The effect of Tubigrip and a rigid belt on rectus abdominus diastasis immediately postpartum: A randomised clinical trial

BACKGROUND

Rectus abdominis (RA) diastasis is a risk factor for abdominal muscle dysfunction and reduced quality of life postpartum. It is thought that supplementary abdominal supports might reduce the diastasis. However, there is limited research assessing the efficacy of abdominal supports/binding.

OBJECTIVE

To determine the effects of Tubigrip and a rigid abdominal belt in reducing RA diastasis in the first eight weeks postpartum.

DESIGN

Randomised clinical trial.

METHODS

62 women undertook ultrasound imaging to measure their RA diastasis prior to and after an eight week intervention wearing either Tubigrip or a rigid abdominal belt. Data analyses involved repeated measures ANOVA and correlational methods.

RESULTS

The RA diastasis reduced by 46% from a mean 4.6 cm-2.5 cm over the eight week intervention period with no significant difference (p > 0.05) across groups. Women wore the Tubigrip for a significantly (p < 0.05) longer number of hours (Median: 278) compared to those in the belt group (Median: 81 h). The length of time that women wore Tubigrip or the belt was not associated with the percentage reduction in the RA diastasis (p > 0.05). There was no significant difference in the diastasis across vaginal and Caesarean section deliveries at baseline. There was a significant difference (p < 0.05) in the percent reduction of the RA diastasis across deliveries post-intervention (vaginal delivery mean: 48% vs C-section: 40%).

CONCLUSION

There was no difference across groups post-intervention in the RA diastasis, and it is questionable whether either support improves upon that associated with natural healing alone.

Development of a prediction model to determine responders to conservative treatment in people with symptomatic hand osteoarthritis: A secondary analysis of a single-centre, randomised feasibility trial

BACKGROUND

Conservative treatments are beneficial for people with hand osteoarthritis (OA).

OBJECTIVE

It was the purpose of this study to develop and internally validate both a basic model and a more complex model that could predict responders to conservative treatments in people with hand OA.

DESIGN

This was a secondary analysis of a single-centre, randomised feasibility study.

METHODS

Fifty-nine participants (34 responders) with hand osteoarthritis were recruited from the general population. Participants were randomised to receive either advice alone, or advice in combination with blood flow restriction training (BFRT), or traditional high intensity training (HIT). Participants underwent supervised hand exercises three times per week for six weeks. The OMERACT-OARSI criteria were utilised to determine responders vs non responders to treatment at the end of six weeks. A basic logistic regression model (treatment type, expectations, adherence) and a more complex logistic regression model (basic model variables plus pain catastrophising and neuropathic pain features) were created. Discrimination ability, and calibration were assessed. Internal model validation through bootstrapping (200 repetitions) was utilised to calculate the prediction model optimism.

RESULTS

The results showed that the basic model presented with acceptable discrimination (optimism corrected c-statistic: 0.72, 95% CI 0.71-0.73) and calibration (slope = 1.41; intercept = 0.68). The more complex model had better discrimination but poorer calibration.

CONCLUSION

A prediction tool was created to provide an individualised estimate of treatment response in people with hand OA. Future studies will need to validate this model in other groups of patients.

TRIAL REGISTRATION

https://www.anzctr.org.au/- ACTRN12617001270303.

Neglect-like symptoms and their relationships with other clinical features in people with hand osteoarthritis: An exploratory study

BACKGROUND

Symptomatic hand osteoarthritis (OA) is a debilitating condition. Body schema impairments such as neglect-like symptoms have been previously reported in people with symptomatic hand OA, however, little is known about their clinical importance, or relationships with other clinical features.

OBJECTIVES

The aim of this cross-sectional study was to assess the prevalence of neglect-like symptoms in painful hand OA and their association with measures of depression, pain catastrophising, sleep quality, function, pain interference and pain duration whilst controlling for important covariates.

DESIGN

Secondary analysis of cross-sectional study.

METHODS

Logistic regression with age, sex, and worst pain intensity as covariates were utilised to assess differences between participants with and without neglect-like symptoms.

RESULTS

A total of 121 participants were recruited. Sixty-one percent of participants presented with neglect-like symptoms. Participants with longer pain duration had greater odds of presenting with neglect-like symptoms (OR: 1.10 95%CI: 1.01 to 1.19; p = 0.012). No difference was observed for depression, pain catastrophising, sleep quality, function, or pain interference.

CONCLUSIONS

A large proportion of participants with symptomatic hand OA reported neglect-like symptoms, the presence of which was associated with longer pain duration.

Six weeks of resistance training (plus advice) vs advice only in hand osteoarthritis: A single-blind, randomised, controlled feasibility trial

BACKGROUND

People with hand osteoarthritis (OA) may benefit from resistance training interventions. To date the feasibility of a such interventions for symptomatic hand OA, as per international guidelines, is unknown.

OBJECTIVE

Determine the feasibility of a clinical trial comparing resistance training to an advice only control group in people with symptomatic hand OA.

DESIGN

Single-blind, randomised, controlled feasibility study.

METHODS

The American College of Rheumatology criteria for hand OA were utilised for inclusion. Participants were randomly allocated (1:1:1) to advice and blood flow restriction training (BFRT), advice and traditional high intensity training (HIT), or advice only (control). Participants receiving BFRT and HIT underwent supervised hand exercises three times a week for six weeks. Feasibility measures included recruitment rate, adherence, exercise induced pain, training acceptability, pain flares, and adverse events. Number of treatment responders, pain, grip strength, and hand function were also recorded.

RESULTS

In total, 191 participants were screened, 59 (31%) were included. Retention rate was 89% for BFRT and 79% for HIT. Exercise did not worsen pain following training sessions, and training acceptability was equal between groups. Pain flares occurred in 1.6% (BFRT) and 4% (HIT) out of all the training sessions. There was one adverse event in the HIT group, with the participants withdrawing from the study due to pain. The number of treatment responders, and improvements in pain, were greater with BFRT and HIT. Grip and function did not improve.

CONCLUSION

A clinical trial comparing resistance training to advice for people with symptomatic hand OA is feasible.

Robotic devices for paediatric rehabilitation: a review of design features

Children with physical disabilities often have limited performance in daily activities, hindering their physical development, social development and mental health. Therefore, rehabilitation is essential to mitigate the adverse effects of the different causes of physical disabilities and improve independence and quality of life. In the last decade, robotic rehabilitation has shown the potential to augment traditional physical rehabilitation. However, to date, most robotic rehabilitation devices are designed for adult patients who differ in their needs compared to paediatric patients, limiting the devices' potential because the paediatric patients' needs are not adequately considered. With this in mind, the current work reviews the existing literature on robotic rehabilitation for children with physical disabilities, intending to summarise how the rehabilitation robots could fulfil children's needs and inspire researchers to develop new devices. A literature search was conducted utilising the Web of Science, PubMed and Scopus databases. Based on the inclusion-exclusion criteria, 206 publications were included, and 58 robotic devices used by children with a physical disability were identified. Different design factors and the treated conditions using robotic technology were compared. Through the analyses, it was identified that weight, safety, operability and motivation were crucial factors to the successful design of devices for children. The majority of the current devices were used for lower limb rehabilitation. Neurological disorders, in particular cerebral palsy, were the most common conditions for which devices were designed. By far, the most common actuator was the electric motor. Usually, the devices present more than one training strategy being the assistive strategy the most used. The admittance/impedance method is the most popular to interface the robot with the children. Currently, there is a trend on developing exoskeletons, as they can assist children with daily life activities outside of the rehabilitation setting, propitiating a wider adoption of the technology. With this shift in focus, it appears likely that new technologies to actuate the system (e.g. serial elastic actuators) and to detect the intention (e.g. physiological signals) of children as they go about their daily activities will be required.

Exercises, Tubigrip and taping: can they reduce rectus abdominis diastasis measured three weeks post-partum?

BACKGROUND

Rectus abdominis diastasis is regarded as a risk factor for abdominal muscle dysfunction and reduced quality of life postpartum. It is thought that specific exercises and additional physical support might reduce the diastasis, with a need to establish efficacy in doing so.

OBJECTIVES

Determine the effect of four abdominal exercises as well as Tubigrip or taping in reducing rectus abdominis diastases three weeks postpartum.

DESIGN

Cross-sectional repeated measures comparison.

METHODS

32 women undertook a single session of ultrasound imaging. Ultrasound measurements of inter-rectus distance were taken at rest and during: 1) crook lying abdominal "drawing in" exercise; 2) crook lying trunk curl-up; 3) early Sahrmann level leg raise; 4) McGill side lying plank. The curl-up and abdominal "drawing in" exercises were assessed under two further conditions: a) wearing Tubigrip, b) taping across the diastasis. Data analyses involved repeated measures ANOVA.

RESULTS

At rest the mean inter-rectus distance above and below the umbilicus was 3.5 cm (SD:1.1) and 2.6 cm (SD:1.2) respectively. A significant decrease (19%, p < 0.05) was observed at both measurement points during the curl-up exercise. No other exercises elicited a significant difference compared to resting. At rest, wearing Tubigrip reduced the inter-rectus distance (7%, p < 0.05). During exercise, there was no additional change in the inter-rectus distance (p > 0.05) with supports.

CONCLUSION

The curl-up exercise was most effective in reducing inter-rectus distance. As no exercises invoked an increase in the rectus diastasis, they could not be regarded as potentially detrimental. Tubigrip and taping did not add to the effects of these exercises.

Effects of worn and new footwear on plantar pressure in people with gout

Background

In clinical trials, good quality athletic shoes offer short-term improvements (two-months) in foot pain and disability in people with gout, but these improvements are not sustained over time. This may be due to wear and subsequent changes to the structural integrity of the shoe. The aim of this study was to examine the effects of wear on plantar pressures and footwear characteristics in shoes over six-months in people with gout.

Methods

Forty people with gout participated in a cross-sectional repeated measures study. Participants wore a pair of commercially available athletic footwear for six-months. Participants then attended a study visit where the worn footwear was compared with a new pair of the same model and size of footwear. Wear characteristics (upper, midsole, outsole) and plantar pressure were measured in the two footwear conditions. Wear characteristics were analysed using paired t-tests and Fisher’s exact tests. Plantar pressure data were analysed using linear mixed models.

Results

Increases in medial midsole (P < 0.001), lateral midsole (P < 0.001) and heel midsole (P < 0.001) hardness were observed in the worn shoes. Normal upper wear patterns (P < 0.001) and outsole wear patterns (P < 0.001) were observed in most of the worn shoes. No differences in peak plantar pressures (P < 0.007) were observed between the two footwear conditions. Reduced pressure time integrals at the first metatarsophalangeal joint (P < 0.001), second metatarsophalangeal joint (P < 0.001) and hallux (P = 0.003) were seen in the worn shoes.

Conclusions

The study found signs of wear were observed at the upper, midsole and outsole in the worn footwear after six-months. These changes to the structural properties of the footwear may affect forefoot loading patterns in people with gout.

Impaired Regulation of Submaximal Force after ACL Reconstruction: Role of Muscle Spindles

Ongoing motor deficits are routinely present following anterior cruciate ligament (ACL) reconstruction, including the ability to regulate muscle force. While such deficits are known, it is unclear why this occurs. The goal of the current study was to investigate the potential influence of muscle spindle input on submaximal force regulation and muscle activity at the knee in people following ACL reconstruction. Fourteen participants (8 female) who were 6-24 months post-ACL reconstruction and 15 control participants (8 female) undertook submaximal force matching and force modulation tasks before and after 20 min of vibration applied to the patella tendon. Across all tasks, the ACL reconstruction participants were poorer at force matching (P=0.007). The effect of vibration was not significant in either group for the force matching tasks (P=0.06), although there was a reduction in maximum voluntary contraction post-vibration in the control group (P<0.001). The ACL reconstruction group also showed evidence of greater activation of the medial hamstring muscles in comparison to controls (P=0.04). Individuals who have undergone ACL reconstruction have a diminished ability to accurately match and regulate submaximal muscle force, but this does not appear to be related to impaired muscle spindle input. Neuromuscular retraining programs that involve force regulation tasks may be necessary to optimize rehabilitation after ACL reconstruction.

Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis

Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective than the best-established pharmacological interventions. In this article, we describe the presentation of OA pain and give an overview of its peripheral and central mechanisms. We then provide a state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise, weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising directions for clinical practice, including novel education strategies to target unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions, and innovative, brain-directed treatments. Finally, we discuss potential future research in areas, such as treatment adherence and personalized rehabilitation for OA pain.

Alignment with Indices of A Care Pathway Is Associated with Improved Survival: An Observational Population-based Study in Colon Cancer Patients

BACKGROUND

Causes of variations in outcomes from cancer care in developed countries are often unclear. Australia has developed health system pathways describing consensus standards of optimal cancer care across the phases of prevention through to follow-up or end-of-life. These Optimal Care Pathways (OCP) were introduced from 2013 to 14. We investigated whether care consistent with the OCP improved outcomes for colon cancer patients.

METHODS

Colon patients diagnosed from 2008 to 2014 were identified from the Australian State of Victoria Cancer Registry (VCR) and cases linked with State and Federal health datasets. Surrogate variables describe OCP alignment in our cohort, across three phases of the pathway; prevention, diagnosis and initial treatment and end-of-life. We assessed the impact of alignment on (1) stage of disease at diagnosis and (2) overall survival.

FINDINGS

Alignment with the prevention phase of the OCP occurred for 88% of 13,539 individuals and was associated with lower disease stage at diagnosis (OR = 0.33, 95% confidence interval 0.24 to 0.42), improved crude three-year survival (69.2% versus 62.2%; p < 0.001) and reduced likelihood of emergency surgery (17.7% versus 25.6%, p < 0.001). For patients treated first with surgery (n = 10,807), care aligned with the diagnostic and treatment phase indicators (44% of patients) was associated with a survival benefit (risk-adjusted HR_{non-aligned vs aligned} = 1.23, 95% confidence interval 1.13 to 1.35), better perioperative outcomes and higher alignment with follow-up and end-of-life care. The survival benefit persists adjusting for potential confounding factors, including age, sex, disease stage and comorbidity.Interpretation.This population-based study shows that care aligned to a pathway based on best principles of cancer care is associated with improved outcomes for patients with colon cancer.

FUNDING

None.

The footwear experiences of people with gout: a qualitative study

Background

Footwear is an important concern for people with gout, who often describe difficulty finding suitable footwear. Previous studies have identified footwear as a major concern for people with gout. The aim of this study was to carry out an exploration of the footwear experiences of people with gout.

Methods

A qualitative descriptive methodological approach was used for both data collection and analysis. A purposive sampling strategy was adopted with semi-structured interviews conducted, involving 11 participants with gout. Thematic analysis was employed to identify key meanings and patterns within the data.

Results

Four key themes derived from interviews included; (1) comfort as a priority, (2) knowing what to buy, (3) knowing what to wear, and (4) challenges of different environments. Footwear comfort was of great importance and linked to characteristics of footwear, with uncomfortable footwear negatively influencing participation in daily activities. The balancing of comfort, appearance and cost, led to less options and reduced confidence when shoe shopping. Footwear use was further limited by the presence of foot tophi and flares, resulting in compromise of footwear choice. Environments such as formal settings and the workplace, led to different footwear requirements.

Conclusion

People with gout experience problems with footwear which can impact many aspects of life. Health care professionals should consider these footwear-related issues to help facilitate those with gout in finding appropriate footwear.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0349-7) contains supplementary material, which is available to authorized users.

Effects of a footwear intervention on foot pain and disability in people with gout: a randomised controlled trial

BACKGROUND

There is limited evidence supporting the long-term effect of a foot care package that includes footwear for people with gout. The aim of this study was to investigate the effectiveness of a footwear intervention on foot pain and disability in people with gout over 6 months.

METHODS

Participants with gout (n = 94) were randomly allocated to either a control group (podiatric care and gout education) or footwear intervention group (podiatric care and gout education plus a commercially available athletic shoe). Measurements were undertaken at baseline and 2, 4, and 6 months. Primary outcome was foot pain severity. Secondary outcomes were overall pain, foot impairment/disability, footwear comfort, fit, ease and weight. Data were analysed using repeated measures models.

RESULTS

Baseline foot pain scores were low, and no differences in foot pain scores were observed between groups over 6 months (adjusted effect estimate: - 6.7, 95% CI - 16.4 to 2.9, P = 0.17). Improvements between groups in overall pain scores (adjusted effect estimate: - 13.2, 95% CI - 22.2 to - 4.3, P < 0.01) and foot impairment/disability scores (- 4.7, 95% CI - 9.1 to - 0.3, P = 0.04) favouring the footwear intervention were observed at 2 months, but not at 4 or 6 months. Improvements between groups in footwear fit (adjusted effect estimate: - 11.1, 95% CI - 21.1 to - 1.0, P = 0.03), ease (- 13.2, 95% CI - 23.8 to - 2.7, P = 0.01) and weight (- 10.3, 95% CI - 19.8 to - 0.8, P = 0.03) favouring the footwear intervention were also observed over 6 months. Similar improvements were observed for footwear comfort at 2 and 4 months. No other differences in secondary outcomes measured were observed at 6 months (P > 0.05).

CONCLUSIONS

Addition of footwear to a foot care package did not improve foot pain in people with gout. Short-term improvements in overall pain and foot impairment/disability and more durable improvements in footwear comfort and fit were observed with the footwear intervention.

TRIAL REGISTRATION

ACTRN12614000209695. Registered 27 February 2014, http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12614000209695&isBasic=True.

The potential role of sciatic nerve stiffness in the limitation of maximal ankle range of motion

It is a long held belief that maximal joint range of motion (ROM) is restricted by muscle tension. However, it exists indirect evidence suggesting that this assumption may not hold true for some joint configurations where non-muscular structures, such as the peripheral nerves, are stretched. Direct evidences are lacking. This study aimed to determine whether a static stretching aiming to load the sciatic nerve without stretch within plantar flexors is effective to: (i) alter nerve stiffness; and (ii) increase the ankle’s maximal ROM. Passive maximal ankle ROM in dorsiflexion was assessed with the hip flexed at 90° (HIP-flexed) or neutral (HIP-neutral, 0°). Sciatic nerve stiffness was estimated using shear wave elastography. Sciatic nerve stretching induced both a 13.3 ± 7.9% (P < 0.001) decrease in the nerve stiffness and a 6.4 ± 2.6° increase in the maximal dorsiflexion ROM assessed in HIP-flexed. In addition, the decrease in sciatic nerve stiffness was significantly correlated with the change in maximal ROM in dorsiflexion (r = −0.571, P = 0.026). These effects occurred in the absence of any change in gastrocnemius medialis and biceps femoris stiffness, and ankle passive torque. These results demonstrate that maximal dorsiflexion ROM can be acutely increased by stretching the sciatic nerve, without altering the muscle stiffness.

Footwear interventions for foot pain, function, impairment and disability for people with foot and ankle arthritis: A literature review

OBJECTIVE

To conduct a literature review on the effectiveness of footwear on foot pain, function, impairment and disability for people with foot and ankle arthritis.

METHODS

A search of the electronic databases Scopus, Medline, CINAHL, SportDiscus and the Cochrane Library was undertaken in September 2017. The key inclusion criteria were studies reporting on findings of footwear interventions for people with arthritis with foot pain, function, impairment and/or disability. The Quality Index Tool was used to assess the methodological quality of studies included in the qualitative synthesis. The methodological variation of the included studies was assessed to determine the suitability of meta-analysis and the grading of recommendations, assessment, development and evaluation (GRADE) system. Between and within group effect sizes were calculated using Cohen's d.

RESULTS

1440 studies were identified for screening with 11 studies included in the review. Mean (range) quality scores were 67% (39-96%). The majority of studies investigated rheumatoid arthritis (n = 7), but also included gout (n = 2), and 1st metatarsophalangeal joint osteoarthritis (n = 2). Meta-analysis and GRADE assessment were not deemed appropriated based on methodological variation. Footwear interventions included off-the-shelf footwear, therapeutic footwear and therapeutic footwear with foot orthoses. Key footwear characteristics included cushioning and a wide toe box for rheumatoid arthritis; cushioning, midsole stability and a rocker-sole for gout; and a rocker-sole for 1st metatarsophalangeal joint osteoarthritis. Between group effect sizes for outcomes ranged from 0.01 to 1.26. Footwear interventions were associated with reductions in foot pain, impairment and disability for people with rheumatoid arthritis. Between group differences were more likely to be observed in studies with shorter follow-up periods in people with rheumatoid arthritis (12 weeks). Footwear interventions improved foot pain, function and disability in people with gout and foot pain and function in 1st metatarsophalangeal joint osteoarthritis. Footwear interventions were associated with changes to plantar pressure in people with rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and walking velocity in people with rheumatoid arthritis and gout.

CONCLUSION

Footwear interventions are associated with reductions in foot pain, impairment and disability in people with rheumatoid arthritis, improvements to foot pain, function and disability in people with gout and improvements to foot pain and function in people with 1st metatarsophalangeal joint osteoarthritis. Footwear interventions have been shown to reduce plantar pressure rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and improve walking velocity in rheumatoid arthritis and gout.

Exploring symptoms of somatization in chronic widespread pain: latent class analysis and the role of personality

Chronic widespread musculoskeletal pain (CWP) is a condition manifesting varied co-symptomatology and considerable heterogeneity in symptom profiles. This poses an obstacle for disease definition and effective treatment. Latent class analysis (LCA) provides an opportunity to find subtypes of cases in multivariate data. In this study, LCA was used to investigate whether and how individuals with CWP could be classified according to 12 additional somatic symptoms (migraine headaches, insomnia, stiffness, etc.). In a second step, the role of psychological and coping factors for the severity of these co-symptoms was investigated. Data were available for a total of N = 3,057 individuals (mean age = 56.6 years), with 15.4% suffering from CWP. In the latter group, LCA resulted in a three-class solution (n_group1 = 123; n_group2 = 306; n_group3 = 43) with groups differing in a graded fashion (i.e., severity) rather than qualitatively for somatic co-symptom endorsements. A consistent picture emerged, with individuals in the first group reporting the lowest scores and individuals in group 3 reporting the highest. Additionally, more co-symptomatology was associated with higher rates of anxiety sensitivity and depression, as well as more extraversion and emotional instability. No group differences for any of the coping strategies could be identified. The findings suggest that CWP has several detectable subtypes with distinct psychological correlates. The identification of CWP subgroups is important for understanding disease mechanisms and refining prognosis as well as stratifying patients in clinical trials and targeting specific treatment at the subgroups most likely to respond.

Mass Effect and Atrophy after Stroke

Cerebral edema, resolution of edema, and subsequent development of cerebral atrophy were studied prospectively in 83 patients with ischemic stroke with CT 3 days, 2 weeks, and 6 months post-stroke. Nineteen patients had large (diameter > 3 cm), 25 medium sized (diameter ≥ 1.5 ≤ 3 cm), and 15 lacunar infarcts (diameter < 1.5 cm). In 24 patients no infarcts were seen. Changes of Evans' ratio (ER), septum-caudate distance (S/C), and width of widest cortical sulci (SuW) were taken as markers of mass effect/atrophy. These parameters were within normal limits in most cases. However, when all CT scans performed in each patient were compared, changes of ER, S/C, and SuW became apparent as evidence of mass effect and subsequent atrophy development. Mass effect occurred in 81 percent and atrophy in 58 percent of patients with large infarcts. In patients with medium sized infarcts, mass effect occurred in 38 percent and atrophy in 45 percent.

Shoulder pain in primary care--part 2: predictors of clinical outcome to 12 months

OBJECTIVE

Identify predictor variables and models for clinical outcomes for primary care shoulder pain patients to 12 months follow-up.

DESIGN

A non-randomized audit with measures of pain and disability at 3 weeks, 3, 6 and 12 months.

PATIENTS

Of 208 patients, 161 agreed to participate with 96.9, 98.1, 87.0 and 83.9% follow-up at 3 weeks, 3, 6 and 12 months respectively. Treatment consisted of exercise and manual therapy-based physiotherapy and corticosteroid injection under specified selection criteria.

METHODS

Potentially useful baseline variables were evaluated in univariate logistic regressions with the dependent variables determined by SPADI Questionnaire at 3 weeks, 3, 6 and 12 months. Variables associated (p-value ≤ 0.2) were retained for potential inclusion within multiple logistic regression analyses.

RESULTS

Pain not improved by rest, intermittent pain, lower pain intensity with physical tests and absence of subacromial bursa pathology on ultrasound at the 3-week follow-up, constant pain and lower pain intensity with physical tests are predictors of excellent outcomes at the 3-month follow- up. Worse baseline pain and disability, no history of asthma, pain better with rest, better physical functioning, greater fear avoidance, male gender, no history of pain in the opposite shoulder, pain referred below the elbow, sleep disturbed by pain, smaller waist circumference, lower pain intensity with physical tests are factors predictive of excellent outcomes at the 12-month follow-up. Only higher pain intensity with physical tests was associated with a poor clinical outcome.

CONCLUSION

Predictive models for clinical outcomes in primary-care patients with shoulder pain were achieved for excellent clinical outcomes, successfully classifying 70-90% of cases.

Fast detection & modelling of the real osteoarthritic holes in the human knee with contour interpolated radial basis functions

In this article, we propose a novel method for the fast 3D reconstruction of real osteoarthritic (OA) holes in a human femoral cartilage. Initially, semi-automated Region-Based Segmentation (region-growing) and Bounding Box techniques are used to extract femoral cartilage slices from MRI scans of the knee. OA holes were detected and filled automatically by our contour interpolation/RBF (CI-RBF) method and 3D models of both the femoral cartilage and OA holes were reconstructed separately. The method was then applied to a single human knee and results proved it fast, reliable and accurate for reconstructing a 3D model of the femoral cartilage from MRI images with an extremely low root mean square error of 1.67% in the estimated volume of the automatically filled to the manually filled femoral cartilage slices. As per authors' knowledge this is the first time real OA hole has automatically been identified and filled.

Do patients undergoing physical testing report pain intensity reliably?

OBJECTIVE

To determine the reliability of patient reports of pain intensity during the application of physical tests.

METHODS

A single examiner required participants to use the numeric pain rating scale (NPRS) to report the intensity of pain provoked during physical testing of the hip. Standardized versions of 14 physical tests were used on 18 people with hip pain. Tests were repeated at 1 hour and 2-7 days later. Within- and between-session reliability of reports of pain intensity was calculated using intraclass correlation coefficients (ICCs) and Lin's concordance correlation coefficients (CCCs). Standard errors of measurement (SEMs) were calculated.

RESULTS

ICC/CCC values for within-session reports of pain intensity ranged from 0.34 (95% confidence interval [95% CI] -0.08, 0.66) to 0.88 (95% CI 0.73, 0.95). Patients demonstrated "substantial" or "almost perfect" reliability in reporting pain intensity with 9 of 14 tests and "moderate" reliability with 3 tests. Two tests were unreliable (ICC 0.35 and 0.34). ICC/CCC values for between-session reports of pain intensity ranged from -0.05 (95% CI -0.42, 0.34) to 0.84 (95% CI 0.44, 0.95). Patients demonstrated substantial or almost perfect reliability in reporting pain intensity with 11 of 14 tests. Two tests were unreliable (ICC 0.26 and -0.05). The average SEM value of 0.9 points on the NPRS was the same for both within- and between-session testing (range 0.6-1.6).

CONCLUSION

Patient reports of the intensity of pain provoked by physical tests are sufficiently reliable to be clinically useful. However, the SEM of 0.9 points should be considered when precise calculations of changes in pain intensity are important.

The effect of good and poor walking shoe characteristics on plantar pressure and gait in people with gout

BACKGROUND

Previous research has shown that good footwear characteristics may reduce foot pain and foot-related disability in people with gout. The aim of this study was to determine the effect of good and poor footwear characteristics on plantar pressure and spatiotemporal parameters of gait in people with gout.

METHODS

Thirty-six people with gout participated in a cross-sectional repeated measures study. Plantar pressure and spatiotemporal parameters were recorded in two shoe conditions: (1) the participants own footwear, and (2) either a new pair of walking shoes with good footwear characteristics (n=21) or poor characteristics (n=15). Differences between good and poor shoe groups compared to participants own shoes were also determined.

FINDINGS

Compared to participant's own shoes, footwear with good characteristics significantly reduced peak pressure at metatarsal 3 and 5, reduced pressure time integrals beneath the heel and metatarsals 3 and 5 and increased pressure time integrals beneath the midfoot. The footwear with poor characteristics significantly increased peak pressure beneath the heel and lesser toes, reduced peak pressure at metatarsal 3 and reduced pressure time integrals in the midfoot compared to participants own shoes. Both good and poor footwear significantly increased walking velocity, step length, and stride length compared to participants own shoes.

INTERPRETATION

Walking shoes with good footwear characteristics can influence plantar pressure values and encourage a more efficient heel to toe gait pattern in people with gout. These changes may contribute to the reduction in foot pain and foot-related problems in this population.

From adverse drug event detection to prevention. A novel clinical decision support framework for medication safety

BACKGROUND

Errors related to medication seriously affect patient safety and the quality of healthcare. It has been widely argued that various types of such errors may be prevented by introducing Clinical Decision Support Systems (CDSSs) at the point of care.

OBJECTIVES

Although significant research has been conducted in the field, still medication safety is a crucial issue, while few research outcomes are mature enough to be considered for use in actual clinical settings. In this paper, we present a clinical decision support framework targeting medication safety with major focus on adverse drug event (ADE) prevention.

METHODS

The novelty of the framework lies in its design that approaches the problem holistically, i.e., starting from knowledge discovery to provide reliable numbers about ADEs per hospital or medical unit to describe their consequences and probable causes, and next employing the acquired knowledge for decision support services development and deployment. Major design features of the framework's services are: a) their adaptation to the context of care (i.e. patient characteristics, place of care, and significance of ADEs), and b) their straightforward integration in the healthcare information technologies (IT) infrastructure thanks to the adoption of a service-oriented architecture (SOA) and relevant standards.

RESULTS

Our results illustrate the successful interoperability of the framework with two commercially available IT products, i.e., a Computerized Physician Order Entry (CPOE) and an Electronic Health Record (EHR) system, respectively, along with a Web prototype that is independent of existing healthcare IT products. The conducted clinical validation with domain experts and test cases illustrates that the impact of the framework is expected to be major, with respect to patient safety, and towards introducing the CDSS functionality in practical use.

CONCLUSIONS

This study illustrates an important potential for the applicability of the presented framework in delivering contextualized decision support services at the point of care and for making a substantial contribution towards ADE prevention. Nonetheless, further research is required in order to quantitatively and thoroughly assess its impact in medication safety.

Weight-Bearing in the Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Randomized Controlled Trial

BACKGROUND

The rate of Achilles tendon ruptures is increasing, but there is a lack of consensus on treatment of acute injuries. The purpose of this trial was to compare outcomes of weight-bearing casts with those of traditional casts in the treatment of acute Achilles tendon ruptures.

METHODS

Eighty-four patients with an acute Achilles tendon rupture were recruited over a two-year period. Patients were randomized to be treated with either a weight-bearing cast with a Böhler iron or a non-weight-bearing cast for eight weeks. Patients underwent muscle dynamometry testing at six months, with additional follow-up at one and two years. The primary outcomes that were assessed were the rerupture rate and the time taken to return to work. Secondary outcomes included return to sports, ankle pain and stiffness, footwear restrictions, and patient satisfaction.

RESULTS

There were no significant differences between groups with regard to patient demographics or activity levels prior to treatment. At the time of follow-up at two years, one (3%) of the thirty-seven patients in the weight-bearing group and two (5%) of the thirty-seven in the non-weight-bearing group had sustained a rerupture (p = 0.62). The patients in the weight-bearing group experienced less subjective stiffness at one year. There were no significant differences in time taken to return to work, Leppilahti scores, patient satisfaction, pain, or return to sports between the groups.

CONCLUSIONS

Use of weight-bearing casts for the nonoperative treatment of Achilles tendon ruptures appears to offer outcomes that are at least equivalent to those of non-weight-bearing casts. The overall rerupture rate in this study was low, supporting the continued use of initial nonoperative management for the treatment of acute Achilles tendon ruptures.

LEVELS OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care

OBJECTIVES

Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort.

METHODS

Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated.

RESULTS

A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86-1.00; negative likelihood ratio: 0.00, 95% CI: 0.00-0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86-0.95; positive likelihood ratio 4.66, 95% CI: 2.34-8.74).

DISCUSSION

Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation.

Fast identification & modelling of osteoarthritic holes in the human knee with contour interpolated radial basis functions

In this article, we propose a new method for the fast 3D reconstruction of simulated osteoarthritic holes in a human patella. Initially, clean patella slices were extracted from MRI scans of the knee using Region-Based Segmentation (region-growing) and Bounding Box techniques. Osteoarthritic (OA) holes were then simulated in the patella slices. Our contour interpolation/RBF (CI/RBF) method was then used to detect the hole automatically and reconstruct 3D models of both the patella and OA hole separately. The method presented here proves fast, reliable and efficient for reconstructing a 3D model of the patella from MRI images with an extremely low error of 0.33%.

The effects of commercially available footwear on foot pain and disability in people with gout: a pilot study

Background

There is limited evidence on non-pharmacological interventions for gout. The aim of the study was to determine whether a footwear intervention can reduce foot pain and musculoskeletal disability in people with gout.

Methods

Thirty-six people with gout participated in a prospective intervention study over 8 weeks. Participants selected one of 4 pairs of shoes and thereafter wore the shoes for 8 weeks. The primary outcome was foot pain using a 100 mm visual analogue scale. Secondary outcomes related to function and disability were also analysed.

Results

The Cardio Zip shoe was selected by 58% of participants. Compared with baseline, overall scores for all shoes at 8-weeks demonstrated a decrease in foot pain (p = 0.03), general pain (p = 0.012), Health Assessment Questionnaire (HAQ)-II (p = 0.016) and Leeds Foot Impact Scale (LFIS) impairment subscale (p = 0.03). No significant differences were observed in other patient reported outcomes including patient global assessment, LFIS activity subscale, and Lower Limb Task Questionnaire subscales (all p > 0.10). We observed significant improvements between baseline measurements using the participants’ own shoes and the Cardio Zip for foot pain (p = 0.002), general pain (p = 0.001), HAQ-II (p = 0.002) and LFIS impairment subscale (p = 0.004) after 8 weeks. The other three shoes did not improve pain or disability.

Conclusions

Footwear with good cushioning, and motion control may reduce foot pain and disability in people with gout.

Biomechanical properties of the plantar flexor muscle-tendon complex 6 months post-rupture of the Achilles tendon

We compared the effects of a non-weight bearing protocol (NWB) and a weight bearing (WB) protocol on energy stored, stiffness, and shock absorption in the plantar flexor muscle-tendon unit of patients managed non-operatively following an Achilles tendon rupture. Thirty-eight subjects were randomized to a WB cast fitted with a Bohler iron or a traditional non-weight-bearing cast. At a 6-month follow-up, a biomechanical assessment utilizing an isokinetic dynamometer allowed measurement of peak passive torque, energy stored, shock absorption, and stiffness. The WB group had greater peak passive torque (≈ 20%). Irrespective of group, peak passive torque in unaffected legs was greater (≈ 26%) than affected legs. Across the groups, energy stored in the NWB group was 74% of the WB group. The energy stored in affected legs was 80% of that in unaffected legs. Shock absorption was not significantly different across legs or groups. Irrespective of group, affected legs had significantly less stiffness (20-40%). While the augmentation of plaster with a Bohler iron to allow increased weight bearing had positive effects, deficits in affected compared to unaffected legs irrespective of group were notable, and should be addressed prior to participation in vigorous physical activities.

Levels of evidence in medicine

Levels of evidence allow clinicians to appreciate the quality of a particular research paper quickly. The levels are generally set out in a hierarchical order, which is based largely upon the experimental design. While there are ideal designs for studies examining the effects of interventions, risk factors for a clinical condition or diagnostic testing, in most instances researchers have had to make compromises and these subsequently decrease the quality of their work. This paper provides information concerning how those compromises relate to subsequent levels that are given to a piece of research. It also provides an understanding of issues related to evaluating papers, and suggest ways in which the reader might discern how relevant a paper might be to one's clinical practice.

Comparing the lower limb tasks questionnaire to the Western Ontario and McMaster Universities Osteoarthritis Index: agreement, responsiveness, and convergence with physical performance for knee osteoarthritis patients

OBJECTIVE

To compare the Lower Limb Tasks Questionnaire (LLTQ) with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in terms of agreement, responsiveness, and convergence.

DESIGN

Cross-sectional with an exploratory repeated-measures subsample analysis.

SETTING

Community-based seniors' centers and arthritis clinics.

PARTICIPANTS

Individuals with symptomatic knee osteoarthritis (N=76) participated, with a subsample of 18 participants contributing to the pre- and postarthroplasty subanalysis.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Bland and Altman plots of agreement with 95% limits of agreement, statistical responsiveness, and standardized response mean (SRM) were calculated for LLTQ and WOMAC subscales. Both t tests and Wilcoxon rank-sum tests were used to examine changes in pre- and postarthroplasty self-reported function, 50-ft walk speed, stair ascent/descent speed, and isometric quadriceps strength.

RESULTS

The agreement (bias) of the LLTQ activities of daily living (ADL) subscale when compared with the WOMAC physical function (PF) subscale was 1%±10% (mean ± SD), and the 95% limits of agreement were -19% to +22%. The statistical responsiveness of the WOMAC-PF and LLTQ ADL was 1.17 and -.63, respectively. The SRMs for these scales were .90 and -.61, respectively. The WOMAC-PF scores showed a notable improvement over the first 6 weeks postarthroplasty, while LLTQ ADL scores were unchanged. The objective measures of function were all significantly worse at 6 weeks.

CONCLUSIONS

The LLTQ demonstrated adequate agreement with the WOMAC and acceptable responsiveness for use in place of the WOMAC in nonspecialized clinics. The LLTQ may more accurately represent functional status after total knee arthroplasty, but further study in larger samples is recommended.

Functional and biomechanical characteristics of foot disease in chronic gout: A case-control study

OBJECTIVES

despite the predilection of gout to the feet, the impact of gout on foot function and biomechanics is currently unknown. The aim of this study was to describe the effects of chronic gout upon function and selected biomechanical parameters associated with gait.

METHODS

twenty-five patients with a history of gout were compared with 25 age and gender matched control participants with no history of gout or other forms of arthritis. General function, foot specific disease activity and lower limb activities were determined using the Health Assessment Questionnaire, Foot Function Index (pain domain), and Leeds Foot Impact Scale respectively. Each patient also underwent a gait assessment that included plantar pressure measurements and an evaluation of temporal-spatial gait parameters.

FINDINGS

patients with chronic gout had higher levels of general and foot-specific disability, pain and impairment (P ≤0.001). Significantly lower peak plantar pressures were observed in the hallux of patients with chronic gout (P ≤0.05). Significantly higher pressure-time integrals were observed in the cases at the midfoot (P ≤0.05), but lower values were observed at the hallux (P ≤0.05). Patients with chronic gout walked slower, with longer step and stride lengths compared to the controls.

INTERPRETATION

patients with chronic gout experience pain and disability associated with their feet. Different toe-off strategies may account for functional changes and pain associated with foot problems in chronic gout.

Active stiffness and strength in people with unilateral anterior shoulder instability: a bilateral comparison

CONTEXT

Active muscle stiffness might protect the unstable shoulder from recurrent dislocation.

OBJECTIVE

To compare strength and active stiffness in participants with unilateral anterior shoulder instability and to examine the relationship between active stiffness and functional ability.

DESIGN

Cross-sectional study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Participants included 16 males (age range, 16-40 years; height = 179.4 ± 6.1 cm; mass = 79.1 ± 6.8 kg) with 2 or more episodes of unilateral traumatic anterior shoulder instability.

MAIN OUTCOME MEASURE(S)

Active stiffness and maximal voluntary strength were measured bilaterally in participants. In addition, quality of life, function, and perceived instability were measured using the Western Ontario Stability Index, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, and Single Alpha Numeric Evaluation, respectively.

RESULTS

We found less horizontal adduction strength (t(15) = -4.092, P = .001) and less stiffness at 30% (t(14) = -3.796, P = .002) and 50% (t(12) = -2.341, P = .04) maximal voluntary strength in the unstable than stable shoulder. Active stiffness was not correlated with quality of life, function, or perceived instability (r range, 0.0-0.25; P > .05).

CONCLUSIONS

The observed reduction in stiffness in the unstable shoulder warrants inclusion of exercises in the rehabilitation program to protect the joint from perturbations that might lead to dislocation. The lack of association between active stiffness and quality of life, function, or perceived instability might indicate that stiffness plays a less direct role in shoulder stability.

Constructing Clinical Decision Support Systems for Adverse Drug Event Prevention: A Knowledge-based Approach

A knowledge-based approach is proposed that is employed for the construction of a framework suitable for the management and effective use of knowledge on Adverse Drug Event (ADE) prevention. The framework has as its core part a Knowledge Base (KB) comprised of rule-based knowledge sources, that is accompanied by the necessary inference and query mechanisms to provide healthcare professionals and patients with decision support services in clinical practice, in terms of alerts and recommendations on preventable ADEs. The relevant Knowledge Based System (KBS) is developed in the context of the EU-funded research project PSIP (Patient Safety through Intelligent Procedures in Medication). In the current paper, we present the foundations of the framework, its knowledge model and KB structure, as well as recent progress as regards the population of the KB, the implementation of the KBS, and results on the KBS verification in decision support operation.

Practical clinical value of the C-peptide response to glucagon stimulation in the choice of treatment in diabetes mellitus

In order to discriminate between insulin-dependent and non-insulin-dependent patients, serum C-peptide concentration was determined using antiserum M1230 in the fasting state and 6 min after an i.v. injection of 1 mg glucagon in 215 patients treated with insulin and 53 treated with diet and oral antidiabetics. A patient was considered well controlled without insulin when fasting blood glucose was below 8 mmol/l and when glucosuria was absent. After re-evaluation of therapy in hospital it was found that the majority of patients with a post-stimulatory serum C-peptide concentration above 0.60 pmol/ml appeared to have non-insulin-dependent diabetes mellitus. When fasting C-peptide was used, a great overlap was found between the two treatment groups. During evaluation of therapy in hospital, 6 previously insulin-treated patients could be well treated with diet and tablets and 6 diet- and tablet-treated patients required insulin. The glucagon test seems to be of value in the outpatient clinic to discriminate non-insulin-dependent from insulin-dependent patients.