A recent clinical trial led by Professor Joanne Kemp FACP (left) at La Trobe University has examined the outcomes of two different exercise-based, physiotherapist-led interventions for femoroacetabular impingement (FAI) syndrome. 

The results of the PhysioFIRST study, published in the British Journal of Sports Medicine, suggest that exercise in general is a factor in improving quality of life for people with FAI syndrome rather than a particular type of exercise. 

FAI syndrome is a common cause of hip pain in young to middle-aged adults and is associated with a higher risk of developing osteoarthritis in the hip joint at a younger age. 

The study compared two six-month-long, physiotherapist-led interventions – a targeted strengthening program and a standardised stretching program – to determine which was better, observing how each intervention affected pain, function and quality of life. 

Joanne says the research team looked closely at previous FAI studies and talked to clinicians to develop the interventions used in the randomised controlled trial. 

‘From our literature review, it became clear that studies where the physio intervention went for at least three months seemed to be the most effective. 

They needed to have had a fairly substantial amount of physio with some elements of hip muscle strengthening and also pelvic control to be most effective.’ 

The other key consideration in designing the clinical trial was working out a suitable control intervention – a credible, legitimate alternative that would keep participants engaged. 

‘You don’t want to get participants to think they haven’t ended up in the best treatment group because then they get something called resentful demoralisation, which is where they say, “I’m sick of this; I don’t want to do this because I didn’t get into the group I was hoping for.” 

‘Then they fully withdraw from the trial. 

‘We wanted patients to stay blinded to their treatment group and feel like they got a really good treatment.’ 

To that end, 154 participants were randomly assigned to two groups. 

Participants in both groups saw a physiotherapist once a week for three months for a supervised exercise session. 

Every second week this session would incorporate a traditional physiotherapy consultation, including some manual therapy if the clinician felt it would be beneficial. 

After three months, all participants were given a membership to a nearby gym for three months and an ongoing exercise program, with physiotherapy sessions once a month. 

The main difference between the two groups came down to the exercise program itself. 

The targeted strengthening group (the STRENGTH group) received an individualised, progressive program focusing on hip, trunk and functional strength exercises, along with education about pain, safety and the importance of maintaining physical activity. 

The control group (the STRETCH group) was given a different set of stretches to do each week but without individualisation or progression and with only very basic education on pain and activity. 

‘To try to keep it feeling legitimate, there were things like standing on one leg, stretching your quad muscle or your calf muscle and that sort of thing, so there was probably a little bit of indirect strength training in there.’ 

The primary outcome measurements looked at hip-related quality of life and patient-perceived global improvement measures for both pain and function. 

Both groups showed a clinically significant improvement from the baseline measurement but there was no difference between the two interventions. 

This surprised the researchers, who expected that the STRENGTH group would improve more. 

Researcher Joanne Kemp says that a physio-led exercise program can improve quality of life for people with FAI syndrome.

Secondary analyses looked further at pain, symptoms, physical function, participation in physical activity and hip and/or groin-related quality of life and here a difference between the two groups emerged. 

The researchers reported that participants in the STRENGTH group were significantly more likely to report improved pain – but not function – compared with the STRETCH group. 

The STRENGTH treatment also led to larger improvements in hip muscle strength than the STRETCH treatment. 

Joanne says the trial provides evidence that a structured exercise program is a safe and credible option for people with FAI syndrome. 

‘I think clinicians can take home the knowledge that a structured six-month supervised physio program is safe for people with FAI syndrome to do. 

‘They don’t need to race off and have surgery because the program was safe and well tolerated and most people improved, particularly with the strengthening intervention, where threequarters of people did feel like they were much improved. 

‘The other thing that’s important is that both groups had significant improvements in their quality of life, so if someone hates strength training but they love yoga or Pilates or something else, it might be enough just to get them doing some sort of structured, supervised exercise program. 

‘Maybe the specific elements are less important than the fact that they’re out there doing something.’ 

She notes that unless there is a strong reason for early surgery, people with FAI syndrome should try a good-quality, exercise-based physiotherapy intervention for six months before considering more invasive treatments like surgery. 

‘There’s a good chance that you will be recovered enough that you won’t need to go down the path of surgery.’ 

Joanne and her team are currently analysing data from a five-year follow-up study, looking at the number of people who have gone on to have arthroscopic surgery for FAI syndrome, and the results suggest that very few have needed it. 

They are planning to extend the follow-up to 10 years to look at long-term progression and are using MRI scans to examine changes to cartilage and the development of osteoarthritis. 

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