More than Just Workload-Personnel's Perspective on Workload at the Royal Netherlands Marechaussee: A Qualitative Study

OBJECTIVES

We investigated the perspective on workload within the Royal Netherlands Marechaussee, part of the Dutch armed forces.

METHODS

This qualitative study follows an emergent design based on grounded theory principles and used semistructured interviews and focus groups with 91 Royal Netherlands Marechaussee employees. The interviews ( n = 31) and focus groups ( n = 14) were transcribed verbatim and analyzed by two researchers (C.B. and J.v.d.Z.) according to comparative data analysis.

RESULTS

Participants believed the perception of workload to be more important than the actual workload. Furthermore, participants mentioned that indirect factors, such as organizational factors and recruitment, could modulate their workload perception.

CONCLUSIONS

The perception of workload is key within the context of the Royal Netherlands Marechaussee. Modifiable factors related to the perceived workload could facilitate employee well-being without reducing the actual workload.

In the Treatment of Lateral Epicondylitis by Percutaneous Perforation, Injectables Have No Added Value

BACKGROUND

No single injection therapy has been proven to be superior in the treatment of lateral epicondylitis. In most studies, the injection technique is not standardized, which makes it challenging to compare outcomes.

QUESTIONS/PURPOSES

(1) Does injection with autologous blood, dextrose, or needle perforation only at the extensor carpi radialis brevis tendon origin produce better VAS pain scores during provocation testing at 5 months of follow-up? (2) Which percutaneous technique resulted in better secondary outcome measures: VAS during rest and activity, VAS during maximum grip, Oxford elbow score (OES), QuickDASH, Patient-related Tennis Elbow Evaluation (PRTEE), or EuroQol-5D (EQ-5D)?

METHODS

In this multicenter, randomized controlled trial performed from November 2015 to January 2020, 166 patients with lateral epicondylitis were included and assigned to one of the three treatment groups: autologous blood, dextrose, or perforation only. Complete follow-up data were available for the primary outcome measures at the 5-month follow-up interval for 77% (127 of 166) of patients. Injections of the extensor carpi radialis brevis tendon were conducted in an accurate and standardized way. The three groups did not differ in terms of key variables such as age, gender, duration of symptoms, smoking habits, pain medication, and physiotherapy use. Data were collected at baseline and 8 weeks, 5 months, and 1 year after treatment and compared among the groups. The primary endpoint was the VAS pain score with provocation at 5 months. Our secondary study outcomes were VAS pain scores during rest, after activity, and after maximum grip strength; functional recovery; and quality of life. Therefore, we report the VAS pain score (0 to 100, with higher scores representing more-severe pain, minimum clinically important difference [MCID] 10), OES (0 to 48, with higher scores representing more satisfactory joint function, MCID 10), QuickDASH (0 to 100, with higher scores representing more severe disability, MCID 5.3), PRTEE (0 to 100, with higher scores representing more pain or more disability, MCID 20), EQ-5D/QALY (EQ-5D sumscore 0 to 1, with the maximum score of 1 representing the best health state, MCID 0.04), and EQ-5D VAS (0 to 100, with higher scores representing the best health status, MCID 8). For analysis, one-way analysis of variance and a linear mixed-model analysis were used. The analyses were performed according to the intention-to-treat principle. Four patients from the perforation group opted to crossover to autologous blood after 5 months.

RESULTS

No injection therapy proved to be superior to any other in terms of VAS pain scores during the provocation test at 5 months of follow-up (VAS for perforation: 25 ± 31; autologous blood: 26 ± 27; dextrose: 29 ± 32; p = 0.35). For the secondary outcomes, only a clinically important difference was found for the QuickDASH score. Both the perforation-only group (-8 [98% CI -4 to -12]) and autologous blood (-7 points [98% CI -3 to -11]) had improved QuickDASH scores over time compared with the dextrose group (MCID 5.3; p < 0.01). For the other outcomes, no clinically important differences were found.

CONCLUSION

There is no benefit to injectable autologous blood and dextrose over perforation alone to treat lateral epicondylitis, and they are therefore not indicated for this condition.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Only Low Patients' Expectations Are Prognostic for Dissatisfaction With Performing Work-Related Knee-Straining Activities After Total Knee Arthroplasty: A Prospective Multicenter Cohort Study

OBJECTIVE

To investigate whether preoperative expectations regarding performing work-related knee-straining activities were associated with being dissatisfied 6 months after total knee arthroplasty (TKA) among working patients, and, to identify prognostic factors for being dissatisfied with performing these work-related knee-straining activities.

DESIGN

Multicenter prospective cohort study.

SETTING

Orthopedic surgery departments of 7 hospitals in the Netherlands.

PARTICIPANTS

A consecutive sample of 175 working patients who were on the waiting list for TKA (median age 59 years, 53% women) and intended to return to work (N=175).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Dissatisfaction with performing work-related knee-straining activities 6 months postoperative was measured using the Work Osteoarthritis or joint-Replacement Questionnaire (score range 0-100). The clinically relevant cut-off points for being satisfied and dissatisfied were ≥71 and ≤50, respectively.

RESULTS

Thirty-three patients (19%) were dissatisfied with performing work-related knee-straining activities 6 months after TKA. Patients who expected to be dissatisfied preoperative had a 5.1 times higher odds (95% CI 1.7-15.5) of being dissatisfied 6 months postoperatively compared with patients who expected to be satisfied preoperative. Regression analyses revealed that only patients' expectations were prognostic for being dissatisfied 6 months postoperatively rather than age, pain level, or having a knee-straining job.

CONCLUSIONS

Two in 10 working patients are dissatisfied with performing work-related knee-straining activities 6 months after TKA. Only preoperative patients' expectations appeared prognostic. Therefore, we should better prepare working patients with low expectations by managing their preoperative expectations and improving their performance of work-related knee-straining activities in rehabilitation.

'Wait…, let me tell you, if I worked for a boss, I would be on sick leave': A Qualitative Study of Self-Employed Workers in Physically Demanding Jobs in the Netherlands

PURPOSE

The purpose of this study was to explore the perspectives of self-employed workers with a physically demanding job on work participation.

METHODS

We interviewed self-employed workers with a physically demanding job, using semi-structured interviews, which were audio recorded. The main topic addressed was the workers' health in relation with their work participation, work demands, and preventive measures. The interviews were transcribed verbatim and coded by three team members of the research team in several steps. We used the consolidated criteria for reporting qualitative research (COREQ) checklist to report our findings.

RESULTS

We interviewed 18 self-employed workers: 83% male, 49 years (SD 7), self-employed for 18 years (SD 9) and the majority (n = 14) worked in the construction sector. Thematic analysis revealed facilitators and barriers for work participation across three main themes: personal factors, work factors, and healthcare. Personal factors compassed sub-themes such as health and financial consequences. Work factors included sub-themes related to work demands and adaptations and healthcare encompassed sub-themes associated with work-related care and medication.

CONCLUSION

To our knowledge, this is the first qualitative study that investigated the perspectives of self-employed workers in physically demanding jobs regarding work participation. While most facilitators and barriers were consistent with those described in the literature for employees, certain factors, such as financial consequences of ceasing work, emerged important factors for work participation among self-employed workers.

Royal Netherlands Marechaussee Personnel's Self-Perceived Occupational Demand Profiles: A Latent Profile Analysis Shows the "Good" Versus the "Bad"

INTRODUCTION

Research has linked high occupational demands to multiple adverse health outcomes, both physical and mental. As far as we know, researchers have not identified the profile characteristics of military police personnel based on occupational demands. The current study aims to identify profiles based on self-perceived occupational demands and work-related factors. This study is a starting point for characterizing performance and health in a military police population.

METHODS

This was a cross-sectional study in which we gathered survey data from 1,135 Royal Netherlands Marechaussee members. We used Latent Profile Analysis to identify profiles based on nine indicators of workload and work characteristics selected via focus groups and interviews with Royal Netherlands Marechaussee personnel. We determined if the profiles differed significantly across all indicators with an analysis of variance. Then, we used binominal logistic regression to determine the odds ratio (OR) for the indicators on profile membership.

RESULTS

We discovered two profiles that were distinct across all indicators. Experience (OR = 1.02, 95% CI [1.00-1.04]), autonomy (OR = 1.18, 95% CI [1.06-1.31]), task clarity (OR = 1.49, [1.32-1.69]), and work support (OR = 2.63, 95% CI [2.26-3.09]) were all predictors for a low perceived occupational demand profile. In contrast, mental (OR = 0.18, 95% CI [0.13-0.25]) and physical (OR = 0.42, 95% CI [0.32-0.54]) fatigue, and boredom (OR = 0.14, 95% CI [0.10-0.20]) were predictors for high perceived occupational demand profiles.

CONCLUSION

We established two distinct profiles that describe the characteristics reported by the Royal Netherlands Marechaussee personnel based on workload and work characteristics. High scores on autonomy, work support, and task clarity predict favorable perceived occupational demands, whereas fatigue and boredom predict unfavorable occupational demands. Remarkably, the physical workload did not predict high perceived occupational demands.

Return-to-work following shoulder arthroplasty in adults with osteoarthritis

BACKGROUND

Anatomic total shoulder arthroplasty (aTSA) and hemiarthroplasty (HA) have demonstrated significant improvement in shoulder function and pain relief. Work-related outcomes have become increasingly important, while the current literature lacks evidence related to return-to-work (RTW) and which factors might have an influence on it.

AIMS

This study aimed to assess RTW in patients who have received aTSA or HA at a minimum of 1-year follow-up after surgery, and secondary to evaluate possible prognostic factors associated with RTW.

METHODS

We performed a retrospective query in employed patients diagnosed with primary osteoarthritis of the shoulder, who received either an aTSA or HA between February 2006 and February 2021. Preoperative and post-operative work and sports participation were assessed.

RESULTS

Forty-four patients participated in this study (98% compliance), of which 40 patients (91%) were able to RTW at a median time of two (interquartile range: 2-4) months post-operatively. Patients with a medium-/high-demand occupation demonstrated RTW at a significantly lower rate (79%) than those with light-demand occupations (100%; P = 0.03). There was a statistically significant association between return to full employment and patients' expectation to fully return, absence of preoperative work adjustments and preoperative sick leave (odds ratio: 16.9 [3.1-93.5]; 18.3 [2.1-160.4]; 0.1 [0.0-0.6]).

CONCLUSIONS

aTSA and HA facilitate excellent RTW rates. Patients with a medium-/high-demand occupation return at a significantly lower rate. The ability to RTW seems to be multifactorial and the results found might not be attributed to shoulder arthroplasty alone.

Does Consulting an Occupational Medicine Specialist Decrease Time to Return to Work Among Total Knee Arthroplasty Patients? A 12-Month Prospective Multicenter Cohort Study

PURPOSE

The aim of this study is to investigate whether total knee arthroplasty (TKA) patients who consulted an occupational medicine specialist (OMS) within 3 months after surgery, return to work (RTW) earlier than patients who did not consult an OMS.

METHODS

A multi-center prospective cohort study was performed among working TKA patients, aged 18 to 65 years and intending to RTW. Time to RTW was analyzed using Kaplan Meier and Mann Whitney U (MWU), and multiple linear regression analysis was used to adjust for effect modification and confounding.

RESULTS

One hundred and eighty-two (182) patients were included with a median age of 59 years [IQR 54-62], including 95 women (52%). Patients who consulted an OMS were less often self-employed but did not differ on other patient and work-related characteristics. TKA patients who consulted an OMS returned to work later than those who did not (median 78 versus 62 days, MWU p < 0.01). The effect of consulting an OMS on time to RTW was modified by patients' expectations in linear regression analysis (p = 0.05). A median decrease in time of 24 days was found in TKA patients with preoperative high expectations not consulting an OMS (p = 0.03), not in patients with low expectations.

CONCLUSIONS

Consulting an OMS within 3 months after surgery did not result in a decrease in time to RTW in TKA patients. TKA patients with high expectations did RTW earlier without consulting an OMS. Intervention studies on how OMSs can positively influence a timely RTW, incorporating patients' preoperative expectations, are needed.

Physical activity after revision knee arthroplasty including return to sport and work: a systematic review and meta-analysis including GRADE

BACKGROUND

The number of primary knee arthroplasties (KAs) performed annually is rising, especially among active, working age patients. Consequently, revision KA is also increasingly performed. Our aim was to systematically review the extent to which patients were physically active following revision KA, and the rate and timing of return to sport and work.

METHODS

A search was conducted in the databases Medline and Embase until February 24^th, 2023. Studies describing patients with revision total knee arthroplasty (rTKA) or revision unicondylar knee arthroplasty (rUKA), with outcomes regarding physical activity or return to sport (RTS) or work (RTW) were included. Quality of studies was assessed using the Newcastle-Ottawa scale, meta-analyses were performed using RevMan 5.4 and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE).

RESULTS

Of the 4,314 articles screened, 22 studies were included describing 2,462 rTKA patients (no rUKA), 42% were male with a mean age of 67 years (range 24 - 95). No studies reported objective physical activity measurements. Twenty-two studies reported patient reported outcome measures (PROMs). The PROMs that were pooled on a scale from zero to ten were the UCLA Activity Score, the Tegner Activity Level Scale, the Lower-Extremity Activity Scale, Devane Activity Score, and physical activity related subscales of the Knee injury and Osteoarthritis Outcome Score. The retrospective studies of moderate quality showed a statistically significant postoperative improvement of 1.7 points (MD = 1.71, 95% CI 1.48 - 1.94 (p < 0.0001); 14 studies, n = 1,211). For the prospective moderate-quality studies, a statistically significant postoperative increase of 0.9 points was found (MD = 0.89, 95% CI 0.48 - 1.30 (p < 0.0001); 6 studies, n = 1,027). Regarding RTS, 12% of patients participated in so-called 'non-recommended' activities (i.e., hockey, soccer, football, gymnastics, jogging, singles tennis, and basketball) after rTKA (1 study, n = 206). The pooled RTW was 86% (2 studies, range 18-95%, n = 234).

CONCLUSIONS

The majority of patients self-reported an improved postoperative activity level after rTKA. Patients could maintain an active lifestyle in daily life, including sports and work. For reliable physical activity, RTS and RTW estimations, more studies are required. In terms of GRADE, the quality of evidence for the five prospective studies was rated as low.

LEVEL OF EVIDENCE

Level 3.

Protocol for a multicenter study on effectiveness and economics of the Back At work After Surgery (BAAS): a clinical pathway for knee arthroplasty

BACKGROUND

Optimizing return to work (RTW) after knee arthroplasty (KA) is becoming increasingly important due to a growing incidence of KA and poor RTW outcomes after KA. We developed the Back At work After Surgery (BAAS) clinical pathway for optimized RTW after KA. Since the effectiveness and cost analysis of the BAAS clinical pathway are still unknown, analysis on effectiveness and costs of BAAS is imperative.

METHOD

This protocol paper has been written in line with the standards of Standard Protocol Items: Recommendations for Interventional Trails. To assess the effectiveness and cost-effectiveness for RTW, we will perform a multicenter prospective cohort study with patients who decided to receive a total KA (TKA) or an unicompartmental KA (UKA). To evaluate the effectiveness of BAAS regarding RTW, a comparison to usual care will be made using individual patient data on RTW from prospectively performed cohort studies in the Netherlands.

DISCUSSION

One of the strengths of this study is that the feasibility for the BAAS clinical pathway was tested at first hand. Also, we will use validated questionnaires and functional tests to assess the patient's recovery using robust outcomes. Moreover, the intervention was performed in two hospitals serving the targeted patient group and to reduce selection bias and improve generalizability. The limitations of this study protocol are that the lead author has an active role as a medical case manager (MCM) in one of the hospitals. Additionally, we will use the data from other prospective Dutch cohort studies to compare our findings regarding RTW to usual care. Since we will not perform an RCT, we will use propensity analysis to reduce the bias due to possible differences between these cohorts.

TRAIL REGISTRATION

This study was retrospectively registered at clinicaltrails.gov ( https://clinicaltrials.gov/ct2/show/NCT05690347 , date of first registration: 19-01-2023).

A Health-Impact Assessment of an Ergonomic Measure to Reduce the Risk of Work-Related Lower Back Pain, Lumbosacral Radicular Syndrome and Knee Osteoarthritis among Floor Layers in The Netherlands

Sand-cement-bound screed floor layers are at risk of work-related lower back pain, lumbosacral radicular syndrome and knee osteoarthritis, given their working technique of levelling screed with their trunk bent while mainly supported by their hands and knees. To reduce the physical demands of bending of the trunk and kneeling, a manually movable screed-levelling machine was developed for floor layers in the Netherlands. The aim of this paper is to estimate the potential health gains of working with a manually movable screed-levelling machine on the risk of lower back pain (LBP), lumbosacral radicular syndrome (LRS) and knee osteoarthritis (KOA) compared to traditional working techniques. This potential health gain was assessed using the epidemiological population estimates of the Population Attributable Fraction (PAF) and the Potential Impact Fraction (PIF), combined with work-related risk estimates for these three disorders from systematic reviews. The percentage of workers exceeding these risk estimates was based on worksite observations among 28 floor layers. For LBP, 16/18 workers were at risk when using traditional working techniques, with a PAF = 38%, and for those using a manually movable screed-levelling machine, this was 6/10 with a PIF = 13%. For LRS, these data were 16/18 with a PAF = 55% and 14/18 with a PIF = 18%, and for KOA, 8/10 with a PAF = 35% and 2/10 with a PIF = 26%. A manually movable screed-levelling machine might have a significant impact on the prevention of LBP, LRS and KOA among floor layers in the Netherlands, and health-impact assessments are a feasible approach for assessing health gains in an efficient way.

(Cost-)effectiveness of a personalized multidisciplinary eHealth intervention for knee arthroplasty patients to enhance return to activities of daily life, work and sports - rationale and protocol of the multicentre ACTIVE randomized controlled trial

BACKGROUND

With the worldwide rising obesity epidemic and the aging population, it is essential to deliver (cost-)effective care that results in enhanced societal participation among knee arthroplasty patients. The purpose of this study is to describe the development, content, and protocol of our (cost-)effectiveness study that assesses a perioperative integrated care program, including a personalized eHealth app, for knee arthroplasty patients aimed to enhance societal participation post-surgery compared to care as usual.

METHODS

The intervention will be tested in a multicentre randomized controlled trial with eleven participating Dutch medical centers (i.e., hospitals and clinics). Working patients on the waiting-list for a total- or unicompartmental knee arthroplasty with the intention to return to work after surgery will be included. After pre-stratification on medical centre with or without eHealth as usual care, operation procedure (total- or unicompartmental knee arthroplasty) and recovery expectations regarding return to work, randomization will take place at the patient-level. A minimum of 138 patients will be included in both the intervention and control group, 276 in total. The control group will receive usual care. On top of care as usual, patients in the intervention group will receive an intervention consisting of three components: 1) a personalized eHealth intervention called ikHerstel ('I Recover') including an activity tracker, 2) goal setting using goal attainment scaling to improve rehabilitation and 3) a referral to a case-manager. Our main outcome is quality of life, based on patient-reported physical functioning (using PROMIS-PF). (Cost-)effectiveness will be assessed from a healthcare and societal perspective. Data collection has been started in 2020 and is expected to finish in 2024.

DISCUSSION

Improving societal participation for knee arthroplasty is relevant for patients, health care providers, employers and society. This multicentre randomized controlled trial will evaluate the (cost-)effectiveness of a personalized integrated care program for knee arthroplasty patients, consisting of effective intervention components based on previous studies, compared to care as usual.

TRIAL REGISTRATION

Trialsearch.who.int; reference no. NL8525, reference date version 1: 14-04-2020.

Imaging of Overuse Injuries of the Ankle and Foot in Sport and Work

Overuse injuries of the ankle and foot are common injuries both in sport and in a work-related context. After clinical assessment, imaging is key for early diagnosis. In this overview article, we focus on imaging techniques, protocols, and imaging findings of overuse injuries of the ankle and foot; we emphasize the important role of structured reporting; and we discuss clinical symptoms, epidemiology, and risk factors in sports and in a work-related context.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis

PURPOSE

The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis.

METHODS

Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol.

RESULTS

The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions.

CONCLUSION

Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers.

LEVEL OF EVIDENCE

Level II.

Implementation of back at work after surgery (BAAS): A feasibility study of an integrated pathway for improved return to work after knee arthroplasty

PURPOSE

Optimizing return to work after knee arthroplasty is becoming more important because of the growing incidence of KA among workers and poor return to work outcomes. The purpose of this study is to investigate the feasibility of Back At work After Surgery (BAAS): an integrated clinical pathway for return to work after knee arthroplasty.

METHOD

Working patients who received unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) between January 2021 and November 2021, younger than 65 years and motivated to return to work were eligible to participate. Feasibility was investigated on five domains: reach, dose delivered, dose received, fidelity and patients' attitudes. These outcomes were obtained by a patient-reported questionnaire and an interview with the occupational case manager and medical case manager.

RESULTS

Of the eligible 29 patients, eleven were willing to participate (response rate 38%; due to travel distance to and from the hospital). The dose delivered was between 91 and 100%, except information given about return to work from the orthopedic surgeon which was 18%. The dose received was 100%. For fidelity, case managers reported nine shortcomings for which five solutions were mentioned. In terms of patients' attitude, all patients were satisfied and one patient mentioned an improvement.

CONCLUSIONS

In terms of reach, participation was low: only 29%. The BAAS clinical pathway seems feasible based on dose delivered, dose received, fidelity and patient attitudes. The next step is to assess the effectiveness of the BAAS clinical pathway for return to work.

A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE

BACKGROUND

High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3-10 years) and long term (>10 years) follow up in patients with TKA.

METHODS

Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.

RESULTS

Five cohort studies and one case-control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4-12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24-1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34-5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2-4.7, level of certainty: low).

CONCLUSION

During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.

Work-relatedness of carpal tunnel syndrome: Systematic review including meta-analysis and GRADE

Background and Aims

Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment syndrome with a high prevalence among workers. Insights on the physical work-related risk factors is necessary to develop appropriate preventative methods. The objective of this systematic review, including meta-analyses, is to assess which physical work-related risk factors are associated with carpal tunnel syndrome.

Methods

Systematic literature searches were carried out using PubMed and Embase until September 6, 2021. Studies were included if: (1) CTS was clinically assessed, (2) the studies were prospective cohort studies, and (3) the exposure was reported using terms of exposed/less or nonexposed. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

Results

In total, 9270 patients with CTS from a population of 1,051,707 workers were included from 17 studies. Meta-analyses revealed high-quality evidence for associations between CTS and high exposures to repetition (hazard ratio [HR] 1.87, 95% CI 1.42-2.46), force intensity (HR 1.84, 95%CI 1.22-2.79), exposures above hand activity level of ACGIH (HR 1.75, 95%CI 1.40-2.17), and the Strain Index >10 (HR 1.58, 95% CI 1.09-2.30). No significant associations were found for pinch gripping, hand-arm vibration or force duration. High computer-use exposure was significantly associated with a decreased rate of work-related CTS (HR 0.28, 95% CI 0.12-0.64).

Conclusion

This systematic review of prospective cohort studies found high certainty for an increased rate of CTS due to a high Strain Index, exposures exceeding the Activity Level of ACGIH, and high force intensity and high repetition. Workers performing tasks requiring both high force and high repetition even have a higher rate of developing CTS.

The Dutch Multidisciplinary Occupational Health Guideline to Enhance Work Participation Among Low Back Pain and Lumbosacral Radicular Syndrome Patients

Purpose Based on current scientific evidence and best practice, the first Dutch multidisciplinary practice guideline for occupational health professionals was developed to stimulate prevention and enhance work participation in patients with low back pain (LBP) and lumbosacral radicular syndrome (LRS). Methods A multidisciplinary working group with health care professionals, a patient representative and researchers developed the recommendations after systematic review of evidence about (1) Risk factors, (2) Prevention, (3) Prognostic factors and (4) Interventions. Certainty of the evidence was rated with GRADE and the Evidence to Decision (EtD) framework was used to formulate recommendations. High or moderate certainty resulted in a recommendation "to advise", low to very low in a recommendation "to consider", unless other factors in the framework decided differently. Results An inventory of risk factors should be considered and an assessment of prognostic factors is advised. For prevention, physical exercises and education are advised, besides application of the evidence-based practical guidelines "lifting" and "whole body vibration". The stepped-care approach to enhance work participation starts with the advice to stay active, facilitated by informing the worker, reducing workload, an action plan and a time-contingent increase of work participation for a defined amount of hours and tasks. If work participation has not improved within 6 weeks, additional treatments should be considered based on the present risk and prognostic factors: (1) physiotherapy or exercise therapy; (2) an intensive workplace-oriented program; or (3) cognitive behavioural therapy. After 12 weeks, multi-disciplinary (occupational) rehabilitation therapy need to be considered. Conclusions Based on systematic reviews and expert consensus, the good practice recommendations in this guideline focus on enhancing work participation among workers with LBP and LRS using a stepped-care approach to complement existing guidelines focusing on recovery and daily functioning.

Return to Sport and Work after Randomization for Knee Distraction versus High Tibial Osteotomy: Is There a Difference?

Knee joint distraction (KJD) is a novel technique for relatively young knee osteoarthritis (OA) patients. With KJD, an external distraction device creates temporary total absence of contact between cartilage surfaces, which results in pain relief and possibly limits the progression of knee OA. Recently, KJD showed similar clinical outcomes compared with high tibial osteotomy (HTO). Yet, no comparative data exist regarding return to sport (RTS) and return to work (RTW) after KJD. Therefore, our aim was to compare RTS and RTW between KJD and HTO. We performed a cross-sectional follow-up study in patients <65 years who previously participated in a randomized controlled trial comparing KJD and HTO. Out of 62 eligible patients, 55 patients responded and 51 completed the questionnaire (16 KJDs and 35 HTOs) at 5-year follow-up. The primary outcome measures were the percentages of RTS and RTW. Secondary outcome measures included time to RTS/RTW, and pre- and postoperative Tegner's (higher is more active), and Work Osteoarthritis or Joint-Replacement Questionnaire (WORQ) scores (higher is better work ability). Patients' baseline characteristics did not differ. Total 1 year after KJD, 79% returned to sport versus 80% after HTO (not significant [n.s.]). RTS <6 months was 73 and 75%, respectively (n.s.). RTW 1 year after KJD was 94 versus 97% after HTO (n.s.), and 91 versus 87% <6 months (n.s.). The median Tegner's score decreased from 5.0 to 3.5 after KJD, and from 5.0 to 3.0 after HTO (n.s.). The mean WORQ score improvement was higher after HTO (16 ± 16) than after KJD (6 ± 13; p = 0.04). Thus, no differences were found for sport and work participation between KJD and HTO in our small, though first ever, cohort. Overall, these findings may support further investigation into KJD as a possible joint-preserving option for challenging "young" knee OA patients. The level of evidence is III.

Editorial Commentary: Timely Surgery, Optimizing Perioperative Care, and Prospective Data Collection Are Next Steps to Improving Return to Sport and Work Outcomes After Knee Osteotomy

Knee osteotomy is a valuable treatment option for younger knee osteoarthritis patients. Improved surgical techniques, including double-level osteotomies to address femoral and tibial malalignment, have led to reappreciation of this joint-sparing alternative to knee arthroplasty. Yet, postoperative ability to resume sport and work at the desired level needs further improvement. We believe that timely surgery, optimized perioperative care, including evidence-based advice for resumption of activities, and prospective data collection are interesting next steps in this process.

The economic burden of knee and hip osteoarthritis: absenteeism and costs in the Dutch workforce

Background

This study aimed to quantify the absenteeism costs of knee and hip osteoarthritis in the Netherlands for the Dutch workforce and specific groups of workers.

Methods

We used a longitudinal, dynamic database from a large occupational health service in which occupational physicians register information about personal information and sick leave of workers with the diagnosis of knee- and/or hip osteoarthritis. We included all employees aged 15 to 75 years performing paid work and diagnosed with knee and/or hip osteoarthritis. Costs were calculated annually and per episode for different subgroups from an employer’s perspective using the Human Capital Approach. In the Netherlands, the employer has to pay 70% of the employee's wage out of pocket for the first two years of sick leave and also for the occupational health care. In this way, employers receive information about the costs of workers on sick leave due to knee or hip osteoarthritis. This might stimulate investments in targeted prevention and work-directed care.

Results

For the period 2015–2017, 1399 workers fulfilled the inclusion criteria. An average sick leave episode of knee osteoarthritis had a duration of 186 calendar days and was associated with €15,550 in costs. For hip osteoarthritis these data were 159 calendar days and €12,482 in costs. These costs are particularly high among male workers and workers with a higher number of weekly working hours. The average annual costs for the Dutch workforce due to sick leave for knee and hip osteoarthritis were €26.9 million and €13.8 million, respectively. Sick leave costs decreased for hip and not for knee osteoarthritis during 2015–2017.

Conclusions

Annual sick leave costs due to knee and hip osteoarthritis are about €40 million for the Dutch workforce and approximately twice as high for knee compared to hip osteoarthritis. Average costs per sick leave episode are particularly high among male workers and workers with a higher number of weekly working hours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05306-9.

Work-relatedness of lateral epicondylitis: Systematic review including meta-analysis and GRADE work-relatedness of lateral epicondylitis

Background

Lateral epicondylitis (LE) is a highly prevalent musculoskeletal disorder in workers, often associated with physically demanding work. Knowledge of work‐relatedness of LE is crucial to develop appropriate preventive measures. This study investigates the prospective association between work‐related physical risk factors and LE.

Methods

A systematic literature review was conducted in MedLine using PubMed from January 1, 2010 until February 16, 2021. Published reports were included if: (1) LE was clinically assessed, (2) exposure to work‐related physical risk factors was assessed, and (3) associations between LE and work‐related physical risk factors were reported in prospective studies. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation.

Results

In total, 318 workers with LE from a population of 5036 workers in five studies were included. Meta‐analyses revealed high‐quality evidence for associations between LE and a Strain Index (SI) score >5.1 (odds ratio [OR]: 1.75, 95% confidence interval (CI): 1.11–2.78) and moderate‐quality evidence for forearm rotation >4 h/day or forearm rotation ≥45° for ≥45% time (OR: 1.85, 95% CI: 1.10–3.10). Gripping, flexion and extension of the wrist, and repetitive movements showed no significant associations with LE.

Conclusion

High‐quality evidence was found indicating that a higher SI increased the risk of LE. Moderate‐quality evidence was found for an association between forearm rotation and LE. No associations were found between other physical risk factors and LE. Primary preventive interventions should focus on a reduction of the SI and of high forearm rotation in work.

Towards harmonisation of case definitions for eight work-related musculoskeletal disorders - an international multi-disciplinary Delphi study

Background

International consensus is needed on case definitions of work-related musculoskeletal disorders and diseases (MSDs) for use in epidemiological research. We aim to: 1) study what information is needed for the case definition of work-related low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral and medial elbow tendinopathy, and knee and hip osteoarthritis, and to 2) seek consensus among occupational health professionals/researchers regarding the case definitions of these work-related MSDs.

Methods

A two-round Delphi study was conducted with occupational health professionals/researchers from 24 countries. Definition of work-related MSDs were composed of a case definition with work exposures. Round 1 included 32 case definitions and round 2, 60 case definitions. After two rounds, consensus required 75% of the panellists to rate a case definition including work exposures ≥7 points on a 9-point rating scale (completely disagree/completely agree).

Results

Fifty-eight panellists completed both rounds (response rate 90%). Forty-five (70%) panellists thought that for LBP a case definition can be based on symptoms only. Consensus was only reached for work-related medial elbow tendinopathy, while the lowest agreement was found for knee osteoarthritis. Where consensus was not reached, this was – except for LBP - related to physical examination and imaging rather than disagreement on key symptoms.

Conclusion

Consensus on case definitions was reached only for work-related medial elbow tendinopathy. Epidemiological research would benefit from harmonized case definitions for all MSDs including imaging and physical examination for LRS, SAPS, CTS, lateral elbow tendinopathy and hip and knee osteoarthritis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04871-9.

Recovery Courses of Patients Who Return to Work by 3, 6 or 12 Months After Total Knee Arthroplasty

Purpose This study compared the preoperative levels and postoperative recovery courses of physical and mental impairments, activity limitations and participation restrictions of working-age patients who return to work (RTW) by 3, 6 or 12 months after total knee arthroplasty (TKA). Methods A prospective survey study including TKA patients (aged < 65) (n = 146) who returned to work (RdTW) in the first postoperative year. Three groups were compared: those who returned by 3 (n = 35), 6 (n = 40) or 12 (n = 29) months. Surveys were completed preoperatively and at 6 weeks and 3, 6 and 12 months postoperatively. Outcomes represented domains of the International Classification of Functioning, i.e. physical impairments (pain, stiffness, vitality), mental impairments (mental health and depressive symptoms), activity limitations (physical functioning) and participation restrictions (social and work functioning). Results Preoperative knee-specific pain and physical functioning levels were better among patients who RdTW by 3 months, compared to those who returned by 12 months. Patients who RdTW by 3 months experienced significantly better recovery from physical impairments than those who returned by 6 months (on general pain) or 12 months (on general and knee-specific pain and on stiffness). Patients returning by 3 months experienced significantly better recovery from activity limitations (on knee-specific physical functioning). Conclusions To optimize return to work outcome after TKA surgery, the focus should lie on physical impairments (general and knee-specific pain, stiffness) and activity limitations (knee-specific physical functioning) during recovery.

Beneficial and limiting factors in return to work after primary total knee replacement: Patients' perspective

BACKGROUND:

Return to work (RTW) is an important outcome in Total Knee Arthroplasty (TKA). At present, 70–80%of TKA patients return to work within three to six months.

OBJECTIVE:

What are patients’ perspectives regarding beneficial and limiting factors in RTW after TKA?

METHODS:

Focus groups were formed in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Three major topics were explored: 1. What was beneficial for RTW after TKA; 2. What was limiting for RTW after TKA; and 3. What additional care would benefit RTW after TKA?

RESULTS:

Data saturation was reached after four focus groups, comprising 17 participants—nine men and eight women (median age 58, range 52–65). The focus group study identified four main themes that contributed to a successful RTW namely rehabilitation (medical) like post-operative physical therapy, patient characteristics (personal), like motivation to RTW, occupational characteristics (work-related) like build-up in work tasks and medical support (medical) like availability of a walker or crutches.

CONCLUSION:

According to participants, factors within the following four themes can contribute to a successful return to work: occupational, patient, rehabilitation and medical care. Incorporating these factors into the integrated care pathway for the “young” TKA patients may increase the chances of a successful RTW.

Accelerometer Measured Sedentary and Physical Activity Behaviors of Working Patients after Total Knee Arthroplasty, and their Compensation Between Occupational and Leisure Time

Purpose Objective measurements of sedentary and physical activity (PA) behavior are scarce among working-age patients who undergo total knee arthroplasty (TKA). Aim was to assess sedentary and PA behaviors using accelerometers and to identify compensation effects between occupational and leisure time of sedentary and PA behavior. Methods One year post-TKA, 51 patients wore an ActiGraph(GT3x) accelerometer for 7 days. Sedentary time, prolonged sedentary bouts (≥ 30 min) and PA (light-intensity and moderate-to-vigorous PA) were examined. Compliance with the guideline of > 150 min moderate-to-vigorous PA per week was calculated. Compensation effects were analyzed using multilevel models, splitting effects into routine and within-day compensation, stratifying by physical and non-physical jobs. The routine compensation effects are the ones of interest, representing habitual compensation during a week. Results Participants spent 60% of time in sedentary bouts and 17% in prolonged sedentary bouts, with 37% of PA spent in light-intensity and 3% in moderate-to-vigorous activity. About 70% of patients met the PA guideline. Routine compensation effects were found for workers in physical jobs, who compensated for their occupational light-intensity PA with less light-intensity PA during leisure time. Workers in non-physical jobs did not compensate for their occupational prolonged sedentary bouts, as these continued during leisure time. Conclusion This study showed that working TKA patients are highly sedentary 1 year after surgery, but most met the PA guideline. Especially those with non-physical jobs do not compensate for their occupational prolonged sedentary bouts. This stresses the need to stimulate PA among TKA patients not complying with the guidelines and those with non-physical jobs.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

Background

The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.

Methods

A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O’Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.

Results

In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.

Conclusion

We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04031-z.

Work Disabling Nerve Injury at Both Elbows Due to Laptop Use at Flexible Workplaces inside an Office: Case-Report of a Bilateral Ulnar Neuropathy

Background: This case report describes whether a female civil servant who developed bilateral ulnar neuropathy can be classified as having an occupational disease. Methods: The Dutch six-step protocol for the assessment and prevention of occupational diseases is used. Results: Based on the six-step protocol, we propose that pressure on the ulnar nerve in the elbow region precipitated the neuropathy for this employee while working prolonged periods in elbow flexion with a laptop. Conclusion: Despite the low incidence laptop use might be a risk factor for the occurrence of ulnar neuropathy due to prolonged pressure on the elbow. Employers and workers need to be educated about this disabling occupational injury due to laptop use and about protective work practices such as support for the upper arm and elbow. This seems especially relevant given the trend of more flexible workspaces inside and outside offices, and given the seemingly safe appearance of laptop use.

Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work, sports, and leisure activities

Background and purpose - Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. Patients and methods - A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned. Results - The questionnaire was completed by 175 patients, age 66 years (range 38-84), 57% female, BMI 29 (IQR 25-33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3-intra-articular injection-was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best. Interpretation - Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

The Impact of Minimally Invasive Treatment for Rotator Cuff Calcific Tendinitis on Self-Reported Work Ability and Sick Leave

Purpose

To examine the impact of rotator cuff calcific tendinitis on patients' self-reported work ability and sick leave, to compare work ability and sick leave with shoulder function after minimally invasive treatment, and to assess which prognostic factors influence the change in work ability.

Methods

A prospective cohort was analyzed in this study. The primary outcome measure was the single-question work ability score (0-10 points). Secondary outcome measures were quality and quantity of work, sick leave, functional outcome, and radiographic resorption. Potential predictive factors (treatment method, age, sex, resorption of the calcific deposit, physical work load, and work status) were tested in a statistical model. Follow-up was at 6 months and 1 year.

Results

The study cohort consisted of 67 patients. The mean age was 49.6 ± 6.4 years and 45 (67%) were female. Physical workload was categorized as light (58%), medium (24%), and heavy (18%). Work ability score improved from a mean of 6.1 ± 2.8 to 8.5 ± 2.0 points after 1 year. Treatment with minimally invasive treatment techniques was associated with a reduction in partial or full-time sick leave from 28% to 6%. The mean days of sick leave a month declined from 3.3 to 0.8 days. Functional disability was greater in patients with partial or full-time sick leave. The physical workload turned out to be the most important patient associated factor predicting change in work ability.

Conclusions

This study supports the hypothesis that rotator cuff calcific tendinitis has a significant impact on work ability and sick leave. Minimally invasive treatment resulted in a clinically relevant improvement in work ability score and decline in sick leave. In particular, patients with medium and high physically demanding work for the shoulder benefit from minimally invasive treatment to improve their work ability.

Level of Evidence

Level II, prospective comparative study.

Development of a Personalized m/eHealth Algorithm for the Resumption of Activities of Daily Life Including Work and Sport after Total and Unicompartmental Knee Arthroplasty: A Multidisciplinary Delphi Study

Evidence for recommendations concerning the resumption of activities of daily life, including work and sport, after knee arthroplasty is lacking. Therefore, recommendations vary considerably between hospitals and healthcare professionals. We aimed to obtain multidisciplinary consensus for such recommendations. Using a Delphi procedure, we strived to reach consensus among a multidisciplinary expert panel of six orthopaedic surgeons, three physical therapists, five occupational physicians and one physician assistant on recommendations regarding the resumption of 27 activities of daily life. The Delphi procedure involved three online questionnaire rounds and one face-to-face consensus meeting. In each of these four rounds, experts independently decided at what time daily life activities could feasibly and safely be resumed after knee arthroplasty. We distinguished patients with a fast, average and slow recovery. After four Delphi rounds, the expert panel reached consensus for all 27 activities. For example, experts agreed that total knee arthroplasty patients with a fast recovery could resume cycling six weeks after the surgery, while those with an average and slow recovery could resume this activity after nine and twelve weeks, respectively. The consensus recommendations will subsequently be integrated into an algorithm of a personalized m/eHealth portal to enhance recovery among knee arthroplasty patients.

Does Activity-Based Rehabilitation With Goal Attainment Scaling Increase Physical Activity Among Younger Knee Arthroplasty Patients? Results From the Randomized Controlled ACTION Trial

BACKGROUND

Especially in younger knee osteoarthritis patients, the ability to perform physical activity (PA) after knee arthroplasty (KA) is of paramount importance, given many patients' wish to return to work and perform demanding leisure time activities. Goal Attainment Scaling (GAS) rehabilitation after KA may improve PA because it uses individualized activity goals. Therefore, our aim was to objectively quantify PA changes after KA and to compare GAS-based rehabilitation to standard rehabilitation.

METHODS

Data were obtained from the randomized controlled ACTION trial, which compares standard rehabilitation with GAS-based rehabilitation after total and unicompartmental KA in patients <65 years of age. At 2 time points, preoperatively and 6 months postoperatively, 120 KA patients wore a validated 3-dimensional accelerometer for 1 consecutive week. Data were classified as sedentary (lying, sitting), standing, and active (walking, cycling, running). Repeated measures analysis of variance was used to compare PA changes over time.

RESULTS

Complete data were obtained for 97 patients (58% female), with a mean age of 58 years (±4.8). For the total group, we observed a significant increase in PA of 9 minutes (±37) per day (P = .01) and significant decrease in sedentary time of 20 minutes (±79) per day (P = .02). There was no difference in standing time (P = .11). There was no difference between the control group and the intervention group regarding changes in PA, nor between the total KA group and the unicompartmental KA group.

CONCLUSION

We found a small but significant increase in overall PA after KA, but no difference between GAS-based rehabilitation and standard rehabilitation. Likely, enhanced multidisciplinary perioperative strategies are needed to further improve PA after KA.

The distal radial physis: Exploring normal anatomy on MRI enables interpretation of stress related changes in young gymnasts

Rationale: Explore the MRI-appearance of the healthy distal radial physis and the distribution of stress-related changes in physeal thickness in young gymnasts to aid in the understanding of the pathophysiological process of stress-related physeal injury. Methods: Symptomatic gymnasts with clinically suspected overuse injury of the distal radial physis and age and gender-matched asymptomatic gymnasts and healthy non-gymnasts underwent an MRI-scan of the wrist. A cartilage-specific sequence was used to obtain three-dimensional reconstructions of the distal radial physis. Heat maps and line charts of these reconstructions visualised distribution of physeal thickness per study group and were used to explore differences between study groups. Symptomatic gymnasts displaying the most profound physeal widening (n = 10) were analysed separately. Results: Twenty-seven symptomatic - (skeletal age 12.9 ± 1.5 years), 16 asymptomatic - (skeletal age 12.8 ± 1.9 years) and 23 non-gymnasts (skeletal age 13.6 ± 1.9 years) were included for analysis. Physes of healthy non-gymnasts had a thin centre and increased in thickness towards the borders. Gymnasts demonstrated an increase in thickness of the entire physeal surface. In symptomatic gymnasts increase in physeal thickness was most prominent at the volar side when compared to asymptomatic gymnasts and non-gymnasts. Conclusion: The healthy distal radial physis is characterised by a thin centre surrounded by thicker borders. Stress applied to the wrist during gymnastics causes an overall increase in physeal thickness. Profound thickness increase is present at the volar side of the physis mainly in symptomatic gymnasts. These results can help unravel the pathophysiological mechanism of stress-related physeal injury in gymnasts and aid early injury identification.

Predictors of Return to Work After High Tibial Osteotomy: The Importance of Being a Breadwinner

Background

Limited evidence exists on patient-relevant outcomes after high tibial osteotomy (HTO), including return to work (RTW). Furthermore, prognostic factors for RTW have never been described.

Purpose

To investigate the extent and timing of RTW in the largest HTO cohort investigated for RTW to date and to identify prognostic factors for RTW after HTO.

Study Design

Cohort study; Level of evidence, 3.

Methods

Consecutive patients who underwent HTO between 2012 and 2015 were included. Patients received a questionnaire at a mean follow-up of 3.6 years. Questions were asked pre- and postoperatively regarding work status, job title, working hours, preoperative sick leave, employment status, and whether patients were their family's breadwinner. The validated Work Rehabilitation Questionnaire (WORQ) was used to assess difficulty with knee-demanding activities. Prognostic factors for RTW were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph.

Results

We identified 402 consecutive patients who underwent HTO, of whom 349 were included. Preoperatively, 299 patients worked, of whom 284 (95%) achieved RTW and 255 (90%) returned within 6 months. Patients reported significant postoperative improvements in performing knee-demanding activities. Being the family's breadwinner was the strongest predictor of RTW (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.27-6.69). In contrast, preoperative sick leave was associated with lower odds of RTW (OR, 0.20; 95% CI, 0.08-0.46).

Conclusion

After HTO, 95% of patients were able to RTW, of whom 9 of 10 returned within 6 months. Breadwinners were more likely to RTW, and patients with preoperative sick leave were less likely to RTW within 6 months. These findings may be used to improve preoperative counseling and expectation management and thereby enhance work-related outcomes after HTO.

Content validity of the SOS-WRIST questionnaire for timely identification of wrist overuse in young athletes

Objectives: Young athletes do not always seek medical help for overuse wrist injuries, risking invalidating long-term consequences resulting from late diagnosis. This study aimed to develop a questionnaire to identify overuse wrist injuries in young athletes. Methods: According to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria, items were collected from literature and 6 focus groups of sports physicians and of young athletes with (previous) overuse wrist injuries. An expert panel and 40 Delphi study participants performed item reduction. Young athletes evaluated comprehensiveness during interviews and English translation was performed according to linguistic validation guidelines. Results: In total 323 items were generated and 110 were marked important by focus group participants. The resulting questionnaire consists of 18 multiple-choice questions about wrist pain during sports (e.g. pain during training, skipping training sessions/elements) and daily life activities (e.g. writing, turning a key), and other symptoms (e.g. reduced strength, swelling). Conclusion: The SOS-WRIST questionnaire for identification of overuse wrist injuries in young athletes has good content validity. It can be used to promote awareness and timely treatment of overuse wrist injuries in young athletes.

Three Out of Ten Working Patients Expect No Clinical Improvement of Their Ability to Perform Work-Related Knee-Demanding Activities After Total Knee Arthroplasty: A Multicenter Study

Purpose Three out of ten patients do not return to work after total knee arthroplasty (TKA). Patient expectations are suggested to play a key role. What are patients' expectations regarding the ability to perform work-related knee-demanding activities 6 months after TKA compared to their preoperative status? Methods A multi-center cross-sectional study was performed among 292 working patients listed for TKA. The Work Osteoarthritis or joint-Replacement Questionnaire (WORQ, range 0-100, minimal important difference 13) was used to assess the preoperatively experienced and expected ability to perform work-related knee-demanding activities 6 months postoperatively. Differences between the preoperative and expected WORQ scores were tested and the most difficult knee-demanding work-related activities were described. Results Two hundred thirty-six working patients (81%) completed the questionnaire. Patients' expected WORQ score (Median = 75, IQR 60-86) was significantly (p < 0.01) higher than their preoperative WORQ score (Median = 44, IQR 35-56). A clinical improvement in ability to perform work-related knee-demanding activities was expected by 72% of the patients, while 28% of the patients expected no clinical improvement or even worse ability to perform work-related knee-demanding activities 6 months after TKA. Of the patients, 34% expected severe difficulty in kneeling, 30% in crouching and 17% in clambering 6 months after TKA. Conclusions Most patients have high expectations, especially regarding activities involving deep knee flexion. Remarkably, three out of ten patients expect no clinical improvement or even a worse ability to perform work-related knee-demanding activities 6 months postoperatively compared to their preoperative status. Therefore, addressing patients expectations seems useful in order to assure realistic expectations regarding work activities.

Effectiveness of standardized ultrasound guided percutaneous treatment of lateral epicondylitis with application of autologous blood, dextrose or perforation only on pain: a study protocol for a multi-center, blinded, randomized controlled trial with a 1 year follow up

Background

In the treatment of Lateral Epicondylitis (LE) no single intervention concerning injection therapies has been proven to be the most effective with regard to pain reduction. In this trial 3 injection therapies (perforation with application of autologous blood, perforation with application of dextrose and perforation only) will be compared in a standardized and ultrasound guided way. The objective is to assess the effectiveness of these 3 injection therapies on pain, quality of life and functional recovery. By conducting this study, we hope to make a statement on the effectiveness of injection therapy in the treatment of LE. Hereby, unnecessary treatments can be avoided, a more universal method of treatment can be established and the quality of the treatment can be improved.

Methods/design

A multicenter, randomized controlled trial with a superiority design and 12 months follow-up will be conducted in four Dutch hospitals. One hundred sixty five patients will be recruited in the age of 18 to 65 years, with chronic symptomatic lateral epicondylitis lasting longer than 6 weeks, which have concordant pain during physical examination. Patients will be randomized by block randomization to one of the three treatment arms. The treatment will be blinded for patients and outcome assessors. The following three injection therapies are compared: perforation with application of autologous blood, perforation with application of dextrose and perforation only. Injections will be performed ultrasound guided in a standardized and automated way. The primary endpoint is: pain (change in ‘Visual Analogue Scale’). Secondary endpoints are quality of life and functional recovery. These measurements are collected at baseline, 8 weeks, 5 months and 1 year after treatment.

Discussion

When completed, this trial will provide evidence on the effectiveness of injection therapy in the treatment of lateral epicondylitis on pain, quality of life and functional recovery. In current literature proper comparison of the effectiveness of injectables for LE is questionable, due to the lack of standardization of the treatment. This study will overcome bias due to manually performed injection therapy.

Trial registration

This study is registered in the Trial Register (www.trialregister.nl) of the Dutch Cochrane centre. Trial ID; NTR4569. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4569

Damage of the distal radial physis in young gymnasts: can three-dimensional assessment of physeal volume on MRI serve as a biomarker?

Objective

To explore the use of quantitative volume assessment to identify the presence and extent of stress-related changes of the distal radial physis in gymnasts with suspected physeal injury, asymptomatic gymnasts, and non-gymnasts.

Methods

Symptomatic gymnasts with clinically suspected distal radial physeal injury, asymptomatic gymnasts, and non-gymnasts (n = 69) were included and matched on skeletal age and sex. Volume measurements were performed on coronal water selective cartilage MRI images by creating three-dimensional physeal reconstructions semi-automatically using active-contour segmentation based on image-intensity thresholding. Inter- and intra-rater reliability of the measurements were assessed using intra-class correlation coefficients (ICC) for absolute agreement.

Results

Twenty-seven symptomatic-, 18 asymptomatic-, and 24 non-gymnasts were included with a median age of 13.9 years (interquartile range (IQR) 13.0–15.0 years). Median physeal volume was significantly increased (p < 0.05) in symptomatic- (971 mm³, IQR 787–1237 mm³) and asymptomatic gymnasts (951 mm³, IQR 871–1004 mm³) compared with non-gymnasts (646 mm³, IQR 538–795 mm³). Inter-rater (ICC 0.96, 95% CI 0.92–0.98) and intra-rater (ICC 0.93, 95% CI 0.85–0.97) reliability of volume measurements were excellent. Of the 10 participants with the highest physeal volumes, nine were symptomatic gymnasts.

Conclusion

Increased volume of the distal radial physis can reliably be assessed and is a sign of physeal stress that can be present in both symptomatic- and asymptomatic gymnasts, but gymnasts with suspected physeal injury showed larger volume increases. Future studies should explore if volume assessment can be used to (early) identify athletes with or at risk for physeal stress injuries of the wrist.

Key Points

• The volume of the distal radial physis can be reliably assessed by creating three-dimensional physeal reconstructions.

• Stress-related volume increase of the distal radial physis is present in symptomatic and asymptomatic gymnasts.

• Gymnasts with clinically suspected physeal injury showed larger volume increases compared with asymptomatic gymnasts and may therefore be a valuable addition in the (early) diagnostic workup of physeal stress injuries.

A hidden mismatch between experiences of young athletes with overuse injuries of the wrist and sports physicians' perceptions: a focus group study

BACKGROUND

Although overuse wrist injuries can have serious consequences, young athletes often do not immediately report their injury to a physician. This qualitative study aimed to identify symptoms and limitations related to overuse wrist injuries that young athletes consider important and to compare those with sports physicians' opinions, in order to improve the diagnostic process for early identification of overuse wrist injuries.

METHODS

Twenty-one athletes aged 13-25 years in wrist-loading sports (gymnastics, tennis, judo, field hockey, volleyball and rowing) with a (previous) overuse wrist injury were included. In five focus groups, participants discussed important signals and limitations of their injury, as well as a list of relevant items previously composed by sports physicians. Data were grouped into themes and (sub)categories and subsequently coded.

RESULTS

Of the resulting 224 signals and 80 limitations, respectively 81 and 20 were labelled important. Athletes considered both pain and limitations during daily life activities important indicators of overuse wrist injury, as well as long pain duration, acute onset of pain, and accompanying symptoms like swelling, cracking and discoloration. All of the sports physicians' items were also considered important by the athletes, but sport-related pain and limitations were regarded by many athletes as a natural part of their sport.

CONCLUSIONS

Discrepancies exist between the opinions of young athletes and sports physicians on sport-related pain reporting and competing regardless of pain or limitations. Although clinicians may be inclined to focus on these aspects, they are advised to also inquire specifically about limitations and pain during daily life activities in young athletes with overuse wrist injuries.

The Effect of Total Hip Arthroplasty on Sports and Work Participation: A Systematic Review and Meta-Analysis

Background

Total hip arthroplasty (THA) is a successful procedure to treat end-stage hip osteoarthritis. The procedure is increasingly performed in adults of working age, who often wish to return to sports (RTS) and return to work (RTW). However, a systematic overview of the evidence on RTS and RTW after THA is lacking.

Objectives

Our aim was to systematically review (1) the extent to which patients RTS and RTW after THA, including (2) the time to RTS and RTW.

Methods

We searched MEDLINE and Embase from inception until October 2017. Two authors screened and extracted the data, including study information, patient demographics, rehabilitation protocols and pre- and postoperative sports and work participation. Methodological quality was assessed using the Newcastle–Ottawa scale. Data on pre- and postoperative sports and work participation were pooled using descriptive statistics.

Results

A total of 37 studies were included, of which seven were prospective studies and 30 were retrospective studies. Methodological quality was high in 11 studies, moderate in 16 studies, and low in ten studies. RTS was reported in 14 studies. Mean RTS was 104% to the pre-surgery level and 82% to the pre-symptomatic sports level. Time to RTS varied from 16 to 28 weeks. RTW was reported in 23 studies; the mean was 69%. Time to RTW varied from 1 to 17 weeks.

Conclusion

A great majority of patients RTS and RTW after THA within a timeframe of 28 and 17 weeks, respectively. For the increasingly younger THA population, this is valuable information that can be used in the preoperative shared decision-making process.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-0924-2) contains supplementary material, which is available to authorized users.

Eight respectively nine out of ten patients return to sport and work after distal femoral osteotomy

PURPOSE

Distal femoral osteotomy (DFO) is a well-accepted procedure for the treatment of femoral deformities and associated symptoms including osteoarthritis, especially in younger and physically active patients in whom knee arthroplasty is undesirable. Still, there is an apparent need for evidence on relevant patient outcomes, including return to sport (RTS) and work (RTW), to further justify the use of knee osteotomy instead of surgical alternatives. Therefore, the purpose of the present study was to investigate the extent and timing of patients' RTS and RTW after DFO.

METHODS

This monocentre, retrospective cohort study included consecutive DFO patients, operated between 2012 and 2015. Out of 126 eligible patients (18-70 years, 63% female), all patients responded, and 100 patients completed the questionnaire. Median follow-up was 3.4 years (range 1.5-5.2). The predominant indication for surgery was symptomatic unicompartmental osteoarthritis and valgus or varus leg alignment caused by a femoral deformity. The primary outcome measure was the percentage of RTS and RTW. Secondary outcome measures included time to RTS/RTW, sports level and frequency, the median pre-symptomatic and postoperative Tegner activity score (1-10, higher is more active) and the postoperative Lysholm score (0-100, higher is better).

RESULTS

Out of 84 patients participating in sports preoperatively, 65 patients (77%) returned to sport postoperatively. Forty-six patients (71%) returned to sports within 6 months. Postoperative participation in high-impact sports was possible though less frequent compared to preoperative participation. Out of 80 patients working preoperatively, 73 (91%) returned to work postoperatively, of whom 59 patients (77%) returned within 6 months. The median pre-symptomatic Tegner activity score [4.0 (range 0-10)] was significantly higher (p < 0.01) than the reported Tegner score at follow-up [3.0 (range 0-10)]. The mean Lysholm score at follow-up was 68 (± 22). No significant differences were found between the osteoarthritis- and non-osteoarthritis group.

CONCLUSION

Eight out of ten patients return to sport and nine out of ten patients return to work after DFO. These are clinically relevant findings, because they further justify DFO as a surgical alternative to KA in young, active knee OA patients who wish to return to high activity levels.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Work-relatedness of lumbosacral radiculopathy syndrome: Review and dose-response meta-analysis

OBJECTIVE

Clinicians need to know whether lumbosacral radiculopathy syndrome (LRS) can be attributed to work. This review describes what work-related risk factors are associated with LRS.

METHODS

A systematic review was performed in PubMed and Embase. Inclusion criteria were that LRS was diagnosed by a clinician and workers exposed to work-related risk factors were compared to workers less or not exposed. A quality assessment and a meta-analysis were performed, including a dose-response analysis.

RESULTS

The search resulted in 7,350 references and 24 studies that fulfilled the inclusion criteria: 19 studies were rated as having a high risk of bias and 5 as having a low risk of bias. The median number of LRS patients per study were 209 (interquartile range 124-504) and the total number of participants was 10,142. The meta-analysis revealed significant associations with heavy physically demanding work (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.48-2.79), bending or twisting of the trunk (OR 2.43, 95% CI 1.67-3.55), and lifting and carrying in combination with bending or twisting of the trunk (OR 2.84, 95% CI 2.18-3.69). No significant associations were found for professional driving (OR 1.46, 95% CI 0.90-2.35) or sitting (OR 1.08, 95% CI 0.49-2.38). A dose-response relation was present per 5 years of exposure for bending (OR 1.12, 95% CI 1.04-1.20), lifting (OR 1.08, 95% CI 1.02-1.14) and the combination of bending and lifting (OR 1.14, 95% CI 1.01-1.29).

CONCLUSIONS

Moderate to high-quality evidence is available that LRS can be classified as a work-related disease depending on the level of exposure to bending of the trunk or lifting and carrying. Professional driving and sitting were not significantly associated with LRS.

Not Physical Activity, but Patient Beliefs and Expectations are Associated With Return to Work After Total Knee Arthroplasty

BACKGROUND

After total knee arthroplasty (TKA), 17%-60% of the patients do not or only partially return to work (RTW). Reasons for no or partial RTW remain unclear, warranting further research. Physical activity (PA) has proven beneficial effects on work participation. Therefore, we hypothesized that preoperative PA is associated with RTW after TKA.

METHODS

Working TKA patients participating in an ongoing prospective cohort study were included. Preoperatively and 1 year postoperatively, patients were asked to define their work status and PA level according to the Dutch Recommendation for Health-Enhancing PA and the Fitnorm. Multivariate logistic regression analysis was performed to assess the effect of PA on RTW, taking into account established prognostic factors for RTW among TKA patients.

RESULTS

Of 283 eligible patients, 266 (93%) completed the questionnaires sufficiently. Preoperatively, 141 patients (54%) performed moderate PA for ≥5 d/wk and 42 (16%) performed intense PA for ≥3 d/wk. Concerning RTW, 178 patients (67%) reported full RTW, 59 patients (22%) partial RTW, and 29 patients (11%) no RTW. Preoperative PA was not associated with RTW. Patients who reported that their knee symptoms were not or only partially work-related had lower odds of no RTW (odds ratio 0.37, 95% confidence interval 0.17-0.81). Also, for each additional week patients expected to be absent from work, the likelihood of no RTW increased (odds ratio 1.11, 95% confidence interval 1.03-1.18).

CONCLUSION

No association between preoperative PA and RTW after TKA was found. Patient beliefs and preoperative expectations did influence RTW and should be addressed to further improve RTW after TKA.

Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management

OBJECTIVES

To assess the association between posterior circumflex humeral artery (PCHA) pathology (PCHAP), symptoms and associated risk factors, in elite volleyball players, and to suggest profiles for clinical management and monitoring.

DESIGN

Cross-sectional study.

METHODS

A questionnaire assessed symptoms of digital ischemia (DI) in the dominant hand and risk factors among 278 elite indoor and beach volleyball players of whom 6.1% (17/278) was diagnosed with PCHAP using ultrasound. Odds Ratios (OR) including 95% confidence intervals (95%CI) were calculated using binary logistic regression.

RESULTS

All 278 players completed the questionnaire. Three participants with PCHAP were symptomatic (18%). Ninety-three of 96 symptomatic participants had no PCHAP (OR=0.39; 95% CI 0.13-1.13). Total years playing volleyball (OR 1.14; 95% CI 1.03-1.25) and age (OR 1.17; 95% CI 1.00-1.29) were dose-response related risk factors: a volleyball career of ≥17 years and age of ≥27 years were associated with a 9-fold and 14-fold increased risk of PCHAP, respectively.

CONCLUSIONS

The volleyball career duration and age are dose-response related risk factors for PCHAP among elite indoor and beach volleyball players. DI symptoms are prevalent in a minority of athletes with PCHAP (3/17; 18%). To enable worldwide standardized care for these athletes at risk, four profiles for clinical management and monitoring have been suggested based on questionnaire and ultrasound outcomes.

Diagnostic properties of the SPIQuestionnaire to detect Posterior Circumflex Humeral Artery Disease in elite volleyball players: a cross-sectional study

OBJECTIVES

Sports related aneurysmal degeneration and thrombosis of the Posterior Circumflex Humeral Artery (PCHA) has been known to cause symptoms of digital ischemia (DI) in elite volleyball players. Studies have reported symptoms of DI in as much as 28% of the elite indoor volleyball players. The purpose of this study was to determine the diagnostic value of the Shoulder PCHA Pathology and digital Ischemia - Questionnaire (SPI-Q) for detection of sports related PCHA disease using ultrasound data as the standard of reference.

METHODS

The SPI-Q was completed by elite indoor volleyball players from the highest and single highest Dutch volleyball division and by elite beach volleyball players participating in the 2014 Grand Slam Beach Tournament The Hague (GSBTH). Ultrasound assessment of the dominant shoulder was performed on-site using the SPI-US protocol. The SPI-Q sensitivity, specificity, positive - and negative predictive value and positive - and negative likelihood ratios, and the diagnostic odds ratio were calculated for detection of sports related PCHA disease, using ultrasound as the standard of reference.

RESULTS

Two hundred twenty-four elite male indoor volleyball players from the Dutch division were included in this study and 62 elite male and female beach volleyball players participating in the GSBTH: a total of 278 players. Thirty-five percent of the players reported symptoms of DI. The prevalence of PCHA disease was 6.1%. For the SPI-Q we found a sensitivity of 18% (95% CI 4-43), specificity of 64% (95% CI 58-70), positive predictive value of 3% (95% CI 0.7-8.9) and negative predictive value of 92% (95% CI 87-96), positive likelihood ratio of 0.50 (95% CI 0.18-1.40), negative likelihood ratio of 1.28 (95% CI 1.01-1.62) and a diagnostic odds ratio of 0.39 (95% CI 0.11-1.38).

CONCLUSION

The diagnostic value of the SPI-Q to detect PCHA disease in elite volleyball players is poor, which makes it unsuitable as a diagnostic instrument for sports related PCHA disease specifically. However, it can be used to assess all-cause symptoms of DI and raise awareness within athletes and sports physicians, which is important for preventing ischemic complications.

High Rates of Return to Sports Activities and Work After Osteotomies Around the Knee: A Systematic Review and Meta-Analysis

BACKGROUND

Knee osteotomies are proven treatment options, especially in younger patients with unicompartmental knee osteoarthritis, for certain cases of chronic knee instability, or as concomitant treatment for meniscal repair or transplantation surgery. Presumably, these patients wish to stay active. Data on whether these patients return to sport (RTS) activities and return to work (RTW) are scarce.

OBJECTIVES

Our aim was to systematically review (1) the extent to which patients can RTS and RTW after knee osteotomy and (2) the time to RTS and RTW.

METHODS

We systematically searched the MEDLINE and Embase databases. Two authors screened and extracted data, including patient demographics, surgical technique, pre- and postoperative sports and work activities, and confounding factors. Two authors assessed methodological quality. Data on pre- and postoperative participation in sports and work were pooled.

RESULTS

We included 26 studies, involving 1321 patients (69% male). Mean age varied between 27 and 62 years, and mean follow-up was 4.8 years. The overall risk of bias was low in seven studies, moderate in ten studies, and high in nine studies. RTS was reported in 18 studies and mean RTS was 85%. Reported RTS in studies with a low risk of bias was 82%. No studies reported time to RTS. RTW was reported in 14 studies; mean RTW was 85%. Reported RTW in studies with a low risk of bias was 80%. Time to RTW varied from 10 to 22 weeks. Lastly, only 15 studies adjusted for confounders.

CONCLUSION

Eight out of ten patients returned to sport and work after knee osteotomy. No data were available on time to RTS. A trend toward performing lower-impact sports was observed. Time to RTW varied from 10 to 22 weeks, and almost all patients returned to the same or a higher workload.