significant within-group improvements in VISA-G score was found for both exercise programs at 12 and 52-week time-points (p < 0.001). Responders to the targeted intervention had significantly better VISA-G, hip dysfunction and osteoarthritis outcome score, Oxford hip score, and lateral hip pain questionnaire scores when compared to responders in the sham group. Discussion: Improvements in both groups reflect the importance of education in the management of GTPS. Education focused on decreasing compression of the gluteal tendons over the greater trochanter. Combined compressive and tensile load cause adaptive changes in the tendon matrix and associated pain and dysfunction. Therefore, a reduction in these loads should result in pain relief and increased function. Some women randomised to the targeted exercise group had better outcomes than others within the group. This suggests that this exercise program may have additional benefit for some women, however, further research to identify the characteristics of this group is necessary. Education on postural strategies and functional activities could be the most important element in the management of GTPS in post-menopausal women. 2
https://doi.org/10.1016/j.jsams.2017.09.292 98 Dorsal root ganglion stimulation as a treatment for intractable groin pain Bruce Mitchell 1,3,∗ , Paul Verrills 1 , David Vivian 1 , Chantelle Sinclair 2 1
Metro Pain Clinic, Monash House, Australia Monash Clinical Research, Monash House, Australia 3 Metro Pain Group, Australia Introduction: Neuromodulation is an effective and safe treatment option for chronic neuropathic pain, especially for low back pain and predominant limb pain1 . The majority of patients with chronic pain experience sustained and significant pain relief with SCS treatment. However, the anatomical pain distributions of some presentations, such as neuropathic pain of the extremities, are not well covered with conventional SCS induced paraesthesias. Groin pain is one of these distributions. Fortunately, a recent iteration of neuromodulation pain therapies is the stimulation of the dorsal root ganglion (DRG). DRG stimulation therapy uses an innovative lead configuration and delivery system around the dorsal root ganglion allowing more effective and individualised treatment of patients, particularly those with persistent focal pain, including areas that are difficult to treat with conventional SCS. A brief overview of the DRG SCS technique as well as the outcome results from a prospective series of patients who presented with groin pain and were implanted with DRG SCS. Methodology: Since 2014, twelve consecutive groin pain patients were prospectively recruited, trialled and implanted with DRG stimulation systems for groin pain. Specifically designed leads were implanted to target the DRGs between T11 and L2. VAS pain scores were recorded at baseline and at 1, 3, 6 and 12 month follow-ups. The technical aspects specific to this procedure will be presented alongside outcome data. Treatment outcome was assessed with the numerical pain rating scale (NPRS). Assessments were made at baseline and at end of trial (EOT), 6 and 12 month follow-ups. Study was HREC approved. Results: The mean baseline VAS was 81.6/100 (SD 14.6). One month after implant, the mean VAS dropped to 19.2/100 (SD 12.9). At 3 months the mean VAS of 17.5/100 (SD 11.9, n = 12 to date) was observed. Pain relief was maintained; at 12 months a mean VAS of 17.8/100 (SD 9.7, n = 9 to date) was observed. All patients had reduced their pain by ≥ 50% at their most recent follow-up visit. Conclusions: DRG stimulation is an exciting evolution in the treatment options for chronic, non-responsive groin pain. It offers compelling therapeutic benefits compared with traditional neuromodulation therapies2 . Indeed in this small but difficult to treat 2
https://doi.org/10.1016/j.jsams.2017.09.294