Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC).

INTRODUCTION: Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT). MATERIALS AND METHODS: This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients. DISCUSSION: The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.

External validation and diagnostic value of the Elderly Functional Index version 2.0 for assessing functional status and frailty in older Danish patients with gastrointestinal cancer receiving chemotherapy: A prospective, clinical study.

INTRODUCTION: Patient perspectives on functioning are often overlooked in oncology practice. This study externally validates the ELderly Functional Index (ELFI), a patient-reported measure for assessing multidimensional functioning, in older patients with gastrointestinal cancer receiving chemotherapy. The study compares ELFI scoring methods, evaluates its diagnostic value with geriatric oncology tools, and proposes a cut-off point for clinical use. MATERIALS AND METHODS: Danish patients aged ≥70 years with gastrointestinal cancer undergoing chemotherapy from a prospective, observational study were included. Two ELFI scoring methods, item-based and domain-based, were compared. Internal consistency reliability, validity, and correlations between ELFI, its component scales, and measures of functioning/frailty (including Eastern Cooperative Oncology Group Performance Status [ECOG-PS], Geriatric-8 [G8], Vulnerable Elders Survey-13 [VES-13], Timed-Up-and-Go [TUG], and 30-s chair stand test [30CST]) were investigated. Sensitivity and specificity analyses evaluated the ability of ELFI to predict frailty outcomes and identified frailty thresholds. Receiver operating characteristic analyses assessed the diagnostic ability of ELFI, alongside other measures, for oncological outcomes and frailty differentiation. Equipercentile equating methods enabled ECOG-PS, ELFI, and G8 mapping. RESULTS: One hundred fifty-four patients (median age 73.5 years, range 70-85) undergoing curative- or palliative-intent chemotherapy (49%) were included. ELFI demonstrated good internal consistency (Cronbach's alpha = 0.82) and acceptable convergent, structural, and discriminant validity. ELFI showed moderate to very strong correlations with its component scales (r = 0.40-0.93), and weaker correlations with frailty measures (r = 0.02-0.60). ELFI score < 80 indicated frailty risk, with almost fivefold risk of ECOG-PS 2 at follow-up (odds ratio[OR] = 4.8, 95% confidence interval [CI] 1.4-15.9), and predicted G8, VES-13, TUG, and 30CST frailty at follow-up, not completing planned chemotherapy (OR = 3.1; 95%CI 1.5-6.2), mono-therapy (OR = 3.5; 95%CI 1.5-8.1), initial dose reduction (OR = 4.9; 95%CI 2.0-12.1), and shorter overall survival (hazard ratio = 2.0, 95%CI 1.4-3.0). A preliminary crosswalk between ECOG-PS, ELFI, and G8 was established. DISCUSSION: ELFI was validated as a concise patient-reported measure of functional status in older patients with cancer and its relationship to frailty. ELFI demonstrated comparable predictive ability to other tools for oncological outcomes. Both scoring methods yielded similar results, with the domain-based method (ELFI v2.0) endorsed for consistency. ELFI v2.0 score of 80 was suggested as the frailty threshold in this population, supporting its clinical utility.

Mobilisation during mechanical ventilation: A qualitative study exploring the practice of conscious patients, nurses and physiotherapists in intensive care unit.

AIM: To explore the practice of mobilisation of conscious and mechanically ventilated patients and the interaction between patients, nurses and physiotherapists. BACKGROUND: Long-term consequences of critical illness can be reduced by mobilisation starting in Intensive Care Units, but implementation in clinical practice is presently sparse. DESIGN: A qualitative study with a phenomenological-hermeneutic approach. METHODS: Participant observations in three Intensive Care Units involved twelve conscious mechanically ventilated patients, thirty-one nurses and four physiotherapists. Additionally seven semi-structured patient interviews, respectively at the ward and after discharge and two focus group interviews with healthcare professionals were conducted. The data analysis was inspired by Ricoeur's interpretation theory. The study adhered to the COREQ checklist. FINDINGS: Healthcare professionals performed a balance of support and guidance to promote mobilisation practice. The complexity of ICU mobilisation required a flexible mobility plan. Furthermore, interaction with feedback and humour was found to be 'a leverage' for patient's motivation to partake in mobilisation. The practice of mobilisation found patients striving to cope and healthcare professionals promoting a 'balanced standing by' and negotiating the flexible mobility plan to support mobilisation. CONCLUSION: The study revealed a need to clarify interprofessional communication to align expectations towards mobilisation of conscious and mechanically ventilated patients. RELEVANCE TO CLINICAL PRACTICE: The study demonstrated the important role of healthcare professionals to perform a stepwise and 'balanced standing by' in adequately supporting and challenging the mobilisation of mechanically ventilated patients. Furthermore, a synergy can arise when nurses and physiotherapists use supplementary feedback and humour, and cooperate based on a flexible situation-specific mobility plan in intensive care.

Getting the body back on track - Understanding the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit.

OBJECTIVE: To gain an in-depth understanding of the phenomenon of mobilisation when conscious and mechanically ventilated patients are mobilised in the intensive care unit. DESIGN: A qualitative study with a phenomenological-hermeneutic approach. Data were generated in three intensive care units from September 2019 to March 2020. Participant observations of twelve conscious mechanically ventilated patients, thirty-five nurses and four physiotherapists were performed. Furthermore, seven semi-structured patient interviews were conducted, both on the ward and after discharge. FINDINGS: Mobilisation during mechanical ventilation in the intensive care unit followed a trajectory from a failing body to a growing sense of independence in getting the body back on track. Three themes were revealed: 'Challenging to move a failing body', 'Ambiguity of both resistance and willingness in the process of strengthen the body', and 'An ongoing effort in getting the body back on track'. CONCLUSIONS: Mobilisation when conscious and mechanically ventilated included support of the living body by physical prompts and ongoing bodily guidance. Resistance and willingness regarding mobilisation were found to be a way of coping with bodily reactions of comfort or discomfort, embedded in a need to feel bodily control. The trajectory of mobilisation promoted a sense of agency, as mobilisation activities at different stages during the intensive care unit stay supported the patients in becoming more active collaborators in getting the body back on track. IMPLICATIONS FOR CLINICAL PRACTICE: Ongoing bodily guidance provided by healthcare professionals can promote bodily control and support conscious and mechanically ventilated patients in active participation in mobilisation. Furthermore, understanding the ambiguity of patients' reactions caused by loss of bodily control provides a potential to prepare mechanically ventilated patients for and assist them with mobilisation. In particular, the first mobilisation in the intensive care unit seems to influence the success of future mobilisation, as the body remembers negative experiences.

Daily variation in physical activity during mechanical ventilation and stay in the intensive care unit.

BACKGROUND: Early mobilisation of mechanically ventilated patients during their stay at an intensive care unit (ICU) can improve physical recovery. Yet, an objective and specified description of physical activities while in the ICU is lacking. Therefore, our aim was to describe the objectively assessed type, quantity, and daily variation of physical activity among mechanically ventilated patients while in the ICU. METHOD: In an observational study in two mixed medical/surgical ICUs, we measured body posture in 39 patients on mechanical ventilation using a thigh- and chest-worn accelerometer while in the ICU. The accelerometer describes time spent lying, sitting, moving, in-bed cycling, standing and walking. Descriptive analysis of physical activity and daily variation was done using STATA. RESULTS: We found that mechanically ventilated patients spend 20/24 h lying in bed, 3 h sitting and only 1 h standing, moving, walking or bicycling while in the ICU. Intervals of non-lying time appeared from 9.00 to 12.00 and again from 18.00 to 21.30, with peaks at the hours of 9.00 and 18.00. CONCLUSION: ICU patients on mechanical ventilation were primarily sedentary. Physical activity of mechanically ventilated patients seems to be related to nurse- and/or physiotherapy-initiated activities. There is a need to create an awareness of improving clinical routines, towards active mobilisation throughout the day, for this vulnerable patient population during their stay in the ICU.

Symptoms of total pain experienced by older people with advanced gastrointestinal cancer receiving palliative chemotherapy.

OBJECTIVE: Little is known about concurrent physical, psychological, social and spiritual distress experienced by older patients during early stages of advanced cancer while receiving life-prolonging treatment. Drawing on the concept of total pain, this study explored the multi-faceted symptoms of pain in older patients with advanced gastrointestinal cancer while receiving palliative chemotherapy. METHODS: A total of 14 in-depth interviews with seven participants were conducted, one interview at the beginning and one after completion of chemotherapy. Participants were ≥70 years, diagnosed with advanced gastrointestinal cancer and receiving palliative chemotherapy. RESULTS: Thematic analysis revealed four themes: variability and inevitability of physical pain, ways of coping with psychological pain, mitigating social pain through contributions to social life and the anticipation of existential pain in old age. Conducting two interviews with each participant foregrounded the changing nature of the participants' experienced symptoms and life perspectives while receiving palliative chemotherapy. Further, old age was experienced as integral to how participants described their situation and indicated an acceptance of old age. CONCLUSION: Older adults with advanced cancer are affected by multiple-faceted symptoms resulting from cancer and its treatment. The concept of total pain is suggested to guide interdisciplinary palliative care in earlier stages of advanced cancer.

Frailty screening for predicting rapid functional decline, rapid progressive disease, and shorter overall survival in older patients with gastrointestinal cancer receiving palliative chemotherapy - a prospective, clinical study.

OBJECTIVES: A growing number of older patients with cancer require well-founded clinical decision-making. Frailty screening is suggested as a service to improve outcomes in vulnerable older patients with cancer. This prospective study examined the value of frailty screening to predict rapid functional decline, rapid progressive disease (PD) and shorter overall survival (OS) in older patients with gastrointestinal cancer receiving palliative chemotherapy. MATERIALS AND METHODS: Patients aged ≥70 years were screened for frailty in an oncologic department after clinical decision but before starting palliative chemotherapy. Screening was repeated at first response evaluation after approximately two months of chemotherapy. Frailty screening tools included performance status (PS), Charlson Comorbidity Index, G-8 using two different cut-offs (G814,G811), VES-13, Timed-Up-and-Go, Handgrip strength and falls. RESULTS: A total of 170 patients were included, median age was 75.5 (70-88) years and 65.9% were male. The frequency of frailty varied from 14% to 74% according to the chosen frailty tool. In multivariate analysis G814 predicted OS (HR 1.5; 95%CI 1.0-2.4), whereas G811 predicted PD (OR 2.4; 1.1-5.6) and OS (HR 2.1; 1.4-2.9). VES-13 predicted functional decline (OR 3.5; 1.0-11.6), PD (OR 3.5; 1.5-8.4) and OS (HR 1.7; 1.2-2.4). Timed-Up-and-Go predicted OS (HR 1.8; 1.1-2.7). Handgrip strength and falls predicted functional decline (OR 4.5; 1.1-19 and OR 6.1; 1.4-25.8, respectively). PS predicted PD (OR 6.2; 2.6-14.7) and OS (HR 2.2; 1.5-3.2). CONCLUSION: VES-13 was useful for predicting all three endpoints of interest. Frailty tools covering domains of functioning and nutrition are suggested for older patients with advanced gastrointestinal cancer.

Health-related quality of life in patients with multiple myeloma participating in a multidisciplinary rehabilitation program.

Patients with multiple myeloma (MM) report high symptom burden and functional disabilities resulting in impaired health-related quality of life (HRQoL). Effective evidence-based rehabilitation guidelines are needed for patients with MM to improve HRQoL. The primary aim of this study was to investigate HRQoL in patients with rehabilitation needs living their everyday life. Patients with MM in remission attended a 12-week multidisciplinary rehabilitation program including a 5-day residential course, home-based exercise and a 2-day follow-up course. The patients were referred by the treating haematologist and completed a booklet of validated HRQoL questionnaires at baseline and before arriving for the 2-day follow-up course. The proportion of participants with moderate to severe symptoms and functional problems were assessed at the two time points and multivariate logistic regression was used to investigate explaining factors of impaired HRQoL at baseline. Ninety-two patients participated with a follow-up compliance rate of 90%. Median age was 67 years and median time since diagnosis was 26 months (ranged 5 months to 15.6 years). The most frequently reported symptoms were global quality of life, role functioning, fatigue, pain, peripheral neuropathy and physical functioning. Pain and fatigue were both highly coherent with impairment in physical functioning and those two symptoms explained most HRQoL impairments. Overall, the participants reported no change in HRQoL after the 12-week rehabilitation program. The study supports the need for an evidence-based guideline for rehabilitation and palliative care to patients with MM in remission living their everyday life.

Everyday living with pain - reported by patients with multiple myeloma.

OBJECTIVES: The prevalence and impact of pain among patients with multiple myeloma (MM) in their everyday life require renewed attention. MM patients' survival has increased considerably over the last decades and active disease episodes are interrupted by longer periods with disease inactivity. The aim with this study is to explore pain intensity and pain interference with daily activities during periods of stable or inactive MM disease. METHODS: In a cross-sectional study from September 2017 to May 2019, self-reliant MM patients in stable disease filled a comprehensive selection of validated questionnaires regarding pain, other symptoms and quality of life, which they experienced in their daily living. Patient reported pain intensity and interference with daily activities were analyzed for associations with several clinical and demographic factors and discussed from a total pain perspective. The two outcomes, pain intensity and pain interfering with daily activities, were analyzed in two age groups (<65 years or ≥65 years). RESULTS: Among 92 participants, 80% experienced pain to interfere with their daily activities (equal in both age groups), and 63% reported moderate to severe pain intensity; (75% ≥65 years, and 49% <65 years). Pain intensity was significantly associated with signs of depression (OR 4.0 [95% CI: 1.2-13.9]) and age ≥65 years (OR 3.3 [95% CI: 1.2-9.2]). Pain interfering with daily activities was nearly significantly associated with bone involvement (OR 3.4 [95% CI: 1.0-11.6]) and signs of depression (OR 5.9 [95% CI: 1.0-36.3]). The patients were bothered with many problems in addition to pain; fatigue (91%), bone involvement (74%), signs of depression (41%), signs of anxiety (32%), comorbidity (29%) and uncertainty in relation to employment or pension (25%). Neuropathic pain was more prevalent in the feet (33% [95% CI: 23%, 43%]) compared with pain in the hands (13% [95% CI: 7%, 22%]). CONCLUSIONS: In periods of stable disease, many MM patients continue to live with intense pain interfering with their daily activities. Additional or associated problems are the presence of bone involvement, neuropathic pain, older age, uncertainty in relation to employment or pension, comorbidity, signs of depression, anxiety and fatigue. This highlights the importance of health professionals being receptive to the patients' experience of pain throughout their trajectories, to assess pain systematically and to interpret this experience from a total pain perspective. While pain problems in relation to diagnosing and treating MM is well known, this study brings the message that even during periods of stable or inactive MM disease, the patients experience pain with a moderate to severe intensity, that interferes with their everyday living. The improved survival and the consequential long trajectories make coherence in the pain treatment even more important for the patients, who may see different professionals in different health care settings for different reasons. The patient group requires a coordinated, holistic patient-centered pain treatment throughout the disease trajectory.

Associations between perceived information needs and anxiety/depressive symptoms among cancer caregivers: A cross-sectional study.

Purpose: Caregivers to cancer patients often experience information needs. This study investigates the associations between perceived information needs and anxiety/depressive symptoms among caregivers to cancer patients.Design: Cross-sectional study using self-completed questionnaires.Sample: A total of 128 caregivers to cancer patients who participated in a rehabilitation stay at REHPA, The Danish Knowledge Center for Rehabilitation and Palliative Care, from April 2016 to March 2017.Methods: The caregivers completed a questionnaire assessing both information needs and anxiety/depressive symptoms. We used ordinal logistic regressions to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between seven information needs and anxiety/depressive symptoms. The reference group was caregivers with no perceived information needs.Findings: The combined score of perceived information needs was associated with higher odds of anxiety (OR = 3.86 per unit increase, 95% CI 1.85-8.03) and depressive symptoms (OR = 3.83 per unit increase, 95% CI 1.15-12.75). For the individual items, our results showed higher odds of anxiety symptoms for caregivers with perceived information needs regarding (1) the disease and its course, for both little need for information (OR = 3.62, 95% CI 1.39-9.43) and substantial need for information (OR = 4.57, 95% CI 1.40-14.93); however, for substantial information needs, an interaction with gender was found showing higher odds for men (OR = 28.90, 95% CI 4.46-187.41), but no significant association for women. Also, substantial need for information regarding the disease and its course were associated with higher odds of depressive symptoms (OR = 11.43, 95% CI 1.18-111.21). Furthermore, we found higher odds of anxiety symptoms for caregivers who perceived information needs regarding (2) which symptoms and adverse effects to be aware of; (3) how to help and support a cancer patient; (4) expected mental responses in a person with cancer; (5) how to find information on the internet, and (6) where to direct caregiver questions and/or concerns after patient discharge.Conclusions: Among caregivers to cancer patients, perceived needs regarding the disease and its course were associated with higher odds of anxiety and depressive symptoms. Furthermore, several other information needs were associated with anxiety symptoms.Implications for Psychosocial Providers or Policy: To prevent unnecessary anxiety and depressive symptoms among cancer caregivers, health care professionals should be aware of the importance of informing caregivers regarding the disease and its course. Other issues to address concerning anxiety symptoms are information regarding which symptoms and adverse effects to be aware of; how to help and support a cancer patient; expected mental responses in a person with cancer; how to find information on the internet; and where to direct caregiver questions and/or concerns after patient discharge.

Childhood motor performance is increased by participation in organized sport: the CHAMPS Study-DK.

Evidence suggests that motor performance in children is declining globally. We tested whether participation in organized sport is associated with motor performance, and estimate the effect of 30 months participation in organized sport on motor performance. Study participants were 1067 primary school students, enrolled in the Danish Childhood Health, Activity, and Motor Performance School study. Participation in organized sport was reported via text messaging. Coordination-related motor performance composite, fitness-related motor performance composite, and total motor performance composite were calculated. Data were analyzed using Generalized Estimating Equations. Participation in organized sport was positively associated with motor performance (all composites) in models that did and did not control for baseline motor performance. For models that did not control for baseline motor performance, this equated to 2-6% increases in motor performance per weekly sport session; for models that did control for baseline motor performance, this equated to 1-5% increases in motor performance per weekly sport session. Positive associations between participation in organized sport and motor performance identify participation in organized sport as a way to improve motor performance in children. These results might provide the basis to determine whether participation in organized sport could be beneficial for children with developmental movement disorders.

S-25OHD Is Associated With Hand Grip Strength and Myopathy at 5 Years in Girls: An Odense Child Cohort Study.

Context: Severe vitamin D deficiency may lead to myopathy in adults. Little is known about vitamin D and muscle strength in children. Objective: To test whether hand grip strength (HGS) in 5-year-old children is associated with serum 25-hydroxyvitamin D (S-25OHD). Design: Observational study in the population-based Odense Child Cohort, Denmark. At 5 years, anthropometrics, body fat percentage by skinfold measurements, HGS (n = 881), and S-25OHD2+3 (n = 499) were obtained. Results: Mean (SD) HGS was higher for boys compared with girls [8.76 (1.76) vs 8.1 (1.64) kg, P < 0.001]. Mean (SD) 5-year S-25OHD was 70.7 (24.5) nmol/L. HGS was directly associated with height in girls and with weight (directly) and body fat percentage (inversely) in both sexes (P < 0.01 for all). In girls, 5-year S-25OHD was associated with HGS, adjusting for height, weight, and body fat percentage [ß = 0.011 (95% CI: 0.004; 0.019), P = 0.003]. S-25OHD ≥75 nmol/L was associated with higher HGS compared with values <50 nmol/L [adjusted ß = 0.783 (95% CI: 0.325; 1.241), P = 0.001]. The odds of having myopathy (HGS <10th percentile) were reduced by approximately 70% for S-25OHD ≥50 vs <50 nmol/L [adjusted OR: 0.310 (95% CI: 0.126; 0.762), P = 0.011]. No associations were seen for boys. Pregnancy or umbilical cord S-25OHD did not associate with 5-year HGS. Conclusions: Five-year S-25OHD was independently associated with HGS and myopathy in girls but not in boys. Muscle strength may be dependent on vitamin D status even in the higher range in preschool girls. The sex difference remains unexplained.

Long-term follow-up on biological risk factors, adiposity, and cardiorespiratory fitness development in a physical education intervention: a natural experiment (CHAMPS-study DK).

BACKGROUND: Schools are a key setting for large-scale primordial non-communicable disease prevention in young people, but little data on sustainability of impacts on cardiometabolic risk markers is available. METHODS: Six and a half year follow-up of a natural experiment. In 2008, six public schools in the municipality of Svendborg (Denmark) augmented their curricular physical education (intervention) and four matched schools served as controls. At long term follow up in 2015 n = 312 participants aged 5-11 years had complete data (33% of children providing necessary baseline data). The intervention, that consisted of a trebling of weekly physical education lessons and courses provided to physical education teachers, was provided at intervention schools up until 6th grade. Participants attended 6th to 10th grade at follow-up. Differences in the homeostasis model assessment of insulin resistance, blood pressure, triglycerides, cholesterol ratios, cardiorespiratory fitness, waist-circumference, and a composite score of these, between participants attending intervention and control schools were analysed by mixed linear regression models. Differences in physical activity at follow-up was analysed cross-sectionally (no baseline available) in n = 495. RESULTS: Compared to controls, children at intervention schools had a non-significant - 0.07 (- 0.32 to 0.18) standard deviations lower composite risk score 6.5 years after project initiation. Likewise, no statistically significant differences between intervention and control schools were found for any of the other outcomes (p-values ≥ 0.41). However, six of seven outcomes were in a direction favouring intervention schools. No statistically significant differences between intervention and control schools were observed for physical activity outcomes (p-values ≥ 0.13). CONCLUSIONS: An augmented physical activity program including 270 min of weekly physical education provided for three to seven years did not materialize in statistically significant differences in established risk markers in children from intervention compared to control schools. As the intervention was discontinued after 6th grade, the post-intervention effect of augmented physical education throughout adolescence is unknown. School-based physical activity programs may benefit from incorporating instruments for behaviour translation to leisure time in their intervention models to increase the probability of achieving public health relevance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03510494 .

Musculoskeletal extremity pain in Danish school children - how often and for how long? The CHAMPS study-DK.

BACKGROUND: Musculoskeletal pain is common in childhood and adolescence, and may be long-lasting and recurrent. Musculoskeletal problems tend to follow adolescents into adulthood, and therefore it is important to design better prevention strategies and early effective treatment. To this end, we need in-depth knowledge about the epidemiology of musculoskeletal extremity problems in this age group, and therefore, the aim of this study was to determine the prevalence, frequency and course of musculoskeletal pain in the upper and lower extremities in a cohort of Danish school children aged 8-14 years at baseline. METHODS: This was a prospective 3-year school-based cohort study, with information about musculoskeletal pain collected in two ways. Parents answered weekly mobile phone text messages about the presence or absence of musculoskeletal pain in their children, and a clinical consultation was performed in a subset of the children. RESULTS: We found that approximately half the children had lower extremity pain every study year. This pain lasted on average for 8 weeks out of a study year, and the children had on average two and a half episodes per study year. Approximately one quarter of the children had upper extremity pain every study year that lasted on average 3 weeks during a study year, with one and a half episodes being the average. In general, there were more non-traumatic pain episodes compared with traumatic episodes in the lower extremities, whereas the opposite was true in the upper extremities. The most common anatomical pain sites were 'knee' and 'ankle/ft'. CONCLUSION: Lower extremity pain among children and adolescents is common, recurrent and most often of non-traumatic origin. Upper extremity pain is less common, with fewer and shorter episodes, and usually with a traumatic onset. Girls more frequently reported upper extremity pain, whereas there was no sex-related difference in the lower extremities. The most frequently reported locations were 'knee' and 'ankle/ft'.

Physical activity is prospectively associated with spinal pain in children (CHAMPS Study-DK).

ABSTARCT: Spinal pain and physical inactivity are critical public health issues. We investigated the prospective associations of physical activity intensity with spinal pain in children. Physical activity was quantified with accelerometry in a cohort of primary school students. Over 19 months, parents of primary school students reported children's spinal pain status each week via text-messaging (self-reported spinal pain). Spinal pain reports were followed-up by trained clinicians who diagnosed each child's complaint and classified the pain as non-traumatic or traumatic. Associations were examined with logistic regression modeling using robust standard errors and reported with odds ratios (OR). Children (n = 1205, 53.0% female) with mean ± SD age of 9.4 ± 1.4 years, participated in 75,180 weeks of the study. Nearly one-third (31%) of children reported spinal pain, and 14% were diagnosed with a spinal problem. Moderate intensity physical activity was protectively associated with self-reported [OR(95%CI) = 0.84(0.74, 0.95)], diagnosed [OR(95%CI) = 0.79(0.67, 0.94)] and traumatic [OR(95%CI) = 0.77(0.61, 0.96)] spinal pain. Vigorous intensity physical activity was associated with increased self-reported [OR(95%CI) = 1.13(1.00, 1.27)], diagnosed [OR(95%CI) = 1.25(1.07, 1.45)] and traumatic [OR(95%CI) = 1.28(1.05, 1.57)] spinal pain. The inclusion of age and sex covariates weakened these associations. Physical activity intensity may be a key consideration in the relationship between physical activity behavior and spinal pain in children.

Leisure-time sport and overuse injuries of extremities in children age 6-13, a 2.5†years prospective cohort study: the CHAMPS-study DK.

OBJECTIVES: It is not known which sports are most likely to cause overuse injuries of the extremities in children. In this study, we report on the incidence of overuse injuries of the upper and lower extremities in children who participate in various leisure-time sports and relate this to the frequency of sport sessions. DESIGN: Natural experiment including a prospective cohort study. SETTING: 10 state schools in 1 Danish municipality: Svendborg. PARTICIPANTS: 1270 children aged 6-13 years participating in the Childhood Health, Activity, and Motor Performance School Study Denmark. OUTCOMES MEASURES: Over 2.5 years, parents answered weekly SMS-track messages (a) on type and frequency of leisure-time sports undertaken by their child, and (b) reporting if their child had experienced any musculoskeletal pain. Children with reported pain were examined by a clinician and diagnosed as having an overuse injury of an extremity or not. The incidence of diagnosed overuse injury was calculated for each of the 9 most common sports in relation to 5-week periods. Incidence by frequency of sessions was calculated, and multivariable analysis was performed taking into account age, sex and frequency of physical education classes at school. RESULTS: Incidence of overuse injuries of the lower extremity ranged from 0.2 to 3.3 for the 9 sports, but was near 0 for overuse injuries of the upper extremities. There was no obvious dose-response. The multivariate analysis showed soccer and handball to be the sports most likely to result in an overuse injury. CONCLUSIONS: Among a general population of schoolchildren, overuse injuries of the lower extremities were not common and overuse injuries of the upper extremities were rare. Organised leisure-time sport, as practised in Denmark, can be considered a safe activity for children.

Back pain in children surveyed with weekly text messages - a 2.5 year prospective school cohort study.

BACKGROUND: Back pain is reported to occur already in childhood, but its development at that age is not well understood. The aims of this study were to describe BP in children aged 6-12 years, and to investigate any sex and age differences. METHODS: Data on back pain (defined as pain in the neck, mid back and/or lower back) were collected once a week from parents replying to automated text-messages over 2.5 school years from 2008 till 2011. The prevalence estimates were presented as percentages and 95% confidence intervals. Differences between estimates were considered significant if confidence intervals did not overlap. A test for trend, using a multi-level mixed-effects logistic regression extended to the longitudinal and multilevel setting, was performed to see whether back pain reporting increased with age. RESULTS: Depending on the age group, 13-38% children reported back pain at least once per survey year, and 5-23% at least twice per survey year. The average weekly prevalence estimate ranged between 1% and 5%. In the final survey year more girls than boys reported back pain at least twice. The prevalence estimates did not increase monotonically with age but showed a greater increase in children younger than 9/10, after which they remained relatively stable up to the age of 12 years. CONCLUSIONS: We found that back pain was not a common problem in this age group and recommend health professionals be vigilant if a child presents with constant or recurring back pain. Our results need to be supplemented by a better understanding of the severity and consequences of back pain in childhood. It would be productive to study the circumstances surrounding the appearance of back pain in childhood, as well as, how various bio-psycho-social factors affect its onset and later recurrence. Knowledge about the causes of back pain in childhood might allow early prevention.

Seasonal variation in musculoskeletal extremity injuries in school children aged 6-12 followed prospectively over 2.5 years: a cohort study.

OBJECTIVES: The type and level of physical activity in children vary over seasons and might thus influence the injury patterns. However, very little information is available on the distribution of injuries over the calendar year. This study aims to describe and analyse the seasonal variation in extremity injuries in children. DESIGN: Prospective cohort study. SETTING: 10 public schools in the municipality of Svendborg, Denmark. PARTICIPANTS: A total of 1259 school children aged 6-12 years participating in the Childhood Health, Activity, and Motor Performance School Study Denmark. METHODS: School children were surveyed each week during 2.5 school-years. Musculoskeletal injuries were reported by parents answering automated mobile phone text questions (SMS-Track) on a weekly basis and diagnosed by clinicians. Data were analysed for prevalence and incidence rates over time with adjustments for gender and age. RESULTS: Injuries in the lower extremities were reported most frequently (n=1049). There was a significant seasonal variation in incidence and prevalence for lower extremity injuries and for lower and upper extremity injuries combined (n=1229). For the upper extremities (n=180), seasonal variation had a significant effect on the risk of prevalence. Analysis showed a 46% increase in injury incidence and a 32% increase in injury prevalence during summer relative to winter for lower and upper extremity injuries combined. CONCLUSIONS: There are clear seasonal differences in the occurrence of musculoskeletal extremity injuries among children with almost twice as high injury incidence and prevalence estimates during autumn, summer and spring compared with winter. This suggests further research into the underlying causes for seasonal variation and calls for preventive strategies to be implemented in order to actively prepare and supervise children before and during high-risk periods.

Total body fat percentage and body mass index and the association with lower extremity injuries in children: a 2.5-year longitudinal study.

BACKGROUND: Overweight youths are generally recognised as being at increased risk of sustaining lower extremity injuries in sports. However, previous studies are inconclusive and choices for measuring overweight are manifold. OBJECTIVE: To examine two different measures of overweight, body mass index (BMI) and total body fat percentage (TBF%), as risk factors for lower limb injuries in a school-based cohort. STUDY DESIGN: A longitudinal cohort study. METHODS: A total of 632 school children, baseline age 7.7-12.0 years, were investigated. Whole body dual energy x-ray absorptiometry scans provided measures of TBF%. Measures of BMI were obtained by standard anthropometric methods. Musculoskeletal complaints were reported by parents answering weekly mobile phone text messages during 2.5 years. Injuries were diagnosed by clinicians. Leisure time sports participation was reported weekly using text messaging. RESULTS: During 2.5 years of follow-up, 673 lower extremity injuries were diagnosed. Children being overweight by both BMI and TBF% showed the highest risk of sustaining lower extremity injuries (IRR 1.38 (95% CI 1.05 to 1.81)). Children who were overweight using BMI and TBF% showed the highest risk of sustaining lower extremity injuries (IRR 1.38 (95% CI 1.05 to 1.81)). CONCLUSIONS: The risk of lower extremity injuries appeared to be increased for overweight children. When comparing two different measures of overweight, overweight by TBF% is a higher risk factor than overweight by BMI. This suggests that a high proportion of adiposity is more predictive of lower extremity injuries, possibly due to a lower proportion of lean muscle mass.

Injuries in children with extra physical education in primary schools.

PURPOSE: (1) Examine the influence of extra physical education (EPE) on the number of musculoskeletal injuries in public schools accounting for organized sports participation (OSP) outside school. (2) Examine the major injury subgroup: growth-related overuse (GRO) through the overuse-related injury group. METHODS: A longitudinal controlled school-based study among Danish public schools. At baseline, 1216 children participated age 6.2-12.4 yr. Six schools (701 children) with EPE and four control schools (515 children) were followed up with weekly automated mobile phone text messages for information on musculoskeletal problems and OSP. Health care personnel diagnosed the children according to the World Health Organization's International Classification of Diseases, Tenth Revision. Data were analyzed using a two-part zero-inflated negative binomial (ZINB) regression model. RESULTS: School type had no influence on the odds of sustaining an injury but increased the probability of sustaining a higher injury count for children with injuries, with total injuries by a factor of 1.29 (95% confidence interval [CI] = 1.07-1.56), overuse by a factor of 1.29 (95% CI = 1.06-1.55), and GRO by a factor of 1.38 (95% CI = 1.02-1.80). Weekly mean OSP decreased the odds of belonging to the group of children with no injuries, by a factor of 0.29 (95% CI = 0.14-0.58), 0.26 (95% CI = 0.14-0.48), and 0.17 (95% CI = 0.06-0.52) for total, overuse, and GRO, respectively. OSP also increased the probability of sustaining a higher injury count for children with injuries by a factor of 1.11 (95% CI = 1.02-1.22), 1.10 (95% CI = 1.00-1.22), and 1.14 (95% CI = 1.00-1.30), respectively. CONCLUSIONS: Children enrolled in EPE schools with high OSP have the highest odds of injury and a high probability of sustaining a higher injury count compared to their peers at schools with normal PE. Special attention should be assigned to these children during compulsory PE.