Abstract Objective Discordance between radiographic and pain severity in osteoarthritis (OA) has led researchers to investigate other pain mechanisms, including neuropathic pain. Accurate ...identification of any neuropathic pain in hip or knee OA is important for appropriate management, but neuropathic pain prevalence is unknown. We aimed to obtain an overall prevalence estimate by systematically reviewing and meta-analysing the prevalence of neuropathic pain in people with hip or knee OA. Method Observational studies which measured neuropathic pain in people aged 18 years and older with hip or knee OA were considered for inclusion. Electronic databases were searched up to February 2016. Two reviewers independently identified eligible studies and assessed methodological quality. Prevalence estimates and 95% confidence intervals were calculated using random effects meta-analytic techniques. Results Nine studies met the inclusion criteria. Study samples were from general population, hospital and community settings and all used self-report questionnaires to determine neuropathic pain. The overall prevalence estimate was 23% (95%CI 10%-39%), with considerable heterogeneity (I2 =97.9%, p<.001). This estimate was largely unchanged with subgroup analyses based on index joint, questionnaire type, setting and consideration of other potential causes of neuropathic pain. However, the estimate for two studies that excluded other potential causes of neuropathic pain was substantially higher (32%, 95%CI 29%-35%). Conclusions Neuropathic pain prevalence in people with knee or hip OA is considerable at 23%, and may be higher after other potential causes of neuropathic pain are excluded. Concerns regarding the validity of neuropathic pain questionnaires, selection bias, methodological quality and study heterogeneity suggest caution with interpretation of these findings. Prevalence studies using standardised criteria for neuropathic pain are required.
Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee ...osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.
To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.
We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.
We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.
Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.
We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).
Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.
A physically-based, distributed hydrological model (MIKE SHE) was used to quantify overland runoff in response to four extreme rain events and four types of simulated land use measure in a catchment ...in Norway. The current land use in the catchment comprises arable lands, forest, urban areas and a stream that passes under a motorway at the catchment outlet. This model simulation study demonstrates how the composition and configuration of land use measures affect discharge at the catchment outlet differently in response to storms of different sizes. For example, clear-cutting on 30% of the catchment area produced a 60% increase in peak discharge and a 10% increase in total runoff resulting from a 50-year storm event in summer, but the effects on peak discharge were less pronounced during smaller storms. Reforestation of 60% of the catchment area was the most effective measure in reducing peak flows for smaller (2-, 5- and 10-year) storms. Introducing grassed waterways reduced water velocity in the stream and resulted in a 28% reduction in peak flow at the catchment outlet for the 50-year storm event. Overall, the results indicate that the specific effect of land use measures on catchment discharge depends on their spatial distribution and on the size and timing of storm events.
•The effect of land use changes depends on their spatial distribution.•The effect of land use changes depends on the size and timing of storm events.•Reforestation proved to be the most effective at reducing peak flow and total runoff.•The effect of reforestation was correlated to its location within the catchment.•The spatial distribution of land use measures must be considered before being implemented.
Falls are a common and disabling feature of Parkinson disease (PD). Early identification of patients at greatest risk of falling is a key goal of physical therapy assessment. The Timed "Up & Go" Test ...(TUG), a frequently used mobility assessment tool, has moderate sensitivity and specificity for identifying fall risk.
The study objective was to investigate whether adding a task (cognitive or manual) to the TUG (TUG-cognitive or TUG-manual, respectively) increases the utility of the test for identifying fall risk in people with PD.
This was a retrospective cohort study of people with PD (N=36).
Participants were compared on the basis of self-reported fall exposure in the preceding 6 months (those who had experienced falls "fallers" versus those who had not "nonfallers"). The time taken to complete the TUG, TUG-cognitive, and TUG-manual was measured for both groups. Between-group differences were calculated with the Mann-Whitney U test. The discriminative performance of the test at various cutoff values was examined, and estimates of sensitivity and specificity were based on receiver operating characteristic curve plots.
Fallers took significantly longer than nonfallers (n=19) to complete the TUG under all 3 conditions. The TUG-cognitive showed optimal discriminative performance (receiver operating characteristic area under the curve=0.82; 95% confidence interval CI=0.64, 0.92) at a cutoff of 14.7 seconds. The TUG-cognitive was more likely to correctly classify participants with a low risk of falling (positive likelihood ratio=2.9) (<14.7 seconds) and had higher estimates of sensitivity (0.76; 95% CI=0.52, 0.90) than of specificity (0.73; 95% CI=0.51, 0.88) at this threshold (negative likelihood ratio=0.32).
Retrospective classification of fallers and nonfallers was used.
The addition of a cognitive task to the TUG enhanced the identification of fall risk in people with PD. The TUG-cognitive should be considered a component of a multifaceted fall risk assessment in people with PD.
Papyrus wetlands are predominant in permanently inundated areas of tropical Sub Saharan Africa (SSA) and offer both provisioning and regulatory services. Although a wealth of literature exists on ...wetland functions, the seasonal behaviour of the papyrus mat and function in water storage has received less attention. The objective of this study was to assess the response of the papyrus root mat to changing water levels in a tropical wetland system in Eastern Uganda. We delineated seven transects through a section of a wetland system and mapped wetland bathymetry along these transects. We used three transects to measure spatial and temporal changes in mat thickness and free water column, and to monitor variations in total depth during two seasons. The free water column increased across all transects in the wet season. However, changes in the mat thickness varied spatially and were influenced by the rate of increase of the free water column as well as wetland bathymetry. The proportion of mat compression was higher at the shallow end of the wetland (83%) compared to the deep end (67%). There was a significant negative correlation between changes in free water column and papyrus mat thickness (r = −0.85, p = 000). Therefore, the mat compresses in response to increase in free water column, which increases the ratio of the free water column to root mat thickness. Hence, the wetland accommodates excess water during rainy seasons. Water depth varied from 1.5 m to 2.1 m during the monitoring period, corresponding to a water storage of 61,597 m3 and 123,355 m3 respectively. This means a 50% change in water volume for the studied wetland section. This water regulatory function mitigates severity of floods downstream, but the stored water is also useful to the surrounding communities for wetland-edge farm irrigation during dry seasons.
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•We quantified water storage and the response of papyrus root mat to changing water levels in a tropical wetland•We measured root mat thickness and depth of the free water column along transects in the dry and wet season•Free water column increased across all transects in the wet season. This facilitates storage of extra water in the wetland•There was a negative correlation between changes in free water column and papyrus mat thickness between the two seasons•The wetland’s storage function can contribute to agriculture through sustainable use of the water for irrigation
To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions.
PubMed, ...EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies).
Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall.
Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.
•Knee flexion at mid-stance demonstrated significant inter-assessment variation•Inter-assessment variation was related to younger age•Flexed-knee gait did not always progress over time without ...surgical intervention
Flexed-knee gait is a common pattern associated with cerebral palsy (CP). It leads to excessive forces on the knee and is thought to contribute to pain and deformity. While studies have shown improvements in mid-stance knee flexion following surgery there remains a lack of prospective data on the progression of flexed-knee gait in the absence of surgery.
Does knee flexion progress over repeated assessments in the absence of surgery in a prospectively assessed cohort with CP?
Inclusion criteria were a diagnosis of bilateral CP, knee flexion at mid-stance >19° and no surgery within one year of the first gait analysis. Gait analysis was carried out at six-month intervals (minimum of three and maximum of six assessments). The progression of knee flexion over repeated analyses was assessed. The association between changes in knee flexion between assessments and gender, age, GMFCS level, change in ankle dorsiflexion, change in height and change in weight was examined.
Forty-eight participants met the initial inclusion criteria and 32 (GMFCS I = 11, II = 17, III = 4) completed the minimum three assessments. Of the 32 included participants, 21 participants (66%) demonstrated decreased knee flexion at mid-stance (mean decrease 6.6° ± 3.4°; range 2.0°–13.0°) and 11 participants (34%) demonstrated increased knee flexion at mid-stance (mean increase 10.4° ± 7.1°; range 2.0°–20.0°) at one-year follow-up. Eighteen (56%) then demonstrated an overall decrease (mean 7.4° ± 5.1°) in knee flexion between the first and last assessment with last follow-up at 1–2 years (n = 3), 2–3 years (n = 3) and 3–4 years (n = 12). The majority of participants (78%) demonstrated episodes of both increasing and decreasing Knee flexion between individual assessments and further analysis found that age was associated with this inter-assessment variability in knee flexion.
Flexed-knee gait is not always progressive in bilateral CP and demonstrated variability associated with age.
There is a lack of reliable and valid measurement tools to assess neck function in infants with congenital muscular torticollis, and most physiotherapists use visual estimation, which has not been ...adequately tested for reliability in this population. We examined the reliability of visual estimation of head tilt and active neck rotation in the upright position, on infants with congenital muscular torticollis by physiotherapists. We recruited 31 infants and 26 physiotherapists. Therapists rated videos of infants’ head position in the frontal plane (tilt) and transverse plane (active rotation) using visual estimation, on two occasions at least one week apart. Overall, inter-rater reliability was good (mean ICC, 0.68 ± 0.20; mean SEM, 5.1° ± 2.1°). Rotation videos had better reliability (mean ICC, 0.79 ± 0.14) than head tilt videos (mean ICC, 0.58 ± 0.20). Intra-rater reliability was excellent (mean ICC, 0.85 ± 0.08). Both head tilt and rotation had excellent reliability (mean ICC, 0.84 ± 0.08 for head tilt and 0.85 ± 0.09 for rotation). There was no correlation between intra-rater reliability and clinical experience.
Conclusion
Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt on infants with congenital muscular torticollis. Visual estimation had acceptable inter-rater reliability in the assessment of neck active rotation but not of head tilt. There was a wide variation in reliability with no correlation between reliability and clinical experience. Assessment tools for head tilt that are more psychometrically robust should be developed.
What is Known:
• A thorough assessment of infants presenting with torticollis is essential, using assessment tools with robust psychometric properties
• Visual estimation is the most commonly used method of assessment of neck function in infants with torticollis
What is New
:
• Visual estimation had excellent intra-rater reliability in the assessment of neck active rotation and head tilt in the upright position in videos of infants and acceptable inter-rater reliability in the assessment of rotation but not of head tilt
• Physiotherapists’ clinical experience had minimal relationship with reliability
Environmental assessments are required prior to remediation and redevelopment of contaminated sites. To date, regulatory guidelines are commonly based on total concentrations. Occasionally, simple ...leaching procedures are included in environmental assessment. Despite being essential for quantification of contaminant transport, analysis of hydraulic conductivity is rarely considered. Cost-effective methods that reflect both contaminant leaching and hydrogeological properties of contaminated soils are needed to ensure proper soil management. The aim of this study was to simultaneously evaluate contaminant leaching and hydraulic conductivity in soil using a combined column test (CCT) and compare this to the leaching results from batch tests (BT) and transport estimates derived from the empirical Hazen equation. Two soils of different origin were characterized using the CCT. By including physical and chemical factors affecting the release and retention of contaminants, the CCT provides an integrated assessment of leaching and transport of trace elements from soils. Additionally, the effect of soil compaction was investigated as a physical treatment to reduce leaching and transport in contaminated soils. Soil compaction did not demonstrate reduced leaching, but a less extensive contaminant transport was observed due to reduced hydraulic conductivity in the soil.
To identify and describe the extent, nature, characteristics, and impact of primary care-based models of care (MoCs) for osteoarthritis (OA) that have been developed and/or evaluated.
Six electronic ...databases were searched from 2010 to May 2022. Relevant data were extracted and collated for narrative synthesis.
Sixty-three studies pertaining to 37 discrete MoCs from 13 countries were included, of which 23 (62%) could be classified as OA management programmes (OAMPs) comprising a self-management intervention to be delivered as a discrete package. Four models (11%) focussed on enhancing the initial consultation between a patient presenting with OA at the first point of contact into a local health system and the clinician. Emphasis was placed on educational training for general practitioners (GPs) and allied healthcare professionals delivering this initial consultation. The remaining 10 MoCs (27%) detailed integrated care pathways of onward referral to specialist secondary orthopaedic and rheumatology care within local healthcare systems. The majority (35/37; 95%) were developed in high-income countries and 32/37 (87%) targeted hip/and or knee OA. Frequently identified model components included GP-led care, referral to primary care services and multidisciplinary care. The models were predominantly ‘one-size fits all’ and lacked individualised care approaches. A minority of MoCs, 5/37 (14%) were developed using underlying frameworks, three (8%) of which incorporated behaviour change theories, while 13/37 (35%) incorporated provider training. Thirty-four of the 37 models (92%) were evaluated. Outcome domains most frequently reported included clinical outcomes, followed by system- and provider-level outcomes. While there was evidence of improved quality of OA care associated with the models, effects on clinical outcomes were mixed.
There are emerging efforts internationally to develop evidence-based models focused on non-surgical primary care OA management. Notwithstanding variations in healthcare systems and resources, future research should focus on model development alignment with implementation science frameworks and theories, key stakeholder involvement including patient and public representation, provision of training and education for providers, treatment individualisation, integration and coordination of services across the care continuum and incorporation of behaviour change strategies to foster long-term adherence and self-management.
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