Amy P. Powell

Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease

BACKGROUND The MCID is the smallest difference in an outcome score which a patient perceives as beneficial. The PASS is the score below which patients consider themselves well. The purpose of this study was to determine the MCID and PASS for a visual analog scale (VAS) measuring pain in patients treated for rotator cuff disease. MATERIAL AND METHODS 81 patients with rotator cuff disease were evaluated after 6 weeks of non-operative treatment with a VAS measuring pain and two transition questions utilized in determining the MCID and PASS. RESULTS The MCID and PASS were estimated to be 1.4 cm (P = .0255) and 3 cm (95% CI - 22.69, 37.31) on a 10 cm VAS measuring pain, respectively. Age (P = .0492) and hand-dominance (P = .0325) affected the MCID while age (P = .0376) and duration of follow-up (P = .0131) affected the PASS. DISCUSSION The MCID and PASS estimates provide the basis to determine if statistically significant changes in VAS pain scores after treatment are clinically important and if the treatment allowed patients to achieve a satisfactory state. LEVEL OF EVIDENCE Level 3; Nonconsecutive series of patients, diagnostic study.

Minimal Clinically Important Differences in ASES and Simple Shoulder Test Scores After Nonoperative Treatment of Rotator Cuff Disease

BACKGROUND The minimal clinically important difference is the smallest difference in an outcome score that a patient perceives as beneficial. The purpose of this study was to determine the minimal clinically important difference in the American Shoulder and Elbow Surgeons (ASES) score and in the Simple Shoulder Test (SST) score for patients treated nonoperatively for rotator cuff disease. METHODS Eighty-one patients with tendinitis or a tear of the rotator cuff were treated with nonoperative modalities. Evaluation with the ASES score and the SST was performed at baseline and at a minimum of six weeks after treatment. At the follow-up evaluation, the minimal clinically important difference was estimated for the two scores with use of an anchor-based approach involving fifteen-item (pain and function) and four-item improvement questions. RESULTS The fifteen-item function and four-item assessments indicated, respectively, that a 2.05-point (p = 0.02) and 2.33-point (p = 0.0009) change in the SST score from baseline represented a minimal clinically important difference. The fifteen-item function, fifteen-item pain, and four-item assessments indicated that a 12.01-point (p = 0.03), 16.92-point (p = 0.004), and 16.72-point (p < 0.0001) change in the ASES score from baseline represented a minimal clinically important difference. Age, sex, initial baseline scores, and hand dominance had no effect on the minimal clinically important differences (p > 0.05). A longer duration of follow-up after treatment was associated with a greater minimal clinically important difference in the ASES score (p < 0.05), although the duration of follow-up had no effect on the minimal clinically important difference in the SST score. CONCLUSIONS Patients with rotator cuff disease who are treated without surgery and have a 2-point change in the SST score or a 12 to 17-point change in the ASES score experience a clinically important change in self-assessed outcome. These minimal clinically important differences can provide the basis for determining if significant differences in outcomes after treatment are clinically relevant.

Vitamin D in orthopaedics.

Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.

Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

Spinal fractures in recreational bobsledders: an unexpected mechanism of injury.

Study design: Retrospective case series and literature review. Objective: To report and discuss spinal fractures occurring in recreational bobsledders. Summary of background data: Spinal fractures have been commonly described following traumatic injury during a number of recreational sports. Reports have focused on younger patients and typically involved high-impact sports or significant injuries. With an aging population and a wider array of recreational sports, spinal injuries may be seen after seemingly benign activities and without a high-impact injury. Methods: A retrospective review of two patients and review of the literature was performed. Results: Two patients with spinal fractures after recreational bobsledding were identified. Both patients, aged 57 and 54 years, noticed a simultaneous onset of severe back pain during a routine turn on a bobsled track. Neither was involved in a high-impact injury during the event. Both patients were treated conservatively with resolution of symptoms. An analysis of the bobsled track revealed that potential forces imparted to the rider may be greater than the yield strength of vertebral bone. Conclusions: Older athletes may be at greater risk for spinal fracture associated with routine recreational activities. Bobsledding imparts large amounts of force during routine events and may result in spinal trauma. Older patients, notably those with osteoporosis or metabolic bone disease, should be educated about the risks associated with seemingly benign recreational sports.

Issues unique to the masters athlete

As our population ages, promotion of physical activity as a tool to prevent and treat disease will become increasingly important. A number of physiologic changes occur with aging that may impact athletic performance, including decrease in muscle mass, decrease in maximum heart rate, and decrease in VO2max. These changes are not completely age-related, however, and losses are diminished with continued physical training. Exercise modestly improves bone density, improves function in osteoarthritis, and is vital for patients with coronary artery disease. Preparticipation evaluation should include screening for cardiovascular disease in high-risk populations. Very few contraindications for exercise in the elderly exist. Exercise in the older population is safe, healthy, and should be encouraged.

Risk Stratification for Athletes and Adventurers in High-Altitude Environments: Recommendations for Preparticipation Evaluation.

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

General Consideration in the History, Physical Examination, and Safety Determination.

A thorough medical history is perhaps the most important aspect when evaluating an athlete before wilderness adventure. A physical examination should follow focusing on conditions that may be affected by changes in atmospheric pressure, extremes of temperature, or altitude. This information can then be used to make safety recommendations ensuring that adventurers are able to safely enjoy participation in the wilderness pursuit of their choice.