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Chêneau-brace (C-Brace) is a potential tool for the treatment of adolescent idiopathic scoliosis (AIS) with a Cobb angle between 20° and 45° for the primary curve. The aim of the present study was (1) to estimate study cohorts with C-brace therapy success and therapy failure and (2) to analyze possible factors that influence the therapy outcome. Seventy-eight patients with AIS were assessed before the initiation of C-brace treatment. Each patient underwent radiography examinations before the brace, in-brace, and at the therapy end. Cobb angle was considered as increased when the value at the end of therapy was increased more than 5° (Δ > 5°), unchanged—when the value was unchanged within ± 5° and decreased- when the value was decreased more than 5° (Δ < −5°). The study cohort was stratified due to curve topography in the thoracic, thoracolumbar, and lumbar scoliosis groups. Global analysis revealed no statistically significant modification of the Cobb angle (Cobb angle pre-brace vs. Cobb angle post-brace: 30.8° ± 8.2 vs. 29.3° ± 15.2, p = 0.26). However, at the end of C-brace therapy, the primary Cobb angle was decreased by more than 5° in 27 patients (35%), unchanged (Δ within the range of ±5°) in 36 patients (46%), and increased more than 5° in 15 patients (19%). Sub-group analysis due to curve topography and skeletal maturity has shown higher rates of brace therapy failure in thoracic curves and in younger patients (Risser grade 0). Patients with higher Cobb angle correction with C-brace had lower rates of therapy failure. The C-brace can be useful for the prevention of scoliotic curve progression in patients with AIS. However, many factors influence the therapy effect.

Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment.The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented.An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain.Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process.A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.HINTERGRUND: Der kindliche Rückenschmerz ist nicht selten. Ausführliche Anamneseerhebung, eine umfassende körperliche Untersuchung sowie eine systematische diagnostische Abklärung sind der Schlüssel für die Evaluation der Schmerzursache und die Festlegung der Behandlungsstrategie.Das Ziel der folgenden Übersichtsarbeit ist die Entwicklung eines diagnostischen Algorithmus zur Unterstützung des behandelnden Arztes zur Beurteilung des kindlichen Rückenschmerzens. Eine umfassende Übersicht zur Prävalenz, Differenzialdiagnosen sowie Behandlungsoptionen wird ebenfalls gegeben.Auf PubMed wurde eine umfangreiche Literaturrecherche zur Prävalenz, Risikofaktoren, Diagnostik sowie Therapiemöglichkeiten durchgeführt.Die aktuelle Literatur zeigt auf, dass Rückenschmerzen im Kindes- und Jugendalter ein nicht seltenes und zunehmendes Problem darstellen. Obwohl die meisten Kinder unter unspezifischen Rückenschmerzen leiden, muss man eine Reihe von Ursachen entzündlicher, neoplastischer, infektiöser und mechanischer Genese in Betracht ziehen. Inaktiver Lebensstil, Übergewicht und übertriebene sportliche Betätigung können zur Entwicklung von Rückenschmerzen bei Kindern beitragen. Wir entwickelten einen Algorithmus zur Entscheidungsfindung im Rahmen der diagnostischen Abklärung.Ein klar definiertes Konzept im Rahmen der diagnostischen Abklärung von Rückenschmerzen im Kindes- und Jugendalter hat den Vorteil die Kosten im Gesundheitssystem, die unnötigen Untersuchen und die geschürten Ängste bei den Betroffenen und deren Familien zu minimieren. Darüber hinaus sollte es dazu beitragen, frühzeitig die korrekte Diagnose zustellen und die entsprechende Therapie einzuleiten.

Medical assessments are aids for legal commissioning parties. Most standards are regulated by the civil legal procedure but differences between fields of law of the expert have to be considered.Professional competence, neutrality and meeting the deadlines are expected by the commissioning party. Inquiries and examinations essential for the interrogatories have to be performed by the expert personally.The interrogatories have to be answered plausibly and conclusively. The language of the legal assessment is German and technical terms are avoided.Medizinische Gutachten sind Hilfsmittel für juristische Auftraggeber. Die meisten Normen ergeben sich aus der Zivilprozessordnung, wobei Unterschiede der einzelnen Rechtsgebiete vom Gutachter beachtet werden müssen.Fachliche Kompetenz, Neutralität und das Einhalten von Fristen werden von den Auftraggebern erwartet. Die für die Beweisfragen wesentlichen Befragungen und Untersuchungen hat der Gutachter persönlich durchzuführen.Die Beweisfragen sind schlüssig und nachvollziehbar zu beantworten. Die Sprache des Gutachtens ist Deutsch und verzichtet auf Fachbegriffe.

ObjectiveTo investigate the effectiveness and mechanisms of a multimodal treatment including perturbation exercise.MethodsA matched cohort study was conducted. The intervention consists of a 12-week back pain prevention course with perturbation exercise and education embedded in primary health care according to German social law. Participants from the intervention group had chronic or recurrent low back pain with heterogenous but on average rather low pain and chronification. Control groups (usual care) were matched from a multi-center RCT. Outcomes were pain, disability, isokinetic trunk strength and balance. Bayesian regression models were used to estimate the Average Treatment effect on the Treated (ATT). Further, sub-group and mediation analyses within the intervention group using the biopsychological avoidance-endurance model were conducted. Median values with highest posterior density intervals (HPDI) from baseline-adjusted analyses are presented.ResultsOver 12 weeks, intervention and control (n = 128 each) experienced a similar decrease in pain and disability, which led to negligible ATTs for pain (−0.3 (HPDI95% [-4.3, 3.4]) and disability (−0.2 (HPDI95% [-4, 3.7])). Changes in functional parameters (n=18) showed small effects in favor of the intervention group, in particular for monopedal stances (standardized mean difference: -0.5 HPDI95% [-0.79, -0.21]). Depression was higher in drop-outs and decreases in pain/disability were associated with decreases in depression. Distress-endurance subgroups experienced higher baseline pain and disability and showed the highest reductions in both parameters upon completion of the intervention.ConclusionPerturbation exercise with education yielded only small treatment effects in a heterogenous population with rather mild symptoms. Targeting distress-endurance subgroups with a multimodal treatment approach is probably an effective strategy in treatment tailoring.

Bandscheibenbedingte Erkrankungen von Hals- und Lendenwirbelsaule kommen dann als Berufskrankheit in Betracht, wenn die arbeitstechnischen und medizinischen Voraussetzungen erfullt sind und der kausale Zusammenhang zwischen den Voraussetzungen wahrscheinlich ist. Zu den arbeitstechnischen Voraussetzungen zahlen berufliche Belastungen mit langjahrigem Heben und Tragen schwerer Lasten bzw. langjahrige Tatigkeiten in extremer Rumpfbeugehaltung, langjahriges Tragen schwerer Lasten auf der Schulter und langjahrige Einwirkung von Ganzkorperschwingungen im Sitzen. Eine medizinische Voraussetzung ist bei einem Schadensbild mit chronischen unteren Rucken- bzw. Nackenschmerzen und belastungskonformem Schadigungsbild der Bandscheiben der LWS bzw. HWS gegeben. Bei der Begutachtung werden die arbeitstechnischen Voraussetzungen durch den Praventionsdienst des Leistungstragers, die medizinischen durch den arztlichen Sachverstandigen gepruft. Dieser pruft auch den kausalen Zusammenhang zwischen den erfullten Voraussetzungen, wobei der zeitliche Zusammenhang (Erreichen der Belastungsmindestdosis vor Realisation des konformen Schadensbilds) und der Ausschluss konkurrierender Faktoren wesentlich sind. Zum 01.01.2021 ist der Aufgabezwang der belastenden beruflichen Tatigkeit weggefallen.

Objective:To compare biomechanical and clinical outcome of laterally wedged insoles (LWI) and an ankle-foot orthosis (AFO) in patients with medial knee osteoarthritis.Design:Single-centre, block-randomized, cross-over controlled trial.Setting:Outpatient clinic.Subjects:About 39 patients with symptomatic medial knee osteoarthritis.Interventions:Patients started with either LWI or AFO, determined randomly, and six weeks later changed to the alternative.Main measures:Change in the 1st maximum of external knee adduction moment (eKAM) was assessed with gait analysis. Additional outcomes were other kinetic and kinematic changes and the patient-reported outcomes EQ-5D-5L, Oxford Knee Score (OKS), American Knee Society Clinical Rating System (AKSS), Hannover Functional Ability Questionnaire – Osteoarthritis and knee pain.Results:Mean age (SD) of the study population was 58 (8) years, mean BMI 30 (5). Both aids significantly improved OKS (LWI P = 0.003, AFO P = 0.001), AKSS Knee Score (LWI P = 0.01, AFO P = 0.004) and EQ-5D-5L Index (LWI P = 0.001, AFO P = 0.002). AFO reduced the 1st maximum of eKAM by 18% ( P Conclusions:AFO reduces medial knee load more than LWI. Nevertheless, no clinical superiority of either of the two aids could be shown.

STUDY DESIGN Prospective 2-year factor-, cluster-, and reliability-multicenter analysis. OBJECTIVE To provide evidence on the uniqueness and usefulness of a set of potential relevant functional outcomes. SUMMARY OF BACKGROUND DATA A very high number of functional outcomes that can be utilized as variables in low back pain (LBP) trials exists. METHODS Participants (n = 1049) with and without current LBP were included. At 7 visits (baseline, 4 wk, 3 mo, 6 mo, 9 mo, 1 yr, and 2 yr), 42 different functional outcomes were assessed. Two exploratory factor analyses (for baseline-values and for changes scores to 3 mo post-baseline) were calculated (maximum likelihood extraction, varimax factor rotation). The strongest factor-loading outcomes were selected for the following hierarchical cluster analyses (average linkage, Euclidean distance measure). For each cluster, time point, and outcome, reliability analyses were subsequently calculated using intraclass correlation coefficients, standard error of measurements and coefficients of variation. RESULTS The factor analysis for the cross-sectional values revealed 9 factors with a cumulative variance explanation of 61.7% and 13 unique ones. The change-score factor analysis revealed nine factors with a total variance explanation of 61.8%, seven outcomes were unique. Ten outcomes were important for both cross-sectional and change-score analyses, 11 were most valuable for cross-sectional and four for the change scores. Patients with pain grades 1 to 3 show comparable patterns (cluster 2). Grade 0 (cluster 1) and grade 4 (cluster 3) are unique and cannot be cumulated with other grades. Most biomechanical outcomes were highly reliable and display low measurement errors. CONCLUSION We found 25 potentially meaningful functional outcomes in the context of objective functional measurements (such as trunk range of motion, dynamic and static balance, strength, and muscle fatigue resistance) and body characteristics. The present framework may help to select appropriate functional outcomes and rate effects beyond the known core set of outcomes.Level of Evidence: 1.

Osteoarthritis (OA) is no longer considered a purely degenerative disease. OA is defined as a disease of the entire joint, in which inflammation occurs in various joint tissues. The overall aim of this study was to analyze the presence and polarization of CD8

This planned MiSpEx-Network reanalysis was designed to derive a dose-response relationship under consideration of further effect modifiers in exercises on low back pain. One thousand four hundred eighty three intervention participants with low back pain (mean age, 40.9 years [SD 14 years]) performed stabilisation exercises (3 weeks supervised, 9 weeks self-administered). Patients reported pain intensity, disability, and disability days at baseline, 3 weeks, 12 weeks, and 6 months post randomisation. Exercise characteristics and effect modifiers were prospectively monitored. Beyond the comparison to the results of the control group, linear mixed models were calculated to determine a dose-response relationship. The interventions led to small but significantly larger symptom reductions than in the control group at each measurement. Longer durations of the intervention led to larger symptom reductions. Higher exercise frequencies were associated with a decrease in pain intensity: to train once more per week led to a mean decrease of 0.93 points in pain intensity [95% CI = -1.54 to -0.32]. Disability days were also impacted (estimate = -0.07 [-0.14 to 0.00]), but disability was not (-0.09 [-0.67 to 0.48]). Adding perturbation was superior to adding stretching or a behavioural module. The relationships were robust when additional effect modifiers were considered and against the control group' effects. The odds ratio for a clinically important effect with higher exercise frequencies decreased at 3 weeks (OR = 0.71 [0.618-0.813] for2.5*week-1) and increased at 12 weeks (1.13 [1.006-1.270],1.5*week-1). Using longer intervention durations, adding a perturbation component to the stabilisation trainings and using higher frequencies (up to a certain point) may lead to an even more beneficial response on exercise in patients with low back pain. Developing strategies to maintain a training frequency of at least 2 times per week may be relevant in stabilisation exercises to treat low back pain.

Background: Long-term clinical and radiographic outcome data after standard cemented long-stem reverse shoulder arthroplasty (RSA) remain underreported. The aim of this study is to report on medium- to long-term data of patients over 60 years of age. Methods: The same type of RSA (Aequalis Reverse II, Memphis, TN, USA) was implanted in 27 patients with a mean age of 73 years (range 61–84). Indications for RSA were cuff tear arthropathy (CTA) in 25 cases and osteoarthritis (OA) in two cases. Pre- and postoperative Constant Score was assessed and component loosening, polyethylene wear, scapular notching and revision rates were recorded at a mean clinical follow-up (FU) of 127.6 months (SD ± 33.7; range 83–185). Results: The mean-adjusted CS (aCS) improved from 30.0 (range 10–59) to 95.0 (range 33–141) points (p < 0.001). Glenoid loosening was found in two (9.1%) and stem loosening was found in three (13.6%) cases. Polyethylene wear was observed in four (18.2%) cases. Scapular notching appeared in 15 (68.2%) cases but was not associated with poor aCS (p = 0.423), high levels of pain (p = 0.798) or external rotation (p = 0.229). Revision surgery was necessary in three (11.1%) cases. Conclusions: RSA with a cemented standard long stem leads to improvement in forward elevation, abduction and pain after a mean FU of 10 years. However, external rotation does not improve with this prosthetic design. Moreover, scapular notching is observed in the majority of cases, and revision rates (11.1%) as well as humeral loosening rates (13.6%) remain a concern. Level of evidence: Level 4, retrospective cohort study.

Resume Les douleurs musculosquelettiques chroniques font reference aux douleurs osseuses, articulaires et tissulaires qui persistent depuis plus de 3 mois. Dans ces affections, il est communement admis que les dysfonctions secondaires ou les consequences de la douleur persistante–peur du mouvement, catastrophisme, anxiete ou sensibilisation du systeme nerveux–semblent les principales causes de la douleur et de l’incapacite fonctionnelle. En cas de douleurs persistantes, les exercices constituent une modalite de traitement fondamentale. Leur objectif principal est souvent l’amelioration de la fonction physique ; peu d’attention est portee aux troubles secondaires. Les interventions basees sur les exercices et qui s’interessent aux troubles secondaires sont en accord avec les pratiques contemporaines destinees a la reeducation de la douleur. Elles presentent un potentiel plus important pour ameliorer les resultats des patients que des exercices seuls. Une approche biopsychosociale, qui valide et tienne compte de la contribution des facteurs biologiques, psychologiques et sociaux de la douleur et de l’incapacite fonctionnelle, est actuellement consideree comme l’approche la plus efficace en cas de douleur chronique. Elle est aussi consideree comme plus efficace que des exercices ou de la kinesitherapie utilises isolement. Cette mise au point clinique aborde les elements-cles d’une approche biopsychosociale qui prend en compte les besoins du patient et les competences du clinicien pour la prescription d’exercices en cas de douleurs musculosquelettiques chroniques. Il existe un consensus pour preconiser des exercices supervises, individualises, bases sur les caracteristiques, les objectifs et les preferences du patient. Celui-ci devrait percevoir ces exercices comme des activites sans danger et non menacants afin d’eviter qu’il etablisse des associations nefastes entre les activites physiques et la douleur. Des etudes portant sur des exercices aerobies et de resistance ont apporte une caution scientifique a l’interet de prescrire des exercices en cas de douleurs musculosquelettiques chroniques. Cependant, certaines incertitudes demeurent quant a meilleure facon d’appliquer les resultats de ces etudes. Cette mise au point s’appuie sur une synthese de la litterature scientifique pour apporter des conseils bases sur l’evidence dans le domaine de l’exercice et de la reeducation en cas de douleurs musculosquelettiques chroniques. Niveau de preuve NA.

Schmerzen, ausgelost durch das Iliosakralgelenk (ISG), machen einen relevanten Anteil lumbaler Ruckenschmerzen aus und konnen unterschiedliche Ursachen haben. Das ISG stellt die zentrale Verbindung zwischen Wirbelsaule und der unteren Extremitat dar. Es zeichnet sich durch eine hohe Stabilitat bei geringer Beweglichkeit aus. Hohe interindividuelle Unterschiede bestehen. Neben der Moglichkeit volliger Beschwerdelosigkeit konnen Funktionsstorungen des ISG Schmerzen im unteren Rucken mit moglicher Ausstrahlung in die untere Extremitat auslosen. In der klinischen Untersuchung bedarf es neben einer strukturierten Anamneseerhebung einer Untersuchung der angrenzenden Gelenke und des neurologischen Status. Spezifischer werden Bewegungs- und Provokationstests sowie Infiltrationen durchgefuhrt. Therapeutisch sind neben der allgemeinen Aufklarung konservative Therapieverfahren zunachst fuhrend. Bei Chronifizierung konnen interventionelle und operative Prozeduren helfen.

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Background The sacroiliac joint is a common cause of low back pain. Due to variable symptoms, the diagnosis is often very difficult. For diagnosis, systemic disease, as well as pathologies in the hips and lumbar spine must be excluded. Objectives To describe anatomy and function of the joint and underlying pathologies. To present the evidence of actual diagnostic and therapeutic options. Materials and methods An extensive literature research was carried out on PubMed. Results The sacroiliac joint is an important and biomechanically complex joint. There are many controversial diagnostic tests to identify the sacroiliac joint as a source of pain. The cause of the dysfunction must be identified in order to treat it correctly and to prevent a chronification of the pain. The gold standard is conservative care. Conclusion The sacroiliac joint must be included in the differential diagnosis in patients with low back pain. Diagnostic tests are often insufficient for the diagnosis of sacroiliac joint pain. Many of the current diagnostic and therapeutic options present weak evidence.

Intervertebral disc-related diseases of the cervical and lumbar spine are considered to be occupational diseases, if the occupational and medical prerequisites are fulfilled and the causal connection between the prerequisites is likely. The working conditions include occupational burdens with long-term lifting and carrying of heavy loads or long-term activities in an extremely bent position of the torso, long-term carrying of heavy loads on the shoulders and long-term effects of whole-body vibration in a sitting position. A medical prerequisite is fulfilled by a damage pattern with chronic lower back or neck pain and damage of the cervical or lumbar vertebrae in a conform manner.In the legal assessment the occupational conditions are examined by the preventive services of the statutory accident insurance and the medical conditions by the medical expert. Furthermore, the medical expert examines the causal connection between the fulfilled prerequisites, whereby the temporal connection (reaching the minimum load dose before realization of the conform damage pattern) and by exclusion of other competing factors are essential. As of 1 January 2021 the necessity to quit the burdening occupation has been omitted by law.Bandscheibenbedingte Erkrankungen von Hals- und Lendenwirbelsäule kommen dann als Berufskrankheit in Betracht, wenn die arbeitstechnischen und medizinischen Voraussetzungen erfüllt sind und der kausale Zusammenhang zwischen den Voraussetzungen wahrscheinlich ist. Zu den arbeitstechnischen Voraussetzungen zählen berufliche Belastungen mit langjährigem Heben und Tragen schwerer Lasten bzw. langjährige Tätigkeiten in extremer Rumpfbeugehaltung, langjähriges Tragen schwerer Lasten auf der Schulter und langjährige Einwirkung von Ganzkörperschwingungen im Sitzen. Eine medizinische Voraussetzung ist bei einem Schadensbild mit chronischen unteren Rücken- bzw. Nackenschmerzen und belastungskonformem Schädigungsbild der Bandscheiben der LWS bzw. HWS gegeben.Bei der Begutachtung werden die arbeitstechnischen Voraussetzungen durch den Präventionsdienst des Leistungsträgers, die medizinischen durch den ärztlichen Sachverständigen geprüft. Dieser prüft auch den kausalen Zusammenhang zwischen den erfüllten Voraussetzungen, wobei der zeitliche Zusammenhang (Erreichen der Belastungsmindestdosis vor Realisation des konformen Schadensbilds) und der Ausschluss konkurrierender Faktoren wesentlich sind. Zum 01.01.2021 ist der Aufgabezwang der belastenden beruflichen Tätigkeit weggefallen.

Wenngleich die Anzahl an Majoramputationen bundesweit rucklaufig ist, finden weiterhin mehr als 57.000 amputationschirurgische Eingriffe statt. Auch aufgrund hoher prothetischer Versorgungskosten resultieren daher weiterhin eine Vielzahl sozialgerichtlicher Auseinandersetzungen, in denen medizinische Sachverstandigengutachten angefordert werden. Unter Kenntnis der juristischen Normen kann der Gutachtenauftrag erfullt werden. Der Gutachter beginnt mit der Auswertung der Patientenakte und der streitgegenstandlichen Passteile. Die Untersuchung umfasst eine Anamnese sowie eine korperliche Untersuchung, um zu den streitigen Gebrauchsvorteilen der Hilfsmittel Stellung nehmen und die Beweisfragen beantworten zu konnen. Fragebogen konnen hilfreich sein.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

Ein nicht zu unterschatzender Anteil von Patienten, die eine Kniegelenksendoprothese implantiert bekommen haben, ist unzufrieden oder klagt uber persistierende Schmerzen nach der Operation. Es sollen die Haufigkeit von postoperativer Unzufriedenheit und persistierenden Schmerzen, bekannte Ursachen sowie Vorhersagewerte dargelegt werden. Die aktuelle Literatur zum Themenkomplex wird kritisch aufgearbeitet und narrativ wiedergegeben. Ein Grosteil der postoperativen Probleme ergab sich nicht aus operationstechnischen Details, sondern aus patientenspezifischen Merkmalen bzw. mangelnder praoperativer Aufklarung und Patientenselektion. Die Zufriedenheit korrelierte am starksten mit der Reduktion des praoperativen Schmerzes. Praoperativ sollte darauf geachtet werden, dass die Patienten ausschlieslich Schmerzen im Kniegelenk mit klinisch und radiologisch fortgeschrittener Gonarthrose aufweisen, moglichst uber 60 Jahre alt sind, ausreichend psychosoziale Ressourcen besitzen, um die Belastungen nach der Operation zu bewaltigen, moglichst keine Opioide einnehmen und eine realistische Erwartung an das Knie nach der Operation besitzen. Postoperativ muss bei Patienten mit uberdauernden Schmerzen der Ausschluss struktureller Ursachen erfolgen und der Zugang zu interdisziplinaren Therapien ermoglicht werden, sollten keine strukturellen Grunde gefunden werden.

Zusammenfassung. Chronisch unspezifische Rückenschmerzen (CURS) gehören international zu den häufigsten Schmerzphänomenen und können für Athletinnen und Athleten karrierelimitierend sein. Knapp ein Drittel der jährlichen Trainingsausfallzeiten werden auf CURS zurückgeführt. In der Entstehung von chronischen Schmerzen ist ein multifaktorielles Ätiologiemodell mit einem signifikanten Einfluss psychosozialer Risikofaktoren evident. Obwohl dies in der Allgemeinbevölkerung bereits gut erforscht ist, gibt es in der Sportwissenschaft vergleichsweise wenige Arbeiten darüber. Dieses Thema wird daher in drei Multicenterstudien und zahlreichen Teilstudien des MiSpEx-Netzwerks ( Medicine in Spine-Exercise-Network, Förderzeitraum 2011 – 2018) aufgegriffen. Entsprechend der Empfehlung einer frühzeitigen Diagnostik von Chronifizierungsfaktoren in der „Nationalen Versorgungsleitlinie Kreuzschmerz“, beschäftigt sich das Netzwerk u. a. mit der Überprüfung, Entwicklung und Evaluation diagnostischer Möglichkeiten. Der vorliegende Beitrag beschreibt die Entwicklung einer Diagnostik von psychosozialen Risikofaktoren, die einerseits eine Einschätzung des Risikos der Entwicklung von CURS und andererseits eine individuelle Zuweisung zu (Trainings)Interventionen erlaubt. Es wird die Entwicklungsrationale beschrieben und dabei verschiedene methodische Herangehensweisen und Entscheidungssequenzen reflektiert.

Osteoarthritis (OA) is no longer considered a purely degenerative disease. OA is defined as a disease of the entire joint, in which inflammation occurs in various joint tissues. The overall aim of this study was to analyze the presence and polarization of CD8+ T cell subsets in OA knee joints, in relation to the OA stage and compartment (synovial fluid (SF), synovial membrane (SM,) peripheral blood (PB)). A quantitative flow analysis of CD8+ T cell subsets to compare the SF, SM, PB, was performed in patients with different stages of OA (early, unicondylar and bicondylar OA). Samples of the SF, SM and PB were harvested from a total of 55 patients at the time of surgery. Early OA was confirmed by independent surgeons intraoperatively. Uni- and bicondylar OA was confirmed and graded by two plane radiographs. Samples were analyzed by flow cytometry for surface markers, and cytokines by intracellular staining (ICS). CD8+ T cells were shown to be differentiated into pro-inflammatory IFN-γ producing Tc1 and IL-17A producing Tc17, as well as anti-inflammatory IL-4 producing Tc2. All CD8+ T cell subsets (Tc1, Tc17, and Tc2) were detected in both the SM and SF. The percentage of CD8+ T cell subsets of the total CD8+ T cell population was dependent on the OA stage and compartment. Compared with the peripheral blood (PB), the proportion of CD8+IFN-γ+ Tc1 and CD8+IL-17A+ Tc17 was significantly increased in OA SF. This was confirmed in our data for both early OA and end-stage OA. In the SM samples of end-stage OA patients, the proportion of CD8+IL-17A+ Tc17 was significantly increased compared to the PB. Comparing SF and SM samples of end-stage OA patients, the proportion of CD8+IFN-γ+ Tc1 was significantly increased in SF, whereas there were no differences concerning CD8+IL-4+ Tc2 and CD8+IL-17A+ Tc17. End-stage OA samples showed a significant increase of CD8+IL-4+ Tc2 in the SM for both unicondylar and bicondylar OA compared to early OA. CD8+ T cells infiltrating the SM and SF in OA knees are differentiated into IFN-γ-, IL-17A-, and IL-4-producing CD8+ T cell subsets (Tc1, Tc17, Tc2). This differentiation depends on the OA stage and OA compartment. Further investigation of CD8+ T cell subsets and their interaction with other inflammatory cells such as CD4+ T cells and macrophages may help to identify novel therapeutic anti-inflammatory strategies for containing OA progression.

Die Arthrose ist weltweit eine der haufigsten Ursachen fur chronische Schmerzen. Entgegen der ursprunglichen Annahme einer nichtentzundlichen Verschleiserkrankung mit Abnutzung des Gelenkknorpels („wear and tear“) wird immunologisch-inflammatorischen Prozessen inzwischen eine entscheidende Beteiligung an der Pathogenese der Arthrose beigemessen. Im Rahmen der Erkrankung kommt es zu einer chronischen Inflammation des gesamten Gelenks mit Infiltration von mononuklearen Zellen (Makrophagen und T‑Zellen) in die Synovialmembran und erhohten Konzentrationen proinflammatorischer Zyto- und Chemokine in der Synovialflussigkeit und im Blut. Die vermehrte Freisetzung von Entzundungsmediatoren wie Interleukin (IL) IL-1β, IL-6, IL-8, IL-15 und Tumornekrosefaktor‑α (TNF‑α) induziert die Expression chondrodestruktiver Matrixmetalloproteinasen und damit die enzymatische Gelenkdegeneration. Humorale und zellulare Mechanismen interagieren zwischen Immun- und Nervensystem auch bei der Entwicklung von Arthroseschmerzen. Entzundungsmediatoren wie IL-6 und TNF‑α fuhren zur peripheren Sensibilisierung freier Nervenendigungen im Gelenk. Weiterhin konnen entzundungsassoziierte Wachstumsfaktoren wie nerve growth factor (NGF) die Expression von Schmerzrezeptoren an primaren Afferenzen triggern, wahrend inflammatorische Neuropeptide die Erregungsschwelle von Gelenknozizeptoren herabsetzen. Der vorliegende Ubersichtsartikel diskutiert den Stellenwert der Inflammation bei arthrosebedingten Gelenkschmerzen unter Berucksichtigung der klinischen Symptomatik und wichtiger inflammatorischer Pathomechanismen.

The effects of exercise interventions on unspecific chronic low back pain (CLBP) have been investigated in many studies, but the results are inconclusive regarding exercise types, efficiency, and sustainability. This may be because the influence of psychosocial factors on exercise induced adaptation regarding CLBP is neglected. Therefore, this study assessed psychosocial characteristics, which moderate and mediate the effects of sensorimotor exercise on LBP. A single-blind 3-arm multicenter randomized controlled trial was conducted for 12-weeks. Three exercise groups, sensorimotor exercise (SMT), sensorimotor and behavioral training (SMT-BT), and regular routines (CG) were randomly assigned to 662 volunteers. Primary outcomes (pain intensity and disability) and psychosocial characteristics were assessed at baseline (M1) and follow-up (3/6/12/24 weeks, M2-M5). Multiple regression models were used to analyze whether psychosocial characteristics are moderators of the relationship between exercise and pain, meaning that psychosocial factors and exercise interact. Causal mediation analysis were conducted to analyze, whether psychosocial characteristics mediate the exercise effect on pain. A total of 453 participants with intermittent pain (mean age = 39.5 ± 12.2 years, f = 62%) completed the training. It was shown, that depressive symptomatology (at M4, M5), vital exhaustion (at M4), and perceived social support (at M5) are significant moderators of the relationship between exercise and the reduction of pain intensity. Further depressive mood (at M4), social-satisfaction (at M4), and anxiety (at M5 SMT) significantly moderate the exercise effect on pain disability. The amount of moderation was of clinical relevance. In contrast, there were no psychosocial variables which mediated exercise effects on pain. In conclusion it was shown, that psychosocial variables can be moderators in the relationship between sensorimotor exercise induced adaptation on CLBP which may explain conflicting results in the past regarding the merit of exercise interventions in CLBP. Results suggest further an early identification of psychosocial risk factors by diagnostic tools, which may essential support the planning of personalized exercise therapy. Level of Evidence: Level I. Clinical Trial Registration: DRKS00004977, LOE: I, MiSpEx: grant-number: 080102A/11-14. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004977.

Background: Spinal infections represent a therapeutic challenge. The often protracted course of the disease is accompanied by pain, which can lead to a chronic pain experience even after the infectious disease has been treated successfully. The aim of this study was to investigate possible risk factors of pain chronification. Methods: In a prospective study, 14 patients with spinal infections were examined at admission (T1), at discharge from inpatient therapy (T2), and three to eight months postoperatively (T3) byquestionnaires on risk factors for pain chronification and by quantitative sensory testing (QST). Results: In-patient treatment lasted on average 45.3 days (&plusmn, 33.13). The patients complained of pain for 3.43 months (&plusmn, 2.77) prior to inpatient treatment. The visual analogue scale (VAS) for pain (0&ndash, 10) and the Oswestry Disability Index detected significant improvement in the course of the study. However, patients also reported catastrophic thinking, as well as fear of movement and (re)-injury. Conclusion: In summary, our results demonstrate that patients with spinal infections did not suffer from pain chronification, but might benefit from an interdisciplinary therapeutic approach, which emphasizes promoting active pain-coping strategies, as well as addressing fear of movement and catastrophic thinking.

Chronic pain is one of the major causes of disability in the general population. Even though there are effective treatment options available for reducing symptoms, these treatments often do not have consistent lasting effects. As the usage of mobile devices has increased enormously during the last few years, mobile application-based treatment options are widespread. Such app-based programs are not yet empirically proven but might enable patients to become more independent in their pain management in order to prevent relapse. The aim of this meta-analysis was to summarize the literature on mobile application-based interventions for chronic pain patients. Therefore, three electronic bibliographic databases, PubMed, PsycINFO, and Web of Science, were searched for studies that investigated the effectiveness of mobile application-based intervention for chronic pain on pain intensity. The final sample comprised twenty-two studies, with a total of 4679 individuals. Twelve of these twenty-two studies used a randomized control trial (RCT) design, while ten studies only used an observational design. For all twenty-two studies, a small but significant effect (d = −0.40) was found when compared to baseline measures or control groups. The results suggest that apps-based treatment can be helpful in reducing pain, especially in the long-term.

Low-to-moderate quality meta-analytic evidence shows that motor control stabilisation exercise (MCE) is an effective treatment of non-specific low back pain. A possible approach to overcome the weaknesses of traditional meta-analyses would be that of a prospective meta-analyses. The aim of the present analysis was to generate high-quality evidence to support the view that motor control stabilisation exercises (MCE) lead to a reduction in pain intensity and disability in non-specific low back pain patients when compared to a control group. In this prospective meta-analysis and sensitivity multilevel meta-regression within the MiSpEx-Network, 18 randomized controlled study arms were included. Participants with non-specific low back pain were allocated to an intervention (individualized MCE, 12 weeks) or a control group (no additive exercise intervention). From each study site/arm, outcomes at baseline, 3 weeks, 12 weeks, and 6 months were pooled. The outcomes were current pain (NRS or VAS, 11 points scale), characteristic pain intensity, and subjective disability. A random effects meta-analysis model for continuous outcomes to display standardized mean differences between intervention and control was performed, followed by sensitivity multilevel meta-regressions. Overall, 2391 patients were randomized, 1976 (3 weeks, short-term), 1740 (12 weeks, intermediate), and 1560 (6 months, sustainability) participants were included in the meta-analyses. In the short-term, intermediate and sustainability, moderate-to-high quality evidence indicated that MCE has a larger effect on current pain (SMD = &minus, 0.15, &minus, 0.19), pain intensity (SMD = &minus, 0.19, &minus, 0.26, &minus, 0.26) and disability (SMD = &minus, 0.27, &minus, 0.25) compared with no exercise intervention. Low-quality evidence suggested that those patients with comparably intermediate current pain and older patients may profit the most from MCE. Motor control stabilisation exercise is an effective treatment for non-specific low back pain. Sub-clinical intermediate pain and middle-aged patients may profit the most from this intervention.

Pain caused by the sacroiliac joint (SIG) makes up a relevant proportion of lumbar back pain and can have a variety of specific and non-specific causes. The SIG represents the central link between the spine and the lower extremity. It is characterized by high stability and low mobility. There are significant inter-individual differences. In addition to the possibility of asymptomatic situations, SIG dysfunction can trigger pain in the lower back with possible radiation to the lower extremity. In addition to a structured medical history, clinical examination requires an examination of the adjacent joints and the neurological status. More specifically, movement and provocation tests as well as infiltrations are carried out. General information and conservative therapeutic methods represent the first-line therapies. Interventional and surgical procedures can help in the case of chronification.

(1) Background: Studies show several advantages of unicompartmental knee replacement (UKR) over total knee replacements (TKR), whereas registry based revision rates of UKR are significantly higher than for TKA. Registry data report lower revision rates for cementless UKR compared to cemented UKR. The aim of this study was to assess clinical and radiological results of cementless Oxford UKR (OUKR) in an independent cohort. (2) Methods: This retrospective cohort study examines a consecutive series of 228 cementless OUKR. Clinical outcome was measured using functional scores (Oxford Knee Score (OKS), American Knee Society Score (AKSS), Hannover Functional Ability Questionnaire for Osteoarthritis (FFbH-OA), range of motion (ROM)), pain and satisfaction. Radiographs were analyzed regarding the incidence of radiolucent lines (RL), implant positioning, and their possible impact on clinical outcome. (3) Results: At a mean follow-up of 37.1 months, the two and three year revision free survival-rates were 97.5% and 96.9%. Reasons for revision surgery were progression of osteoarthritis, inlay dislocation and pain. All clinical outcome scores showed a significant improvement from pre- to postoperative. The incidence of RL around the implant was highest within the first year postoperatively (36%), and decreased (5%) within the second year. Their presence was not correlated with inferior clinical outcome. Implant positioning showed no influence on clinical outcome. (4) Conclusion: Cementless OUKR showed excellent clinical outcome and survival rates, with reliable osteointegration. Neither the incidence of radiolucent lines nor implant positioning were associated with inferior clinical outcome.

Background The back pain screening tool Risk-Prevention-Index Social (RPI-S) identifies the individual psychosocial risk for low back pain chronification and supports the allocation of patients at risk in additional multidisciplinary treatments. The study objectives were to evaluate (1) the prognostic validity of the RPI-S for a 6-month time frame and (2) the clinical benefit of the RPI-S. Methods In a multicenter single-blind 3-armed randomized controlled trial, n = 660 persons (age 18–65 years) were randomly assigned to a twelve-week uni- or multidisciplinary exercise intervention or control group. Psychosocial risk was assessed by the RPI-S domain social environment (RPI-SSE) and the outcome pain by the Chronic Pain Grade Questionnaire (baseline M1, 12-weeks M4, 24-weeks M5). Prognostic validity was quantified by the root mean squared error (RMSE) within the control group. The clinical benefit of RPI-SSE was calculated by repeated measures ANOVA in intervention groups. Results A subsample of n = 274 participants (mean = 38.0 years, SD 13.1) was analyzed, of which 30% were classified at risk in their psychosocial profile. The half-year prognostic validity was good (RMSE for disability of 9.04 at M4 and of 9.73 at M5; RMSE for pain intensity of 12.45 at M4 and of 14.49 at M5). People at risk showed significantly stronger reduction in pain disability and intensity at M4/M5, if participating in a multidisciplinary exercise treatment. Subjects at no risk showed a smaller reduction in pain disability in both interventions and no group differences for pain intensity. Regarding disability due to pain, around 41% of the sample would gain an unfitted treatment without the back pain screening. Conclusion The RPI-SSE prognostic validity demonstrated good applicability and a clinical benefit confirmed by a clear advantage of an individualized treatment possibility., Journal of Clinical Medicine, 9 (4), ISSN:2077-0383