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Better Outcomes for Older people with Spinal Trouble (BOOST) Trial: a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication, a protocol
<jats:sec><jats:title>Introduction</jats:title><jats:p>Neurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention.</jats:p></jats:sec><jats:sec><jats:title>Methods and analysis</jats:title><jats:p>This is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by ‘intention to treat’. There is a parallel health economic evaluation and qualitative study.</jats:p></jats:sec><jats:sec><jats:title>Ethics and dissemination</jats:title><jats:p>Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website.</jats:p></jats:sec><jats:sec><jats:title>Trial registration number</jats:title><jats:p><jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="ISRCTN12698674" ext-link-type="isrctn" specific-use="clinicaltrial pre-results">ISRCTN12698674</jats:ext-link>; Pre-results.</jats:p></jats:sec>
Prevalence of and Risk Factors for Total Hip and Knee Replacement in Retired National Football League Athletes.
BACKGROUND: Osteoarthritis is a substantial cause of disability. Joint replacement prevalence relates to the burden of severe osteoarthritis, and identifying risk factors for end-stage disease may indicate intervention opportunities. American football has high youth and elite participation, and determining risk factors for severe osteoarthritis may support future morbidity prevention. PURPOSE: To (1) determine the prevalence of hip and knee replacement in retired National Football League (NFL) athletes, (2) examine risk factors for replacement, and (3) identify the association between knee injuries and knee replacement. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Retired NFL athletes who participated in a general health survey were included. This historical cohort included those playing between 1929 and 2001. The association between self-reported playing or injury history, and replacement after retirement, was assessed with prevalence ratios (PRs). Models were adjusted for potential confounders of age and weight. RESULTS: Data for 2432 retired male NFL players (69.3% response rate) who had participated in football for a mean 15.2 years were included, in which 277 players reported replacement after retirement (11.4%). More participants reported knee replacement (7.7%) than hip replacement (4.6%). The majority of participants reported previous severe knee injury (53%), and the most prevalent was meniscal tear (32.2%). In multivariable models, age (10-year increase, PR, 2.23; 95% CI, 1.99-2.51), current weight (PR, 1.10; 95% CI, 1.06-1.14), and reporting 1 (PR, 1.78; 95% CI, 1.14-2.77), 2 (PR, 1.91; 95% CI, 1.16-3.15), or ≥3 knee injuries (PR, 3.44; 95% CI, 2.33-5.09) were associated with knee replacement. Age (10-year increase, PR, 1.86; 95% CI, 1.59-2.18), linemen (PR, 1.62; 95% CI, 1.03-2.55), and reporting 1 (PR, 1.72; 95% CI, 1.05-2.80), 2 (PR, 2.77 95% CI, 1.58-4.84), or ≥3 (PR, 2.44; 95% CI, 1.52-3.91) hip injuries were associated with hip replacement. Each reported knee injury type was cross-sectionally associated with replacement after retirement (P < .05). CONCLUSION: Knee replacement was more prevalent than hip replacement. Risk factors differed between the hip and the knee, with age and severe joint injury associated with hip and knee replacement, weight with knee replacement, and playing position associated with hip replacement. Joint injury and weight management may be prevention opportunities to reduce morbidity and end-stage osteoarthritis in this population.
Assessment on patient outcomes of primary hip replacement: an interrupted time series analysis from ‘The National Joint Registry of England and Wales’
<jats:sec><jats:title>Objectives</jats:title><jats:p>Effects of the UK Department of Health’s national Enhanced Recovery After Surgery (ERAS) Programme on outcomes after primary hip replacement.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Natural experimental study using interrupted time series to assess the changes in trends before, during and after ERAS implementation (April 2009 to March 2011).</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>Surgeries in the UK National Joint Registry were linked with Hospital Episode Statistics containing inpatient episodes from National Health Service trusts in England and patient reported outcome measures.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>Patients aged ≥18 years from 2008 to 2016.</jats:p></jats:sec><jats:sec><jats:title>Main outcome measures</jats:title><jats:p>Regression coefficients of monthly means of length of hospital stay, bed day cost, change in Oxford Hip Scores (OHS) 6 months post-surgery, complications 6 months post-surgery and revision rates 5 years post-surgery.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>438 921 primary hip replacements were identified. Hospital stays shortened from 5.6 days in April 2008 to 3.6 in December 2016. There were also improvements in bed day costs (£7573 in April 2008 to £5239 in December 2016), positive change in self-reported OHS from baseline to 6 months post-surgery (17.7 points in April 2008 to 22.9 points in December 2016), complication rates (4.1% in April 2008 to 1.7% March 2016) and 5 year revision rates (5.9 per 1000 implant-years (95% CI 4.8 to 7.2) in April 2008 to 2.9 (95% CI 2.2 to 3.9) in December 2011). The positive trends in all outcomes started before ERAS was implemented and continued during and after the programme.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Patient outcomes after hip replacement have improved over the last decade. A national ERAS programme maintained this improvement but did not alter the existing rate of change.</jats:p></jats:sec>
Physical activity and health-related quality of life in former elite and recreational cricketers from the UK with upper extremity or lower extremity persistent joint pain: a cross-sectional study
<jats:sec><jats:title>Objective</jats:title><jats:p>To evaluate and compare physical activity (PA) and health-related quality of life (HRQoL) in former elite and recreational cricketers with upper extremity (UE), lower extremity (LE) or no joint pain.</jats:p></jats:sec><jats:sec><jats:title>Study design</jats:title><jats:p>Cross-sectional cohort.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>Despite the high prevalence of joint pain in former athletes, the impact of UE pain and LE pain on PA and HRQoL and potential differences between former recreational and elite athletes are poorly understood.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>703 former cricketers aged ≥18 years (mean age 58.7, SD 12.9, played an average of 30 (IQR 20–40) seasons, 72% of whom had played at a recreational level) were recruited through the Cricket Health and Wellbeing Study and met eligibility requirements (UE pain, LE pain or no joint pain (defined as pain on most days of the past month)).</jats:p></jats:sec><jats:sec><jats:title>Primary and secondary outcomes</jats:title><jats:p>The International Physical Activity Questionnaire-Short Form collected weekly metabolic equivalents (METS), while the Short-Form 8 collected physical (PCS) and mental (MCS) component scores. Kruskal-Wallis tests with Dunn’s post-hoc and multivariable linear regressions were performed.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Weekly METS were similar in former cricketers with UE pain (median (IQR) 2560 (722–4398)), LE pain (2215 (527–3903)) and no pain (2449 (695–4203), p=0.39). MCS were similar between groups (UE pain 56.0 (52.1–60.0); LE pain 55.2 (51.1–59.4); no pain 54.7 (50.7–58.7), p=0.38). PCS were more impaired in former cricketers with UE pain (49.8 (44.9–54.8)) or LE pain (46.7 (41.0–51.9)) compared with no pain (54.2 (51.5–56.9), p<0.0001). Former cricketers with LE pain reported worse PCS than those with UE pain (p=0.04). Similar relationships were observed in former elite and recreational cricketers.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Despite impaired physical components of HRQoL in former cricketers with UE pain or LE pain, pain was not related to PA levels or mental components of HRQoL. Physical components of HRQoL were most impaired in those with LE pain, and findings were similar among former elite and recreational cricketers.</jats:p></jats:sec>
An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).
OBJECTIVES: The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) sought to revisit the 2014 algorithm recommendations for knee osteoarthritis (OA), in light of recent efficacy and safety evidence, in order to develop an updated stepwise algorithm that provides practical guidance for the prescribing physician that is applicable in Europe and internationally. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, a summary of evidence document for each intervention in OA was provided to all members of an ESCEO working group, who were required to evaluate and vote on the strength of recommendation for each intervention. Based on the evidence collected, and on the strength of recommendations afforded by consensus of the working group, the final algorithm was constructed. RESULTS: An algorithm for management of knee OA comprising a stepwise approach and incorporating consensus on 15 treatment recommendations was prepared by the ESCEO working group. Both "strong" and "weak" recommendations were afforded to different interventions. The algorithm highlights the continued importance of non-pharmacological interventions throughout the management of OA. Benefits and limitations of different pharmacological treatments are explored in this article, with particular emphasis on safety issues highlighted by recent literature analyses. CONCLUSIONS: The updated ESCEO stepwise algorithm, developed by consensus from clinical experts in OA and informed by available evidence for the benefits and harms of various treatments, provides practical, current guidance that will enable clinicians to deliver patient-centric care in OA practice.