Systematic reviews and quality assessment of patient-reported outcome measures for physical function in comparative effectiveness studies regarding acute postoperative pain after total knee arthroplasty-Do we need to start all over again?

BACKGROUND AND OBJECTIVE: Recently, a consensus process specified a core outcome set (COS) of domains to be assessed in each comparative effectiveness research and clinical practice related to acute postoperative pain. Physical function (PF) was one of these domains. The aim of this review was to investigate which patient-reported outcome measures (PROMs) are used to assess PF after total knee arthroplasty (TKA) in clinical trials and if they fulfil basic requirements for a COS of PROMs based on their psychometric properties. METHODS: A systematic review of randomized controlled trials and observational studies based on a search in MEDLINE, EMBASE and CENTRAL was undertaken. PROMs and performance measures were extracted and investigated, including evaluation of psychometric properties of PROMs based on COSMIN recommendations. RESULTS: From initially 2896 identified records, 479 studies were included in the qualitative synthesis. Only 87 of these trials (18%) assessed PF using PROMs, whereas especially performance outcome measures were used in 470 studies (98%). Application of the 'COSMIN Risk-of-Bias-Box 1' to 13 of the 14 identified PROMs resulted in insufficient content validity of the included PROMs regarding the target population based on the inauguration or development articles. CONCLUSION: Our data indicate that a patient-centred postoperative assessment of PF in pain-related clinical trials early after TKA is not common, even though patient-reported assessment is widely recommended. In addition, none of the applied PROMs shows content validity based on their inauguration or development articles for the assessment of postoperative pain-related PF after TKA. SIGNIFICANCE: A systematic search for patient-reported outcome measures assessing postoperative, pain-related physical function after total knee arthroplasty in clinical trials and assessment of their content validity revealed none that fulfilled requirements based on COSMIN recommendations.

Training with blood flow restriction. Mechanisms, gain in strength and safety.

Blood flow restriction training has proven to be effective, but it is not well known and is limited by initially producing discomfort. Blood flow restriction (BFR) induces hypoxia and metabolic effects, as well as reduction of proteolysis and induction of anabolic processes. Growth hormone levels are regularly increased. Controversies exist concerning neuromuscular effects. Twenty-eight of 30 studies, showed an increase in strength usually associated with muscle hypertrophy in both men and women, although data for women are sparse. Initial reports exist on positive effects on bone health after measuring rises in bone markers. A gain in strength has also been reported in non-occluded muscles after BFR training. BFR without training can lead to a rise in strength and reduce atrophy in knee extensor muscles during immobilisation. Controversial results have been observed concerning changes in aerobic capacity. Up to now no standard BFR training guidelines exist. Occlusion pressure, intensity of training, number of sets and duration of a training unit remain unclear. Presently, an occlusion pressure of 150 mmHg may be recommended with an intensity of 20 % 1-repetition maximum (1 RM), and wider cuffs are more efficient than narrow ones. Between training sets BFR should be continued. Rheologic investigations after BFR have shown no evidence for increased risk of thrombosis, when studying possible contraindications. Safety aspects for older patients must be more thoroughly addressed. The low-intensity needed may establish this training method in cardiac and pulmonary patients after future research.

[Physical activity for primary prevention of prostate cancer. Possible mechanisms]. / Körperliche Aktivität zur Primärprävention des Prostatakarzinoms: Mögliche Mechanismen.

BACKGROUND: An explanation of the possible connection between physical activity and prevention of prostate cancer was sought by reviewing the controversial data from prospective and case-control studies. Possible preventive mechanisms are to be described. METHOD: Scientific publications mainly from the past 10 years were reviewed. RESULTS: Because of the postulated dependence of prostate carcinoma on testosterone, lowering the testosterone concentration by physical activity is of importance and seems to be a possible explanation. According to many studies there is a speculative connection between prostate carcinoma and calcium concentration in blood, parathormone and vitamin D(3), and the possibly preventive modulation by physical activity results in another beneficial mechanism. Less specific is the possible increase of the antioxidant capacity of the organism by physical activity. Strength training seems to have adverse effects on testosterone, while possibly yielding a beneficial effect on the immune system. CONCLUSION: High intensive physical activity may contribute to the prevention of prostate carcinoma.

Effect of an 8-week endurance training program on markers of antioxidant capacity in women.

AIM: The effects of endurance training and of exhaustive treadmill running on low density lipoprotein (LDL) oxidation in women are not clearly established. METHODS: Twenty training and 10 control persons, all not endurance trained, aged 26+/-4 and 23+/-3 years, were recruited for 8 weeks of running training 3x/week 30 min. The susceptibility of LDL to in vitro oxidation, conjugated dienes, malondialdehyde (MDA), nitric oxide (NO) and cholesterol, lipoproteins, triglycerides, apolipoprotein (apo) A-I, apo B and lipoprotein (a) were determined before and after training, at rest and after exhaustive spiroergometric exercise. The training was tailored individually at the speed of the 4 mmol/L lactate threshold. RESULTS: At rest and after treadmill running, training induced an increase in lag-time (P<0.05), a decrease in MDA (P<0.05), and lower values for cholesterol (P<0.001), LDL (P<0.01), triglycerides (P<0.05) and apo B (P<0.001), but no increase for high density lipoprotein (HDL) or apo A-I. Before training, treadmill running induced lower conjugated dienes and malondialdehyde, after training an increase for LDL and decrease for cholesterol and triglycerides, no increase for HDL or apo A-I. In the control group, all parameters remained unchanged, only NO lowered (P<0.01). CONCLUSION: Endurance training in women shows favorable effects on LDL oxidation, cholesterol, LDL-cholesterol, triglycerides and apo B.

[Discomforts and injuries of the spine and medical examinations in young talented female gymnasts]. / Wirbelsäulenbeschwerden und -verletzungen sowie sportmedizinische Untersuchungen bei Nachwuchsleistungsturnerinnen.

The distribution of pain and injuries in gymnasts is dependent on the quality of training, but also on sport-medical supervision. In a retrospective analysis 41 female gymnasts aged 11 +/- 2.8 years training 14 h/week filled in a questionnaire on pain and injuries as well as on frequency of sports medical and spine specific examinations. 14 reported partly recurring pain mainly in the lumbar spine and 10 injuries mainly in the cervical spine. Medical treatment needed 6 after recurring pain and 6 after the injuries. Except 3 gymnasts all had been investigated medically at least once, in the mean 1.5 years, after beginning with intensive training. The clinical investigation included an investigation of the spine in 64 % out of which (2/3) received additional x-ray diagnostics. Only among the older participants scoliosis and spondylolisthesis where found twice each. Though no connection between pain or injury was found in relation to previous medical investigation, a thorough clinical and in case of doubt additional radiological investigation of the spine should be performed before intensive training.

[Sport climbing with adolescents: effect on spine stabilising muscle strength]. / Klettertraining bei Jugendlichen: Erfolge für die wirbelsäulenstabilisierende Muskulatur.

Indoor climbing and boulder facilities gain importance in therapy for patients with back pain or with psychic disorders. The effect of climbing on strength of the spine musculature has hardly been investigated in young men and women. To address this question 17 high school students agreed to enrol into a 10-week climbing course twice a week and 9 to serve as controls. All participants were measured before and after training on special devices for measuring the isometric strength of cervical extensors and lateral flexors as well as for thoracic/lumbal spine, the flexors, extensors, the right and left rotators and lateral flexors. The mobility was measured for the transversal and frontal plane. After the climbing course, a gain in strength was measured in all but two muscle groups, the thoracic/lumbal extensors and left lateral flexors, in the control group only for the thoracic/lumbal flexors and left lateral flexors. The gain in strength was higher in the climbing group. The ratio of maximal strength of the right to left rotators was smaller after climbing. Sport climbing in adolescence leads to increased muscle strength of the spine muscles and to an increased muscular balance; thus, for prevention of back pain climbing courses may be introduced in high schools.

Hypertrophic cardiomyopathy--sports-related aspects of diagnosis, therapy, and sports eligibility.

Hypertrophic cardiomyopathy (HCM) is one of the primary causes of sudden cardiac death in athletes < 35 years of age. The highest risk of sudden cardiac death is associated with syncope, early age, extreme ventricular hypertrophy, ventricular tachycardia, and a family history of sudden death. The relative risk in competitive sports is unknown. Usually, sports eligibility is rejected. However, some athletes with HCM tolerate extreme athletic lifestyles without complications. Sports-related aspects of diagnosis, therapy, and sports eligibility are presented, and discussed. Two case reports are presented: a 20-year-old professional soccer player and a 66-year-old long-distance runner. Athletes with HCM should not participate in most competitive sports with the possible exception of those of low dynamic and low static intensity. Participation in low to moderate athletic activities may be allowed in selected patients without risk factors and > 35 years of age.

Gain in strength and muscular balance after balance training.

The isolated effect of balance training on muscle strength of the flexors and extensors of the knee, without accompanying strength training, has not been addressed in the past. Effects of a balance training program alone were compared to a strength training program. Balance and strength training were performed by 15 persons each for 6 weeks including 12 training units of 25 min. Balance training was performed on instability training devices such as rolling board, mini trampoline and large rubber ball. The 15 persons of the strength training group trained on machines for leg curls and on leg presses for 25 min per unit. Measurements for balance were performed with one-leg balance on a narrow edge and a tilting stabilometer for 30 s; maximum isometric strength was measured using an isokinetic device for each leg separately. The muscular balance between dominant and non-dominant leg was calculated. Strength gain was similar for the flexors and extensors in both groups. One-leg balance improved after balance training (P< 0.01) with a 100% increase over the strength training group (P < 0.05) and the stabilometer test for each person in the balance (P < 0.01), but not in the strength training group. In the balance group the initial difference between right and left diminished. The results indicate balance training to be effective for gain in muscular strength, and secondly, in contrast to strength training, equalisation of muscular imbalances may be achieved after balance training.

[Lactate in cardiac rehabilitation]. / Lactat in der kardialen Rehabilitation.

BACKGROUND: Training increases work capacity and concomitantly quality of life, and also, according to new data, the life expectancy of patients with coronary heart disease and heart failure. At the same time, the importance of adequate training intensity increases aiming at low complications and high efficacy. ASSESSMENT OF EXERCISE CAPACITY: The objective of the present work is to define objective training guidance parameters in cardiac rehabilitation. Maximal exercise capacity must be distinguished from the performance without symptoms of oxygen deficit. The latter used to be early surpassed in untreated stabile angina pectoris. Within the last decade optimized therapy often yields a cardiac performance limit above the anaerobic threshold derived from lactate measurements. The concepts of aerobic and anaerobic thresholds derived from the lactate performance curve are introduced and modified leaving the 4 mmol/l lactate threshold concept to meet the criteria for performance capacity and breaking point in cardiac patients. The relationship to threshold concepts derived from spirometric data is mentioned as well as from stress hormones. The heart rate at the anaerobic threshold measured at treadmill ergometry systematically lies above the one from bicycle ergometry. Lactate increases faster with advancing age and the anaerobic threshold is earlier reached and progressively so because of the reduced muscle mass and reduced endurance capacity of people of the industrialized countries. IMPORTANCE: The determination of the anaerobic threshold as an objective criteria independent of motivation leads to training control, as shown by an example. Ineffective training above the threshold giving rise to catecholamines can be avoided by lactate performance diagnostic. Additionally, the success of rehabilitation measures can objectively be quantified and documented much better from the threshold work capacity than from maximal exercise tolerance. Preliminary reports indicate the importance of lactate diagnostics for rehabilitation guidance in heart failure.

In-line skating: injuries and prevention.

BACKGROUND: Most reports on in-line skating injuries describe severe injuries admitted to injury clinics. Little is known about the overall rate of injury and the contribution of the different disciplines. METHODS: In a retrospective inquiry data on injuries were obtained of 105 in-line skaters of whose 69% were active in fitness skating, 59% in jumping/grinding and 51% in the halfpipe. Beside the nature, location and degree of the injury, information was given on where the injury happened and whether protectors were worn at the time of injury. RESULTS: Of 197 injuries 145 healed without medical treatment, 28 needed medical advice once, 22 several times and 2 needed hospitalisation. Injury location were 38% in the upper, 31% in the lower extremities, 21% in the hip/pelvis region and 10% on the head. The most frequent injuries pertained to concussions and skin lesions, 35% each, followed by ligament injuries with 10% and fractures with 5%. Simple injuries were 83% in fitness skating, 70% in jumping/grinding and 60% in the halfpipe. Several visits were necessary for 4% of fitness skaters, 10% of jumpers/grinders and 23% in halfpipe injured persons. All four protectors were worn at the time of injury by 5% in fitness skating, 18% in jumping/grinding and 55% in the halfpipe. No protectors were worn in 26% of the fitness injuries, in 9% jumping/grinding and in 6% in the halfpipe. CONCLUSIONS: The results reveal an apparent discipline specific degree of danger and that fitness in-line skating is less dangerous than the resulting benefits for preventive medicine.

[Individual isokinetic strength training in patients with gonarthrosis]. / Individuelles isokinetisches Krafttraining bei Patienten mit Gonarthrose.

PROBLEM: To date, therapy of osteoarthritis of the knee is aimed at relieving pain and changing behavior patterns, which usually leads to reduced activity. The weakening of the quadricep's musculature leads to an increase in both joint instability and arthritis. Walking time is prolonged and the pain-induced reaction of knee angle velocity is onset by increased stress on other joints. The progressive muscle atrophy correlates to the degree of pain. The aim of this study was to demonstrate an improvement in strength and pain based on 4-week isokinetic strength training in gonarthritis patients. METHOD: During a conservative hospitalization period, isokinetic strength training was performed by 19 randomized patients with gonarthritis in addition to regular physiotherapy. Another 19 patients functioned as a control group. The work was examined at 60 degrees/s and 180 degrees/s and rated using a pain questionnaire at the start and end of the investigation. RESULTS: In addition to the expected increase of strength and strength endurance in the test group, the degree of pain could also be statistically significantly decreased compared to the control group. Activities of daily living, such as climbing stairs and standing-up, were also performed more easily. CONCLUSIONS: The therapeutic strategy for patients with osteoarthritis of the knee should be reconsidered to include less expensive therapeutic sport measures. Anglo-american and Scandinavian studies support this statement. Overuse and pain can be avoided by precise and low-dose strength training. Objective and reproducible measurements in the patients are essential to make individual training possible.

The influence of age on isokinetic torque of the upper and lower leg musculature in sedentary men.

While strength patterns in aging for the knee joint have been well investigated in the concentric mode, few data are available about the behaviour in the eccentric mode and for either modus in the ankle. The purpose of this study was to compile reference data for the lower extremities in untrained men between 20 and 60 years of age to determine the influence of age, especially in the eccentric work mode. Sixty-four male subjects between 20 and 60 years were divided into four age groups. Using a LIDO ACTIVE dynamometer, maximum torque was tested for the knee between 90 degrees to 0 degrees and for the ankle between 30 degrees to -10 degrees at velocities 60, 180, 240, 300 degrees/s concentric, 60 and 120 degrees/s eccentric and isometric with angles 15 degrees, 30 degrees, 45 degrees, 60 degrees, 75 degrees for the knee and 30 degrees, 20 degrees, 10 degrees, 0 degrees , -10 degrees for the ankle. Individual parameters for age-dependence were checked using linear correlation calculation with p < 0.01 set as significant. The peak torque (PT) of the knee extensors and flexors showed a typical course with the highest values in the eccentric and isometric mode and a decrease in the concentric mode with increasing angular velocity. In the concentric mode there was a significant negative correlation between PT and age at all angular velocities, but none for isometric and eccentric mode. The greatest maximum torque in the ankle was attained in the eccentric mode at 60 degrees/s. The difference to the knee was smallest in this mode compared to isometric and concentric. The plantar flexion showed age-dependence at all concentric velocities, less in eccentric and none in isometric mode. There was no correlation in dorsiflexion. The influence of loss of muscle fiber and degeneration in the course of aging has thus less influence in eccentric measurements than in the concentric mode. On the contrary, it must be assumed that the high eccentric tensions which are possible due to the quasi-elastic structures in the muscle, are maintained by the increase in stiffness of the connective tissue.

[Extended life expectancy with physical activity]. / Lebensverlängerung durch körperliche Aktivität.

New connections between physical activity and aging, arteriosclerosis and carcinoma point towards life extension by physical activity. For the slow down of the aging process, the reduction of highly reactive radicals generated from reactive radicals seems to be important by upregulating endogenous antioxidative mechanisms by physical activity. Preventive effects for arteriosclerosis by physical activity were found by positive influences on lipid and carbohydrate metabolism, blood pressure regulation, rheology and the vegetative nervous system. New data confirm this idea also as to older people. Associations between physical activity and carcinoma were lately found more often. These associations mainly concern hormone depending carcinoma in men and women, and also colon carcinoma; physical activity extents favourable effects on the hormonal system. Increasing evidence for protective effects of physical activity on aging, onkogenesis and arteriosclerosis must not lead to the assumption of causal connections.

[The significance of physical activity on the physiological stress reaction]. / Die Bedeutung der körperlichen Aktivität für die physiologische Stressreaktion.

The extent of physical activity and the dynamic performance capacity show an inverse relationship to cardiovascular mortality, independent of the influence of other risk factors, but the underlying mechanism remains uncertain. Most concepts assume that the aerobic capacity of the peripheral musculature is increased by training, and thus improved cardiocirculatory regulation and especially a more favorable stress reaction pattern are attained. This adaptation is essentially an inverse adaptation mechanism as in established cardiocirculatory insufficiency. Based on an extended stress concept, it can be seen that training effects, especially in autonomic circulatory regulation, occur under physiological conditions to a lower degree in the renin-angiotensin-aldosterone system and in inflammatory reaction. The training effects depend on the form of exercise, the baseline condition, the extent of training, and genetic predisposition. It can be particularly demonstrated when the aerobic capacity has been sufficiently enlarged in an adequate proportion of the peripheral musculature. To what extent and under what conditions these training effects can be used under the pathophysiological conditions of established cardiocirculatory insufficiency is presently under investigation.

Ventilatory, lactate-derived and catecholamine thresholds during incremental treadmill running: relationship and reproducibility.

Anaerobic threshold as a basic criterion of training recommendation can be estimated by various parameters. The purpose of this study was to investigate the relationship and the reproducibility of ventilatory, lactate-derived and catecholamine thresholds of an incremental treadmill exercise. Therefore, 11 male subjects underwent two incremental treadmill tests within 7 days. The lactate threshold (LT) was determined at the lowest value of the lactate-equivalent (ratio lactate/performance). The individual anaerobic threshold (IAT) was calculated at LT+1.5 mmol/L lactate. The ventilatory thresholds, using mass-spectrometry, were defined by the V-slope method (AT) and at the deflection point of end-tidal CO2 (ET-CO2) concentration (RCP). The thresholds of epinephrine (TE) and norepinephrine (TNE) were calculated in the manner of LT. The running velocities were highly reproducible at LT (test-retest correlation coefficient r=0.90), IAT (r=0.97), AT (r=0.88) and RCP (r=0.95). By contrast TE (r=0.49) and TNE (r=0.46) showed a poor reproducibility. TE and TNE occurred 5-11% below LT and AT with a low correlation to LT and AT. LT was found 4% below AT, both were correlated with r=0.70 (p<0.01, test 1) and r=0.95 (p<0.01, test 2). IAT occurred 7-8% above RCP, in both tests a close correlation was found between IAT and RCP of r=0.97 (p<0.01). In summary, the ventilatory and lactate-derived thresholds show a high and similar reproducibility, but the catecholamine threshold does not. In the present exercise protocol, there are systematic differences between the lactate-derived and ventilatory thresholds, in spite of a close relationship, and these must be taken into account in recommendations derived for training.

[Traumatology and sports injuries in equestrian acrobatics in the adolescent]. / Traumatologie und Sportschäden im Voltigiersport des Jugendlichen.

The objective of this study was to compile knowledge of athletic injuries and complaint patterns related specifically to equestrian acrobatics (e.a.). A 20-page standardized questionnaire was sent to 114 e.a. participants. The mean age of the participants in e.a. groups was 15 +/- 3 years, that of independent participants 21 +/- 3 years. A total of 489 injuries was reported, mainly to muscles and tendons (35%), skin (33%) and joints and ligaments (25%). Bone injuries (6%) and head injuries (2%) were infrequent. Analysis of the localization showed that the head-face-neck region was involved in the injury in 3.9%, the torso in 5.5%, the upper extremities in 28%, pelvis and hip region in 3.9%, and the lower extremities in 52%. More than half the injuries were categorized in severity grade I (55%) (not requiring medical attention), 25% were grade II (single medical treatment), 15% grade III (several outpatient medical treatments) and 5% grade IV (requiring hospitalization). Nearly half of the injuries to the lower extremities resulted from jumping exercises, while the cause in upper-extremity injuries was mostly falling (37%). The importance of fall training and limitation of difficulty as well as the number and height of the jumps is discussed. Regular medical examination and improved education of the trainers are demanded.

Endurance training in females: changes in beta-endorphin and ACTH.

Previous results from endurance training in women have been discrepant in regard to influences on basal and maximum adrenocorticotropin (ACTH) and beta-endorphin (beta-EP) concentrations before and after exhaustive exercise. A group of 23 untrained young women ran 3 times a week for 30 min at an individual specific intensity corresponding to their respective anaerobic threshold, derived from the lactate performance curve obtained from prior treadmill testing. ACTH and beta-EP were measured at rest, as well as 5 and 30 min after exhaustive progressive spiroergometric treadmill running, both before and after the 8 week endurance training program. Basal beta-EP did not change after training, but less elevated concentrations were measured both 5 (p < 0.05) and 30 min (p < 0.05) after exercise, after the training program. In contrast, the resting concentration of ACTH increased significantly; the respective maximum concentration was less elevated after 5 min and much less elevated 30 min after the exercise (p < 0.05). Positive correlations were found after the exhaustive exercise between beta-EP and ACTH, as well as between maximum lactate and ACTH. Training was associated with significant changes in maximum running speed (p < 0.01), maximum oxygen uptake (p < 0.01) and the running speed at the anaerobic threshold (p < 0.05). Maximum lactate and the level of perceived exertion remained unchanged, showing a similar level of exhaustion. Our results indicate that endurance training modulates the hormonal responses of beta-EP and ACTH to comparable workloads of high intensity. After the training program the maximum concentrations are significantly lower during the recovery period. The tendency to elevated basal ACTH, and thus elevated cortisol, might be a new factor to consider in evaluation of endurance training induced hormonal disturbances in women.

[Riding injuries and injuries due to handling horses in experienced riders]. / Reitverletzungen und Verletzungen beim Umgang mit Pferden bei erfahrenen Reitern.

A group of experienced riders who qualified for the German riding badge 9.5 years ago answered a questionnaire pertaining to injuries during jumping, dressage and cross-country riding, as well as handling the horse. During riding 69% of the persons had had 187 injuries and while handling the horse 52% had had 124 injuries. Fractures and contusions were the most-frequent injuries; most riding injuries were located in the upper extremities and shoulder while handling mainly in the hands and feet. The number of injuries was comparable in jumping, dressage or cross-country riding. The time engaged in jumping was about one-third of the other types of riding, but the injuries were more severe. While handling the horse the number of injuries relative to the time spent during the activity were higher but less complicated. No change in safety precautions had been implemented by 67% of the persons injured. The injury rate for equestrians is relatively low both in handling the horse and during riding. The frequent fractures and contusions may be reduced by following the required safety regulations.

The echocardiographic determination of volume and muscle mass of the heart.

One- and two-dimensional echocardiography permits assessment of left ventricular size and muscle mass, whereas the validity and reliability differ. It is comparable to other methods, such as angiography, scintigraphy and magnetic resonance imaging, but has the advantage of being noninvasive and of lower cost. It therefore appears particularly well-suited for applications in sports medicine. However, changes of 10%-20%, depending on the parameter, are necessary in individual cases to permit assumption of a proven change. A further methodical improvement, especially in respect to reliability but also to validity may be expected in the future from three-dimensional, computer-supported examination techniques. Enlargement of the heart due to endurance sports is harmonic and affects all four cardiac chambers. Limits to the increase in left ventricular volume and muscle mass can be recognized in relation to body weight. They usually do not exceed 70% of the baseline value or the value obtained for untrained persons. Power training, even in extreme forms, results in no or only minimal dimensional changes.