Exercise for knee osteoarthritis pain:Association or causation?

Exercise is universally recommended as a primary strategy for the management of knee osteoarthritis (OA) pain. The recommendations are based on results from more than 100 randomized controlled trials (RCTs) that compare exercise to no-attention control groups. However, due to the inherent difficulties with adequate placebo control, participant blinding and the use of patient-reported outcomes, the existing RCT evidence is imperfect. To better understand the evidence used to support a causal relationship between exercise and knee OA pain relief, we examined the existing evidence through the Bradford Hill considerations for causation. The Bradford Hill considerations, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework for assessment of possible causal relationships. There are 9 considerations by which the evidence is reviewed: Strength of association, Consistency, Specificity, Temporality, Biological Gradient (Dose-Response), Plausibility, Coherence, Experiment, and Analogy. Viewing the evidence from these 9 viewpoints did neither bring forward indisputable evidence for nor against the causal relationship between exercise and improved knee OA pain. Rather, we conclude that the current evidence is not sufficient to support claims about (lack of) causality. With our review, we hope to advance the continued global conversation about how to improve the evidence-based management of patients with knee OA.</p

Exercise for knee osteoarthritis pain:Association or causation?

Exercise is universally recommended as a primary strategy for the management of knee osteoarthritis (OA) pain. The recommendations are based on results from more than 100 randomized controlled trials (RCTs) that compare exercise to no-attention control groups. However, due to the inherent difficulties with adequate placebo control, participant blinding and the use of patient-reported outcomes, the existing RCT evidence is imperfect. To better understand the evidence used to support a causal relationship between exercise and knee OA pain relief, we examined the existing evidence through the Bradford Hill considerations for causation. The Bradford Hill considerations, first proposed in 1965 by Sir Austin Bradford Hill, provide a framework for assessment of possible causal relationships. There are 9 considerations by which the evidence is reviewed: Strength of association, Consistency, Specificity, Temporality, Biological Gradient (Dose-Response), Plausibility, Coherence, Experiment, and Analogy. Viewing the evidence from these 9 viewpoints did neither bring forward indisputable evidence for nor against the causal relationship between exercise and improved knee OA pain. Rather, we conclude that the current evidence is not sufficient to support claims about (lack of) causality. With our review, we hope to advance the continued global conversation about how to improve the evidence-based management of patients with knee OA.</p

The Influence of Radiographic Severity on the Relationship between Muscle Strength and Joint Loading in Obese Knee Osteoarthritis Patients

Objective. To investigate the relationship between knee muscle strength and the external knee adduction moment during walking in obese knee osteoarthritis patients and whether disease severity influences this relationship. Methods. This cross-sectional study included 136 elderly obese (BMI > 30) adults with predominant medial knee osteoarthritis. Muscle strength, standing radiographic severity as measured by the Kellgren and Lawrence scale, and the peak external knee adduction moment were measured at self-selected walking speed. Results. According to radiographic severity, patients were classified as “less severe” (KL 1-2, N = 73) or “severe” (KL 3-4, N = 63). A significant positive association was demonstrated between the peak knee adduction moment and hamstring muscle strength in the whole cohort (P = .047). However, disease severity did not influence the relationship between muscle strength and dynamic medial knee joint loading. Severe patients had higher peak knee adduction moment and more varus malalignment (P < .001). Conclusion. Higher hamstring muscle strength relates to higher estimates of dynamic knee joint loading in the medial compartment. No such relationship existed for quadriceps muscle strength. Although cross sectional, the results suggest that hamstrings function should receive increased attention in future studies and treatments that aim at halting disease progression

The risk associated with spinal manipulation:an overview of reviews

BACKGROUND: Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT. METHODS: We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated. RESULTS: We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe. CONCLUSIONS: It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015030068. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13643-017-0458-y) contains supplementary material, which is available to authorized users

Make it REAL : Four simple points to increase clinical relevance in sport and exercise medicine research

Peer reviewedPostprin

Rally for Normative Demands and Solidarity of Workers

This research is initiated by an interesting fact that there are still many labor strikes and rallies in Indonesia. The purpose of this study is to determine: the influence of normative demands and solidarity together on job dissatisfaction of workers. This research is intended as explanatory research. Sampling method used in this research is accidental sampling. The sample consists of 100 workers/laborers who joined rallies on May 1, 2014. The results show on the indicator the amount of City Minimum Wage Rates in normative demands variable, respondents believe the amount of wages earned are still not in accordance with the provisions of the minimum wage set by the government. Participation of workers in the fight for economic security must be done in various ways including demonstrations, based on solidarity between workers in order to put pressure on policy makers with regard to labor issues. In conclusion, good normative demands in accordance with the provisions of the agreement and the strong solidarity between workers will reduce dissatisfaction. Suggestions are made on normative demands variable; review should be made on the amount of the city minimum wage rates; leave entitlements, workers social security and dismissal policies should be in compliance with the current government policy

How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment. Methods We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation. Findings Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening. Conclusions Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work.publishedVersio

Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome:a randomized controlled trial

BACKGROUND: Subacromial pain syndrome (SAPS) accounts for around 50 % of all cases of shoulder pain. The most commonly used treatments are glucocorticosteroid (steroid) injections and exercise therapy; however, despite treatment SAPS patients often experience relapse of their symptoms. Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify. The aim of this randomized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain. METHODS: In this two-arm randomized trial running over 26 weeks, patients with unilateral shoulder pain (> 4 weeks) and thickened subacromial bursa (> 2 mm on US) were included. At baseline all participants received two steroid injections into the painful shoulder with an interval of one week. Subsequently they were randomized (1:1) to either 10 weeks exercise of the involved shoulder (intervention group) or exercise of the uninvolved shoulder (control group). The patients were re-examined after the exercise program (at week 13) and again at week 26. The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle (non-responder imputation). RESULTS: Ninety-nine SAPS patients (58 female) participated (49 intervention/50 control). At both follow up visits (week 13 and 26) no statistically significant between-group differences in pain changes on a visual analog scale (mm) were seen (13 weeks: pain at rest 1.7 (95 % CI –3.6 to 7.0; P = 0.53); pain in activity 2.2 (95 % CI –6.5 to 10.9; P = 0.61), 26 weeks: rest 5.6 (95 % CI –0.9 to 12.1; P = 0.09); activity 2.2 (95 % CI –6.8 to 11.2; P = 0.62). The reduction in pain was most evident in the control group at all four pain measurements. The only difference between groups was seen by US examination at week 13, where fewer participants with impingement were observed in the intervention group compared with the controls (9 vs. 19 participants; P = 0.03). CONCLUSION: Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01506804). Registration date 5 May 2011. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13075-016-1002-5) contains supplementary material, which is available to authorized users