Search

We performed a cross-sectional study of 160 adult patients with severe cerebral palsy to study the relationship between radiographic hip disorders (migration and deformity of the femoral head), on the one hand, and complications such as handling problems, seating problems, decubitus ulcers, fractures and contractures, on the other hand. Both migration and deformity were positively related to the need for a special seat in the wheelchair and adduction contractures of the hip. We conclude that migration and deformity of the femoral head, if possible, should be prevented in patients with severe cerebral palsy.

Study Design: Prospective study with 6 weeks of follow-up., Objective: To examine the predictors of outcome for patients with (sub)acute low back pain (LBP) receiving usual care (UC) or a minimal intervention strategy (MIS) aimed at psychosocial factors., Summary of Background Data: A randomized controlled trial in general practice showed no differences in average effect between UC and MIS., Methods: Socio-demographic variables, characteristics of LBP, and psychosocial factors were included as potential predictors of outcome. The outcome clinically important improvement was defined as a reduction of at least 30% on functional disability plus patient perceived recovery. Logistic regression analyses were used to study the associations between predictors and outcome at 6 weeks follow-up., Results: In the UC group (n = 163), the multivariable model included a shorter duration of the LBP episode, few previous episodes, less pain catastrophizing, and good perceived general health. The area under the curve (AUC) of the model was 0.77 (95% confidence interval, 0.70-0.85). In the MIS group (n = 142), the multivariable model included less somatizing symptoms, more solicitous responses by an important other, lower perceived risk for chronic LBP, more fear avoidance beliefs, higher level of education, and shorter duration of the LBP episode. This AUC was 0.78 (95% confidence interval, 0.71-0.86)., Conclusions: As we found two different profiles, our approach may contribute to the important question: what intervention works for whom?

Study Design: A critical appraisal of the literature., Objectives: To increase awareness of the importance of applicability and clinical relevance of the results of randomized controlled trials (RCTs) in the field of spinal disorders by formulating a list of items for assessment of applicability and clinical relevance of results of RCTs., Summary of Background Data: In systematic reviews of randomized controlled trials (RCTs), critical appraisal of methodologic quality is considered important. Less attention has been paid to the assessment of the applicability and the clinical relevance of the results., Methods: RCTs in an update of the Cochrane review on exercise therapy for low back pain were used. Most of the trials did not score positively on the five Cochrane Back Review Group basic items describing patients: intervention and setting, outcome, effect size, and benefits related to adverse effects. Item 1 was met by 88% of the trials, but item 2 only by 51%, item 3 by 67%, item 4 by 35%, and item 5 by 0%. Subsequently, a more comprehensive list of items for the assessment of applicability and clinical relevance of results of RCTs was developed. These criteria were pilot tested on the RCTs. After pilot testing and a subsequent consensus meeting, the list of items was drafted and circulated among the members of the Editorial Board of the Cochrane Back Review Group. Changes were made in response to comments., Results: The final list consists of 40 items. The items are ordered on two headings: Does the report enable the assessment of applicability? Are the study results clinically relevant? We present examples of informative and noninformative reporting of RCTs in order to illustrate how information on applicability and clinical relevance of results can be assessed., Conclusions: Authors of RCTs should adequately report on items that are essential to assess the applicability and clinical relevance of results. The presented list of items may help clinicians reading RCTs and authors of systematic reviews to draw more balanced conclusions on applicability and clinical relevance of results.

Objectives: The authors' goals were to compare the effectiveness of manual therapy (MT; mainly spinal mobilization), physical therapy (PT; mainly exercise therapy), and continued care by the general practitioner (GP; analgesics, counseling and education) over a period of 1 year., Methods: One hundred eighty-three patients suffering for at least 2 weeks from nonspecific neck pain were randomized to receive a 6-week treatment strategy of MT once a week, PT twice a week, or GP care once every 2 weeks. The primary outcome measures were perceived recovery, severity of physical dysfunctioning, pain intensity, and functional disability., Results: The differences between groups considered over 1 year were statistically significant (repeated measurements analyses P<0.001 to P=0.02) for all outcomes but borderline for the Neck Disability Index (P=0.06). Higher improvement scores were observed for MT for all outcomes, followed by PT and GP care. The success rate, based on perceived recovery after 13 weeks, was 72% for MT, which was significantly higher than the success rate for continued GP care (42%, P=0.001) but not significantly higher compared with PT treatment (59%, P=0.16). The difference between PT and GP approached statistical significance (P=0.06). After 1 year the success rates were 75%, 63%, and 56%, respectively, and no longer significantly different., Conclusions: Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up.

Objective: The mechanisms responsible for the increased cardiovascular disease risk that accompanies type 2 diabetes (T2D) remain poorly understood. It is commonly held that endothelial dysfunction and low-grade inflammation can explain, at least in part, why deteriorating glucose tolerance is associated with cardiovascular disease. However, there is no direct evidence for this contention., Methods and Results: In this population-based study (n=631), T2D was cross-sectionally associated with both endothelial dysfunction and low-grade inflammation, whereas impaired glucose metabolism (IGM) was associated only with low-grade inflammation. These findings were independent of other risk factors that accompany T2D or IGM. During a follow-up of 11.7 years (median; range 0.5 to 13.2 years), low-grade inflammation was associated with a greater risk of cardiovascular mortality (hazard ratio, 1.43 [95% CI, 1.17 to 1.77] per 1 SD difference). For endothelial dysfunction, the association with cardiovascular mortality was stronger in diabetic (hazard ratio, 1.87 [95% CI, 1.43 to 2.45]) than in nondiabetic individuals (hazard ratio, 1.23 [95% CI, 0.86 to 1.75]; P interaction=0.06). Finally, T2D-associated endothelial dysfunction and low-grade inflammation explained approximately 43% of the increase in cardiovascular mortality risk conferred by T2D., Conclusions: These data emphasize the necessity of randomized controlled trials of strategies that aim to decrease cardiovascular disease risk by improving endothelial function and decreasing low-grade inflammation, especially for T2D patients.

Study Design: Data were derived from a randomized controlled trial on the (cost-) effectiveness of the implementation of the clinical guidelines on physiotherapy for low back pain in primary care., Objectives: To describe the course of low back pain in patients who are referred to physiotherapy, to identify clinically important prognostic factors on different outcomes, and to evaluate the influence of different statistical techniques in developing a prognostic model., Summary of Background Data: Several studies have aimed to identify prognostic factors for low back pain in primary care. These studies focused on different outcome measures and used various statistical techniques., Methods: Primary outcomes were perceived recovery, improvement in pain, improvement in functioning, and presence of disabling low back pain at 3 and 12 months follow-up. Multivariate logistic regression analyses were performed for each outcome variable. Two cut-off points were used to determine significance with respect to the univariate analysis, and two selection methods were used to build the final multivariate models. The resulting prognostic models were compared., Results: A total of 500 patients were included. Pain and disability reduced considerably in the first 3 months, but further reduction was only modest. Prognostic factors varied for different outcomes, but the duration of the current episode was included in all models generated. Varying the statistical techniques also resulted in a different prognostic model with some change to the amount of variance explained., Conclusions: A substantial proportion of patients still experienced some pain and disability at 12 months follow-up. The most stable predictor of prognosis in low back pain was the duration of the current episode. The choice of statistical method influenced the final model; however, changes in the explained variance were small.

Study Design: An observational prospective cohort study in general practice., Objectives: To describe the clinical course and to identify predictors of recovery, changes in pain intensity, and changes in functional disability in patients with neck or shoulder symptoms at 3- and 12-month follow-up., Summary of Background Data: Knowledge on the clinical course and predictors of outcome in neck and shoulder symptoms is limited. Such knowledge would facilitate treatment decisions and may help to inform patients about their prognosis., Methods: Four hundred and forty-three patients who consulted their general practitioner with neck or shoulder symptoms participated in the study. Baseline scores of pain and disability, symptom characteristics, sociodemographic and psychological factors, social support, physical activity, general health, and comorbidity were investigated as possible predictors of recovery, changes in pain intensity, and changes in functional disability using multiple regression analyses., Results: The recovery rate was low; 24% of the patients reported recovery at 3 months and 32% reported recovery at 12-month follow-up. Duration of the symptoms before consulting the GP and a history of neck or shoulder symptoms increased the probability of an unfavorable outcome. Furthermore, less vitality and more worrying were consistently associated with poorer outcome after 3 and 12 months. The area under the receiver-operator characteristic curve for the model predicting recovery was 0.8 at 3 months and 0.75 at 12 months. The explained variance of the models on pain and functional disability ranged from 43 to 54%., Conclusions: The results found in this study indicate that besides clinical characteristics, psychological factors also predict the outcome of neck and shoulder symptoms.

Background: Different definitions of the metabolic syndrome have been proposed. Their value in a clinical setting to assess cardiovascular disease (CVD) risk is still unclear. We compared the definitions proposed by the National Cholesterol Education Program Adult Treatment Panel III (NCEP), World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), and American College of Endocrinology (ACE) with respect to the prevalence of the metabolic syndrome and the association with 10-year risk of fatal and nonfatal CVD., Methods and Results: The Hoorn Study is a population-based cohort study. The present study population comprised 615 men and 749 women aged 50 to 75 years and without diabetes or a history of CVD at baseline in 1989 to 1990. The prevalence of the metabolic syndrome at baseline ranged from 17% to 32%. The NCEP definition was associated with about a 2-fold increase in age-adjusted risk of fatal CVD in men and nonfatal CVD in women. For the WHO, EGIR, and ACE definitions, these hazard ratios were slightly lower. Risk increased with the number of risk factors. Elevated insulin levels were more prevalent in subjects with multiple risk factors, but metabolic syndrome definitions including elevated insulin level were not more strongly associated with risk., Conclusions: The metabolic syndrome, however defined, is associated with an approximate 2-fold increased risk of incident cardiovascular morbidity and mortality in a European population. In clinical practice, a more informative assessment can be obtained by taking into account the number of individual risk factors.

The reported relationships between nerve conduction studies (NCS) and outcome measures in carpal tunnel syndrome (CTS) are weak to moderate. However, selection of patients may have confounded nonrandomized studies. NCS have potentially great value in selecting patients for a specific treatment and in objectively assessing the efficacy of treatments in CTS, especially if they correlate significantly with clinical outcome measures. To investigate the relationship between clinical outcome measures for the severity of complaints and NCS in patients treated for CTS, data were obtained from a multicenter randomized controlled trial on the efficacy of splinting versus surgery for CTS. At baseline and 12 months after randomization, clinical outcome measures were assessed and NCS were performed. In total, 138 patients completed the questionnaires and underwent repeated NCS. Relationships were analyzed with Spearman rank correlation coefficients and Pearson correlation coefficients. All NCS parameters showed highly significant improvement compared with baseline (P < 0.001). Modest correlations (< 0.4) were found between the neurophysiologic and clinical outcome measures after 12 months, and between the changes in these different categories of outcome measures. This study confirms that the parameters of NCS improve significantly after treatment for CTS, but the modest correlations between neurophysiologic and clinical outcome measures do not support that NCS are routinely performed in clinical practice to evaluate treatment effects. However, studies investigating the effects of treatment for CTS should incorporate both clinical outcome measures and NCS, because they are complementary. Furthermore, NCS can provide additional information to the clinician when treatment effects are unsatisfactory.

The purpose of our investigation was to study the relationship between radiographic results of the femoral head and pain in people with severe cerebral palsy. We conducted a cross-sectional study on hip radiography results and pain in 160 patients with severe cerebral palsy. Eighteen percent of our patients had hip pain in hip-loading situations. Migration and deformity were closely related. There was a significant association with hip pain (odds ratio, 2.79; 95% confidence interval 1.01-7.70). There is a high prevalence of hip pain after unsuccessful femoral bone surgery. Migration and deformity of the femoral head are strongly interrelated, and are associated with pain.

An elevated urinary albumin excretion rate (UAER) is associated with an increased risk of cardiovascular mortality, but the pathophysiological mechanism underlying this association is poorly understood. To investigate the role of endothelial dysfunction, leukocyte adhesion, and low-grade inflammation (1) in the development of elevated UAER (study I) and (2) in linking elevated UAER with risk of cardiovascular mortality (study II), we performed a prospective study in an age-, sex-, and glucose tolerance- stratified sample of a population-based cohort aged 50 to 75 years. High levels of von Willebrand factor, soluble vascular cell adhesion molecule-1 (sVCAM-1), and C-reactive protein (CRP) were used as markers of endothelial dysfunction, leukocyte adhesion, and low-grade inflammation, respectively. For study I, subjects who had normal UAER at baseline (n=316 subjects, 66 with type 2 diabetes) were reexamined after a mean follow-up of 6.1 years. The development of elevated UAER was defined as a mean albumin-to-creatinine ratio >2.0 mg/mmol at follow-up. Age-, sex-, and glucose tolerance- adjusted logistic regression analyses showed the development of elevated UAER to be significantly associated with levels of sVCAM-1 and CRP (odds ratio 1.14 [95% CI 1.02 to 1.27] per 10% increase of sVCAM-1 and odds ratio 1.17 [95% CI 1.04 to 1.32] per 50% increase of CRP). The results were not materially different after additional adjustment for hypertension, body mass index, cardiovascular disease, and creatinine clearance or stratification by the presence of diabetes. For study II, the vital status of all subjects (n= 575) was determined after a mean follow-up of 6.6 years. Eighty-one of 575 subjects died (30 died of cardiovascular disease). The presence of elevated UAER at baseline was associated with a 4.1-fold (1.94 to 8.73) increased risk of cardiovascular death after adjustment for age, sex, and glucose tolerance status. Adjustment for levels of von Willebrand factor, sVCAM-1, or CRP did not materially affect the results, nor did additional adjustment for the presence of hypertension, retinopathy, and cardiovascular disease and for levels of homocysteine, triglycerides, and high density lipoprotein cholesterol. Leukocyte adhesion (sVCAM-1) and low-grade inflammation (CRP) are determinants of the development of elevated UAER. However, these determinants do not explain the association between elevated UAER and cardiovascular mortality.

Studies on the efficacy of available methods of treatment for hemiplegic shoulder pain are reviewed in an attempt to identify the most effective treatment for this problem. Because of the poor quality of the 14 selected studies, no definite conclusion can be drawn about the most effective method of treatment. However, functional electrical stimulation and intra-articular triamcinolone acetonide injections seem to be the most promising treatment options.