Abstract
Background
Psychiatric disorders are known to have a negative impact on outcomes attained from hip-preservation surgery. Psychosocial traits such as resiliency and pain avoidance likely also affect treatment outcomes, however these characteristics are less easily identified, and data is lacking supporting their presence and impact on related outcomes within the hip preservation population. We therefore evaluated hip preservation patients for a variety of maladaptive psychosocial traits and assessed patient-reported outcomes (PROs) in order to ascertain which specific traits were most associated with hip pain and dysfunction.
Methods
62 subjects aged 15-49 years presenting for evaluation of a nonarthritic hip condition completed psychosocial questionnaires and patient reported outcome measures via electronic survey as listed in table one. Participants were tested again eight weeks later to evaluate the relationship between changes in physical function, pain, and mental health behaviors. Pearson correlation coefficients assessed association between hip PROs and psychosocial tests and analyses were corrected for multiple comparisons.
Results
Pain Catastrophizing (PCS), Kinesiophobia (TSK), Stress, and PROMIS-Global Mental Health (GMH) scores correlated with poor physical function and high pain scores at zero and eight weeks. Low resiliency (BRS) and depression were also associated with elevated pain on PRO tests as well as HOOS-Physical Function. There was a moderately strong correlation between improvement in PROMIS-Physical Function (PF) from zero to eight weeks and subjects initial scores for kinesiophobia, anxiety, and stress (r= -0.45, -0.41, -0.44, all p<0.05).
Conclusion
PCS, TSK, Stress, Depression, and low BRS are associated with pain and disability in hip preservation subjects. Elevated TSK, Anxiety and Stress may be predictors of failure to improve with nonoperative treatment. These psychosocial characteristics should be investigated further as predictors of clinical outcomes in the hip preservation population.
Level of Evidence: II
Keywords: hip preservation, patient reported outcomes, hip arthroscopy, psychosocial
Introduction
Over the last 30 years, there has been a drastic increase in the number of joint preservation surgeries performed for pre-arthritic hip conditions in the United States.1 Despite advances in surgical technique and our understanding of the biomechanics of pre-arthritic hip conditions such as impingement and dysplasia, failure rates range from 5-20%2,3 at early follow up, and can be even higher with continued monitoring.4 These failures are often attributed to the presence of pre-operative osteoarthritis,5 increased age,6 or unaddressed structural deformity.7,8 The influence of psychosocial factors on surgical and rehabilitative outcomes has been recognized in multiple populations but has largely been ignored in individuals with hip pathology, despite growing recognition by clinicians as to how psychosocial factors may contribute to patient outcomes.
Recent studies demonstrate that poor mental health is associated with lower physical function9 and certain psychiatric diagnoses are being identified as independent factors associated with failure of hip arthroscopy.10 Maladaptive psychological features such as anxiety, depression, pain catastrophizing, and kinesiophobia are known to negatively influence treatment outcomes in surgery.11,12,13 Conversely, resiliency, self-efficacy, and grit appear to be positively associated with improvement during rehabilitation.9,14 Unfortunately, approximately one third of young adult patients undergoing hip preservation surgery demonstrate maladaptive behavior patterns, with between 14-25% demonstrating mild to moderate depression or anxiety in prior studies.2,15,16 Studies further demonstrate that mental health predicts baseline physical function in patients with symptomatic femoroacetabular impingement (FAI),9,18 a common cause of hip pain in young adults; patients with FAI who have documented psychiatric comorbidities are 3 times more likely to fail hip arthroscopy and go onto require revision hip surgery.10,19 Further investigation into the incidence of these psychosocial conditions and their contributions to surgical and non-surgical outcomes needs to be performed in musculoskeletal medicine, specifically in the developing field of hip preservation surgery.
We therefore evaluated hip preservation patients for a variety of maladaptive psychosocial traits and assessed patient-reported outcomes (PROs) to ascertain which specific traits were most associated with hip pain and dysfunction. We hypothesized that maladaptive psychosocial traits (low resiliency, self-efficacy, and grit, and high kinesiophobia, pain catastrophizing, and hazardous alcohol use) will be associated with higher pain scores and lower reported physical function (HOOS, PROMISPI, PROMIS-PB, PROMIS-PF).
Methods
This prospective study was approved by the institutional review board. Patients between the ages of 15-49 years presenting for new or return appointment at an academic hip preservation clinic run by an open and arthroscopic hip surgeon (M.C.W, R.W.) were eligible for inclusion. Inclusion criteria included a chief complaint of hip pain or dysfunction and a diagnosis of a nonarthritic hip condition including labral tear, femoroacetabular impingement (FAI), snapping hip, femoral anteversion or dysplasia. Exclusion criteria included age <15 or >50 years, difficulty with written English, surgery scheduled within eight weeks or treatment for alternative conditions such as trochanteric bursitis, osteoarthritis, hip dislocation, avascular necrosis, or fracture. Patients were screened for inclusion by the medical provider or research assistant after receiving their medical care. Following enrollment demographic data including age, gender, athletic interests, education level, occupation, and contact information were collected using an electronic survey administered via RedCap electronic data capture tools.2 Participants were then prompted to complete the following tests administered in a randomized order on a handheld electronic tablet: Visual Analog Scale (VAS)17 for pain, Hip Disability Osteoarthritis Outcome Score (HOOS), PROMIS Physical Function computer adaptive tests (PROMIS PF-CAT), Depression Anxiety Stress Scale (DASS-21),1 PROMIS Global Mental (GM),1 Pain Behavior (PB) and Pain Interference (PI) adaptive tests,1 Alcohol use Disorders Identification Test (AUDIT),1 Short Tampa Scale for Kinesiophobia (TSK-11),1 Brief Resiliency Scale (BRS),1 Short Grit Scale (GRIT-S),1 and Pain Catastrophizing Scale (PCS).1 Patients who were unable to complete the testing during the visit due to time limitations were allowed to complete testing after the visit using an emailed link to the online surveys. The test closed automatically after 48 hours regardless of completion status. Eight weeks after enrollment participants received via email a link to a new RedCap survey repeating the same set of surveys to again evaluate pain, physical function, and mental health; surveys were electronically randomized so that participants received the tests in a new order. Study personnel monitored survey completion within the RedCap system and contacted participants via phone and/or email to confirm that the survey was received.
Statistical Analysis
Data analysis was performed by a statistician using SAS statistical software (SAS Institute, Cary, NC); P value of <.05 was considered statistically significant. Presence and severity of maladaptive traits, depression, and anxiety in young adults with hip pain was calculated. Pearson and Spearman Correlations were used to determine association between continuous variables, and multivariate analysis was conducted to evaluate for associations between individual tests and demographic and clinical features such as dysplasia severity (lateral center edge angle). Subgroup analysis was performed with ANOVA with post-hoc unpaired t- tests with a Bonferroni Holm correction to evaluate for differences between patients diagnosed with FAI versus dysplasia. Effect size, recruitment and retention rates were analyzed to guide the design and conduct of future interventions. Linear mixed models were used to evaluate for any significant difference in mental health, pain and function scores over the duration of the study; MDC for PROMIS PF-CAT, Pain Interference, Pain Behavior and HOOS were used as cutoffs to define clinically significant improvement. For PROMIS measures the established minimally importance difference (MID) in patients with back pain undergoing psychotherapy was used. Scoring and normative data for the psychological metrics are described in table one.
Results
62 participants were consented and enrolled in this study. Of these, 50 participants completed initial testing and 12 did not. Following the eight-week period, 23 participants completed follow-up testing and a total of 27 did not (Figure 1). The mean age for our study group was 28.7±10.5 years and BMI was 25.4±5.2 kg/m2. Of the 62 participants enrolled, 30 presented with right hip pain, 21 with left hip pain and 11 with bilateral hip pain (table 2). Most participants had prior treatment consisting of physical therapy (46), followed by other forms of nonoperative treatment such as chiropractic care, activity modification (42) and corticosteroid injections (18). Eight participants had a history of prior surgery such as hip arthroscopy (5), periacetabular osteotomy (2), and total hip arthroplasty (1). Diagnosis of nonarthritic hip conditions such as femoroacetabular impingement and hip dysplasia were made in 11 and 7 participants, respectively. The majority of participants were found to have multiple diagnosis at presentation which included both nonarthritic hip conditions such as labral tear with femoroacetabular impingement and arthritic hip conditions such as osteoarthritis with labral tear.
Figure 1.
CONSORT diagram depicting study enrollment and timeline.
Table 1.
Overview of Psychological Tests Administered
| Measure | Test | Format | Scoring |
|---|---|---|---|
| Self-Efficacy | Generalized Self Efficacy Scale (GSE)7 | 10 item test 1-4 points each | 10 (low SE) to 40 (high SE) |
| Grit | Short Grit Scale (Grit-S)1 | 8 item test 1-5 points each, divided by 8 | 1 (not at all gritty) to 5 (extremely gritty) |
| Pain Catastrophizing | Pain Catastrophizing Scale (PCS)9 | 13 item test 0-4 points each | 0-52 >30 clinically significant level of pain catastrophizing, high risk of developing chronic pain and disability |
| Kinesiophobia | Shortened Tampa Scale for Kinesiophobia (TSK-11)10 | 11 item test 1-4 points each | 11 (no kinesiophobia) – 44 (high kinesiophobia) no specific cutoff exists |
| Depression, Anxiety, Stress | Short Depression Anxiety Stress Scale (DASS21)3 | 21 item test 7 items for each subscale 0-3 points each | 0-21 score for each subscale: 0-2: Normal 3-5: Mild 5-9: Moderate 10+ Severe |
| Resiliency | Brief Resiliency Scale (BRS)8 | 6 item test 1-5 points each divide by 6 | 1-5 score: 1.0-2.99: Low Resilience 3.0-4.3: Normal resilience 4.3-5.0: High resilience |
| Overall Mental Health and Wellbeing | PROMIS Pain interference (PI), Pain behavior (PB) Global Mental Health (GMH), and Physical Function (PF)1 | Adaptive test T score output | 40 One SD below mean 50 Mean 60 one SD above mean |
| Alcohol Misuse | AUDIT6 | 10 item test 0-4 points each | 8+ harmful/hazardous drinking 13+ alcohol dependence (F) 15+ alcohol dependence (M) |
| Pain Rating | Visual Analog Scale (VAS)17 | Scale from 0-10 | 1 (no pain) to 10 (extreme pain) |
Table 2.
Participant Demographics and Radiographic Measurements
| Variable | Mean± SD (range) | p-value | |
|---|---|---|---|
| Age (years) | 28.7±10.5 (15-49) | NS | |
| BMI (kg/m2) | 25.4±5.2 (17.3-44.6) | NS | |
| AA (degrees) | 62.1±16.6 (25.0-90.0) | NS | |
| LCEA (degrees) | 27.7±9.7 (15.0-65.0) | NS | |
| Variable | N (%) | p-value | |
| Gender | Male | 14 (23) | NS |
| Female | 48 (77) | ||
| Affected Hip | Right | 30 (48) | NS |
| Left | 21 (34) | ||
| Bilateral | 11 (18) | ||
LCEA=Lateral Center Edge Angle, AA=Alpha Angle.
Table 3.
Pearson Correlation Coefficients (r) for Patient Reported Outcome Measures and Psychological Tests in Hip Preservation Patients
| VAS | PROMIS PF | PROMIS PI | PROMIS PB | HOOS | HOOS PF | HOOS PAIN | HOOS SPORT | |
|---|---|---|---|---|---|---|---|---|
| PROMIS GMH | NS | r=0.297 p=0.03 | r=-0.539 p<0.001 | r=-0.588 p<0.001 | r=-0.269 p=0.06 | r=-0.378 p=0.007 | r=-0.378 p=0.007 | NS |
| Pain Catastrophizing (PCS) | r=0.30 p=0.037 | r=-0.488 p=<0.001 | r=0.648 p<0.001 | r=0.630 p<0.001 | r=0.547 p<0.001 | r=0.502 p<0.001 | r=0.534 p<0.001 | r=0.404 p=0.004 |
| Kinesiophobia (TSK) | NS | r=-0.619 p=<0.001 | r=0.49 p<0.001 | r=0.589 p<0.001 | r=0.423 p=0.002 | r=0.336 p=0.01 | r=0.336 p=0.01 | r=0.509 p<0.001 |
| Grit (SGS) | NS | NS | NS | NS | NS | NS | NS | NS |
| Self-Efficacy (GSE) | NS | NS | NS | NS | NS | NS | NS | NS |
| Stress (DASS-S) | NS | r=-0.29 p=0.04 | r=0.467 p<0.001 | r=0.460 p<0.001 | r=0.294 p=0.03 | r=0.345 p=0.01 | r=0.303 p=0.03 | r=0.436 p=0.03 |
| Anxiety (DASS-A) | NS | NS | r=0.412 p=0.003 | r=0.413 p<0.003 | NS | NS | NS | NS |
| Depression (DASS-D) | NS | NS | r=0.460 p<0.001 | r=0.471 p<0.001 | NS | r=0.279 p=0.05 | r=0.596 p=0.002 | r=0.538 p=0.008 |
| Alcohol Use (AUDIT) | NS | NS | NS | NS | NS | NS | NS | NS |
| Resiliency (BRS) | NS | NS | r=0.405 p=0.02 | r=-0.388 p=0.02 | NS | r=0.333 p=0.06 | r=0.445 p=0.05 | NS |
NS = not significant.
The correlation between administered psychological tests and hip reported outcomes at both zero and eight weeks in our hip preservation population are reported in table 3. Higher PROMIS-Global Mental Health (GMH) scores correlated with lower pain perception scores such as Pain Interference (PI), Pain Behavior (PB), and HOOS-Pain (r= -0.54, -0.59, -0.38, all p<0.05). Higher Pain Catastrophizing (PCS) and Kinesiophobia (TSK) scores correlated with higher pain perception and lower physical function scores on hip PRO’s. Patients who reported higher Stress, Anxiety, and Depression (DASS) also reported higher Pain Interference, Pain Behavior, and HOOS-Pain whereas higher Stress alone was correlated with lower PROMIS-Physical Function (r= -0.29, p<0.05). Depression and Low Resiliency (BRS) were also associated with elevated pain on pain-related patient-reported outcome tests (PI and PB) as well as on the HOOS Pain test. Alcohol use, self-efficacy, grit, age, gender, and BMI were not significant (all p>0.05) as they did not show a correlation between psychological tests and patient reported outcomes.
Baseline scores at week zero, week eight, and total change in scores for all participants are reported in the appendix as the median with interquartile range and range of completed scores. Although there was a moderately strong correlation between improvement in PROMIS PF from 0 to 8 weeks and subjects initial scores for kinesiophobia, anxiety, and stress (r= -0.45, -0.41, -0.44, all p<0.05), no such association existed when comparing the change in median value scores between psychological tests and patient reported outcomes.
Discussion
It is well established that a patient’s emotional health and coping skills significantly influence the outcome of many orthopedic surgeries.20,23 A biopsychosocial model that recognizes these variables and includes intervention for those that are modifiable may be a future strategy to optimize outcome of treatment, however identifying which maladaptive traits may be most relevant and correlate best with pain and function in a given orthopedic population is a necessary first step to design and test future interventions.
Our primary study objectives were therefore to evaluate hip preservation patients for a wide variety of maladaptive psychosocial traits, to assess patient-reported outcomes (PROs), and to ascertain which specific maladaptive traits were associated with hip pain and dysfunction during evaluation and treatment of their hip condition at two separate time points eight weeks apart.
Our study results align with current published data supporting the presence and association of various maladaptive psychosocial traits with hip arthroscopy outcomes. Depression has been associated with worse function (iHOT-12) and pain (VAS) prior to and after hip arthroscopy.20,21,22 Veterans RAND 12-Item Health Survey-Mental Component Score (VR-12 MCS), an overall measure of mental health disease burden, has also been associated with worse 1-year outcomes after hip arthroscopy.19,23,24 To our knowledge the present study is the first to evaluate a much broader range of factors such as pain catastrophizing (PCS), kinesiophobia (TSK), resiliency (BRK), DASS-21 (anxiety, stress, and depression) and alcohol use (DASS-21). Our findings that several of these factors including pain catastrophizing, kinesiophobia, low resiliency, along with depression, anxiety, stress, and poor PROMIS-Global Mental Health (GMH) scores were correlated with poor physical function (PROMIS-Physical Function)1 and high pain and dysfunction (HOOS-Pain, PROMIS-PI, PROMIS-PB)1 are therefore unique. It is also the first to specifically evaluate the association between these traits and changes in pain and function in the nonoperative setting. Our additional findings that kinesiophobia, stress, and anxiety are associated with failure to improve pain or function during 8 weeks of nonoperative treatment in particular bears further investigation. We hypothesize these characteristics may be indicative of poor participation in rehabilitative therapies, potentially affecting both operative and nonoperative treatments, however this relationship is outside of the scope of this study.
Based on the findings of this study we recommend kinesiophobia, stress, and anxiety as more specific maladaptive traits that should be considered in the evaluation of hip preservation patients, instead of or in addition to broad mental health scores or depression scales which may not effectively capture the maladaptive coping strategies most relevant orthopedic provider. This data also supports the value of a holistic treatment approach in addition to the routine physical care provided to these orthopedic patients.23,25
Limitations
This study had several significant limitations. First, many of our participants did not complete follow-up testing at eight weeks (27) leading to attrition bias which may poses a threat to the internal validity of this study and its conclusion. Second, many of the psychosocial questionnaires employed in this study have been primarily tested on adults (>18 years of age) whereas our study included some participants 15-17 years of age. These tests may not be appropriate or accurate in this age group due to lack of consistent research on this subgroup utilizing these questionnaires. Third, some psychosocial tests such as kinesiophobia (TSK) do not have a strict cutoff to determine clinical importance or significance making results of those tests difficult to translate clinically. Finally, the broad inclusion of a variety of hip conditions including both impingement and dysplasia and multiple treatment protocols means we are unable to correlate changes in physical function or pain at eight weeks with a specific nonoperative treatment algorithm or therapy protocol.
Conclusion
Maladaptive psychosocial traits including pain catastrophizing, kinesiophobia, stress, depression, and low resiliency are associated with increased pain and disability in the hip preservation population. Kinesiophobia, anxiety, and stress may be predictors of failure to improve with nonoperative treatment, but further investigation is needed to understand association and should be investigated further as predictors of clinical outcomes.
APPENDIX A. Baseline, Week 8, and Change in Score for Study Participants
| Week 0 | Week 8 | Δ 0 to 8 weeks | ||||
|---|---|---|---|---|---|---|
| Pain and Function Tests | N | Median (IQR) range | N | Median (IQR) range | Median (IQR) range | p-value |
| VAS | 49 | 28 (18-37) 15-49 | 20 | 58.0 (40.0-71.5) 0-80.0 | -0.5 (-9-11) -28.0-60.0 | NS |
| PROMIS PI | 49 | 61.7 (59.1-66.9) 50.1-77.8 | 23 | 63.9 (57.7-68.2) 47.1-76.4 | -1.3 (-4.7-5.2) -10.9-14.3 | NS |
| PROMIS PB | 49 | 59.6 (57.5-61.9) 51.2-67.6 | 23 | 59.6 (57.4-62.6) 49.7-66.9 | 0.0 (-2.0-2.9) -6.3-10.4 | NS |
| PROMIS PF | 49 | 39.9 (38.0-44.0) 27.2-73.3 | 23 | 39.0 (30.9-41.7) 22.2-50.1 | 3.4 (-1.8-9.0) -17.6-23.2 | 0.031 |
| HOOS | 49 | 82.0 (63.0-93.0) 16.0-160.0 | 23 | 83.0 (58.0-105.0) 16.0-155.0 | -2.0 (-15.0-17.0) -63.0-51.0 | NS |
| Symptom | 49 | 11.0 (9.0-13.0) 4.0-20.0 | 23 | 11.0 (9.0-14.0) 3.0-19.0 | -1.0 (-2.0-2.0) -6.0-6.0 | NS |
| Pain | 49 | 19.0 (15.0-24.0) 2.0-40.0 | 23 | 21.0 (14.0-27.0) 3.0-40.0 | -2.0 (-4.0-3.0) -19.0-24.0 | NS |
| Function | 49 | 26.0 (20.0-34.0) 1.0-68.0 | 23 | 36.0 (19.0-42.0) 0-68.0 | 0.0 (-7.0-5.0) -33.0-14.0 | NS |
| Sport | 49 | 10.0 (8.0-12.0) 2.0-16.0 | 23 | 11.0 (7.0-15.0) 2.0-16.0 | -1.0 (-3.0-2.0) -5.0-13.0 | NS |
| Psychological Tests | ||||||
| PCS | 50 | 19.5 (13.0-28.0) 1-48.0 | 23 | 19.0 (9.0-24.0) 0-42.0 | 2.0 (-4.0-6.0) -23-26 | NS |
| DASS | ||||||
| Stress | 49 | 12.0 (8.0-20.0) 0-40.0 | 23 | 10.0 (6.0-16.0) 0-40.0 | 2.0 (-4.0-4.0) -18.0-26.0 | NS |
| Anxiety | 49 | 1.0 (0.0-5.0) 0.0-51.0 | 23 | 0.0 (0.0-2.0) 0.0-22.0 | 0.0 (0.0-2.0) -12.0-33.0 | NS |
| Depression | 50 | 2.0 (0.0-10.0) (0.0-51.0) | 23 | 2.0 (0.0-6.0) 0.0-26.0 | 0.0 (-1.0-4.0) -18.0-41.0 | NS |
| PROMIS GMH | 49 | 47.7 (44.1-52.7) 25.8-64.6 | 23 | 46.3 (36.0-52.7) 25.8-64.6 | 0.0 (-6.3-8.1) -14.6-14.9 | NS |
| AUDIT | 49 | 2.0 (0.0-5.0) 0.0-11.0 | 23 | 1.0 (0.0-4.0) 0.0-10.0 | 0.0 (0.0-1.0) -5.0-4.0 | NS |
| BRS | 32 | 3.6 (2.9-4.0) 1.8-5.0 | 19 | 3.8 (3.2-4.2) 2.0-5.0 | -0.2 (-0.3-0.0) -1.8-0.7 | NS |
| GSE | 48 | 30 (29-36) 14 - 40 | 22 | 32 (30-38) 21-40 | 0 (-3-1) -12-6 | NS |
| Grit-S | 47 | 3.9 (3.4-4.3) 2.3-4.8 | 21 | 4.0 (3.6-4.1) 2.8-4.8 | 0.0 (-0.4-0.1) -2.0-0.6 | NS |
| TSK | 48 | 29.0 (26.5-31.5) 11.0-40.0 | 21 | 27.0 (24.0-33.0) 11.0-39.0 | 1.0 (-1.0-3.0) -8.0-17.0 | NS |
NS= not significant.
APPENDIX B. Number of Study Participants at Week 0 and Week 8
APPENDIX C. Median Scores of Participants at Week 0 and Week 8
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