Ankeltrening for alle : Et kvalitetsforbedringsprosjekt ved Skadelegevakten i Oslo

I denne oppgaven tar vi for oss rehabilitering av ankelovertråkk med tanke på å forhindre nye overtråkk, og dermed spare samfunnet for store kostnader. For å oppnå dette vil vi med prosjektet ”Ankeltrening for alle” forbedre retningslinjene for håndtering av ankelovertråkk ved å gi pasienten et bedre informasjonsskriv med illustrasjoner, QR kode, DVD og nettressurs med video av aktuelle øvelser, samt ha en utlånsordning for balansepute. Vi har tatt for oss mikrosystemet Skadelegevakten i Oslo ettersom det der i dag kun blir gitt enkle råd om opptrening av proprioseptiv sans etter ukompliserte ankelovertråkk. Årsaken til at vi har valgt å skrive om akkurat dette er en nylig publisert nederlandsk studie som viste at utdeling av balansebrett samt DVD med treningsøvelser reduserte antall nye overtråkk, og i forlengelsen av dette også samfunnets kostnader. Som mål på kvaliteten av vårt kvalitetsforbedringsprosjekt bruker vi to prosessindikatorer; registrering av hvilke pasienter som har fått informasjon og utlevert materiell, samt dokumentasjon i legejournal. Prosjektgruppen bør ha forankring i ledelsen. På den måten vil man antageligvis oppnå større gjennomslag for at dette skal utføres ved hvert ankelovertråkk. Basert på et vitenskapelig kunnskapsgrunnlag bør Skadelegevakten i Oslo innføre nye rutiner for håndtering av akutte ankelovertråkk som inkluderer en deponeringsløsning for balansebrett og forbedret informasjon om opptrening etter skade

How reliable are knee kinematics and kinetics during side-cutting manoeuvres?

INTRODUCTION: Side-cutting tasks are commonly used in dynamic assessment of ACL injury risk, but only limited information is available concerning the reliability of knee loading parameters. The aim of this study was to investigate the reliability of side-cutting data with additional focus on modelling approaches and task execution variables. METHODS: Each subject (n=8) attended six testing sessions conducted by two observers. Kinematic and kinetic data of 45° side-cutting tasks was collected. Inter-trial, inter-session, inter-observer variability and observer/trial ratios were calculated at every time-point of normalised stance, for data derived from two modelling approaches. Variation in task execution variables was regressed against that of temporal profiles of relevant knee data using one-dimensional statistical parametric mapping. RESULTS: Variability in knee kinematics was consistently low across the time-series waveform (≤5°), but knee kinetic variability was high (31.8, 24.1 and 16.9Nm for sagittal, frontal and transverse planes, respectively) in the weight acceptance phase of the side-cutting task. Calculations conveyed consistently moderate-to-good measurement reliability. Inverse kinematic modelling reduced the variability in sagittal (∼6Nm) and frontal planes (∼10Nm) compared to direct kinematic modelling. Variation in task execution variables did not explain any knee data variability. CONCLUSION: Side-cutting data appears to be reliably measured, however high knee moment variability exhibited in all planes, particularly in the early stance phase, suggests cautious interpretation towards ACL injury mechanics. Such variability may be inherent to the dynamic nature of the side-cutting task or experimental issues not yet known

Zero- vs. one-dimensional, parametric vs. non-parametric, and confidence interval vs. hypothesis testing procedures in one-dimensional biomechanical trajectory analysis.

Biomechanical processes are often manifested as one-dimensional (1D) trajectories. It has been shown that 1D confidence intervals (CIs) are biased when based on 0D statistical procedures, and the non-parametric 1D bootstrap CI has emerged in the Biomechanics literature as a viable solution. The primary purpose of this paper was to clarify that, for 1D biomechanics datasets, the distinction between 0D and 1D methods is much more important than the distinction between parametric and non-parametric procedures. A secondary purpose was to demonstrate that a parametric equivalent to the 1D bootstrap exists in the form of a random field theory (RFT) correction for multiple comparisons. To emphasize these points we analyzed six datasets consisting of force and kinematic trajectories in one-sample, paired, two-sample and regression designs. Results showed, first, that the 1D bootstrap and other 1D non-parametric CIs were qualitatively identical to RFT CIs, and all were very different from 0D CIs. Second, 1D parametric and 1D non-parametric hypothesis testing results were qualitatively identical for all six datasets. Last, we highlight the limitations of 1D CIs by demonstrating that they are complex, design-dependent, and thus non-generalizable. These results suggest that (i) analyses of 1D data based on 0D models of randomness are generally biased unless one explicitly identifies 0D variables before the experiment, and (ii) parametric and non-parametric 1D hypothesis testing provide an unambiguous framework for analysis when one׳s hypothesis explicitly or implicitly pertains to whole 1D trajectories

Is the risk of infection higher during treatment with secukinumab than with TNF inhibitors? An observational study from the Nordic countries

Objectives The positioning of secukinumab in the treatment of axial SpA (axSpA) and PsA is debated, partly due to a limited understanding of the comparative safety of the available treatments. We aimed to assess the risk of the key safety outcome infections during treatment with secukinumab and TNF inhibitors (TNFi). Methods Patients with SpA and PsA starting secukinumab or TNFi year 2015 through 2018 were identified in four Nordic rheumatology registers. The first hospitalized infection during the first year of treatment was identified through linkage to national registers. Incidence rates (IRs) with 95% CIs per 100 patient-years were calculated. Adjusted hazard ratios were estimated through Cox regression, with secukinumab as the reference. Several sensitivity analyses were performed to investigate confounding by indication. Results Among 7708 patients with SpA and 5760 patients with PsA, we identified 16 229 treatment courses of TNFi (53% bionaive) and 1948 with secukinumab (11% bionaive). For secukinumab, the first-year risk of hospitalized infection was 3.5% (IR 5.0; 3.9-6.3), compared with 1.7% (IR 2.3; 1.7-3.0) during 3201 courses with adalimumab, with the IRs for other TNFi lying in between these values. The adjusted HR for adalimumab, compared with secukinumab, was 0.58 (0.39-0.85). In sensitivity analyses, the difference from secukinumab was somewhat attenuated and in some analyses no longer statistically significant. Conclusion When used according to clinical practice in the Nordic countries, the observed first-year absolute risk of hospitalized infection was doubled for secukinumab compared with adalimumab. This excess risk seemed largely explained by confounding by indication.Peer reviewe

Biomechanical but not timed performance asymmetries persist between limbs 9 months after ACL reconstruction during planned and unplanned change of direction

© 2018 Elsevier Ltd Whilst anterior cruciate ligament injury commonly occurs during change of direction (CoD) tasks, there is little research on how athletes execute CoD after anterior cruciate ligament reconstruction (ACLR). The aims of this study were to determine between-limb and between-test differences in performance (time) and joint kinematics and kinetics during planned and unplanned CoD. One hundred and fifty-six male subjects carried out 90° maximal effort, planned and unplanned CoD tests in a 3D motion capture laboratory 9 months after ACLR. Statistical parametric mapping (2 × 2 ANOVA; limb × test) was used to identify differences in CoD time and biomechanical measures between limbs and between tests. There was no interaction effect but a main effect for limb and task. There was no between-limb difference in the time to complete both CoD tests. Between-limb differences were found for internal knee valgus moment, knee internal rotation and flexion angle, knee extension and external rotation moment and ankle external rotation moment with lower values on the ACLR side (effect size 0.72–0.5). Between test differences were found with less contralateral pelvis rotation, distance from centre of mass to the ankle in frontal plane, posterior ground reaction force and greater hip abduction during the unplanned CoD (effect size 0.75–0.5). Findings demonstrated that kinematic and kinetic differences between limbs are evident during both CoD tests 9 months after surgery, despite no statistical differences in performance time. Biomechanical differences between tests were found in variables, which have previously been associated with ACL injury mechanism during unplanned CoD

Comparative effectiveness of TNF inhibitors and tocilizumab with and without conventional synthetic disease-modifying antirheumatic drugs in a pan-European observational cohort of bio-naive patients with rheumatoid arthritis

Objectives To compare treatment effectiveness in rheumatoid arthritis (RA) patients naïve to biological disease-modifying antirheumatic drugs (bDMARDs) treated with tocilizumab (TCZ) or TNF-inhibitor (TNFi) with (-combo) or without (-mono) conventional synthetic DMARDs (csDMARDs). Methods Patients with RA across 7 European registries, naïve to bDMARDs who initiated treatment with TCZ or TNFi from 2009 to 2016 were included. Drug retention rate was analyzed using Kaplan–Meier and Cox models, and CDAI over time by mixed models. The proportions of patients reaching CDAI low disease activity (LDA) and remission after one year were corrected for attrition. Results 6713 TNFi-combo, 3762 TNFi-mono, 646 TCZ-combo and 384 TCZ-mono were eligible. Crude median retention was 3.67 years (95%CI 3.41-3.83) for TNFi-combo, 4.14 (3.77-4.62) for TNFi-mono, 2.98 (2.76-3.34) for TCZ-combo and 3.63 years (3.34-5.03) for TCZ-mono. After adjustment for covariates, country and year of treatment initiation stratification, hazards of discontinuation were lower for TCZ-mono (0.60, 95% CI 0.52-0.69) and TCZ-combo (0.66, 95% CI 0.54-0.81) compared to TNFi-combo. Adjusted CDAI evolution was not significantly different between groups. CDAI LDA and remission corrected for attrition were similar between TCZ with or without csDMARDs and TNFi-combo. Conclusion In routine care across 7 European countries, the adjusted drug retention, adjusted CDAI over time and attrition-corrected response proportion for RA patients were similar for bio-naïve patients if treated with TNFi-combo, TCZ-combo or TCZ-mono.Peer reviewe

Effect of sand on landing knee valgus during single leg land and drop jump tasks: Possible implications for ACL injury prevention and rehabilitation.

Context: Despite significant emphasis on Anterior Cruciate Ligament (ACL) injury prevention, injury rates continue to rise and re-injury is common. Interventions to reduce injury have included resistance, balance and jump training elements. The use of sand-based jump training has been postulated as an effective treatment. However, evidence on landing mechanics is limited. Objective: To determine potential differences in landing strategies and subsequent landing knee valgus when performing single leg landing (SLL) and drop jump (DJ) tasks onto sand and land, and compare between both male and female populations. Design: A randomised repeated measures crossover design. Setting: University Laboratory. Participants: 31 participants (20 males, 11 females) from a university population. Interventions: All participants completed DJ and SLL tasks on both sand and land surfaces. Main Outcome Measures: 2-dimensional Frontal Plane Projection Angle (FPPA) of knee valgus was measured in both the DJ and SLL tasks (right and left) for both sand and land conditions. Results: FPPA was lower (moderate to large effect) for SLL in sand compared to land in both legs (Left: 4.3⁰ ±2.8⁰; Right: 4.1⁰ ±3.8⁰) for females. However, effects were unclear (Left: -0.7⁰ ±2.2⁰) and trivial for males (Right: -1.1⁰ ±1.9⁰). FPPA differences for males and females performing DJ were unclear, thus more data is required. Differences in FPPA (land vs sand) with respect to grouping (sex) for both SLL (Left: 4.9⁰ ±3.0⁰) and (Right: 5.1⁰ ±4.0⁰) were both very likely higher small/ possibly moderate for females compared to males

Opportunities and challenges for real-world studies on chronic inflammatory joint diseases through data enrichment and collaboration between national registers : the Nordic example

RMD Open 2018;4:e000655. doi:10.1136/ rmdopen-2018-000655Peer reviewe

Whole-body biomechanical differences between limbs exist 9 months after ACL reconstruction across jump/landing tasks

© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Introduction: Previous studies examining jump tasks after anterior cruciate ligament reconstruction (ACLR) have focused on performance measures without examining joint kinematic and kinetic variables. The aim of this study was to identify differences in biomechanical and performance measures between limbs across tests 9 months after surgery. Methods: Four jump tests (double-leg drop jump (DLDJ), single-leg drop jump (SLDJ), single-leg hop for distance (SLHD) and hurdle hop (HH)) were carried out on 156 male subjects in a 3D motion capture laboratory 9 months after surgery. Statistical parametric mapping was used to identify differences in jump performance and biomechanical variables between limbs. Results: Biomechanical measures were lower on the ACLR side across all four tests for internal knee valgus moment (effect size (ES) 0.77-0.92), knee internal rotation angle (ES 0.59-0.8), and ankle external rotation moment (ES 0.59-0.73), with the center of mass less posterior to the knee during the single-leg tests (ES 0.61-0.82). The timing of the largest difference between limbs was not at the same % stance between variables within a test or for any variable across tests. Large ES differences were observed in performance in the SLDJ (ES 0.73-0.81; LSI 78%) and small differences in the SLHD (ES 0.36; LSI 94%) between the limbs. Conclusion: Findings highlighted biomechanical differences between limbs which are consistent across jump tasks suggesting insufficient rehabilitation at 9 months post surgery. Results indicate that the SLDJ may identify greater performance deficits between limbs than SLHD, which may over-estimate rehabilitation status