Patient and public involvement to inform the protocol of a clinical trial comparing total hip arthroplasty with exercise: an exploratory qualitative case study.

OBJECTIVE: To explore patient, clinician and decision-maker perceptions on a clinical trial evaluating the effectiveness of total hip arthroplasty (THA) compared with exercise to inform the trial protocol. DESIGN: This is an exploratory qualitative case study using a constructivist paradigm. SETTING AND PARTICIPANTS: Participants were enrolled into three key stakeholder groups: patients eligible for THA, clinicians, and decision makers. Focus group interviews were conducted in undisturbed conference rooms at two hospitals in Denmark, according to group status using semi-structured interview guides. ANALYSIS: Interviews were recorded, transcribed verbatim and thematic analysed using an inductive approach. RESULTS: We conducted 4 focus group interviews with 14 patients, 1 focus group interview with 4 clinicians (2 orthopaedic surgeons and 2 physiotherapists) and 1 focus group interview with 4 decision-makers. Two main themes were generated. 'Treatment expectations and beliefs impact management choices' covered three supporting codes: Treatment without surgery is unlikely to lead to recovery; Clinician authority impacts the management narrative; The 'surgery vs exercise' debate. 'Factors influencing clinical trial integrity and feasibility' highlighted three supporting codes: Who is considered eligible for surgery?; Facilitators and barriers for surgery and exercise in a clinical trial context; Improvements in hip pain and hip function are the most important outcomes. CONCLUSIONS: Based on key stakeholder treatment expectations and beliefs, we implemented three main strategies to improve the methodological rigorousness of our trial protocol. First, we added an observational study investigating the generalisability to address a potential low enrolment rate. Second, we developed an enrolment procedure using generic guidance and balanced narrative conveyed by an independent clinician to facilitate communication of clinical equipoise. Third, we adopted change in hip pain and function as the primary outcome. These findings highlight the value of patient and public involvement in the development of trial protocols to reduce bias in comparative clinical trials evaluating surgical and non-surgical management. TRIAL REGISTRATION NUMBER: NCT04070027 (pre-results).

Increased shoulder pain across an exercise session and subsequent shoulder exercise: a prospective cohort study.

BACKGROUND: Shoulder complaints are common and the recommended first-line treatment is exercise therapy. However, it remains unknown if increased shoulder pain after an exercise session is a barrier for subsequent exercise dose, particularly in people with high fear-avoidance beliefs. Such knowledge could indicate ways to optimise shoulder rehabilitation. The aim was to examine whether increased shoulder pain across an exercise session was associated with a lower subsequent exercise dose, and if high fear-avoidance beliefs exaggerated this association. METHODS: We conducted a prospective cohort study using data from a randomised controlled trial in Central Denmark Region 2017-2019. Participants were employees (n = 79) with shoulder complaints and high occupational shoulder exposures. The intervention was a home-based or partly supervised exercise programme lasting 2-3 months. Linear mixed models were used to examine the associations between change in shoulder pain and exercise dose (number of repetitions, progression level (1-3), resistance level (1-3), and time until next exercise session [days]). RESULTS: At baseline, the participants had a median pain intensity at rest of 2 on a numerical rating scale (0-10). For a 1-cm increase in pain on a visual analogue scale (0-10 cm) during an exercise session, the subsequent number of repetitions, progression level and resistance level were - 1.3 (95% confidence interval [CI] - 3.4 to 0.9), 0.0 (95% CI - 0.1 to 0.0) and - 0.0 (95% CI - 0.1 to 0.0), respectively. Likewise, the time until next exercise session was - 0.6 (95% CI - 2.4 to 1.3) days for a 1-cm increase. There were no interactions with fear-avoidance beliefs. CONCLUSION: Increased pain across an exercise session was not associated with subsequent exercise dose, regardless of fear-avoidance beliefs, among employees with shoulder complaints and high occupational shoulder exposures. TRIAL REGISTRATION: The trial was registered at Clinicaltrials.gov 19/05/2017 (ID: NCT03159910).

Total hip arthroplasty versus progressive resistance training in patients with severe hip osteoarthritis: protocol for a multicentre, parallel-group, randomised controlled superiority trial.

INTRODUCTION: Hip osteoarthritis (OA) is the leading cause for total hip arthroplasty (THA). Although, being considered as the surgery of the century up to 23% of the patients report long-term pain, and deficits in physical function and muscle strength may persist after THA. Progressive resistance training (PRT) appears to improve multiple outcomes moderately in patients with hip OA. Current treatment selection is based on low-level evidence as no randomised controlled trials have compared THA to non-surgical treatment. The primary aim of this trial is to investigate whether THA followed by standard care is superior to 12 weeks of supervised PRT followed by 12 weeks of optional unsupervised PRT for improving hip pain and function in patients with severe hip OA. METHODS AND ANALYSIS: This is a protocol for a multicentre, parallel-group, assessor-blinded, randomised controlled superiority trial conducted at four hospitals across three healthcare regions in Denmark. 120 patients aged ≥50 years with clinical and radiographic hip OA found eligible for THA by an orthopaedic surgeon will be randomised to THA followed by standard care, or 12 weeks of PRT (allocation 1:1). The primary outcome will be change in patient-reported hip pain and function, measured using the Oxford Hip Score, from baseline to 6 months after initiating the treatment. Key secondary outcomes will be change in the Hip disability and Osteoarthritis Outcome Score subscales, University of California Los Angeles Activity Score, 40 m fast-paced walk test, 30 s chair stand test and occurrence of serious adverse events. Patients declining participation in the trial will be invited into a prospective observational cohort study. ETHICS AND DISSEMINATION: The trial has been approved by The Regional Committees on Health Research Ethics for Southern Denmark (Project-ID: S-20180158). All results will be presented in peer-reviewed scientific journals and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT04070027).

Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic - a mixed methods study.

BACKGROUND: Extended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration. METHODS: 1) In an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated. 2) Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted. RESULTS: 1) Agreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional's primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]). 2) Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills. CONCLUSIONS: In the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03343951 . Registered 10 November 2017.

Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2).

Background: Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life.

Effectiveness of supervised resistance training for patients with hip osteoarthritis - a systematic review.

INTRODUCTION: The overall effectiveness of supervised progressive resistance training among patients with hip osteoarthritis is only scarcely investigated. The objective of this study was to estimate the effectiveness of supervised progressive resistance training compared with common treatment for patients with hip osteoarthritis, focusing on patient-reported function, pain, health-related quality of life, performance-based function at end of treatment and patient-reported function at 6-12 months. METHODS: This was a systematic review and meta-analysis. A systematic search was performed on 30 January 2019 in eight electronic databases (Medline, Embase, Cochrane, Pedro, AMED, Scopus, SPORTDiscus and Cinahl). The methodology of the included studies and the overall quality of evidence was assessed using the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: A total of 189 participants with hip osteoarthritis > 50 years of age were included in the three studies. A significant difference in favour of the supervised progressive resistance groups was found in patient-reported function (weighted mean difference (MD) = 9.13 (95% confidence interval (CI): 4.45-13.80)), hip-related pain (weighted MD = 7.83 (95% CI: 2.64-13.02)) and health-related quality of life (weighted MD = 6.80 (95% CI: 1.96-11.63)) at end of treatment. The overall quality of evidence was downgraded to low due to a lack of blinding in the included studies and due to imprecision. CONCLUSIONS: Supervised progressive resistance training might be of clinical relevance for patients with hip osteoarthritis and was effective in improving patient-reported function, hip-related pain and health-related quality of life. The level of evidence is low and future studies may therefore affect the findings reported herein.

A retrospective study of 251 patients admitted to a multidisciplinary, neurorehabilitation unit with intensive care unit capabilities.

Introduction: In Denmark, specialised neurorehabilitation is centralised in two centres; one is Hammel Neurocentre. The neurointensive stepdown unit at Silkeborg Regional Hospital offers intensive care in addition to specialised neurorehabilitation of patients transferring to Hammel. Knowledge on patient's characteristics and course of rehabilitation in this kind of setting is sparse.Objective: To characterise the patients, their change in function and to identify variables associated with referral time to Hammel.Methods: Functional scores and available covariates were extracted from hospital records on 251 patients admitted from 01 November 2011 to 31 July 2016. Statistical methods included logistic regression and paired tests.Results: Mean (standard deviation) time from injury to admission at the neurointensive stepdown unit was 30 (22) d, medians (interquartile range) of Functional Independence Measure and Early Functional Abilities increased significantly from 18 (18, 19) to 24 (18, 44) and 37 (30, 46) to 52 (43, 70), respectively, during admission (p < 0.01). Spontaneous ventilation and Early Functional Abilities score on admission were positively associated with early referral. Obesity and anoxic brain injury were negatively associated with early referral.Conclusions: This study demonstrated functional improvement in patients in a neurointensive stepdown unit and identified variables associated with early referral. The study indicated higher sensitivity of the Early Functional Abilities score as compared to the Functional Independence Measure.Implications for rehabilitationPatients requiring prolonged intensive care services after severe acquired brain injury may require the fusion of neurorehabilitation and intensive care services to benefit maximally.There is a need for a consensus on which functional scores to use when documenting functional level and functional changes in patients with severe acquired brain injury and very low functional levels.The Early Functional Abilities score is an example of a valuable tool when assessing functional levels of patients with severe acquired brain injury and very low functional levels.

Reducing shoulder complaints in employees with high occupational shoulder exposures: study protocol for a cluster-randomised controlled study (The Shoulder-Café Study).

BACKGROUND: In Denmark, exercise therapy in combination with work modification is the first-choice treatment for persons with shoulder complaints and high occupational shoulder exposures. To obtain this treatment they must visit several healthcare providers, which makes usual care fragmented and uncoordinated. Therefore, we developed a new intervention which unifies the expertise that is needed. The main hypotheses are that a group-based Shoulder-Café intervention will more effectively reduce (1) shoulder complaints and (2) occupational shoulder exposures than an individual-based Shoulder-Guidance intervention (active control - enhanced usual care). METHODS: A cluster-randomised trial is conducted including 120 employees with high occupational shoulder exposures. Companies (clusters) are randomised to either Shoulder-Café or Shoulder-Guidance with a 1:1 allocation ratio. Participants are 18-65 years old and have an Oxford Shoulder Score (OSS) ≤ 40. Both interventions include a home-based shoulder-exercise programme, assessment of shoulder exposures by technical measurements and self-report, and general information on how to reduce shoulder exposures. The Shoulder-Café course also includes three café meetings with physiotherapist-supervised exercises, clinical shoulder evaluation, education on shoulder anatomy, workplace-orientated counselling, and an opportunity for a workplace visit by a health and safety consultant. The primary outcomes are the OSS at 6-month follow-up (hypothesis I), and the mean number of min/day with the arm elevated > 60° shortly after the end of the intervention (hypothesis II). We will use a mixed-model analysis that allows for company clustering, and data will be analysed according to the intention-to-treat principle. DISCUSSION: Persons with shoulder complaints and high occupational shoulder exposures are an obvious target group for secondary prevention efforts. We developed the Shoulder-Café to reduce shoulder complaints and shoulder exposures while unifying the expertise that is needed to evaluate and treat shoulder complaints. If the intervention is effective, it would warrant widespread implementation. TRIAL REGISTRATION: Clinicaltrials.gov, ID: NCT03159910. Registered on 18 May 2017.

Pragmatic Home-Based Exercise after Total Hip Arthroplasty - Silkeborg: Protocol for a prospective cohort study (PHETHAS-1).

Introduction: Rehabilitation exercises are offered to patients after total hip arthroplasty (THA); however, the effectiveness and optimal type and dose of exercise remains unknown. The primary objective of this trial is to indicate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the relationship between the performed exercise dose and the change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery. The secondary objective is to investigate if a dose-response relationship exists between the performed exercise dose and changes in: hip-related disability, lower-extremity functional performance, and hip muscle strength Methods: In this prospective cohort study, patients scheduled for THA will be consecutively included until 88 have completed the intervention period from 3 to 10 weeks postoperatively. Participants perform the standard rehabilitation program with elastic band exercises. Exercise dose (exposure) will be objectively quantified using a sensor attached to the elastic band. The primary outcome is gait speed measured by the 40-m fast-paced walk test. Secondary outcomes include: patient reported hip disability (Hip disability and Osteoarthritis Outcome Score (HOOS)), hip muscle strength (hand-held dynamometry) and lower extremity function (30-s chair stand test). Discussion: This trial will add knowledge concerning the relationship between performed exercise dose and post-operative outcomes after THA. The protocol paper describes the study design and methods in detail, including the statistical analysis plan. Trial registration: Pre-registered on March 27, 2017 at ClinicalTrails.gov (ID: NCT03109821).

Improving the referral pattern of patients with knee osteoarthritis to the orthopaedic surgeon: Development and evaluation of a new screening algorithm based on patient-reported data and radiographs.

INTRODUCTION: Many patients with knee osteoarthritis referred to orthopaedic surgeons are not eligible for surgery and might benefit from being examined by other healthcare professionals. The objective of this study was to develop and test a screening algorithm to define relevant referral to the OS. METHODS: Prior to clinical examination, 173 consecutive patients referred to the orthopaedic outpatient clinic completed questionnaires, and radiographic osteoarthritis severity was graded. The gold standard for relevant referral to an orthopaedic surgeon was based on actual treatment. The performance of the algorithm in predicting relevant referrals and total knee replacement (TKR) was assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Referral to an orthopaedic surgeon was considered relevant in 65% (113/173) of patients. Sensitivity, specificity, PPV and NPV for predicting relevant referral to an orthopaedic surgeon were 0.70, 0.56, 0.76 and 0.48, respectively. The corresponding estimates for predicting TKR surgery were 0.92, 0.56, 0.55 and 0.92. CONCLUSIONS: The algorithm was able to identify most patients relevant for referral to an orthopaedic surgeon, but less suitable for identifying those not relevant. The algorithm demonstrated excellent performance in predicting TKR surgery. With further development, this screening algorithm might contribute to improvement of the referral pattern in the orthopaedic outpatient clinic.

An Obturator Nerve Block does not Alleviate Postoperative Pain after Total Hip Arthroplasty: a Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: A substantial group of patients suffer from moderate to severe pain following elective total hip arthroplasty (THA). Due to the complex innervation of the hip, peripheral nerve block techniques can be challenging and are not widely used. Since the obturator nerve innervates both the anteromedial part of the joint capsule as well as intra-articular nociceptors, we hypothesized that an obturator nerve block (ONB) would decrease the opioid consumption after THA. METHODS: Sixty-two patients were randomized to receive ONB or placebo (PCB) after primary THA in spinal anesthesia. Primary outcome measure was opioid consumption during the first 12 postoperative hours. Secondary outcome measures included postoperative pain score, nausea score and ability to ambulate. RESULTS: Sixty patients were included in the analysis. Mean (SD) opioid consumption during the first 12 postoperative hours was 39.9 (22.3) mg peroral morphine equivalents (PME) in the ONB group and 40.5 (30.5) mg PME in the PCB group (p=0.93). No difference in level of pain or nausea was found between the groups. Paralysis of the hip adductor muscles in the ONB group reduced the control of the operated lower extremity compared with the PCB group (p=0.026). This did, however, not affect the subjects' ability to ambulate. CONCLUSIONS: A significant reduction in postoperative opioid consumption was not found for active versus PCB ONB after THA. TRIAL REGISTRATION NUMBER: NCT03064165 and 2017-000068-14.

Effects of supervised exercise compared to non-supervised exercise early after total hip replacement on patient-reported function, pain, health-related quality of life and performance-based function - a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND:: The rehabilitation after a total hip replacement varies in degree of supervision; however, it remains unknown whether supervised programmes are more effective than non-supervised. OBJECTIVE:: This study compared the effectiveness of supervised exercise compared to non-supervised home-based exercise after total hip replacement on patient-reported function, hip-pain, health-related quality of life and performance-based function. METHODS:: A systematic review and meta-analysis of randomized controlled trials investigating the effect of supervised exercise compared to non-supervised home-based exercise. An electronic search was performed in Medline, Embase and CINAHL on 14 March 2018. The methodological quality was assessed using the Cochrane Risk of Bias tool. RESULTS:: Seven studies were included with a total of 389 participants. A small and non-significant difference in favour of the supervised groups was found in patient-reported function (standardized mean difference (SMD) -0.22 (95% confidence interval (CI) -0.46 to 0.02)), hip-related pain (SMD -0.03 (95% CI -0.27 to 0.21)), health-related quality of life (mean difference (MD) -3.08 (95% CI -6.29 to 0.14)) and performance-based function (SMD -0.26 (95% CI -0.68 to 0.17)) at end of treatment and in patient-reported function (MD -1.31 (95% CI -3.79 to 1.16)) at the 6- to 12-month follow-up. LIMITATIONS:: The literature search was systematic, but limited to three databases. The overall quality of evidence was downgraded to moderate due to lack of blinding in included studies. CONCLUSION:: Supervised exercise was not significantly effective compared to non-supervised home-based exercise on patient-reported function, pain, health-related quality of life and performance-based function after primary total hip replacement. OTHERS:: PROSPERO registration number: CRD42017055604.

Reliability of the Danish version of the short questionnaire to assess health-enhancing physical activity (SQUASH).

OBJECTIVE: To translate and cross-cultural adapt the short questionnaire to assess health-enhancing physical activity (SQUASH) to Danish, and to investigate the Danish version's reliability. METHODS: The study was conducted according to the COSMIN guidelines. The reliability was evaluated in 53 healthy subjects, mean age 47.1 ± 12.4 years and mean period 37.8 ± 14.8 days between test and retest. RESULTS: For the total activity score ICC was 0.73 (0.57 to 0.83), SEM was 2316 (24% of the grand mean), and SDC was 6419 (67% of the grand mean). CONCLUSION: The relative reliability was acceptable and indicates that the Danish version of SQUASH can be used to distinguish between individuals; however, the absolute reliability was poor and SQUASH is not considered suitable for measuring physical activity on an individual level.

The psychosocial effect of web-based information in fast-track surgery.

The psychosocial effects of web-based information have yet to be tested for patients joining a fast-track total hip arthroplasty programme. This study compared and evaluated the psychosocial impact of standard total hip arthroplasty programme, with and without supplementation with a web-based information platform (E-total hip arthroplasty programme). Totally, 299 patients were enrolled in an un-controlled, before-and-after study, 117 in the S-total hip arthroplasty programme group and 182 in the E-total hip arthroplasty programme group. Psychosocial outcomes before and during admission and then 3 months post-surgery were evaluated, with analyses conducted between and within groups. All outcomes improved significantly from pre-admission to 3 months post-surgery, with no between-group differences. In all, 112 of the 182 E-total hip arthroplasty programme patients accessed the learning platform. A subgroup analysis showed no significant differences between users and non-users, either at baseline or in terms of outcome. This study found no positive psychosocial effect between groups, but a significant effect within groups.

The Analgesic Effect of Obturator Nerve Block Added to a Femoral Triangle Block After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) is associated with severe pain, and effective analgesia is essential for the quality of postoperative care and ambulation. The analgesic effects of adding an obturator nerve block (ONB) to a femoral triangle block (FTB) after TKA have not been tested previously. We hypothesized that combined ONB and FTB will reduce opioid consumption and pain compared with those of a single FTB or local infiltration analgesia (LIA). METHODS: Seventy-eight patients were randomized to combined ONB and FTB, single FTB, or LIA after primary unilateral TKA. The primary outcome was morphine consumption during the first 24 postoperative hours. Secondary outcomes included morphine consumption during the first 48 postoperative hours, pain at rest and passive knee flexion, nausea and vomiting, cumulated ambulation score, and Timed Up and Go test. RESULTS: Seventy-five patients were included in the analysis. The total intravenous morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR], 0-15) in the combined ONB and FTB group, 20 mg (IQR, 10-26) in the FTB group (P = 0.0007), and 17 mg (IQR, 10-36) in the LIA group (P = 0.002). The combined ONB and FTB group displayed reduced pain, nausea, and vomiting compared with the other groups. The ambulation tests showed no statistically significant differences between the groups. CONCLUSIONS: Addition of ONB to FTB significantly reduced opioid consumption and pain after TKA compared with a single FTB or LIA, without impaired ambulation.

[An interdisciplinary journal club improves hospital staff competence and commitment]. / Tværfaglig journal club øger kompetencer og tværfagligt engagement hos hospitalsansatte.

The demands of the health-care sector for quality and evidence-based knowledge require nurses, secretaries and allied health-care professionals to keep up to date professionally. An interdisciplinary journal club (IJC) provides a self-reported improvement in the competence of critical reading as well as increasing knowledge about research designs and research methods. Furthermore, IJC leads to an increased sense of community, understanding of an interdisciplinary culture and appears to strengthen the foundations for cooperation across disciplines.

A study of the inter-rater reliability of a test battery for use in patients after total hip replacement.

OBJECTIVE: To assess the within-day inter-rater reliability of a test battery of functional performance, muscle strength and leg extension power on total hip replacement patients. DESIGN: A test-retest design was used. SETTING: Orthopaedic department at a Regional Hospital in Denmark. SUBJECTS: Two convenience samples of 20 total hip replacement patients were included. INTERVENTION: The tests were performed three months after total hip replacement. Two raters performed test and re-test, with two hours rest in-between. MAIN MEASURES: The test battery included: sit-to-stand performance, 20-metre maximum walking speed, stair climb performance, isometric muscle strength (hip abduction/flexion), and leg extension power. Absolute reliability was assessed with Bland Altman plots, standard error of measurement (SEM), and minimal detectable change. Relative reliability was assessed with intra-class correlation coefficient. RESULTS: Systematic differences between testers were seen in tests of walking speed (0.32 seconds p = 0.03) and stair climb performance (0.18 seconds p = 0.003). In per cent of the grand mean, the standard error of measurement was 3%-10%, indicating the measurement error on a group level, and the minimal detectable change was 10%-27%, indicating the measurement error on an individual level. The intra-class correlation coefficients were above 0.80 in all tests (range 0.83-0.95). CONCLUSIONS: The tests showed acceptable relative and absolute inter-rater reliability on a group level, but not on an individual level (except from test of walking speed and stair climb performance). Systematic differences between testers were considered clinically irrelevant (0.3 and 0.2 seconds).

No inflammatory gene-expression response to acute exercise in human Achilles tendinopathy.

Although histology data favour the view of a degenerative nature of tendinopathy, indirect support for inflammatory reactions to loading in affected tendons exists. The purpose of the present study was to elucidate whether inflammatory signalling responses after acute mechanical loading were more pronounced in tendinopathic versus healthy regions of human tendon and if treatment with non-steroidal anti-inflammatory medications (NSAID's) reduces this response. Twenty-seven tendinopathy patients (>6 months) were randomly assigned to a placebo (n = 14) or NSAID (Ibumetin NYCOMED GmbH Plant Oranienburg Germany (600 mg) × 3/day/1 week) group (n = 13) in a double-blinded-fashion. Tendon biopsies were taken from the painful and a healthy region of the same tendon 2 h after 1 h running. Gene-expression of several targets was analysed in the sampled Achilles tendon biopsies. The mRNA for TGF-ß, collagen-I and collagen-III were significantly higher expressed, and decorin, CTGF, IL-6 and IL-10 were significantly lower expressed in the tendinopathic versus healthy tendon area. Only IL-10 was lower in expression in experiments with NSAID administration, while all other determined parameters were unaffected by NSAID. All ultrasonographic outcomes were unchanged in response to acute exercise and not influenced by NSAID. The signalling for collagen and TGF-beta was upregulated after acute loading in tendinopathic tendon. In contrast to the hypothesis, inflammatory signalling was not exaggerated in tendinopathic tendon 2 h after acute mechanical loading.