Abstract Background Ankle sprains are one of the most common musculoskeletal injuries. In order to evaluate the effectiveness of therapeutic interventions and to guide management decisions, it is ...important to have clear insight of the course of recovery after an acute lateral ankle injury and to evaluate potential factors for nonrecovery and re-sprains. Methods A database search was conducted in MEDLINE, CINAHL, PEDro, EMBASE, and the Cochrane Controlled trial register. Included were observational studies and controlled trials with adult subjects who suffered from an acute lateral ankle sprain that was conventionally treated. One of the following outcomes had to be described: pain, re-sprains, instability, or recovery. Two reviewers independently assessed the methodological quality of each included study. One reviewer extracted relevant data. Results In total, 31 studies were included, from which 24 studies were of high quality. There was a rapid decrease in pain reporting within the first 2 weeks. Five percent to 33% of patients still experienced pain after 1 year, while 36% to 85% reported full recovery within a period of 3 years. The risk of re-sprains ranged from 3% to 34% of the patients, and re-sprain was registered in periods ranging from 2 weeks to 96 months postinjury. There was a wide variation in subjective instability, ranging from 0% to 33% in the high-quality studies and from 7% to 53% in the low-quality studies. One study described prognostic factors and indicated that training more than 3 times a week is a prognostic factor for residual symptoms. Conclusions After 1 year of follow-up, a high percentage of patients still experienced pain and subjective instability, while within a period of 3 years, as much as 34% of the patients reported at least 1 re-sprain. From 36% up to 85% of the patients reported full recovery within a period of 3 years.
Objectives Recently, numerous studies have reported that psychological factors can influence the outcome of total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, a systematic ...overview is missing. The objective of this study was to examine which psychological factors influence the outcome of TKA and THA and to what extent. Methods Data were obtained from the MEDLINE and EMBASE databases from inception to January 2011. Search terms included TKA and THA, outcome measures, and psychological aspects. Two reviewers independently selected the studies. Studies with a prospective before–after design with a minimum follow-up time of 6 weeks were included. One reviewer extracted the results and 2 reviewers independently conducted quality assessment. We distinguished between follow-up shorter and equal or longer than 1 year. Results Thirty-five of 1837 studies met the inclusion criteria and were included in this systematic review. In follow-ups shorter than 1 year, and for knee patients only, strong evidence was found that patients with pain catastrophizing reported more pain postoperatively. Furthermore, strong evidence was found that preoperative depression had no influence on postoperative functioning. In long-term follow-up, 1 year after TKA, strong evidence was found that lower preoperative mental health (measures with the SF-12 or SF-36) was associated with lower scores on function and pain. For THA, only limited, conflicting, or no evidence was found. Conclusions Low preoperative mental health and pain catastrophizing have an influence on outcome after TKA. With regard to the influence of other psychological factors and for hip patients, only limited, conflicting, or no evidence was found.
Abstract Background With accumulating knowledge on osteoarthritis development, the next step is to focus on possibilities for primary prevention. Methods In a 2 × 2 factorial design, the effects of a ...diet-and-exercise program and of oral glucosamine sulfate (double blind and placebo-controlled) on the incidence of knee osteoarthritis were evaluated in a high-risk group of 407 middle-aged women with a body mass index ≥ 27 kg/m2 without clinical signs of knee osteoarthritis at baseline (ISRCTN 42823086). Primary outcome was the incidence of knee osteoarthritis, defined as Kellgren & Lawrence grade ≥ 2, joint space narrowing of ≥ 1.0 mm, or clinical knee osteoarthritis (clinical and radiographic American College of Rheumatology criteria) after 2.5 years. Results After 2.5 years, only 10% of all subjects were lost to follow-up, and 17% of all knees showed incident knee osteoarthritis. Accounting for the significant interaction between the interventions, no significant main effect of either intervention was found. Independently, both interventions alone showed indications of reduced knee osteoarthritis incidence (odds ratio OR 0.69; 95% CI, 0.39-1.21 for the diet-and-exercise program and OR 0.60; 95% CI, 0.31-1.12 for the glucosamine intervention). These effects were neutralized in subjects receiving both interventions (OR 0.97; 95% CI, 0.55-1.71). Conclusions No significant main effects of the diet-and-exercise program and of glucosamine sulfate were found on incident knee osteoarthritis. Nevertheless, this trial provides valuable insights for future trial design for preventive osteoarthritis studies.
Abstract Objective To evaluate the possibility of assessing knee cartilage with T2-mapping and delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) in one post-contrast MR examination at 3 Tesla ...(T). Design T2 mapping was performed in 10 healthy volunteers at baseline; directly after baseline; after 10 minutes of cycling; and after 90 minutes delay, and in 16 osteoarthritis patients before and after intravenous administration of a double dose gadolinium dimeglumine contrast agent, reflecting key dGEMRIC protocol elements. Differences in T2 relaxation times between each timepoint and baseline were calculated for 6 cartilage regions using paired t-tests or Wilcoxon signed-rank tests and the smallest detectable change (SDC). Results After cycling, a significant change in T2 relaxation times was found in the lateral weight-bearing tibial plateau (+1.0 ms, p=0.04). After 90 minutes delay, significant changes were found in the lateral weight-bearing femoral condyle (+1.2 ms, p=0.03) and the lateral weight-bearing tibial plateau (+1.3 ms, p=0.01). In these ROIs, absolute differences were small and lower than the corresponding SDCs. T2-mapping after contrast administration only showed statistically significantly lower T2 relaxation times in the medial posterior femoral condyle (-2.4 ms, p<0.001) with a change exceeding the SDC. Conclusion Because dGEMRIC protocol elements resulted in only small differences in T2 relaxation times that were not consistent and lower than the SDC in the majority of regions, our results suggest that T2-mapping and dGEMRIC can be performed reliably in a single imaging session to assess cartilage biochemical composition in knee OA at 3 T.
To assess the diagnostic accuracy of history taking and physical examination for assessing anterior cruciate ligament (ACL) lesions in primary care.
Cross-sectional diagnostic study.
Primary care.
...Patients (N=134; age, 18-65y) who consulted their general practitioner (GP) within 5 weeks after injury.
Not applicable.
Index tests were obtained with a questionnaire and physical examination. Magnetic resonance imaging (MRI) was used as the reference test. Logistic regression analysis was used to determine associations with ACL lesions. Diagnostic accuracy was determined by calculating sensitivity (Se), specificity (Sp), predictive values, and likelihood ratio (LR).
MRI showed an ACL lesion in 28 of 134 included patients. "Effusion," "popping sensation," "giving way," and "anterior drawer test (ADT)" showed associations with an ACL lesion (P<.05). Popping sensation showed Se, Sp, positive predictive value (PPV), and positive LR (LR(+)) of .63, .73, .39, and 2.3, respectively. Combining determinants from history taking (2 of 3 positive results regarding effusion, popping sensation, and giving way) improved diagnostic accuracy (Se, .71; Sp, .71; PPV, .42; and LR(+), 2.5). The ADT added diagnostic accuracy to these combinations (Se, .63; Sp, .85; PPV, .52; and LR(+), 4.2).
ACL lesions are seen frequently. Based on history taking (effusion, popping sensation, and/or giving way) and physical examination (ADT), GPs can screen for ACL lesions in primary care.
Abstract Purpose Abdominal pain is a common complaint in children. Because few data exist on its natural history, we wanted to investigate the prognosis of abdominal pain in children in general ...practice. Methods In a prospective cohort study of children (aged 4 to 17 years) complaining of abdominal pain, follow-up was at 3, 6, 9, and 12 months using standardized questionnaires. The primary outcome measure was chronic abdominal pain: abdominal pain at least 1 time a month during at least 3 consecutive months that had an impact on daily activities. Prevalence, incidence, and duration of chronic abdominal pain were assessed. Results Three hundred five children (116 boys, 189 girls), with a median age of 7.8 years (interquartile range IQR = 5.7–10.5 years) were included. Chronic abdominal pain was present in 142 (46.6%) children at an initial visit to the primary care physician for this complaint. During follow-up, 78.7% fulfilled the criteria for chronic abdominal pain at 1 or more follow-up points. Among 163 children at risk for developing chronic abdominal pain, the cumulative incidence of chronic abdominal pain was 60.1% (95% CI, 52.1%–67.7%) and was higher in girls than in boys (RR = 1.23; 95% CI, 0.94–1.61). Median duration of abdominal pain was 7.5 months (IQR = 4.5–12.0 months). Children aged 10 to 17 years had the longest duration of abdominal pain (median = 9.0 months; IQR = 7.5–12.4 months). Children with symptoms of irritable bowel syndrome seemed to have a less favorable prognosis compared with children with symptoms of functional dyspepsia or functional abdominal pain. Conclusions The presence and development of chronic abdominal pain is common and of long duration among children consulting in primary care for abdominal pain. These poor outcome data warrant follow-up.
ABSTRACT PURPOSE Abdominal pain is a frequent symptom among children but is rarely associated with organic disease. Although it may persist for years, no factors have been identified that predict its ...prognosis. Our aim was to determine whether patient characteristics at initial consultation can predict chronic abdominal pain severe enough to influence the child's well-being at 1 year of follow-up. METHODS We conducted this prospective cohort study in primary care, including consecutive children aged 4 to 17 years seen for abdominal pain by their family physician. Multivariate logistic regression analysis was used to identify prognostic factors that predicted chronic abdominal pain 1 year later. Discriminative ability of identified predictors was assessed using the area under the receiver operating characteristic curve and explained variance. RESULTS The risk of having chronic abdominal pain at 1 year of follow-up was 37.1% in the cohort overall. Increasing age, waking up at night with pain, high levels of other somatic complaints, and chronic abdominal pain at baseline independently predicted chronic abdominal pain at 1 year. These predictors had a poor to moderate discriminative ability, however; the area under the receiver operating characteristic curve was only 0.69, and the predictors collectively explained only 14.3% of variance in the development of chronic abdominal pain. The absolute risk ranged from 19.4% among children having none of the predictors to 65.5% among children having 3 or 4 predictors. CONCLUSIONS Chronic abdominal pain sufficient to affect well-being is common among children initially seen for abdominal pain by family physicians. Although the risk of this outcome increases with number of predictors, these predictors are of limited value in identifying children in whom pain will become chronic, suggesting that other, as yet unidentified factors play an important role.
Abstract Purpose We undertook a study to evaluate the effectiveness of corticosteroid injections in primary care patients with greater trochanteric pain syndrome (GTPS). Methods We evaluated the ...effect of corticosteroid injections compared with expectant treatment (usual care) in a pragmatic, multicenter, open-label, randomized clinical trial in the Netherlands. Patients (aged 18 to 80 years) with GTPS visiting 81 participating primary care physicians were randomly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). Primary outcomes of pain severity (numerical rating scale 0 to 10) and recovery (yes or no total or major recovery) were evaluated at 3-month and 12-month follow-up visits. Adverse events were collected at 6 weeks. Results At the 3-month follow-up visit, 34% of the patients in the usual care group had recovered compared with 55% in the injection group (adjusted OR = 2.38; 95% CI, 1.14–5.00, number needed to treat = 5). Pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 (95% CI, 0.31–2.05) and in pain with activity of 1.30 (95% CI, 0.32–2.29). At the 12-month follow-up, 60% of the patients in the usual care group had recovered compared with 61% in the injection group (OR = 1.05; 95% CI, 0.50–2.27). Pain severity at rest and on activity decreased in both groups and the 12-month follow-up showed no significant differences, with adjusted differences of 0.14 (95% CI, −0.75 to 1.04) for pain at rest and 0.45 (95% CI, −0.55 to 1.46) for pain with activity. Aside from a short period with superficial pain at the site of the injection, no differences in adverse events were found. Conclusion In this first randomized controlled trial assessing the effectiveness of corticosteroid injections vs usual care in GTPS, a clinically relevant effect was shown at a 3-month follow-up visit for recovery and for pain at rest and with activity. At a 12-month follow-up visit, the differences in outcome were no longer present.
Introduction Intra-articular needle placement in the knee joint, such as injection or aspirations, are commonly used for therapeutic, diagnostic, and research purposes. Although several approaches ...can be used to establish an intra-articular injection or aspiration of the knee joint, the accuracy differs per approach. Objective To summarize the evidence concerning the accuracy of different approaches for intra-articular needle placements in the knee. Additionally, to assess whether the accuracy of different approaches is related to factors such as underlying disease, severity of underlying disease, approach-related factors, and/or the rate of local reactions. Methods The literature was systemically reviewed until July 2010. Risk of bias of the included studies was assessed by the QUADAS tool. Study characteristics were extracted; accuracy results were pooled per approach. Results Nine studies were included. The superolateral approach with the leg in extension was studied most (230 injections) and resulted in the highest pooled accuracy of 91% (95% CI 84-99%). The lateral midpatellar approach, the anterolateral approach, and the anteromedial approach resulted in the lowest pooled accuracy rates, 85% (95% CI 68-100%), 67% (95% CI 43-91%) and 72% (95% CI 65-78%), respectively. Conclusions The superolateral approach was investigated most and resulted in the highest pooled accuracy rate of 91% (95% CI 84-99%). Nevertheless, this approach still results in a substantial amount of extra-articular needle placements. Guidance of intra-articular needle placements by imaging techniques may enhance the accuracy. The costs and extra time associated with these techniques should be taken into consideration.
Abstract Objective The aim of the present study was to evaluate the effect of a 2.5 year glucosamine sulphate intervention on haemoglobin A1c (HbA1c) levels and the incidence of new-onset diabetes ...mellitus over 6.5 years in middle-aged women with a BMI ≥27 kg/m2. Methods In total, 407 women were randomized into either oral crystalline glucosamine sulphate or placebo. At baseline, 1 year, 2.5 years and 6.5 years a blood sample for the HbA1c level was drawn and a questionnaires were taken. After 6.5 years there was missing data for some variables, therefore multiple imputation was used. With the imputed data, a generalized estimating equation was performed to analyze the effect of glucosamine sulphate usage over 6.5 years. Finally, these analyses were rerun for the two subgroups of participants with and without high HbA1c level (≥42 mmol/mol) at baseline. Results There was no significant effect of a 2.5 year glucosamine sulphate intervention on mean HbA1c level or on obtaining a high HbA1c level and/or new-onset diabetes mellitus over 6.5 years. The subgroup analyses of participants with and without high HbA1c level at baseline were also not statistically significant. However, participants with a high HbA1c level at baseline had higher ORs compared with the participants with a normal HbA1c at baseline. Conclusions There was no effect of glucosamine sulphate on mean HbA1c level nor on obtaining a high HbA1c level and/or new-onset diabetes mellitus over 6.5 years, especially in participants with a normal HbA1c level at baseline.
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