Cost-effectiveness of strength exercise or aerobic exercise compared with usual care for patients with knee osteoarthritis: secondary results from a multiarm randomised controlled trial in Norway.

OBJECTIVES: To evaluate the 1-year cost-effectiveness of strength exercise or aerobic exercise compared with usual care for patients with symptomatic knee osteoarthritis (OA), from a societal and healthcare perspective. DESIGN: Cost-effectiveness analysis embedded in a three-arm randomised controlled trial. PARTICIPANTS AND SETTING: A total of 161 people with symptomatic knee OA seeking Norwegian primary or secondary care were included in the analyses. INTERVENTIONS: Participants were randomised to either 12 weeks of strength exercise (n=54), 12 weeks of aerobic exercise (n=53) or usual care (n=54). OUTCOME MEASURES: Quality-adjusted life-years (QALYs) estimated by the EuroQol-5 Dimensions-5 Levels, and costs related to healthcare utilisation and productivity loss estimated in euros (€), aggregated for 1 year of follow-up. Cost-effectiveness was expressed with mean incremental cost-effectiveness ratios (ICERs). Bootstrapping was used to estimate ICER uncertainty. RESULTS: From a 1-year societal perspective, the mean cost per patient was €7954, €8101 and €17 398 in the strength exercise, aerobic exercise and usual care group, respectively. From a 1-year healthcare perspective, the mean cost per patient was €848, €2003 and €1654 in the strength exercise, aerobic exercise and usual care group, respectively. Mean differences in costs significantly favoured strength exercise and aerobic exercise from a 1-year societal perspective and strength exercise from a 1-year healthcare perspective. There were no significant differences in mean QALYs between groups. From a 1-year societal perspective, at a willingness-to-pay threshold of €27 500, the probability of strength exercise or aerobic exercise being cost-effective was ≥98%. From a 1-year healthcare perspective, the probability of strength exercise or aerobic exercise being cost-effective was ≥97% and ≥76%, respectively. CONCLUSION: From a 1-year societal and healthcare perspective, a 12-week strength exercise or aerobic exercise programme is cost-effective compared with usual care in patients with symptomatic knee OA. TRIAL REGISTRATION NUMBER: NCT01682980.

Treatment effect modifiers for return-to-work in patients with musculoskeletal disorders.

Investigating how individual characteristics modify treatment effects can improve understanding, interpretation, and translation of trial findings. The purpose of this secondary analysis was to identify treatment effect modifiers of the MI-NAV trial, a three arm, parallel randomized controlled trial which compared motivational interviewing and stratified vocational advice intervention in addition to usual case management, to usual case management alone. This study included (n=514) participants with musculoskeletal disorders on sick leave for at least 50% of their contracted work hours for at least 7 consecutive weeks with the Norwegian Labour and Welfare Administration. Sickness absence days was the primary outcome, measured from baseline assessment date until the six-month follow-up. Potential treatment effect modifiers, identified a priori and informed by expert consultation and literature, were evaluated using linear regression models and statistical interaction tests. For motivational interviewing versus usual case management, age (mean difference -0.7, 95% confidence interval -1.5 to 0.2; P=0.13) and self-perceived health status (mean difference -0.3, 95% confidence interval -0.7 to 0.1; P=0.19) were identified as potential effect modifiers (p ≤ 0.2). For stratified vocational advice intervention versus usual case management, analgesic medication use (MD -26.2, 95% CI -45.7 to -6.7; P=0.009) was identified as a treatment effect modifier (p ≤ 0.05). These findings may assist in more targeted treatment adaptation and translation as well as the planning of future clinical trials. PERSPECTIVE: This secondary analysis of the MI-NAV trial found that analgesic medication use, age and self-perceived health may modify the effect of two vocational interventions on reducing sickness absence in people with musculoskeletal disorders.

Six-month cost-effectiveness of adding motivational interviewing or a stratified vocational advice intervention to usual case management for workers with musculoskeletal disorders: the MI-NAV economic evaluation.

OBJECTIVES: This study evaluates the six-month cost-effectiveness and cost-benefits of motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) added to usual case management (UC) for workers on sick leave due to musculoskeletal disorders. METHODS: This study was conducted alongside a three-arm RCT including 514 employed workers on sick leave for at least 50% for ≥ 7 weeks. All participants received UC. The UC + MI group received two MI sessions, and the UC + SVAI group received 1-4 SVAI sessions. Sickness absence days, quality-adjusted life-years (QALYs), and societal costs were measured between baseline and six months. RESULTS: Adding MI to UC, resulted in incremental cost-reduction of -2580EUR (95%CI -5687;612), and a reduction in QALYs of -0.001 (95%CI -0.02;0.01). Secondly, adding MI to UC resulted in an incremental cost-reduction of -538EUR (95%CI -1358;352), and reduction of 5.08 (95%CI -3.3;13.5) sickness-absence days. Financial return estimates were positive, but not statistically significant. Adding SVAI to UC, resulted in an incremental cost-reduction of -2899 EUR (95% CI -5840;18), and a reduction in QALYs of 0.002 (95% CI -0.02;0.01). Secondly, adding SVAI to UC resulted in an statistically significant incremental cost-reduction of -695 EUR (95% CI -1459;-3), and a reduction of 7.9 (95% CI -0.04;15.9) sickness absence days. Financial return estimates were positive and statistically significant. The probabilities of cost-effectiveness for QALYs were high for adding MI or SVAI (ceiling ratio 0.90). CONCLUSIONS: In comparison to UC only, adding MI to UC tends to be cost-effective. Adding SVAI to UC is cost-effective for workers on sick leave due to musculoskeletal disorders. TRIAL REGISTRATION: ClinicalTrials.gov (identifier: NCT03871712).

Body Mass Index, Quality of Life and Activity Limitation Trajectories over 2 Years in Patients with Knee or Hip Osteoarthritis: A Dual Trajectory Approach Based on 4265 Patients Included in the AktivA Quality Register.

(1) Background: Recent studies claim that weight-neutral approaches emphasizing physical activity might be as effective as weight-loss-centered approaches for improving pain and physical function in patients with knee and hip osteoarthritis. The objectives were to identify distinctive groups of individuals with similar BMI, quality of life and activity limitation trajectories over two years, to compare the overall differences between BMI trajectory groups for baseline variables and to explore the probabilities of the quality of life and activity limitation trajectory groups conditional on the BMI group. (2) Methods: Baseline data for age, gender, BMI, quality of life, activity limitations, pain, general health, knee or hip osteoarthritis and follow-up data on BMI, quality of life and activity limitations at 3, 12 and 24 months were retrieved from the "Active with osteoarthritis" (AktivA) electronic quality register. Group-based trajectory modeling was used to identify distinct trajectories for BMI, quality of life and activity limitations. (3) Results: 4265 patients were included in the study. Four distinct BMI trajectories were identified, normal weight (31%), slightly overweight (43%), overweight (20%) and obese (6%). At baseline, there were highly significant differences between all BMI groups, pain increased and age and general health decreased with higher BMI. Irrespective of weight category, minimal changes in BMI were found over the two-year follow-up period. Over 80% of the participants showed moderate-to-considerable improvements both in quality of life and activity limitations. (4) Conclusions: Almost 70% of the participants belonged to the overweight trajectories. Despite no significant weight reduction over the two years, eight in every 10 participants improved their quality of life and reduced their activity limitations after participating in the AktivA program.

The efficacy of strength or aerobic exercise on quality of life and knee function in patients with knee osteoarthritis. A multi-arm randomized controlled trial with 1-year follow-up.

OBJECTIVE: To evaluate the efficacy of strength exercise or aerobic exercise compared to usual care on knee-related quality of life (QoL) and knee function at 4 months and 1 year in individuals with knee osteoarthritis. METHODS: A three-arm randomized controlled trial (RCT) compared 12 weeks of strength exercise or aerobic exercise (stationary cycling) to usual care supervised by physiotherapists in primary care. We recruited 168 participants aged 35-70 years with symptomatic knee osteoarthritis. The primary outcome was The Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL at 1 year. Secondary outcomes were self-reported function, pain, and self-efficacy, muscle strength and maximal oxygen uptake (VO2max) at 4 months and 1 year. RESULTS: There were no differences between strength exercise and usual care on KOOS QoL (6.5, 95% CI -0.9 to 14), or for aerobic exercise and usual care (5.0, 95% CI -2.7 to 12.8), at 1 year. The two exercise groups showed better quadriceps muscle strength, and VO2max at 4 months, compared to usual care. CONCLUSION: This trial found no statistically significant effects of two exercise programs compared to usual care on KOOS QoL at 1 year in individuals with symptomatic and radiographic knee osteoarthritis, but an underpowered sample size may explain lack of efficacy between the intervention groups and the usual care group. GOV IDENTIFIER: NCT01682980.

Mechanisms of vocational interventions for return to work from musculoskeletal conditions: a mediation analysis of the MI-NAV trial.

OBJECTIVES: To investigate whether and to what extent, return to work (RTW) expectancy and workability mediate the effect of two vocational interventions on reducing sickness absence in workers on sick leave from a musculoskeletal condition. METHODS: This is a preplanned mediation analysis of a three-arm parallel randomised controlled trial which included 514 employed working adults with musculoskeletal conditions on sick leave for at least 50% of their contracted work hours for ≥7 weeks. Participants were randomly allocated (1:1:1) to one of three treatment arms; usual case management (UC) (n=174), UC plus motivational interviewing (MI) (n=170) and UC plus a stratified vocational advice intervention (SVAI) (n=170). The primary outcome was the number of sickness absence days over 6 months from randomisation. Hypothesised mediators included RTW expectancy and workability assessed 12 weeks after randomisation. RESULTS: The mediated effect of the MI arm compared with UC on sickness absence days through RTW expectancy was -4.98 days (-8.89 to -1.04), and workability was -3.17 days (-8.55 to 2.32). The mediated effect of the SVAI arm compared with UC on sickness absence days through RTW expectancy was -4.39 days (-7.60 to -1.47), and workability was -3.21 days (-7.90 to 1.50). The mediated effects for workability were not statistically significant. CONCLUSIONS: Our study provides new evidence for the mechanisms of vocational interventions to reduce sickness absence related to sick leave due to musculoskeletal conditions. Changing an individual's expectation that RTW is likely may result in meaningful reductions in sickness absence days. TRIAL REGISTRATION NUMBER: NCT03871712.

Effectiveness of adding motivational interviewing or a stratified vocational advice intervention to usual case management on return to work for people with musculoskeletal disorders: the MI-NAV randomised controlled trial.

OBJECTIVES: To evaluate if adding motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) to usual case management (UC), reduced sickness absence over 6 months for workers on sick leave due to musculoskeletal disorders. METHODS: We conducted a three-arm parallel pragmatic randomised controlled trial including 514 employed workers (57% women, median age 49 (range 24-66)), on sick leave for at least 50% of their contracted work hours for ≥7 weeks. All participants received UC. In addition, those randomised to UC+MI were offered two MI sessions from social insurance caseworkers and those randomised to UC+SVAI were offered vocational advice from physiotherapists (participants with low/medium-risk for long-term sickness absence were offered one to two sessions, and those with high-risk were offered three to four sessions). RESULTS: Median sickness absence was 62 days, (95% CI 52 to 71) in the UC arm (n=171), 56 days (95% CI 43 to 70) in the UC+MI arm (n=169) and 49 days (95% CI 38 to 60) in the UC+SVAI arm (n=169). After adjusting for predefined potential confounding factors, the results showed seven fewer days in the UC+MI arm (95% CI -15 to 2) and the UC+SVAI arm (95% CI -16 to 1), compared with the UC arm. The adjusted differences were not statistically significant. CONCLUSIONS: The MI-NAV trial did not show effect on return to work of adding MI or SVAI to UC. The reduction in sickness absence over 6 months was smaller than anticipated, and uncertain due to wide CIs. TRIAL REGISTRATION NUMBER: NCT03871712.

Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies.

OBJECTIVE: To evaluate the sex-specific association between low knee extensor and flexor muscle strength and the risk of knee structural worsening. MATERIALS AND METHODS: Systematic searches in five databases identified longitudinal studies (≥ 1 year follow-up) reporting an association between knee extensor or flexor strength and structural decline in individuals with, or at risk of, knee osteoarthritis. Results were pooled for tibiofemoral and patellofemoral osteoarthritis worsening (and stratified by sex/gender where possible) using a random-effects meta-analysis estimating the risk ratio and 95% confidence interval or a best-evidence synthesis. Risk of bias and overall certainty of evidence were assessed. RESULTS: Fourteen studies were included with participants (mean age 27-72 years) with osteoarthritis (n = 8), at risk of osteoarthritis (n = 3), or a combination with, or at risk of, osteoarthritis (n = 3). Low knee extensor strength was associated with an increased risk of worsening tibiofemoral (12 studies: RR 1.18, 95% CI 1.04 to 1.35) and patellofemoral osteoarthritis (4 studies: RR 1.62, 95% CI 1.01 to 2.61). Significant associations between low knee extensor strength and worsening tibiofemoral osteoarthritis were observed for women (4 studies: RR 1.25, 95% CI 1.04 to 1.51) but not men (4 studies: RR 1.10, 95% CI 0.87 to 1.39). Low knee flexor strength increased the risk of worsening tibiofemoral osteoarthritis (5 studies: RR 1.16, 95% CI 1.07 to 1.26). Ten studies were high risk of bias, and all estimates were graded as very low certainty of evidence. CONCLUSION: Low knee extensor and flexor strength increased the risk of worsening tibiofemoral osteoarthritis. Low knee extensor strength increased the risk of worsening patellofemoral osteoarthritis. The relationship between low knee extensor strength and worsening tibiofemoral osteoarthritis may be modified by sex/gender.

Association between single leg hop tests and patient reported outcome measures and patellar instability in patients with recurrent patellar dislocations.

Objectives: To assess the associations between the single leg hop tests at two premises; baseline and the change after 12 months, and change in patient reported outcome measures and persistent instability after 12 months in patients with recurrent lateral patellar dislocation (RLPD). Methods: 61 RLPD patients aged 12-30 with a mean (±SD) of 19.2 (±5.3) were assessed at baseline, and at 12 months after treatment with either active rehabilitation alone, or medial patellofemoral ligament reconstruction and active rehabilitation. Single leg hop for distance, triple hop for distance, crossover hop for distance and 6-metre timed hop were performed for both legs, and the Limb Symmetry Index (LSI) was calculated. Persistent patellar instability was self-reported as 'Yes' or 'No' at 12-month follow-up. Knee function in sport and recreational activities and knee-related quality of life were assessed at baseline and 12 months follow-up using the Knee injury and Osteoarthritis Outcome Score (KOOS). Results: LSI for the baseline single leg hop for distance and the triple hop for distance was significantly associated with persistent patellar instability at 12 months follow-up with an OR of 0.94 (95% CI 0.88 to 0.99) and OR of 0.91 (95% CI 0.84 to 0.99), respectively. No other statistically significant associations were detected. Conclusion: Individuals with higher LSI values for the single leg hop for distance and triple hop for distance conducted at baseline had lower odds for persistent patellar instability at 12 months follow-up. Clinicians can use results from these hop tests to assess the risk of future recurrent patellar instability prior to treatment. Study design: Retrospective cohort study. Trial registration number: NCT02263807.

Accumulation of health complaints is associated with persistent musculoskeletal pain two years later in adolescents: The Fit Futures study.

There is limited knowledge on the association between different health complaints and the development of persistent musculoskeletal pain in adolescents. The aims of this study were to assess whether specific health complaints, and an accumulation of health complaints, in the first year of upper-secondary school, were associated with persistent musculoskeletal pain 2 years later. We used data from a population-based cohort study (the Fit Futures Study in Norway), including 551 adolescents without persistent musculoskeletal pain at baseline. The outcome was persistent musculoskeletal pain (≥3 months) 2 years after inclusion. The following self-reported health complaints were investigated as individual exposures at baseline: asthma, allergic rhinitis, atopic eczema, headache, abdominal pain and psychological distress. We also investigated the association between the accumulated number of self-reported health complaints and persistent musculoskeletal pain 2 years later. Logistic regression analyses estimated adjusted odds ratios (ORs) with 95% confidence intervals (CIs). At the 2-year follow-up, 13.8% (95% CI [11.2-16.9]) reported persistent musculoskeletal pain. Baseline abdominal pain was associated with persistent musculoskeletal pain 2 years later (OR 2.33, 95% CI [1.29-4.19], p = 0.01). Our analyses showed no statistically significant associations between asthma, allergic rhinitis, atopic eczema, headache or psychological distress and persistent musculoskeletal pain at the 2-year follow-up. For the accumulated number of health complaints, a higher odds of persistent musculoskeletal pain at the 2-year follow-up was observed for each additional health complaint at baseline (OR 1.33, 95% CI [1.07-1.66], p = 0.01). Health care providers might need to take preventive actions in adolescents with abdominal pain and in adolescents with an accumulation of health complaints to prevent development of persistent musculoskeletal pain. The potential multimorbidity perspective of adolescent musculoskeletal pain is an important topic for future research to understand the underlying patterns of persistent pain conditions in adolescents.

OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis.

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7-9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5-5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.

Measurement properties for muscle strength tests following anterior cruciate ligament and/or meniscus injury: What tests to use and where do we need to go? A systematic review with meta-analyses for the OPTIKNEE consensus.

OBJECTIVES: Critically appraise and summarise the measurement properties of knee muscle strength tests after anterior cruciate ligament (ACL) and/or meniscus injury using the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist. DESIGN: Systematic review with meta-analyses. The modified Grading of Recommendations Assessment, Development and Evaluation-guided assessment of evidence quality. DATA SOURCES: Medline, Embase, CINAHL and SPORTSDiscus searched from inception to 5 May 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies evaluating knee extensor or flexor strength test reliability, measurement error, validity, responsiveness or interpretability in individuals with ACL and/or meniscus injuries with a mean injury age of ≤30 years. RESULTS: Thirty-six studies were included involving 31 different muscle strength tests (mode and equipment) in individuals following an ACL injury and/or an isolated meniscus injury. Strength tests were assessed for reliability (n=8), measurement error (n=7), construct validity (n=27) and criterion validity (n=7). Isokinetic concentric extensor and flexor strength tests were the best rated with sufficient intrarater reliability (very low evidence quality) and construct validity (moderate evidence quality). Isotonic extensor and flexor strength tests showed sufficient criterion validity, while isometric extensor strength tests had insufficient construct and criterion validity (high evidence quality). CONCLUSION: Knee extensor and flexor strength tests of individuals with ACL and/or meniscus injury lack evidence supporting their measurement properties. There is an urgent need for high-quality studies on these measurement properties. Until then, isokinetic concentric strength tests are most recommended, with isotonic strength tests a good alternative.

Lifestyle behaviour in adolescence and musculoskeletal pain 11 years later: The Trøndelag Health Study.

BACKGROUND: There is limited knowledge on the association between lifestyle behaviour in adolescence and musculoskeletal pain in young adulthood. This study aimed to investigate whether an accumulation of adverse lifestyle behaviours in adolescents with and without musculoskeletal pain at baseline, was associated with persistent musculoskeletal pain (pain duration ≥3 consecutive months the last year) 11 years later. METHODS: Longitudinal data from the Trøndelag Health Study in Norway including 1824 adolescents (13-19 years old) was analysed. The outcome was persistent musculoskeletal pain (≥3 months). The number of adverse lifestyle behaviours (low physical activity level, sleep problems, insufficient fruit/vegetables consumption, smoking, frequent alcohol intoxication [drunkenness] and/or illicit drug use) were summed up to comprise an ordinal variable and analysed with 0 or 1 adverse behaviours as the reference. Multiple logistic regression analyses, stratified by individuals with and without baseline musculoskeletal pain, were conducted. The results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: In adolescents with musculoskeletal pain at baseline, reporting ≥ four adverse lifestyle behaviours increased the odds of persistent musculoskeletal pain (OR 2.23, 95% CI 1.36, 3.66) 11 years later. Two and three adverse behaviours were not associated with future persistent musculoskeletal pain. In adolescents without musculoskeletal pain at baseline, an accumulation of adverse lifestyle behaviours was not associated with future persistent musculoskeletal pain. CONCLUSION: An accumulation of adverse lifestyle behaviours in adolescents with musculoskeletal pain at baseline was associated with persistent musculoskeletal pain 11 years later, but not in adolescents without musculoskeletal pain at baseline. SIGNIFICANCE: An accumulation of four or more adverse lifestyle behaviours in adolescents with musculoskeletal pain was associated with persistent musculoskeletal pain in young adulthood. In future health care of adolescents with musculoskeletal pain, lifestyle behaviours should be assessed, with emphasis on accumulation of multiple adverse lifestyle behaviours. Focusing on an accumulation of multiple adverse lifestyle behaviours, rather than each individual behaviour, might provide a potential area for future research and interventions targeting musculoskeletal pain in youth.

What tests should be used to assess functional performance in youth and young adults following anterior cruciate ligament or meniscal injury? A systematic review of measurement properties for the OPTIKNEE consensus.

OBJECTIVES: To critically appraise and summarise measurement properties of functional performance tests in individuals following anterior cruciate ligament (ACL) or meniscal injury. DESIGN: Systematic review. DATA SOURCES: Systematic searches were performed in Medline (Ovid), Embase (Ovid), CINAHL (EBSCO) and SPORTSDiscus (EBSCO) on 7 July 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies evaluating at least one measurement property of a functional performance test including individuals following an ACL tear or meniscal injury with a mean injury age of ≤30 years. The COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist was used to assess methodological quality. A modified Grading of Recommendations Assessment, Development and Evaluation assessed evidence quality. RESULTS: Thirty studies evaluating 26 functional performance tests following ACL injury were included. No studies were found in individuals with an isolated meniscal injury. Included studies evaluated reliability (n=5), measurement error (n=3), construct validity (n=26), structural validity (n=1) and responsiveness (n=1). The Single Leg Hop and Crossover Hop tests showed sufficient intrarater reliability (high and moderate quality evidence, respectively), construct validity (low-quality and moderate-quality evidence, respectively) and responsiveness (low-quality evidence). CONCLUSION: Frequently used functional performance tests for individuals with ACL or meniscal injury lack evidence supporting their measurement properties. The Single Leg Hop and Crossover Hop are currently the most promising tests following ACL injury. High-quality studies are required to facilitate stronger recommendations of performance-based outcomes following ACL or meniscal injury.

Low social acceptance among peers increases the risk of persistent musculoskeletal pain in adolescents. Prospective data from the Fit Futures Study.

BACKGROUND: Musculoskeletal pain has a high prevalence in adolescence and causes huge consequences for the individuals and the society. Little knowledge exists on social risk factors for musculoskeletal pain in adolescents. This study aimed to investigate if low social acceptance among peers during the first year of upper secondary school was associated with persistent and severe persistent musculoskeletal pain 2 years later and if psychological distress modified this association. METHODS: Longitudinal data from the Norwegian Fit Futures Study was used. Students in the first year of upper secondary school answered an electronic questionnaire, covering health status, pain, social acceptance among peers, and psychological distress. Persistent musculoskeletal pain was measured 2 years later. Multiple logistic regression analyses and moderation analyses were conducted adjusting for sex and chronic diseases. Main analyses were conducted on participants without persistent musculoskeletal pain at baseline, and secondary analyses were conducted on all participants with and without persistent musculoskeletal pain at baseline. RESULTS: Of 775 participants (52% females), 556 (71.7%) were pain-free at baseline and included in the main analyses. Significant associations between low social acceptance among peers and persistent musculoskeletal pain 2 years later were found in crude (Odds ratio (OR) = 1.8, 95%CI [1.0-3.1]) and adjusted analyses (OR = 1.8, 95%CI [1.0-3.2]). No statistically significant effect modification of psychological distress (p = 0.89) on this association was found. A significant association between low social acceptance and persistent musculoskeletal pain was found in adjusted secondary analyses of all the students (n = 692) (OR = 1.6, 95%CI [1.0-2.3]). CONCLUSIONS: Our results indicate that low social acceptance among peers increases the risk of future persistent musculoskeletal pain in adolescents. Thus, interventions strengthening adolescent's social arenas may be helpful to prevent persistent musculoskeletal pain. TRIAL REGISTRATION: Retrospective registered at clinicaltrials.org NCT04526522 .

Implementing a Stratified Vocational Advice Intervention for People on Sick Leave with Musculoskeletal Disorders: A Multimethod Process Evaluation.

Purpose To perform a process evaluation of a stratified vocational advice intervention (SVAI), delivered by physiotherapists in primary care, for people on sick leave with musculoskeletal disorders participating in a randomised controlled trial. The research questions concerned how the SVAI was delivered, the content of the SVAI and the physiotherapists' experiences from delivering the SVAI. Methods We used qualitative and quantitative data from 148 intervention logs documenting the follow-up provided to each participant, recordings of 18 intervention sessions and minutes from 20 meetings with the physiotherapists. The log data were analysed with descriptive statistics. A qualitative content analysis was performed of the recordings, and we identified facilitators and barriers for implementation from the minutes. Results Of 170 participants randomised to the SVAI 152 (89%) received the intervention and 148 logs were completed. According to the logs, 131 participants received the correct number of sessions (all by telephone) and 146 action plans were developed. The physiotherapists did not attend any workplace meetings but contacted stakeholders in 37 cases. The main themes from the recorded sessions were: 'symptom burden', 'managing symptoms', 'relations with the workplace' and 'fear of not being able to manage work'. The physiotherapists felt they were able to build rapport with most participants. However, case management was hindered by the restricted number of sessions permitted according to the protocol. Conclusion Overall, the SVAI was delivered in accordance with the protocol and is therefore likely to be implementable in primary care if it is effective in reducing sick leave.

Knee extensor muscle weakness is a risk factor for the development of knee osteoarthritis: an updated systematic review and meta-analysis including 46 819 men and women.

OBJECTIVE: To update a systematic review on the association between knee extensor muscle weakness and the risk of incident knee osteoarthritis in women and men. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Systematic searches in PubMed, EMBASE, SPORTDiscus, CINAHL, AMED and CENTRAL in May 2021. ELIGIBLE CRITERIA FOR SELECTING STUDIES: Longitudinal studies with at least 2 years follow-up including baseline measure of knee extensor muscle strength, and follow-up measure of symptomatic or radiographic knee osteoarthritis. Studies including participants with known knee osteoarthritis at baseline were excluded. Risk of bias assessment was conducted using six criteria for study validity and bias. Grading of Recommendations Assessments, Development and Evaluation assessed overall quality of evidence. Meta-analysis estimated the OR for the association between knee extensor muscle weakness and incident knee osteoarthritis. RESULTS: We included 11 studies with 46 819 participants. Low quality evidence indicated that knee extensor muscle weakness increased the odds of symptomatic knee osteoarthritis in women (OR 1.85, 95% CI 1.29 to 2.64) and in adult men (OR 1.43, 95% CI 1.14 to 1.78), and for radiographic knee osteoarthritis in women: OR 1.43 (95% CI 1.19 to 1.71) and in men: OR 1.39 (95% CI 1.07 to 1.82). No associations were identified for knee injured populations except for radiographic osteoarthritis in men. DISCUSSION: There is low quality evidence that knee extensor muscle weakness is associated with incident symptomatic and radiographic knee osteoarthritis in women and men. Optimising knee extensor muscle strength may help to prevent knee osteoarthritis. PROSPERO REGISTRATION NUMBER: CRD42020214976.

Fidelity of a Motivational Interviewing Intervention for Improving Return to Work for People with Musculoskeletal Disorders.

The objective of this study was to conduct a fidelity evaluation of a motivational interviewing (MI) intervention delivered by social insurance caseworkers, in a three-arm randomized controlled trial (RCT) for improving return to work for people on sick leave with musculoskeletal disorders. The caseworkers received six days of MI training, including an intervention manual prior to the trial onset, as well as supervision throughout the trial. The caseworkers recorded 21 MI sessions at regular intervals during the trial. An independent MI analysis center scored the recordings using the MI treatment integrity code (MITI 4). In addition, three experienced MI trainers assessed the adherence to the MI intervention manual on a 1-4 Likert scale and MI competence. Total MITI 4 mean scores were at beginning proficiency levels for two components (global technical, mean 3.0; SD 0.6 and the reflections/questions ratio, mean 1.1; SD 0.2) and under beginning proficiency for two components (global relational, mean 3.2; SD 0.7 and complex question, mean 34.0; SD 21.2). The MI trainers' assessment showed similar results. The mean adherence score for the MI sessions was 2.96 (SD 0.9). Despite delivering a thorough course and supervision package, most of the caseworkers did not reach proficiency levels of good MI competence during the study. The fidelity evaluation showed that a large amount of training, supervision and practice is needed for caseworkers to become competent MI providers. When planning to implement MI, it is important that thorough consideration is given regarding the resources and the time needed to train caseworkers to provide MI in a social insurance setting.

Risk factors and risk profiles for neck pain in young adults: Prospective analyses from adolescence to young adulthood-The North-Trøndelag Health Study.

The objective was to investigate risk factors and risk profiles associated with neck pain in young adults using longitudinal data from the North-Trøndelag Health Study (HUNT). Risk factors were collected from adolescents (13-19 years of age), and neck pain was measured 11 years later. The sample was divided into two: Sample I included all participants (n = 1433), and Sample II (n = 832) included only participants who reported no neck/shoulder pain in adolescence. In multiple regression analyses in Sample I, female sex (OR = 1.9, 95% CI [1.3-2.9]), low physical activity level (OR = 1.6, 95% CI [1.0-2.5]), loneliness (OR = 2.0, 95% CI [1.2-3.5]), headache/migraine (OR = 1.7, 95% CI [1.2-2.6]), back pain (OR = 1.5, 95% CI [1.0-2.4]) and neck/shoulder pain (OR = 2.0, 95% [CI 1.3-3.0]) were associated with neck pain at the 11-year follow-up. Those with a risk profile including all these risk factors had the highest probability of neck pain of 67% in girls and 50% in boys. In Sample II, multiple regression analyses revealed that female sex (OR = 2.2, 95% CI [1.3-3.7]) and perceived low family income (OR = 2.4, 95% CI [1.1-5.1]) were associated with neck pain at the 11-year follow-up. Girls and boys with a perceived low family income had a 29% and 17% higher probability of neck pain than adolescents with a perceived high family income. The risk profiles in both samples showed that co-occurrence of risk factors, such as headache/migraine, neck/shoulder pain, back pain, low physical activity level, loneliness, and perceived low family income cumulatively increased the probability of neck pain in young adulthood. These results underline the importance of taking a broad perspective when studying, treating, and preventing neck pain in adolescents.

Neck and shoulder pain in adolescents seldom occur alone: Results from the Norwegian Ungdata Survey.

BACKGROUND: No previous studies have investigated the prevalence of co-occurring neck/shoulder pain, other musculoskeletal pain, headache and depressive symptoms in adolescents. This study aimed to describe the prevalence of isolated neck/shoulder pain and the co-occurrence of neck/shoulder pain with other musculoskeletal pain, headache and depressive symptoms in Norwegian adolescents. METHODS: This is a cross-sectional study using data from the Norwegian Ungdata survey (2017-2019). Adolescents from almost all municipalities in Norway answered a comprehensive questionnaire, including physical complaints. We investigated the prevalence of self-reported neck/shoulder pain in isolation and neck/shoulder pain in combination with other musculoskeletal pain, headache and depressive symptoms. The results were presented with per cent and stratified by school level and sex. RESULTS: In total, 253,968 adolescents (50% girls) participated in the study, of which 56.5% were from lower secondary school. The total prevalence of neck/shoulder pain was 24%, but only 5% reported isolated neck/shoulder pain. Among students reporting neck/shoulder pain, half of them also reported other musculoskeletal pain, and 50% of the boys and 70% of the girls reported co-occurring headache. Depressive symptoms were reported in 28% of the boys and 45% of the girls with neck/shoulder pain. CONCLUSION: Neck/shoulder pain in adolescents is seldom isolated, but seems to co-occur with headache, other musculoskeletal pain and depressive symptoms. Researchers and clinicians should keep a broader health perspective in mind when approaching adolescents with neck/shoulder pain. SIGNIFICANCE: One in five adolescents reported neck/shoulder pain in this large population-based study of Norwegian adolescents. A majority of adolescents reported neck/shoulder pain in co-occurrence with other musculoskeletal pain, headache and depression. Researchers and clinicians should assess these comorbidities when assessing adolescents with neck/shoulder pain.