Inger Holm

Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.

Study Design. Single blind randomized study. Objectives. To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Summary of Background Data. To the authors’ best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician. Patients and Methods. Sixty-four patients aged 25–60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4–L5 and/or L5–S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index. Results. At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (−6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rateaccording to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%. Conclusion. The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion.

A prospective cohort study of anterior cruciate ligament injuries in elite Norwegian team handball

The purpose of this study was to examine gender differences in the incidence of anterior cruciate ligament (ACL) injuries in a population of highlevel team handball players. We also wanted to examine injury mechanisms and possible risk factors for ACL injuries, including menstrual status. The study was done prospectively during the 1993‐94, 1994‐95, and 1995–96 seasons. We found 28 ACL injuries, 23 among women (incidence: 0.31 ± 0.06 injuries per 1000 player hours) and 5 among men (0.06 ± 0.03 inj./1000 h; P < 0.001 vs women; risk ratio: 5.0). Of the 28 injuries, 24 occurred during competiton (0.91 ± 0.19 inj./1000 h; women: 1.60 ± 0.35 inj./1000 h; men: 0.23 ± 0.13 inj./1000 h; P±0.001 vs. women; risk ratio: 7.0) and 4 during training (0.03 ± 0.02 inj./1000 h; P±0.001 vs. competition; risk ratio: 29.9). Nearly all the injuries (n= 25) occurred in noncontact situations when the players performed high‐speed plant‐and‐cut movements which they were well accustomed to. A reliable menstrual history could be obtained in 17 of the 23 cases among females. Five of the injuries occurred in the menstrual phase, 2 in the follicular phase, 1 in the early luteal phase and 9 in the late luteal phase (chi‐square3 d.f.= 13.2; P±0.01). The results suggest that there may be an increased risk of ACL injury during the week prior to or after the start of the menstrual period.

Four-Strand Hamstring Tendon Autograft Compared with Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction A Randomized Study with Two-Year Follow-Up

Seventy-two patients with subacute or chronic rupture of the anterior cruciate ligament were randomly assigned to autograft reconstruction with four-strand gracilis and semitendinosus tendon (N = 37) or with patellar tendon-bone (N = 35) from the ipsilateral side. The groups were similar in terms of age, sex, level of activity, degree of laxity, meniscal lesions found surgically, and rehabilitation program. The follow-up was performed at another hospital by independent observers after 6, 12, and 24 months. Sixty-one patients (32 with hamstring tendon grafts and 29 with patellar tendon grafts) complied with the follow-up routine for the full 24 months. No differences were found between the groups with respect to Cincinnati functional score, KT-1000 arthrometer measurements, or stairs hopple test results. The subjective result and the single-legged hop test result were better for the hamstring tendon group after 6 and 12 months, but no differences were found after 24 months. The hamstring tendon group showed better isokinetic knee extension strength than did the patellar tendon group after 6 months, but not after 12 and 24 months. There was a significant weakness in isokinetic knee flexion strength among the hamstring tendon group. Anterior knee pain was not significantly different between the groups, but kneeling pain was significantly less common in the hamstring tendon group after 24 months.

Knee Function and Prevalence of Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction A Prospective Study With 10 to 15 Years of Follow-up

Background Few prospective long-term studies of more than 10 years have reported changes in knee function and radiologic outcomes after anterior cruciate ligament (ACL) reconstruction. Purpose To examine changes in knee function from 6 months to 10 to 15 years after ACL reconstruction and to compare knee function outcomes over time for subjects with isolated ACL injury with those with combined ACL and meniscal injury and/or chondral lesion. Furthermore, the aim was to compare the prevalence of radiographic and symptomatic radiographic knee osteoarthritis between subjects with isolated ACL injuries and those with combined ACL and meniscal and/or chondral lesions 10 to 15 years after ACL reconstruction. Study Design Cohort study; Level of evidence, 2. Methods Follow-up evaluations were performed on 221 subjects at 6 months, 1 year, 2 years, and 10 to 15 years after ACL reconstruction with bone-patellar tendon-bone autograft. Outcome measurements were KT-1000 arthrometer, Lachman and pivot shift tests, Cincinnati knee score, isokinetic muscle strength tests, hop tests, visual analog scale for pain, Tegner activity scale, and the Kellgren and Lawrence classification. Results One hundred eighty-one subjects (82%) were evaluated at the 10- to 15-year follow-up. A significant improvement over time was revealed for all prospective outcomes of knee function. No significant differences in knee function over time were detected between the isolated and combined injury groups. Subjects with combined injury had significantly higher prevalence of radiographic knee osteoarthritis compared with those with isolated injury (80% and 62%, P = .008), but no significant group differences were shown for symptomatic radiographic knee osteoarthritis (46% and 32%, P = .053). Conclusion An overall improvement in knee function outcomes was detected from 6 months to 10 to 15 years after ACL reconstruction for both those with isolated and combined ACL injury, but significantly higher prevalence of radiographic knee osteoarthritis was found for those with combined injuries.

Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study.

Abstract The effectiveness of lumbar fusion for chronic low back pain after surgery for disc herniation has not been evaluated in a randomized controlled trial. The aim of the present study was to compare the effectiveness of lumbar fusion with posterior transpedicular screws and cognitive intervention and exercises. Sixty patients aged 25–60 years with low back pain lasting longer than 1 year after previous surgery for disc herniation were randomly allocated to the two treatment groups. Experienced back surgeons performed transpedicular fusion. Cognitive intervention consisted of a lecture intended to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The primary outcome measure was the Oswestry Disability Index (ODI). Outcome data were analyzed on an intention‐to‐treat basis. Ninety‐seven percent of the patients, including seven of eight patients who had either not attended treatment (n = 5) or changed groups (n = 2), completed 1‐year follow‐up. ODI was significantly improved from 47 to 38 after fusion and from 45 to 32 after cognitive intervention and exercises. The mean difference between treatments after adjustment for gender was −7.3 (95% CI −17.3 to 2.7, p = 0.15). The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group. For patients with chronic low back pain after previous surgery for disc herniation, lumbar fusion failed to show any benefit over cognitive intervention and exercises.

Physical Therapy Interventions for Patients With Osteoarthritis of the Knee: An Overview of Systematic Reviews

Patients with osteoarthritis of the knee are commonly treated by physical therapists. Practice should be informed by updated evidence from systematic reviews. The purpose of this article is to summarize the evidence from systematic reviews on the effectiveness of physical therapy for patients with knee osteoarthritis. Systematic reviews published between 2000 and 2007 were identified by a comprehensive literature search. We graded the quality of evidence across reviews for each comparison and outcome. Twenty-three systematic reviews on physical therapy interventions for patients with knee osteoarthritis were included. There is high-quality evidence that exercise and weight reduction reduce pain and improve physical function in patients with osteoarthritis of the knee. There is moderate-quality evidence that acupuncture, transcutaneous electrical nerve stimulation, and low-level laser therapy reduce pain and that psychoeducational interventions improve psychological outcomes. For other interventions and outcomes, the quality of evidence is low or there is no evidence from systematic reviews.

Clinical, Functional, and Radiologic Outcome in Team Handball Players 6 to 11 Years after Anterior Cruciate Ligament Injury A Follow-up Study

Background Long-term outcome after anterior cruciate ligament injury among top-level pivoting athletes is unknown. Purpose To evaluate outcome among competitive team handball players after anterior cruciate ligament injury. Study Design Prospective cohort study. Methods A previously studied group of 86 elite players who had an anterior cruciate ligament rupture were invited to participate in follow-up evaluations a mean of 7.8 years later. Results Among the 57 operatively treated patients who returned for follow-up, 33 (58%) returned to team handball at their preinjury level, compared with 18 of 22 (82%) in the nonoperative group. Eleven of the 50 players (22%) who continued playing reinjured their anterior cruciate ligament when playing team handball. The overall Lysholm score was 85 ± 13 in both groups, but the five players classified as poor were all operatively treated. Nearly half of the players had an International Knee Documentation Committee classification of abnormal or severely abnormal. There were significant differences between the injured and uninjured leg in functional (2.5% to 8%), strength (3.8% to 10.1%), and KT-1000 arthrometer tests (27%). In the operatively treated group, 11 developed radiologic gonarthrosis, compared with 6 in the nonoperatively treated group. There was no correlation between radiologic findings and pain scores. Conclusion A more restrictive attitude regarding return to competitive pivoting sports after anterior cruciate ligament injury may be warranted.

Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction

Objective: To identify preoperative predictive factors for knee function two years after reconstructive surgery of the anterior cruciate ligament (ACL). The main hypothesis was that preoperative quadriceps strength would be the most significant predictor for knee function two years after reconstructive surgery. Design: Cohort study. Setting: ACL injured individuals treated at a University Hospital and an outpatient clinic in Oslo, Norway. Participants: Seventy-three individuals with complete unilateral rupture of the ACL scheduled for reconstruction with a bone-patellar-bone autograft were included in the study, from where 60 were available for two-year follow up and included in the final analyses. Interventions: Not applicable. Main outcome measurements: Identification of baseline independent variables that may predict knee function assessed with the Cincinnati Knee Score as dependent variable two years after ACL reconstruction. Results: Quadriceps muscle strength, meniscus injury and the Short-Form-36 Bodily Pain sub score were identified as significant predictors for knee function assessed from the Cincinnati Knee Score two years after ACL reconstruction. Individuals with preoperative quadriceps strength deficits above 20% also had persistent significantly larger strength deficits two years after surgery. Conclusions: Preoperative quadriceps muscle strength deficits and meniscus injuries have significant negative consequences for the long-term functional outcome after ACL reconstruction. From our findings we suggest that ACL reconstruction should not be performed before quadriceps muscle strength deficits of the injured limb is less than 20% of the uninjured limb.

Effect of Neuromuscular Training on Proprioception, Balance, Muscle Strength, and Lower Limb Function in Female Team Handball Players

ObjectiveIntroduction of a neuromuscular training program will increase muscle strength, balance, and proprioception in elite female handball players. DesignProspective intervention study. ParticipantsThirty-five female team handball players from 2 teams in the elite division participated. Their mean age was 23 (±2.5) years, and their mean weight was 69.2 (±7.3) kg. They had played handball for 14.9 (±3.2) years, 4.7 (±2.8) years at the top level. The total number of training hours per week was 10 to 11. InterventionBased on earlier studies and knowledge about common risk situations in team handball, an anterior cruciate ligament (ACL) injury prevention program with 3 different sets of exercises was developed, each set with a 5-step progression from simple to more challenging exercises. The teams were instructed to use the program a minimum of 3 times a week during a training period of 5 to 7 weeks, and then once a week during the season. The duration of each training session was approximately 15 minutes. Main outcome measuresBalance (KAT 2000), proprioception (threshold to detection of passive motion), muscle strength (Cybex 6000), and 3 functional knee tests. The players were tested pretraining (test 1) and 8 weeks (test 2) and 12 months (test 3) after the training started. ResultsThere was a significant improvement in dynamic balance between test 1 and test 2, with a balance index (BI) of 924 (±225) and 778 (±174), respectively (P = 0.01). The effect on dynamic balance was maintained 1 year after training (BI, 730 ± 156). For static balance, no statistically significant changes were found. For the other variables measured, there were no statistical differences during the study period. ConclusionThe ACL injury prevention training program improved dynamic balance in an elite team handball players.

MUSCULOSKELETAL PAIN IN ADULTS WITH CEREBRAL PALSY COMPARED WITH THE GENERAL POPULATION

OBJECTIVE To examine prevalence and localization of musculo-skeletal pain in adults with cerebral palsy compared with the general population and to investigate variables potentially associated with pain. DESIGN A postal survey. SUBJECTS Persons with cerebral palsy and no intellectual disabilities, 18 years or more, living in Norway. METHODS A multidimensional questionnaire, including items on musculo-skeletal pain, was sent to 766 adults with cerebral palsy. RESULTS In total 406 persons responded, 49% females and 51% males age range 18-72 years (mean 34 years). All categories of cerebral palsy were represented. Nearly one-third of the adults with cerebral palsy had chronic pain, vs 15% in the general population. Mean scores of domain of bodily pain on Short Form 36 were significantly lower from an earlier age in adults with cerebral palsy. Back pain was the most common in both groups. Pain in adults with cerebral palsy was significantly associated with gender, chronic fatigue, low life satisfaction and deteriorating physical function. CONCLUSION Musculo-skeletal pain is a pronounced problem in adults with cerebral palsy from an early age, and should be addressed specifically in the follow-up programs, and in further clinical studies on potential causal pathways.