Acute effects of an isometric neck warm-up programme on neck performance characteristics and ultrasound-based morphology

OBJECTIVE

Athletic performance can be enhanced immediately after an isometric warm-up, a phenomenon termed post-activation performance enhancement (PAPE). While isometric warm-ups can improve lower extremity sprint and jump performance, neck-specific isometric warm-ups need development and validation for mild traumatic brain disorders and neck pain. This study examined acute effects of isometric warm-ups on neck performance and morphology.

METHODS

Arm 1: Twenty-six adults (13 M:13F) completed neck performance testing before and after a 10-minute neck isometric warm-up or stationary bike (sham) between two visits. Testing included visual-motor reaction time, peak force, rate of force development, force steadiness, and force replication/proprioception measured by a 6-axis load cell. An inclinometer assessed range-of-motion. Paired t-tests and two-way ANOVA examined effects of neck/bike warm-up and interaction effects, respectively. Arm 2: 24 adults (11 M:13F) completed ultrasound scans of cervical muscles: before 20-minute rest (sham), and before/after a 5-min neck isometric warm-up. Longus colli cross-sectional area and sternocleidomastoid/upper trapezius thickness and stiffness, and cervical extensors thickness was assessed. One-way ANOVA compared morphological values at sham, before, and after warm-up. Significance was set at p < 0.05.

RESULTS

Isometric neck warm-up increased rate of force development in flexion (p = 0.022), extension (p = 0.001-0.003), right lateral flexion (p = 0.004-0.032), left lateral flexion (p = 0.005-0.014), while peak force improved only in left lateral flexion (p = 0.032). Lateral flexion range-of-motion increased after neck warm-up (p = 0.003-0.026). Similarly, longus colli cross-sectional area (p = 0.016) and sternocleidomastoid thickness (p = 0.004) increased.

CONCLUSIONS

Increased neck performance characteristics and morphology are likely due to PAPE effects of isometric neck warm-up. For coaches and athletes, simple isometric contractions could be added to existing warm-ups to reduce prevalence, incidence, and severity of mild traumatic brain injuries and neck pain.

Fatigue, patient reported outcomes, and objective measurement of physical activity in systemic lupus erythematosus

OBJECTIVE

Fatigue is a common symptom in systemic lupus erythematosus (SLE), and engaging in physical activity may reduce fatigue. We aimed to characterize relationships between fatigue, other health status measures assessed with the Patient Reported Outcomes Measurement Information System (PROMIS) instruments, and accelerometer-based physical activity measurements in patients with SLE. The internal consistency of each PROMIS measure in our SLE sample was also evaluated.

METHODS

This cross-sectional study analyzed 123 adults with SLE. The primary fatigue outcome was Fatigue Severity Scale score. Secondary outcomes were PROMIS standardized T-scores in seven health status domains. Accelerometers were worn for seven days, and mean daily minutes of light, moderate/vigorous, and bouted (10 minutes) moderate/vigorous physical activity were estimated. Cronbach's alpha was determined for each PROMIS measure to assess internal consistency. Relationships between Fatigue Severity Scale, PROMIS, and physical activity were summarized with Spearman partial correlation coefficients (r), adjusted for average daily accelerometer wear time.

RESULTS

Mean Fatigue Severity Scale score (4.3, SD 1.6) was consistent with clinically relevant levels of fatigue. Greater daily and bouted moderate/vigorous physical activity minutes correlated with lower Mean Fatigue Severity Scale score (r = -0.20, p = 0.03 and r = -0.30, p = 0.0007, respectively). For PROMIS, bouted moderate/vigorous physical activity minutes correlated with less fatigue (r = -0.20, p = 0.03). PROMIS internal consistency was excellent, with Cronbach's alpha > 0.90 for each domain. Mean PROMIS T-scores for fatigue, pain interference, anxiety, sleep disturbance, sleep-related impairment, and physical function were worse than reported for the general US population. More moderate/vigorous physical activity minutes were associated with less pain interference (r = -0.22, p = 0.01). Both light physical activity and moderate/vigorous physical activity minutes correlated with better physical function (r = 0.19, p = 0.04 and r = 0.25, p = 0.006, respectively).

CONCLUSION

More time spent in moderate/vigorous physical activity was associated with less fatigue (Fatigue Severity Scale and PROMIS), less pain interference, and better physical function (PROMIS). PROMIS had excellent internal consistency in our SLE sample, and six of seven PROMIS measures indicated poorer average health status in SLE patients compared with the general US population.

Sedentary behavior and blood pressure control among osteoarthritis initiative participants

OBJECTIVE

To examine the association between sedentary behavior and blood pressure (BP) among Osteoarthritis Initiative (OAI) participants.

DESIGN

We conducted a cross-sectional analysis of the OAI 48-month visit participants whose physical activity was measured using accelerometers. Participants were classified into four quartiles according to the percentage of wear time that was sedentary (<100 activity counts per min). Users of antihypertensive medications or non-steroidal anti-inflammatory drugs (NSAIDs) were excluded. Our main outcomes were systolic and diastolic blood pressures (SBP and DBP) and "elevated BP" defined as BP ≥ 130/85 mm Hg.

RESULTS

For this study cohort (N = 707), mean BP was 121.4 ± 15.6/74.7 ± 9.5 mm Hg and 33% had elevated BP. SBP had a graded association with increased sedentary time (P for trend = 0.02). The most sedentary quartile had 4.26 mm Hg higher SBP (95% confidence interval (CI), 0.69-7.82; P = 0.02) than the least sedentary quartile, adjusting for age, moderate-to-vigorous (MV) physical activity, and other demographic and health factors. The probability of having elevated BP significantly increased in higher sedentary quartiles (P for trend = 0.046). There were no significant findings for DBP.

CONCLUSION

A strong graded association was demonstrated between sedentary behavior and increased SBP and elevated BP, independent of time spent in MV physical activity. Reducing daily sedentary time may lead to improvement in BP and reduction in cardiovascular risk.

Nutritional assessment using a microcomputer. 2. Programme evaluation

Nutritional assessment ideally should be used to determine the nutritional requirements of a patient taking into account his nutritional and metabolic status. It should also be used to monitor a patient's progress and any alteration in requirements. In addition, nutritional assessment should be able to identify groups of patients at risk from the effects of malnutrition. Finally, the parameters used for assessment should be simple, yet effective and readily available to any hospital. A computer program designed by the Nutrition Support Service, Riyadh Armed Forces Hospital, Saudi Arabia and in use for the past 2 years has been evaluated and found to fulfil these criteria.

European randomised trial of dual versus triple tacrolimus-based regimens for control of acute rejection in renal allograft recipients

Two large multicentre studies have shown superiority of tacrolimus-based immunosuppressive regimens compared with standard cyclosporine-based therapy in renal transplantation. In these studies, tacrolimus was used in a triple drug regimen of tacrolimus, corticosteroids, and azathioprine. The present study aimed to determine whether a tacrolimus-based dual regimen achieves a similar efficacy and safety profile compared with conventional triple therapy. In this prospective, open, multicentre trial, 249 patients were randomised to receive either dual therapy (n = 125) of oral tacrolimus (initial daily dose of 0.2 mg/kg) and oral prednisone or additionally, as a triple therapy (n = 124), oral azathioprine. The primary endpoint was the incidence of acute rejection at month 3. In addition, all patients were included into a follow-up evaluation at 1 year after transplantation. Both treatment groups had similar baseline characteristics. At month 3, patient survival was 97.6 % (dual) and 96.7 % (triple); graft survival was 92.7 % (dual) and 91.7 % (triple). The incidence of treated acute rejection confirmed by biopsy was 27.4 % (dual) and 24.8 % (triple); difference 2.6 %, 95 % CI [-9.4 %-12.9 %], P = 0.755. The incidence of corticosteroid-resistant rejection (biopsy-confirmed) was 9.7 % (dual) and 10.7 % (triple). The overall adverse events profile was similar; leukopenia (1.6 % vs 11.6 %, P = 0.002) was more frequent with triple therapy. Between months 4 and 12, six (dual) and eight (triple) patients had a rejection. At month 12, patient survival was 95.6 % (dual) and 93.6 % (triple); graft survival was 91.8 % (dual) and 90.7 % (triple). Tacrolimus proved to be efficacious and safe with both dual and triple low-dose regimens. The addition of azathioprine to a tacrolimus/corticosteroid-based therapy did not result in an increased efficacy.

Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model

OBJECTIVE

To develop a predictive model to triage patients for discharge from intensive care units to reduce mortality after discharge.

DESIGN

Logistic regression analyses and modelling of data from patients who were discharged from intensive care units.

SETTING

Guy's hospital intensive care unit and 19 other UK intensive care units from 1989 to 1998.

PARTICIPANTS

5475 patients for the development of the model and 8449 for validation.

MAIN OUTCOME MEASURES

Mortality after discharge and power of triage model.

RESULTS

Mortality after discharge from intensive care was up to 12.4%. The triage model identified patients at risk from death on the ward with a sensitivity of 65.5% and specificity of 87.6%, and an area under the receiver operating curve of 0.86. Variables in the model were age, end stage disease, length of stay in unit, cardiothoracic surgery, and physiology. In the validation dataset the 34% of the patients identified as at risk had a discharge mortality of 25% compared with a 4% mortality among those not at risk.

CONCLUSIONS

The discharge mortality of at risk patients may be reduced by 39% if they remain in intensive care units for another 48 hours. The discharge triage model to identify patients at risk from too early and inappropriate discharge from intensive care may help doctors to make the difficult clinical decision of whom to discharge to make room for a patient requiring urgent admission to the unit. If confirmed, this study has implications on the provision of resources.

Arthritis prevalence and activity limitations in older adults

OBJECTIVE

To evaluate the prevalence of arthritis and activity limitations among older Americans by assessing their demographic, ethnic, and economic characteristics.

METHODS

Data from the Asset and Health Dynamic Survey Among the Oldest Old (AHEAD), a national probability sample of community-dwelling adults born before 1924, were analyzed cross-sectionally. Arthritis that resulted in a physician's visit or a joint replacement not associated with a hip fracture was ascertained by self-report.

RESULTS

The prevalence of arthritis in older adults ranged from 25% in non-Hispanic whites to 40% in non-Hispanic blacks to 44% in Hispanics. A higher prevalence of arthritis was associated with less education as well as lower income and less wealth. The prevalence of limitations in activities of daily living (ADL) among non-Hispanic white, non-Hispanic black, and Hispanic adults who reported arthritis only was 29%, 30%, and 37%, respectively, and increased to 48%, 57%, and 56%, respectively, among those reporting arthritis plus other chronic conditions, after adjustment for age and sex.

CONCLUSION

Non-Hispanic black and Hispanic older adults reported having arthritis at a substantially higher frequency than did non-Hispanic whites. In addition, Hispanics reported higher rates of ADL limitations than did non-Hispanic whites with comparable disease burden. Further study is needed to confirm and elucidate the reasons for these racial and economic disparities in older populations.

A pilot study on the effects of exercise in patients with systemic lupus erythematosus

OBJECTIVE

A pilot study was designed to assess the efficacy and safety of different exercise therapies on patient-reported fatigue and functional status.

METHODS

Ten patients with systemic lupus erythematosus (SLE) were randomly placed in either an aerobic exercise group (group 1: n = 5) or a range of motion/muscle strengthening (ROM/MS) exercise group (group 2: n = 5). Outcome measures assessed at baseline and the end of the study were fatigue, functional status, disease activity, cardiovascular fitness, isometric strength, bone mineral density (BMD) of the lumbar spine and femoral neck, and parathyroid hormone and osteocalcin as representative bone biochemical markers for bone resorption and bone formation, respectively.

RESULTS

Both aerobic and ROM/MS types of exercise were safe and did not worsen SLE disease activity. Patients in both exercise groups showed some improvement in fatigue, functional status, cardiovascular fitness, and muscle strength. Both groups showed increased bone turnover, but BMD was unchanged. Eighty percent of the patients met the compliance standard for the study.

CONCLUSIONS

This pilot study shows the feasibility of exercise for SLE patients. The potential value of this approach shows promise in the routine management of these patients.

Impact of joint impairment on disability-specific domains at four years

The objective of this study was to assess the longitudinal impact of joint impairment on overall disability and crossing domain-specific thresholds for physical activity, mobility, dexterity, instrumental activities of daily living (IADL), and activities of daily living (ADL) that are associated with use of long-term care. This 4-year longitudinal study observed 484 persons older than age 60. Logistic regression assessed the contribution of demographics, psychological mediators, lower- and upper-extremity joint impairment, and comorbidities to increased domain-specific self-reported disability above a threshold associated with use of long-term care. Lower-extremity joint impairment and age predicted crossing thresholds by year 4 in physical activity, mobility, IADL, and ADL disability that were associated with use of long-term care. Lower-extremity joint impairment is a strong risk factor for future disability that is associated with use of long-term care.

Markers of glutamatergic neurotransmission and oxidative stress associated with tardive dyskinesia

OBJECTIVE

Tardive dyskinesia is a movement disorder affecting 20%-40% of patients treated chronically with neuroleptic drugs. The dopamine supersensitivity hypothesis cannot account for the time course of tardive dyskinesia or for the persistence of tardive dyskinesia and the associated structural changes after neuroleptics are discontinued. The authors hypothesized that neuroleptics enhance striatal glutamatergic neurotransmission by blocking presynaptic dopamine receptors, which causes neuronal damage as a consequence of oxidative stress.

METHOD

CSF was obtained from 20 patients with schizophrenia, 11 of whom had tardive dyskinesia. Markers for oxidative stress, including superoxide dismutase, lipid hydroperoxide, and protein carbonyl groups, and markers for excitatory neurotransmission, including N-acetylaspartate, N-acetylaspartylglutamate, aspartate, and glutamate, were measured in the CSF specimens. Patients were also rated for tardive dyskinesia symptoms with the Abnormal Involuntary Movement Scale.

RESULTS

Tardive dyskinesia patients had significantly higher concentrations of N-acetylaspartate, N-acetylaspartylglutamate, and aspartate in their CSF than patients without tardive dyskinesia when age and neuroleptic dose were controlled for. The significance of the higher levels of protein-oxidized products associated with tardive dyskinesia did not pass Bonferroni correction, however. Tardive dyskinesia symptoms correlated positively with markers of excitatory neurotransmission and protein carbonyl group and negatively with CSF superoxide dismutase activity.

CONCLUSIONS

These findings suggest that there are elevated levels of oxidative stress and glutamatergic neurotransmission in tardive dyskinesia, both of which may be relevant to the pathophysiology of tardive dyskinesia.

Effect of age and osteoarthritis on knee proprioception

OBJECTIVE

To test the hypotheses that 1) knee position sense declines with age; 2) patients with osteoarthritis (OA) have worse knee position sense than elderly controls; and 3) knee position sense is correlated with functional status.

METHODS

The threshold for detection of knee joint displacement was measured in 30 patients with bilateral knee OA (Kellgren/Lawrence grade > or =2 in both knees), 29 elderly controls (who met clinical and radiographic criteria for exclusion of OA), and 25 young controls. Range of motion, laxity, radiographic severity, and functional status were also assessed.

RESULTS

A moderate correlation was found between joint displacement detection threshold and age (r = 0.598 and r = 0.501 for the right knee and the left knee, respectively). The threshold was substantially and significantly different between the OA patients and the elderly controls. Proprioceptive impairment was associated with worse disease-specific functional status.

CONCLUSION

Proprioception declines with age, and is further impaired in elderly patients with knee OA. Poor proprioception may contribute to functional impairment in knee OA.

Predictors of decline in manual performance in older adults

OBJECTIVE

To determine factors that predict decline in manual performance using a multivariate model of determinants of functional limitation.

DESIGN

Longitudinal observational study.

SETTINGS

Ambulatory general medicine clinics, residences of homebound individuals, and a continuing care retirement community.

PARTICIPANTS

Subjects were 485 persons more than 60 years of age and included continuing care retirement community (CCRC) residents (n = 215), chronically homebound older persons (n = 65), and ambulatory older adults (n = 205). Mean age at baseline was 78 years.

MEASUREMENT

Independent variables included demographics, physician measures of upper-extremity joint impairment, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variable was 2-year decline in timed manual performance below a threshold associated with need for long-term care services.

RESULTS

The proportion of subjects who exceed a Timed Manual Performance Test threshold of 350 seconds increased slowly from baseline through Year 4 for all age groups but rose rapidly from Year 4 to Year 6 for the oldest group (> 85 years at baseline). Using a discrete survival model, we found that age, education, grip strength, and psychological status predicted crossing the manual performance threshold within a 2-year period.

CONCLUSIONS

The findings, coupled with earlier findings that upper extremity joint impairment predicted both grip strength and manual performance, suggest that joint impairment may be an important risk factor for future functional limitation. Since diminished hand function has been shown to predict dependency, development and testing of interventions to maintain or restore upper extremity joint function and reduce pain would appear to be a high research priority.

Rehabilitation advances in the treatment of arthritis and musculoskeletal disease

The current literature is reviewed related to three disease processes commonly encountered by the physiatrist, rheumatologist, and internist in clinical practice, including osteoarthritis, rheumatoid arthritis, and osteoporosis. These diseases often have effects beyond the pathology that has an impact on the individual's function and integration into society. Emphasis is on the specific rehabilitative approach to the individual.

Role of growth hormone status in the outcome of total knee replacement

The objective was to assess whether the aging related, variable decline in growth hormone influences total knee replacement outcome. In this prospective cohort study, consecutive patients who underwent unilateral total knee replacement and who met criteria were enrolled from the practice of 1 orthopaedic surgeon at a university hospital. Participants were evaluated 1 month before and 3 months after total knee replacement. Evaluators were not involved in patient care. The primary outcome measure was the Medical Outcome Study 36-item Short Form Health Survey Physical Functioning Scale score 3 months after total knee replacement. In a multiple regression analysis performed to assess the influence of growth hormone status, controlling for social support, body mass index, gender, previous reconstruction, mental health, motivation, and baseline physical functioning, only mental health contributed significantly to outcome. Mental health accounted for 18% of outcome variance. Growth hormone levels did not predict functional status after total knee replacement. Psychological status contributes significantly to total knee replacement physical functional outcome.

Ethnicity and access to care in systemic lupus erythematosus

OBJECTIVE

To define access to care and to examine the relationship between ethnicity and access to care in systemic lupus erythematosus (SLE).

METHODS

A review of published literature was supplemented with preliminary data from a pilot study. Data from patient interviews, chart reviews, and insurer surveys were collected at 2 sites and used to develop several measures of access. The relationship between ethnicity and access was examined through chi-square analyses, difference of means testing, and multivariate regression.

RESULTS

Although African-American SLE patients appear less likely to be privately insured and more likely to be uninsured, no significant differences in utilization rates were detected between ethnic groups. Uninsured patients, however, had significantly fewer physician visits than both the Medicaid and the privately insured patients. Multivariate regression confirm a strong and negative relationship between physician visits and patient coinsurance rates.

CONCLUSION

Careful examination of multiple dimensions of access may highlight differences between ethnic groups. Further research is necessary to document these differences and explore their relationships to outcomes.

Functional outcome and patient satisfaction in total knee patients over the age of 75

Seventy-four patients, age 75 or older, who had undergone 98 primary total knee arthroplasties were evaluated in a retrospective cohort study, with validated questionnaires that assessed self-reported pain, physical function, mental health, and satisfaction. Average follow-up period was 34 months (range, 12-67 months). Overall, 90.8% reported improvement, 88.8% were satisfied with the results of surgery, and 91.8% felt they had made the right decision. Dissatisfaction with the results correlated with poorer mental health scores, decreased physical function, and increased bodily pain scores (P < .05). Satisfaction was correlated with better pain scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and SF-36 (P < .05) but not with Hospital for Special Surgery scores (P = .328). Poor surgical results leading to revision surgery (5%) were associated with preoperative deformity greater than 20 degrees. Based on this patient-assessed outcome analysis, total knee arthroplasty is a worthwhile and beneficial procedure in the elderly.

Prognostic factors for functional outcome of total knee replacement: a prospective study

BACKGROUND

The objective was to investigate whether baseline physical functioning, medical, psychosocial, or demographic variables predict functional outcome in patients undergoing total knee replacement.

METHODS

A prospective cohort study was performed between December 1991 and August 1993. Consecutive, unilateral tricompartmental total knee replacement patients aged > or = 55 yr with osteoarthritis, who met criteria, were enrolled and evaluated one month before and 3 months after total knee replacement. The primary outcome measure was the Medical Outcome Study 36 Item Short Form Health Survey (known as the SF36) Physical Functioning Scale score. The outcome evaluator was not involved in patient care.

RESULTS

A hierarchical multiple regression analysis was performed to calculate the contribution of baseline variables to TKR outcome. Of the 27% of outcome variance explained by the model, demographic variables accounted for 4%, psychosocial variables (motivation, role functioning-emotional, and social functioning) for 19% (p = .013), medical variables (previous reconstruction, comorbidity, body mass index, bodily pain) for 2%, and baseline physical function for 2%.

CONCLUSIONS

Psychosocial variables are significantly related to total knee replacement functional outcome. Assessment of baseline psychological and social functioning may identify a subset of patients at risk for worse outcome. Specific interventions for these patients should be developed and evaluated as components of patient management prior to and after the procedure.

A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip

OBJECTIVE

To quantify the trade-off between the expected increased short- and long-term costs and the expected increase in quality-adjusted life expectancy (QALE) associated with total hip arthroplasty (THA) for persons with functionally significant hip osteoarthritis.

DESIGN

A cost-effectiveness study was performed from the societal perspective by constructing stochastic tree, decision analytic models designed to estimate lifetime functional outcomes and costs of THA and nonoperative managements.

MAIN OUTCOME MEASURES

A modified four-state American College of Rheumatology functional status classification was used to measure effectiveness. These functional classes were assigned utility values to allow the relative effectiveness of THA to be expressed in quality-adjusted life years (QALYs). Lifetime costs included costs associated with primary and potential revision surgeries and long-term care costs associated with the functionally dependent class. DATA USED IN THE COST-EFFECTIVENESS MODEL: Probability and incidence rate data were summarized from the literature. The THA hospital cost data were obtained from local teaching hospitals' cost accounting systems. Estimates of recurring medical costs for functionally significant hip osteoarthritis and for custodial care were derived from the literature.

RESULTS

The THA cost-effectiveness ratio increases with age and is higher for men than for women. In the base-case scenario for 60-year-old white women who have functionally significant but not dependent hip osteoarthritis, the model predicts that THA is cost saving because of the high costs of custodial care associated with dependency due to worsening hip osteoarthritis and that the procedure increases QALE by about 6.9 years. In the base-case scenario for men aged 85 years and older, the average lifetime cost associated with THA is $9100 more than nonoperative management, with an average increase in QALE of about 2 years. Thus, the THA cost-effectiveness ratio for men aged 85 years and older is $4600 per QALY gained, less than that of procedures intended to extend life such as coronary artery bypass surgery or renal dialysis. Worst-case analysis suggests that THA remains minimally cost-effective for this oldest age category ($80,000/QALY) even if probabilities, rates, utilities, costs, and the discount rate are simultaneously varied to extreme values that bias the analysis against surgery.

CONCLUSIONS

For persons with hip osteoarthritis associated with significant functional limitation, THA can be cost saving or, at worst, cost- effective in improving QALE when both short- and long-term outcomes are considered. Further research is needed to determine whether this procedure is actually being used in this cost-effective manner, especially in older age categories.

Predictors of change in walking velocity in older adults

OBJECTIVE

To determine factors that predict change in walking velocity in older people using a multivariate model.

DESIGN

Longitudinal observational study.

SUBJECTS

A total of 588 persons older than age 60, including subjects residing in a continuing care retirement community (CCRC) (n = 248), and homebound (n = 79) and ambulatory (n = 261) subjects. Mean age at baseline = 77.

MEASUREMENT

Independent variables included demographics, physician measures of lower-extremity joint impairment and other musculoskeletal and neurological variables, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variables were 2- and 4-year decline in walking velocity below a threshold associated with nursing home placement.

MAIN RESULTS

From baseline to Year 4, median walking velocity declined from 61.8 to 53.0 m/min, and the proportion of subjects above a threshold value of 11.5 m/min declined from 95.3% to 80.4%. Age, joint impairment, and weakness of quadriceps, measured at baseline, predicted 2-year and 4-year decline in walking velocity.

CONCLUSIONS

The findings indicate that joint impairment and quadriceps strength contribute significantly to crossing a clinically significant threshold in walking velocity among older people over time. Future research is needed to determine whether these risk factors can be modified through preventive interventions such as muscle-strengthening exercises and pain medication.

The determinants of walking velocity in the elderly. An evaluation using regression trees

OBJECTIVE

To determine predictors of walking velocity in the elderly.

METHODS

Five hundred thirty-two persons from 3 cohorts of elderly persons (retirement community, ambulatory care medical clinic, or chronically homebound population) performed a 10-foot (for the homebound subjects) or 50-foot (for all other subjects) walk time test and underwent a standardized interview, chart review, and clinical examination. The 73 independent variables that were evaluated included demographic, musculoskeletal, neurologic, psychologic, and other comorbidity items. Least-squares and least-absolute-deviation regression tree analyses were performed to determine the strongest predictive factors associated with walking velocity.

RESULTS

Sampling cohort (homebound versus non-homebound), quadriceps strength, hip flexion strength, lumbosacral spine impairment, lower joint impairment, and education were found to be associated with walking velocity. Joint pain measures were not associated with walking velocity.

CONCLUSION

Muscle strength variables are better predictors of walking velocity than are joint pain variables. Thus, clinical trials and observational studies using walking velocity as an outcome need to take into consideration the influence of muscle strength on this outcome variable.

Impact of joint impairment on longitudinal disability in elderly persons

Recent longitudinal data indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. This longitudinal study included baseline physical examinations of joints of 541 persons over age 60. Previous results from a cross-sectional multivariate model of disability in this sample found that joint impairment (and, its absence, arthritis pain) explained a significant proportion of variance in overall disability. We have retested this model using generalized estimation equations (GEE) analysis to estimate the effect of joint impairment and arthritis pain on baseline and Year 2 disability. Findings indicate that baseline joint impairment contributes substantially to longitudinal disability. If direct measures of baseline joint impairment are unavailable, concurrent self-reported arthritis pain also predicts longitudinal disability well. These findings indicate that longitudinal studies should monitor arthritis pain and that symptomatic arthritis is a risk factor for future disability.

Alteration in multijoint dynamics in patients with bilateral knee osteoarthritis

OBJECTIVE

To document the alterations of joint motion and torque in patients with bilateral knee osteoarthritis (OA), using a well-defined functional maneuver, the sit-to-stand (STS) task.

METHODS

Twelve patients with bilateral knee OA and 12 age-, sex-, and height-matched control subjects performed the STS maneuver from a stool of a standard height at their natural speeds. A motion analysis system and 2 force platforms were employed to determine the dynamic joint motion and the resultant joint torques at the ankle, knee, and hip joints.

RESULTS

The results showed that OA patients exhibited substantially reduced knee extension torques, accompanied by other alterations in initial sitting posture (more extended knee and more plantar-flexed ankle), movement duration (increased), dynamic range of motion at the knee (reduced), and extension torques at the hip (increased).

CONCLUSION

The alterations in joint dynamics among patients with knee OA may have revealed an adaptive motor behavior characterized by redistributing the load from impaired to less-impaired or nonimpaired joints through multijoint dynamics. Two major potential pitfalls of such a movement strategy have subsequently been postulated.

Cost containment: the Middle East. Saudi Arabia

The 1970s and early 1980s saw the phenomenal growth and development of healthcare services in Saudi Arabia. This growth was unique in that it took place in a country that lacked basic infrastructure and trained personnel, but had recently acquired great wealth. Developments that took hundreds of years to occur in other countries took only 20 yrs to attain in Saudi Arabia. This growth posed unique challenges and required novel solutions. Recently, the country has had to cope with a drastic decrease in oil revenue, as well as cutbacks in healthcare funding. Now that the basic foundations of a national healthcare service have been constructed, it remains to be seen whether gains can be consolidated and steady progress made as more and more Saudi nationals take over and run their own public and private healthcare services.

Outcome prediction for the individual patient in the ICU

A very difficult clinical problem facing surgeons is knowing when further treatment is futile and no longer appropriate in a patient who has developed severe complications after surgery and is being treated in an intensive care unit. It is now possible to prolong the process of dying among such patients. This results in unnecessary pain and loss of dignity for the patient, anguish and distress for the patient's relatives and is dehumanizing for the clinical and nursing staff. It has also tremendous implications in the use of limited health care resources. A computer model designed to aid this process has to have the following properties: it must reflect the dynamic pathophysiological process and be able to predict death with extreme accuracy and early in the clinical course. The Riyadh algorithm uses computerised dynamic trend analysis of daily organ failure scores (APACHE II score corrected for the number and duration of organ failures), noting the rate of change in score relative to that of the previous day and an absolute threshold to predict death has been developed for this purpose. The algorithm was developed by tracking the daily scores of 200 IUC patients until their death or discharge from the intensive care unit. It was subsequently validated perspectively on 831 patients. During the validation process, the clinicians were blinded to the predictions. There wer 290 deaths and the program predicted 109 deaths (38% of all deaths) with no false-positive predictions. Forty percent of the predictions were made within 48 h in the ICU and 74% within a week.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimates and determinants of valid self-reports of musculoskeletal disease in the elderly

This study examined the extent and nature of bias associated with self-reported versus standardized physician-examination/assessment-based accounts of musculoskeletal disease in a sample of 406 persons chosen to represent an aging and dependency continuum. Prevalence of musculoskeletal disease based on standardized physician examination/assessments was 97%. Using the standardized findings as the criterion, the self-report underestimated prevalence by 16%. Overall, the results indicated that self-reports of musculoskeletal conditions by the elderly capture the vast majority of persons with painful or functionally significant disease and are most valid for persons from ages 65 to 74 but do not reflect the presence of asymptomatic joint pathology. Standardized physician examinations/assessments would more accurately determine the presence of risk factors in epidemiological studies of musculoskeletal disability.

A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee

OBJECTIVE

To compare arthroscopic surgery and closed-needle joint lavage for patients with non-end-stage osteoarthritis (OA) of the knee under controlled, experimental conditions.

METHODS

Thirty-two subjects who met specific clinical, radiologic, medical, and rehabilitation criteria were randomized to receive arthroscopic surgery (n = 18) or joint lavage (n = 14). Outcome measures evaluated at baseline and at 3 and 12 months of followup included 3 standard clinical parameters, self-reported pain and functional status (by the Arthritis Impact Measurement Scales), 50-foot walk time, 2 global scales, and direct and indirect medical costs.

RESULTS

At 3 months of followup, there were no significant between-group differences in pain, self-reported and observed functional status, and patient and "blinded" physician global assessments. The arthroscopic procedure cost $3,840 more than did closed-needle joint lavage. After 1 year, there were no between-group differences in medication costs, utilization of medical services, or indirect costs related to employment or use of household help. After 1 year, 44% of subjects who underwent arthroscopy reported improvement and 58% of subjects who underwent joint lavage improved. Patients with tears of the anterior two-thirds of the medial meniscus or any lateral meniscus tear had a higher probability of improvement (by "blinded" physician assessment) after arthroscopic surgery (0.63) than did patients with other intraarticular pathology (0.20).

CONCLUSION

The search for and removal of soft tissue abnormalities via arthroscopic surgery does not appear justified for all patients with non-end-stage OA of the knee who fail to respond to conservative therapy, but it may be beneficial for certain subgroups.

Joint impairment and self-reported disability in elderly persons

Recent findings indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. We conducted physical examinations of the joints at baseline on 541 older persons. We then tested a multivariate model of total/generic disability which included respondent group, demographic and chronic disease variables (joint impairment and comorbid conditions), arthritis pain, and psychological status. Hierarchical multiple regression found that the model explained 55 percent (adjusted R2 = .55) of the variance in baseline disability with joint impairment accounting for 15 percent (change in R2 = .15) of the variance. When joint impairment was removed from the model, arthritis pain worked well as a surrogate. Together, these findings strongly support the importance of musculoskeletal disease in explaining disability in the elderly population.

Rehabilitation and biomechanics

In this review, we discuss large epidemiologic and focused clinical and laboratory studies published over the past year that advanced our current knowledge of the physical and functional impairments, societal handicaps, and disability related to the rheumatic diseases. Studies of rehabilitative methods appropriate for patients with a variety of rheumatic and musculoskeletal disorders are presented.

Assessment of clinical competence of medical students by using standardized patients with musculoskeletal problems

OBJECTIVE

To assess medical students' clinical competence in addressing musculoskeletal problems.

METHODS

Nineteen junior medical students completed 2 standardized patient-based tests structured to capture their clinical decisions from undiagnosed chief complaint to management.

RESULTS

No student approached the highest possible score on either test, and the students as a group received less than half the possible points on 5 important aspects of diagnostic reasoning.

CONCLUSION

Standardized patient-based tests can be structured to provide enlightening information about medical students' clinical competence with regard to musculoskeletal problems.

The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement

This study tested the effects of a project network technique called the Critical Path Method (CPM) on the costs and outcomes of inpatient team stroke rehabilitation. On admission to a large, academic, inpatient rehabilitation hospital adults who had a recent (< 120 days) stroke were randomly assigned to receive rehabilitation services from a team trained in CPM (N = 53) or from usual care teams (N = 68). Results showed no significant difference between groups in length of stay, hospital charges, or functional status at discharge. CPM may be effective in patient care services that are less influenced by specialization, professional issues, and external regulation and in settings where patient outcomes are relatively fixed and predictable, and medical care is integrated across institutions.

Joint impairment and hand function in the elderly

OBJECTIVE

To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model.

DESIGN

Cross-sectional observational data (baseline data from an ongoing longitudinal study).

SUBJECTS

Five hundred forty-one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0).

MEASUREMENT

Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)].

MAIN RESULTS

The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%).

CONCLUSIONS

Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).

Seeing the forest despite the trees. The benefit of exploratory data analysis to program evaluation research

In the present article, it is argued that there is a benefit to applying techniques of exploratory data analysis (EDA) to program evaluation. To exemplify this, an evaluation of a rehabilitation program for people with rheumatoid arthritis is presented. The perceived health status of patients receiving intensive rehabilitation services from a major rehabilitation institute was compared with that of patients receiving customary office-based care over an 18-month period. The data were analyzed in a conventional way (analysis of variance) and then by way of EDA techniques (graphic display of medians and boxplots). The conventional analysis suggested that all patients improved over time and that intensive rehabilitation services provided no particular benefit or harm. The exploratory analysis showed that the distribution of the outcome variable was patently nonnormal, thus casting doubt on the validity of the conventional analysis. The EDA further showed that the rehabilitation group lagged behind the comparison group for a year, with a precipitious improvement at the 18-month period. This suggests that a selection factor was operating (i.e., those in the rehabilitation group could have been sicker) or that the patients in the rehabilitation group were made more aware of their condition by the intensive health services they received. The EDA provided an important insight.