CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
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understanding how clinical practice guidelines are developed;
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discussing best practices and guidelines with colleagues;
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having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Hip Osteoarthritis Care Pathway
Date of last update: October, 2024
About Hip Osteoarthritis (OA)
Overview: OA is the most common cause of hip pain in older adults (> 50 years of age). It results from a degenerative process that causes loss of joint space, development of osteophytes, and subchondral sclerosis. Symptomatic hip OA is described as anterior, lateral, or posterior hip pain during weight-bearing activity, with morning stiffness less than one hour, and limited hip range of motion in internal rotation and flexion. Hip OA can also be accompanied by muscle weakness that develops around the joint and/or referred pain into the buttock, thigh, or calf. Symptomatic hip OA is amenable to conservative care; however, underlying pathologies requiring medical attention should be ruled out such as cauda equina syndrome, fracture, infection, or tumour.
Effective Management: Given its multifactorial and progressive nature, influenced by physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment for hip OA. The treatment approach should be comprehensive and individualized. Effective management is ethical, evidence-driven, transparent, flexible and responsive to the person’s needs. Core interventions include education, reassurance, addressing psychosocial factors, exercise, and weight loss/management. Optional interventions are selected through shared decision-making to align with patient goals, ultimately optimizing their ability to function and participate in life. Continuous monitoring of progress and consistent assessment of outcomes against goals are crucial to ensure that care strategies remain aligned with the patient's objectives and best interests. Management can be conducted through in-person, virtual or hybrid care.
About the Care Pathway
Purpose: This pathway offers structured, evidence-based guidance for providers delivering conservative care, outlining key steps of the clinical encounter. It also supports referral and co-management decisions for providers not directly providing such care.
Development: This pathway draws on current best practices synthesized from clinical guidelines when available, and from systematic reviews when guidelines are lacking. Content is reviewed periodically to reflect emerging evidence and to ensure continued relevance. Where evidence is evolving or mixed, guidance is informed by the most robust available sources. Input from clinicians, educators, and researchers facilitates alignment with real-world needs and encourages ongoing improvement.
Disclaimer:
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This care pathway is intended to support, not replace, clinical decision-making or advice from a qualified healthcare provider. It offers practice guidance by presenting evidence-informed recommendations in a simplified and user-friendly format. Terminology used throughout is intended to aid understanding and application in clinical settings and should not be interpreted as formal diagnostic or billing terminology. This document is not authoritative, prescriptive, or regulatory.
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Providers are expected to use their professional judgment and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems like ICD-10-CA, scope-of-practice documents, continuing professional education materials, and peer-reviewed literature. While this content is periodically reviewed to reflect current evidence, it is not definitive and may not apply to all clinical scenarios.
1. Record Keeping
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Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).
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Adhere to jurisdictional standards.
2. Informed Consent
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Document verbal consent for health history taking, physical examination, contact in sensitive areas.
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Obtain written consent for treatment.
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Adhere to jurisdictional standards.
3. Health History
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Apply cultural awareness and trauma-informed care principles.
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Sociodemographic: Age, gender, sex.
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Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
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Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
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Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work environment.
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Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
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Previous treatments and responses: Effectiveness and any adverse events.
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Beliefs and expectations: Understanding of their condition, treatment expectations.
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Red, yellow, and orange flags (sections 4 – 6).
Meaningful Outcomes:
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Pain: Pain scales (e.g., NRS), pain diagram.
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Function and Participation: Impact of hip on daily activities (HOOS, WOMAC, AIMS2, PSFS, WHODAS, LEFS).
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Recovery: Self-rated recovery scales.
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Quality of Life: SF-12.
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Sleep quality: PSQI
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Work Status: Return to work/school/activities.
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Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
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Patient Feedback: Experience and satisfaction with care.
4. Differential Diagnosis Requiring Medical Attention
ACTION: Refer to emergency care immediately for red flags:
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Cauda Equina Syndrome: Saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs.
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Hip Infection: Rapid worsening of symptoms and/or the presence of a red, hot, swollen joint. History of immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained systemic symptoms (e.g., fever, chills), IV drug use, poor living conditions.
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Traumatic Hip Fracture: Severe trauma, redness, bruising, swelling, inability to weight bear.
ACTION: Refer to appropriate medical provider:
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Non-traumatic Hip Fracture: Sudden onset, localized severe pain, osteoporosis, corticosteroid use, female sex, older age (>60), history of osteoporotic fracture or cancer.
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Malignancy: (e.g., Chondrosarcoma, Multiple Myeloma): Progressive pain, history of cancer, constitutional symptoms (e.g., fatigue, weight loss, night pain).
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Inflammatory Arthritides (e.g., spondyloarthropathies, polymyalgia rheumatica): Morning stiffness >1 hour, constitutional symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling and deformity.
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Referred Pain: (from abdominal/pelvic visceral conditions): Abdominal or pelvic tenderness.
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Avascular Necrosis (e.g., Chandler’s disease): pain in the hip, reduced range of motion, antalgic gait, progressive worsening of pain and/or range of motion. History of corticosteroid use, alcoholism, trauma, hemoglobinopathies, etc.
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Hernia (e.g., femoral or inguinal hernia): Groin pain, swelling or bulge that appears with coughing/straining and goes away with lying down. Immediate medical referral is only required if hernia is firm or tender and/or sudden severe pain.
6. Psychosocial Factors (Yellow Flags)
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Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.
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Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.
7. Physical Examination
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Observation: Abnormalities, posture, balance, movements, gait, walking capacity (measured by distance or time).
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Range of Motion: Active, passive, resisted (flexion, extension, internal and external rotation, abduction and adduction).
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Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
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Neurological Examination: Motor strength, sensory and reflex testing (L4, L5, S1); upper and lower motor neuron signs; balance testing (e.g. tandem gait, Romberg’s).
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Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
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Advanced Diagnostics: Plain-film radiography is not routinely recommended in the absence of red flags or specific individual factors.
8. Clinical Presentation for Hip OA
A. Hip Osteoarthritis
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Location: Anterior, lateral, or posterior hip pain.
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Signs/Symptoms: Pain, aching, and/or stiffness, bilateral or unilateral, during weight-bearing activities. Loss of range of motion. Morning stiffness that lasts less than 1 hour. May include weakness around the hip joint and/or pain that refers into the buttock, thigh, or calf.
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Physical Exam: Pain reproduced by physical tests; reduced hip range of motion in internal rotation and flexion compared to nonpainful side; no neurological deficits.
9. Treatment Considerations for Hip OA
After providing a report of findings and obtaining written informed consent.
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Core Interventions:
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Education and reassurance
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Exercise therapy (e.g., home-based, aquatic exercise, general aerobic exercise, strengthening)
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Weight loss/management, if indicated (individuals with body mass index ³30)
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Address yellow flags (psychosocial factors)
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Optional Interventions (with Rationale and Shared Decision Making):
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Manual therapy (e.g., manipulation/mobilization, soft tissue techniques, clinical or relaxation massage)
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Oral or topical medications (e.g., paracetamol, non-steroidal anti-inflammatory drugs)
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Cognitive Behavioural Therapy
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Heat therapy
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Walking aids (e.g., walkers, canes)
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Corticosteroid injections
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10. Prognosis
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Recovery: Depends on several factors (e.g., OA severity, treatment response, overall health). The majority of individuals with mild to moderate OA have a favorable prognosis, but symptomatic OA can recur or persist for many.
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Negative Prognostic Factors: Smoking, obesity, higher initial pain and disability levels, poor recovery expectations, mental health issues, persistent symptoms.
11. Ongoing Follow-up
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Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgement.
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Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).
12. Criteria for Discharge
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Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
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Discuss post-discharge plans, including self-management strategies and potential follow-ups.
References or links to primary sources
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Gibbs AJ, Gray B, Wallis JA, Taylor NF, Kemp JL, Hunter DJ, et al. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthr Cartil. 2023;31:1280–92.
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Long H, Liu Q, Yin H, Wang K, Diao N, Zhang Y, et al. Prevalence Trends of Site-Specific Osteoarthritis From 1990 to 2019: Findings From the Global Burden of Disease Study 2019. Arthritis Rheumatol (Hoboken, NJ). 2022;74:1172–83.
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McGovern RP, Christoforetti JJ, Martin RRL, Phelps AL, Kivlan BR. Evidence for Reliability and Validity of Functional Performance Testing in the Evaluation of Nonarthritic Hip Pain. J Athl Train 1 March 2019; 54 (3): 276–282.
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Ayeni O, Chu R, Hetaimish B, Nur L, Simunovic N, Farrokhyar F, Bedi A, Bhandari M. A painful squat test provides limited diagnostic utility in CAM-type femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):806-11.
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