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RehabMeasures Instrument

International Hip Outcome Tool

Last Updated

Purpose

The iHOT questionnaire was developed to assess deficiencies with respect to outcome assessment for young, active patients with hip disorders.

Link to Instrument

Instrument Details

Acronym iHOT-33, iHOT-12

Area of Assessment

Activities of Daily Living
Coordination
Functional Mobility
Gait
Life Participation
Mental Health
Pain
Quality of Life
Seating
Strength
Stress & Coping

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Limb Loss + Impairment
  • Pain Management

Key Descriptions

  • iHOT33:
    1) Scoring ranges from 0-100 for each question
    2) A higher score represents a better quality of life
  • iHOT12 (Jónasson et al., 2014):
    A) Includes 12 items instead of the original 33
    B) Designed to be more easily used in clinical settings
    C) Validated and tested for reliability
    D) Answer each question by marking a visual analogue scale (VAS) between two anchor statements
    E) Scores for each item range from 0 to 100
    F) 100 represents the best quality of life
    G) Total score is a mean score mean score of the different items

Number of Items

33
Short version: 12

Time to Administer

15 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Instrument Reviewers

Amanda Friedline Weber, ATC, LAT, SPT Hannah Leshin, SPT Kate Nagel, SPT Jessica Reynolds, SPT Kip Stromberg, ATC, SPT Whitney Wilson, SPT

Body Part

Lower Extremity

ICF Domain

Body Structure
Body Function
Activity
Participation
Environment

Measurement Domain

Activities of Daily Living
Emotion
General Health
Motor

Professional Association Recommendation

Recommendations for use based on acuity level of the patient

Jónasson et al (2014) 
The iHOT12-S can also be utilised for older patients (i.e. 60–75 years) and for patients with other hip disorders although further studies on these patient groups are needed to verify this belief.

Mohtadi (2012) 
Valid for patients with labral tears and in hip arthroscopy patients, but only with respect to physical function. 
The appropriate population for this tool includes patients aged between 18 and 60 years who have a Tegner activity level of 4 or higher, meaning that they are engaged in recreational physical activities at least once a week or have an occupation involving moderately heavy labor.

Recommendations based on level of care in which the assessment is taken:

Mohtadi (2012) 
The purpose of the described outcome tool is to evaluate patients so that they can be followed up over time and the success of various treatments can be assessed.

Griffin (2012) 
Griffin et al suggested that the iHOT-33 be used in prospective clinical studies due to its length, while the iHOT-12 can be used in routine clinical practice. The iHOT-12 is 1/3 the length and can provide easier and more efficient administration for patients.

Jónasson et al (2014) 
The iHOT12-S is a valid, reliable and responsive HR-PRO, for patients with femoro-acetabular impingement, undergoing hip arthroscopy. “The iHOT12-S showed good reliability, validity and responsiveness and can be safely used both for research and clinically at group level and, to a certain degree, at individual level, in active patients with femoro-acetabular impingement.” 

Kemp (2013) 
Due to the composite nature of the measure, it may be difficult to use in research since there aren’t separate subscales. The IHOT-33, however appears to be a strong outcome measure to use in patients 12-24 months post hip arthroscopic surgery for intra-articular lesions including labral lesions, femoral acetabular impingement (FAI) and chondropathy. 

Mohtadi (2012) 
In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

Considerations

Griffin (2012) 
The iHOT-12 is valid, reliable, and responsive to change. The iHOT-12 demonstrated almost identical sensitivity to change as the iHOT-33, and can be easily used in the clinic. The shortening of the questionnaire did not decrease the quality of the outcome measure and would be appropriate in initial patient assessments and re-evaluations. 

Jónasson (2014) 
The iHOT12-S can be utilized for older patients (i.e. 60–75 years) and for patients with other hip disorders although further studies on these patient groups are needed.

Kemp (2013) 
The IHOT-33 has good reliability, construct validity, discriminative ability, and adequate responsiveness. The IHOT-33 does not appear to have any floor or ceiling effects, but the use of a single aggregate score is a limitation in its ability to discriminate between domains of importance in patients who are 12-24 months post hip arthroscopic surgery. 

Mohtadi (2012) 
iHOT-33 is highly responsive with a small MCID, showing great value for use as an evaluative outcome measure. The iHOT-33 has yet to be specifically evaluated for its discriminative properties, and this requires a future study.

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Non-Specific Patient Population

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Standard Error of Measurement (SEM)

Femoroacetabular impingement:

Jónasson et al (2014) & Thomee et al (2014) 
502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • Average SEM of iHOT12 was 6.2

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013)

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • Total score was 6 points

 

A variety of symptomatic hip conditions:

Mohtadi (2012)

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • Total score was 3 points (95% confidence interval, 5.5 to 6.8)

Minimal Detectable Change (MDC)

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • 90% MDC = 14.4

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Total score was 6 points

  • 90% MDC = 13.9 
  • 95% MDC = 16.6 
  • 16 (patients); 2 (control group)

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Total score was 3 points (95% confidence interval, 5.5 to 6.8)

  • 90% MDC = 7.0

Minimally Clinically Important Difference (MCID)

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • “MIC of 9 to 16 for the individual items and 9 for the average iHOT12-S score at baseline and a 4-month follow-up.”

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • The MCID was found to be 10 (of 100 points total) 

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • The MCID was calculated to be 6.1 showing that the iHOT-33 is very sensitive to change.

Normative Data

Griffin (2012) 

Adults (18-60 years) who came as new pts to a hip clinic for young adults or who were participating in a follow-up after a hip-preserving treatment for diagnoses including, but not limited to: chondral defects, trauma, FAI, labral tears, early OA, instability, loose bodies, Perthes disease, AVN, SCFE, and dysplasia, were used to develop this new (shortened) outcome measure.

  • N = 1,833. Mean iHOT-33 score = 44.3 (95% CI 43.1-45.5)

 

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • Mean:39.3 (Baseline), 39.9 (4 months) 
  • Standard Deviation:17.7(Baseline), 17.4 (4 months)

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • Hip arthroscopic surgery group: 72 ± 20.1 
  • Control group: 97 ± 5.9 

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • The mean score was 32 of 100 at baseline and 65 of 100 at 6 months.

Test/Retest Reliability

Griffin (2012) 

Adults (18-60 years) who came as new pts to a hip clinic for young adults or who were participating in a follow-up after a hip-preserving treatment for diagnoses including, but not limited to: chondral defects, trauma, FAI, labral tears, early OA, instability, loose bodies, Perthes disease, AVN, SCFE, and dysplasia, were used to develop this new (shortened) outcome measure.

  • Excellent test-retest reliability (ICC=0.89 for the iHOT-12). Data from administering additional iHOT-33 to population (n=104) a mean of 24 days after first assessment was used to calculate ICC. 

 

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • Excellent test-retest reliability (ICC=0.88). "The ICC ranged from 0.59 to 0.93 for the iHOT12-S individual items, with an ICC of 0.88 for the average iHOT12-S score. Wilcoxon’s paired test revealed no statistically significant difference between the test and retest scores.”

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • Excellent test-retest reliability (ICC=0.93 [0.87-0.96] with 95% confidence interval)

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • Excellent, all questions have a Pearson correlation of greater than 0.80

Internal Consistency

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • Excellent, iHOT12-S (Cronbach’s alpha = 0.89)

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • Excellent (Cronbach’s alpha = 0.96)

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • Excellent (Cronbach’s alpha = .99)

Construct Validity

Griffin (2012) 

Adults (18-60 years) who came as new pts to a hip clinic for young adults or who were participating in a follow-up after a hip-preserving treatment for diagnoses including, but not limited to: chondral defects, trauma, FAI, labral tears, early OA, instability, loose bodies, Perthes disease, AVN, SCFE, and dysplasia, were used to develop this new (shortened) outcome measure.

  • Excellent: r=.979 (derived from regression indicating that iHOT-12 accounted for 95.9% of the variation of the iHOT-33)

 

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

  • Spearman’s correlation coefficients were calculated at baseline between the iHOT12-S and EQ5D and the iHOT12-S and HAGOS-S. There were significant correlations with all the subscales of the HAGOS-S, the EQ-5D total score and the EQ-5D VAS score. Correlations between the iHOT12-S and EQ-5D were good for the mobility, usual activities and pain/discomfort subscales. Interestingly, there was a higher correlation than expected with the anxiety/depression subscale (Spearman r = 0.34), indicating a larger psychological factor than hypothesized. The physical activity subscale of the HAGOS was lower than hypothesized.

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.

  • SF-36 Subscales
    • Excellent, Physical Functioning: r = .751
    • Adequate, Physical Role: r = .552
    • Adequate, Bodily Pain: r = .529
    • Adequate, General Health: r = .439
    • Adequate, Vitality: r = .432
    • Adequate, Social Functioning: r = .498
    • Adequate, Emotional Role: r = .319
    • Poor, Mental Health: r = .256
  • Hip arthroscopic surgery group: 72 ± 20.1
  • Control group: 97 ± 5.9
  • Shows this test has discriminative ability.

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

  • Excellent correlation with NAHS (r= 0.81)

 

Thomee et al (2014) 

  • Spearman’s correlation coefficients of the Swedish iHOT 12-S with the HAGOS-S: 
    Adequate, Symptoms: r=.58
    Excellent, Pain: r=.65
    Excellent, Functional in Daily Living: r=.68
    Excellent, Function in Sport and Recreation: r= .67
    Adequate, Participation in Physical Activities: r=.37
    Excellent, Quality of Life (Hip and/or Groin-related): r=.61
    Per Thomee et al., the correlations are all significant.

Content Validity

Mohtadi, 2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.

Content validity was assessed through consensus agreement with a group of participating orthopaedic hip arthroscopists. This group, the MAHORN, provided input at all stages of the development of the questionnaire. Members of the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) provided feedback into the original set of items and rated each of the items with respect to importance in a similar fashion to the patients in the item reduction phase. The surgeons also evaluated each item in the pretest questionnaire for its relevance, whether the item would change as a result of treatment, and whether the response format was appropriate.

Ten additional items were included based on consensus agreement between the research team and the MAHORN surgeons.

Content validity was not further tested on patients with and without the condition.

Face Validity

Femoroacetabular impingement:

(Jónasson et. al., 2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.


Face validity of iHOT12-S was deemed acceptable, according to consensus among the expert panel.

 

 A variety of symptomatic hip conditions:(Mohtadi, 2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.


Patients were involved in the development of the tool to establish face validity of the tool. Face validity was determined throughout the development of the questionnaire by reviewing the relevant literature, as well as through the direct involvement and contribution from representative samples of patients with hip problems, orthopaedic hip surgeons, and physiotherapists.

Floor/Ceiling Effects

Femoroacetabular impingement:

Jónasson et al (2014) 

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.


Excellent, floor and ceiling effects were not detected in the iHOT12-S.

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013) 

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.


Excellent, no floor or ceiling effect detected.

 

A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.


Excellent, no floor or ceiling effect detected.

Responsiveness

Griffin (2012) 

Adults (18-60 years) who came as new pts to a hip clinic for young adults or who were participating in a follow-up after a hip-preserving treatment for diagnoses including, but not limited to: chondral defects, trauma, FAI, labral tears, early OA, instability, loose bodies, Perthes disease, AVN, SCFE, and dysplasia, were used to develop this new (shortened) outcome measure.


Determined using standardized effect size: 

  • Large responsiveness, 0.98 (95% CI, 0.67-1.28) for iHOT-12
  • Large responsiveness1.03 (95% CI, 0.70-1.36) for iHOT-33

 

Femoroacetabular impingement:

Jónasson et al (2014)

502 Swedish men and women age 15-75 (average age 37) with femoroacetabular impingement.

 
“The changes in the GPE score between baseline and the 4-month follow-up were in agreement with the SRM and ES results, indicating good responsiveness by the iHOT12-S.” 

 

Hip arthroscopic surgery for intra-articular hip lesion:

Kemp (2013)

Age 16-80 who underwent hip arthroscopic surgery for intra-articular hip lesion performed by one specific orthopedic surgeon in past 12-24 months.


Correlation with Global Rating of Change (GRC): r =0 .57; p < 0.001. Moderate responsiveness, effect Size = 0.22. Relationship considered if r > 0.40 and significance if p < .05. 

 

 A variety of symptomatic hip conditions:

Mohtadi (2012) 

Young, active patients (aged 18 to 60 years, Tegner activity level > 4) presenting with a variety of symptomatic hip conditions.


The mean change in score was 33 with a SD of 19.3. Responsiveness was determined using several different measures, including a comparison of baseline and 6-month data with a paired t test, standardized effect size, standardized response mean, and responsiveness ratio. 
For the comparison of baseline and 6-month data, the paired t test showed highly significant differences, with p < .01. The standardized mean response was 1.7, standardized effect size is 2.0--Large responsiveness, responsiveness ratio was 6.7.

Bibliography

Griffin DR, Parsons N, Mohtadi NGH, Safran MR. A Short Version of the International Hip Outcome Tool (iHOT-12) for Use in Routine Clinical Practice. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2012;28(5):611-618. 

Jónasson P, Baranto A, Karlsson J, et al. A standardised outcome measure of pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement: cross-cultural adaptation and validation of the international Hip Outcome Tool (iHOT12) in Swedish. Knee Surgery, Sport Traumatol Arthrosc. 2014;22(4):826-834. doi:10.1007/s00167-013-2710-x.

Kemp JL, Collins NJ, Roos EM, Crossley KM. Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery. Am J Sports Med. 2013;41(9):2065-2073. doi:10.1177/0363546513494173.

Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The international hip outcome tool (iHOT-33). Arthroscopy. 2012;28(5):595-605; quiz 606-10.e1. doi: 10.1016/j.arthro.2012.03.013 [doi].

Thomeé R, Jónasson P, Thorborg K, et al. Cross-cultural adaptation to Swedish and validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms and physical function in patients with hip and groin disability due to femoro-acetabular impingement. Knee Surgery, Sport Traumatol Arthrosc. 2014;22(4):835-842. doi:10.1007/s00167-013-2721-7.

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