Key Points
- ▸Three-month postoperative, but not preoperative, psychological factors were associated with perceived improvement following hip arthroscopy for femoroacetabular impingement syndrome.
- ▸Lower postoperative pain catastrophizing, lower postoperative kinesiophobia, and higher postoperative self-efficacy were associated with greater perceived improvement.
- ▸Three months following hip arthroscopy may be an important time point for assessing psychological factors, which may help identify avenues to enhance patient-reported improvement/satisfaction and inform psychologically informed clinical practice.
Femoroacetabular impingement syndrome (FAIS) is comprised of a triad of variant hip morphology (e.g., of the femoral head/neck and/or acetabulum), symptoms (e.g., motion- or position-related pain of the hip or groin), and clinical signs (e.g., limited hip range of motion).1 FAIS affects 60% of young to middle-aged adults with hip pain, limits sports participation and other daily activities, and is a precursor to osteoarthritis.2–4 Treatment options include nonoperative management (i.e., therapeutic exercise, intraarticular joint injections, and activity modification), and surgical management (i.e., hip arthroscopy or open dislocation, typically reserved for complex cases).1 Hip arthroscopy has seen a 95-fold increase in recent years and involves reshaping of the femoral head and acetabulum, which may slow the progression of subsequent hip osteoarthritis.5
For some patients, hip arthroscopy resolves their symptoms and allows them to successfully return to their previous activity levels. For others, however, it fails to provide sufficient pain relief and acceptable functional improvements. Two years following hip arthroscopy, one-in-four patients still suffer from persistent pain,6 and two-in-three report unacceptable daily function.7 Impaired movement also persists following hip arthroscopy,8 which perpetuates the cycle of pain and dysfunction. Understanding which factors influence these varied outcomes is important. Mounting evidence suggests that psychological factors are associated with surgical outcomes, including pain and function, for patients with FAIS.
The fear-avoidance model describes how interpretations of pain and subsequent pain-related emotions and behaviors may promote either swift recovery or persistent pain and physical dysfunction following hip arthroscopy.9,10 Specifically, interpreting pain as catastrophic (i.e., a sign of serious pathology) leads to increased fear of pain and the belief that one cannot successfully control or cope with it (i.e., low pain self-efficacy), which in turn may extend to fear and avoidance of movements that could elicit pain (i.e., kinesiophobia), thus promoting physical deconditioning, depression, and disability over the long term. Indeed, higher kinesiophobia and lower pain self-efficacy have been associated with worse patient-reported function among individuals with FAIS.11 Furthermore, the odds of elevated postoperative pain and poorer postoperative function are higher for patients with low preoperative self-efficacy, high preoperative pain catastrophizing, or kinesiophobia.12 Though the associations between psychological factors and pain and functional outcomes have been explored, to date no studies have examined the links between these psychological factors and patient perceived improvement. Patient perceived improvement, a global rating of symptom improvement, is becoming increasingly important as efforts shift to emphasize a value-based health care system and it may provide valuable insight into the patient experience in postarthroscopy recovery.13,14
Despite the growing body of evidence supporting the biopsychosocial model in musculoskeletal health care, the associations between psychological factors (pain catastrophizing, kinesiophobia, and pain self-efficacy) and posthip arthroscopy patient perceived improvement have not been explored. This study aimed to investigate differences in preoperative and 3-month postoperative pain, pain catastrophizing, kinesiophobia, and pain self-efficacy between individuals who reported less than or greater than 75% overall improvement from baseline. 75% improvement was selected for the following reasons: (a) At the 3-month time point average scores on the modified Harris Hip Score are 81.4 and the average scores on the Hip Disability and Osteoarthritis Outcome Score subscales of Symptoms, Pain, and Activities of Daily Living are 71.4, 77.2, and 84.5, respectively (all on 0–100 scales).15 (b) Two years posthip arthroscopy for FAIS, 73% of patients achieved the patient acceptable symptomatic state for the modified Harris Hip Score, and risk of reoperation was associated with not meeting the patient acceptable symptomatic state by 3 months postoperatively.16 (c) Posthip arthroscopy, patient satisfaction on a scale from 0 to 100 is 62.2%–68.8%. (d) A 75% improvement in patient-rated function has been associated with patient satisfaction after other arthroscopic procedures.17 It is important to consider that global patient-perceived improvement accounts for more than just patient-reported function or satisfaction. It is likely influenced by expectations, life stressors, coping skills, social support, and more. We chose the 3-month time point because the greatest improvement in patient-reported outcomes occurs within the first 3 months following hip arthroscopy,15 and reoperation is associated with not achieving the patient acceptable symptomatic state within this timeframe.16 We hypothesized that individuals who reported less than 75% improvement would have higher pain levels, pain catastrophizing, higher kinesiophobia, and lower pain self-efficacy preoperatively and 3 months postoperatively than individuals who reported ≥75% improvement. Understanding the associations between pain, psychological factors, and patient perceived improvement may highlight viable treatment targets to improve surgical outcomes and well-being for patients with FAIS.
Methods
Participants
This study was approved by the University of Kentucky Institutional Review Board. From April 2017 to August 2018, 82 participants were consented into the study. The findings of the original study were published,12 and this is a secondary analysis of these data. Of the enrolled participants, 11 participants were considered screen fails as they did not meet this study’s inclusion and exclusion criteria (did not undergo surgery, n = 8; open dislocation procedure, n = 3). Of the remaining 71 participants, 12 did not complete preoperative surveys and 16 did not complete postoperative surveys. After eliminating these participants, 43 (33 females and 10 males) were included in this analysis. All of the participants underwent unilateral hip arthroscopy by the same fellowship-trained surgeon and had the same postoperative protocols.
Procedures
Following informed consent, participants completed a survey that included duration of hip symptoms (months). Then participants completed patient-reported outcome measures including hip pain severity during rest and activity (Pain-Visual Analog Scale), Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia (TSK-17), and Pain Self-Efficacy Questionnaire (PSEQ). The PCS, TSK-17, and PSEQ have good reliability and internal consistency.18–20
Pain Visual Analog Scale
To complete the Pain-Visual Analog Scale, participants indicated their hip pain, and rest and hip pain during activity on a 10 cm scale where 0 indicates no pain and 10 indicates the worst pain. The Pain-Visual Analog Scale is a reliable and valid measure of hip pain.6,21
Pain Catastrophizing Scale
The PCS measures the extent of catastrophic thinking about pain including pain magnification, rumination (e.g., recurring, negative thoughts about pain), and helplessness about pain on a 13-item scale. Total scores range from 0 to 52 and higher scores indicate greater pain catastrophizing.18,22
Tampa Scale for Kinesiophobia
The TSK-17 measures fear of painful movement and reinjury, and is comprised of 17 questions and scores ranging from 17 (lowest fear; best) to 68 (highest fear; worst).9
Pain Self-Efficacy Questionnaire
The PSEQ measures a participant’s confidence in their ability to complete tasks despite their pain, and is comprised of 10 questions with scores ranging from 0 (lowest self-efficacy; worst) to 60 (highest self-efficacy; best).22,23
Three months postoperatively, participants completed the same surveys (minus duration of symptoms) as well as reported their overall improvement, “How much did you improve following your hip arthroscopy on a scale from 0% to 100%, with 100% being normal?”
Statistical Analysis
Following the Levene’s test for homogeneity of variance and the Shapiro–Wilks test for normality, pre- and postoperative psychological factors (PCS, TSK-17, and PSEQ) were compared between improvement groups (<75%; ≥75%) using independent t tests or Mann–Whitney U tests, as appropriate. Cohens d effect sizes (small effect 0.2, medium effect 0.5, and large effect 0.8)24 and 95% confidence intervals were reported for all analyses.
Results
Of the 43 participants (33 females/10 males; 42.0 ± 11.2 years; 26.7 ± 4.0 kg/m2), four underwent revision hip arthroscopy (9.3%) and 39 (90.7%) underwent primary hip arthroscopy. In total, 13 (30.2%) reported less than 75% improvement 3 months after surgery. The average improvement 3 months after surgery was 75.7% ± 24.2%, and the average duration of hip symptoms prior to surgery was 32.4 ± 33.2 months. PCS, TSK-17, and PSEQ scores improved pre- to 3 months postoperatively (p ≤ .008; Table 1).
Changes in Psychological Factors From Preoperative to 3-Months Postoperative
| Psychological factor | Preoperative | Postoperative | p |
|---|---|---|---|
| PCS | 19 (8.5, 32.5) | 2 (0, 12) | <.001* |
| TSK-17 | 42.9 ± 6.6 | 37.1 ± 7.0 | <.001* |
| PSEQ | 44 (27, 49) | 51 (40, 59) | .008* |
Note. Reported as mean ± SD or median (IQR), as appropriate. IQR = interquartile range; PCS = Pain Catastrophizing Scale; PSEQ = Pain Self-Efficacy Questionnaire; TSK-17 = Tampa Scale for Kinesiophobia.
*Statistical significance at p < .05.
Improvement groups (<75%; ≥75%) did not differ in terms of age, sex, body mass index, duration of hip symptoms, preoperative hip pain, or preoperative psychological health (p ≥ .07; Table 2). Participants who reported less than 75% improvement 3 months after surgery had worse pain at rest (p = .03), worse pain during activity (p = .03), higher pain catastrophizing (p = .04), higher kinesiophobia (p = .02), and lower self-efficacy (p = .007) 3 months following surgery. Participants reporting less than (compared to greater than) 75% improvement 3 months after surgery also reported less of a decrease in pain catastrophizing (p = .02) and kinesiophobia (p = .002), and less of an increase in self-efficacy (p = .006) from baseline to 3-month follow up.
Variables of Interest Compared Between Patient-Perceived Improvement Groups (<75% Improvement and ≥75% Improvement)
| Variable of interest | <75% improvement | ≥75% improvement | p | Cohens d | 95% CI |
|---|---|---|---|---|---|
| Number of participants | 13 | 30 | — | — | — |
| Age | 41.2 ± 13.5 | 42.3 ± 10.3 | .81 | −0.09 | [−9.8, 7.7] |
| Sex (F/M) | 9 F/5M | 28 F/5M | .14 | — | — |
| BMI (kg/m2) | 26.8 ± 3.1 | 26.9 ± 4.3 | .90 | −0.03 | [−2.2, 2.5] |
| DOS (months) | 36 (14, 84) | 17 (11.3, 24) | .07 | 0.68 | [−1.1, 46.1] |
| Preoperative patient-reported outcome measures | |||||
| Pain at rest | 4.8 ± 2.1 | 4.0 ± 2.6 | .34 | 0.34 | [−0.84, 2.4] |
| Pain during activity | 8 (5, 9) | 7 (6, 8) | .69 | 0.13 | [−1.3, 1.9] |
| PCS | 20 (9, 32) | 17.5 (8.3, 33.8) | .85 | −0.08 | [−10.8, 8.5] |
| TSK-17 | 43.0 ± 7.0 | 42.9 ± 6.5 | .97 | 0.01 | [−4.6, 4.8] |
| PSEQ | 45 (27, 54) | 43.5 (27, 47.8) | .67 | 0.03 | [−10.7, 11.4] |
| Postoperative patient-reported outcome measures | |||||
| Pain at rest | 2.8 (1, 3) | 1 (0, 2) | .03* | 0.80 | [−0.03, 3.0] |
| Pain during activity | 5.3 ± 2.6 | 3.3 ± 2.1 | .03* | 0.84 | [0.24, 3.8] |
| PCS | 4 (2, 14) | 1 (0, 6.5) | .04* | 0.57 | [−2.4, 16.3] |
| TSK-17 | 41.2 ± 7.8 | 35.2 ± 6.0 | .02* | 0.86 | [0.91, 11.1] |
| PSEQ | 40 (25, 49) | 56 (44.5, 59) | .007* | −0.82 | [−22.5, −1.6] |
| Change scores for psychological patient-reported outcome measures | |||||
| Pre- to postoperative ΔPCS | 5 (0, 9) | 11.5 (6.3, 20.8) | .02* | −0.73 | [−15.1, −0.99] |
| Pre- to postoperative ΔTSK-17 | 1.8 ± 4.2 | 7.7 ± 6.9 | .002* | −1.03 | [−9.4, −2.4] |
| Pre- to postoperative ΔPSEQ | 1.5 ± 11.6 | −11.0 ± 15.0 | .006* | −0.71 | [3.8, 21.1] |
Note. Reported as mean ± SD or median (IQR), as appropriate. BMI = body mass index; DOS = duration of symptoms; PCS = Pain Catastrophizing Scale; TSK-17 = Tampa Scale for Kinesiophobia; PSEQ = Pain Self-Efficacy Questionnaire; CI = confidence interval; IQR = interquartile range; F = female; M = male.
*Statistical significance at p < .05.
Discussion
We investigated differences in preoperative and 3-month postoperative pain, pain catastrophizing, kinesiophobia, and pain self-efficacy between patients with FAIS who reported greater versus less than 75% overall perceived improvement 3 months after hip arthroscopy. In this study, the majority of patients (69.8%) reported greater than 75% improvement 3 months following surgery. Participants who reported less than 75% improvement had higher pain (at rest and during activity), as well as higher pain catastrophizing and kinesiophobia, and lower self-efficacy 3 months postoperatively but not preoperatively. These findings add to the growing evidence showing that psychological factors are associated with key patient-reported outcomes following hip arthroscopy—in this case, patient-perceived improvement.
Our finding that participants who perceived less than 75% improvement 3 months after surgery also reported higher pain is consistent with findings on the association between pain and patient-reported satisfaction and hip functioning following hip arthroscopy.25 Because the pain experience hinges upon emotional and cognitive factors (e.g., anxiety, pain-focused attention),26 it is possible that the relationship between pain and psychosocial health (pain catastrophizing, kinesiophobia, and pain self-efficacy) may be bidirectional among these individuals (although such hypotheses cannot be tested cross-sectionally at the 3-month time point). Indeed, the fear-avoidance model posits that pain-related fear and avoidance leads to disuse, disability, and subsequently, increased pain—perpetuating a vicious cycle.10
Notably, this study found that postoperative, but not preoperative, psychological factors were associated with perceived improvement following hip arthroscopy. Clapp et al.27 also found postoperative, not preoperative, PCS scores were associated with not meeting the minimal clinically important difference on hip-specific patient-reported outcome questionnaires. It may be that, at baseline (before surgery), patients’ reported pain catastrophizing, kinesiophobia, and pain self-efficacy are more representative of their typical responses to their hip pain, or pain broadly. However, when responding to these measures 3 months postoperatively, patients’ may focus more narrowly on their pain and recovery following the index surgery. Lower perceived improvement at, and leading up to this time point may trigger catastrophic/avoidant responses to pain and other concerns about recovering successfully (e.g., low self-efficacy). However, other studies have shown that preoperative psychological factors are associated with postsurgical outcomes in orthopedic surgery broadly, as well as in hip arthroscopy.12,28,29 Therefore, further work is needed to better understand psychological risk factors of poor surgical outcomes—in particular, the timing and granularity of pre- and postoperative assessments, and how these psychological factors can fluctuate throughout the rehabilitation process.
Pain catastrophizing, kinesiophobia, and self-efficacy improved within 3 months of hip arthroscopy for patients in this study. This improvement in psychological health is consistent with Clapp et al.27 who also found reductions in pain catastrophizing and kinesiophobia following hip arthroscopy. Importantly, they did not find any additional improvement in these psychological factors from 6 months to 1 year following surgery.27 This short recovery window is further supported by Flores et al.15 who found that for hip-related patient-reported outcome measures, the greatest improvements occur within the first 3 months following hip arthroscopy. In fact, for some hip-related outcomes, including the Hip Disability and Osteoarthritis Outcome Score Symptoms and Activities of Daily Living scales, the percentage of patients meeting the minimal clinically important difference no longer increases after the 3-month point.15 Given the relationship between postoperative psychological factors and perceived improvement, the 3-month postoperative time point may be important for assessing psychological predictors of persistent pain, disability, and inferior outcomes.
Several limitations are worth noting. Given the small sample size, the results should be interpreted cautiously and verified with future studies. A post hoc power analysis using a Mann–Whitney U test and the primary outcome of postoperative self-efficacy (37.7 ± 15.6; 37.7 ± 15.6; d = 0.82) was conducted. The post hoc power analysis revealed we had 76.6% power at an alpha level of .05. The associative nature of these findings warrants future, larger studies to determine the causal relationship between poor postoperative psychosocial health and clinical outcomes following hip arthroscopy. Two of the 95% confidence intervals include 0 (pain at rest [−0.03, 3.0] and postoperative pain catastrophizing [−2.4, 16.3]). Though both p values are less than .05 (.03 and .04, respectively) and Cohens d effect sizes are large (0.80) to moderate (0.57), these results should be interpreted cautiously. Four participants underwent revision hip arthroscopy. All four participants reported ≥75% improvement; however, given that revision hip arthroscopy has been associated with worse pain and functional outcomes,30,31 future studies should examine whether revision hip arthroscopy impacts patient-perceived improvement. Patients may have had different definitions of perceived improvement. Some may have perceived their improvement, or lack of, based on pain, while others may have placed a heavier emphasis on function. Future studies should assess domain-specific patient-reported outcomes (i.e., pain, hip-related function, return to activity) as they relate to treatment satisfaction, including overall perceived improvement. The participants in this study were primarily female (78.7%). Though epidemiology data suggest that FAIS is more common in females than males,32,33 future studies should aim to confirm these findings in male subjects.
Despite these limitations, our findings have several implications for clinical practice. Athletic trainers working with individuals reporting persistent pain 3 months after hip arthroscopy might assess for pain catastrophizing, kinesiophobia, pain self-efficacy, and other psychological factors as potential contributors. However, not all patients with maladaptive psychological responses to pain will report greater pain 3 months after arthroscopy (e.g., it is possible to interpret dull or fleeting pain as catastrophic). Athletic trainers might consider assessing these psychological factors routinely at each postsurgical visit, as higher pain catastrophizing, for example, can predict increased pain and disability prospectively among diverse patients with musculoskeletal pain.34 The current findings add additional support for the first 3 months following hip arthroscopy being a critical treatment window. Athletic trainers are encouraged to regularly evaluate and subsequently intervene on both physical and psychosocial impairments to support early posthip arthroscopy recovery.
Interventions to prevent poor surgical outcomes, including perceived improvement, may be appropriate 3 months after surgery when most patients are still engaging in formal physical therapy. One such approach is psychologically informed clinical practice, which has demonstrated preliminary efficacy to improve pain and function.35,36 Following the biopsychosocial model, psychologically informed clinical practice emphasizes the need to address both physical and psychological impairments during rehabilitation.35 Such psychosocial factors can include low self-efficacy, high pain catastrophizing, and kinesiophobia. To implement psychologically informed clinical practice, athletic trainers can incorporate mind–body skills into rehabilitation sessions and home exercise programs. As examples, mindfulness decreases pain and anxiety;37,38 specific, measurable, actionable, realistic, time-bound (SMART) goal-setting improves self-efficacy;39 and teaching patients diaphragmatic breathing techniques can facilitate muscle relaxation,40 and therefore greater gains in range of motion and self-efficacy. Rigorous evidence for the feasibility and efficacy of mind–body interventions to address psychosocial factors within musculoskeletal psychologically informed clinical practice are necessary to support its’ broad adoption.
Conclusion
In the current study, 3-month postoperative, but not preoperative, psychological factors were associated with perceived improvement following hip arthroscopy for FAIS. Specifically, lower postoperative pain catastrophizing, lower postoperative kinesiophobia, and higher postoperative self-efficacy were associated with greater perceived improvement. We cannot make any causal assumptions given the cross-sectional nature of these associations; however, these data do suggest that the 3-month postoperative time point may be important for assessing psychological factors, which may help identify avenues to enhance patient-reported improvement/satisfaction and inform psychologically informed clinical practice.
Acknowledgments
Dr. Doorley is supported by an NIH/NCCIH training grant (T32 AT000051). Dr. Duncan reports grants and personal fees from Smith and Nephew, grants from Zimmer/Biomet, grants from Stryker, grants from Medtronic, grants from Bone Support, outside the submitted work. This study was approved by the University of Kentucky Institutional Review Board.
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