Immediate effect of passive hamstring stretching on flexibility and relationship with psychosocial factors in people with chronic low back pain

Background

Hamstring muscle tightness contributes to disability in people with chronic low back pain (CLBP). HM stretching improves flexibility in healthy individuals, but the immediate effect of stretching is unknown in people with CLBP. Moreover, the stretching effect could be influenced by psychosocial factors.

Objectives

To evaluate the immediate effect of passive HM stretching on flexibility in people with CLBP and the relationships between psychosocial factors and change in hamstring flexibility.

Design

Non-randomized, pilot trial.

Method

One minute of passive stretching was performed in 90 people with CLBP. Change in Active Knee Extension and Straight Leg Raise angles (digital inclinometer), and Fingertips-to-Floor distance (measuring tape) were measured before and immediately after stretching. Correlations between change in flexibility and baseline Fear-Avoidance Beliefs Questionnaire (FABQ) and Hospital Anxiety and Depression Scale (HADS) scores were analyzed.

Results

Hamstring flexibility improved significantly after stretching; Active Knee Extension mean difference was 4° (95% CI, 2.4 to 5.1; p < 0.001, right ES = 0.24, left ES = 0.23); Straight Leg Raise mean difference was 7° (95% CI, 5.5 to 8.6, p < 0.001, right ES = 0.44, left ES = 0.42), Fingertips-to-Floor mean difference was 2 cm (95% CI, 1.7 to 3.0, p < 0.001, ES = 0.20). No correlation was found between improvement in any of the hamstring flexibility measurements and FABQ or HADS scores (p > 0.05).

Conclusions

Passive hamstring stretching induced an immediate, statistically significantly improvement in hamstring flexibility, but only the change in Straight Leg Raise amplitude was clinically important. Psychosocial factors were not related to improvements in flexibility after hamstring stretching.

Early shoulder-girdle MRI findings in severe COVID-19-related intensive care unit-acquired weakness: a prospective cohort study

OBJECTIVE

To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge.

METHODS

A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge.

RESULTS

We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction.

CONCLUSIONS

Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW.

KEY POINTS

• We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.

Differences in Disability Perception in Systemic Sclerosis: A Mirror Survey of Patients and Health Care Providers

Differences in disability perception between patients and care providers may impact outcomes. We aimed to explore differences in disability perception between patients and care providers in systemic sclerosis (SSc). We conducted a cross-sectional internet-based mirror survey. SSc patients participating in the online SPIN Cohort and care providers affiliated with 15 scientific societies were surveyed using the Cochin Scleroderma International Classification of Functioning, Disability and Health (ICF)-65 questionnaire, including 65 items (from 0 to 10), representing 9 domains of disability. Mean differences between patients and care providers were calculated. Care providers' characteristics associated with a mean difference ≥ 2 of 10 points were assessed in multivariate analysis. Answers were analyzed for 109 patients and 105 care providers. The mean age of patients was 55.9 (14.7) years and the disease duration was 10.1 (7.5) years. For all domains of the ICF-65, care providers' rates were higher than those of patients. The mean difference was 2.4 (1.0) of 10 points. Care providers' characteristics associated with this difference were organ-based specialty (OR = 7.0 [2.3-21.2]), younger age (OR = 2.7 [1.0-7.1]) and following patients with disease duration ≥5 years (OR = 3.0 [1.1-8.7]). We found systematic differences in disability perception between patients and care providers in SSc.

Barriers and facilitators to bracing in adults with painful degenerative scoliosis: a single-centred mixed-method feasibility study

BACKGROUND

Conservative treatments including bracing and exercise therapy are prescribed on the first-line in adults with degenerative scoliosis. However, adherence to conservative treatments is low. We aimed to assess barriers and facilitators to bracing in adults with painful degenerative scoliosis.

METHODS

We conducted a single-centred mixed-method pilot and feasibility study. All patients scheduled for a multidisciplinary custom-made bracing consultation, from July 2019 to January 2020, in a French tertiary care centre, were screened. Patients were eligible if they had painful adult degenerative scoliosis and a prescription for a rigid custom-made lumbar-sacral orthosis. The primary outcome was barriers and facilitators to bracing assessed by a qualitative approach using semi-structured interviews. Secondary outcomes were back pain, spine-specific activity limitations, symptoms of depression and satisfaction with bracing post-intervention assessed by a quantitative approach.

RESULTS

Overall, 56 patients were screened and 14 (25%) were included. Mean age was 68.2 (12.3) years. Mean follow-up was 9.8 (2.0) months. Barriers to bracing were increased limitations in some activities, discomfort in hot weather and burden of aesthetic appearance. Facilitators to bracing were reduced pain, improved activities of daily living, suitable weight and improved spinal alignment. Participants self-implemented solutions to enhance adherence. The mean reduction from baseline in pain intensity was 1.7 (2.3) of 10 points, and 6 of 13 patients (46%) had pain intensity < 4 of 10 points.

CONCLUSION

Bracing is a feasible intervention for people with painful adult degenerative scoliosis. Patients self-implemented their own solutions to enhance adherence.

Physical activity and low back pain: A critical narrative review

BACKGROUND

Non-specific low back pain (LBP) is the leading cause of years lived with disability worldwide. Physical activity is an integral part of LBP treatment.

OBJECTIVE

To critically review available evidence regarding the efficacy of physical activity for people with LBP.

METHODS

Up to date critical narrative review of the efficacy of physical activity for the managment LBP. The process of article selection was unsystematic; articles were selected based on authors' expertise, self-knowledge and reflective practice.

RESULTS

Therapeutic physical activity for LBP includes a wide range of non-specific and specific activities. The efficacy of physical activity on pain and activity limitations has been widely assessed. In acute and subacute LBP, exercise did not reduce pain compared to no exercise. In chronic low back pain (CLBP), exercise reduced pain at the earliest follow-up compared with no exercise. In a recent systematic review, exercise improved function both at the end of treatment and in the long-term compared with usual care. Exercice also reduced work disability in the long-term. We were unable to establish a clear hierarchy between different exercise modalities. Multidisciplinary functional programs consistently improved pain and function in the short- and long-term compared with usual care and physiotherapy and improved the long-term likelihood of returning to work compared to non-multidisciplinary programs.

CONCLUSION

Physical activity of all types is an effective treatment for CLBP.

Intra-articular botulinum toxin A injection for painful base-of-thumb osteoarthritis: a double-blind, randomised, controlled, phase 3 trial (RHIBOT)

BACKGROUND

Intra-articular botulinum toxin A injection might have analgesic effects in patients with joint diseases. We aimed to compare the effects of intra-articular botulinum toxin A injection with those of intra-articular saline injection for patients with painful base-of-thumb osteoarthritis.

METHODS

RHIBOT was a double-blind, randomised, controlled, phase 3 trial conducted at Cochin Hospital, Paris, France. We recruited adult patients with x-ray evidence of trapeziometacarpal osteoarthritis who fulfilled the 1990 American College of Rheumatology criteria for hand osteoarthritis and reported a pain intensity score of at least 30 on an 11-point numeric rating scale (0: no pain to 100: maximal pain). Participants were randomly assigned (1:1), using a computer-generated randomisation list with permuted blocks of variable size (4 or 6), to receive an ultrasound-guided injection of either botulinum toxin A (50 Allergan units) in 1 mL of saline (experimental group) or 1 mL of saline alone (control group) in the trapeziometacarpal joint, in addition to custom-made rigid splinting. The primary outcome was the mean change from baseline in base-of-thumb pain in the previous 48 h on a numeric rating scale at 3 months after injection, analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT03187626.

FINDINGS

Between Nov 2, 2018, and Nov 3, 2020, we assessed 370 individuals for eligibility and recruited 60 (16%) participants (mean age 64·9 years [SD 9·4], 47 [78%] women and 13 [22%] men), of whom 30 (50%) participants were randomly assigned to the experimental group and 30 (50%) to the control group. At baseline, base-of-thumb pain score was 60·0 of 100·0 (SD 15·9). At 3 months, the mean reduction in base-of-thumb pain was -25·7 (95% CI -35·5 to -15·8) in the experimental group and -9·7 (-17·1 to -2·2) in the control group (absolute difference -16·0 [-28·1 to -3·9]; p=0·043). Overall, 51 adverse events were reported in both groups: 27 (53%) in the experimental group and 24 (47%) in the control group. During follow-up, 14 (47%) participants in the experimental group and two (7%) participants in the control group reported mild transient motor deficit of the thenar muscle. No serious adverse events were reported.

INTERPRETATION

Botulinum toxin A could be considered as a fast-acting, intra-articular therapy targeting chronic pain in individuals with base-of-thumb osteoarthritis. Future studies are needed to investigate the potential mechanism of the effects observed in this trial, to replicate our findings, and to assess the effects of repeated injections over time and their clinical effectiveness, including an analysis of cost-effectiveness.

FUNDING

Assistance Publique-Hôpitaux de Paris.

AB1570-PARE PROFILING LOW BACK PAIN PATIENTS FOR THE DEVELOPMENT OF A PERSONALIZED COACHING APPLICATION

Background

Low back pain is a major public health problem that is increasing with the aging of the population. It is the leading cause of disability in most countries [1]. The recommendations of Inserm (2019) include personalized physical activity programs according to the individual characteristics (motivation, preferences, attitude towards physical activity) and life context of each patient (family and professional load, socioeconomic level, living place) [2]. However, the current management of chronic low back pain includes rehabilitation programs that are costly and/or not always personalized, which reduces their effectiveness.

Objectives

The objective of this research is to better understand the characteristics of people with chronic low back pain to identify main motivational profiles that will allow us to offer personalized coaching via a mobile application.

Methods

After a review of the literature and following advice from experts in the management of chronic low back pain, we selected 8 scales to characterize patients: General Health Status (MYMOP), Treatment Burden (TBQ), Quality of Life (EQ-5D-5L), Level (IPAQ), Fears and Beliefs (FABQ-AP), and Motivation (EMAPS) for physical activity, Emotional Status (PHQ-9), and Sense of Self-Efficacy (FC-CPSES). These questionnaires were administered online to participants in the ComPaRe (Community of Patients for Research) chronic low back pain cohort. An initial descriptive analysis of the results allowed us to describe our sample. In order to distinguish different motivational profiles of patients towards physical activity, we performed a Agglomerative Hierarchical Clustering (AHC) and a principal component analysis (PCA) of the results of the EMAPS, PHQ-9, FABQ-AP and FC-CPSES scales.

Results

A total of 193 patients with chronic low back pain were included (m ≃ 54years, s ≃ 13years; majority women (74%); duration of low back pain: m ≃ 15years, s ≃ 12years; occupational status: 44% employed, 22% on disability, 19% retired). Clustering analysis allowed us to distinguish 4 main profiles that we named as follows: (1) “Amotivated,” characterized by the lowest motivation and highest amotivation toward physical activity (i.e. they do not understand why it is useful), (2) “Cautious” with low motivation and having the highest fears and beliefs toward physical activity, (3) “Depressed” with good intrinsic motivation but also a significant level of depressive symptoms, and (4) “Confident” also showing good intrinsic motivation and having the highest sense of self-efficacy.

Conclusion

The main novelty of this research is a new classification of 4 motivational profiles in the low back pain population determined by a clustering method. This typology is in line with the HAPA model of behavior change [3]. It will allow us to make recommendations for the design of a personalized mobile coaching application. Future work will aim to test and evaluate the personalization of e-coaching according to these profiles.

References

[1]Hurwitz, E.L., Randhawa, K., Yu, H. et al. Initiative mondiale de soins de la colonne vertébrale: un résumé du fardeau mondial des études sur les douleurs lombaires et cervicales. Eur Spine J 27, 796–801 (2018). https://doi.org/10.1007/s00586-017-5432-9

[2]Julie Boiche, Béatrice Fervers, Damien Freyssenet, Isabelle Gremy, Thibaut Guiraud, et al. Activité physique: Prévention et traitement des maladies chroniques. [Rapport de recherche] Institut national de la santé et de la recherche médicale(INSERM). 2019, Paris: Inserm: Éditions EDP Sciences (ISSN: 0990-7440) / 824 p.〈inserm-02102457〉

[3]Schwarzer, R. (2016). Health action process approach (HAPA) as a theoretical framework to understand behavior change. Actualidades en Psicología, 30(121), 119–130. https://doi.org/10.15517/ap.v30i121.23458

Disclosure of Interests

None declared

Patient acceptable symptom state for burden from appearance changes in people with systemic sclerosis: a cross-sectional survey

OBJECTIVE

People with systemic sclerosis (SSc) often report substantial burden from appearance changes. We aimed to estimate the patient acceptable symptom state (PASS) for burden from appearance changes in people with SSc.

METHODS

We conducted a secondary analysis of the SCISCIF II study, a cross-sectional survey of 113 patients with SSc from France enrolled in the Scleroderma Patient-centered Intervention Network Cohort. Burden from appearance changes was assessed with a self-administered numeric rating scale (0, no burden to 10, maximal burden). Acceptability of the symptom state was assessed with a specific anchoring question. Participants who answered "yes" were in the group of patients who considered their symptom state as acceptable. The PASS for the burden from appearance changes was estimated with the 75th percentile method.

RESULTS

Assessments of burden from appearance changes and answers to the anchoring question were available in 82/113 (73%) participants from the SCISCIF II study. Mean age was 55.9 (14.3) years, disease duration 9.6 (6.5) years and 32/82 (40%) participants had diffuse cutaneous SSc. The PASS estimate for the burden from appearance changes was 4.8 (95% CI from 1.0 to 7.0) of 10 points.

CONCLUSION

Our study provides a PASS estimate for burden from appearance changes. Our estimate could serve as a binary response criterion to assess the efficacy of treatments targeting burden from appearance changes.

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial

IMPORTANCE

Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period.

OBJECTIVE

To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019.

INTERVENTIONS

Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR.

MAIN OUTCOMES AND MEASURES

The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale.

RESULTS

A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01671917.

Assessing Smoothness of Arm Movements With Jerk: A Comparison of Laterality, Contraction Mode and Plane of Elevation. A Pilot Study

Measuring the quality of movement is a need and a challenge for clinicians. Jerk, defined as the quantity of acceleration variation, is a kinematic parameter used to assess the smoothness of movement. We aimed to assess and compare jerk metrics in asymptomatic participants for 3 important movement characteristics that are considered by clinicians during shoulder examination: dominant and non-dominant side, concentric and eccentric contraction mode, and arm elevation plane. In this pilot study, we measured jerk metrics by using Xsens^® inertial measurement units strapped to the wrists for 11 different active arm movements (ascending and lowering phases): 3 bilateral maximal arm elevations in sagittal, scapular and frontal plane; 2 unilateral functional movements (hair combing and low back washing); and 2 unilateral maximal arm elevations in sagittal and scapular plane, performed with both arms alternately, right arm first. Each arm movement was repeated 3 times successively and the whole procedure was performed 3 times on different days. The recorded time series was segmented with semi-supervised algorithms. Comparisons involved the Wilcoxon signed rank test (p < 0.05) with Bonferroni correction. We included 30 right-handed asymptomatic individuals [17 men, mean (SD) age 31.9 (11.4) years]. Right jerk was significantly less than left jerk for bilateral arm elevations in all planes (all p < 0.05) and for functional movement (p < 0.05). Jerk was significantly reduced during the concentric (ascending) phase than eccentric (lowering) phase for bilateral and unilateral right and left arm elevations in all planes (all p < 0.05). Jerk during bilateral arm elevation was significantly reduced in the sagittal and scapular planes versus the frontal plane (both p < 0.01) and in the sagittal versus scapular plane (p < 0.05). Jerk during unilateral left arm elevation was significantly reduced in the sagittal versus scapular plane (p < 0.05). Jerk metrics did not differ between sagittal and scapular unilateral right arm elevation. Using inertial measurement units, jerk metrics can well describe differences between the dominant and non-dominant arm, concentric and eccentric modes and planes in arm elevation. Jerk metrics were reduced during arm movements performed with the dominant right arm during the concentric phase and in the sagittal plane. Using IMUs, jerk metrics are a promising method to assess the quality of basic shoulder movement.

Neuralgic amyotrophy and hepatitis E infection: 6 prospective case reports

Introduction

Hepatitis E virus (HEV) represents the main cause of enterically transmitted hepatitis worldwide. It is known that neuralgic amyotrophy (NA) is one of the most frequent neurological manifestations of HEV. However, clinical, electrodiagnostic (EDX) and MRI characteristics, as well as long-term follow-up of HEV-related NA have not been fully described yet.

Case reports

We describe longitudinally clinical, EDX, biological and MRI results of six cases of HEV-associated NA, diagnosed from 2012 to 2017. Patients were between the ages of 33 and 57 years old and had a positive HEV serology. Clinical patterns showed the whole spectrum of NA, varying from extensive multiple mononeuropathy damage to single mononeuropathy. EDX results showed that the patients totalised 26 inflammatory mononeuropathies (1 to 8 per patient). These involved classical nerves such as suprascapular (6/6 cases), long thoracic (5/6 cases) and accessory spinal nerves (2/6 cases) and, some less frequent more distal nerves like anterior interosseous nerve (3/6 cases), as well as some unusual ones such as the lateral antebrachial cutaneous nerve (1/6 case), sensory fibres of median nerve (1/6 case) and phrenic nerves (1/6 case). After 2 to 8 years, all nerves had clinically recovered (muscle examination above 3/5 on MRC scale for all muscles except in one patient).

Discussion

HEV should be systematically screened when NA is suspected, whatever the severity, if the onset is less than 4 months (before IgM HEV-antibodies disappear) and appears to be frequently associated with severe clinical and EDX pattern, without increasing the usual recovery time.

French recommendations for the management of systemic sclerosis

Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.

Lumbosacral immobilization following glucocorticoid intradiscal injection in patients with chronic low back pain and active discopathy: A feasibility study

BACKGROUND

In people with chronic low back pain (cLBP) and active discopathy, glucocorticoid intradiscal injection (GC IDI) reduces LBP in the short-term. Lumbosacral immobilization may be useful to obtain long-term results.

OBJECTIVE

To assess the feasibility of a lumbosacral immobilization using a pantaloon cast following GC IDI in people with cLBP sand active discopathy.

METHODS

We conducted a retrospective feasibility study. Participants were allocated to experimental or control groups by preferences. The experimental group received lumbosacral immobilization using a custom-made pantaloon cast worn continuously for one week following a GC IDI of 25 mg of prednisolone acetate. The control group received GC IDI alone. The primary endpoint was the feasibility of lumbosacral immobilization assessed by the rate of refusal and early withdrawal of the cast.

RESULTS

Twelve patients were offered lumbosacral immobilization following GC IDI: the rate of refusal was 3/12 (25.0%) and was 3/9 (33.3%) of early withdrawal. Mean (95% CI) acceptability of the procedure was 55.0 (26.9-83.1)/100 in the experimental group (N= 6) and 61.6 (25.1-98.2)/100 in the control group (N= 6).

CONCLUSIONS

We found high rates of refusal and early withdrawal of the lumbosacral immobilization using a pantaloon cast following GC IDI in people with nonspecific cLBP and active discopathy.

AB0941 NEURALGIC AMYOTROPHY AND HEPATITIS E INFECTION: REPORT OF 6 CASES AND REVIEW OF THE LITERATURE

Background:

Neuralgic amyotrophy (NA) or Parsonage and Turner syndrome is triggered at least in 25% by a viral infection: parvovirus B19, CMV, HSV, etc... Recently, few cases of Hepatitis E Virus (HEV) related NA were reported. This particular association remains little known and is overlooked by most physicians. Besides, clinical, electrodiagnostic (EDX) and MRI characteristics, as well as evolution of HEV-related NA have not been fully described yet.

Objectives:

To describe 6 cases of HEV-related NA and to perform a review of the literature.

Methods:

We describe longitudinally clinical examination, electrodiagnostic (EDX), biological and MRI results of 6 cases of HEV-associated NA, diagnosed in our center.

Results:

The 6 cases were aged between 33 and 57 years old (mean 44.5), sex ratio was 5M/1F. All patients had positive IgM anti-HEV (serology) and a cervical MRI that could not explain clinical presentation. Overall, the 6 patients totalize 26 mononeuropathies (range 1 to 8 per patient), 5/6 patients had a severe presentation of NA, with bilateral and asymmetric symptoms (3 cases). HEV-related NA involved classical nerves such as supra-scapular (6 cases, twice bilaterally) and long thoracic nerves (5 cases), some less classical nerves like anterior interosseous nerve (3 cases, twice bilaterally), and some very unusual ones such as the lateral antebrachial cutaneous nerve (1 case) and the sensory fibers of median nerve (1 case). NA also involved accessory spinal (2 cases, once bilaterally) and phrenic nerves (1 case bilaterally), both originating from cervical plexus. The EDX pattern of these nerve lesions consisted of unique or multiple extensive asymmetric inflammatory mononeuropathies with severe axonal loss and numerous denervation signs damage involving mostly the supra-scapular. On scapular MRI (available for 5/6 patients), amyotrophy in at least one muscle was observed in all patients. Out of 26 nerves involved, after 12 months all had well recovered (above 3/5 MRC scale).

Conclusion:

HEV should be systematically screened when NA is suspected, whatever the severity, if the onset is less than 3 or 4 months (before IgMs anti-HEV disappear). HEV-related NA appears to be frequently associated with a severe pattern, without modifying the recovery usually observed.

Disclosure of Interests:

Romain Garofoli: None declared, Paul Seror: None declared, Jennifer Zauderer: None declared, Christelle Nguyen: None declared, François Rannou Grant/research support from: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Fondation Arthritis, Consultant of: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Speakers bureau: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Jean-Luc Drapé: None declared, Alexandra Roren: None declared, Marie-Martine Lefevre Colau: None declared

THU0486 2019 FRENCH GUIDELINES AND CARE PATHWAY ABOUT LOW BACK PAIN MANAGEMENT IN ADULTS

Background:

Low back pain (LBP) is a frequent, disabling symptom, for which the risk of chronicity is increased by heterogeneous care. Developing and implementing recommendations is likely to improve LBP management.

Objectives:

To develop French guidelines and care pathway on the management of LBP, coordinated by the French National Authority for Health (FNAH) and based on previous international guidelines in addition to update literature.

Methods:

A compilation report was constituted on the basis of a systematic review of guidelines between January 2013 and December 2018, and systematic reviews and meta-analysis in the field of LBP between January 2015 and December 2018. This report summarized the state-of-the-art for each predefined area of the guideline. A panel of experts including patients’ representatives and 19 health professionals involved in LBP management was constituted to elaborate the guideline based on the compilation report. A care pathway was constituted to identify the trajectory and the different steps followed by a patient with LBP. Then, the compilation report and the preliminary guidelines were submitted to 24 academic institutions and stakeholders for feedback. Based on the preliminary guideline and the responses of academic institutions and stakeholders, the final recommendations were drawn up by the expert panel. The guideline was finally submitted to an independent committee of the FNAH for final validation. For each area of the guidelines, agreement between experts of the working group was evaluated through the RAND/UCLA method.

Results:

The initial literature search identified 572 references of recent international guidelines or systematic reviews about LBP. After selection, the compilation report included 101 references. The compilation report was submitted to the expert group during 3 different meetings to reach a consensus on different topics. Thirty-one preliminary recommendations and a care pathway (divided in two parts to facilitate its use and readability) were drafted and submitted to academic institutions and stakeholders. Having considered their comments, final recommendations and care pathway were written. The final guideline was validated by the FNAH. Then, the consensus of the expert panel was assessed about all the final guidelines separately: 32 recommendations (including the care pathway) were evaluated as appropriate; none were evaluated uncertain or inappropriate. Strong approval was obtained for 27 of them (including the care pathway) and weak for 5 of them.

Conclusion:

This new LBP guideline was based on recent scientific evidence. It introduced several concepts, including the need to identify low back pain at risk of chronicity, in order to provide quicker intensive management if necessary. This guideline should be updated in 5 years’ time, in order to keep it in line with ongoing scientific evidence.

Disclosure of Interests: :

Florian Bailly Consultant of: Consultation fees from Lilly and Grünenthal laboratories, Anne Priscille Trouvin Speakers bureau: Speaker for menarini, recordati, pfizer, astellas, Sandrine Bercier: None declared, Sabrina Dadoun: None declared, Jean Philippe Deneuville: None declared, Rogatien Faguer: None declared, Jean Baptiste Fassier: None declared, Michèle Koleck: None declared, Louis Lassalle: None declared, Thomas Le Vraux: None declared, Brigitte Liesse: None declared, Karine Petitprez: None declared, Aline Ramond: None declared, Jean François Renard: None declared, Alexandra Roren: None declared, Sylvie Rozenberg Consultant of: Pfizer, Catherine Sebire: None declared, Gilles Viudes: None declared, François Rannou Grant/research support from: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier, Fondation Arthritis

, Consultant of: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne, Genévrier

, Speakers bureau: Pierre Fabre, Fidia, MSD, Pfizer, Bone Therapeutics, Expanscience, Grunenthal, Thuasne

, Audrey Petit: None declared

Construction of an ICF core set and ICF-based questionnaire assessing activities and participation in patients with systemic sclerosis

OBJECTIVES

To develop an International Classification of Functioning, Disability and Health (ICF) core set for SSc and to conceive a patient-centred ICF-based questionnaire assessing activities and participation in patients with SSc.

METHODS

The construction of the ICF core set followed two steps. In the first step, meaningful concepts related to SSc were collected using data source triangulation from patients (n = 18), experts (n = 10) and literature (n = 174 articles). In the second step, concepts were linked to the best-matching ICF categories by one reviewer according to prespecified linking rules. Finally, patient-reported activities and participation categories of the ICF core set were translated into understandable questions.

RESULTS

After linking concepts to ICF categories, 150 ICF categories were collected from focus groups, 22 from experts and 82 from literature. After fusion of the sources and removal of duplicates, the ICF core set included 164 categories: one at the first level, 157 at the second level and six at the third level, with 50 categories on body functions, 15 on body structures, 52 on activities and participation, and 47 on environmental factors. Patient-reported ICF categories on activities and participation were translated into a patient-centred ICF-based 65-item questionnaire.

CONCLUSION

The present study proposes an ICF core set that offers a conceptual framework for SSc patients' care and health policy. Using a patient-centred approach, a patient-centred ICF-based questionnaire, the Cochin Scleroderma ICF-65 questionnaire, assessing activities and participation in patients with SSc, was conceived.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT01848418.

Infraspinatus muscle palsy involving suprascapular nerve, brachial plexus or cervical roots related to inflammatory or mechanical causes: Experience of 114 cases

OBJECTIVES

To report a large series of neurogenic infraspinatus muscle (ISM) palsy, in order to improve knowledge of diagnosis, diverse etiologies and care management.

METHODS

Clinical and electrodiagnostic (EDX) data for 114 cases of ISM palsy were collected over a 21-year period. Cases were attributed to 4 clinical conditions: (1) isolated suprascapular nerve mononeuropathy (n=48), (2) multiple mononeuropathies (n=33), (3) plexus lesions (n=17), and (4) cervical radiculopathy (n=16). These were related to 2 mechanisms: inflammatory (dysimmune) and mechanical.

RESULTS

Group 1 cases were younger, had the most severe ISM palsies, were mostly related to inflammatory lesions (81%) such as neuralgic amyotrophy (NA), and frequently had delayed diagnosis because disability was mild. Group 2 cases were all related to inflammatory lesions and had slightly less severe ISM palsies that were frequently hidden by winged scapula. In groups 3 and 4, ISM palsies were milder and all cases were related to mechanical lesions such as brachial plexus trauma or C4-C5-C6 radiculopathy. In these cases, deltoid and ISM palsies were equal in frequency and severity whereas biceps brachii impairment was less frequent and much milder. Deltoid palsy frequently appeared predominant as compared with ISM palsy, because upper limb elevation palsy was more disabling than external rotation palsy.

CONCLUSIONS

ISM palsy is a rare condition, often under-diagnosed and misidentified. The 4 main conditions of ISM palsy may be recognized by careful clinical, EDX and other examinations when necessary. Analysis of the present series highlights some clinical and EDX points that should help non-specialist and even specialist clinicians who are faced with this rare condition, to distinguish mechanical and inflammatory causes, and thus adapt patient management accordingly.

Exercise programmes for ankylosing spondylitis

BACKGROUND

Exercise programmes are often recommended for managing ankylosing spondylitis (AS), to reduce pain and improve or maintain functional capacity.

OBJECTIVES

To assess the benefits and harms of exercise programmes for people with AS.

SEARCH METHODS

We searched CENTRAL, the Cochrane Library, MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, PEDro, Scopus, and two trials registers to December 2018. We searched reference lists of identified systematic reviews and included studies, handsearched recent relevant conference proceedings, and contacted experts in the field.

SELECTION CRITERIA

We included reports of randomised controlled trials (RCT) of adults with AS that compared exercise therapy programmes with an inactive control (no intervention, waiting list) or usual care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 14 RCTs with 1579 participants with AS. Most participants were male (70%), the median age was 45 years (range 39 to 47), and the mean symptom duration was nine years. The most frequently used exercises were those designed to help improve strength, flexibility, stretching, and breathing. Most exercise programmes were delivered along with drug therapy or a biological agent. We judged most of the studies at unclear or high risk of bias for several domains. All 14 studies provided data obtained immediately upon completion of the exercise programme. The median exercise programme duration was 12 weeks (interquartile range (IQR) 8 to 16). Three studies (146 participants) provided data for medium-term follow-up (< 24 weeks after completion of the exercise programmes), and one (63 participants) for long-term follow-up (> 24 weeks after completion of the exercise programmes). Nine studies compared exercise programmes to no intervention; five studies compared them to usual care (including physiotherapy, medication, or self-management).Exercise programmes versus no interventionAll data were obtained immediately upon completion of the exercise programme.For physical function, measured by a self-reporting questionnaire (the Bath Ankylosing Spondylitis Functional Index (BASFI) scale, 0 to 10; lower is better), moderate-quality evidence showed a no important clinically meaningful improvement with exercise programmes (mean difference (MD) -1.3, 95% confidence interval (CI) -1.7 to -0.9; 7 studies, 312 participants; absolute reduction 13%, 95% CI 17% to 9%).For pain, measured on a visual analogue scale (VAS, 0 to 10, lower is better), low-quality evidence showed an important clinically meaningful reduction of pain with exercise (MD -2.1, 95% CI -3.6 to -0.6; 6 studies, 288 participants; absolute reduction 21%, 95% CI 36% to 6%).For patient global assessment of disease activity, measured by a self-reporting questionnaire (the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scale, 0 to 10, lower is better), moderate-quality evidence showed no important clinically meaningful reduction with exercise (MD -0.9, 95% CI -1.3 to -0.5; 6 studies, 262 participants; absolute reduction 9%, 95% CI 13% to 5%).For spinal mobility, measured by a self-reporting questionnaire (the Bath Ankylosing Spondylitis Metrology Index (BASMI) scale, 0 to 10, lower is better), very low-quality evidence showed an improvement with exercise (MD -0.7 95%, -1.3 to -0.1; 5 studies, 232 participants) with no important clinical meaningful benefit (absolute reduction 7%, 95% CI 13% to 1%).For fatigue, measured on a VAS (0 to 10, lower is better), very low-quality evidence showed a no important clinically meaningful reduction with exercise (MD -1.4, 95% CI -2.7 to -0.1; 2 studies, 72 participants; absolute reduction 14%, 95% CI 27% to 1%).Exercise programmes versus usual careAll data were obtained immediately upon completion of the exercise programme.For physical function, measured by the BASFI scale, moderate-quality evidence showed an improvement with exercise (MD -0.4, 95% CI -0.6 to -0.2; 5 studies, 1068 participants). There was no important clinical meaningful benefit (absolute reduction 4%, 95% CI 6% to 2%).For pain, measured on a VAS (0 to 10, lower is better), moderate-quality evidence showed a reduction of pain with exercise (MD -0.5, 95% CI -0.9 to -0.1; 2 studies, 911 participants; absolute reduction 5%, 95% CI 9% to 1%). No important clinical meaningful benefit was found.For patient global assessment of disease activity, measured by the BASDAI scale, low-quality evidence showed a reduction with exercise (MD -0.7, 95% CI -1.3 to -0.1; 5 studies, 1068 participants), but it was not clinically important (absolute reduction 7%, 95% CI 13% to 1%) with important clinical meaningful benefitFor spinal mobility, measured by the BASMI scale, very low-quality evidence found a no important clinically meaningful improvement with exercise (MD -1.2, 95% CI -2.8 to 0.5; 2 studies, 85 participants; absolute reduction 12%, 95% CI 5% less to 28% more). There was no important clinical meaningful benefit.None of the studies measured fatigue.Adverse effectsWe found very low-quality evidence of the effect of exercise versus either no intervention, or usual care. We are uncertain of the potential for harm of exercises, due to low event rates, and a limited number of studies reporting events.

AUTHORS' CONCLUSIONS

We found moderate- to low-quality evidence that exercise programmes probably slightly improve function, may reduce pain, and probably slightly reduce global patient assessment of disease activity, when compared with no intervention, and measured upon completion of the programme. We found moderate- to low-quality evidence that exercise programmes probably have little or no effect on improving function or reducing pain, when compared with usual care, and may have little or no effect on reducing patient assessment of disease activity, when measured upon completion of the programmes. We are uncertain whether exercise programmes improve spinal mobility, reduce fatigue, or induce adverse effects.

Agreement among physiotherapists in assessing patient performance of exercises for low-back pain

Background

There is no agreement for the performance assessment of patients who practice exercises.. (2 points to withdraw) This assessment is currently left to the physiotherapist’s personal judgement. We studied the agreement among physiotherapists in rating patient performance during exercises recommended for chronic low-back pain (LBP).

Methods

A vignette-based method was used. We first identified ten exercises recommended for LBP in the literature. Then, 42 patients with chronic LBP participating in a rehabilitation program were videotaped during their performance of one of the ten exercises. A vignette was an exercise video preceded by clinical information. Ten physiotherapists from primary (4) and tertiary care (6) viewed the 42 vignettes twice, one month apart, and rated patient performance from zero (worse performance) to ten (excellent performance) by considering the position and duration of the contraction or stretching. Intra-class correlation coefficients (ICCs) and 95% confidence intervals (95% CIs) were computed to assess inter- and intra-rater reliability.

Results

The overall inter-rater agreement was fair (ICC 0.48 [95% CI 0.33–0.56]) but was better for stretching exercises (0.55 [0.35–0.64]) than strengthening exercises (0.42 [0.20–0.52]) and for tertiary-care physiotherapists (0.66 [0.54–0.76]) than primary-care physiotherapists (0.28 [0.09–0.37]). The intra-rater agreement was overall good (0.72 [0.57–0.81] to 0.88 [0.79–0.94]). It was better for stretching exercises (from 0.68 [0.46–0.81] to 0.96 [0.91–0.98]) than strengthening exercises (from 0.68 [0.38–0.84]) to 0.82 [0.56–0.92]).

Conclusion

The agreement in rating patient performance of exercises for LBP is good among physiotherapists trained in managing LBP but is low among non-trained physiotherapists.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2173-9) contains supplementary material, which is available to authorized users.

Intra-articular botulinum toxin A for base-of-thumb osteoarthritis: protocol for a randomised trial (RHIBOT)

INTRODUCTION

Recent studies have suggested that intra-articular injection of botulinum toxin A (BTA) may have analgesic effects in degenerative joint diseases. We aim to assess the efficacy of intra-articular injection of BTA associated with splinting in patients with trapeziometacarpal osteoarthritis (TMC OA).

METHODS AND ANALYSIS

We will conduct a randomised double-blind controlled trial. Overall, 60 individuals with TMC OA fulfilling adapted 1990 American College of Rheumatology criteria for hand OA will be recruited in one tertiary care centre in France and randomised to receive splinting + a single ultrasound-guided injection in the TMC joint of 50 Allergan Units of BTA resuspended in 1 mL saline or splinting +1 mL saline. Randomisation will be centralised. The allocation ratio will be 1:1. The primary outcome will be the mean change from baseline in base-of-thumb pain on a self-administered 11-point Numeric Rating Scale in 10-point increments at 3 months after injection. Secondary outcomes will be the mean change in base-of-thumb pain at 1 and 6 months, mean change in hand-specific activity limitations assessed by the self-administered Cochin Hand Function Scale, proportion of responders assessed by the Osteoarthritis Research Society International -Outcome Measures in Rheumatology (OMERACT) criteria and consumption of analgesics and non-steroidal anti-inflammatory drugs assessed by a self-administered 4-class scale at 3 and 6 months. Cointerventions will be allowed in both groups and will be self-reported. Adverse events will be recorded at 3 and 6 months. Participants, care providers and statisticians will be blinded to the allocated treatment.

ETHICS AND DISSEMINATION

The RHIBOT trial has been authorised by the Agence Nationale de Sécurité du Médicament and approved by the Comité de Protection des Personnes de Tours Ouest-1. The findings of the study will be disseminated in peer-reviewed journals and at conferences. If the results are positive, intra-articular BTA could be an efficient and safe complementary therapeutic option for patients with TMC OA.

DATE AND VERSION IDENTIFIER OF THE PROTOCOL

8 January 2018, V. 2.0.

TRIAL REGISTRATION NUMBER

NCT03187626; Pre-results.

Home-based cycling program tailored to older people with lumbar spinal stenosis: Barriers and facilitators

BACKGROUND

Lumbar-flexion-based endurance training, namely cycling, could be effective in reducing pain and improving function and health-related quality of life in older people with chronic low back pain.

OBJECTIVES

To assess barriers and facilitators to home-based cycling in older patients with lumbar spinal stenosis (LSS).

METHODS

We conducted a retrospective mixed-method study. Patients≥50 years old followed up for LSS from November 2015 to June 2016 in a French tertiary care center were screened. The intervention consisted of a single supervised session followed by home-based sessions of cycling, with dose (number of sessions and duration, distance and power per session) self-determined by patient preference. The primary outcome was assessed by a qualitative approach using semi-structured interviews at baseline and 3 months and was the identification of barriers and facilitators to the intervention. Secondary outcomes were assessed by a quantitative approach and were adherence monitored by a USB stick connected to the bicycle, burden of treatment assessed by the Exercise Therapy Burden Questionnaire (ETBQ) and clinical efficacy assessed by change in lumbar pain, radicular pain, disability, spine-specific activity limitation and maximum walking distance at 3 months.

RESULTS

Overall, 15 patients were included and data for 12 were analyzed at 3 months. At baseline, the mean age was 70.9 years (95% CI: 64.9-76.8) and 9/15 patients (60.0%) were women. Barriers to cycling were fear of pain and fatigue, a too large bicycle, burden of hospital follow-up and lack of time and motivation. Facilitators were clinical improvement, surveillance and ease-of-use of the bicycle. Adherence remained stable overtime. The burden of treatment was low [mean ETBQ score: 21.0 (95% confidence interval: 11.5-30.5)]. At 3 months, 7/12 patients (58.3%) self-reported clinical improvement, with reduced radicular pain and disability [mean absolute differences: -27.5 (-43.3 to -11.7), P<0.01 and -17.5 (-32.1 to -2.9), P=0.01, respectively].

CONCLUSIONS

For people with LSS, home-based cycling is a feasible intervention.

A new description of scapulothoracic motion during arm movements in healthy subjects

The participation of scapula motion in arm movement is clinically well known and recent three dimensional (3D) analyses using kinematic techniques have confirmed its importance. Scapular motion relative to the thorax has a theoretical maximum of 6 degrees of freedom (DoF), resulting from rotations at both clavicular joints (3 rotational DoF each). However, most recent kinematic studies have only analysed the 3D rotations of the scapula relative to the thorax. In the present study, the 3D translations of the barycentre of the scapula were considered in order to complete the description of movement at the shoulder complex. Eight healthy subjects performed arm elevation in the sagittal and frontal planes, simulated activities of daily living (hair combing and back washing) and maximum voluntary scapula movement (forward and backward rolling). Measurements were recorded using a 6 DoF electromagnetic device and the acromial method of analysis was used. The results showed that 3D scapular rotations and translation of its barycentre were functionally consistent for all tasks. A principal component analysis (PCA) yielded three factors, explaining 97.6% of the variance. The first two factors (protraction and shrug, according to clinical descriptions) combined rotations and translations, consistent with the hypothesis that the scapula rolls over the curved thoracic surface. The third factor related to lateral-medial rotation, thus representing rotation in the plane tangential to the thorax. The PCA suggested that scapular motion can be described using these 3 DoF. This should be studied in a larger group of individuals, including patients with pathological conditions.

Specific scapular kinematic patterns to differentiate two forms of dynamic scapular winging

BACKGROUND

Dynamic scapular winging (DSW) is a rare and misdiagnosed disorder causing considerable disability due to reduced scapular stability and abnormal motion. Two common causes are long thoracic nerve lesions resulting in serratus anterior muscle palsy and spinal accessory nerve lesions resulting in trapezius muscle palsy. The aim of this study was to analyse 3D scapular kinematic patterns in patients with DSW due to long thoracic (LTNL) or spinal accessory nerve lesions (SANL).

METHODS

3D scapular kinematics were assessed using a non invasive method involving an electromagnetic device during arm elevation in the frontal and sagittal planes in 9 patients (4 with SANL and 5 with LTNL) with unilateral DSW confirmed by electrical evidence. Within subject affected-unaffected differences were measured and compared between pathological groups (Mann-Whitney).

FINDINGS

Differences between affected and unaffected shoulders were significantly greater for scapular posterior tilt (at rest and 30° for sagittal arm elevation, at rest, 30° and 60° for frontal arm elevation) in the LTNL compared to the SANL group. Differences between affected and unaffected shoulders were significantly greater for scapular protraction (at rest and 60° of sagittal arm elevation, at rest, 30° and 60° of frontal arm elevation) and scapular lateral rotation at 60° for frontal arm elevation in the SANL compared to the LTNL group.

INTERPRETATIONS

These kinematic findings show two different scapular patterns that are specific to the neurological lesion. Moreover our kinematic data relate to specific clinical signs and the functional roles of the muscles involved.

Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

BACKGROUND

There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy.

METHODS

We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion.

RESULTS

At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted.

CONCLUSIONS

Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.