Prognostic models for identifying risk of poor outcome in people with acute ankle sprains: the SPRAINED development and external validation study

Comparative Efficacy of Micro-Needle-Knife Therapy and Acupuncture in Acute Ankle Sprains: A Randomized Controlled Trial

BACKGROUND Micro-needle knife (MNK) therapy releases the superficial fascia to alleviate pain and improve joint function in patients with acute ankle sprains (AAS). We aimed to evaluate the efficacy and safety of MNK therapy vs that of acupuncture. MATERIAL AND METHODS This blinded assessor, randomized controlled trial allocated 80 patients with AAS to 2 parallel groups in a 1: 1 ratio. The experimental group received MNK therapy; the control group underwent conventional acupuncture treatment at specified acupoints. Clinical efficacy differences between the 2 groups before (time-point 1 [TP1]) and after treatment (TP2) were evaluated using the visual analogue scale (VAS) and Kofoed ankle score. Safety records and evaluations of adverse events were documented. One-month follow-up after treatment (TP3) was conducted to assess the intervention scheme's reliability. RESULTS VAS and Kofoed ankle scores significantly improved in both groups. No patients dropped due to adverse events. At TP1, there were no significant differences between the 2 groups in terms of VAS and Kofoed scores (P>0.05). However, at TP2, efficacy of MNK therapy in releasing the superficial fascia was significantly superior to that of acupuncture treatment (P<0.001). At TP3, no significant differences in scores existed between the groups (P>0.05). CONCLUSIONS This study demonstrates that 6 sessions of MNK therapy to release the superficial fascia safely and effectively alleviated pain and enhanced ankle joint function in patients with AAS, surpassing the efficacy of conventional acupuncture treatment. Future studies should increase the sample size and introduce additional control groups to further validate the superior clinical efficacy of this intervention.

Higher Age is Associated with Lower Likelihood of Conversion to Surgery after Primary Nonoperative Treatment for Osteochondral Lesions of the Talus

INTRODUCTION

The first line of treatment for osteochondral lesions of the talus (OLT) is nonoperative. To date, there is limited evidence on risk factors that may influence conversion to surgery after primary nonoperative treatment for symptomatic OLTs. The aim of this study was therefore to identify risk factors for conversion to surgery after initial nonoperative treatment of OLTs.

METHODS

For this cohort study, patients with a primary OLT who were nonoperatively treated for at least 6 months between 1990 and 2020 were included. Univariable Cox regression analysis, resulting in hazard ratios (HRs), on the primary outcome (i.e. conversion to surgery after initial nonoperative treatment) was performed for potential risk factors. The following risk factors were analyzed: gender, age, body mass index (BMI), numeric rating scale (NRS), lesion size (depth, sagittal length, coronal length, volume, surface), lesion morphology (presence of fragments and presence of cysts), lesion location (medial/central/lateral), congruency of the ankle joint and trauma in history. Data imputation was conducted according to the multiple data principle with pooling.

RESULTS

Forty-two patients with primary OLTs were included in this study: 23 (55%) males and 19 (45%) females with a mean age of 39.1 (SD: 14.2). The median overall follow-up time was 66 months (range: 7-188). Around 23% of the patients had a conversion to surgery at the median observation time. The Kaplan-Meier analysis revealed a survival rate of 93% (95% confidence interval [CI]:84-100), 90% (95% CI: 81-99), and 77% (95% CI: 63-91) at 1, 2, and 5 years after the initiation of treatment, respectively. After performing the COX regression analysis, age was the sole risk factor significantly associated with conversion to surgery with an HR of 0.93 (95% CI: 0.87-0.99). The different HRs for all other risk factors were as follows: gender: 0.33 (95% CI: 0.08-1.34), BMI: 0.87 (95% CI 0.76-1.01), depth: 0.97 (95% CI: 0.79-1.18), coronal length: 1.19 (95% CI: 0.97-1.44), sagittal length: 0.98 (95% CI: 0.87-1.12), surface area: 1.17 (95% CI: 0.41-3.31), volume: 0.96 (95% CI: 0.24-3.91), presence of fragments: 4.17 (95% CI: 0.84-20.61).

CONCLUSION

For primary OLTs, 77% of the patients were successfully treated nonoperatively at a median follow-up of 66 months without the need for a surgical intervention. Survival rates of 93%, 90%, and 77% were found at 1, 2, and 5 years after the initiation of treatment, respectively. We found that a higher age at the moment of diagnosis was significantly associated with a lower likelihood of conversion to surgery with a 7% decrease of likelihood each year the patient is older at the moment of diagnosis. The findings of this study are clinically relevant as it ameliorates the quality of the shared decision-making process between the patient and the treating team as we can advise OLT patients at a higher age with tolerable symptomatology that there is a relatively lower risk of conversion to surgery.

Six Externally Validated Prognostic Models Have Potential Clinical Value to Predict Patient Health Outcomes in the Rehabilitation of Musculoskeletal Conditions: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to identify and appraise externally validated prognostic models to predict a patient's health outcomes relevant to physical rehabilitation of musculoskeletal (MSK) conditions.

METHODS

We systematically reviewed 8 databases and reported our findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. An information specialist designed a search strategy to identify externally validated prognostic models for MSK conditions. Paired reviewers independently screened the title, abstract, and full text and conducted data extraction. We extracted characteristics of included studies (eg, country and study design), prognostic models (eg, performance measures and type of model) and predicted clinical outcomes (eg, pain and disability). We assessed the risk of bias and concerns of applicability using the prediction model risk of bias assessment tool. We proposed and used a 5-step method to determine which prognostic models were clinically valuable.

RESULTS

We found 4896 citations, read 300 full-text articles, and included 46 papers (37 distinct models). Prognostic models were externally validated for the spine, upper limb, lower limb conditions, and MSK trauma, injuries, and pain. All studies presented a high risk of bias. Half of the models showed low concerns for applicability. Reporting of calibration and discrimination performance measures was often lacking. We found 6 externally validated models with adequate measures, which could be deemed clinically valuable [ie, (1) STart Back Screening Tool, (2) Wallis Occupational Rehabilitation RisK model, (3) Da Silva model, (4) PICKUP model, (5) Schellingerhout rule, and (6) Keene model]. Despite having a high risk of bias, which is mostly explained by the very conservative properties of the PROBAST tool, the 6 models remain clinically relevant.

CONCLUSION

We found 6 externally validated prognostic models developed to predict patients' health outcomes that were clinically relevant to the physical rehabilitation of MSK conditions.

IMPACT

Our results provide clinicians with externally validated prognostic models to help them better predict patients' clinical outcomes and facilitate personalized treatment plans. Incorporating clinically valuable prognostic models could inherently improve the value of care provided by physical therapists.

Describing characteristics clinicians believe predictive of patient reported outcomes after adult's ankle fracture - A modified Delphi study

BACKGROUND

Despite explanatory studies have identified a wide range of modifiable and non-modifiable characteristics, uncertainty persists as to what characteristics are predictive of patient reported outcome following ankle fracture in adults, therefore hindering the selection of candidate variables in prognostic models without compromising the accuracy.

OBJECTIVE

To establish consensus-based characteristics which clinicians believe are predictive of patient reported outcomes following ankle fracture.

DESIGN

Three-round online modified Delphi survey.

METHODS

In Round 1, participants provided responses to open-ended questions, as to what characteristics within the first eight weeks following ankle fracture are predictive of short- (<6 months), medium- (6 months-2 years) and long-term (>2 years) patient reported outcome. Rounds 2 and 3 presented consensus and gathered agreement on statements.

RESULTS

Twenty participants answered the open-ended questions, including 13 physiotherapists and seven orthopaedic/trauma surgeons. Participants reached consensus for fracture characteristics and agreement for age, recovery of signs and symptoms, fracture management complexity, medical comorbidities, mental health status and patient journey at the short-term timepoint; agreement for age, engagement in recovery process, recovery of signs and symptoms, fracture characteristics, medical comorbidities and socioeconomic status at the medium-term timepoint; agreement for engagement in recovery process, fracture characteristics and medical comorbidities at the long-term timepoint.

CONCLUSION

Clinicians believed in certain modifiable and non-modifiable characteristics predictive of patient reported outcome following ankle fracture. Our findings may provide insights about characteristics which can be selected in prognostic model development and future explanatory studies, allowing targeting adults at risk of developing long-standing symptoms and disability.

Reflections on dynamic consent in biomedical research: the story so far

Dynamic consent (DC) was originally developed in response to challenges to the informed consent process presented by participants agreeing to 'future research' in biobanking. In the past 12 years, it has been trialled in a number of different projects, and examined as a new approach for consent and to support patient engagement over time. There have been significant societal shifts during this time, namely in our reliance on digital tools and the use of social media, as well as a greater appreciation of the integral role of patients in biomedical research. This paper reflects on the development of DC to understand its importance in an age where digital health is becoming the norm and patients require greater oversight and control of how their data may be used in a range of settings. As well as looking back, it looks forwards to consider how DC could be further utilised to enhance the patient experience and address some of the inequalities caused by the digital divide in society.

Predicting patient-reported and objectively measured functional outcome 6 months after ankle fracture in people aged 60 years or over in the UK: prognostic model development and internal validation

OBJECTIVE

To predict functional outcomes 6 months after ankle fracture in people aged ≥60 years using post-treatment and 6-week follow-up data to inform anticipated recovery, and identify people who may benefit from additional monitoring or rehabilitation.

DESIGN

Prognostic model development and internal validation.

SETTING

24 National Health Service hospitals, UK.

METHODS

Participants were the Ankle Injury Management clinical trial cohort (n=618) (ISRCTN04180738), aged 60-96 years, 459/618 (74%) female, treated surgically or conservatively for unstable ankle fracture. Predictors were injury and sociodemographic variables collected at baseline (acute hospital setting) and 6-week follow-up (clinic). Outcome measures were 6-month postinjury (primary) self-reported ankle function, using the Olerud and Molander Ankle Score (OMAS), and (secondary) Timed Up and Go (TUG) test by blinded assessor. Missing data were managed with single imputation. Multivariable linear regression models were built to predict OMAS or TUG, using baseline variables or baseline and 6-week follow-up variables. Models were internally validated using bootstrapping.

RESULTS

The OMAS baseline data model included: alcohol per week (units), postinjury EQ-5D-3L visual analogue scale (VAS), sex, preinjury walking distance and walking aid use, smoking status and perceived health status. The baseline/6-week data model included the same baseline variables, minus EQ-5D-3L VAS, plus five 6-week predictors: radiological malalignment, injured ankle dorsiflexion and plantarflexion range of motion, and 6-week OMAS and EQ-5D-3L. The models explained approximately 23% and 26% of the outcome variation, respectively. Similar baseline and baseline/6 week data models to predict TUG explained around 30% and 32% of the outcome variation, respectively.

CONCLUSIONS

Predictive accuracy of the prognostic models using commonly recorded clinical data to predict self-reported or objectively measured ankle function was relatively low and therefore unlikely to be beneficial for clinical practice and counselling of patients. Other potential predictors (eg, psychological factors such as catastrophising and fear avoidance) should be investigated to improve predictive accuracy.

TRIAL REGISTRATION NUMBER

ISRCTN04180738; Post-results.