Treatment decisions after interdisciplinary evaluation for non-arthritic hip pain: a randomized controlled trial

Abstract

Introduction:

Physical therapy and hip arthroscopy are two viable treatment options for patients with non-arthritic hip pain(NAHP); however, patients may experience considerable decisional conflict when making a treatment decision. Interdisciplinary evaluation with a physical therapist and surgeon may better inform the decision-making process and reduce decisional conflict.

Objective:

Identify the extent to which an interdisciplinary evaluation between a surgeon, physical therapist, and patient influences treatment plans and decisional conflict of persons with NAHP.

Design:

Randomized controlled trial

Setting:

Hip preservation clinic

Participants:

Adults with primary NAHP

Interventions:

Participants were randomized to receive a standard (surgeon) or interdisciplinary (surgeon+physical therapist) evaluation. Surgeon evaluations included patient interview, strength and range-of-motion examination, palpation, gross motor observation, and special testing. Interdisciplinary evaluations started with the surgeon evaluation, then a physical therapist evaluated movement impairments during sitting, sit-to-stand, standing, single-leg stance, single-leg squat, and walking. All evaluations concluded with treatment planning with the respective provider(s).

Outcome Measures:

Treatment plan and decisional conflict were collected pre- and post-evaluation. Inclusion of physical therapy(PT) in participants’ post-evaluation treatment plans and post-evaluation decisional conflict were compared between groups using chi-squared tests and Mann Whitney U tests, respectively.

Results:

78 participants (39 in each group) met all eligibility criteria and were included in all analyses. Sixty-six percent of participants who received an interdisciplinary evaluation included PT in their post-evaluation treatment plan, compared to 48% of participants who received a standard evaluation (P=0.10). Participants who received an interdisciplinary evaluation reported 6.3 points lower decisional conflict regarding their post-evaluation plan (100-point scale; P=0.04). The interdisciplinary and standard groups reduced decisional conflict on average 24.8±18.9 and 23.6±14.6 points, respectively.

Conclusions:

Adding a physical therapist to a surgical clinic increased interest in PT treatment, but this increase was not statistically significant. The interdisciplinary group displayed lower post-evaluation decisional conflict; however, both groups displayed similar reductions in decisional conflict from pre- to post-evaluation. This study also demonstrated the feasibility of an interdisciplinary evaluation in a hip preservation clinic.

1. Introduction:

Patients with non-arthritic hip pain who present to a hip preservation clinic may experience considerable decisional conflict. Decisional conflict is a quantifiable measure of how uncertain a healthcare consumer may feel regarding a decision.¹ These patients’ prolonged symptoms,² including depression and anxiety,^3,4 and extensive (and potentially excessive) healthcare provider visits^2,5 may contribute to decisional conflict. Greater decisional conflict has been associated with greater decisional regret, reduced patient involvement, and lower satisfaction with physicians in primary care settings.^6,7 Healthcare providers should consider decisional conflict of their patients to engage them in the treatment planning process.⁸

Decisional conflict has become increasingly popular to evaluate the impact of shared decision-making interventions for cancer, diabetes, end-of-life, and pediatric health conditions^9–13; however, decisional conflict is minimally reported in orthopaedic literature. A cross-sectional survey study of 100 adults considering total joint replacement reported clinically-significant decisional conflict.^14–16 Persons considering joint replacement were more conflicted if they reported less instrumental support such as tangible assistance for transportation, house work, and self-care.¹⁴ The findings from this single study highlight the mental distress that patients may experience when considering elective surgery. This notion was recently echoed in a discussion piece that encouraged surgeons to improve decision quality by considering why their patients may be conflicted.¹⁷

Interdisciplinary efforts to support patients through the decision-making process is a potential solution to combat decisional conflict. Interdisciplinary teams have been proposed as mechanisms to aid patients in the decision-making processes for treatment of back pain.^18,19 An interdisciplinary evaluation for patients with non-arthritic hip pain may be particularly beneficial due to the scarcity of evidence-based comparisons for operative versus non-operative interventions for non-arthritic hip pain.^4,20,21 Three recent randomized clinical trials evaluating operative and non-operative treatment for non-arthritic hip pain compared hip arthroscopy and physical therapy.^4,20,21 Two meta analyses were published summarizing the results of these three trials. Bastos and colleagues affirm no significant differences between surgery and physical therapy at six months, 1 year or 2 years,²² whereas Schwabe and colleagues report significantly better surgical outcomes at last follow-up based on their analyses.²³ Both meta analyses acknowledge the heterogeneity of studies limits interpretation of pooled results. Additional non-operative treatments beside physical therapy include patient education, activity reduction or modification, medication, or injections which may be provided in combination with each other and with physical therapy.^24,25 While a surgeon can prescribe any of these operative or non-operative treatments, a physical therapist ultimately determines a patient’s appropriateness for physical therapy treatment. Including both operative and non-operative providers in the evaluation and treatment-planning discussion may better inform patients and reduce decisional conflict. Furthermore, this approach to consider all treatment options with the patient aligns with expert-based recommendations for evaluation and treatment of femoroacetabular impingement syndrome, a form of non-arthritic hip pain.²⁴

The purpose of this study was to identify the extent to which an interdisciplinary evaluation between a surgeon, physical therapist, and patient influences treatment decisions of persons presenting to a hip preservation clinic for non-arthritic hip pain. The primary a priori hypotheses tested were that participants who received an interdisciplinary evaluation would (a) more often include physical therapy in their expected treatment plan, and (b) report lower post-evaluation decisional conflict regarding their treatment plan when compared to participants who received a standard evaluation. Changes in treatment plan and decisional conflict from pre- to post-evaluation were described via secondary analyses due to the preliminary nature of this work.

2. Methods

2.1. Study Design

A feasibility randomized controlled trial with allocation ratio 1:1 was designed and implemented over a planned 15-month recruitment period to compare treatment plans for persons with non-arthritic hip pain who received a standard evaluation compared to those who received an interdisciplinary evaluation.²⁶ This study was the first part of a larger, 2-part prospective trial (NCT03519087) which aimed to evaluate the impact of both interdisciplinary evaluation (part 1) and treatment (part 2). The present study was a primary analysis of a randomized, controlled trial to evaluate the impact of interdisciplinary evaluation on plan of care. This study was approved by the biomedical sciences Institutional Review Board at The Ohio State University (reference number 2017H0340).

2.2. Setting

This study was conducted in a single-site hip preservation clinic. The hip preservation clinic was operated by two orthopaedic surgeons whose primary treatment population was patients with hip conditions. This clinic was housed within an academic medical center’s sports medicine facility.

2.3. Participants

Participants were identified from new patients scheduled to see one of the two orthopaedic surgeons. New adult patients with active health insurance were approached for participation if they had an appointment during interdisciplinary hours (when one of two study physical therapists were available to participate in an interdisciplinary evaluation). New patients were not approached if they met any exclusion criteria (Table 1); patients with bilateral pain (≥4/10 on both hips) were excluded for the first 12 months but were included after eligibility criteria were expanded to increase recruitment. All participants completed an informed consent process prior to participation.

Table 1.

Eligibility criteria

Exclusion

Inclusion

Spine Spinal pathologya History of lumbar spine surgery Hip Extra-articular condition Osteoporosis Osteoarthritis (Tönnis grade ≥2)45 Previous surgery Fracture Legg-Calvé-Perthes disease Slipped capital femoral epiphysis Periacetabular osteotomy candidate (LCEA<18°, ACEA <18°, acetabular index >10)46 Global health Systematic health conditionb Inflammatory disease Pregnancy Cancer Cognition Decision-making impairment or limitation

≥1 of the following hip morphologies: Femoroacetabular impingementc Labral teard Cartilage defecte Acetabular dysplasiaf Symptomology Hip joint or groin pain Clinical signs (≥1 of the following): Pain reproduction to FADIR Pain reproduction to FABER Demographics At least 18 years of age

Radiographs collected for surgeon examination included anterior-posterior pelvis, anterior-posterior hip, false profile, and 45° Dunn lateral angle. LCEA: lateral center edge angle; ACEA: anterior center edge angle; FADIR: flexion adduction internal rotation of the hip; FABER: flexion abduction external rotation of the hip

^a.Spinal pathology that contributed or explained to participants hip pain was cause for exclusion as evaluated during physician examination. Example pathology were herniated disc, scoliosis, stenosis, spinal cord injury

^b.Cancer, neurological condition (brain injury, stroke, multiple sclerosis)

^c.Radiographs were evaluated by the surgeon for presence of a cam lesion considering alpha angle (>55°) and pincer lesion considering the cross-over sign and center edge angle (>39 °).²⁴

^d.Diagnosed via magnetic resonance image

^e.Diagnosed via radiograph and magnetic resonance image

^f.Radiographs were evaluated by the surgeon for acetabular dysplasia considering LCEA. Participants with LCEA 18–25° were considered dysplastic but not candidate for a periacetabular osteotomy, and thus were included in this study.

2.4. Randomization

A randomization scheme with random blocks (sizes 2–8) was computer-generated (psych, R package)²⁷ by the first author and uploaded to Research Electronic Data Capture (REDCap^™)²⁸ for group assignment. Using the REDCap randomization function, participants were randomized by a research assistant after the informed consent process to either receive a standard or interdisciplinary evaluation. No blinding occurred as part of this study.

2.5. Intervention

2.5.1. Standard Evaluation (Control Group)

Participants were evaluated by one of two fellowship-trained orthopaedic surgeons (five and three years of experience) to confirm eligibility criteria (Table 1). A clinical diagnosis of non-arthritic hip pain was confirmed using surgeon impression of radiographs (and magnetic resonance images, when available) in combination with patient symptoms and clinical signs.²⁴ Eligibility criteria was confirmed after randomization, by the surgeon to maintain clinical productivity and avoid excessive burden to the surgeon workflow. Participants who did not meet all eligibility criteria were removed from the study. Remaining participants in the control group proceeded with their standard-care surgeon evaluation and treatment planning discussions.

2.5.2. Interdisciplinary Evaluation (Intervention Group)

Participants received the same standard-care surgeon evaluation, excluding the treatment planning discussion. Participants in this interdisciplinary group then received a posture and movement screen from one of two study physical therapists (six and three years of experience). Participants were removed from the study if the surgeon or physical therapist identified any exclusion criteria during the evaluation. The physical therapist documented movement impairments and pain during the following tasks: sitting, rising from seated, standing, standing on a single-leg, walking, and squatting on a single-leg. These tasks have previously been identified to elicit movement abnormalities in persons with NAHP.^29–34 Details of the screen were developed based on previous work³⁴ and have been described elsewhere.²⁶ The physical therapist interviewed the participant to identify if they had previously received physical therapy for their hip pain and to gather details regarding the contents of that episode of care. This information on prior physical therapy was used in combination with the patient presentation to inform the physical therapist’s recommendation for or against physical therapy treatment.

The surgeon and physical therapist convened after both separate evaluations were complete for participants in the interdisciplinary group. The physical therapist reported the findings of the posture and movement screen to the surgeon along with an initial treatment recommendation. The surgeon then reported evaluation findings and respective treatment recommendation to the physical therapist. The providers jointly discussed a recommended treatment plan before returning to the participant’s examination room. All three stakeholders (surgeon, physical therapist, and patient) engaged in an interdisciplinary decision-making process to discuss the treatment plan. This process was initiated by the surgeon, but both providers were encouraged to participate in the discussion and engage the patient in considerations of alternative treatment options, risks and benefits of the recommended treatment plan, personal values and resources, and outcome expectations. The provider-recommended treatment plan and subsequent treatment planning discussion could include any combination of treatment options. Furthermore, the participant-reported treatment plan could include multiple treatment options even though this study only focused on inclusion of physical therapy in the participant-reported treatment plan.

2.6. Outcome Measures

2.6.1. Primary Outcomes

The participant’s choice to include physical therapy in their post-evaluation treatment plan and the participant’s decisional conflict regarding their self-reported, post-evaluation treatment plan were the primary outcomes. Participants completed treatment surveys before the surgeon evaluation (pre-evaluation treatment plan) and after their final evaluation (post-evaluation treatment plan). Participants indicated their plan to pursue any combination of the following treatments: injection, surgery, physical therapy, other, or none (no treatment). Participants also completed the Decisional Conflict Scale in regards to both the pre- and post-evaluation treatment plans.¹ The Decisional Conflict Scale is a validated patient-reported measure of how uncertain a patient feels regarding a decision. The Decisional Conflict Scale is scored 0 to 100 with 100 representing maximal conflict. Increasing decisional conflict has been associated with increased likelihood for patients to change their mind, delay decisions, regret decisions, fail knowledge tests regarding treatment options, and blame physicians for bad outcomes.^35,36 This scale contains five subscales: informed, values clarity, support, uncertainty, and effective decision. Each subscale is also scored 0 to 100 with 100 representing least informed, lowest clarity of values, least supported, most uncertain, and least-effective decision.

2.6.2. Secondary Variables of Interest

Secondary variables of interest included prior physical therapy, symptom duration, activity level, and patient-reported hip function, all of which were collected after their final evaluation. A custom survey was used to collect participant-reported history of past physical therapy treatment, duration of symptoms (categorical), and previous and current activity level (Supplemental File 1). Lastly, the 33-item International Hip Outcome Tool (iHOT33) was used to collect participant-reported hip function.³⁷ This outcome tool measures hip function and has demonstrated validity, reliability, and responsiveness to measure hip function in young active adults and has been used to measure changes in function for persons seeking treatment in hip preservation clinics.^38,39 The iHOT33 measures function 0 to 100; higher scores represent better hip-related function. The minimal clinically important difference has been proposed ranging from 6–12 points^37,40 and the patients’ acceptable symptomatic state is 58 points;³⁸ however, these values were established in an operative population for patients who underwent hip arthroscopy.

2.7. Statistical Analysis

2.7.1. Primary Analysis

The distribution of participants who included physical therapy in their post-evaluation treatment plan was compared across groups using a chi-squared test (P≤0.025) to test the hypothesis that participants who received an interdisciplinary evaluation would more often include physical therapy in their treatment plan. Post-evaluation decisional conflict was compared between groups using a Mann-Whitney U test (P≤0.05) to test the hypothesis that participants who received an interdisciplinary evaluation would report lower decisional conflict. The Hodges-Lehmann Statistic with 95% confidence interval was used to describe the group difference in post-evaluation decisional conflict scores. All statistical procedures were performed using SPSS (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.) and R (The R Foundation for Statistical Computing, Vienna, Austria; http://www.r-project.org).⁴¹

2.7.2. Secondary Analysis

Changes in treatment plan and decisional conflict from pre- to post-evaluation were evaluated and described without statistical testing due to the preliminary nature of this work. The number of participants in each group who added or removed physical therapy to/from their treatment plan from pre- to post-evaluation were reported. Additionally, the number, sex distribution, BMI, previous physical therapy, iHOT33 score, change in decisional conflict, and post-evaluation decisional conflict were reported for all participants, regardless of group, based on their inclusion of physical therapy in their pre- and post-evaluation treatment plans.

Changes in decisional conflict were reported for each group as a secondary variable, without statistical analysis, due to the preliminary nature of this work. Average decisional conflict in each group was described in relation to established values for patients who are ready to make a decision (conflict <25%) and for those who are uncertain and may delay their decision (conflict >37.5%).^1,16

2.8. Sample Size

This randomized controlled trial was a feasibility trial for which an estimated recruitment rate was used to determine the recruitment period. This single-site hip preservation clinic evaluates an average of 800 new patients per year across two orthopaedic surgeons. Previous data from this clinic indicated that 15% of the expected 800 new patients would present with non-arthritic hip pain (n=120). An a priori sample size (n=96) was calculated based off the assumption that 80% of approached participants would enroll; a 15-month recruitment period was planned to achieve this sample size.

Completion of the 15-month recruitment period was the primary goal of this feasibility trial and the estimated sample size (n=96) was used to calculate expected power. At the time of study planning, no published evidence was available to inform an estimated effect size. Preliminary data showed 30% of participants indicated an interest in physical therapy after evaluation in this hip preservation clinic. We hypothesized the alternative would be 30% greater, resulting in an effect size of 0.61 (p1=0.60, p2=0.30). At this effect size, 96 participants would provide 85% power at one-sided alpha of 0.025 to detect a significant increase in the interdisciplinary group’s inclusion of physical therapy in their post-evaluation treatment plans. An a priori power analysis was not performed to evaluate expected power in the test of group differences for decisional conflict. Group differences in decisional conflict were tested as a two-sided test.

2.9. Role of Funding Source

The funders played no role in the design, conduct, or reporting of this study.

3. Results

3.1. Sample

Eighty-one percent of the 139 approached patients enrolled in the study. Exclusion criteria were identified during evaluation of 34 participants (16 and 18 from the interdisciplinary and standard groups, respectively) who were removed from the study, leaving 78 participants remaining for the study (Figure 1). Recruitment was only conducted during 68% of expected hours due to limited availability of the study physical therapist, therefore we did not achieve the targeted sample size of 96 during the planned 15-month recruitment period from March 2018 through May 2019.

Figure 1.

Participant recruitment

Modified Consolidated Standards of Reporting Trials (CONSORT) flow diagram

All 78 remaining participants completed baseline and post-evaluation surveys for the primary variable of interest (treatment plan); no participants withdrew. Participants were evenly distributed across groups (n=39 in each). All participants were included in all analyses according to their originally assigned group. Both groups were primarily overweight women in their upper 30s to lower 40s (Table 2). All participants demonstrated intra-articular morphology, signs, and symptoms consistent with femoroacetabular impingement except one participant in the standard group who presented with signs and symptoms consistent with labral tear. Approximately half of the participants with femoroacetabular impingement also presented with labral tear (n=19 interdisciplinary, n=15 standard), borderline hip dysplasia (n=1 in each group), combined labral tear and borderline hip dysplasia (n=1 interdisciplinary, n=2 standard), or combined labral tear and chondral defect (n=1 standard). Over half of participants (51% interdisciplinary, 56% standard) reported prior physical therapy for their hip. On average, participants reported hip function below the patient acceptable symptomatic state (58) for the iHOT33 (34.5±19.4 interdisciplinary, n=36; 42.0±20.5 standard, n=35).

Table 2.

Participant Demographics

	Standard Evaluation	Interdisciplinary Evaluation
N	39	39
Female N(%)	24 (61%)	28 (71%)
Age (y)	41±11	36±10
Body mass index (kg/m2)	29.5±7.0	30.0±5.7
Duration of symptoms N(%)
<3mo	4 (11%)	3 (8%)
3–6mo	5 (14%)	7 (18%)
6–12mo	9 (26%)	10 (26%)
1–2yr	10 (29%)	8 (21%)
2–5yr	6 (17%)	5 (13%)
>5yr	1 (3%)	5 (13%)
Previous activity level47 N(%)
Sports with jumping, cutting, pivoting	4 (11%)	7 (18%)
Sports with lateral movement, less jumping	4 (11%)	7 (18%)
Light aerobic activity or weight lifting	20 (57%)	17 (45%)
Sedentary	7 (20%)	7 (18%)
Current activity level47 N(%)
Sports with jumping, cutting, pivoting	0 (0%)	2 (5%)
Sports with lateral movement, less jumping	2 (6%)	0 (0%)
Light aerobic activity or weight lifting	13 (37%)	8 (21%)
Sedentary	20 (57%)	28 (74%)
Past physical therapy N(%)	22 (56%)	20 (51%)
Physical therapy included in pre-evaluation treatment plan N(%)	23 (58%)	19 (48%)
Physical therapy included in post-evaluation treatment plan N(%)	19 (48%)	26 (66%)
Pre-evaluation decisional conflict	40.1±18.6	35.0±19.6
Post-evaluation decisional conflict	16.5±13.6	10.2±11.2

3.2. Primary Analyses

3.2.1. Post-Evaluation, Participant-reported Treatment Plan

More participants in the interdisciplinary group (66%) included physical therapy in their self-reported treatment plan, but this was not significantly different than the standard group (48%; X²=2.57; P=0.10).

3.2.2. Post-evaluation Decisional Conflict

Participants in the interdisciplinary group reported significantly less decisional conflict regarding their post-evaluation treatment plan (10.2±11.2) compared to the standard group (16.5±13.6, P=0.04; mean ± standard deviation). The interdisciplinary group demonstrated a median 4.6 (95% CI: 0, 12.5) points lower decisional conflict compared to the standard group. Both groups’ post-evaluation decisional conflict were, on average, at a level associated with decision implemention.^1,16

3.3. Secondary Analyses

3.3.1. Changes in Participant-reported Treatment Plan

More participants in the interdisciplinary group gained interest in physical therapy after the evaluation than participants in the standard group (Figure 2). Twenty-five of 78 participants changed their mind after their evaluation(s) regarding the inclusion of physical therapy in their treatment plan. Most participants (7 of 10) who changed their mind after standard evaluation were initially interested in physical therapy, but after surgeon evaluation, excluded physical therapy from their post-evaluation, self-reported treatment plan (Figure 2). In contrast, most participants (11 of 15) who changed their mind after interdisciplinary evaluation were not initially interested in physical therapy, but included it in their post-evaluation, self-reported treatment plan after completing their evaluations (Figure 2). Of the 36 participants who were not initially interested in physical therapy, the 14 who included physical therapy in their post-evaluation treatment plan reported an average 11.4 points better hip function than the 22 who did not include physical therapy in their post-evaluation treatment plan (Table 3).

Figure 2.

Changed Interest in Physical Therapy Treatment after Evaluation in Hip Preservation Clinic

Each participant randomized to the standard or interdisciplinary group is represented as a figure who either gained interest in physical therapy (dark), lost interest in physical therapy (white), or maintained their interest (or disinterest) in physical therapy (gray) from pre- to post-evaluation. PT: physical therapy. Exact mean and standard deviation values are available in Supplemental File 2.

Table 3.

Inclusion of Physical Therapy in the Treatment Plans

	Was PT included in the treatment plan?
Pre-evaluation	Yes		No
Post-evaluation	Yes	No	Yes	No
N	31	11	14	22
Female N (%)	20 (64%)	7 (63%)	11 (78%)	14 (63%)
Age (y)	35±11	38±12	42±12	40±10
BMI (kg/m2)	30.4±7.3	25.3±5.0	30.1±6.2	30.9±5.0
Past PT N (%)	10 (34%)*	9 (81%)	6 (42%)	17 (89%)ǂ
iHOT33	41.9±21.6	45.5±13.9	39.5±21.3	28.1±17.3
DCS reduction	27.7±14.2	28.4±15.7	18.9±21.5	20.6±16.9
Post-evaluation DCS	11.2±11.8	16.3±17.4	15.6±13.1	13.3±11.8

^*29 of 31 participants responded regarding history of physical therapy for their hip;

^ǂ19 of 22 participants responded regarding history of physical therapy for their hip;

PT: physical therapy; BMI: body mass index; iHOT33: 33-item International Hip Outcome Tool; DCS: decisional conflict scale

3.3.2. Changes in Decisional Conflict

Participants’ decisional conflict regarding their treatment interests before evaluation was, on average, at or near levels of uncertainty (interdisciplinary: 35.0±19.6, standard: 40.1±18.6). Participants in the interdisciplinary group reduced decisional conflict, on average, by 24.8±18.9 points compared to a 23.6±14.6 point-reduction for the standard group. All subscales of the Decisional Conflict Scale also reduced, on average, after evaluation for both groups (Figure 3).

Figure 3.

Decisional Conflict Changes

STAND: Standard; INT: Interdisciplinary; *significant group difference (P=0.04) identified for post-evaluation decisional conflict.

4. Discussion

The results of this study partially supported the hypotheses tested. No significant group differences existed for the proportion of participants who included physical therapy in their expected treatment plan; however, the interdisciplinary group demonstrated significantly lower decisional conflict regarding their post-evaluation treatment plan.

The results of this study provide clinically meaningful, initial steps to understand the impact of interdisciplinary care for non-arthritic hip pain. Although nonsignificant, 18% more participants in the interdisciplinary group included physical therapy in their treatment plan after evaluation in the clinic. The addition of a physical therapist to the evaluation process appears to have swayed participants who were initially uninterested in physical therapy; however, interdisciplinary evaluation may not have provided any additional support, beyond the standard evaluation, for patients already interested in physical therapy when they presented to clinic. These results are the first of their kind to demonstrate treatment plan changes after interdisciplinary evaluation for non-arthritic hip pain.

Patients who present to a hip preservation clinic for non-arthritic hip pain may experience considerable decisional conflict due to their many visits to healthcare providers, their prolonged physical and mental symptoms, and an inadequate resource of treatment comparisons. Fifty-eight percent of this study sample reported high baseline decisional conflict, at or above a level associated with delaying a decision. Seventy-eight percent of participants reported low decisional conflict after their evaluation(s), at or below a level associated with implementing a decision. Only two of 78 participants in this study reported higher decisional after evaluation compared to baseline, both of which were in the interdisciplinary group. Both of these participants reported low (<25) decisional conflict pre- and post-evaluation, and thus, their increased decisional conflict is likely clinically insignificant. This study is one of the first to contribute to the paucity of orthopaedic literature regarding decisional conflict; however, qualitative work is needed to further understand specifically why patients are conflicted to develop effective interventions to reduce that conflict.

While decisional conflict regarding the post-evaluation treatment plan was lower for the interdisciplinary group, when considering changed conflict from pre- to post-evaluation, the addition of a physical therapist did not appear to provide additional reductions in decisional conflict compared to the standard evaluation. Further investigation may be warranted for subscales of the Decisional Conflict Scale. The primary purpose of this model for interdisciplinary care was to provide a more comprehensive evaluation to improve patients’ understanding of their condition and treatment options, and to encourage joint decision-making. These concepts would most likely impact patient response to questions in the informed and support subscales of the Decisional Conflict Scale. The greatest group difference observed was for the support subscale; participants in the interdisciplinary group reported an average four points greater reduction in decisional conflict compared to the standard group. Additional support was provided to the interdisciplinary group by providing an additional evaluation from a physical therapist, but also by providing an interdisciplinary discussion of treatment options with both the surgeon and physical therapist. Future work should consider how each of these strategies may contribute to the decision-making process for patients with non-arthritic hip pain.

Participants in this study reported treatment interests beyond surgery, despite presenting to a surgical clinic for evaluation. Over half of participants in this study (53%) included physical therapy in their pre-evaluation treatment plan, before evaluation with the surgeon. Only 30% of participants indicated initial interest in both physical therapy and surgery, prior to seeing the surgeon, which is similar to previously reported patient interests in this clinic.⁴² This statistic is starkly low compared to approximately 70% of patients in hip preservation clinics who indicated no preference between physical therapy and surgery.⁴³ Importantly, Boye and colleagues (2015) did not standardize whether treatment interests of patients were recorded before or after consultation with the surgeon.⁴³ Many participants who included physical therapy in their pre- (19 of 42) and post-evaluation (16 of 45) treatment plans had previously received physical therapy for their hip pain. The content, duration, and quality of physical therapy may impact a patient’s decision to pursue additional rehabilitation over surgical intervention. Surgical treatment is more cost prohibitive and may impact patients’ ability to perform requirements at home or work.²⁰ This study evaluated treatment decisions, but did not record why each participant included specific treatments in their plan. Patients’ past experiences and current knowledge may influence how they participate in the treatment planning process and how they decide upon the resultant treatment plan.

While hip arthroscopy and physical therapy are the most frequently compared treatments for non-arthritic hip pain as of 2020,^4,20,21 they are not the only treatment options.²⁴ Interdisciplinary evaluation with additional providers may further benefit these patients. Psychology and orthopaedic surgery have been studied as a multidisciplinary approach for non-arthritic hip pain, which aligns with the documented mental distress of those seeking hip arthroscopy procedures.^3,4 Richard and colleagues identified perioperative psychological treatment for adolescents who underwent hip arthroscopy reduced negative mental health symptomology and improved positive mental health capacities.⁴⁴ Including additional providers may best be accomplished via remote, or multiple coordinated multidisciplinary visits, when a single interdisciplinary visit cannot be implemented.

4.1. Study limitations

Randomization timing was amended from the original published protocol (NCT03519087) to occur before surgeon evaluation. Best practices for randomized controlled trials suggest randomization to occur after all eligibility criteria are confirmed. In this instance the clinical workflow required that the surgeon know group assignment before entering the examination room, and thus randomization occurred before the surgeon was able to confirm the final eligibility criterion (diagnosis of non-arthritic hip pain). The study team decided surgeon productivity could be negatively affected if the surgeons were required to conduct randomization in the examination room after their evaluation, and thus randomization occurred after baseline surveys for primary variables of interest, before surgeon examination. Potential bias may have been introduced because the surgeon knew the group assignment prior to the examination. Participants in both groups were excluded in similar proportions after examination based on relatively equal exclusion criteria. Both groups completed secondary measures after all examinations to describe past treatment, activity level, and symptoms. These secondary measures occurred after randomization and thus could have been influenced by the type of examination the participant received, although we perceive this risk as low since perceived function is not expected to change after examination. This study design is also limited by lack of audio or video recording to evaluate content of each provider’s evaluation and the combined treatment planning discussion for participants in the interdisciplinary group.

This study incorporated two orthopaedic surgeons and two physical therapists who may have individualized patient care practices. Examination components were standardized across providers, based on discipline. Providers were not restricted to use a decision tree to develop a recommendation based on evaluation results. Each provider was permitted to make recommendations based on their own evaluation and clinical reasoning. This strategy was implemented to mimic current clinical practice that lacks clinical prediction rules for operative and non-operative care of this population.

Participants with a variety of intra-articular morphological abnormalities were included in this study. All participants, except one, presented with signs and symptoms consistent with femoroacetabular impingement syndrome. The bony morphology of femoroacetabular impingement syndrome was likely more easily identified and included in physician diagnosis due to the availability of radiography for every participant. Only 42 of 78 participants (24 interdisciplinary and 18 standard) presented with a magnetic resonance imaging report which was used by the surgeon to diagnose labral tear (if present). Despite the individual morphological characteristics of non-arthritic hip pain, participants undergo similar evaluation procedures, and thus inclusion of multiple medical diagnoses is appropriate for this study that evaluated an interdisciplinary evaluation procedure.

The final sample (n=78) was below the a priori sample size calculation (n=96), and thus the study was not powered to detect a difference in the primary outcome (inclusion of physical therapy in the participant-reported treatment plan). Recruitment was closed after the planned 15-month recruitment period to produce feasibility metrics for this randomized controlled trial to better understand recruitment pathways and patient interest in interdisciplinary care. The a priori sample size was calculated off expected recruitment hours which over-estimated the time the study physical therapists would be available. Furthermore, the a priori power calculation utilized an arbitrary 30% group difference due to significant gaps in the literature to support an informed estimated effect. The observed effect size based on a two-way probability table was 0.18. The observed power for significance level 0.05 at this effect size with a sample of 78 participants was 35%. Future studies would need a sample of 242 participants to observe 80% power considering this effect size.

Physician referral for evaluation by an orthopaedic surgeon was required for patients who presented to this hip preservation clinic; however, information on which providers participants may have seen before this evaluation was not collected. It is common for patients to see multiple providers prior to seeing a hip preservation specialist, which may impact the patient’s decisional conflict. We recommend this data be collected in future studies.

5. Conclusion

This feasibility randomized controlled trial is the first published study to evaluate treatment plans of persons with non-arthritic hip pain who received an interdisciplinary evaluation with both an orthopaedic surgeon and physical therapist. While there was no significant group difference for inclusion of physical therapy in the post-evaluation treatment plan, this study provided preliminary evidence to suggest that addition of a physical therapist to a hip preservation clinic may impact treatment plans for some patients, particularly those not initially interested in physical therapy. Additional interdisciplinary models should be explored to best identify patients who may benefit from interdisciplinary evaluation.