Abstract
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.
Nonarthritic hip disease (NAHD) is commonly used in clinical research as an umbrella term to include symptomatic intra-articular hip morphology such as femoroacetabular impingement, labral tears, chondral defects, or borderline dysplasia.1 Minimal research has been focused on NAHD as an inclusive clinical condition2–7; however, many groups have evaluated diagnosis and treatment for femoroacetabular impingement syndrome (FAIS),8–11 a form of NAHD. An international consensus meeting was held in 2016 that included 150 invited health care professionals with experience in managing young adults with hip pathology.9 These experts concluded that clinical signs, patient symptoms, and joint imaging should be used to inform diagnosis.9 A group of 61 multidisciplinary experts in orthopedic surgery, sports medicine, radiology, physical therapy, and hip-related research expanded upon these diagnostic domains of FAIS via a Delphi approach to include patient-reported outcome measures, subjective examination (patient interview), physical examination, physical performance measures, radiographic examination, and special testing.10 Although not specifically addressed as a diagnostic parameter, movement assessment was advocated by both reports as part of the evaluation process. Currently unknown are adherence to or use of recommendations and how these recommendations relate to treatment planning for NAHD.
Despite rising rates in hip arthroscopy to treat various forms of NAHD,12,13 many patients are amenable to nonoperative treatment options. Both arthroscopy and physical therapy have demonstrated positive patient-reported outcomes up to 2 years posttreatment.13,15 Almost 80% of participants reported no strong preference between physical therapy and hip arthroscopy in a feasibility study for a randomized controlled trial to compare these interventions.16 This suggests that patients with NAHD can experience considerable decisional conflict regarding treatment planning. Decisional conflict represents a person’s uncertainty in making a decision and can be measured for health care consumers.17 Current evaluation processes focus on radiographic findings to support surgical decision making,8 rather than the multidimensional approach suggested by experts.9–11 Imaging-focused evaluation might neglect additional, and potentially more relevant, impairments that contribute more to poor function than bony morphology.18 Physical therapists are trained in movement diagnosis and treatment,19 and thus could fill a critical gap in the evaluation process to complement the physician evaluation by identifying how movement, joint morphology, and symptoms collectively contribute to individual patient presentation. A collaborative evaluation and discussion regarding treatment options could assist patients in their decision making process to select a treatment pathway.
Understanding how physical therapists and physicians can contribute to an interdisciplinary approach is the first step to developing an evaluation that optimizes patient experience and patients’ understanding of their condition and treatment options. The purpose of this study was to describe the current state of evaluation for NAHD by both physical therapists and physicians, separately, to inform future interdisciplinary evaluations and evaluate national adherence to suggested evaluation guidelines. Our primary hypothesis was that physical therapists would more often report movement assessment to be of great importance when deciding on treatment recommendations, whereas physicians would more often report imaging to be of great importance. Our secondary hypothesis was that fewer than half of physical therapists and physicians would report use of expert-recommended evaluation components as proposed by expert consensus groups.
Methods
A national survey study distributed in the United States was implemented to accomplish the objective (level of evidence: IV).
Survey Development
The development group was composed of 3 physical therapists, 1 orthopedic surgeon, and 1 sports medicine physician from a single institution. This group had a combined 44 years working with individuals with NAHD in both clinical and research capacities. The goal of the first meeting was to discuss survey content that would capture how physical therapists and physicians evaluate persons with NAHD. The development group reviewed and edited the initial survey draft prior to survey piloting.
The survey was designed in the Research Electronic Data Capture System (REDCap)20 to take less than 10 minutes to maximize clinician participation. The survey included questions regarding clinical demographics (practice region and setting, experience, training) and prompted participants to list the percentage of their caseload that represented NAHD. Respondents then described their use of the following evaluation domains: patient-reported outcomes, patient history, movement assessment, clinical tests (mobility, strength, and palpation), special tests (for impingement, laxity, alignment, labral or lumbar testing), and imaging for evaluation of patients with NAHD. Evaluation content across these domains was collected using predefined checklists of tests and measures defined from pilot testing. To prevent or reduce social desirability bias, lists were not exclusive to only expert-recommended tests and measures. Free-text options for other nonlisted tests and measures were available for each domain. Lastly, respondents identified how important each domain was to making a diagnosis and plan of care via a 5-point Likert scale (not important, slightly important, important, very important, or extremely important). The pilot survey also prompted survey participants to provide free-text feedback regarding the mechanics and content of the survey to inform changes before national distribution.
The survey was pilot tested via a convenience sample of 40 clinicians across 4 academic institutions in separate regional divisions of the United States. A single collaborator at each institution (MH-H, AL, WKV, CL) sent the pilot survey to 10 potential participants. Collaborators were encouraged to send to 5 physical therapists and 5 physicians; however, any distribution of these disciplines was accepted. Pilot responses were accepted over a 2-month period, after which the development group reconvened to review and modify survey content and structure. The final distributed survey is available as Supplemental Material.
Survey Participants
Physical therapists and physicians who evaluate and treat persons with NAHD were the population of interest for the national sample. The survey was distributed in 2018 via email to members of the Academy of Orthopaedic Physical Therapy (February) and the American Medical Society for Sports Medicine (August). The American Medical Society for Sports Medicine was the only organization that redistributed the survey as a reminder for nonrespondents 2 weeks after initial distribution. The survey was also posted for 6 weeks to the member-sponsored survey page of the American Orthopaedic Society for Sports Medicine (March). The American Medical Society for Sports Medicine and American Orthopaedic Society for Sports Medicine were used primarily to recruit physician participants, whereas the Academy of Orthopaedic Physical Therapy was used to recruit physical therapists.
Ethics
This survey was determined to be exempt from review by the Institutional Review Board at the senior author institution. This study was conducted in agreement with the 1964 Helsinki Declaration and its later amendments. Survey participants were required to consent to participate before continuing to survey content. All data obtained from the national survey were deidentified to reduce bias that might be introduced if participants felt their answers would be judged individually.
Statistical Approach
Descriptive statistics were calculated for participants’ clinical demographics, caseloads, and listed importance of each evaluation domain. Continuous variables were described with means and standard deviations (SDs) whereas categorical variables were presented as percentages. Odds ratios (ORs) and 95% CIs were calculated to identify the odds that physical therapists, compared with physicians, would report each evaluation domain as at least very important. The order of this comparison was chosen based on the a priori hypothesis and did not reflect a biased directional comparison. If importance level was not indicated for a domain, the participant was excluded from that domain’s OR calculation. Fisher exact tests were performed to identify statistically significantly ORs. Percentages were calculated for respondents who indicated use of expert-recommended evaluation components10 in each evaluation domain. Expert-recommended evaluation components included: patient interview for pain location and description, intra-articular injection, hip radiographs, flexion adduction internal rotation, hip range-of-motion testing, double-leg squat assessment, the 12- or 33-item International Hip Outcome Tool, and the Copenhagen Hip And Groin Outcome Score.10
Sample Size
Based on pilot responses, a national sample of 192 physical therapists and 96 physicians would provide 95% confidence to detect an OR of 2.0 (with 40% precision) that a physical therapist, compared with a physician, was more likely to consider movement assessment as at least very important.
Role of the Funding Source
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Foundation for Physical Therapy Research or the National Institutes of Health. The funders played no role in the design, conduct, or reporting of this work.
Results
Pilot Results
Forty participants provided informed consent and opened the survey, and 34 (85%) participants completed the survey. Twenty-five of these pilot survey participants (73.5%) were physical therapists, and 9 of these pilot survey participants (26.5%) were physicians. Eleven (32.4%) pilot survey participants were from New England, 7 (20.6%) were from the mid-Atlantic, 9 (26.4%) were from east north central, and 7 (20.6%) were from west north central.
All pilot participants who completed the pilot survey (n = 34) ranked patient history as at least very important for making a diagnosis and plan of care. A large percentage of both physical therapist (92%) and physician (100%) participants indicated clinical tests as at least very important. More physical therapists indicated patient-reported outcomes (48%) and movement assessment (96%) as at least very important compared with physician participants (22% and 55%, respectively). A larger proportion of physicians indicated special tests (100%) as at least very important compared with physical therapists (56%). Only 14 of 25 physical therapist participants responded to the survey question regarding importance of imaging for making a diagnosis and plan of care; only 2 (14%) of these physical therapists ranked imaging as at least very important compared with 88% of physicians.
The following survey changes were made after the pilot: reduction in demographic information collected from physical therapist participants, inclusion of more professional organization options, and addition of an option for “I don’t know” to all Likert-scale questions that prompted survey participants to identify how important each evaluation domain was to developing a diagnosis and plan of care (Fig. 1). An operational definition for NAHD was added as follows:
Figure 1.
Importance Ranking for Each Evaluation Domain (patient-reported outcomes, patient history, special tests, movement assessment, clinical tests, and imaging)
Non-arthritic hip disease (NAHD) is defined as intra-articular hip disease, not due to arthritis. NAHD may include labral tear, chondral defect, femoroacetabular impingement, borderline dysplasia. NAHD does not include greater trochanteric pain syndrome or tendinopathies about the hip.
Survey Participants
The survey was accessible to 25,027 potential respondents through 3 professional organizations. Approximately 4% of these potential respondents (n = 969) consented and completed the survey. The informed consent indicated that participants should be a licensed physical therapist or physician. Participants were not required to be currently practicing in clinical care; however, participants who indicated no regular evaluation of persons with NAHD were excluded from the analysis (n = 29; Fig. 2). Survey responses from pilot participants were also removed from the study (n = 26; Fig. 2). Seventy percent of potential participants (the sampling frame) were members of the Academy of Orthopaedic Physical Therapy and thus were expected to be physical therapists. Our resultant sample had a similar distribution of physical therapists (66%, n = 603) and physicians (34%, n = 311).
Figure 2.
Survey Completion Rates. These surveys were distributed to a list of physical therapist members of the Academy of Orthopaedic Physical Therapy; however, 1 respondent indicated their profession as a physician. AMSSM = American Medical Society for Sports Medicine; AOSSM = American Orthopaedic Society for Sports Medicine; PT = physical therapist.
The majority (85%) of our physical therapist sample were employed in a nonacademic setting. The physician sample was split similarly across academic (49%) and nonacademic (51%) settings. Descriptive statistics were analyzed based on participant discipline and setting (Tab. 1).
Table 1.
Participant Clinical Demographicsa
| Discipline (Setting) | ||||
|---|---|---|---|---|
| Descriptive Variable | Physician—Academic (n = 150) | Physician—Nonacademic (n = 161) | Physical Therapist—Academic (n = 88) | Physical Therapist—Nonacademic (n = 515) |
| Experience | ||||
| <2 y | 8 (5) | 11 (7) | 10 (11) | 66 (13) |
| 2–5 y | 39 (26) | 25 (15) | 16 (18) | 107 (21) |
| 6–10 y | 32 (21) | 40 (25) | 32 (36) | 115 (22) |
| >11 y | 71 (47) | 85 (53) | 30 (34) | 227 (44) |
| Caseload | ||||
| (≥50%) caseload are hips | 20 (13) | 19 (12) | 15 (17) | 67 (13) |
| (≥50%) hip caseload is NAHD | 106 (71) | 115 (71) | 57 (65) | 301 (58) |
| Education/training | ||||
| DPTb | 71 (81) | 368 (71) | ||
| BS/MS of Physical Therapy | 17 (19) | 147 (29) | ||
| MD | 118 (78) | 128 (80) | ||
| DO | 33 (22) | 33 (20) | ||
| PhD | 0 (0) | 1 (<1) | 7 (8) | 19 (4) |
| Physical therapy board-certified specializations | ||||
| SCS | 12 (14) | 20 (4) | ||
| OCS | 52 (59) | 262 (51) | ||
| Other | 3 (3) | 26 (5) | ||
| American boards of medical specialties | ||||
| Orthopedic surgery | 0 (0) | 6 (4) | ||
| Family medicine | 91 (61) | 116 (72) | ||
| PMR | 16 (11) | 8 (5) | ||
| Other | 41 (27) | 30 (19) | ||
| Subspecialties | ||||
| Orthopedic sports medicine | 0 (0) | 3 (2) | ||
| Sports medicine | 122 (81) | 150 (93) | ||
| Pain | 0 (0) | 1 (1) | ||
| Other | 3 (2) | 0 (0) | ||
| Fellowships | ||||
| Surgical | 1 (1) | 4 (2) | ||
| Nonsurgical | 115 (77) | 141 (88) | ||
| Practice | ||||
| Surgical | 0 (0) | 5 (3) | ||
| Nonsurgical | 139 (93) | 144 (89) | ||
| Both | 11 (7) | 12 (7) | ||
Data are represented as n (%) for each discipline and setting. BS/MS of Physical Therapy = Physical therapist with a degree other than DPT; DO = Doctor of Osteopathic Medicine; DPT = Doctor of Physical Therapy; MD = Medical Doctor; NAHD = nonarthritic hip disease; OCS = orthopedic clinical specialist; PMR = Physical Medicine and Rehabilitation; SCS = sports certified specialist.
Entry-level and postprofessional degrees included.
Importance of Evaluation Domains
Over 85% of both disciplines considered patient history and clinical tests as at least very important to diagnose and develop a plan of care for persons with NAHD (Tab. 2). Physical therapists were at 2.56 (95% CI: 1.67–3.99; P < .001) greater odds to rank patient-reported outcomes as at least very important to develop a diagnosis and plan of care. The majority of both physical therapists and physicians reported movement assessment as at least very important (Tab. 2); however, physical therapists had greater odds to indicate movement assessment (4.23 [95% CI: 2.99–6.02]; P < .001) as at least very important for determining a diagnosis and plan of care (Fig. 3). A majority (60%) of physicians, but not physical therapists (12%) reported imaging as at least very important. Odds were lower that physical therapists, compared with physicians, rated imaging or special testing as at least very important (0.09 [95% CI: 0.062–0.14], P < .001; and 0.72 [95% CI: 0.53–0.98], P = .03, respectively).
Table 2.
Evaluation Domains Report as at Least “Very Important” for Each Discipline and Settinga
| Physician | Physical Therapist | |||||||
|---|---|---|---|---|---|---|---|---|
| Academic | Nonacademic | Total | n | Academic | Nonacademic | Total | n | |
| PROs | 27% | 25% | 26% | 137 | 62% | 45% | 48% | 582 |
| Patient history | 95% | 97% | 96% | 305 | 95% | 97% | 97% | 603 |
| Movement assessment | 66% | 60% | 63% | 306 | 88% | 88% | 88% | 603 |
| Clinical tests | 85% | 88% | 87% | 310 | 85% | 87% | 87% | 602 |
| Special tests | 72% | 70% | 71% | 309 | 51% | 66% | 64% | 599 |
| Imaging | 55% | 65% | 60% | 305 | 9% | 13% | 12% | 394 |
Percentages of each participant subgroup who reported the evaluation domain “very important” or “extremely important” to develop a diagnosis and plan of care. PROs = patient-reported outcomes.
Figure 3.
Physical Therapists Odds to Rate Each Evaluation Domain as at Least “Very Important.” An odds ratio (OR) =1 indicates the odds that a physical therapist would rate that domain as at least very important were equal to the odds that a physician would rate that domain as at least very important. An OR > 1 indicates increased odds that a physical therapist would rate that domain as at least very important compared with a physician. An OR < 1 indicates increased odds that a physician would rate that domain at least very important compared with a physical therapist. Horizontal bars represent 95% CIs for odds ratios. PRO = patient-reported outcome measure.
Seventy-five percent (n = 688) of survey participants rated importance levels for both imaging and movement assessment, and did not rank the importance as “I don’t know” (Fig. 1). These 688 participants were categorized into 1 of 3 groups: (1) they reported equal levels of importance for both movement assessment and imaging (physical therapist: 10%; physician: 41%), (2) they reported a greater level of importance for imaging than for movement assessment (physical therapist: <1%; physician: 27%), or (3) they reported a greater level of importance for movement assessment than for imaging (physical therapist: 90%; physician: 32%). The distribution of these categories was significantly different between physical therapists and physicians (χ2 = 260.17; P < .001).
Use of Expert-Recommended Evaluation Components
Participants of this study reported use of 209 tools and measures to evaluate persons they believe to have NAHD (Appendix). The large majority of participants reported use of pain location/description (99.34%), injury history (99.12%), hip strength testing (98.14%), hip range-of-motion testing (97.81%), hip and pelvic palpation (96.71%), past medical history (96.60%), previous/current/desired activity level (96.06%), previous treatment or evaluation (95.84%), sports participation (95.62%), walking gait assessment (95.62%), flexion abduction external rotation (94.84%), flexion adduction internal rotation (91.57%), patient demographics (90.26%), and patient goals (90.26%). At least 90% of participants reported adherence to expert-recommended subjective and physical examination components; however, patient-reported outcome measures, diagnostic injections, and movement assessment were used less frequently (Fig. 4).
Figure 4.
Use of Expert Recommendations. The percentage of participants from each profession are reported for those listed expert-recommended10 evaluation measures and tools. DL squat = double-leg squat; FADIR = flexion, adduction, internal rotation; HAGOS = Copenhagen Hip And Groin Outcome Score; iHOT12 = 12-item International Hip Outcome Tool; iHOT33 = 33-item International Hip Outcome Tool; ROM = range of motion; XR = radiograph.
Discussion
The results of this survey study support the primary hypothesis that physical therapists placed greater importance on movement whereas physicians placed greater importance on imaging when evaluating individuals with NAHD. The differences observed in this survey study are likely not solely specific to NAHD and could be observed across other populations as a function of clinician training and scope of practice. Although physicians placed more importance on imaging than physical therapists, this did not show that radiology was the only tool physicians used in their scope of practice. Lynch and colleagues11 recommend a comprehensive consideration of joint imaging, previous treatment, and patient history based on a Delphi survey of 15 orthopedic surgeons’ preoperative practices. Imaging remains a helpful tool to evaluate the patient and support treatment-planning conversations. Information shared across these disciplines could expand each clinician’s perspective of the patient’s condition and inform their plan-of-care discussions with the patient.
Combining approaches of both physical therapists and physicians could improve patients’ understanding of their health condition and better engage them in the decision making process. Participation from patients and multiple care providers could improve the quality of the decision making process, as hypothesized by shared decision making models.21,22 As movement experts, physical therapists can provide an evaluation of movement impairments and rehabilitation potential,19 whereas physicians use their training for interpretation of joint imaging to consider joint pathology that may be amenable to intra-articular treatments. This discipline-specific weighting of various evaluation domains can help patients understand both anatomical and functional aspects of their health condition, then discuss treatment options that prioritize their individual needs. Hearing multiple opinions from separate disciplines could reduce patients’ decisional conflict as they consider the various treatment options and allow them to select an evidence-based treatment most appropriate to their values, expectations, and situation.
The secondary purpose of this survey study was to compare current clinical examination with expert-recommended examination for evaluation of NAHD. Interestingly, previously published recommendations for evaluation of FAIS included 26 tests or measures across 6 evaluation domains10; however, survey participants in this study reported use of 209 tests or measures across the 6 evaluation domains. These 209 tests or measures were reported by a total of 914 clinicians compared with 26 recommended tests or measures defined by 61 experts. The larger sample partly explains the greater number of tests; however, range in expertise and research involvement related to these evidence-based recommendations could also contribute to the larger list reported in this survey study. Additional measures provided by survey respondents included the examination of adjacent joints, which demonstrated that survey respondents favor a comprehensive multijoint evaluation as opposed to a more traditional joint-specific evaluation.
Both physical therapists and physicians reported use of recommendations including pain description and location in their subjective examination and to include hip range of motion in their objective examination. These are critical components to understanding a variety of lower extremity impairments, but are not necessarily specific to evaluation of NAHD. In contrast, diagnostic injections are a specific tool to use in the diagnosis of FAIS (a form of NAHD). Few physician participants in this survey study reported use of diagnostic injections despite an international consensus statement supporting injections to confirm pain relief consistent with FAIS.9 Physician participants might use diagnostic injections at subsequent visits after the initial evaluation to confirm an intra-articular pain source23 and subsequently determine surgical eligibility.24 Physicians might not have felt that injections were appropriate to include in this survey about an initial evaluation if injections are typically performed at follow-up visits. Alternatively, physician participants might also refer to a specialist for these injections. Although the majority of physician participants were either family medicine or physical medicine and rehabilitation, we did not collect information regarding additional training or certification for ultrasound-guided intra-articular injections.
Physical therapists might consider imaging useful, but not important, for their management of patients with NAHD. Interestingly, almost 45% of physical therapists reported use of hip radiographs to diagnose and develop a plan of care for patients with NAHD; however, only 12% ranked hip radiographs as at least very important for diagnosis and plan-of-care development. Physical therapists appeared to prioritize nonimaging evaluation domains such as movement assessment, which is easily explained due to its emphasis throughout their didactic and clinical training. Only 1 state in the United States specifically permits physical therapists to order imaging, but many physical therapists are actively pursuing changes to their state licensure to allow ordering of imaging. Physical therapists also appear to experience poor accessibility to imaging reports. Approximately 35% of physical therapist participants in this survey reported that they did not have access to view imaging reports. This limitation restricts their use of imaging during patient evaluation and plan-of-care development.
Although physical therapists were more likely to consider movement assessment important to developing a diagnosis and plan of care, approximately 50% of physicians included expert-recommended squat assessment in their list of tools and measures. The large percentage of physicians who include movement assessment in their evaluation could reflect increasing recognition that movement impairments are a critical component to evaluation and treatment of NAHD9; however, physicians likely do not have the space, resources, time, or extensive training to evaluate movement as comprehensively as physical therapists. Despite the increased awareness of movement contributions to the clinical presentation of patients with NAHD, physicians do not need to become movement specialists. Collaborative evaluation including physical therapists and physicians, either in a multi- or interdisciplinary manner, would allow clinicians to gain additional information beyond what they can currently accomplish independently, which could produce more comprehensive plans of care.
Physical therapists from academic settings had the largest proportion (>60%) of participants who reported patient-reported outcomes as at least very important; however, few physical therapists and no physicians were using the expert-recommended patient-reported outcomes (12-item or 33-item International Hip Outcome Tool). Instead, a majority of physical therapists (77%) listed the Lower Extremity Functional Scale, and physicians most often reported the Visual Analog Scale or the Numeric Pain Rating Scale as a patient-reported outcome tool (Appendix). These patient-reported outcome measures are more generalizable across diagnoses and have been used in the clinic much longer than the 33-item International Hip Outcome Tool, which was published in 2011. Adoption of patient-reported outcomes into clinical care has been recognized as a difficult process,25–27 let alone specifying which outcome to use for which patient.
Limitations
Despite achieving adequate power, we acknowledge this online survey study had a low response rate (3.6%). The results of this study cannot be generalized to nonrespondents or potential participants who were not reached with our recruitment methods. Our findings are biased toward clinicians who engage in professional organizations and might be more likely to receive evidence updates as part of newsletters or other resources supported by the organization. Notably, the number of physician participants with surgical training was limited, and thus results of this study likely do not reflect the practice of orthopedic surgeons. The low response from orthopedic surgeons from the American Orthopaedic Society for Sports Medicine was likely due to the survey being posted on a member-sponsored webpage rather than directly distributed via email to members. Orthopedic surgeons have previously been included in an international consensus group, an expert-based survey, and a literature review for diagnosis and management of FAIS.8–10 These resources can provide information regarding surgical evaluation of patients with NAHD, but are highly biased toward expert clinician-scientists highly engaged in evidence-based practice.
To produce a comprehensive list of tools and measures in current clinical use, this survey provided participants with the opportunity to list other tools and measures not listed on the survey. Due to an error in branching logic, 84 “other” check-boxes were selected by participants and a free-text option did not display, potentially limiting the amount of information collected. Fortunately, this was a low percentage of the completed survey responses.
This survey was developed based on the input from 5 individuals from a single institution. Collective practice patterns or experience among these individuals could bias the survey toward the developers’ beliefs and knowledge. The survey was intentionally piloted across 4 institutions (including the development institution) as a strategy to reduce bias from development.
Survey responses were compared with expert-recommended evaluation practices; however, survey responses were in relation to NAHD as a broad clinical syndrome, whereas expert-recommended evaluation practices were in relation to FAIS (a form of NAHD).10 Clinicians could use more evaluation techniques and tools when considering NAHD as a more inclusive condition compared with evaluation of patients with a more specific diagnosis such as FAIS.
Survey language did not distinguish between medical diagnosis or physical therapy diagnosis; the term “diagnosis” was used alone for both physical therapist and physician participants. Different physical therapist participants might have interpreted “diagnosis” differently when prompted to rank the important of each evaluation domain for diagnosis and plan-of-care development. This concept was not brought up as a limitation during survey piloting.
Future Work
The results of this study highlight discipline-specific evaluation practices between physical therapists and physicians. This information should be considered when developing multi- or interdisciplinary care models to treat patients with NAHD. Furthermore, collaboration with psychology should be further investigated28 because mental health considerations can be a critical component to providing comprehensive care within the biopsychosocial model for patients with NAHD. Functional outcomes should be compared between patients evaluated, and subsequently treated, with an interdisciplinary approach to those treated by physical therapist or physician alone.
Conclusion
As expected, physical therapists were more likely to report movement to be of greater importance and imaging of lesser importance when developing a diagnosis and plan of care for patients with NAHD when compared with a predominantly nonsurgical group of sports medicine physicians. These results highlight discipline-specific scopes of practice and the potential for interdisciplinary collaboration for more comprehensive evaluations. The large majority of both disciplines reported use of expert-recommended subjective and physical examination measures. Physical therapist and physician participants also reported use of movement assessment recommendations; however, low percentages of both disciplines reported use of recommended patient-reported outcome measures specific to the population of NAHD. Future work will investigate when interdisciplinary care is recommended and how to coordinate efforts from these 2 disciplines to provide more comprehensive evaluation of patients with NAHD and hopefully reduce decisional conflict during treatment planning.
Supplementary Material
Appendix.
Evaluation Components Reported by Survey Participants
| Test/Measure | Physical Therapist | Physician | ||
|---|---|---|---|---|
| Patient-reported outcome measures | ||||
| n | % | n | % | |
| Lower Extremity Functional Scale (LEFS) | 467 | 77.45 | 3 | 0.96 |
| Visual Analog Scale (VAS)/Numeric Pain Rating Scale (NPRS) | 232 | 38.47 | 112 | 36.01 |
| Oswestry Disability Index | 223 | 36.98 | 5 | 1.61 |
| Patient Specific Functional Scale (PSFS) | 150 | 24.88 | 15 | 4.82 |
| Fear Avoidance and Beliefs Questionnaire (FABQ) | 126 | 20.90 | 1 | 0.32 |
| Hip Outcome Score (HOS) | 59 | 9.78 | 4 | 1.29 |
| Hip Disability and Osteoarthritis Outcome Score (HOOS) | 41 | 6.80 | 7 | 2.25 |
| Focus on Therapeutic Outcomes (FOTO) | 34 | 5.64 | 0 | 0.00 |
| Modified Hip Harris Score (MHHS) | 22 | 3.65 | 5 | 1.61 |
| Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) | 21 | 3.48 | 6 | 1.93 |
| Patient-Reported Outcomes Measurement Information System (PROMIS) | 12 | 1.99 | 4 | 1.29 |
| Short Form Survey (SF-12 or SF-36) | 10 | 1.66 | 3 | 0.96 |
| 33-item International Hip Outcome Tool (iHOT-33) | 8 | 1.33 | 0 | 0.00 |
| Activity Measure for Post-Acute Care (AM-PAC) | 7 | 1.16 | 0 | 0.00 |
| Global Rating of Change (GROC) | 7 | 1.16 | 0 | 0.00 |
| Tegner Activity Score | 3 | 0.50 | 1 | 0.32 |
| Care Connect | 3 | 0.50 | 0 | 0.00 |
| Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) | 3 | 0.50 | 0 | 0.00 |
| Pain Diagram | 3 | 0.50 | 0 | 0.00 |
| 30-second Sit-to-Stand | 3 | 0.50 | 0 | 0.00 |
| Tampa Kinesiophobia Scale | 3 | 0.50 | 0 | 0.00 |
| Timed Up and Go (TUG) | 3 | 0.50 | 0 | 0.00 |
| Central Sensitization Inventory (CSI) | 2 | 0.33 | 0 | 0.00 |
| Roland-Morris Disability Questionnaire | 2 | 0.33 | 0 | 0.00 |
| Self-Efficacy for Physical Function | 2 | 0.33 | 0 | 0.00 |
| Berg Balance Scale | 1 | 0.17 | 0 | 0.00 |
| Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) | 1 | 0.17 | 0 | 0.00 |
| Sit & Reach | 1 | 0.17 | 0 | 0.00 |
| Disabilities of the Arm, Shoulder, and Hand (DASH) | 1 | 0.17 | 0 | 0.00 |
| GMCMa | 1 | 0.17 | 0 | 0.00 |
| Copenhagen Hip And Groin Outcome Score (HAGOS) | 1 | 0.17 | 0 | 0.00 |
| Hip Harris Score | 1 | 0.17 | 0 | 0.00 |
| Lower Limb Functional Index (LLFI) | 1 | 0.17 | 0 | 0.00 |
| Pain Catastrophizing Scale | 1 | 0.17 | 0 | 0.00 |
| Pain Disability Index | 1 | 0.17 | 0 | 0.00 |
| Peabody Developmental Motor Scales | 1 | 0.17 | 0 | 0.00 |
| Pelvic Girdle Questionnaire (PGQ) | 1 | 0.17 | 0 | 0.00 |
| n | % | n | % | |
| Daily steps | 1 | 0.17 | 0 | 0.00 |
| Victorian Institute of Sports Assessment for Gluteal Tendinopathy (VISA-G) | 1 | 0.17 | 0 | 0.00 |
| Wong-Baker FACES Pain Rating Scale | 1 | 0.17 | 0 | 0.00 |
| Cincinnati Occupational Rating Scale | 0 | 0.00 | 1 | 0.32 |
| History | ||||
| Injury history | 601 | 99.67 | 305 | 98.07 |
| Pain location/description | 600 | 99.50 | 308 | 99.04 |
| Past medical history | 593 | 98.34 | 290 | 93.25 |
| Activity level | 586 | 97.18 | 292 | 93.89 |
| Patient goals | 584 | 96.85 | 241 | 77.49 |
| Previous treatment/evaluation | 576 | 95.52 | 300 | 96.46 |
| Sports/hobby participation | 573 | 95.02 | 301 | 96.78 |
| Demographics | 539 | 89.39 | 286 | 91.96 |
| Employment | 535 | 88.72 | 234 | 75.24 |
| Social history or family history | 428 | 70.98 | 230 | 73.95 |
| Aggravating/alleviating factors | 116 | 19.24 | 2 | 0.64 |
| Medication | 68 | 11.28 | 1 | 0.32 |
| Red flags | 21 | 3.48 | 2 | 0.64 |
| Sleep | 20 | 3.32 | 0 | 0.00 |
| Limitations | 16 | 2.65 | 3 | 0.96 |
| Patient involvement | 9 | 1.49 | 0 | 0.00 |
| Expectations | 8 | 1.33 | 0 | 0.00 |
| Falls | 7 | 1.16 | 0 | 0.00 |
| Emotions | 6 | 1.00 | 1 | 0.32 |
| Assistive devices | 3 | 0.50 | 0 | 0.00 |
| Learning style | 3 | 0.50 | 0 | 0.00 |
| Shoes | 2 | 0.33 | 0 | 0.00 |
| UpToDate https://www.uptodate.com/home | 1 | 0.17 | 0 | 0.00 |
| Movement assessment | ||||
| Walking | 590 | 97.84 | 284 | 91.32 |
| Single-leg stance | 547 | 90.71 | 199 | 63.99 |
| Double-leg squat | 463 | 76.78 | 156 | 50.16 |
| Patient-specific movement | 453 | 75.12 | 227 | 72.99 |
| Sit-to-stand | 415 | 68.82 | 157 | 50.48 |
| Standing posture | 415 | 68.82 | 141 | 45.34 |
| Step-down | 361 | 59.87 | 63 | 20.26 |
| Single-leg squat | 319 | 52.90 | 166 | 53.38 |
| Seated posture | 288 | 47.76 | 132 | 42.44 |
| Running | 215 | 35.66 | 48 | 15.43 |
| n | % | n | % | |
| Functional Movement Systems (FMS) | 97 | 16.09 | 25 | 8.04 |
| Selective Functional Movement Assessment (SFMA) | 20 | 3.32 | 0 | 0.00 |
| Repeated motions | 19 | 3.15 | 0 | 0.00 |
| Forward/backward bending | 8 | 1.33 | 1 | 0.32 |
| Bed mobility | 5 | 0.83 | 0 | 0.00 |
| Lunge | 5 | 0.83 | 0 | 0.00 |
| Y Balance Test | 4 | 0.66 | 0 | 0.00 |
| Balance | 4 | 0.66 | 0 | 0.00 |
| Stairs | 3 | 0.50 | 0 | 0.00 |
| Quadruped rock | 3 | 0.50 | 0 | 0.00 |
| Resisted movements | 2 | 0.33 | 2 | 0.64 |
| Bridge | 2 | 0.33 | 1 | 0.32 |
| Side-lying abduction | 2 | 0.33 | 0 | 0.00 |
| Marching | 2 | 0.33 | 0 | 0.00 |
| Deadlift | 2 | 0.33 | 0 | 0.00 |
| Sleep position | 1 | 0.17 | 0 | 0.00 |
| Rising from floor | 1 | 0.17 | 0 | 0.00 |
| Decreased weight-bearing ambulation | 1 | 0.17 | 0 | 0.00 |
| Hip extension swing | 1 | 0.17 | 0 | 0.00 |
| Step-up | 1 | 0.17 | 0 | 0.00 |
| Toe walking | 1 | 0.17 | 0 | 0.00 |
| Heel walking | 1 | 0.17 | 0 | 0.00 |
| Side plank | 1 | 0.17 | 0 | 0.00 |
| Bird dog | 1 | 0.17 | 0 | 0.00 |
| Clinical tests | ||||
| Hip strength | 594 | 98.51 | 303 | 97.43 |
| Hip range-of-motion | 591 | 98.01 | 303 | 97.43 |
| Hip/pelvis palpation | 576 | 95.52 | 308 | 99.04 |
| Lumbar range-of-motion | 561 | 93.03 | 246 | 79.10 |
| Lumbar palpation | 503 | 83.42 | 259 | 83.28 |
| Knee strength | 490 | 81.26 | 195 | 62.70 |
| Hip arthrokinematics | 457 | 75.79 | 126 | 40.51 |
| Knee/ankle range-of-motion | 448 | 74.30 | 225 | 72.35 |
| Abdominal activation | 332 | 55.06 | 89 | 28.62 |
| Lumbar strength | 299 | 49.59 | 146 | 46.95 |
| Knee palpation | 256 | 42.45 | 172 | 55.31 |
| Ankle strength | 238 | 39.47 | 66 | 21.22 |
| Spine arthrokinematics | 228 | 37.81 | 36 | 11.58 |
| Knee/ankle arthrokinematics | 159 | 26.37 | 43 | 13.83 |
| n | % | n | % | |
| Thoracic range-of-motion | 114 | 18.91 | 41 | 13.18 |
| Thoracic palpation | 72 | 11.94 | 47 | 15.11 |
| Ankle palpation | 54 | 8.96 | 31 | 9.97 |
| Sacroiliac joint mobility/provocation | 16 | 2.65 | 3 | 0.96 |
| Neural tension testing | 4 | 0.66 | 0 | 0.00 |
| Snapping hip | 3 | 0.50 | 2 | 0.64 |
| Stinchfield resisted hip flexion test | 2 | 0.33 | 10 | 3.22 |
| Muscle palpation | 2 | 0.33 | 4 | 1.29 |
| Neurological screen | 2 | 0.33 | 1 | 0.32 |
| Pelvic floor strength | 2 | 0.33 | 0 | 0.00 |
| Gillette test | 1 | 0.17 | 1 | 0.32 |
| Sahrmann movement system impairment syndromes (MSIS) | 1 | 0.17 | 0 | 0.00 |
| Prone hip extension motor control | 1 | 0.17 | 0 | 0.00 |
| Sacral rocking | 1 | 0.17 | 0 | 0.00 |
| Seated flexion abduction external rotation (FABER) | 1 | 0.17 | 0 | 0.00 |
| Muscle inhibition | 1 | 0.17 | 0 | 0.00 |
| Lower quarter screen | 1 | 0.17 | 0 | 0.00 |
| Muscle energy technique | 1 | 0.17 | 0 | 0.00 |
| Diagnostic injection | 0 | 0.00 | 8 | 2.57 |
| Labs | 0 | 0.00 | 2 | 0.64 |
| Special tests | ||||
| Flexion abduction external rotation (FABER) | 573 | 95.02 | 294 | 94.53 |
| Flexion adduction internal rotation (FADIR) | 549 | 91.04 | 288 | 92.60 |
| Scour test | 519 | 86.07 | 152 | 48.87 |
| Thomas test | 500 | 82.92 | 181 | 58.20 |
| Straight leg raise | 484 | 80.27 | 239 | 76.85 |
| Sacroiliac joint compression/distraction | 465 | 77.11 | 155 | 49.84 |
| Trendelenburg sign | 437 | 72.47 | 158 | 50.80 |
| Ober test | 409 | 67.83 | 235 | 75.56 |
| Lumbar quadrant test | 363 | 60.20 | 21 | 6.75 |
| Leg length | 354 | 58.71 | 186 | 59.81 |
| Long axis femoral distraction | 344 | 57.05 | 20 | 6.43 |
| Prone instability test | 281 | 46.60 | 24 | 7.72 |
| Supine to long-sit | 240 | 39.80 | 27 | 8.68 |
| Stork test | 225 | 37.31 | 169 | 54.34 |
| Craig test | 216 | 35.82 | 24 | 7.72 |
| Log roll | 213 | 35.32 | 229 | 73.63 |
| Hip flexor contracture | 195 | 32.34 | 88 | 28.30 |
| Beighton score | 194 | 32.17 | 89 | 28.62 |
| n | % | n | % | |
| Sign of the buttock | 177 | 29.35 | 4 | 1.29 |
| Abduction extension external rotation (ABDEER) | 158 | 26.20 | 88 | 28.30 |
| Rectus femoris contracture | 151 | 25.04 | 42 | 13.50 |
| Apprehension test | 150 | 24.88 | 79 | 25.40 |
| McCarthy test | 120 | 19.90 | 64 | 20.58 |
| Posterior rim impingement | 118 | 19.57 | 55 | 17.68 |
| Lateral rim impingement | 113 | 18.74 | 49 | 15.76 |
| Nobel compression test | 108 | 17.91 | 78 | 25.08 |
| Dynamic internal rotatory impingement test (DIRI) | 108 | 17.91 | 77 | 24.76 |
| Fulcrum test | 97 | 16.09 | 90 | 28.94 |
| Dynamic external rotatory impingement test (DEXRIT) | 87 | 14.43 | 65 | 20.90 |
| Fitzgerald test | 80 | 13.27 | 34 | 10.93 |
| Patellar-pubic percussion | 67 | 11.11 | 5 | 1.61 |
| Dial test | 59 | 9.78 | 60 | 19.29 |
| Resisted external derotation | 55 | 9.12 | 31 | 9.97 |
| Percussion test | 52 | 8.62 | 23 | 7.40 |
| Squeeze test | 45 | 7.46 | 38 | 12.22 |
| Pace sign | 34 | 5.64 | 35 | 11.25 |
| Philippon internal rotation | 24 | 3.98 | 23 | 7.40 |
| O’Donnell test | 21 | 3.48 | 5 | 1.61 |
| Freiberg test | 19 | 3.15 | 30 | 9.65 |
| Foveal distraction | 16 | 2.65 | 7 | 2.25 |
| Bicycle stress test | 6 | 1.00 | 17 | 5.47 |
| Slump test | 6 | 1.00 | 3 | 0.96 |
| Thigh thrust | 4 | 0.66 | 1 | 0.32 |
| Gaenslen test | 3 | 0.50 | 1 | 0.32 |
| C-sign | 2 | 0.33 | 0 | 0.00 |
| Resisted straight leg raise | 2 | 0.33 | 0 | 0.00 |
| 90–90 straight leg raising test | 2 | 0.33 | 0 | 0.00 |
| Hip quadrant test | 2 | 0.33 | 0 | 0.00 |
| Piriformis stretch | 1 | 0.17 | 2 | 0.64 |
| Ely test | 1 | 0.17 | 1 | 0.32 |
| Posterior capsule | 1 | 0.17 | 0 | 0.00 |
| Anterior inferior chain (AIC) | 1 | 0.17 | 0 | 0.00 |
| Drehmann sign | 1 | 0.17 | 0 | 0.00 |
| Hip lag sign | 1 | 0.17 | 0 | 0.00 |
| Clunk test | 1 | 0.17 | 0 | 0.00 |
| Lumbar spring | 1 | 0.17 | 0 | 0.00 |
| Flexion adduction internal rotation (FAIR) | 1 | 0.17 | 0 | 0.00 |
| Standing hip flexion | 1 | 0.17 | 0 | 0.00 |
| n | % | n | % | |
| Internal rotation with overpressure | 1 | 0.17 | 0 | 0.00 |
| Hip on axis rotation | 1 | 0.17 | 0 | 0.00 |
| Flexion impingement | 0 | 0.00 | 1 | 0.32 |
| Imaging | ||||
| Radiograph—hip | 267 | 44.28 | 285 | 91.64 |
| Magnetic resonance image/angiogram—pelvis/hip | 241 | 39.97 | 202 | 64.95 |
| No access to imaging | 209 | 34.66 | 6 | 1.93 |
| Radiograph—pelvis | 190 | 31.51 | 208 | 66.88 |
| Radiograph—lumbar spine | 185 | 30.68 | 85 | 27.33 |
| Magnetic resonance image/angiogram—lumbar spine | 148 | 24.54 | 41 | 13.18 |
| Radiograph—femur | 99 | 16.42 | 27 | 8.68 |
| Computed tomography—pelvis/hip | 99 | 16.42 | 10 | 3.22 |
| Access to imaging, but no use | 97 | 16.09 | 3 | 0.96 |
| Computed tomography—lumbar spine | 62 | 10.28 | 2 | 0.64 |
| Radiograph—knee | 43 | 7.13 | 13 | 4.18 |
| Magnetic resonance image/angiogram—knee | 42 | 6.97 | 9 | 2.89 |
| Computed tomography—knee | 33 | 5.47 | 1 | 0.32 |
| Ultrasound | 18 | 2.99 | 94 | 30.23 |
| Dual x-ray absorptiometry (DEXA) | 1 | 0.17 | 0 | 0.00 |
Unknown acronym, possibly Gross Motor Function Measure
Author Contributions and Acknowledgments
Concept/idea/research design: L. Brown-Taylor, A. Lynch, R. Foraker, M. Harris-Hayes, S. Di Stasi, B. Walrod, W.K. Vasileff, K. Glaws
Writing: L. Brown-Taylor, A. Lynch, R. Foraker, M. Harris-Hayes, B. Walrod, W.K. Vasileff, K. Glaws, S. Di Stasi
Data collection: L. Brown-Taylor
Data analysis: L. Brown-Taylor, A. Lynch, R. Foraker, M. Harris-Hayes, S. Di Stasi
Project management: L. Brown-Taylor, S. Di Stasi
Fund procurement: L. Brown-Taylor, S. Di Stasi
Providing participants: A. Lynch, M. Harris-Hayes, S. Di Stasi, B. Walrod
Providing facilities/equipment: S. Di Stasi
Providing institutional liaisons: A. Lynch, S. Di Stasi, M. Harris-Hayes
Consultation (including review of manuscript before submitting): A. Lynch, R. Foraker, M. Harris-Hayes, B. Walrod, W.K. Vasileff, K. Glaws, S. Di Stasi
The authors acknowledge Dr Cara Lewis for her contributions during pilot testing for this study.
Ethics Approval
This survey was determined to be exempt from review by the institutional review board at the senior author’s institution. This study was conducted in agreement with the 1964 Declaration of Helsinki and its later amendments. Survey participants were required to consent to participate before continuing to survey content. All data obtained from the national survey were deidentified to reduce bias that could be introduced if participants felt that their answers would be judged individually.
Funding
This work was supported in part by a Promotional of Doctoral Studies Level I Scholarship from the Foundation for Physical Therapy Research. Research reported in this publication was supported, in part, by the National Center for Advancing Translational Sciences (award no. TL1TR002735) and the National Center for Medical Rehabilitation Research of the National Institute of Child Health and Human Development (award no. F30HD094520).
The authors also acknowledge The Ohio State University Center for Clinical and Translational Science grant support (National Center for Advancing Translational Sciences, grant nos. 8UL1TR000090-05, KL2TR002734, TL1TR002735, UL1TR002733) for REDCap support related to this project. The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. Stephanie Di Stasi and Marcie Harris-Hayes declare a biannual honorarium for service as associate editors of Journal of Orthopaedic and Sports Physical Therapy. The remaining authors report no conflicts of interest.
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