The meaning and feeling of the time and space between psychotherapy sessions and everyday life: Client experiences of transitions

OBJECTIVE

To explore how clients in psychodynamic or psychoanalytic psychotherapy, conducted in the traditional in-person setting, experience the transitions in time and space between psychotherapy sessions and everyday life.

METHOD

Twelve semi-structured interviews were analyzed with inductive experiential thematic analysis, focusing on how the participants experience and make sense of the phenomenon in focus.

RESULTS

The participants described therapy as a sheltered space where they could be open, vulnerable, receptive, and present. Approaching and leaving psychotherapy sessions, the participants established different behavioral patterns and routines dealing with their anxieties and resistances. In this in-between area, the participants could handle interconnections and differences between therapy and everyday life. Participants stressed the clinical impact of transitions: transitions affect both therapy and everyday life; disturbed transitions have an adverse impact; transitions are insufficiently addressed in therapy.

CONCLUSION

Transitions between therapy and life appear to be an essential but seldom recognized part of the therapy process beyond the borders of therapy sessions. Implications of these findings for psychotherapy training and practice are discussed, and a tentative transtheoretical framework for further research is proposed.

Development of osteoarthritis in patients with degenerative meniscal tears treated with exercise therapy or surgery: a randomized controlled trial

OBJECTIVE

To evaluate progression of individual radiographic features 5 years following exercise therapy or arthroscopic partial meniscectomy as treatment for degenerative meniscal tear.

DESIGN

Randomized controlled trial including 140 adults, aged 35-60 years, with a magnetic resonance image verified degenerative meniscal tear, and 96% without definite radiographic knee osteoarthritis. Participants were randomized to either 12-weeks of supervised exercise therapy or arthroscopic partial meniscectomy. The primary outcome was between-group difference in progression of tibiofemoral joint space narrowing and marginal osteophytes at 5 years, assessed semi-quantitatively by the OARSI atlas. Secondary outcomes included incidence of radiographic knee osteoarthritis and symptomatic knee osteoarthritis, medial tibiofemoral fixed joint space width (quantitatively assessed), and patient-reported outcome measures. Statistical analyses were performed using a full analysis set. Per protocol and as treated analysis were also performed.

RESULTS

The risk ratios (95% CI) for progression of semi-quantitatively assessed joint space narrowing and medial and lateral osteophytes for the surgery group were 0.89 (0.55-1.44), 1.15 (0.79-1.68) and 0.77 (0.42-1.42), respectively, compared to the exercise therapy group. In secondary outcomes (full-set analysis) no statistically significant between-group differences were found.

CONCLUSION

The study was inconclusive with respect to potential differences in progression of individual radiographic features after surgical and non-surgical treatment for degenerative meniscal tear. Further, we found no strong evidence in support of differences in development of incident radiographic knee osteoarthritis or patient-reported outcomes between exercise therapy and arthroscopic partial meniscectomy.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT01002794).

The role of delayed bone age in the evaluation of stature and bone health in glucocorticoid treated patients with Duchenne muscular dystrophy

Background

Low bone mineral density and an increased risk of appendicular and vertebral fractures are well-established consequences of Duchenne muscular dystrophy (DMD) and the risk of fractures is exacerbated by long-term glucocorticoid treatment. Monitoring of endocrine and skeletal health and timely intervention in at-risk patients is important in the management of children with DMD.

Methods

As part of the Norwegian Duchenne muscular dystrophy cohort study, we examined the skeletal maturation of 62 boys less than 18 years old, both currently glucocorticoid treated (n = 44), previously treated (n = 6) and naïve (n = 12). The relationship between bone age, height and bone mineral density (BMD) Z-scores was explored.

Results

The participants in the glucocorticoid treated group were short in stature and puberty was delayed. Bone age was significantly delayed, and the delay increased with age and duration of treatment. The difference in height between glucocorticoid treated and naïve boys was no longer significant when height was corrected for delayed skeletal maturation. Mean BMD Z-scores fell below − 2 before 12 years of age in the glucocorticoid treated group, with scores significantly correlated with age, duration of treatment and pubertal development. When BMD Z-scores were corrected for by retarded bone age, the increase in BMD Z-scores was significant for all age groups.

Conclusion

Our results suggest that skeletal maturation should be assessed in the evaluation of short stature and bone health in GC treated boys with DMD, as failing to consider delayed bone age leads to underestimation of BMD Z-scores and potentially overestimation of fracture risk.

Comparison of gait with and without ankle-foot orthoses after lower limb surgery in children with unilateral cerebral palsy

PURPOSE

Children with spastic unilateral cerebral palsy (SUCP) frequently undergo lower limb surgery to improve gait. Postoperatively, ankle-foot orthoses (AFOs) are used to maintain the surgical corrections and provide adequate mechanical support. Our aim was to evaluate changes in gait and impacts of AFOs one-year postoperatively.

METHODS

In all, 33 children with SUCP, 17 girls and 16 boys, mean age 9.2 years (5 to 16.5) were measured by 3D gait analysis walking barefoot preoperatively and walking barefoot and with AFOs one-year postoperatively. Changes in Gait Profile Scores (GPS), kinematic, kinetic and temporal spatial variables were examined using linear mixed models, with gender, gross motor function and AFO type as fixed effects.

RESULTS

The results confirm significant gait improvements in the GPS, kinematics and kinetics walking barefoot one year after surgery. Comparing AFOs with barefoot walking postoperatively, there was additionally reduced ankle plantarflexion by an average of 5.1° and knee flexion by 4.7° at initial contact, enhanced ankle moments during loading response, increased velocity, longer steps and inhibited push-off power generation. Stance and swing phase dorsiflexion increased in children walking with hinged AFOs versus children walking with ground reaction AFOs. Changes in the non-affected limbs indicated less compensatory gait postoperatively.

CONCLUSION

Major changes were found between pre- and postoperative barefoot conditions. The main impact of AFOs was correction of residual drop foot and improved prepositioning for initial contact, which could be considered as indications for continued use after the one-year follow-up.

LEVEL OF EVIDENCE

Level II - Therapeutic.

Cold hypersensitivity after hand injuries. A prospective 7-year follow-up

We studied changes in cold hypersensitivity from 3 to 7 years following severe hand injuries. Data was collected using postal questionnaires 7 years after injury in 71 patients who had participated in a 3-year follow-up from the time of injury. There was no change in cold sensitivity measured using the McCabe Cold Sensitivity Severity scale (CSS) from 3 to 7 years after injury. However, there was a trend toward decreased severity measured using a five-level scale of self-reported cold hypersensitivity. Compared to the 3-year follow-up, fewer respondents rated their condition as severe and two patients had recovered from their cold hypersensitivity at the 7-year follow-up. Furthermore, 21 (30%) of the respondents stated a decrease in cold hypersensitivity during the last 2 years. Limitations in cold associated activities and the importance of being less limited in leisure activities (NRS 0-10) did not change between the two follow-ups. In conclusion, the CSS-scores did not change from 3 to 7 years after injury. Several patients experienced improvements in cold hypersensitivity, but few recovered completely from the condition.

Physical function and health-related quality of life in young adults with unilateral congenital lower-limb deficiencies

PURPOSE

The primary aim was to examine if there were differences in physical function and health-related quality of life (HRQoL) between young adults (18 to 35 years) with unilateral congenital lower-limb deficiency (CLLD) who had been surgically lengthened (Surg) and those using lengthening prostheses (Pros). Second, we wanted to compare their health status with an age- and gender-matched reference group (Ref) without CLLD.

METHODS

Cross-sectional study including a study-specific questionnaire, clinical examination, two field tests evaluating physical function (the six-minute walk test and the Stair test) and HRQoL questionnaires (Short Form (SF)-36 and EuroQol (EQ)-5D-3L).

RESULTS

Physical function and HRQoL did not differ between the two treatment groups. The odds for having painful or disfiguring scars were 18 times higher in the Surg group (n = 16) compared with the Pros group (n = 14). The CLLD group showed significantly reduced physical function compared with the Ref group. HRQoL, measured by the EQ-5D-3L visual rating scale, was significantly reduced in the CLLD group compared with the Ref group, as was the SF-36 physical function domain in both genders. Men with CLLD also showed increased bodily pain and reduced general health (SF-36), while we found a reduction in the emotional role domain in women compared with Ref.

CONCLUSION

There were no significant differences in physical function and quality of life in young adults with CLLD treated with surgical lengthening compared with those using lengthening prostheses. Compared with the general Norwegian population, young adults with CLLD had significantly lower physical function and reduced HRQoL in some domains.

Locomotion skills in adults with cerebral palsy

Objectives: To investigate self-reported locomotion skills in persons with cerebral palsy (CP) and to investigate variables potentially associated with deterioration of walking skills.

Design: Cross-sectional retrospective survey.

Setting and subjects: A multidimensional mailed questionnaire was sent to 766 persons with CP, 18 years or over, without intellectual disabilities, living in Norway.

Main outcome measures: The questionnaire consisted of demographic and diagnostic items, items on locomotion skills, and physical function (SF-36).

Results: In total 406 persons, 51% males and 49% females from 18 to 72 years (mean 34 years, SD 11 years) with all categories of CP responded. Median age for reported walking debut was 3 years, with a range from 1 to 14 years. In total 216 respondents (53%) walked without support, 104 persons (25%) walked with support, 39 persons (10%) had lost their walking skills, and 47 (12%) had never been able to walk. Mean level of physical function (SF-36) was 53 out of 100. There were 97 persons (27%) who reported improvement of walking skills, mainly before 25 years, 102 (28%) reported no change, and 160 (44%) reported deterioration, mainly before 35 years of age. Deterioration was significantly associated with older age, delayed walking debut and severe neurological impairment. Self-reported causes of deterioration were pain, fatigue and lack of adapted physical activity.

Conclusion: Deterioration of locomotion skills is a significant problem in persons with CP from an early age, documenting the need for life-long follow-up. The predictors above should be investigated in further clinical studies, searching for potential causal pathways.

Small-to-moderate decreases in cold hypersensitivity up to 3 years after severe hand injuries: A prospective cohort study

BACKGROUND

The natural course and predictors for decreased cold hypersensitivity were studied in 85 patients with severe hand injuries involving nerve lesions.

METHODS

Questionnaires including the McCabe Cold Sensitivity Severity scale (CSS 0-400) were collected after injury, and at 6-month, 12-month, 2-year, and 3-year follow-ups.

RESULTS

Between the 12-month and 3-year follow-up, there was a small decrease in cold hypersensitivity as measured by the CSS (median = 24; Q1-Q3 = -11-75; n = 85). Five of the patients recovered from cold hypersensitivity, and ∼ 40% of the patients were less affected by cold hypersensitivity in daily life. Little or no pain early after injury and higher CSS-scores 12 months after primary surgery were weakly associated with the reduced CSS-scores (R(2) = 0.20) at the 3-year follow-up. Six patients had changed work or did not work due to cold hypersensitivity, but the majority of the patients had kept their cold-exposed work.

CONCLUSION

Cold-hypersensitive patients may have a reasonable chance for decreased cold sensitivity and cold-associated activity limitations over time, although the majority of the patients will experience persistent problems. Tools to predict improvement remain insufficient.

Patients with musculoskeletal conditions do less vigorous physical activity and have poorer physical fitness than population controls: a cross-sectional study

OBJECTIVES

To compare physical activity and physical fitness in patients with various musculoskeletal conditions receiving physiotherapy in primary care with population controls.

DESIGN

Cross-sectional.

PARTICIPANTS

One hundred and sixty-seven patients with musculoskeletal conditions receiving physiotherapy in primary care and 313 population controls from various settings and geographical areas.

MAIN OUTCOME MEASURES

Physical activity was measured with the International Physical Activity Questionnaire short-form (IPAQ-sf) and reported in metabolic equivalents (METs). The 6-minute walk test and 30-second sit-to-stand test reflected cardiorespiratory endurance and muscular strength, respectively.

RESULTS

Differences in physical activity between the groups were explored using the Mann-Whitney U-test. The patient group reported significantly less vigorous activity compared with the control group {median 0 [interquartile range (IQR) 0 to 960] vs median 240 [IQR 0 to 1440] MET minutes/week, respectively)} (P=0.001). A similar proportion of patients (68%) and controls (75%) reached the recommended level of health-enhancing physical activity (P=0.11). Linear regression analyses adjusted for age, body mass index and gender showed significantly poorer fitness in the patient group compared with the control group, reflected by the 6-minute walk test and the 30-second sit-to-stand test {mean difference 69m [95% confidence interval (CI) 52 to 85; P≤0.001] and six repetitions [95% CI 5 to 7; P≤0.001], respectively}.

CONCLUSIONS

Patients with various long-term musculoskeletal conditions receiving physiotherapy in primary care had significantly poorer physical fitness and reported less vigorous physical activity compared with population controls.

High-intensity interval training improves peak oxygen uptake and muscular exercise capacity in heart transplant recipients

Heart transplant (HTx) recipients usually have reduced exercise capacity with reported VO(2peak) levels of 50-70% predicted value. Our hypothesis was that high-intensity interval training (HIIT) is an applicable and safe form of exercise in HTx recipients and that it would markedly improve VO(2peak.) Secondarily, we wanted to evaluate central and peripheral mechanisms behind a potential VO(2peak) increase. Forty-eight clinically stable HTx recipients >18 years old and 1-8 years after HTx underwent maximal exercise testing on a treadmill and were randomized to either exercise group (a 1-year HIIT-program) or control group (usual care). The mean ± SD age was 51 ± 16 years, 71% were male and time from HTx was 4.1 ± 2.2 years. The mean VO(2peak) difference between groups at follow-up was 3.6 [2.0, 5.2] mL/kg/min (p < 0.001). The exercise group had 89.0 ± 17.5% of predicted VO(2peak) versus 82.5 ± 20.0 in the control group (p < 0.001). There were no changes in cardiac function measured by echocardiography. We have demonstrated that a long-term, partly supervised and community-based HIIT-program is an applicable, effective and safe way to improve VO(2peak) , muscular exercise capacity and general health in HTx recipients. The results indicate that HIIT should be more frequently used among stable HTx recipients in the future.

Frontotemporal dementia caused by CHMP2B mutations

CHMP2B mutations are a rare cause of autosomal dominant frontotemporal dementia (FTD). The best studied example is frontotemporal dementia linked to chromosome 3 (FTD-3) which occurs in a large Danish family, with a further CHMP2B mutation identified in an unrelated Belgian familial FTD patient. These mutations lead to C-terminal truncations of the CHMP2B protein and we will review recent advances in our understanding of the molecular effects of these mutant truncated proteins on vesicular fusion events within the endosome-lysosome and autophagy degradation pathways. We will also review the clinical features of FTD caused by CHMP2B truncation mutations as well as new brain imaging and neuropathological findings. Finally, we collate the current data on CHMP2B missense mutations, which have been reported in FTD and motor neuron disease.

Rehabilitation after anterior cruciate ligament injury influences joint loading during walking but not hopping

OBJECTIVE

The purpose of this study was to identify changes in clinical outcome and lower extremity biomechanics during walking and hopping in ACL-injured subjects before and after a 20-session neuromuscular and strength training programme.

STUDY DESIGN

Pre and post experimental design.

SETTING

Outpatient clinic, primary care.

PATIENTS

32 subjects with unilateral ACL injury, mean 60 (SD 35) days after injury, with a mean age of 26.2 (5.4) years.

INTERVENTION

The rehabilitation programme consisted of neuromuscular and strength exercises.

MAIN OUTCOME MEASUREMENTS

Outcome measurements assessed before and after a 20-session rehabilitation programme were: self-assessment questionnaires (KOS-ADL, IKDC2000, Global function), four single-leg hop tests, and isokinetic muscle strength tests. Lower extremity kinematics and kinetics were captured during the stance phase of gait and landing after a single leg hop, synchronised with three force plates.

RESULTS

These ACL-injured individuals significantly improved their clinical outcome after rehabilitation. Gait analysis disclosed a significantly improved knee extension moment after rehabilitation, but no change in hip or knee excursions. During landing after hop no change in knee excursion or knee moment was recorded.

CONCLUSION

After rehabilitation the ACL-injured subjects showed a significantly improved clinical outcome, but lower extremity biomechanics were still significantly impaired during both walking and hopping. The rehabilitation programme influenced knee joint loading during walking, but not during hopping. Longer rehabilitation should be considered before ACL-injured individuals return to jumping activities.

Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction

OBJECTIVE

To identify preoperative predictive factors for knee function two years after reconstructive surgery of the anterior cruciate ligament (ACL). The main hypothesis was that preoperative quadriceps strength would be the most significant predictor for knee function two years after reconstructive surgery.

DESIGN

Cohort study.

SETTING

ACL injured individuals treated at a University Hospital and an outpatient clinic in Oslo, Norway.

PARTICIPANTS

Seventy-three individuals with complete unilateral rupture of the ACL scheduled for reconstruction with a bone-patellar-bone autograft were included in the study, from where 60 were available for two-year follow up and included in the final analyses.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Identification of baseline independent variables that may predict knee function assessed with the Cincinnati Knee Score as dependent variable two years after ACL reconstruction.

RESULTS

Quadriceps muscle strength, meniscus injury and the Short-Form-36 Bodily Pain sub score were identified as significant predictors for knee function assessed from the Cincinnati Knee Score two years after ACL reconstruction. Individuals with preoperative quadriceps strength deficits above 20% also had persistent significantly larger strength deficits two years after surgery.

CONCLUSIONS

Preoperative quadriceps muscle strength deficits and meniscus injuries have significant negative consequences for the long-term functional outcome after ACL reconstruction. From our findings we suggest that ACL reconstruction should not be performed before quadriceps muscle strength deficits of the injured limb is less than 20% of the uninjured limb.

Cold hypersensitivity 6 to 10 years after replantation or revascularisation of fingers: consequences for work and leisure activities

We investigated cold hypersensitivity and activity in 81 adults (male/female 76/5), 6 to 10 years after finger replantation/revascularisation (mean age at injury 43 (SD 15) years). Questionnaires included the McCabe Cold Sensitivity Severity Scale, Potential Work-Exposure Scale and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Eighty per cent of the respondents were cold hypersensitive; 20% were severely or extremely cold hypersensitive. Of the 74 patients employed at injury, 7% had changed work and 4% were not working due to cold hypersensitivity. The median score for cold exposure at work at follow-up was 153 (scale 0-300). The correlation between cold sensitivity and DASH work was low. One-third of the respondents experienced limitations in their leisure activities because of cold complaints. Long-term cold sensitivity was mild or moderate for most patients. Many cold hypersensitive patients managed to continue to work even under cold conditions and cold hypersensitivity was a greater problem in leisure activities.

A normative sample of isotonic and isokinetic muscle strength measurements in children 7 to 12 years of age

AIM

To provide normative age- and gender-associated values on muscular strength, power and endurance and to establish a reference database on healthy school children aged 7 to 12 years. In addition, associations between some simple functional tests and the more sophisticated isokinetic strength measures were investigated.

METHODS

Three hundred seventy-six children, 191 girls and 185 boys, performed different muscle-strength tests like knee flexion/extension, handgrip, back extension and vertical jump.

RESULTS

There was a significant and linear increase in strength with no gender differences from 7 up to 11 years of age. There was a large variability within each age group, indicating that a normative sample of muscle-strength measurements includes a wide range of values for each age group. The relationship between hand- grip strength and observed quadriceps strength was high (r = 0.84) and the correlation between vertical jump and relative quadriceps strength was moderate (r = 0.50).

CONCLUSION

All the different strength measures showed almost the same pattern, indicating increased absolute strength values with increasing age and no significant gender differences except for flexion at the age of 11 and 12 years . The association between grip strength, vertical jump and quadriceps strength measured isokinetically was moderate to strong. The back muscle endurance test (The Biering-Sørensen test) showed a great roof effect and should not be included in a test battery for school children.

Hip arthroplasty in patients younger than 30 years: excellent ten to 16-year follow-up results with a HA-coated stem

It is well accepted that youth and high activity levels are among the factors that increase the risk of mechanical failure of total hip prostheses. However, there are few reports of long-term results in very young patients. In this study, we evaluated the results of total 49 hip replacements (THRs) using an uncemented total hip prosthesis in 44 patients (28 females) who were 30 years or younger (range: 15-30 years). The diagnosis was ostearthritis due to congenital dislocations in 28 patients, with the remaining patients having diagnoses of sequelae of fracture, infection, Calve-Legg-Perthes disease, avascular necrosis, chondrodystrophia and epiphyseal dysplasia. In all cases we used an uncemented straight stem fully coated with hydroxyapatite (HA). In 36 cases we used a hemispherical cup inserted with press fit, and in seven cases we used a hemispherical screw cup. The patients were evaluated ten to 16 years (mean: 13 years) after the operation by radiographic and clinical examinations, including the Harris Hip, WOMAC and EuroQol-5D scores. In a sub-group of nine patients with a unilateral prosthesis, the muscle strength of the quadriceps and hamstrings was tested using a Cybex 6000. None of the stems were revised at the follow-up examination, and all were classified as well integrated, with no signs of radiological loosening. Twenty-four hips had revision of the acetabular component due to mechanical failure. The Harris Hip score was, on average, 88 (range: 62-100), the WOMAC score 80 (range: 37-100) and the EuroQol score 0.68 (range: -0.14-1). Isokinetic muscle strength testing showed that seven of the nine tested patients were weaker on the operated side. In conclusion, we found mechanical failures at the acetabular side, but excellent results with a fully HA-coated femoral stem, with no revisions after ten to 16 years.

Crystal structure of a Fab complex formed with PfMSP1-19, the C-terminal fragment of merozoite surface protein 1 from Plasmodium falciparum: a malaria vaccine candidate

Merozoite surface protein 1 (MSP1) is the major protein component on the surface of the merozoite, the erythrocyte-invasive form of the malaria parasite Plasmodium. Present in all species of Plasmodium, it undergoes two distinct proteolytic maturation steps during the course of merozoite development that are essential for invasion of the erythrocyte. Antibodies specific for the C-terminal maturation product, MSP1-19, can inhibit erythrocyte invasion and parasite growth. This polypeptide is therefore considered to be one of the more promising malaria vaccine candidates. We describe here the crystal structure of recombinant MSP1-19 from P.falciparum (PfMSP1-19), the most virulent species of the parasite in humans, as a complex with the Fab fragment of the monoclonal antibody G17.12. This antibody recognises a discontinuous epitope comprising 13 residues on the first epidermal growth factor (EGF)-like domain of PfMSP1-19. Although G17.12 was raised against the recombinant antigen expressed in an insect cell/baculovirus system, it binds uniformly to the surface of merozoites from the late schizont stage, showing that the cognate epitope is exposed on the naturally occurring MSP1 polypeptide complex. Although the epitope includes residues that have been mapped to regions recognised by invasion-inhibiting antibodies studied by other workers, G17.12 does not inhibit erythrocyte invasion or MSP1 processing.

Coping potential and disability--sense of coherence in adults with cerebral palsy

PURPOSE

The aim of the present study was to investigate sense of coherence (SOC) in adults with cerebral palsy (CP) compared to the general population.

METHOD

A questionnaire was sent to a representative sample of adults with CP, including the 3-item version of SOC and items on their life situation and follow-up programmes. The study included persons over 18 years of age with CP and without intellectual disability. The results were compared with the results from a reference group.

RESULTS

The 406 respondents with CP (48.5% females, 51.5% males) were 18-72 years of age. The distribution of the different types of CP coincided with international epidemiological studies. Mean SOC was significantly lower in the adults with CP than in the reference group. The largest difference was found in the domain of comprehensibility. The factors most important in relation to SOC were level of education, marital status, life satisfaction and fatigue.

CONCLUSIONS

Early experiences of predictability, balance between challenges and personal resources and finding these challenges worthy of investment, are prerequisites for developing sense of coherence. The present study suggests that these factors are less present in early socialization of persons with CP compared to the general population, and underlines the need for follow-up programmes that emphasize existential aspects and coping strategies.

Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction

Neuromuscular training programs are increasingly integrated into clinical practice for lower extremity rehabilitation. A few rehabilitation programs have been evaluated for patients with anterior cruciate ligament (ACL) deficiency and for injury prevention, but there is limited scientific evidence of the effect of neuromuscular training following ACL reconstruction. Therefore, a neuromuscular training program was developed for patients after ACL reconstruction. The objective of the neuromuscular training was to improve the ability to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, and to relearn movement patterns and skills necessary during activities of daily living and sports activities. The main areas considered when designing the postoperative rehabilitation program after ACL reconstruction were: ACL graft healing and ACL strain values during exercises, proprioception and neuromuscular control, and clinical studies on the effect of neuromuscular training programs. The rehabilitation program consists of balance exercises, dynamic joint stability exercises, jump training/plyometric exercises, agility drills, and sport-specific exercise. The patients exercise 3 times a week for 6 months. The scientific and clinical evidence for the rehabilitation program are described and the main exercises in the program are outlined.

Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up

Seventy-two patients with subacute or chronic rupture of the anterior cruciate ligament were randomly assigned to autograft reconstruction with four-strand gracilis and semitendinosus tendon (N = 37) or with patellar tendon-bone (N = 35) from the ipsilateral side. The groups were similar in terms of age, sex, level of activity, degree of laxity, meniscal lesions found surgically, and rehabilitation program. The follow-up was performed at another hospital by independent observers after 6, 12, and 24 months. Sixty-one patients (32 with hamstring tendon grafts and 29 with patellar tendon grafts) complied with the follow-up routine for the full 24 months. No differences were found between the groups with respect to Cincinnati functional score, KT-1000 arthrometer measurements, or stairs hopple test results. The subjective result and the single-legged hop test result were better for the hamstring tendon group after 6 and 12 months, but no differences were found after 24 months. The hamstring tendon group showed better isokinetic knee extension strength than did the patellar tendon group after 6 months, but not after 12 and 24 months. There was a significant weakness in isokinetic knee flexion strength among the hamstring tendon group. Anterior knee pain was not significantly different between the groups, but kneeling pain was significantly less common in the hamstring tendon group after 24 months.

Reliability of goniometric measurements and visual estimates of hip ROM in patients with osteoarthrosis

BACKGROUND AND PURPOSE

Range of motion (ROM) measurements have been included in several hip scores evaluating the results after hip surgery. The clinical procedures of performing these measurements vary and disagreement exists about the accuracy of visual estimatess compared to goniometer measurements. The purpose of this study was to study the reliability of goniometric measurements and visual estimates of hip ROM in patients with osteoarthrosis.

METHOD

Hip ROM measurements (abduction, adduction, extension, flexion and internal/external rotation) were recorded by four different teams on the same day and were repeated one week later. Teams 1, 2 and 3 consisted of physiotherapists using standardized goniometric measurements. Team 4 involved an experienced orthopaedic surgeon making the assessments from visual estimates only. Twenty-five patients (6 M, 19 F; mean age 68.5 years, range 46-76 years) with osteoarthrosis of the hip, verified both clinically and radiologically, participated in the study.

RESULTS

With the exception of abduction (p = 0.03), there were no significant differences between the measurements recorded on the first and the second occasions for the same teams. The coefficient of variance was 5.5% for flexion (lowest) and 26.1% for extension (highest). Reproducibility was best for flexion. There was also high reliability when all the arcs of motion were summed up (abuction + adduction + extension + flexion + internal/external rotation). With the exception of internal rotation, there were highly significant differences between the teams when two people performed the measurements compared to the values measured by a single individual. Concordance, expressed as the standardized agreement index, between visual estimates made by one individual (the orthopaedic surgeon) and goniometric measurements made by two experienced physiotherapists, were 0.77-0.83 which indicates good agreement.

CONCLUSION

The reproducibility of hip ROM measurements was highest for flexion. There was also high reliability when all the six arcs of motion were summed up. Concordance between visual estimates and goniometric measurements indicates good agreement.

Minimal influence of facet joint anesthesia on isokinetic muscle performance in patients with chronic degenerative low back disorders

STUDY DESIGN

Experimental design.

OBJECTIVES

To examine the influence of pain reduction after facet joint injections on isokinetic back muscle performance.

SUMMARY OF BACKGROUND DATA

Methods for evaluating the effect of facet joint injections vary. Recent studies base their results solely on the patient's subjective opinion and suggest a need for more objective, concrete, and reliable measurements.

METHODS

Eighty-seven patients with a degenerative low back disorder (49 women and 38 men; mean age, 48 years; range, 22-79) who had facet joint injections as a part of preoperative evaluation participated. The mean duration of symptoms was 12.3 years (range, 1-45). The patients underwent isokinetic trunk flexor and extensor muscle strength testing at angular velocities of 60 deg/sec and 120 deg/sec. They performed two tests before the facet joint injections (to eliminate learning effect). All patients had bilateral facet joint injections at L5-S1. Those who did not report pain relief had additional injections at L4-L5. The flexion-extension test was repeated 15 minutes after each injection. Pain and fear were registered on visual analog scales.

RESULTS

All 87 patients could perform the isokinetic tests. For extension at 60 deg/sec, a significant improvement was found between the two pretests (P < 0.05). Pain increased significantly from the first to the second pretest (P = 0.02), and a significant decrease in pain was found after the first injection (P = 0.0001). Fear decreased between each test, with a significant decrease after the first injection. No significant change was found for the muscle strength measurements after facet joint anesthesia. There were only weak correlations between decrease in pain and alteration in muscle performance, ranging from 0.06 to 0.37.

CONCLUSION

Pain reduction after facet joint injections did not influence isokinetic muscle performance in patients with degenerative low back disorders.

Distal biceps tendon rupture operated on with the Boyd-Anderson technique: follow-up of 9 patients with isokinetic examination after 1 year

We operated on 9 patients for distal biceps tendon rupture using the Boyd-Anderson technique. All patients were re-examined after at least 1 year using a questionnaire, radiographs, motion measurements and isokinetic testing. 2 patients had temporary radial nerve dysfunction and 7 patients had diminished forearm rotation. Elbow flexion strength was reduced by median 13% and supination strength by 19%. We think the Boyd-Anderson technique can be recommended, but slightly reduced strength and forearm rotation must be expected.

Dynamics of gap junctions observed in living cells with connexin43-GFP chimeric protein

To study the aggregation of cell-to-cell channels into gap junctions at individual cell-cell contacts, we transfected cells with an expression vector for a chimeric protein composed of the cell-to-cell channel protein connexin43 and a green fluorescent protein. The chimeric channel protein was visualized in the fluorescence microscope and was found to form gap junctions at the cell-cell contacts just like wild-type connexin43. Cells expressing the chimeric protein had functional cell-to-cell channels. Using timelapse videomicroscopy on live cells we observed individual gap junctions over long periods and recorded the time course of aggregation of the chimeric channel protein into gap junctions at newly formed cell-cell contacts. We found that individual small gap junctions were very dynamic, moving about or becoming assembled and disassembled in the course of minutes. Larger gap junctions were more stable than small punctate ones. In control condition, stable new gap junctions were not formed during observation times of 30 min or longer. But at elevated levels of cyclic adenosine monophosphate, the chimeric channel protein began aggregating at new junctions 5-10 minutes after cell-cell contact and continued to concentrate there for at least one hour. Also already established junctions grew in size. The fluorescent chimeric channel protein will be an excellent tool to investigate the regulation of trafficking of connexin from and to the membrane and the mechanism of connexin channel aggregation into gap junctions.

An educational programme for persistent life-style changes in patients with chronic renal disease

The aim of this study was to produce positive life-style changes in patients with chronic renal disease through a residential education programme about the medical aspects of chronic renal failure and the various treatment options in order to increase their physical capacity, emotional stability and general well-being. The programme was available to all categories of patients with chronic renal disease irrespective of treatment modality. Comparison of data pre and post course demonstrated improvements in physical activity, mental well-being and nutritional awareness.

Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score. A prospective study of 120 ACL reconstructed patients with a 2-year follow-up

The purpose of this study was to determine: (1) the sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score, (2) the relationship between the IKDC form, the Lysholm score and the Cincinnati knee score, (3) the criterion validity of each graded variable included in the IKDC form, and (4) if a functional knee test should be included as a graded variable and part of the final result of the IKDC form. We included in this prospective study 120 subjects who underwent ACL reconstruction with follow-up times of 3 and 6 months, and 1 and 2 years after surgery. Outcome measurements were the graded variables of the IKDC form (IKDC1-4 and IKDC-final), the Lysholm score, the Cincinnati knee score, a visual analogue scale for patient's satisfaction, knee joint laxity measurement (KT-1000 knee arthrometer), and two functional knee tests (the triple jump and stairs hopple tests). The IKDC1, IKDC2, IKDC-final, and the Lysholm score were not sensitive to changes over time. The Cincinnati knee score was highly sensitive to changes over time and showed significantly improved outcome between each follow-up. IKDC1-4 showed high criterion validity, indicating that the IKDC1-4 is a good means of documenting clinical examination at one follow-up, but not of detecting changes over time. The functional knee tests were significant outcome measurements after ACL reconstruction, and should be reported separately.

Prospective study of changes in impairments and disabilities after anterior cruciate ligament reconstruction

STUDY DESIGN

Single-group, repeated-measures prospective study.

OBJECTIVES

To analyze changes in impairments and disabilities among patients with anterior cruciate ligament (ACL) reconstruction and to assess the relationships between the impairment and disability outcome measures from 3 months to 2 years following ACL reconstruction.

BACKGROUND

Outcomes after ACL reconstruction can be categorized as impairments or disabilities. The relationship between impairments and disabilities may be crucial to understanding physical therapy interventions and predicting long-term outcome.

METHODS AND MEASURES

Sixty patients who had undergone ACL reconstruction participated in the study. Impairment measures were range of motion, pain, knee-joint laxity, and muscle performance using isokinetic muscle tests. Disability measures were the Cincinnati knee score and lower limb performance using the triple-jump and stair-hop tests. Follow-up times were 3 and 6 months and 1 and 2 years after surgery.

RESULTS

The Cincinnati knee score results show significant improvement 1 year after surgery (84.2 +/- 13.6) compared with 6 months (76.8 +/- 13.7) and 3 months (67.4 +/- 16.3) after surgery. Quadriceps total work (percentage of normal leg) significantly improved 2 years after surgery (92.6 +/- 14.1%) compared with 1 year after surgery (81.6 +/- 16.8%). Between 37 and 75% of the variability in the Cincinnati knee score could be explained by variation in the impairment variables, and quadriceps muscle performance and pain were the most significant predictors of disability. Extension deficit and pain at 3 months were significantly related to the Cincinnati knee score at the 2-year follow-up.

CONCLUSIONS

Up to 2 years may be needed to regain normal quadriceps muscle performance following ACL reconstruction. Pain and quadriceps muscle performance explained most of the variability in the Cincinnati knee score.

Immune responses to Plasmodium falciparum-merozoite surface protein 1 (MSP1) antigen, II. Induction of parasite-specific immunoglobulin G in unsensitized human B cells after in vitro T-cell priming with MSP119

A baculovirus recombinant antigen corresponding to the C-terminal 19 000 MW fragment of Plasmodium falciparum merozoite surface protein 1 (MSP119), has been used to prime T cells from individuals with no previous exposure to malaria, to provide help for the induction of a parasite specific antibody response in vitro. Although MSP119 alone could induce a small but detectable T-cell response, which included interleukin-4 (IL-4) secretion, this response was significantly increased by the presence of IL-2. In addition, IL-4 was shown to synergize with IL-2 for the induction of antigen-specific T-cell responses. If interferon-gamma (IFN-gamma), IL-12, or neutralizing anti-IL-4 antibody was present at the time of priming, the T-cell responses were abolished. Parasite-specific immunoglobulin G (IgG) could be detected after secondary restimulation with MSP119, IL-10 and anti-CD40 monoclonal antibody in cultures containing MSP119 primed T cells, autologous B cells, IL-2 and IL-4. No antibody was secreted in the absence of primed T cells in this B-cell culture assay. These data show that recombinant MSP119, a leading malaria vaccine candidate, can prime non-immune human lymphocytes under defined in vitro experimental conditions, which include regulatory cytokines and/or other costimulatory molecules. This is a complementary approach for exploring immunogenic mechanisms of potential vaccine candidates such as P. falciparum antigens in humans.

Secretion of parasite-specific immunoglobulin G by purified blood B lymphocytes from immune individuals after in vitro stimulation with recombinant Plasmodium falciparum merozoite surface protein-119 antigen

The C-terminal 19 000 MW fragment of merozoite surface protein-1 (MSP119) is one of the most promising candidate antigens for a malaria vaccine. Baculovirus recombinant Plasmodium falciparum MSP119 has been used to define conditions for the in vitro production of specific antibodies by purified human blood B cells in a culture system where T-cell signals were provided by the engagement of CD40 molecules and exogenous cytokines. MSP119 preferentially induced surface immunoglobulin G (IgG) -positive (sgamma+) B lymphocytes from P. falciparum-immune donors to differentiate and produce antigen-specific IgG. In contrast, naïve B cells or cells from non-immune donors could not be induced to secrete parasite-specific IgG in vitro. Although IgG secretion was obtained in the absence of exogenous cytokines, it was dependent on B-cell-derived interleukin-10 (IL-10) and/or B-cell factor(s) under the control of IL-10, since IgG levels were significantly decreased in the presence of neutralizing anti-IL-10 antibodies. These results demonstrate at the cellular level that a single malaria vaccine candidate polypeptide can direct parasite-specific antibody production mediated by the secretion of potentiating factors.

[Patients with chronic degenerative spinal disease--can conservative treatment reduce the waiting list for surgery?]

Patients with a degenerative lumbar disorder selected for spinal fusion surgery by an experienced orthopaedic surgeon, were invited to participate in an exercise and behavioural modification programme. The goal was to let the patients experience that it is safe to move. 50 patients; mean age 49 years (19-76 years), mean duration of complaints ten years (2-39 years), agreed to participate. 26 patients had undergone back surgery. 80% were on sick leave or disability pension; 85% had either previously diagnosed psychiatric disorder or high scores for somatization or abnormal illness behaviour. At follow-up, 21 (42%) patients wanted surgery, 8 (16%) were uncertain, and 18 (36%) did not want surgery, 17 patients reported improved main symptoms, 18 were unchanged, and 12 had deteriorated. Previous surgery, illness behaviour and weak trunk muscles were associated with poor improvement and desire for surgery. Age, gender, emotional distress, intensity of pain, neurological or radiological signs or the number of exercise sessions taken did not influence results.

The crystal structure of C-terminal merozoite surface protein 1 at 1.8 A resolution, a highly protective malaria vaccine candidate

The C-terminal proteolytic processing product of merozoite surface protein 1 (MSP1) appears essential for successful erythrocyte invasion by the malarial parasite, Plasmodium. We have determined the crystal structure at 1.8 A resolution of a soluble baculovirus-recombinant form of the protein from P. cynomolgi, which confers excellent protective efficacy in primate vaccination trials. The structure comprises two EGF-like domains, and sequence comparisons strongly suggest that the same conformation is present in all species of Plasmodium, including P. falciparum and P. vivax, which are pathogenic in man. In particular, conserved interdomain contacts between the two EGF modules should preserve the compact form of the molecule in all species. Implications of the crystal structure for anti-malarial vaccine development are discussed.

The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomized study with two years' follow-up

The purpose of this prospective, randomized, clinical trial was to evaluate the effect of knee bracing after anterior cruciate ligament reconstruction. Sixty patients were randomized into one of two groups: Patients in the braced group wore rehabilitative braces for 2 weeks, followed by functional braces for 10 weeks, and patients in the nonbraced group did not wear braces. Data were recorded preoperatively, and postoperatively after 6 weeks, 3 and 6 months, and 1 and 2 years. The following outcome measures were used: KT-1000 arthrometry, the Cincinnati knee score, goniometry to record range of motion, computed tomography to determine thigh atrophy, Cybex 6000 isokinetic testing to evaluate muscle strength, three functional knee tests, and a visual analog scale to evaluate pain. At all follow-up times there were no significant differences between the two groups with regard to knee joint laxity, range of motion, muscle strength, functional knee tests, or pain. However, the Cincinnati knee score showed that patients in the braced group had significantly improved knee function compared with patients in the nonbraced group at the 3-month follow-up, even though the braced group showed significantly increased thigh atrophy compared with the nonbraced group at 3 months.