Movement Pattern Training in People With Intra-articular, Prearthritic Hip Disorders

University of Pittsburgh, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Intra-articular, prearthritic hip disorders (PAHD) result in substantial dysfunction in young adults and are proposed precursors to hip osteoarthritis (OA). Effective treatment of PAHD is needed to improve function in the young adult and prevent or delay the onset of hip OA, however evidence related to treatment of PAHD is limited. This research will provide the foundation for a future clinical trial to assess the efficacy of movement pattern training, an innovative rehabilitation approach for the treatment of PAHD.

Significance: Intra-articular, prearthritic hip disorders (PAHD) result in substantial dysfunction in young adults and are proposed precursors to hip osteoarthritis. The number of surgical procedures to treat PAHD has grown exponentially in the past decade, despite the lack of high level evidence to guide treatment decisions. The potential exists for surgery to become standard treatment before rigorous investigation of treatment options has been completed. This trend may be partially due to a lack of evidence related to rehabilitation. Although some authors believe rehabilitation can improve function in people with PAHD, others state that rehabilitation is contra-indicated and recommend surgery as the best option. There are no published clinical trials to support or refute either opinion, therefore little is known about the comparative effectiveness of rehabilitation. Innovation: The investigators' long term goal is to develop effective treatment strategies for people with PAHD that will improve function and prevent or delay the onset of OA. Movement pattern training is an innovative rehabilitation approach designed to reduce stresses on the hip joint by optimizing the biomechanics of functional tasks through task-specific instruction. Preliminary work suggests that abnormal movement patterns may be associated with PAHD and that movement pattern training may be an effective treatment approach, however comparison to standard rehabilitation has not been completed. Purpose: This study was designed to assess the feasibility of conducting a multicenter randomized clinical trial (RCT) to determine the efficacy of movement pattern training compared to standard rehabilitation for people with PAHD. Participants enrolled at Washington University and University of Pittsburgh will be randomized into one of two treatment groups, movement pattern training or standard rehabilitation. In addition to assessing feasibility of the trial, preliminary estimates of effect sizes for treatment outcomes will be obtain in preparation for the future definitive trial. Post-treatment improvements in patient-reported function as measured by the Hip disability and Osteoarthritis Outcome Score and hip adduction motion during functional tasks, a proposed mechanistic factor associated with PAHD will be assessed. Upon completion of this study, the investigators will be positioned to implement a multicenter RCT to definitively assess the efficacy of movement pattern training. Impact: Ultimately, if movement pattern training is determined to be effective, it will provide a relatively inexpensive alternative to surgical intervention. Further, the theoretical concepts of movement pattern training could be used to possibly serve a role in injury prevention, as well as optimize post-surgical outcomes in those who do require surgery.

Treatment: 10 sessions over 12 weeks and a home program provided by a physical therapist. Treatment includes assessment of patient goals and patient education. Movement Pattern Training (MPT) will focus on task-specific training to improve lower extremity movement patterns during basic tasks, such as sit to stand and stairs, and reported patient-specific tasks. Patient education will include instruction in abnormal movement patterns and methods to optimize movement patterns during each task. Exercises will include repeated practice of tasks using optimized movement patterns. Verbal cues and visual aids will be used to assist the participant. Difficulty of the task-specific activities will be progressed by varying repetitions performed, increasing load or changing the support surface.

Treatment: 10 sessions over 12 weeks and a home program provided by a physical therapist. Treatment includes assessment of patient goals and patient education. For the Standard Rehabilitation, focus will be on progressive lower extremity and trunk strengthening and lower extremity flexibility. Patient education will include instruction to modify intensity, frequency or duration of patient-specific tasks. Using current clinical practice guidelines and previous reports, strengthening and flexibility exercises will be prescribed and progressed by varying the repetitions performed or increasing the load.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Activities in Daily Living Subscale From Baseline to Post-treatment (13 Weeks)

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Activities in Daily Living subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOS Activities in Daily Living from the post-treatment HOOS Activities in Daily Living .

Change in Hip Disability and Osteoarthritis Outcome Score (HOOS) Symptoms Subscale From Baseline to Post-treatment (13 Weeks)

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOSSymptoms subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSSymptoms from the post-treatment HOOSSymptoms.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain Subscale From Baseline to Post-treatment (13 Weeks)

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Pain subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOS Pain from the post-treatment HOOS Pain.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Sport Subscale From Baseline to Post-treatment (13 Weeks)

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Sport subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOS Sport from the post-treatment HOOS Sport.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Quality of Life (QOL) Subscale From Baseline to Post-treatment (13 Weeks)

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Quality of Life subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOS Quality of Life from the post-treatment HOOS Quality of Life.

Change in Function Using the Patient Specific Functional Scale From Baseline to Post-treatment (13 Weeks)

The Patient Specific Functional Scale (PSFS), a patient-reported outcome measure of patient-specific activity limitations. Patients are asked to identify "3-5 activities you are unable to do or having difficulties performing due to the pain or symptoms in your hip". Patients then rated level of difficulty from 0-10, 0 indicating they are unable to perform the activity and 10 indicating they are able to perform the activity at their preinjury level. The final score is an average of all scores provided. Change was calculated by subtracting the baseline PSFS from the post-treatment PSFS.

Change in Average Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to Post-treatment (13 Weeks)

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For average NPRS, patients are asked to rate what their pain was over the last week. Change was calculated by subtracting the baseline average NPRS from the post-treatment average NPRS.

Change in Worst Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to Post-treatment (13 Weeks)

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For worst NPRS, patients are asked to rate what was their worst (highest) level of pain was over the last week. Change was calculated by subtracting the baseline worst NPRS from the post-treatment worst NPRS.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) ADL Subscale From Baseline to 6 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Activity Daily Living (ADL) subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSADL from the 6 month HOOSADL.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Symptoms Subscale From Baseline to 6 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Symptoms subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSSymptom from the 6 month HOOSSymptom.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain Subscale From Baseline to 6 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Pain subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSPain from the 6 month HOOSPain.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Sport Subscale From Baseline to 6 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Sport subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSSPort from the 6 month HOOSSport.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) QOL Subscale From Baseline to 6 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Quality of Life (QOL) subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSQOL from the 6 month HOOSQOL.

Change in Function Using the Patient Specific Functional Scale From Baseline to 6 Months After Treatment Completion.

The Patient Specific Functional Scale (PSFS), a patient-reported outcome measure of patient-specific activity limitations. Patients are asked to identify "3-5 activities you are unable to do or having difficulties performing due to the pain or symptoms in your hip". Patients then rated level of difficulty from 0-10, 0 indicating they are unable to perform the activity and 10 indicating they are able to perform the activity at their preinjury level. The final score is an average of all scores provided. Change was calculated by subtracting the baseline PSFS from the 6 month PSFS.

Change in Average Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to 6 Months After Treatment Completion.

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For average NPRS, patients are asked to rate what their pain was over the last week. Change was calculated by subtracting the baseline average NPRS from the 6 month average NPRS.

Change in Worst Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to 6 Months After Treatment Completion.

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For worst NPRS, patients are asked to rate what was their worst (highest) level of pain was over the last week. Change was calculated by subtracting the baseline worst NPRS from the 6 month worst NPRS.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) ADL Subscale From Baseline to 12 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Activity Daily Living (ADL) subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSADL from the 12 month HOOSADL.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Symptom Subscale From Baseline to 12 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Symptom subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSSymptom from the 12 month HOOSSymptom.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain Subscale From Baseline to 12 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Pain subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSPain from the 12 month HOOSPain.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) Sport Subscale From Baseline to 12 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Sport subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSSport from the 12 month HOOSSport.

Change in Function Using the Hip Disability and Osteoarthritis Outcome Score (HOOS) QOL Subscale From Baseline to 12 Months After Treatment Completion.

The Hip disability and Osteoarthritis Outcome Score (HOOS) is a patient reported outcome measure to quantify activity limitations due to hip pain. The outcome reported is the change (improvement) in function using the HOOS Quality of Life (QOL) subscale. Scoring of each subscale ranges from 0-100, with lower scores indicating greater impairment or activity limitation. Change was calculated by subtracting the baseline HOOSQOL from the 12 month HOOSQOL.

Change in Function Using the Patient Specific Functional Scale From Baseline to 12 Months After Treatment Completion.

The Patient Specific Functional Scale (PSFS), a patient-reported outcome measure of patient-specific activity limitations. Patients are asked to identify "3-5 activities you are unable to do or having difficulties performing due to the pain or symptoms in your hip". Patients then rated level of difficulty from 0-10, 0 indicating they are unable to perform the activity and 10 indicating they are able to perform the activity at their preinjury level. The final score is an average of all scores provided. Change was calculated by subtracting the baseline PSFS from the 12 month PSFS.

Change in Average Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to 12 Months After Treatment Completion.

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For average NPRS, patients are asked to rate what their pain was over the last week. Change was calculated by subtracting the baseline average NPRS from the 12 month average NPRS.

Change in Worst Pain Intensity Quantified by a Numeric Pain Rating Scale (NPRS) From Baseline to 12 Months After Treatment Completion.

The numeric pain rating scale (NPRS) is a patient-reported outcome measure of pain intensity quantified using a 0-10 scale, 0 indicating the patient perceives no pain and 10 indicating the patient perceives the pain to be "worst pain imaginable". For worst NPRS, patients are asked to rate what was their worst (highest) level of pain was over the last week. Change was calculated by subtracting the baseline worst NPRS from the 12 month worst NPRS.

The outcome reported is the change (increase) in gluteus minimus muscle volume measured in centimeters cubed, using magnetic resonance imaging. Positive scores indicate an increase in volume. Change was calculated by subtracting the baseline muscle volume from the post-treatment muscle volume.

The outcome reported is the change (decrease) in the proportion of fatty infiltration within the gluteus maximus muscle, measured by magnetic resonance imaging. A muscle fat index (MFI) was calculated to represent the proportion of fat within a muscle. To be able to analyze fat across the entire length of the muscle (from proximal to distal), muscle length was normalized so that 0% represented the most proximal slice and 100% represented the most distal slice. Mean MFI within every slice was then represented at every 1% of muscle length using spline interpolation.

The outcome reported is the change (increase) in gluteus medius muscle volume measured in centimeters cubed, using magnetic resonance imaging. Positive scores indicate an increase in volume. Change was calculated by subtracting the baseline muscle volume from the post-treatment muscle volume.

The outcome reported is the change (increase) in gluteus maximus muscle volume measured in centimeters cubed, using magnetic resonance imaging. Positive scores indicate an increase in volume. Change was calculated by subtracting the baseline muscle volume from the post-treatment muscle volume.

The outcome reported is the change (decrease) in the proportion of fatty infiltration within the gluteus maximus muscle, measured by magnetic resonance imaging. A muscle fat index (MFI) was calculated to represent the proportion of fat within a muscle. To be able to analyze fat across the entire length of the muscle (from proximal to distal), muscle length was normalized so that 0% represented the most proximal slice and 100% represented the most distal slice. Mean MFI within every slice was then represented at every 1% of muscle length using spline interpolation.

The outcome reported is the change (decrease) in the proportion of fatty infiltration within the gluteus maximus muscle, measured by magnetic resonance imaging. A muscle fat index (MFI) was calculated to represent the proportion of fat within a muscle. To be able to analyze fat across the entire length of the muscle (from proximal to distal), muscle length was normalized so that 0% represented the most proximal slice and 100% represented the most distal slice. Mean MFI within every slice was then represented at every 1% of muscle length using spline interpolation.

Inclusion Criteria: be 15-40 years old report deep hip joint or anterior groin pain, confirmed upon physical exam report pain > 3/10 and present > 3 months demonstrate functional limitation with modified Harris Hip Score <90. Exclusion Criteria: previous hip surgery, fracture, pelvic/hip infection pain due to high impact trauma inflammatory disease, e.g. rheumatoid arthritis, gout neurological involvement affecting balance age <15 or >40 Slipped Capital Femoral Epiphysis (SCFE) or Legg-Calve-Perthes Disease (LCP) pain, numbness or tingling that radiates into the thigh known pregnancy

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