OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.
|Rehab Clinician (OT/PT)|
These findings are useful in affirming the benefit of nonoperative treatments for nonarthritic hip pain, but the usefulness is hindered by the uncertainty regarding which modality to prescribe.
In this well-conducted systematic review, the satisfactory response rate to non-operative rehabilitation for femoroacetabular impingement, acetabular dysplasia, acetabular labral tear and/or non-arthritic hip pain was only 54% with a wide confidence interval (95% CI: 32%, 76%), and there was no clear superiority of any particular element of physiotherapy over another. The conclusions of the paper are affected by the variable risk of bias and heterogeneity of clinical outcomes of the original studies, and by the fact that most patients were recruited from surgical clinics. Better methodologically conducted RCTs are needed to generalise the results to a primary care setting.
The implications of this research are clear in that a focused course of nonoperative management should likely be considered for most patients with hip-related pain before deciding to proceed with a surgical intervention. However, there is a lack of clear superiority of any particular element of physiotherapy over another.
It is useful to know that approximately 50% of patients will respond to non-operative treatment - if only we could identify who these would be *before* treatment! Since these patients came from a surgical referral centre, it is reasonable to assume that less-affected patients may be even more responsive. As the authors point out, treatment should match the patient clinical findings.
This article would be more useful information for a physiotherapist.