Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Abstract. Introduction. Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives. To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods. Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P<0.05. Results. There was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P<0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P<0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P<0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P<0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P<0.001). Conclusion. Skeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Although the aetiology of chronic low back pain (CLBP) is unknown, it is suggested that several subgroups among CLBP-patients might be identified who are likely to benefit from different interventions. The results of these interventions might be improved by matching interventions to patient characteristics. Purpose. The purpose of this longitudinal study is to determine which subgroup of CLBP-patients benefits most from the short, intensive pain management program of RealHealth_NL. Methods. A prospective cohort of 524 selected consecutive CLBP-patients was followed. Potential predictive indicators included demographic characteristics, functional disability, experienced pain and cognitive behavioural factors as measured at pre-treatment assessment. The outcome is defined as one year improvement in functional disability. A successful outcome is a value as seen in healthy populations. The two-week residential program is in line with recommendations in international guidelines, based on cognitive behavioural principles and delivered in collaboration with orthopedic spine surgeons. Results. Multivariate logistic regression revealed pre-treatment being employed (OR 3.609 [95%CI 1.795–7.256]), and functional disability (OR 0.943 [95%CI 0.921–0.965]) as significant predictive factors of a successful outcome in functional disability at one year follow-up. Conclusion. The results imply that CLBP-patients, who are employed, and less disabled at pre-treatment assessment, who participated in the RealHealth_NL program, are consistently associated with one year follow-up improvement of functional disability toward normal values. A small set of indicators is more easily identified and addressed and CLBP-patients who are more likely to benefit from the program could be given a higher entry priority. Conflict of Interest: J O'Dowd owns shares in RealHealth_NL; Research Development & Education independent research organisation; Sint Maartenskliniek health care provider and referral organisation. Source of funding: None. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Background. While many studies have investigated long-term outcomes after lower limb arthroplasty, rather less is known about the trajectory of short-term outcomes in the first post-operative year. It is difficult for a surgeon to know when, in terms of disease severity, it is best to operate, or to make an accurate prediction of the patient pattern of post-operative recovery. We explored the trajectory of change in pain and function following primary hip and knee arthroplasty and the influence of pre-operative self-reported symptoms on post-operative improvements. Methods. A prospective UK cohort study of 164 patients undergoing primary hip (n=80) or knee (n=84) arthroplasty. WOMAC pain and function measures were collected pre-operatively and at 3 and 12 months post-operatively. Hip and knee arthroplasties were analysed separately, and patients were split into two groups: those with high or low symptoms pre-operatively. Multilevel regressions were used for each outcome (pain and function), and the trajectory of change (0–3 months and 3–12 months) charted. The study was approved by Southwest 4 Research Ethics Committee (09/H0102/72) and all patients provided informed, written consent. The authors have no competing interests to disclose. Results. Most improvement after hip arthroplasty occurred within the first 3 months post-operative. One year after surgery there was no difference in the outcomes between patients with high or low pain/function scores pre-operatively. Similarly, most improvement after knee arthroplasty occurred in the first 3 months. Improvement was greater for those patients with worse pre-operative functional disability and pain, although these patients never ‘caught-up’ with those with less severe pre-operative symptoms. Conclusions. Earlier intervention may be warranted for patients undergoing knee arthroplasty compared to hip arthroplasty to achieve the best post-operative patient-reported outcomes. Level of evidence. 2b, Individual cohort study

Objective. Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) bring relief of pain and functional disability to patients with end stage osteoarthritis, however the literature on their impact on patients’ level of physical activity (PA) is scarce. Methods. Cross-sectional study, performed in 2012, in 515 patients who underwent THA/TKA surgery in 2010–2011 and a random sample of persons aged >40 years from the Dutch general population participating in a national survey in the same period. PA in minutes per week (min/week) and adherence to the Dutch recommendation for health enhancing PA was measured by means of the Short QUestionnaire to ASsess Health enhancing PA (SQUASH) Additional assessments included socio-demographic characteristics, the presence of comorbidities, BMI and Short Form-12. Multivariable linear (total min/week) and logistic regression analyses (meeting PA recommendation), adjusting for confounders, were performed for THA and TKA separately. Results. 258 THA patients (64% female, mean age 70.0 (SD9.2)), 221 TKA patients (67% female, mean age 70.2 (SD8.9)) and 4373 persons from the general population sample (52% female, age 59.0 (SD12.0)) were included. In both regression analyses, the presence of joint arthroplasty was statistically significantly associated with more total min/week spent on PA (THA 7.0% increase, 95%-CI (2.0%–12.6%); TKA 7.4% increase, 95%-CI (1.6%–13.4%)) and a higher chance of adherence with PA recommendations (THA OR 1.90, 95%-CI (1.12–3.03); TKA OR 1.94, 95%-CI (1.19–3.15)). Conclusion. 6-18 months after surgery, THA/TKA patients were more physically active than a random sample of persons >40 years from the Dutch general population

To collate and present epidemiological data collected by Scottish National Brachial Injury Service over the past decade. The Brachial Plexus Injury Service is based at the Victoria Infirmary, Glasgow and has been a designated National Service since 2004. It provides an integrated multidisciplinary service for traumatic brachial plexus injury and plexus tumours. The Service maintains an active archive recording details of all clinical referrals and procedures conducted by the Service over the past decade. The data presented here was derived from analysis of this database and information contained in the National Brachial Plexus Injury Service Annual Report 2010/11 & 2011/12. Data shows that there has been a steady rate in the number of referrals to the Service, particularly since 2004, with an average of 50 cases referred per annum. Of these, approximately 25% required formal surgical exploration for traumatic injury and a further 10% required surgery for brachial plexus tumour removal. The vast majority of referred cases are treated non-operatively, with appropriate support from specialist physiotherapy and occupational therapy. Referrals to the Service appear well distributed from around Scotland. However, data from 2011 shows that Greater Glasgow & Clyde is the greatest individual source of referrals and subsequent hospital admissions for surgical treatment. The commonest mechanism of brachial plexus injury appears to be secondary to falls and motorcycle RTA. Using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, improved functional outcomes have been demonstrated consistently in patients who have undergone surgery for brachial plexus injuries within the Service. Over the past decade, the Brachial Plexus Injury Service has had a steady patient referral record from across the Scotland, particularly Glasgow. Data indicates that there is an on-going clinical need for provision of the service with improved outcomes and reduced functional disability in patients treated by the service. It is envisaged that data from the Service will also act as a useful planning model for the provision of UK national services in the future

Background and Objectives. Triangular fibrocartilaginous complex (TFCC) tears are common sources of ulna sided wrist pain and resultant functional disability. Diagnosis is based on history, clinical examination and radiological evidence of a TFCC central perforation or radial/ulna tear. The purpose of this study is therefore to evaluate the diagnostic accuracy of Magnetic Resonance Imaging (MRI) and Magnetic Resonance Arthrography (MRA) in the detection of TFCC injury in the adult population. Methods. Published and unpublished literature databases were systematically review independently by two researchers. Two-by-two tables were constructed to calculate the sensitivity and specificity of MRI or MRA investigations against arthroscopic outcomes. Pooled sensitivity and specificity values and summary Receiver Operating Characteristic curve (sROC) evaluations were performed. Methodological quality of each study was assessed using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool. Results. Twenty one studies were eligible, including 910 wrists. On meta-analysis, MRA was superior to MRI in the investigation of complete TFCC tears with a pooled sensitivity of 0.75 (95% Confidence Interval (CI): 0.70, 0.79) and specificity of 0.81 (95% CI: 0.76, 0.86), compared to MRAs 0.84 (95% CI: 0.79, 0.89), and 0.95 (95% CI: 0.92, 0.98) respectively. MRA and MRI performed at greater field strengths reported greater sensitivity and specificity findings. For 3.0 Tesla (T) MRI, the meta-analysis indicated a sensitivity of 0.86 (95% CI: 0.65, 0.97), and specificity of 1.00 (0.87, 1.00). In comparison, the pooled sensitivity for the 1.5T MRI assessment was 0.70 (95% CI: 0.64, 0.75) and specificity of 0.79 (95% CI: 0.72, 0.85). This trend was repeated for MRA where 3.0T MRA exhibited a sensitivity was 1.00 (95% CI: 0.79, 1.00) and specificity of 1.00 (95% CI: 0.82, 1.00), whilst pooled analysis 1.5T MRA demonstrated a sensitivity of 0.83 (95% CI: 0.78, 0.89) and specificity of 0.95 (95% CI: 0.91, 0.98). There was insufficient data to assess the diagnostic test accuracy of partial TFCC lesions. Conclusions. Given its acceptable diagnostic test accuracy, it is recommended that in cases where there are questions over the diagnosis and subsequent management of patients with ulna wrist pain, a MRA should be undertaken rather than MRI

Objectives

The aim of this study was to systematically review the literature on measurement of muscle strength in patients with femoroacetabular impingement (FAI) and other pathologies and to suggest guidelines to standardise protocols for future research in the field.

Objective

Excessive mechanical stress on synovial joints causes osteoarthritis (OA) and results in the production of prostaglandin E2 (PGE2), a key molecule in arthritis, by synovial fibroblasts. However, the relationship between arthritis-related molecules and mechanical stress is still unclear. The purpose of this study was to examine the synovial fibroblast response to cyclic mechanical stress using an in vitro osteoarthritis model.

The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism in vitro. The clinical benefits of intra-articular hyaluronic acid injections are thought to occur through improved joint lubrication. Recent findings have shown that exogenous hyaluronic acid is incorporated into articular cartilage where it may have a direct biological effect on chondrocytes through CD44 receptors.

Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes.

There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes in vitro. Low concentrations of hyaluronic acid (0.1 mg/mL and 1 mg/mL) significantly increase DNA, sulphated glycosaminoglycan and hydroxyproline synthesis. Immunohistology confirmed the maintenance of cell phenotype with increased matrix deposition of chondroitin-6-sulphate and collagen type II. These findings confirm a stimulatory effect of hyaluronic acid on chondrocyte metabolism.