Find out how flawed measurements of improvement in hip surgery patients make hip surgery seem like a great idea.
Hey, everybody! This is Matt Hsu from Upright Health and welcome to Episode 15 of the Upright Health Podcast. Today, I am looking at something called the Harris Hip Score. And we’re looking at that in the context of hip surgery for people who Femoroacetabular Impingement nerve who have been given the diagnosis of FAI. I’ve talked in depth about this in videos and online in many different formats. I believe that this diagnosis is one of basically illusory misplaced faith in diagnostic imaging, and then you pile surgery on top of that and you leave people in a pretty terrible lurch.
So I have been getting a lot of comments and emails from people who have been doing those stretches and taking a different approach to their hip problems and they’ve been seeing marked improvements. And I really appreciate your sharing those stories with me because it motivates me to continue digging deeper into the research and helping share more information that others can use to first, change their mindset and second, start doing different things like stretching properly, addressing muscle properly, addressing coordination issues properly so that they can start moving their hips better. So for all of all of you who have already sent those messages to me, I really appreciate it. I really enjoy hearing your stories of success and seeing you succeed, really with what can be a really frustrating, painful and stubborn problem.
But in any case, today, we’re talking about the Harris Hip Score because it’s something that I noticed was referenced in a lot of studies on surgery for hip impingements. So basically, the Harris Hip Score is a questionnaire that’s used to determine how healthy your hips are. It’s only thirteen questions in its full form. There’s a modified version which is a little bit shorter. It takes out a number of questions that have almost no… I mean very little amount of points that they add to your total score and that, you know, from my experience are probably — from my vantage point anyway – are probably not that effective and useful for assessments, but in any case, it’s got thirteen questions in its full form and you can have a total score of 100 points.
The Harris Hip Score is used to determine whether or not surgery is successful. So in order to consider a surgery a success, you are supposed to have improvement in your Harris Hip Score of 20 points. So for example, if I were going to consider surgery for my hips, I would graded using the Harris Hip Score before surgery and after the surgery, I’d follow up, whatever, a couple months down the line, a year down the line, two years down the line. We’d check in and see what my Harris Hip Score is. As long as I’m maintaining a twenty point improvement, it’s considered a successful surgery.
So, I’m going to give you a study here to take a look at and it’s from March 2009 edition of the clinical orthopedics and related research journal by J. W. Thomas Byrd and Kay S. Jones. What they had was two hundred people with hip problems. A couple of them had more than one hip that was problematic, so they had 207 hips to work on. Average age was thirty three years with a hundred and thirty eight men and sixty two women. They underwent correction of cam impingement, and also forty two patients underwent surgery for cam and pincer impingement. So in this abstract they mentioned that the increase in the Harris Hip Score — the average increase — was twenty points. Yes! So, based on the average, pretty successful.
If we look deeper into the results, we see that… let’s see, average improvement in the Harris Hip Score at last follow up was twenty points with a range of -17 to 60 points. Overall, eighty three percent were improved, although here, they don’t mention by what amount all those eighty three percent improved. And they said, “We noted continued improvement throughout the first year, with scores maintained in those with 2-year follow-up.” And let’s see… they did have one patient who had some issues that resulted in pain that didn’t improve and then they went ahead and did a total hip arthroplasty, so no fun there.
Now, let’s say let’s assume that eighty five percent… and we know that this is not true, but let’s assume that eighty five percent had 20-point improvement or more in your Harris Hip Score. Let’s assume a 100% of these people had a 20-point improvement in their Harris Hip Score. That would make a pretty strong case for the usefulness of doing this arthroscopic surgery to improve hip impingement symptoms, right? Twenty points – that is our threshold and this is our objective measure. If we’re going to use an objective measure like this, we have to know whether this questionnaire is actually measuring things that matter to you as the patient considering the surgery, right?
So having seen the Harris Hip Score mentioned so many times, I went ahead and pulled up the Harris Hip Score and I had my… let’s see here… I have them opened right here. So the Harris Hip Score. I’m going to talk you through a little bit of it. I’m also going to give you the link so you can take a look at it and play with it yourself and see how the points work. Section one is about a lot of stuff that matter to you as a human being. So there’s a section one that talks about pain, whether you have none… excuse me, let me read this to you the opposite way. This is the section that gives you the most points improvements. So I want you to pay really close attention to this.
In section one, pain, the worst possible answer you can give is “Totally disabled, crippled, pain in bed, bedridden,” next is “Marked pain, serious limitation of activities,“ and then “Moderate pain, tolerable but makes concessions to pain. Some limitations of ordinary activity or work. May require occasional pain medication stronger than aspirin.” The next best one is “Mild pain, no effect on average activities, rarely moderate pain with unusual activity, may take aspirin.” The next better one this “Slight, occasional, no compromise in activity,” so you have pain now and then, but doesn’t really compromise your activity level. And then the best one — the very best one — is “none, or ignores it,” that is your best option in the pain section. This is where you get the most points on your Harris Hip Score. So you can have no pain or you could ignore the pain and that would actually give you top marks.
So if we play around with this, let’s say I’m in the marked pain category. I’ve filled out a couple other things on basically all the other fields I’ve filled, but when I clicked on the fact that I have marked pain and serious limitation of activities, I get a Harris Hip Score with everything else here filled out, I get a Harris Hip Score of 83.6. If I then go ahead and click down to “Slight, occasional, no compromise in activity,” I get a Harris Hip Score of 113.6, which I’ve managed to be spectacular. If I click again to “none or ignores it,” I can get myself of all the way to 117.6 points. So if I go down just from marked pain, if I go from “marked pain” to just “moderate pain,” that’s just one step. So again, “marked pain, serious limitation of activities,” then I go “moderate pain” where I have tolerable pain but I have to make concessions, I have to not do certain things, I have limitations on ordinary activity or work, and I may have to take occasional pain medication stronger than aspirin, I can already increase my score… here we go, marked pain, 83.6 and moderate pain, I get 93.6.
So just by going one notch from marked pain to moderate pain, I have already gotten ten points. Now, let’s say I had the surgery and I went form “marked pain” to “moderate pain,” I already achieved ten points improvement. In my mind as a person, I’m not very happy. So maybe — maybe — if I can get another ten point somewhere, I would consider my surgery a success, so how else would I be getting my ten points? Well, let’s see, there’s another section here called “Limp”. Let’s say if I have a severe limp. In the limp section, I could be “severe or unable to walk,” I could have a “moderate limp,” I can have a “slight limp” or I could have no limp. So I’m going to start off with this “severe limp” and I’m going to take it down to, let’s say it worked out pretty well; let’s say I got a slight limp. That actually results in an eight-point improvement. I’m not at no limp, mind you. Actually, I’m still in moderate pain and I still occasionally have to take stronger pain meds than aspirin — and I’m still limping — and I’m at 18 points improvement already.
Let’s say I need to also to look at how long I can walk. So here we have, you can stay in your bedroom chair only, you can be indoors only, you can only walk two or three blocks, ten to fifteen minutes, six blocks thirty minutes or unlimited. So if I’m at, let’s just say, I’m at indoors only, and… well, actually, you know what, let’s say bed and chair only and then I get to 10-15 minutes of walking (so, two to three blocks of walking), my improvement there gives me another six points. So I got ten points from going from marked pain to moderate pain, I got another eight points from making my limp severe to slight and then I got another six points for being able to get out of the bed and chair and walk a couple blocks.
Does that sound like a huge smashing success to you if you’re considering surgery? If you ask me, a 20-point improvement on the Harris Hip Score is not that great. In fact, it’s actually achievable if you just use a strong enough narcotic. And I’m not suggesting that anyone do that, but what I am suggesting is that the picture of improvement that is painted by studies that use the Harris Hip Score is not really that great, right? If you can get a 10-point improvement in just a tiny little change in your pain levels, you have a scale that is wildly, wildly subject to improper interpretation. If I have marked pain and serious limitation of activities, and that just goes down to like a slight pain and I’ve already gained thirty points, okay, success but is that pain comes back, gets worse, and then I just ignore it and you ask me how’s it going, then I say “well, there is some pain, but I just ignore it,” bingo, bingo! Top score!
So I would love to hear what you think about this — whether you think this makes any sense to judge success based on a questionnaire that does not appear to measure things that matter to the human being — and I’d like to hear any stories that you have of what you’ve done to you battle your own hip pain. Go ahead and shoot me an email. Send me message. And definitely, give this some thought and share this information with others that you know are considering the idea of hip surgery. So that’s it for Episode 15. I’m Matt Hsu from Upright Health. Please remember that pain sucks – life shouldn’t.