Anterior lengthening in scoliosis occurs only in the disc and is similar in different types of scoliosis.

Relative anterior spinal overgrowth (RASO) was proposed as a generalized growth disturbance and a potential initiator of adolescent idiopathic scoliosis (AIS). However, anterior lengthening was also observed in neuromuscular (NM) scoliosis, was shown to be restricted to the apical areas and to be located in the intervertebral discs, not in the bone. In this study the goal was to determine if other scoliotic curves of known origin exhibit the similar mechanism of anterior lengthening without changes in the vertebral body. Therefore CT-scans of 18 patients in whom a short segment congenital malformation had led to a long thoracic compensatory curve without bony abnormality were included. Of each vertebral body and intervertebral disc in the compensatory curve, the anterior and posterior length was measured on CT-scans in the exact mid-sagittal plane, corrected for deformity in all three planes. The total AP% of the compensatory curve in congenital scoliosis showed a lordosis (+1.8%) that differed from the kyphosis in non-scoliotic controls (-3.0%; p<0.001), and was comparable to AIS (+1.2%) and NM scoliosis (+0.5%). This anterior lengthening was not located in the bone; the vertebral body AP% showed a kyphosis (-3.2%), similar to non-scoliotic controls (-3.4%), as well as AIS (-2.5%) and NM scoliosis (-4.5%; p=1.000). However, the disc AP% showed a lordosis (+24.3%), which sharply contrasts to the kyphotic discs of controls (-1.5%; p<0.001), but was similar to AIS (+17.5%) and NM scoliosis (+20.5%). The results demonstrate that anterior lengthening is part of the three-dimensional deformity in different types of scoliosis and is exclusively located in the intervertebral discs. The bony vertebral bodies maintain their kyphotic shape, which indicates that there is no active bony overgrowth. Anterior lengthening appears to be a passive result of any scoliotic deformity, rather than being related to the specific cause of AIS.

F.E.M. Stress-Investigation of Scolios Apex.

BACKGROUND: In scoliosis, kypholordos and wedge properties of the vertebrae should be involved in determining how stress is distributed in the vertebral column. The impact is logically expected to be maximal at the apex. AIM: To introduce an algorithm for constructing artificial geometric models of the vertebral column from DICOM stacks, with the ultimate aim to obtain a formalized way to create simplistic models, which enhance and focus on wedge properties and relative tilting. MATERIAL/METHODS: Our procedure requires parameter extraction from DICOM image-stacks (with PACS,IDS-7), mechanical FEM-modelling (with Matlab and Comsol). As a test implementation, models were constructed for five patients with thoracal idiopathic scoliosis with varying apex rotation. For a selection of load states, we calculated a response variable which is based upon distortion energy. RESULTS: For the test implementation, pairwise t-tests show that our response variable is non-trivial and that it is chiefly sensitive to the transversal stresses (transversal stresses where of main interest to us, as opposed to the case of additional shear stresses, due to the lack of explicit surrounding tissue and ligaments in our model). Also, a pairwise t-test did not show a difference (n = 25, p-value≈0.084) between the cases of isotropic and orthotropic material modeling. CONCLUSION: A step-by-step description is given for a procedure of constructing artificial geometric models from chest CT DICOM-stacks, such that the models are appropriate for semi-global stress-analysis, where the focus is on the wedge properties and relative tilting. The method is inappropriate for analyses where the local roughness and irregularities of surfaces are wanted features. A test application hints that one particular load state possibly has a high correlation to a certain response variable (based upon distortion energy distribution on a surface of the apex), however, the number of patients is too small to draw any statistical conclusions.

Workshop 8 (synthesis): water governance--a key driver for food and urban security.

Water governance has profound impact on the livelihoods of urban and rural people and on environmental sustainability. Yet governance has not received the same attention as technical issues. Governance is about processes of choices, decisions and estimating trade-offs.

Workshop 2a (synthesis): linking drainage basin management to local action plans and policy.

The complexity of linking drainage basin management to local action plans and policy has been largely underestimated by the water profession. Water management issues may be similar between areas but solutions are not universal--they must be specific to each local context. A particular problem is that a drainage basin is likely to cover a number of administrative and/or political boundaries.

Workshop 2b (synthesis): linking drainage basin management to local action plans and national security--theory and practice in eastern European countries.

Efforts to link and balance national water policies, local water action and national security issues are discussed. There needs to be greater clarity of water roles, rights and responsibilities among national stakeholders as well as between states. In some cases, insufficient attention has been paid to local concerns and, in balancing national and local actions, it is necessary to address decentralization in the context of a transboundary state. There is a strong need for enhanced stakeholder participation in the formulation and implementation of national and local water management plans.

Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To describe the consequences of shoulder pain on activity and participation in spinal cord-injured paraplegic wheelchair users. To describe the prevalence and type of shoulder pain. SETTING: Two spinal cord injury (SCI) centres in Sweden. METHODS: All subjects with paraplegia due to an SCI of more than 1 year living in the counties of Uppsala and Linköping, Sweden were contacted by mail and asked to fill in a questionnaire (89 subjects). Those of the responding 56 subjects with current shoulder pain were asked to participate in further examination and interviews. A physiotherapist examined 13 subjects with shoulder pain in order to describe type and site of impairment. To describe consequences of shoulder pain on activity and participation, the Constant Murley Scale (CMS), the Wheelchair Users Shoulder Pain Index (WUSPI) the Klein & Bell adl-index and the Canadian Occupational Performance Measure (COPM) were used. RESULTS: Out of all respondents, 21 had shoulder pain (37.5%). Data from 13 of those subjects were used in the description of type and consequences of shoulder pain. Findings of muscular atrophy, pain, impingement and tendinits were described. We found no difference in ADL-performance with, respectively without, shoulder pain (P=0.08) using the Klein & Bell adl-index. No correlation was found between the various descriptions of impairment, activity limitations and participation restriction (P>0.08). All together 52 problems with occupational performance due to shoulder pain were identified using the COPM. Of these, 54% were related to self-care activities. CONCLUSION: The consequences of shoulder pain in paraplegic wheelchair users are mostly related to wheelchair activities. Since the wheelchair use itself presumably cause shoulder problems, this will become a vicious circle. More research is needed in order to reduce shoulder problems in wheelchair users.

Workshop 8 (synthesis): urban dynamics, livable cities and water.

A major wave of urbanisation is taking place in small- and medium-sized cities in developing countries. Water governance and integrated approaches are key factors in providing adequate services and maintaining the water resource. Intermediate technologies and practices need to be applied on a much wider scale.

Absence of back disorders in adults and work-related predictive factors in a 5-year perspective.

Factors important for avoiding back disorders in different age-groups have seldom been compared and studied over time. We therefore set out to study age-related differences in socio-economic and work-related factors associated with the absence of back disorders in a 5-year comparative cohort study using a mailed questionnaire. Two subgroups (aged 25-34 and 54-59 years) derived from a representative sample of the Swedish population were followed at baseline, 1 year and 5 years. Questions were asked about the duration of back pain episodes, relapses, work changes and work satisfaction. A work adaptability, partnership, growth, affection, resolve (APGAR) score was included in the final questionnaire. Multivariate logistic regression was used to identify factors predicting the absence of back disorders. Absence of physically heavy work predicted an absence of back disorders [odds ratio (OR), 2.86; 95% confidence interval (CI), 1.3-6.3] in the older group. In the younger age-group, the absence of stressful work predicted absence of back disorders (OR, 2.0; 95% CI, 1.1-3.6). Thirty-seven per cent of the younger age-group and 43% of the older age-group did not experience any back pain episodes during the study period. The exploratory work APGAR scores indicated that back disorders were only associated with lower work satisfaction in the older group. The analyses point out the importance of avoiding perceived psychological stress in the young and avoiding perceived physically heavy work in the older age-group for avoiding back disorders. The results suggest a need for different programmes at workplaces to avoid back disorders depending on the age of the employees concerned.

Clinical findings in a population with back pain. Relation to one-year outcome and long-term sick leave.

OBJECTIVE: To investigate whether physical examination findings can be used in predicting recovery from back pain and new episodes of sick leave. DESIGN: One-year prospective study of a single cohort. SETTINGS: Semi-rural Swedish county. POPULATION: A cross-section of a general population with back pain (207 women, 176 men) between 20 and 59 years of age. MAIN OUTCOME MEASURES: Cumulative incidence of sick leave due to back pain, cumulative incidence of sick leave due to back pain > 30 days, incidence of recovery from back pain. RESULTS: For recovery from pain, the absence of tenderness in the trapezius muscle (OR 0.33; CI 0.1-0.5) was predictive. New sick leave was predicted by tenderness in the trapezius muscle (OR 2.67; CI 1.5-4.9), and had a tendency to be associated with a flattened lumbar lordosis and a restricted cervical range of motion. For long-term sick leave, the same findings and also observation of scoliosis (OR 3.44; CI 1.1-10.5) were predictive. CONCLUSION: There are subgroups with back pain predisposed to development of more persistent symptoms and a higher risk for sick-listing.

The epidemiology of back pain in vocational age groups.

OBJECTIVES: To investigate the prevalence of back pain in a general population aged between 20 and 59 years. POPULATION: A representative sample of 2000 individuals from Ostergotland County, Sweden (population 400,000). STUDY DESIGN: Cross-sectional study using a questionnaire including the pain drawing. RESULTS: The observed point prevalence was 28% (95% confidence interval 26-31%). The adjusted prevalence taking into account the non-responders was 23% (21-25%). Lumbar pain with radiation was reported by 40%, while 4% had only cervical pain with radiation. Twelve per cent were on sick-leave due to back pain. Activity of daily life was affected mainly in the group of men aged 40-59 and only in household tasks. The back problems did not affect social activity. CONCLUSIONS: The prevalence of back problems in the vocational ages was found to be 23%. Only small parts of a pain population are on sick-leave or have changed working tasks because of back problems. The distribution of pain in most cases is combined with radiation to extremities and not isolated to a single region. The combination of different localisations shows the pain problem to be more than just a "low back" problem.

Pain drawing evaluation--the problem with the clinically biased surgeon. Intra- and interobserver agreement in 50 cases related to clinical bias.

To assess whether the clinical knowledge of the treating surgeon had any effect on the reliability of the pain-drawing evaluation, drawings from 50 low-back pain patients were evaluated by the treating surgeon and by three colleagues who had no clinical knowledge of the patient. The evaluation was repeated after 10 days. The treating surgeons were also blinded to clinical data. The kappa value in the evaluation when the surgeon had clinical knowledge of the patient was lower (0.29 (95% Cl 0.13-0.45)) than the kappa value in the evaluations made without clinical knowledge (0.60 (Cl 0.45-0.75)). The differences observed in interobserver reliability between open and blind evaluations suggest that clinical knowledge of a patient influences the evaluation of the pain drawings.

Power output for wheelchair driving on a treadmill compared with arm crank ergometry.

OBJECTIVES: The limiting factors with regard to power output available for wheelchair ambulation have not been identified. The aim of the present study was to correlate power output during wheelchair driving with (i) power output and oxygen uptake during arm crank ergometry and (ii) arm muscle strength. METHODS: Eleven disabled men were examined for maximal power output (POmax) during wheelchair driving on a treadmill and during arm crank ergometry. Oxygen uptake (VO2) was recorded at submaximal and maximal arm crank ergometry in all men and during submaximal wheelchair driving on a treadmill in four men. Power output during wheelchair driving on a treadmill was measured. Static and dynamic elbow muscle strength was measured isokinetically. RESULTS: POmax was significantly lower (P < 0.001) for wheelchair driving (109 (31) W; mean (SD)) than for arm ergometry (163 (49) W). There was a significant correlation between POmax for arm crank ergometry and wheelchair driving (r = 0.73). There was no correlation between POmax and elbow strength. The mechanical efficiency was constant for the different levels on the arm crank ergometry test. The submaximal testing showed a consistently lower mechanical efficiency for wheelchair driving than for arm crank ergometry. CONCLUSIONS: It is suggested that the lower level of power output for wheelchair driving is fully explained by the lower mechanical efficiency. Any improvement in power output available for ambulation must be based on wheelchair ergonomics.

Postural corrections after standardised perturbations of single limb stance: effect of training and orthotic devices in patients with ankle instability.

OBJECTIVE: Soccer players with functional instability of the ankle joint have shown impairment of postural control in single limb stance. The aim of this study was to examine the effect of stance perturbation. METHODS: A standardised method for the study of postural corrections after perturbation (Equitest) was used. Female soccer players with and without functional instability were examined. RESULTS: The subjects showed a relative change from ankle to hip synergy at medially directed translations of the support surface. This impairment was restored after eight weeks of ankle disk training. The effect of a shoe and brace did not exceed the effect of the shoe alone. CONCLUSIONS: Functional instability seems to be related to impaired ability to retain equilibrium in single limb stance by means of ankle corrections. A positive effect of ankle disk training leading to functional restoration was confirmed.

Development of an instrument for clinical evaluation after surgery for neuromuscular scoliosis.

Surgical treatment for neuromuscular scoliosis is effective for most patients. Although those afflicted constitute a heterogeneous group, the aim of surgical treatment is approximately the same for all patients: a spine balanced in the coronal and sagittal planes over a level pelvis. Surgery results in a more stable and straighter spine, which should in turn improve performance in different activities. Previous evaluations of surgery for neuromuscular scoliosis reported in the literature have focused primarily on Cobb angles; there are very few studies dealing with the ability to perform various activities. A new tool for evaluation was developed in several steps, starting with a telephone interview with patients who had undergone surgery and a literature search. The evaluation instrument was then developed, followed by a pilot study and validation of new parts of the instrument. The instrument focuses on performance components and on activity performance. Eight items are evaluated before and after surgery. These data are complemented by a questionnaire administered to the patient or relatives at follow-up. The new parts of the instrument were developed specifically for patients with neuromuscular scoliosis, and the data obtained have been shown to have a high correlation with established measures of activities of daily living of daily living). They should therefore provide us with useful information concerning functional gains as a result of surgery as well as the effect of surgery on activity performance.

Can a pharmacological pain analysis in patients with chronic low back pain predict the outcome of lumbar fusion? Preliminary report.

Chronic low back pain patients chosen for lumbar fusion surgery were entered into a prospective study with the aim of evaluating whether pre-operative pharmacological pain classification correlated with the outcome of surgical treatment. Twenty consecutive patients (mean age 39 years, range 29-50 years) with a mean pain duration of 4.6 years (range 1-8 years) participated. The patients' pain, disability and work situation were evaluated pre- and post-operatively. According to the results of pharmacological pain testing the patients were classified into five pain groups: (1) those with nociceptive pain, (2) those with neuropathic pain, (3) placebo responders, (4) non-responders and (5) unclassified. This classification was based on the following approaches: intravenous morphine, intravenous lidocaine, epidurally administered fentanyl and a local anaesthetic. Surgical treatment consisted of posterolateral fusion of the lower two functional lumbosacral spinal units combined, if necessary with appropriate decompression. The results of the pharmacological pain assessment were not disclosed until the end of the follow-up period and outcome was evaluated by an unbiased observer. The distribution of patients between pain groups was as follows; nine had nociceptive pain, two suffered neuropathic pain, there were no placebo responders and seven were non-responders. Two patients could not be classified into any of these groups. Outcome was rated at 6, 12 and 24 months as excellent/good in eight out of nine patients with nociceptive pain. In the group with non-responding pain surgical outcome was significantly poorer (P < 0.01), and was ranked as excellent/good in only one out of seven patients. There was a significant improvement (P < 0.05) concerning both pain and disability in the nociceptive group, but not in the non-responding group. Pre-operative pharmacological pain testing may be useful as a predictor of surgical outcome and we suggest that it can be employed as a means to identify patients with non-responding pain and poor surgical prognosis.

Can a pharmacological pain analysis be used in the assessment of chronic low back pain?

A battery of pharmacological tests was used to differentiate the pain in patients with chronic low back pain (CLBP) referred for pain diagnosis and assessment of whether surgery was indicated or not. Forty patients (mean age 39 years, range 22-51 years) suffering from CLBP (mean pain duration 5.9 years, range 1-12 years) participated. Three pharmacological approaches were used: (1) intravenous infusion of morphine, (2) intravenous infusion of lidocaine and (3) a diagnostic epidural opioid blockade. The patients were tested in a single-blind, placebo-controlled fashion. The pain was considered nociceptive if it decreased by 50% or more in response to both intravenous morphine and epidural fentanyl, but increased in response to intravenous naloxone. The pain was considered neuropathic if it decreased by 50% or more in response to both intravenous lidocaine and the epidural local anaesthetic. Patients who registered a pain decrease of 50% or more in response to saline were classified as placebo responders. Those who registered less than 50% pain decrease in all the tests were considered nonresponders. According to the results of the tests, 16 of the patients were classified as having nociceptive pain, 8 neuropathic pain, 2 were placebo responders, 10 non-responders and 4 were unclassified. The results support the idea that this battery of pharmacological tests can be used in the classification of CLBP patients into different pain categories. This approach may prove useful as a guide for further patient evaluation and as a basis for choice of a suitable treatment strategy.

Ankle performance after ankle fracture: a randomized study of early mobilization.

In a prospective, randomized study, 30 patients were evaluated after ankle fracture treated by means of open reduction and internal fixation. The patients were randomized to either postoperative immobilization in a plaster cast for 6 weeks or early mobilization (1-2 weeks after surgery) in an ankle brace. Both regimens allowed weightbearing. Evaluation after 10 weeks and after 12 months included clinical assessment and isokinetic muscle strength measurements. Patients with impaired ankle function, as shown by means of an ankle score at 12 months, were followed for 3 years. At 10 weeks, impaired muscle torque and restricted range of motion was found on the affected side. This impairment was significantly less in the brace group. At 12 months, range of motion of the ankle and subtalar joints was restored, but dorsiflexion was still better in the brace group. Score values from a functional score did not correlate with muscle strength.