Knee crepitus is not associated with the occurrence of total knee replacement in knee osteoarthritis – a longitudinal study with data from the Osteoarthritis Initiative

Objective(s)To investigate whether the presence of knee crepitus is associated with the occurrence of total knee replacement (TKR), quality of life and deficits in physical function at long-term.MethodsSetting – This observational study uses longitudinal data (up to 4-year follow-up) from the Osteoarthritis Initiative (OAI). Participants – 4566 participants. Main Outcome Measure(s) – Logistic regression models were used to test if baseline knee crepitus is associated with the occurrence of TKR. Linear mixed models with adjustment for confounding variables (age, gender, BMI and Kellgren–Lawrence grade) were used to test the association between baseline knee crepitus and longitudinal changes in the pain, self-reported physical function, quality of life and performance-based function.ResultsThe presence of knee crepitus at baseline does not predict the occurrence of TKR at 36 months (p = 0.58 and 0.67 for right and left knees, respectively). The crepitus group presented a slightly knee extension strength decline from baseline to 48 months (p = 0.03 for the right and 0.01 for the left knee; between group difference = 2% for both right [95%CI = −0.12; −0.01] and left knees [95%CI = −0.13; −0.02]).ConclusionThe presence of knee crepitus is not associated with the occurrence of TKR in the following three years. Knee crepitus is associated with slightly declines in knee extension strength, but this does not seem to affect physical function and quality of life at long-term.     

What components of rehabilitation are helpful from the perspective of individuals with multiple sclerosis?

Abstract

Purpose: To investigate the helpful components of rehabilitation from the point of view of people with multiple sclerosis (MS). Methods: Sixteen focus groups were conducted for 68 adults with MS, who were 6 months through their 2-year multi-professional group-based out-patient rehabilitation programs in three regions of Finland. Data were analyzed using qualitative inductive content analysis combined with counts of the coded data. Results: Participants described 20 helpful components of rehabilitation that were clustered to themes of the rehabilitee himself/herself, structures of everyday life, information, activity, environmental interventions, social relationships and support. The most frequently described components of the seven main themes were peers, advice, physical exercise, assistive technology and home adaptations, and personal responsibility. Conclusions: The helpful components of both in-patient and out-patient rehabilitation that are of particular importance to people with MS are diverse and show the relevance of ICF in rehabilitation and the need for a comprehensive view in rehabilitation. The importance of peers and peer support should be taken into account in rehabilitation planning and related recommendations. The findings show that helpful rehabilitation for people with MS is not a set of mechanistic interventions but requires good social relationships and support.

• Implications for Rehabilitation

• Helpful components of rehabilitation for people with MS are diverse and show the need for a comprehensive and individual view in rehabilitation.

• Professionally guided peer support should be offered as a part of rehabilitation.

• Interventions related to assistive technology and home adaptations should be an obvious part of rehabilitation.

• It is important to support people with MS to preserve identity as an active person and to take personal responsibility in their own rehabilitation.

     

Understanding insulin resistance. What are the clinical implications?

Insulin resistance is an important clinical issue in patients with other prominent components of metabolic syndrome, such as central adiposity and diabetes. However, its presence may be less evident in patients who are neither obese nor diabetic. Is measurement of insulin resistance important in clinical practice? How might its presence change management in individual patients? In this concise review, Dr Sivitz discusses the underlying mechanisms involved in insulin resistance, the issues surrounding assessment, and the implications for management in patients in whom insulin resistance is either detected or suspected.     

Does physical activity change following hip and knee replacement? Matched case-control study evaluating Physical Activity Scale for the Elderly data from the Osteoarthritis Initiative

Objectives

To determine whether physical activity measured using the Physical Activity Scale for the Elderly (PASE), changes during the initial 24 months post-total hip (THR) or knee replacement (TKR), and how this compares to a matched non-arthroplasty cohort.

What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review

BackgroundExercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence.ObjectiveTo summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA.MethodsReviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores.ResultsOf 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates.ConclusionsClinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.     

Are trained individuals more likely to perform bystander CPR? An observational study

Background

This study aimed to evaluate the association of cardiopulmonary resuscitation (CPR) training with bystander resuscitation performance and patient outcomes after out-of-hospital cardiac arrest (OHCA).

Methods

This was a prospective, population-based cohort study of all persons aged 18 years or older with OHCA of presumed intrinsic origin and their rescuers from January through December 2008 in Takatsuki, Osaka prefecture, Japan. Data on resuscitation of OHCA patients were obtained by emergency medical service (EMS) personnel in charge based on the Utstein style. Rescuers’ characteristics including experience of CPR training were obtained by EMS personnel interview on the scene. The primary outcome was the attempt of bystander CPR.

Results

Data were collected for 120 cases out of 170 OHCAs of intrinsic origin. Among the available cases, 60 (50.0%) had previous CPR training (trained rescuer group). The proportion of bystander CPR was significantly higher in the trained rescuer group than in the untrained rescuer group (75.0% and 43.3%; p = 0.001). Bystanders who had previous experience of CPR training were 3.40 times (95% confidence interval 1.31-8.85) more likely to perform CPR compared with those without previous CPR training. The number of patients with neurologically favorable one-month survival was too small to evaluate statistical difference between the groups (2 [3.3%] in the trained rescuer group versus 1 [1.7%] in the untrained rescuer group; p = 0.500).

Conclusions

People who had experienced CPR training had a greater tendency to perform bystander CPR than people without experience of CPR training. Further studies are needed to prove the effectiveness of CPR training on survival.     

Are the kinematics of the knee joint altered during the loading response phase of gait in individuals with concurrent knee osteoarthritis and complaints of joint instability? A dynamic stereo X-ray study

Background

Joint instability has been suggested as a risk factor for knee osteoarthritis and a cause of significant functional decline in those with symptomatic disease. However, the relationship between altered knee joint mechanics and self-reports of instability in individuals with knee osteoarthritis remains unclear.

Methods

Fourteen subjects with knee osteoarthritis and complaints of joint instability and 12 control volunteers with no history of knee disease were recruited for this study. Dynamic stereo X-ray technology was used to assess the three-dimensional kinematics of the knee joint during the loading response phase of gait.

Findings

Individuals with concurrent knee osteoarthritis and joint instability demonstrated significantly reduced flexion and internal/external rotation knee motion excursions during the loading response phase of gait (P < 0.01), while the total abduction/adduction range of motion was increased (P < 0.05). In addition, the coronal and transverse plane alignment of the knee joint at initial contact was significantly different (P < 0.05) for individuals with concurrent knee osteoarthritis and joint instability. However, the anteroposterior and mediolateral tibiofemoral joint positions at initial contact and the corresponding total joint translations were similar between groups during the loading phase of gait.

Interpretations

The rotational patterns of tibiofemoral joint motion and joint alignments reported for individuals with concurrent knee osteoarthritis and joint instability are consistent with those previously established for individuals with knee osteoarthritis. Furthermore, the findings of similar translatory tibiofemoral motion between groups suggest that self-reports of episodic joint instability in individuals with knee osteoarthritis may not necessarily be associated with adaptive alterations in joint arthrokinematics.     

What is the influence of severity levels of knee osteoarthritis on gait initiation?

BackgroundThe anticipatory postural adjustments required for gait initiation have not yet been investigated in older adults with different levels of severity of knee osteoarthritis. This study aimed to evaluate the anticipatory postural adjustments adopted by older adults with different severity levels of knee osteoarthritis during gait initiation.MethodsSixty-seven older adults with knee osteoarthritis (mild, moderate, and severe levels) and 11 healthy older adults control were evaluated bilaterally with a force plate to analyze gait initiation. The center of pressure trajectory during gait initiation was divided into four phases: three anticipatory postural adjustments, and a locomotor phase. The length, duration, and velocity of each phase were calculated.FindingsThe results showed that during the right and left limbs swing forward, the severe and moderate knee osteoarthritis groups presented a significant reduction in the length of anticipatory postural adjustment phases, locomotion, duration, and velocity (P < 0.05). The severe knee osteoarthritis group presented a significantly higher body mass index (P < 0.003) than the other groups. However, just the healthy group presented a correlation between body mass index and anticipatory postural adjustments.InterpretationOur results demonstrated that older adults with severe and moderate levels of knee osteoarthritis adopt longer lasting and slower anticipatory postural adjustment phases, lower locomotion, and lower center of pressure displacement during gait initiation, suggesting that this population has adaptive strategy in performing gait initiation, which is significantly changed by the knee osteoarthritis severity level.     

How vital are the vital signs? a multi-center observational study from emergency departments of Pakistan

Background

Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints.

Methods

Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were >12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status.

Results

A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs.

Conclusion

Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms.

     

Is hyperlipasemia in critically ill patients of clinical importance? An observational CT study

Objective To assess morphological alterations of the pancreas by contrast-enhanced computed tomography (cCT) and subclinical cellular damage of the pancreas by measuring pancreatitis-associated protein (PAP) in critically ill patients without prior pancreatic disorder who presented with raised serum lipase levels. Design Prospective, observational study Setting Mixed surgical/neurosurgical intensive care unit of a German university hospital. Patients One hundred and thirty consecutive critically ill patients without prior damage or disease of the pancreas and an expected length of stay of more than 5 days. Interventions Daily serum lipase measurements and daily serum PAP measurements. Contrast-enhanced upper abdominal cCT study in patients with triple increase of serum lipase. Measurements and results Thirty-eight patients showed raised serum lipase levels and qualified for the cCT scan study. In 20 patients cCT scans were performed. Morphological alterations of the pancreas were found in 7 out these 20 patients while serum PAP levels were raised in all patients. Conclusion Hyperlipasemia is a common finding in critically ill patients without prior pancreatic disorder. While elevated serum PAP levels indicate pancreatic cellular stress morphological alterations of the pancreas are rare and of little clinical importance. C. Denz and L. Siegel contributed equally to this study. Results were presented in part and published as an abstract at the 18th ESICM Annual Congress, 25–28 September 2005, Amsterdam, Netherlands.     

Headache management—Are we doing enough? An observational study of patients presenting with headache to the emergency department

Objectives: To identify the causes of acute headache presenting to the emergency department (ED), assess the adequacy of history, examination, and investigation, and determine which clinical features are predictive of secondary headache.

Method: A retrospective study of alert (GCS14) patients presenting with headache, to an ED over a one year period. Patients were followed up for three months. The adequacy of history, examination, and investigation were compared with published standards. Analysis using Bayes's theorem determined which clinical features were predictive of secondary headache.

Results: Headache in alert patients accounted for 0.5% (n = 353) of new patient episodes, 81.2% (n = 280) of patients had a primary headache disorder. One patient (0.3%) had an adequate history recorded. No patient had a complete examination recorded. Seventy seven (21.8%) patients underwent computed tomography of the head; 80.5% (n = 62) were normal. Lumbar puncture was performed in 23 (6.5%) cases; 18 (78.3%) were normal. A number of clinical features were found to be predictive of secondary headache.

Conclusion: Headache is an uncommon symptom in alert patients presenting to the ED. The recorded history, examination, and subsequent investigation do not comply with published standards. A number of predictive features have been identified that may permit the development of a clinical prediction rule to improve the management of this patient group.

     

What are the criteria that mentors use to make judgements on the clinical performance of student mental health nurses? An exploratory study of the formal written communication at the end of clinical nursing practice modules

Issues concerning the assessment of student nurse performance in clinical practice have pre-occupied nurse educationalists for some time and continue to pose problems. The debate in the nursing literature tends to revolve around two seemingly mutually exclusive positions related to competence vs. learning outcomes. These are views that seem to be held by academics with little reference to clinical nurses who have responsibility for the assessment of student performance in clinical practice. This paper adds to the wider debate on clinical assessment by reporting on a small research study that explored the written comments that 150 mentors made in relation to the performance of student mental health nurses following periods of clinical practice. An extensive literature review is provided in order to place the debate in context, followed by a brief outline of the research study, its findings, discussion and conclusion. This analysis of findings demonstrates that student learning is of major concern to mentors, and that the assessment of student performance in clinical practice is not restricted by pre-determined behavioural learning outcomes. Personal characteristics of students exert a great influence on judgements about clinical performance. This paper does not offer solutions to the search for the perfect clinical assessment, but it does call for an increased dialogue between educationalists and mentors to discuss the implications of this research for the development of an appropriate clinical assessment tool.     

Individuals’ experience of living with osteoarthritis of the knee and perceptions of total knee arthroplasty

This study investigated the physical and psychosocial consequences of living with osteoarthritis (OA) in daily life and peoples’ views of total knee arthroplasty (TKA) and the role of physiotherapy. In-depth interview data were used from a prospective qualitative study conducted by the senior author (KY). Participants were 15 volunteers with knee OA who were awaiting TKA at a specialized orthopaedic tertiary care facility in Toronto. A modified grounded theory method approach was used to analyze the interview data. The findings showed that experiences for the participants with OA were conceptualized as a “breakpoint.” The breakpoint was centred on the experiences/processes of living with unremitting pain, the limitations of mobility, leisure and social activities, and the resulting consequences to the participant's physical and psychological well-being. In addition to the above experiences, participants also discussed their perceptions of TKA surgery. The findings showed that expectations of TKA were linked to participants’ knowledge of the procedure and its outcomes. The participants listed acquaintances, friends, family members, and doctors as the main sources of knowledge for TKA. On the basis of the above analysis, recommendations are made for developing a preoperative physiotherapy program that would focus on minimizing preoperative disability and maximizing postoperative recovery.     

Efficacy of core exercises in patients with osteoarthritis of the knee: A randomized controlled clinical trial

Trial designRandomized, evaluator blinded, controlled, parallel group.MethodsThis trial was conducted between July 2011 and January 2015 at a public hospital in Argentina. Patients older than 40 years with a medical diagnosis of osteoarthritis (OA) were randomly assigned to the experimental group (EG) or control group (CG). Both groups performed conventional exercises 3 times a week for 12 weeks and core exercises were added to the EG intervention.The objective was to compare the efficacy of conventional treatment combined with core muscle strengthening exercises, with conventional treatment alone in terms of short- and medium-term pain reduction and physical function in patients with knee OA.The primary outcome was knee pain assessed using a visual analog scale and the secondary outcome was physical function assessed at baseline, week 8 and 12, and 2 follow-up visits held 1 month and 3 months after the end of treatment.Results113 patients were randomized to a CG (n = 60) or EG (n = 53). 66 patients were eliminated and 25 patients in the EG and 22 in the CG were analyzed.Both pain reduction and improved physical function were observed throughout the intervention in both groups. At the end of the treatment, a statistically and clinically significant pain reduction was observed in the EG. No adverse effects were reported.ConclusionThe combination of core muscle activation exercises and conventional treatment was more effective in short-term pain reduction in patients with knee OA.     

Does acupuncture provide pain relief in patients with osteoarthritis knee? An overview of systematic reviews

BackgroundKnee osteoarthritis (OA) is the most common condition that causes pain and disability in adults over 50 years old. The application of acupuncture, as a method of complementary intervention, could be beneficial for pain relief and knee function in patients with knee OA.ObjectiveAnalyze the effectiveness of acupuncture versus control interventions in patients with knee OA.MethodsAn electronic search was performed in the MEDLINE (via PubMed), EMBASE, PEDro, Cochrane CENTRAL, CINAHL, Web of Science and LILACS databases. The eligibility criteria for selecting systematic reviews included clinical trials that compared acupuncture versus control interventions for pain intensity in patients with knee OA.ResultsA total of 15 systematic reviews met the eligibility criteria for the quantitative synthesis. In the short term, the mean difference (MD) for pain intensity was −0.32 cm (95% CI = −0.57 to −0.08, p = 0.01). There was a very low quality of evidence according to the GRADE rating. In the short term, the mean difference (MD) for knee function was −8.74 points (95% CI = −13.36 to −4.12, p ≤ 0.001). There was low quality of evidence according to the GRADE rating. All differences were in favor of acupuncture.ConclusionAt short-term, there was low to very low evidence and there were statistically significant differences in pain intensity and knee function in favor of acupuncture versus control interventions in patients with knee OA. However, these differences were not clinically important. For the acupuncture versus sham, in the short-term, no differences clinical neither statistically significant to favor of acupuncture in pain intensity and knee function.     

What are the beliefs and attitudes of paramedics to prehospital thrombolysis? A questionnaire study

Methods: The authors conducted a postal questionnaire study of 250 paramedics in the West Yorkshire Metropolitan Ambulance Service (WYMAS). This included the knowledge of risks and benefits of AMI treatments, and their views on possible paramedic delivered PHT.

Results: 193 paramedics replied (77%); of these 83% felt paramedics could deliver PHT, 67% felt thrombolysis was safe, and only 12% felt that paramedics should not carry out PHT. There was a similar preference towards autonomous PHT (42%) and telemetry with physician directed PHT (46%). 96% wanted a nationally recognised certificate. There were concerns regarding the risks of AMI treatment, with underestimates of the benefits of aspirin, and overestimates of the benefits of thrombolysis. They also greatly overestimated the risks of thrombolysis in terms of extra deaths (71%), and bleeding (90%).

Conclusion: The majority of paramedics in WYMAS responding to the questionnaire supported the principle of PHT. Concerns included the risks of thrombolytic treatment, training, and the medico-legal implications for them as individual paramedics. Models for paramedic thrombolysis for each ambulance service should include the views of paramedics.