The experience of living with adolescent idiopathic scoliosis: a qualitative evidence synthesis using meta-ethnography.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity with physical and psychosocial implications for adolescents. The aim of this qualitative evidence synthesis (QES) was to systematically search for, identify, and synthesise qualitative research in order to improve our understanding of what it is like to live with AIS and to facilitate empathetic and effective healthcare. METHODS: We systematically searched 4 databases (Medline, EMBASE, PsycINFO and CINAHL) and used the 7 phases of meta-ethnography to synthesise qualitative evidence including studies with children and adolescents, and additional viewpoints from parents about the experience of AIS. RESULTS: We distilled 7 themes. (1) Diagnosis turned time on its head revolves around the AIS diagnosis and the uncertainty of the future that accompanied it. (2) Usual activities no longer the same explores how activities and participation in everyday life are impacted by AIS. (3) Hiding my body describes the pervasive struggle with self-image and appearance. (4) I want to feel normal again explores adolescents' desire to return to 'normality' and challenges of feeling different. (5) Balancing isolation and support considers the relationships in the adolescents' lives alongside their feelings of isolation. (6) Trying to keep control of treatment decisions explores how adolescents and their parents strive to feel in control. (7) Fearing surgery yet feeling hopeful focused on the apprehension and fear around spinal surgery and the beacon of hope it represented. CONCLUSIONS: Our QES contributes to the understanding of the adolescent experience of living with AIS. From our findings, clinicians can better understand the physical and psychosocial obstacles and the challenges faced throughout the journey of AIS to inform their clinical interactions with these patients.

Associations Between Physical Activity and Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate the associations between adolescent idiopathic scoliosis (AIS) and physical activity (PA). DATA SOURCES: MEDLINE, EMBASE, AMED, SPORTDiscus, Cochrane Library, and CINAHL electronic databases were searched from inception to August 2022/plus citation tracking. STUDY SELECTION: Observational studies of participants with radiographically confirmed AIS with ≥10° lateral spinal curvature (Cobb method) and comparator groups without AIS that measured PA were selected by 2 reviewers. DATA EXTRACTION: Data were extracted independently and cross-checked by 2 reviewers. Risk of bias was evaluated using Newcastle Ottawa Scales and overall confidence in the evidence using the GRADE approach. DATA SYNTHESIS: Sixteen studies with 9627 participants (9162, 95% women) were included. A history of vigorous PA significantly reduced the odds of being newly diagnosed with AIS by 24% (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.65-0.89) (high certainty). Moderate PA reduced odds by 13% (moderate certainty) and light PA increased odds by 9% (low certainty), but neither analysis was statistically significant. Ballet or gymnastics (OR 1.47, 95% CI 3.08 (1.90, 5.00) were the only individual sports significantly associated with AIS diagnosis (moderate certainty). Case-control studies of people with and without AIS provided greater evidence that having AIS reduces vigorous PA and sports participation, and less evidence light PA and walking are affected. CONCLUSION: Adolescents who participate in more vigorous PA are less likely to be diagnosed with AIS. Ballet and gymnastics are associated with AIS diagnosis, but the direction of this association is uncertain. People with AIS are likely to do less vigorous physical and sporting activity compared with those without AIS, which could negatively affect health and quality of life. Further research is warranted into the inter-relations between PA and AIS, studies need to be of sufficient size, include men, and evaluate vigorous including higher-impact PA compared with moderate or light PA.

Physiotherapy exercise rehabilitation with tailored exercise adherence support for people with osteoporosis and vertebral fractures: protocol for a randomised controlled trial - the OsteoPorosis Tailored exercise adherence INtervention (OPTIN) study.

INTRODUCTION: Vertebral fragility fractures affect at least 20% of the older population in the UK. Best practice guidelines recommend the use of exercise to slow the rate of bone loss, to maintain muscle strength and physical function, and to prevent falls and further fractures. However, treatment effects are often small and difficult to sustain and adherence, or the extent to which patients engage in treatment, has been identified as an important issue by many studies. Our hypothesis is that integrating adherence intervention strategies with an exercise intervention will be beneficial. We will compare physiotherapy exercise rehabilitation with adherence support versus physiotherapy exercise rehabilitation alone in terms of effects on (A) physical function, quality of life and fear of falling and (B) exercise self-efficacy and adherence. METHODS AND ANALYSIS: A multicentre, two-arm, parallel group, superiority randomised controlled trial with blinded assessments at baseline (0) and 4, 8 and 12 months, with a nested qualitative study and health economic analysis. 116 participants will be allocated to either (1) outpatient physiotherapy which will include a musculoskeletal assessment and treatment including balance, posture, strength training and low impact weight-bearing exercises over 16 weeks or (2) OsteoPorosis Tailored exercise adherence INtervention intervention. This includes standard physiotherapy as above plus an additional, integrated assessment interview (30 min) and 60 min of adherence support spread over the subsequent 16 weeks. ETHICS AND DISSEMINATION: The study protocol was approved by West of Scotland Research Ethics Committee 4 (21/WS/0071). Trial registration number ISRCTN 14465704. The paper is based on Protocol V.4. TRIAL REGISTRATION NUMBER: ISRCTN 14465704.

Does thoracic kyphosis severity predict response to physiotherapy rehabilitation in patients with osteoporotic vertebral fracture? A secondary analysis of the PROVE RCT.

OBJECTIVES: To describe participant characteristics based on kyphosis severity, examine the relationship between kyphosis and physical function, and investigate whether kyphosis severity predicts improvement after physiotherapy intervention. DESIGN AND SETTING: Secondary longitudinal analysis of the PROVE trial, a multicentre RCT. Data from all three trial arms were pooled and divided into quartile groups according to baseline kyphosis severity for linear mixed model analysis. PARTICIPANTS: 604 men and women with osteoporotic vertebral fracture. MAIN OUTCOME MEASURES: Estimated marginal means reported from adjusted mixed models for thoracic kyphosis, Six-minute Walk Test (6MWT), functional reach and Short Performance Physical Battery (SPPB). RESULTS: Thoracic kyphosis improved at 4-months and 12-months in participants with moderate hyperkyphosis (-2.4 ° and -3.0 °) and severe hyperkyphosis (-5.7 ° and -8.0 °). Functional reach scores were lower in the severe hyperkyphosis group compared to normal and hypokyphosis groups by at least 2.3 cm. 6MWT scores were worse in the severe hyperkyphosis group compared to the normal kyphosis group by 39.6 m. SPPB scores were worse in severe hyperkyphosis group compared to the normal kyphosis group by 0.72 points, but all participants, regardless of kyphosis severity, improved SPPB at 4 months by 0.42 points and at 12 months by 0.25 points. CONCLUSIONS: Results suggest that presenting with hyperkyphosis and osteoporotic vertebral fracture does not prevent improvement in thoracic curvature and physical performance after physiotherapy compared with baseline values. While higher kyphosis correlated with poorer physical function scores, baseline kyphosis severity could not predict change in physical function measures. REGISTRY: ISRCTN 49117867.

Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT.

BACKGROUND: A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role. OBJECTIVE: The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session. DESIGN: This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies. SETTING: This trial was based in 21 NHS physiotherapy departments. PARTICIPANTS: The participants were people with symptomatic OVF. INTERVENTIONS: Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT). MAIN OUTCOME MEASURES: Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version. RESULTS: A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events. CONCLUSIONS: This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49117867. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.

Osteoporosis is a condition in which bones lose their strength and are more likely to break. It affects around 3 million people in the UK. Fractures of the spine are very common in people with osteoporosis. They can cause a change in body shape, back pain and difficulty with carrying out daily tasks. A treatment that may help people is physiotherapy. There is evidence that several different types of physiotherapy, such as exercise or manual (hands-on) therapy, may help. This was the largest trial of physiotherapy for people with osteoporotic vertebral fracture to date. Seven sessions of physiotherapy treatment based on either exercise or manual therapy were compared with a single 1-hour session of individualised advice from a physiotherapist. The outcome of these treatments was assessed using recognised measures of quality of life, back muscle strength, pain, function and activity at 4 months and 1 year after treatment. How safe the treatments were and whether or not they had any impact on falls or the costs of health and social care were also examined. Interviews were conducted with some of the participants in the trial to seek their opinion about the treatment that they had received. The results show that the participants tolerated all the treatments well, with no significant safety issues, and perceived treatment to be beneficial. The study did not find significant differences between the three treatments in terms of clinical effectiveness or cost-effectiveness at 1 year, although there were benefits in some areas at 4 months.

The reliability and validity of the Figure of 8 Walk test in older people with knee replacement: does the setting have an impact?

OBJECTIVE: To determine the reliability and validity of the Figure of 8 Walk test (F8W) for older people after knee replacement surgery in the home setting. DESIGN: Observational repeated measures. SETTING: A specialist orthopaedic hospital and participants homes. PARTICIPANTS: Seventy-four older adults aged over 55 years one year following knee replacement surgery participated in two assessments more than one week apart. MAIN OUTCOME MEASURE: The time to complete, steps, boundary limits and smoothness score from the Figure of 8 Walk test (F8W), the time to complete the Timed Up and Go (TUG) test and the time to complete the Timed Walk Test (TWT). RESULTS: Overall, on 95% of occasions, the difference between the measurements for intra-rater reliability were within 1.8second of the two test times. The difference between the measurements for inter-rater reliability were found to be narrower than for intra-rater reliability with scores within 1.2second overall on 95% of occasions. The time to perform the F8W was highly correlated to the Timed Up and Go (overall sample r=0.921) and the variability spread within narrow limits (-0.8 to 0.8 z-scores). This was also true for the Timed Walk Test (overall sample r=0.834) with a narrow limit of variability on almost all of the observations (-1.16 to 1.16 z-scores). CONCLUSIONS: The F8W test has good reliability and validity when used in either a clinical or home setting for patients around one year following knee replacement surgery.

Development of an exercise intervention for the prevention of musculoskeletal shoulder problems after breast cancer treatment: the prevention of shoulder problems trial (UK PROSPER).

BACKGROUND: Musculoskeletal shoulder problems are common after breast cancer treatment. There is some evidence to suggest that early postoperative exercise is safe and may improve shoulder function. We describe the development and delivery of a complex intervention for evaluation within a randomised controlled trial (RCT), designed to target prevention of musculoskeletal shoulder problems after breast cancer surgery (The Prevention of Shoulder Problems Trial; PROSPER). METHODS: A pragmatic, multicentre RCT to compare the clinical and cost-effectiveness of best practice usual care versus a physiotherapy-led exercise and behavioural support intervention in women at high risk of shoulder problems after breast cancer treatment. PROSPER will recruit 350 women from approximately 15 UK centres, with follow-up at 6 and 12 months. The primary outcome is shoulder function at 12 months; secondary outcomes include postoperative pain, health related quality of life, adverse events and healthcare resource use. A multi-phased approach was used to develop the PROSPER intervention which was underpinned by existing evidence and modified for implementation after input from clinical experts and women with breast cancer. The intervention was tested and refined further after qualitative interviews with patients newly diagnosed with breast cancer; a pilot RCT was then conducted at three UK clinical centres. DISCUSSION: The PROSPER intervention incorporates three main components: shoulder-specific exercises targeting range of movement and strength; general physical activity; and behavioural strategies to encourage adherence and support exercise behaviour. The final PROSPER intervention is fully manualised with clear, documented pathways for clinical assessment, exercise prescription, use of behavioural strategies, and with guidance for treatment of postoperative complications. This paper adheres to TIDieR and CERT recommendations for the transparent, comprehensive and explicit reporting of complex interventions. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: ISRCTN 35358984 .

Rehabilitation of revision total hip replacement: A multi-centre survey of current practice.

BACKGROUND: Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation. AIMS AND OBJECTIVES: To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery. METHODS: An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically. RESULTS: There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably. CONCLUSIONS: This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.

Spinal Orthoses for Vertebral Osteoporosis and Osteoporotic Vertebral Fracture: A Systematic Review.

OBJECTIVE: To systematically review the evidence of effectiveness of spinal orthoses for adults with vertebral osteoporosis. DATA SOURCES: We conducted a systematic literature search using the databases of PubMed, MEDLINE, EMBASE, AMED, CINAHL, PEDro, and the Cochrane Library from January 1995 to October 2014. STUDY SELECTION: Two reviewers evaluated eligibility. Randomized controlled trials (RCTs), pilot RCTs, and prospective nonrandomized controlled studies of spinal orthoses for people with vertebral osteoporosis or osteopenia with and without osteoporotic vertebral fracture (OVF) that examined outcomes related to fracture consolidation, pain, strength, posture, balance, physical function, quality of life, and complications were eligible. DATA EXTRACTION: Two reviewers independently extracted data and evaluated methodological quality using a domain-based risk-of-bias approach. DATA SYNTHESIS: Twelve studies were included: 8 RCTs or pilot RCTs and 4 nonrandomized studies involving 626 participants. Three studies (n=153) evaluated orthoses after acute OVF; none were of high quality. Complications were highest with rigid orthoses. Evidence that orthoses could affect vertebral deformity was lacking. Nine studies (n=473) of varying quality considered orthoses in subacute and longer rehabilitation. Three suggested a semirigid backpack thoracolumbar orthosis (TLO) could benefit strength, pain, posture, and quality of life. One found a weighted kypho-orthosis (WKO) improved balance. CONCLUSIONS: The limited evidence about orthoses after acute OVF is inconclusive; better evidence of efficacy is needed, particularly when considering complications. The promising evidence regarding the backpack TLO and WKO needs to be explored further in studies of sufficient size and quality that include men.

Physiotherapy Rehabilitation for Osteoporotic Vertebral Fracture (PROVE): study protocol for a randomised controlled trial.

BACKGROUND: Osteoporosis and vertebral fracture can have a considerable impact on an individual's quality of life. There is increasing evidence that physiotherapy including manual techniques and exercise interventions may have an important treatment role. This pragmatic randomised controlled trial will investigate the clinical and cost-effectiveness of two different physiotherapy approaches for people with osteoporosis and vertebral fracture, in comparison to usual care. METHODS/DESIGN: Six hundred people with osteoporosis and a clinically diagnosed vertebral fracture will be recruited and randomly allocated to one of three management strategies, usual care (control - A), an exercise-based physiotherapy intervention (B) or a manual therapy-based physiotherapy intervention (C). Those in the usual care arm will receive a single session of education and advice, those in the active treatment arms (B + C) will be offered seven individual physiotherapy sessions over 12 weeks. The trial is designed as a prospective, adaptive single-blinded randomised controlled trial. An interim analysis will be completed and if one intervention is clearly superior the trial will be adapted at this point to continue with just one intervention and the control. The primary outcomes are quality of life measured by the disease specific QUALLEFO 41 and the Timed Loaded Standing test measured at 1 year. DISCUSSION: There are a variety of different physiotherapy packages used to treat patients with osteoporotic vertebral fracture. At present, the indication for each different therapy is not well defined, and the effectiveness of different modalities is unknown. TRIAL REGISTRATION: Reference number ISRCTN49117867.

Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme.

OBJECTIVE: To identify if a tailored rehabilitation programme is more effective than standard practice at improving function in patients undergoing metal-on-metal hip resurfacing arthroplasty. DESIGN: Randomized controlled trial. SETTING: Specialist orthopaedic hospital. SUBJECTS: 80 men with a median age of 56 years. INTERVENTIONS: Tailored post-operative physiotherapy programme compared with standard physiotherapy. MAIN OUTCOMES: Primary outcome - Oxford Hip Score (OHS), Secondary outcomes: Hip disability and Osteoarthritis Outcome Score (HOOS), EuroQol (EQ-5D-3L) and UCLA activity score. Hip range of motion, hip muscle strength and patient selected goals were also assessed. RESULTS: At one year the mean (SD) Oxford Hip Score of the intervention group was higher, 45.1 (5.3), than the control group, 39.6 (8.8). This was supported by a linear regression model, which detected a 5.8 unit change in Oxford Hip Score (p < 0.001), effect size 0.76. There was a statistically significant increase in Hip disability and Osteoarthritis Outcome Score of 12.4% (p < 0.0005), effect size 0.76; UCLA activity score differed by 0.66 points (p < 0.019), effect size 0.43; EQ 5D showed an improvement of 0.85 (p < 0.0005), effect size 0.76. A total of 80% (32 of 40) of the intervention group fully met their self-selected goal compared with 55% (22 of 40) of the control group. Hip range of motion increased significantly; hip flexion by a mean difference 17.9 degrees (p < 0.0005), hip extension by 5.7 degrees (p < 0.004) and abduction by 4 degrees (p < 0.05). Muscle strength improved more in the intervention group but was not statistically significant. CONCLUSIONS: A tailored physiotherapy programme improved self-reported functional outcomes and hip range of motion in patients undergoing hip resurfacing.

Effect of different angles of knee flexion on leg extensor power in healthy individuals.

OBJECTIVES: To investigate the effect of fixed flexion knee deformity on leg extensor power as measured by the Nottingham leg extensor power rig. DESIGN: Cross-sectional observational study. SETTING: Orthopaedic hospital. PARTICIPANTS: A convenience sample of 135 adult participants. MAIN OUTCOME MEASURES: leg extensor power normalised for body weight, UCLA activity scale. RESULTS: Power values at 0° FF were found to be significantly less than power values at 15° FF [difference 0.21W/kg SD .36], and power values at 15° FF were significantly less than those at 30° FF [difference 0.31W/kg SD .43; P<0.001) in both right and left legs. Age and activity levels were moderately negatively correlated, with UCLA score decreasing with increasing age (-0.343, P<0.0005). No significant correlation was found between activity levels measured on the UCLA and power on the LEP. CONCLUSIONS: Given the large range of pre-operative maximal extension, the validity of testing each patient at their own maximal range of pre-intervention extension and then at the same angle post-intervention is questionable. In studies assessing change in power following an intervention, the end point angle should be standardised between individuals. In future studies investigating leg extensor power on the LEP rig pre and post intervention, it could be more appropriate to standardise the angle of FF to 30°, with individuals who are unable to achieve this position excluded from the study.

The effect of supported standing in adults with upper motor neurone disorders: a systematic review.

OBJECTIVES: To evaluate whether supported standing can affect lower limb muscle length, spasticity, bone mineral density or the function of adults with upper motor neurone disorders. DATA SOURCES: A search was conducted of MEDLINE, EMBASE, AMED, CINAHL and Cochrane library electronic databases; clinical trial registers via www.controlled-trials.com and complemented with citation tracking. REVIEW METHODS: Two reviewers independently evaluated eligibility and methodological quality. Class I and II studies of assisted standing for adults with stroke, multiple sclerosis, traumatic brain injury or spinal cord injury were eligible. A domain-based risk of bias approach was used to assess quality. RESULTS: Seventeen studies were included: 11 class I and 6 class II studies involving 540 participants, of whom 73% were non-ambulant. Quality was generally low, with only two high quality trials identified. High-quality evidence suggested tilt-table standing has a small effect on preventing loss of ankle dorsiflexion. One high-quality study found a low-dose standing programme did not alter bone loss early after spinal injury. Class II low-quality evidence suggested long-term, higher dose programmes may slow bone loss. Limited evidence for the effectiveness of standing on spasticity and function was inconclusive. CONCLUSION: Supported standing can prevent small losses of ankle mobility but the clinical importance of these effects is uncertain. Low-dose standing is unlikely to protect bone health.

Patients' views of a multimedia resource featuring experiences of rheumatoid arthritis: pilot evaluation of www.healthtalkonline.org.

The Internet is used increasingly for health information and patient support. Online health information users gravitate to websites that feature patient experiences. However, experiential accounts may mislead if they are unrepresentative. The quality of experiential websites remains unexplored. Obtaining user feedback online can be problematic. This study explored views of www.dipex.org/arthritis, a website based on, and featuring, clips from interviews about experiences of rheumatoid arthritis (RA). Thirty-seven rheumatology outpatients viewed the site and completed a questionnaire. Overall the website appeared relevant and understandable and could be recommended. Comments highlighted the need to update the site regularly with experiences of new treatments; to ensure positive and negative experiences are balanced; and to ensure information is easy to find. The site has since been updated with new experiences and rewritten summaries that present a better balance of experiences. Changes were incorporated in an entire site redesign launched in autumn 2008 as www.healthtalkonline.org.

The effects of stretching in spasticity: a systematic review.

OBJECTIVES: To investigate the general effect of stretching on spasticity and to explore the complexity of stretching in patients with spasticity. DATA SOURCES: Two researchers independently performed a systematic literature search using the databases: Medline, PEDro, Cochrane library, Web of Science, CINAHL, and Allied and Complementary Medicine. STUDY SELECTION: Studies on adults receiving a stretching technique to reduce spasticity were included. DATA EXTRACTION: Randomized controlled trials (RCTs) were assessed on the PEDro scale for methodologic quality. Thirteen items from the CONSORT list and the Critical Appraisal Skills Program guideline were used to assess the methodologic quality of the other studies. DATA SYNTHESIS: RCTs (n=10) and other clinical trials (n=11) were included. The methodologic quality of the RCTs was low, varying between 4 and 8 on the PEDro scale. All studies show great diversity at the levels of methodology, population, intervention, and outcome measures making a meta-analysis not feasible. Both manual and mechanical stretching methods were studied. Stretching protocols were generally inadequately described and poorly standardized. The outcome measures used often assessed impairments such as available range of motion but were unable to distinguish between neural and nonneural components of spasticity. Associated functional benefits were not usually investigated. Although there is some positive evidence supporting the immediate effects of 1 stretching session, it remains unclear how long these effects abide and its long-term consequences. CONCLUSIONS: There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive. We recognize the need for consensus on a paradigm for stretching and for good-quality studies. Future research should address this issue and should investigate the clinical importance of the short- and long-term effects.

Outcomes after metal-on-metal hip resurfacing: could we achieve better function?

OBJECTIVE: To report functional outcomes after metal-on-metal (MOM) hip resurfacing. DESIGN: A cohort of 126 MOM hip resurfacing operations were reviewed 1 year after surgery. SETTING: Hospital trust specializing in orthopedic surgery. PARTICIPANTS: Sixty-seven right and 59 left hips were reviewed in patients (N=120; 71 men, 49 women; mean age, 56+/-9y; range, 24-76y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Administered once at follow-up. Function was measured using the Oxford Hip Score (OHS), Hip disability and Osteoarthritis Outcome Score, and UCLA Activity Score. Complications, pain, range of motion, Trendelenburg test, strength, walking, single-leg stand, stair climbing, and 10-m walk time were assessed. RESULTS: Overall examination was satisfactory with few complications. High functional levels were reported. The median OHS was 15 and median UCLA Activity Score 7 (active). For 25%, outcome was poor with persistent pain, reduced hip flexion (mean, 94.46 degrees +/-12.7 degrees ), decreased strength (P<.001), restricted walking, and functional limitations. CONCLUSIONS: Information about outcomes is important for patients undergoing surgery. Hip resurfacing remains an emergent technology, with further follow-up and investigation warranted. One explanation for suboptimal recovery may be current rehabilitation, originally developed after total hip arthroplasty. Rehabilitation tailored to hip resurfacing, paced for this active population and progressed to higher demand activities, may improve outcomes.