Work ability and physical activity after major bone sarcoma resection and reconstruction with tumour prosthesis of the lower extremities. A cross-sectional study.

PURPOSE: The aim of this study was to evaluate work ability, activity limitations and physical activity in adults that had gone through major bone sarcoma resection and reconstruction surgery in hip and knee. MATERIALS AND METHODS: Twenty patients, of 72 enrolled, and 20 controls were included in this cross-sectional study. Work Ability Index scores (general [0-10 points], physical and mental [1-5 points]), the Patient Specific Functional Scale (0-10 points), step counts and the International Physical Activity Questionnaire (IPAQ) were assessed. Adjusted and unadjusted general linear models were applied. RESULTS: The patients had a mean age of 43 (range, 20-71) years and were assessed 7 years (range, 2-12) after surgery (proximal femoral n = 9, distal femoral n = 7, proximal tibia n = 4). Compared with controls, patients had lower general work ability (mean difference [95%CI], -1.3 points [-2.1, -0.5]) and work ability in relation to physical demands at work (-1.4 points [-2.0, -0.8]). The patients reported higher severities of activity limitation (-6.7 points [-7.9, -5.4]). There were no between-group differences in step counts or IPAQ-scores. CONCLUSION: Despite similar levels of physical activity, patients showed poorer work ability and severe activity limitation. Post-operative rehabilitation in patients of the working-age population should include assessments of work ability and activities important to the individual.IMPLICATIONS FOR REHABILITATIONAdults that have gone through resection and reconstruction surgery following bone sarcoma in lower extremity show clinically relevant reductions in work ability and self-selected activitiesTo tailor post-operative rehabilitation at short and long term, initial assessment and monitoring should include work ability and activities important to the individual patient.

Clinically Important Reductions in Physical Function and Quality of Life in Adults with Tumor Prostheses in the Hip and Knee: A Cross-sectional Study.

BACKGROUND: Patients with a bone sarcoma who undergo limb-sparing surgery and reconstruction with a tumor prosthesis in the lower extremity have been shown to have reduced self-reported physical function and quality of life (QoL). To provide patients facing these operations with better expectations of future physical function and to better evaluate and improve upon postoperative interventions, data from objectively measured physical function have been suggested. QUESTIONS/PURPOSES: We sought to explore different aspects of physical function, using the International Classification of Functioning, Disability, and Health (ICF) as a framework, by asking: (1) What are the differences between patients 2 to 12 years after a bone resection and reconstruction surgery of the hip and knee following resection of a bone sarcoma or giant cell tumor of bone and age-matched controls without walking limitations in ICF body functions (ROM, muscle strength, pain), ICF activity and participation (walking, getting up from a chair, daily tasks), and QoL? (2) Within the patient group, do ICF body functions and ICF activity and participation outcome scores correlate with QoL? METHODS: Between 2006 and 2016, we treated 72 patients for bone sarcoma or giant cell tumor of bone resulting in bone resection and reconstruction with a tumor prosthesis of the hip or knee. At the timepoint for inclusion, 47 patients were alive. Of those, 6% (3 of 47) had undergone amputation in the lower limb and were excluded. A further 32% (14 of 44) were excluded because of being younger than 18 years of age, pregnant, having long transportation, palliative care, or declining participation, leaving 68% (30 of 44) for analysis. Thus, 30 patients and 30 controls with a mean age of 51 ± 18 years and 52 ± 17 years, respectively, were included in this cross-sectional study. Included patients had been treated with either a proximal femoral (40% [12 of 30]), distal femoral (47% [14 of 30]), or proximal tibia (13% [4 of 30]) reconstruction. The patients were assessed 2 to 12 years (mean 7 ± 3 years) after the resection-reconstruction. The controls were matched on gender and age (± 4 years) and included if they considered their walking capacity to be normal and had no pain in the lower extremity. Included outcome measures were: passive ROM of hip flexion, extension, and abduction and knee flexion and extension; isometric muscle strength of knee flexion, knee extension and hip abduction using a hand-held dynamometer; pain intensity (numeric rating scale; NRS) and distribution (pain drawing); the 6-minute walk test (6MWT); the 30-second chair-stand test (CST); the Toronto Extremity Salvage Score (TESS), and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The TESS and the EORTC QLQ-C30 were normalized to 0 to 100 points. Higher scoring represents better status for TESS and EORTC global health and physical functioning scales. Minimum clinically important difference for muscle strength is 20% to 25%, NRS 2 points, 6MWT 14 to 31 meters, CST 2 repetitions, TESS 12 to 15 points, and EORTC QLQ-C30 5 to 20 points. RESULTS: Compared with controls, the patients had less knee extension and hip abduction strength in both the surgical and nonsurgical limbs and regardless of reconstruction site. Mean knee extension strength in patients versus controls were: surgical limb 0.9 ± 0.5 Nm/kg versus 2.1 ± 0.6 Nm/kg (mean difference -1.3 Nm/kg [95% CI -1.5 to -1.0]; p < 0.001) and nonsurgical limb 1.7 ± 0.6 Nm/kg versus 2.2 ± 0.6 Nm/kg (mean difference -0.5 Nm/kg [95% CI -0.8 to -0.2]; p = 0.003). Mean hip abduction strength in patients versus controls were: surgical limb 1.1 ± 0.4 Nm/kg versus 1.9 ± 0.5 Nm/kg (mean difference -0.7 Nm/kg [95% CI -1.0 to -0.5]; p < 0.001) and nonsurgical limb 1.5 ± 0.4 Nm/kg versus 1.9 ± 0.5 Nm/kg (-0.4 Nm/kg [95% CI -0.6 to -0.2]; p = 0.001). Mean hip flexion ROM in patients with proximal femoral reconstructions was 113° ± 18° compared with controls 130° ± 11° (mean difference -17°; p = 0.006). Mean knee flexion ROM in patients with distal femoral reconstructions was 113° ± 29° compared with patients in the control group 146° ± 9° (mean difference -34°; p = 0.002). Eighty-seven percent (26 of 30) of the patients reported pain, predominantly in the knee, anterior thigh, and gluteal area. The patients showed poorer walking and chair-stand capacity and had lower TESS scores than patients in the control group. Mean 6MWT was 499 ± 100 meters versus 607 ± 68 meters (mean difference -108 meters; p < 0.001), mean CST was 12 ± 5 repetitions versus 18 ± 5 repetitions (mean difference -7 repetitions; p < 0.001), and median (interquartile range) TESS score was 78 (21) points versus 100 (10) points (p < 0.001) in patients and controls, respectively. Higher pain scores correlated to lower physical functioning of the EORTC QLQ-C30 (Rho -0.40 to -0.54; all p values < 0.05). Less muscle strength in knee extension, knee flexion, and hip abduction correlated to lower physical functioning of the EORTC QLQ-C30 (Rho 0.40 to 0.51; all p values < 0.05). CONCLUSION: This patient group demonstrated clinically important muscle weaknesses not only in resected muscles but also in the contralateral limb. Many patients reported pain, and they showed reductions in walking and chair-stand capacity comparable to elderly people. The results are relevant for information before surgery, and assessments of objective physical function are advisable in postoperative monitoring. Prospective studies evaluating the course of physical function and which include assessments of objectively measured physical function are warranted. Studies following this patient group with repetitive measures over about 5 years could provide information about the course of physical function, enable comparisons with population norms, and lead to better-designed, targeted, and timely postoperative interventions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial.

BACKGROUND: There are indications of beneficial short-term effect of pre-operative exercise in reducing pain and improving activity of daily living after total hip replacement (THR) and total knee replacement (TKR) surgery. Though, information from studies conducting longer follow-ups and economic evaluations of exercise prior to THR and TKR is needed. The aim of the study was to analyse 12-month clinical effect and cost-utility of supervised neuromuscular exercise prior to THR and TKR surgery. METHODS: The study was conducted alongside a randomised controlled trial including 165 patients scheduled for standard THR or TKR at a hospital located in a rural area of Denmark. The patients were randomised to replacement surgery with or without an 8-week preoperative supervised neuromuscular exercise program (Clinical Trials registration no.: NCT01003756). Clinical effect was measured with Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Quality adjusted life years (QALYs) were based on EQ-5D-3L and Danish preference weights. Resource use was extracted from national registries and valued using standard tariffs (2012-EUR). Incremental net benefit was analysed to estimate the probability for the intervention being cost effective for a range of threshold values. A health care sector perspective was applied. RESULTS: HOOS/KOOS quality of life [8.25 (95% CI, 0.42 to 16.10)] and QALYs [0.04 (95% CI, 0.01 to 0.07)] were statistically significantly improved. Effect-sizes ranged between 0.09-0.59 for HOOS/KOOS subscales. Despite including an intervention cost of €326 per patient, there was no difference in total cost between groups [€132 (95% CI -3942 to 3679)]. At a threshold of €40,000, preoperative exercise was found to be cost effective at 84% probability. CONCLUSION: Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery at conventional thresholds for willingness to pay. One-year clinical effects were small to moderate and favoured the intervention group, but only statistically significant for quality of life measures. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01003756 ) October 28, 2009.

Long-Term Effect of Exercise Therapy and Patient Education on Impairments and Activity Limitations in People With Hip Osteoarthritis: Secondary Outcome Analysis of a Randomized Clinical Trial.

BACKGROUND: The effect of exercise on specific impairments and activity limitations in people with hip osteoarthritis (OA) is limited. OBJECTIVE: The study objective was to evaluate the long-term effect of exercise therapy and patient education on range of motion (ROM), muscle strength, physical fitness, walking capacity, and pain during walking in people with hip OA. DESIGN: This was a secondary outcome analysis of a randomized clinical trial. SETTING: The setting was a university hospital. PARTICIPANTS: One hundred nine people with clinically and radiographically evident hip OA were randomly allocated to receive both exercise therapy and patient education (exercise group) or patient education only (control group). INTERVENTION: All participants attended a patient education program consisting of 3 group meetings led by 2 physical therapists. Two other physical therapists were responsible for providing the exercise therapy program, consisting of 2 or 3 weekly sessions of strengthening, functional, and stretching exercises over 12 weeks. Both interventions were conducted at a sports medicine clinic. MEASUREMENTS: Outcome measures included ROM, isokinetic muscle strength, predicted maximal oxygen consumption determined with the Astrand bicycle ergometer test, and distance and pain during the Six-Minute Walk Test (6MWT). Follow-up assessments were conducted 4, 10, and 29 months after enrollment by 5 physical therapists who were unaware of group allocations. RESULTS: No significant group differences were found for ROM, muscle strength, predicted maximal oxygen consumption, or distance during the 6MWT over the follow-up period, but the exercise group had less pain during the 6MWT than the control group at 10 months (mean difference=-8.5 mm; 95% confidence interval=-16.1, -0.9) and 29 months (mean difference=-9.3 mm; 95% confidence interval=-18.1, -0.6). LIMITATIONS: Limitations of the study were reduced statistical power and 53% rate of adherence to the exercise therapy program. CONCLUSIONS: The previously described effect of exercise on self-reported function was not reflected by beneficial results for ROM, muscle strength, physical fitness, and walking capacity, but exercise in addition to patient education resulted in less pain during walking in the long term.

Gait Characteristics, Symptoms, and Function in Persons With Hip Osteoarthritis: A Longitudinal Study With 6 to 7 Years of Follow-up.

STUDY DESIGN: Longitudinal laboratory study. OBJECTIVES: (1) To compare gait characteristics between individuals with early-stage hip osteoarthritis who underwent total hip replacement (THR) and those who did not undergo THR, and (2) to evaluate whether gait characteristics, function, and symptoms declined among individuals who did not undergo THR during a 6- to 7-year follow-up. BACKGROUND: The natural history of symptoms, function, and gait changes secondary to hip osteoarthritis, including potential differences at an early stage of disease, is unknown. METHODS: Forty-three individuals (mean age, 58.9 years) with radiographic and symptomatic hip osteoarthritis participated. Outcome measures included 3-D gait analysis; self-reported pain, stiffness, and function; hip range of motion; and the six-minute walk test. Baseline comparisons between individuals who later underwent THR and those who did not undergo THR were made using independent t tests or Mann-Whitney U tests. Comparisons of baseline measures and 6- to 7-year follow-up for the nonoperated individuals were conducted with paired-samples t tests or Wilcoxon signed-rank tests (P<.05). RESULTS: Twelve (27.9%) of the 43 individuals initially evaluated had not undergone THR at the 6- to 7-year follow-up. At baseline, these individuals had larger sagittal plane hip and knee joint excursions, larger joint space width, lower body mass index, and superior self-reported function compared with the individuals who later underwent THR. At the 6- to 7-year follow-up, the individuals who did not undergo THR exhibited no decline in gait characteristics, minimum joint space, or overall function. Furthermore, their self-reported pain had significantly decreased (P = .024). CONCLUSION: Individuals who did not undergo THR during a 6- to 7-year follow-up period did not exhibit a decline in gait, function, or symptoms compared to those who underwent THR. These findings are suggestive of a phenotype of hip osteoarthritis with a very slow disease progression, particularly in regard to pain. LEVEL OF EVIDENCE: Prognosis, level 1b.

No effects of a 12-week supervised exercise therapy program on gait in patients with mild to moderate osteoarthritis: a secondary analysis of a randomized trial.

BACKGROUND: It is unknown whether gait biomechanics in hip osteoarthritis patients with mild to moderate symptoms change following exercise therapy interventions. The aim of the present study was to compare stance phase gait characteristics in hip osteoarthritis patients with mild to moderate symptoms participating in a randomized trial with two different interventions; patient education only or patient education followed by a 12-week supervised exercise therapy program. RESULTS: The study was conducted as a secondary analysis of a single-blinded randomized controlled trial. Patients aged 40 to 80 years, with hip osteoarthritis verified from self-reported pain and radiographic changes, were included. The final material comprised 23 patients (10 males/13 females, mean (SD) age 58.2 (10.02) years) in the patient education only group, and 22 patients (9 males/13 females, mean (SD) age 60.2 (9.49) years) in the patient education + exercise therapy group. Three-dimensional gait analysis was conducted at baseline and at four month follow-up. Sagittal and frontal plane joint angle displacement and external joint moments of the hip, knee and ankle were compared from a one-way analysis of covariance between the groups at follow-up, with baseline values as covariates (p < 0.05). No group differences were observed at the four-month follow-up in gait velocity, joint angle displacement, or moments. As the compliance in the exercise therapy group was inadequate, we calculated possible associations between the number of completed exercise sessions and change in each of the kinematic or kinetic variables. Associations were weak to neglible. Thus, the negative findings in this study cannot be explained from inadequate compliance alone, but most likely also suggest the exercise therapy program itself to be insufficient to engender gait alterations. CONCLUSIONS: Adding a 12-week supervised exercise therapy program to patient education did not induce changes in our selected biomechanical variables during the stance phase of gait, even when adjusting for poor compliance. Thus, we did not find evidence to support our exercise therapy program to be an efficacious intervention to induce gait alterations in this population of hip osteoarthritis patients. TRIAL REGISTRATION: NCT00319423 at ClinicalTrials.gov (registration date 2006-04-26).

Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial.

BACKGROUND: Exercise treatment is recommended for all patients with hip osteoarthritis (OA), but its effect on the long-term need for total hip replacement (THR) is unknown. METHODS: We conducted a long-term follow-up of a randomised trial investigating the efficacy of exercise therapy and patient education versus patient education only on the 6-year cumulative survival of the native hip to THR in 109 patients with symptomatic and radiographic hip OA. Results regarding the primary outcome measure of the trial, self-reported pain at 16 months follow-up, have been reported previously. RESULTS: There were no group differences at baseline. The response rate at follow-up was 94%. 22 patients in the group receiving both exercise therapy and patient education and 31 patients in the group receiving patient education only underwent THR during the follow-up period, giving a 6-year cumulative survival of the native hip of 41% and 25%, respectively (p=0.034). The HR for survival of the native hip was 0.56 (CI 0.32 to 0.96) for the exercise therapy group compared with the control group. Median time to THR was 5.4 and 3.5 years, respectively. The exercise therapy group had better self-reported hip function prior to THR or end of study, but no significant differences were found for pain and stiffness. CONCLUSIONS: Our findings in this explanatory study suggest that exercise therapy in addition to patient education can reduce the need for THR by 44% in patients with hip OA. ClinicalTrials.gov number NCT00319423 (original project protocol) and NCT01338532 (additional protocol for long-term follow-up).

Weight-bearing asymmetries during Sit-To-Stand in patients with mild-to-moderate hip osteoarthritis.

The Sit-To-Stand (STS) transition is a mechanically demanding task that may pose particular challenges for individuals with lower limb osteoarthritis (OA). Biomechanical features of STS have been investigated in patients with OA, but not in patients with early stage hip OA. The purpose of this study was to explore inter-limb weight-bearing asymmetries (WBA) and selected kinematic and kinetic variables during STS in patients with mild-to-moderate hip OA compared with healthy controls. Twenty-one hip OA patients and 23 controls were included in the study. Sagittal and frontal plane kinematic and kinetic data were collected using an eight-camera motion analysis system synchronized with two force plates embedded in the floor. There were no distinctive biomechanical alterations in sagittal or frontal plane kinematics or kinetics, movement time, or time to reach peak ground reaction force (GRF) in hip OA patients compared with controls. However, the hip OA patients revealed a distinct pattern of WBA compared with the controls, in unloading their involved limb by 18.4% at peak GRF. These findings indicate that patients with early stage hip OA are not yet forced into a stereotypical movement strategy for STS; however, the observed pattern of WBA requires clinical attention.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Sagittal plane gait characteristics in hip osteoarthritis patients with mild to moderate symptoms compared to healthy controls: a cross-sectional study.

BACKGROUND: Existent biomechanical studies on hip osteoarthritic gait have primarily focused on the end stage of disease. Consequently, there is no clear consensus on which specific gait parameters are of most relevance for hip osteoarthritis patients with mild to moderate symptoms. The purpose of this study was to explore sagittal plane gait characteristics during the stance phase of gait in hip osteoarthritis patients not eligible for hip replacement surgery. First, compared to healthy controls, and second, when categorized into two subgroups of radiographic severity defined from a minimal joint space of ≤/>2 mm. METHODS: Sagittal plane kinematics and kinetics of the hip, knee and ankle joint were calculated for total joint excursion throughout the stance phase, as well as from the specific events initial contact, midstance, peak hip extension and toe-off following 3D gait analysis. In addition, the Western Ontario and McMaster Universities Osteoarthritis Index, passive hip range of motion, and isokinetic muscle strength of hip and knee flexion and extension were included as secondary outcomes. Data were checked for normality and differences evaluated with the independent Student's t-test, Welch's t-test and the independent Mann-Whitney U-test. A binary logistic regression model was used in order to control for velocity in key variables. RESULTS: Fourty-eight hip osteoarthritis patients and 22 controls were included in the final material. The patients walked significantly slower than the controls (p=0.002), revealed significantly reduced joint excursions of the hip (p<0.001) and knee (p=0.011), and a reduced hip flexion moment at midstance and peak hip extension (p<0.001). Differences were primarily manifested during the latter 50% of stance, and were persistent when controlling for velocity. Subgroup analyses of patients with minimal joint space ≤/>2 mm suggested that the observed deviations were more pronounced in patients with greater radiographic severity. The biomechanical differences were, however, not reflected in self-reported symptoms or function. CONCLUSIONS: Reduced gait velocity, reduced sagittal plane joint excursion, and a reduced hip flexion moment in the late stance phase of gait were found to be evident already in hip osteoarthritis patients with mild to moderate symptoms, not eligible for total hip replacement. Consequently, these variables should be considered as key features in studies regarding hip osteoarthritic gait at all stages of disease. Subgroup analyses of patients with different levels of radiographic OA further generated the hypothesis that the observed characteristics were more pronounced in patients with a minimal joint space ≤2 mm.

Validity and responsiveness of the Measure of Activity Performance of the Hand (MAP-Hand) in patients with hand osteoarthritis.

BACKGROUND: The Measure of Activity Performance of the Hand (MAP-Hand) is reliable and valid in patients with rheumatoid arthritis. OBJECTIVE: To assess the validity and responsiveness of the MAP-Hand in patients with hand osteoarthritis. METHODS: Patients were recruited from 2 rheumatology centres. The internal consistency of the MAP-Hand was assessed by Cronbach's α. Content validity was evaluated based on patient interviews. Construct validity and responsiveness were based on predefined hypotheses of correlation between the MAP-Hand and concurrent measures. RESULTS: Ten men and 201 women, mean age 62.8 years (standard deviation (SD) 6.8) and disease duration 12.5 (SD 7.5) years were included. A Cronbach's α of 0.86 was determined. All 18 items in the MAP-Hand were described in the interviews. Sixty-seven percent of the correlation coefficients for baseline scores and 75% for change scores were in correspondence with the predefined hypotheses. A high correlation was found between the MAP-Hand and the Australian/Canadian Hand Osteoarthritis Index function score at baseline (rho = 0.76). A moderate correlation was found for change scores (rho = 0.52). CONCLUSION: The content of the MAP-Hand adequately reflects described activity limitations in patients with hand osteoarthritis. The results suggest that the MAP-Hand has adequate internal consistency and responsiveness. Before the MAP-Hand is used in patients with hand osteoarthritis, evaluations of reliability and further construct validity are warranted.

Cross-cultural adaptation and validation of the Norwegian pain catastrophizing scale in patients with low back pain.

BACKGROUND: Pain catastrophizing has been found to be an important predictor of disability and days lost from work in patients with low back pain. The most commonly used outcome measure to identify pain catastrophizing is the Pain Catastrophizing Scale (PCS). To enable the use of the PCS in clinical settings and research in Norwegian speaking patients, the PCS had to be translated. The purpose of this study was therefore to translate and cross-culturally adapt the PCS into Norwegian and to test internal consistency, construct validity and reproducibility of the PCS. METHODS: The PCS was translated before it was tested for psychometric properties. Patients with subacute or chronic non-specific low back pain aged 18 years or more were recruited from primary and secondary care. Validity of the PCS was assessed by evaluating data quality (missing, floor and ceiling effects), principal components analysis, internal consistency (Cronbach's alpha), and construct validity (Spearman's rho). Reproducibility analyses included standard error of measurement, minimum detectable change, limits of agreement, and intraclass correlation coefficients. RESULTS: A total of 38 men and 52 women (n = 90), with a mean (SD) age of 47.6 (11.7) years, were included for baseline testing. A subgroup of 61 patients was included for test-retest assessments. The Norwegian PCS was easy-to-comprehend. The principal components analysis supported a three-factor structure, internal consistency was satisfactory for the PCS total score (α 0.90) and the subscales rumination (α 0.83) and helplessness (α 0.86), but not for the subscale magnification (α 0.53). In total, 86% of the correlation analyses were in accordance with predefined hypothesis. The reliability analyses showed intraclass correlation coefficients of 0.74 - 0.87 for the PCS total score and subscales. The PCS total score (range 0-52 points) showed a standard error of measurement of 4.6 points and a 95% minimum detectable change estimate of 12.8 points. CONCLUSIONS: The Norwegian PCS total score showed acceptable psychometric properties in terms of comprehensibility, consistency, construct validity, and reproducibility when applied to patients with subacute or chronic LBP from different clinical settings. Our study support the use of the PCS total score for clinical or research purposes identifying or evaluating pain catastrophizing.

Daily use of a cane for two months reduced pain and improved function in patients with knee osteoarthritis.

QUESTION: Does daily use of a cane for two months produce clinical benefits in patients with knee osteoarthritis (OA)? DESIGN: A randomised, controlled trial where group allocation was carried out by computer-generated randomisation in a 1:1 ratio. SETTING: An outpatient rheumatology clinic in Sao Paulo, Brazil. PARTICIPANTS: Men and women with the diagnosis of knee OA according to the American College of Rheumatology criteria, knee pain score between 3 and 7 (on a 0-10 Visual Analogue Scale), stable doses of non-steroidal anti-inflammatory drugs (NSAIDs), and no regular physical exercise or use of canes in the months prior to the study. Additional exclusion criteria were: symptomatic heart disease, symptomatic disease of the lower limbs (other than knee osteoarthritis) or of the upper limb that would hold the cane, symptomatic lung disease, severe systemic disease, and severe psychiatric illness. INTERVENTIONS: Each participant in the intervention group received an individually height adjusted wooden cane with a T-shaped handle and instruction in how to use it on the contralateral side at the start of the intervention and after one month. They were instructed to use the cane daily. The participants in the control group were instructed not use any gait device for two months, but otherwise to maintain their normal lives including treatment as usual. OUTCOME MEASURES: The primary outcome was pain measured on a 0-10 Visual Analogue Scale at one and two months. Secondary outcomes were function measured with the Lequesne knee questionnaire and the Western Ontario and McMaster Universities (WOMAC) questionnaire), health related quality of life (SF-36), energy expenditure during a 6-minute walk test, and consumption of NSAIDs. RESULTS: In total 64 patients were assigned to the intervention (n=32) and control groups (n=32), and 59 completed the two month follow-up. Mean differences in pain were 0.8 (95% CI 0.3 to 1.3) at one month follow up and 2.1 (95% CI 1.4 to 2.8) at two months, both in the favour of the intervention group. There were significant differences in favour of the intervention group in Lequesne knee questionnaire, SF-36 Bodily Pain and Role Physical scores, and consumption of NSAIDs. CONCLUSION: Use of a cane can diminish pain and improve physical functioning in patients with knee osteoarthritis. [95% CIs calculated by the CAP Editors.].

Functioning and disability in patients with hip osteoarthritis with mild to moderate pain.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To compare functioning and disability in patients with hip osteoarthritis (OA) not candidates for surgery, to a matched control group, and thereby to examine the relationship between the functioning and disability components used in this study in patients with hip OA. BACKGROUND: It is well known that patients with severe hip OA have deficits in functioning and disability. However, in patients with hip OA not candidates for surgery, the knowledge regarding functioning and disability is sparse. METHODS: Twenty-six patients (12 men, 14 women; mean age, 60 years) with radiographic and symptomatic hip OA were matched to 26 controls without hip pain. The following variables were measured: muscle strength using isokinetic peak force, hip passive range of motion, submaximal aerobic capacity using a cycling test, walking ability using the 6-minute walk test, self-reported pain, stiffness, and physical function using the Western Ontario and McMaster University Osteoarthritis Index, and health-related quality of life using the SF-36. RESULTS: The patients with hip OA had mild to moderate pain, as indicated by the Western Ontario and McMaster University Osteoarthritis Index, and significantly lower knee extension strength (mean difference [95% confidence interval {CI}]: -19.5 [-34.3, -4.7] Nm). Hip range of motion was significantly less in the patients with hip OA, with mean (95% CI) differences of -10° (-14°, -6°) for extension, -18° (-26°, -11°) for flexion, -9° (-14°, -4°) for abduction, -2° (-5°, 0°) for adduction, -16° (-23°, -9°) for internal rotation, and -21° (-28°, -14°) for external rotation. The patients with hip OA walked a significantly shorter distance in 6 minutes (mean difference, -75 m; 95% CI: -131, -20 m). There were no significant differences in hip extension/flexion, knee flexion, ankle dorsiflexion/plantar flexion muscle strength, or aerobic capacity between the 2 groups. There were significant associations between body function and activity components. CONCLUSION: Physical therapists should consider including quadriceps-strengthening and hip range-of-motion exercises when developing rehabilitation programs for patients with hip OA, with mild to moderate pain, aiming to improve functioning and reduce disability.

Development of a therapeutic exercise program for patients with osteoarthritis of the hip.

BACKGROUND AND PURPOSE: No detailed exercise programs specifically for patients with hip osteoarthritis (OA) have been described in the literature. This lack of data creates a gap between the recommendation that people with OA should exercise and the type and dose of exercises that they should perform. The purpose of this case report is to describe and demonstrate the use of a therapeutic exercise program for a patient with hip OA. CASE DESCRIPTION: A 58-year-old woman with hip OA completed a 12-week therapeutic exercise program (TEP) with a 6-month follow-up. The patient reported hip pain, joint stiffness, and limited physical function, and she had decreased hip range of motion (ROM) at baseline. OUTCOMES: The patient performed 19 sessions during the TEP, with a mean of 19.5 exercises per session. She increased the resistance in 3 of 5 strength (force-generating capacity) training exercises and achieved the highest degree of difficulty in all functional exercises. During the TEP and follow-up, the patient reported improvements in pain, joint stiffness, and physical function. Performance improved on the following physical tests: isokinetic peak torque strength (60 degrees /s) in hip extension (40%), hip flexion (27%), knee extension (17%), and knee flexion (42%); hip ROM extension (8 degrees ); and 6-minute walk distance (83 m). DISCUSSION: The patient experienced less pain and improved physical function and physical test outcomes after intervention and at the 6-month follow-up. The main challenges when prescribing an exercise program for a patient with hip OA are monitoring the exercises to provide improvements without provoking persistent pain and motivating the patient to achieve long-term adherence to exercising. Randomized clinical trials are needed to evaluate the efficacy of this TEP in patients with hip OA.

Muscle activity in pilots with and without pressure breathing during acceleration.

BACKGROUND: Fighter pilots are frequently exposed to high acceleration (+Gz) forces during sorties. To counter these forces the pilots wear anti-G ensembles, use positive pressure breathing for G protection (PBG), and perform anti-G straining maneuvers (AGSMs). The purpose of this study was to analyze the muscle activity during sustained high G when no positive pressure breathing was used (control) compared with that during the use of PBG. METHOD: Seven Swedish Air Force fighter pilots volunteered to be exposed to gradual and rapid onset runs to +9 Gz with and without PBG in a human centrifuge. Surface electromyography was recorded from the intercostals, rectus abdominis, vastus lateralis, biceps femoris, and gastrocnemius lateralis. Measured variables included mean muscle activity, relative time with high muscle activity levels, and individual activation preferences. RESULTS: G duration tolerance was significantly longer (p = 0.028) when PBG was used (57 s) compared with control (32 s) during rapid onset runs. The vastus lateralis and the gastrocnemius lateralis generated activity > 50% of a reference contraction for a longer relative time during control (5.8% and 33.6%, respectively) than during PBG (0.3% and 12.7%, respectively). Cumulative muscle activity during acceleration was compared between trials and indicated that some pilots preferred contracting their leg muscles and others their abdominal muscles. CONCLUSION: G duration tolerance time increased when PBG was used during rapid onset sustained exposures. Less relative time with high muscle activity was seen during the use of PBG in two groups of leg muscles. The pilots seemed to have individual muscle activation sequence preferences while performing the AGSMs.