Identifying latent subgroups in the older population seeking primary health care for a new episode of back pain - findings from the BACE-N cohort.

BACKGROUND: Back pain is the number one condition contributing to years lived with disability worldwide, and one of the most common reasons for seeking primary care. Research on this condition in the ageing population is sparse. Further, the heterogeneity of patients with back pain complicates the management in clinical care. It is possible that subgrouping people with similar characteristics would improve management. This paper aimed to identify latent classes based on demographics, pain characteristics, psychosocial behavior, and beliefs and attitudes about back pain, among older patients seeking primary care with a new episode of back pain, and to examine if there were differences regarding the classes' first point-of-contact. METHODS: The study was part of the international BACE (Back complaints in elders) consortium and included 435 patients aged ≥ 55 years seeking primary care (general practitioners, physiotherapists, and chiropractors) in Norway from April 2015 to March 2020. A latent class analysis was performed to identify latent classes. The classes were described in terms of baseline characteristics and first point-of-contact in primary care. RESULTS: Four latent classes were identified. The mean age was similar across groups, as were high expectations towards improvement. Class 1 (n = 169, 39%), the "positive" class, had more positive attitudes and beliefs, less pain catastrophizing and shorter duration of current pain episode. Class 2 (n = 31, 7%), the "fearful" class, exhibited the most fear avoidance behavior, and had higher mean pain intensity. Class 3 (n = 33, 8%), the "distressed" class, had the highest scores on depression, disability, and catastrophizing. Finally, class 4 (n = 202, 46%), the "hopeful" class, showed the highest expectations for recovery, although having high pain intensity. The identified four classes showed high internal homogeneity, sufficient between-group heterogeneity and were considered clinically meaningful. The distribution of first point-of-contact was similar across classes, except for the positive class where significantly more patients visited chiropractors compared to general practitioners and physiotherapists. CONCLUSIONS: The identified classes may contribute to targeting clinical management of these patients. Longitudinal research on these latent classes is needed to explore whether the latent classes have prognostic value. Validation studies are needed to evaluate external validity. TRIAL REGISTRATION: Clinicaltrials.gov NCT04261309.

The 6-m timed hop test is a prognostic factor for outcomes in patients with meniscal tears treated with exercise therapy or arthroscopic partial meniscectomy: a secondary, exploratory analysis of the Odense-Oslo meniscectomy versus exercise (OMEX) trial.

PURPOSE: To identify the prognostic factors for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears treated with exercise therapy (ET) or arthroscopic partial meniscectomy (APM). METHODS: One hundred and seven patients, with mean age 49.6 (SD 6.2) years and BMI 25.7 (SD 3.7), were included in this analysis of data from the OMEX trial ( http://www.clinicaltrials.gov NCT01002794). Linear and Poisson regression models were built to explore the associations between potential prognostic factors (patient characteristics, knee function-related and disease-related factors) and 2-year patient-reported outcomes: the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales Pain, Symptoms, ADL, Sport/Rec, QoL and 5-point Global Rating of Change scales for knee pain (GRC Pain) and function (GRC Function). Analyses were performed for the whole cohort and for the two treatment groups (n = 55 and 52) with adjustments for age, sex, BMI and baseline KOOS. RESULTS: For the whole cohort, a 1-s better baseline 6-m timed hop test result was associated with 3.1-7.1 points better 2-year scores for all KOOS subscales (95% CIs 1.1-5.2 to 4.1-10.1 points). A 1.61-2.80 s better test was associated with scores equivalent to previously calculated clinical relevant differences for each KOOS subscale. For the groups of patients treated with ET and APM, respectively, 2.09-3.60 s and 0.63-1.99 s better tests were associated with clinical relevant differences. For the whole cohort, a 1-s better test was associated with 26% (95% CI 15-38%) and 22% (95% CI 11-34%) higher possibility for better or much better GRC Pain and Function scores. Patients treated with ET had 17% (95% CI 2-33%) increased possibility for better or much better GRC Pain score, and patients treated with APM had 65% (95% CI 32-108%) and 70% (95% CI 38-109%) increased possibility for better or much better GRC Pain and Function scores. CONCLUSIONS: The 6-m timed hop test result was a significant prognostic factor for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears, especially in those treated with APM. LEVEL OF EVIDENCE: II.

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up.

OBJECTIVE:  To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears. DESIGN:  Randomised controlled superiority trial. SETTING:  Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway. PARTICIPANTS:  140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis. INTERVENTIONS:  12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone. MAIN OUTCOME MEASURES:  Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months. RESULTS:  No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit. CONCLUSION:  The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option.Trial registration www.clinicaltrials.gov (NCT01002794).

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up.

OBJECTIVE: To determine if exercise therapy is superior to arthroscopic partial meniscectomy for knee function in middle aged patients with degenerative meniscal tears. DESIGN: Randomised controlled superiority trial. SETTING: Orthopaedic departments at two public hospitals and two physiotherapy clinics in Norway. PARTICIPANTS: 140 adults, mean age 49.5 years (range 35.7-59.9), with degenerative medial meniscal tear verified by magnetic resonance imaging. 96% had no definitive radiographic evidence of osteoarthritis. INTERVENTIONS: 12 week supervised exercise therapy alone or arthroscopic partial meniscectomy alone. MAIN OUTCOME MEASURES: Intention to treat analysis of between group difference in change in knee injury and osteoarthritis outcome score (KOOS4), defined a priori as the mean score for four of five KOOS subscale scores (pain, other symptoms, function in sport and recreation, and knee related quality of life) from baseline to two year follow-up and change in thigh muscle strength from baseline to three months. RESULTS: No clinically relevant difference was found between the two groups in change in KOOS4 at two years (0.9 points, 95% confidence interval -4.3 to 6.1; P=0.72). At three months, muscle strength had improved in the exercise group (P≤0.004). No serious adverse events occurred in either group during the two year follow-up. 19% of the participants allocated to exercise therapy crossed over to surgery during the two year follow-up, with no additional benefit. CONCLUSION: The observed difference in treatment effect was minute after two years of follow-up, and the trial's inferential uncertainty was sufficiently small to exclude clinically relevant differences. Exercise therapy showed positive effects over surgery in improving thigh muscle strength, at least in the short term. Our results should encourage clinicians and middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT01002794).

Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial.

OBJECTIVE: The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears. DESIGN: A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change. RESULTS: Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P ≤ 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions. CONCLUSION: A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.

Knee function and knee muscle strength in middle-aged patients with degenerative meniscal tears eligible for arthroscopic partial meniscectomy.

BACKGROUND: Functional limitations exist postmeniscectomy, but preoperative data are scarce. PURPOSE: To examine knee function, knee muscle strength and performance in middle-aged patients with degenerative meniscal tears, eligible for arthroscopic partial meniscectomy. STUDY DESIGN: Cross-sectional study. METHODS: Eighty-two participants with MRI verified degenerative meniscal tear (35% women, mean age 49 years) answered the Knee injury and Osteoarthritis Outcome Score (KOOS) and were tested for isokinetic knee muscle strength and lower extremity performance (one-leg hop for distance, 6 m timed hop and maximum number of knee-bends in 30 s). Limb Symmetry Index (LSI) was used to express side-to-side differences in per cent using the non-injured leg as the control. An LSI ≥90% was considered normal. RESULTS: Mean scores of the five subscales of the KOOS were from 13 to 36 points lower compared with a population-based reference group and similar to patients prior to anterior cruciate ligament reconstruction. Quadriceps strength and lower-extremity performance were impaired for the injured leg compared with the non-injured leg (p<0.001), with a mean difference of 13% in quadriceps strength and between 8% and 13% in lower-extremity performance. Between 41% and 52% of the participants had abnormal LSI values in quadriceps muscle strength and lower-extremity performance. CONCLUSION: Middle-aged patients with a symptomatic degenerative meniscal tear experience functional knee problems when eligible for meniscectomy. Included participants reported difficulty with knee pain, symptoms, function and quality of life and quadriceps strength and lower-extremity performance were impaired. Approximately 50% of the study group had clinically relevant impairments in quadriceps strength and lower-extremity performance, defined as >10% differences between the injured and the non-injured leg.

A 12-week exercise therapy program in middle-aged patients with degenerative meniscus tears: a case series with 1-year follow-up.

STUDY DESIGN: Case series. BACKGROUND: Exercise is a viable treatment alternative to arthroscopic partial meniscectomy in patients with degenerative meniscus tears. No study has reported in detail the type of exercises, progression, tolerance, and potential benefit from an exercise therapy program in these patients who have not had surgery. This case report describes a progressive exercise therapy program aimed at improving neuromuscular function and muscle strength in middle-aged patients with degenerative meniscus tears, the outcome over a 12-week period, and the ability to maintain improvements up to 1 year. CASE DESCRIPTION: The first 20 patients (age range, 38-58 years) included in an ongoing randomized controlled trial. OUTCOMES: Outcomes data included the Knee injury and Osteoarthritis Outcome Score, a 7-point global rating of change scale, isokinetic knee muscle strength tests, and 3 lower extremity performance tests. Postintervention, 16 of 20 patients showed clinically meaningful changes (greater than 10 points) on the Knee injury and Osteoarthritis Outcome Score knee-related quality of life subscale, 19 of 20 patients rated themselves as "a lot better" or "better" on the global rating of change scale, all patients had increased quadriceps muscle strength, and the majority of patients improved on the lower extremity performance tests. At 1 year postintervention, the majority of patients had maintained the improvements and none of the patients had undergone surgery. DISCUSSION: The described neuromuscular- and strength-training program should be considered for rehabilitation of middle-aged individuals with degenerative meniscus tears. However, head-to-head comparison of programs in a randomized design is needed to determine if this specific program is significantly better than other interventions.

Correlation between two-dimensional video analysis and subjective assessment in evaluating knee control among elite female team handball players.

Poor frontal plane knee control has been shown to be a risk factor for anterior cruciate ligament injuries in ball/team sports. It is necessary to develop simple tests that can identify players with poor knee control and among other factors be able to optimise preventive training programmes. The present study investigated the correlation between a two-dimensional (2D) video analysis and subjective assessment performed by one physiotherapist in evaluating knee control. We also tested the correlation between three simple clinical tests using both methods. A cohort of 186 female elite team handball players completed three tests: single-leg squat (SLS), single-leg vertical drop jump (SLVDJ) and two-leg vertical drop jump (VDJ). Receiver operating characteristic (ROC) analyses showed good to excellent agreement between 2D video analysis and subjective assessment for SLS and VDJ (area under the ROC curve (AUC) 0.83-0.89), but not for SLVDJ (AUC 0.65-0.76). Poor knee control was detected in 25-40% of the players using SLS and VDJ. In contrast, poor knee control was identified in less than 1% of the subjects based on the SLVDJ test. This indicates that SLVDJ may be inadequate for evaluating poor frontal plane knee control. The correlation between the SLS and VDJ tests was found to be low, suggesting that these tests identified different subjects with poor knee control. These results indicate that subjective assessment can be used to screen for poor knee control and that both SLS and VDJ tests should be used in screening athletes for poor knee control.