Comparison of three sets of clinical classification criteria for knee osteoarthritis: a cross-sectional study of 13,459 patients treated in primary care.

OBJECTIVE: To determine and compare the proportion of patients treated in a primary care setting that have knee osteoarthritis (OA) according to the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), and the National Institute for Health and Care Excellence (NICE) clinical classification criteria. DESIGN: A cross-sectional analysis of baseline data from 13,459 patients with knee symptoms or functional limitations associated with OA participating in the Good Life with osteoArthritis in Denmark (GLA:D®) treatment program. The prevalence of knee OA according to the EULAR, ACR and NICE criteria were calculated in all participants and in the subgroup of patients with self-reported radiographic changes associated with knee OA (n = 10,651 or 79%). RESULTS: Mean age (SD) was 65.3 (9.8) years, median (IQR) duration of symptoms 12 (6-36) months and mean pain intensity (0-100; SD) 46.5 (22.1) mm. 39% fulfilled all three sets of criteria. 48%, 52% and 89% fulfilled the EULAR, ACR, and NICE criteria for having knee OA, respectively. In the subgroup with self-reported radiographic changes, the corresponding numbers were 49%, 54% and 90%. CONCLUSIONS: While the EULAR and ACR criteria only identified around half of those, with or without self-reported radiographic knee OA, that were treated because of symptoms or functional limitations associated with knee OA, the NICE criteria identified most patients. The results indicate that the NICE criteria are relevant and appropriate to identify individuals treated for knee OA in primary care.

Discontinuation of the PACE Plus trial: problems in patient recruitment in general practice.

BACKGROUND: The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies. METHODS: General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment. RESULTS: GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%). DISCUSSION: Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial's scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment. CONCLUSION: Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice. TRIAL REGISTRATION: Dutch Trial Registration NTR6089, registered September 14th 2016.

Sick leave in workers with arm, neck and/or shoulder complaints; defining occurrence and discriminative trajectories over a 2-year time period.

OBJECTIVES: Impediments due to complaints of non-traumatic arm, neck and/or shoulder (CANS) during work often leads to consultation in primary care. This study examines the occurrence of sick leave among workers with new CANS, and evaluates sick leave trajectories and their characteristics. METHODS: This prospective 2-year cohort study included workers with a new CANS presenting in general practice. Participants filled out postal questionnaires on sick leave at 6-monthly intervals. Latent class growth mixture modelling was used to identify distinct trajectories of sick leave. Multinomial regression analyses identified characteristics of the subgroups. RESULTS: During follow-up, of the 533 participants 190 reported at least one episode of sick leave due to CANS. Three sick leave trajectories were distinguished: (1) 'low-risk' trajectory (n=366), with a constant low probability over time; (2) 'intermediate risk' trajectory, with a high probability at first consultation followed by a steep decrease in probability of sick leave (n=122); (3) 'high-risk' trajectory (n=45), with a constant high probability of sick leave. Compared to the 'low-risk' trajectory, the other trajectories were characterised by more functional limitations, less specific diagnoses, more work-related symptoms and low coworker support. Specific for the 'high-risk' subgroup were more recurrent symptoms, more musculoskeletal comorbidity, high score on somatisation and low score on job demands. CONCLUSIONS: Three trajectories of sick leave were distinguished, graded from favourable to unfavourable. Several complaint-related and work-related factors and somatisation contributed modestly to identify an unfavourable trajectory of sick leave when presenting in primary care with CANS.

Efficacy of paracetamol, diclofenac and advice for acute low back pain in general practice: design of a randomized controlled trial (PACE Plus).

BACKGROUND: Low back pain is common and associated with a considerable burden to patients and society. There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain. This trial will assess the effectiveness of paracetamol, diclofenac and placebo for acute low back pain over a period of 4 weeks. Furthermore, this trial will assess the additional effectiveness of paracetamol, diclofenac and placebo compared with advice only for acute low back pain over a period of 4 weeks. METHODS: The PACE Plus trial is a multi-center, placebo-blinded, superiority randomized controlled trial in primary care, with a follow-up of 12 weeks. Patients with acute low back pain aged 18-60 years presenting in general practice will be included. Patients are randomized into four groups: 1) Advice only (usual care conforming with the clinical guideline of the Dutch College of General Practitioners); 2) Advice and paracetamol; 3) Advice and diclofenac; 4) Advice and placebo. The primary outcome is low back pain intensity measured with a numerical rating scale (0-10). Secondary outcomes include compliance to treatment, disability, perceived recovery, costs, adverse reactions, satisfaction, sleep quality, co-interventions and adequacy of blinding. Between group differences for low back pain intensity will be evaluated using a repeated measurements analysis with linear effects models. An economic evaluation will be performed using a cost-effectiveness analysis with low back pain intensity and a cost-utility analysis with quality of life. Explorative analyses will be performed to assess effect modification by predefined variables. Ethical approval has been granted. Trial results will be released to an appropriate peer-viewed journal. DISCUSSION: This paper presents the design of the PACE Plus trial: a multi-center, placebo-blinded, superiority randomized controlled trial in primary care that will assess the effectiveness of advice only, paracetamol, diclofenac and placebo for acute low back pain. TRIAL REGISTRATION: Dutch Trial Registration NTR6089 , registered September 14th, 2016. PROTOCOL: Version 4, June 2016.

Cost-utility of exercise therapy in patients with hip osteoarthritis in primary care.

OBJECTIVE: To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care. METHOD: This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data. RESULTS: A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group (€ 1233) compared to the control group (€ 1331). The average annual societal costs per patient were lower in the intervention group (€ 2634 vs € 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02). CONCLUSION: Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects. TRIAL REGISTRATION NUMBER: NTR1462.

Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: a pragmatic randomized controlled trial.

OBJECTIVE: To assess the effectiveness of exercise therapy added to general practitioner (GP) care compared with GP care alone, in patients with hip osteoarthritis (OA) during 12 months follow-up. METHODS: We performed a multi-center parallel pragmatic randomized controlled trial in 120 general practices in the Netherlands. 203 patients, aged ≥45 years, with a new episode of hip complaints, complying with the ACR criteria for hip OA were randomized to the intervention group (n = 101; GP care with additional exercise therapy) or the control group (n = 102; GP care only). GP care was given by patient's own GP. The intervention group received, in addition, a maximum of 12 exercise therapy sessions in the first 3 months and hereafter three booster sessions. Blinding was not possible. Primary outcomes were hip pain and hip-related function measured with the HOOS questionnaire (score 0-100). RESULTS: The overall estimates on hip pain and function during the 12-month follow-up showed no between-group difference (intention-to-treat). At 3-months follow-up there was a statistically significant between-group difference for HOOS pain -3.7 (95% CI: -7.3; -0.2), effect size -0.23 and HOOS function -5.3 (95% CI: -8.9; -1.6), effect size -0.31. No adverse events were reported. CONCLUSIONS: No differences were found during 12-months follow-up on pain and function. At 3-months follow-up, pain and function scores differed in favor of patients allocated to the additional exercise therapy compared with GP care alone. TRIAL REGISTRATION: The Netherlands Trial Registry NTR1462.

Association of urinary biomarker COLL2-1NO2 with incident clinical and radiographic knee OA in overweight and obese women.

OBJECTIVE: To investigate the association between urinary biomarker Coll2-1NO2 (uColl2-1NO2) and incident knee OA after 2.5 years follow-up in middle-aged overweight and obese women at high risk for knee osteoarthritis (OA). DESIGN: Data were used from PROOF, a randomized controlled trial with 2.5 years follow-up evaluating the preventive effects of a diet and exercise program and oral glucosamine sulphate (double blind and placebo controlled), on development of incident knee OA in women with body mass index ≥ 27 kg/m(2) without signs of knee OA at baseline. Baseline and 2.5 years uColl2-1NO2 concentrations were assessed with enzyme-linked immunosorbent assay (ELISA). Primary outcome measure was incidence of knee OA in one or both knees, defined as incidence of either Kellgren & Lawrence grade ≥2, joint space narrowing of ≥1.0 mm or knee OA according to the combined clinical and radiographic ACR-criteria. We used binary logistic regression for the association analyses. RESULTS: 254 women were available for analyses. At 2.5 years follow-up, incident knee OA was present in 72 of 254 women (28.3%). An inversed association was found between baseline uColl2-1NO2 and incident knee OA at 2.5 years (OR 0.74, 95% CI 0.55-0.99). The concentration at 2.5 years and the change in concentration over 2.5 years did not show significant associations with the outcome. CONCLUSIONS: In overweight and obese middle-aged women, not higher but lower baseline uColl2-1NO2 concentration was significantly associated with an increased risk for incident knee OA. This interesting but counterintuitive outcome makes further validation of this biomarker warranted.

The 6-year trajectory of non-traumatic knee symptoms (including patellofemoral pain) in adolescents and young adults in general practice: a study of clinical predictors.

AIMS: (1) To assess the 1-year and 6-year courses of non-traumatic knee symptoms in adolescents and young adults presenting in general practice. (2) To identify prognostic factors for persistent knee symptoms at 1-year follow-up. METHODS: Adolescents and young adults (12-35 years; n=172) with non-traumatic knee symptoms were included in the cohort study by their general practitioner (GP) and followed for 6 years. Multivariable logistic regression analysis was used to identify prognostic factors for persistent knee symptoms at 1-year follow-up and the area under the receiver operating curve (AUC) was calculated. RESULTS: Persistent knee symptoms in patients receiving a GP diagnosis of unspecified knee symptoms were reported by 41% of the patients at 1-year follow-up and by 19% of the available patients at 6-year follow-up. Patients receiving a GP diagnosis of patellofemoral pain syndrome had the worse prognosis, with 40% reporting persistent knee symptoms at 6-year follow-up. Prognostic factors associated with persistent knee symptoms at 1-year follow-up were BMI >25, low/middle education level, bilateral symptoms and self-reported absence of crepitus of the knee (AUC 0.80) for patients receiving a GP diagnosis of unspecified knee symptoms. For patients receiving a GP diagnosis of patellofemoral pain syndrome, prognostic factors were low/middle education level, poor health, having bilateral symptoms and self-report of a swollen knee (AUC 0.76). CONCLUSIONS: The prognosis of non-traumatic knee symptoms in adolescents and young adults in general practice is not as good as was previously assumed. Several prognostic factors collected at baseline were associated with persistent knee symptoms at follow-up. However, the results should be replicated in another larger study.

Incidence and Risk Factors for Upper Extremity Climbing Injuries in Indoor Climbers.

The purpose of this study was to describe the prevalence, incidence and risk factors for climbing-related injuries of the upper extremities in recreational climbers. A total of 426 recreational climbers were recruited from indoor climbing halls. The baseline questionnaire included questions on potential risk factors for climbing injuries: personal factors, climbing-related factors and upper extremity injuries that had occurred in the previous 12 months. Follow-up questionnaires collected information on new injuries that occurred during the follow-up period. The incidence of climbing-related injuries during one-year follow-up was 42.4% with 13 injuries per 1000 h of climbing. The finger was the most frequently affected injury location (36.0%). The following risk factors were associated with the occurrence of upper extremity injuries: higher age (OR 1.03, 95% CI 1.01;1.05), performing a cooling-down (OR 2.02, 95% CI 1.28;3.18), climbing with campus board (OR 2.48, 95% CI 1.23;5.02), finger strength middle finger (OR 1.12, 95% CI 1.05;1.18) and previous injuries (OR 3.05, 95% CI 2.01;4.83). Climbing injuries of the upper body extremities are very common among recreational climbers in indoor halls and several risk factors can be identified that are related to a higher injury risk.

Crepitus is a first indication of patellofemoral osteoarthritis (and not of tibiofemoral osteoarthritis).

OBJECTIVE: The patellofemoral joint (PFJ) is important in early detection of knee osteoarthritis (OA). Little is known about the relationship between specific clinical findings and PFJ Magnetic resonance Imaging (MRI) features. The objective was to examine the relationship between (early) clinical findings and PFJ MRI features in females (45-60 years) without knee OA (PFJ or tibiofemoral joint (TFJ) OA) based on a recently suggested MRI definition. METHODS: MRIs of knees of women of a sub-study of the Rotterdam Study were scored with semi-quantitative scoring. Specific patellar tests were performed on physical examination. Current knee pain and history of patellar knee pain were reported. Binomial logistic generalized estimated equations were used to determine the association between clinical findings of OA and PFJ MRI features. All associations were adjusted for age, body mass index (BMI) and TFJ MRI features. RESULTS: In 888 women (1776 knees, mean age: 55.1 years and mean BMI: 27.0 kg/m(2)) we found significant associations between crepitus and all PFJ MRI features (Odds ratios (OR) range: 2.61-5.49). A history of patellar pain was significantly associated with almost all PFJ MRI features (ORcartilage: 1.95; ORcysts: 1.86; ORbone marrow lesions: 1.83), except for osteophytes. No significant associations were found between the clinical findings and TFJ MRI features. CONCLUSION: Crepitus and history of patellar pain are clinical findings that indicate PFJ lesions seen on MRI. These tests could help to indicate signs of PFJOA. Follow-up data needs to confirm whether these tests have an additional diagnostic value for early knee OA in PFJ or TFJ.

Does pain medication influence outcomes in elderly people seeking care for back pain? BACE cohort study.

BACKGROUND: Back pain is common among older adults resulting in the high societal and economic burden of persistent pain and disability. Pain medications are frequently prescribed for back pain, especially among older patients, but the efficacy of analgesics on back pain in this patient population remains under debate. In the present study, we investigated the outcomes (i.e. pain intensity and disability) of pain medication use in older people with back pain participating in a prospective cohort study. METHODS: A total of 669 patients aged >55 years consulting a general practitioner for a new episode of back complaints were included in this study. The association between pain medication use and outcomes (pain intensity and disability) was assessed at 3-month follow-up. RESULTS: Pain medication users were observed to experience more pain and disability at baseline compared with non-users. At 3-month follow-up, patients from all subgroups (e.g. pain medication users versus non-users) improved over time. Yet medication users had higher pain intensity and poorer disability scores compared with non-users. Patients who de-escalated or stopped pain medication had lower pain and disability than non-users. When comparing different types of medications (i.e. paracetamol, non-steroidal anti-inflammatory drugs, opioids), none of the groups showed better scores regarding pain and disability in users compared with non-users. Opioid users displayed the highest levels of pain and disability. CONCLUSIONS: In the present study, although patients who de-escalated or stopped analgesics had less pain and disability, pain medication overall does not result in better outcomes in older people with back pain. SIGNIFICANCE: Older patients taking pain medication did not report better outcomes than the ones who did not, except for those who de-escalated or stopped pain medication. Caution should be taken in prescribing pain medication for older patients with back pain in primary care.

The (cost-)effectiveness of combined lifestyle interventions for people with persistent low-back pain who are overweight or obese: A systematic review.

INTRODUCTION: Lifestyle factors are expected to contribute to the persistence and burden of low-back pain (LBP). However, there are no systematic reviews on the (cost-)effectiveness of combined lifestyle interventions for overweight or obese people with LBP. AIM: To assess whether combined lifestyle interventions are (cost-)effective for people with persistent LBP who are overweight or obese, based on a systematic review. DESIGN: Systematic review METHOD: PubMed, Cochrane, Embase, CINAHL, PsycINFO and the Wiley/Cochrane Library were searched from database inception till January 6th 2023. Two independent reviewers performed study selection, data-extraction and risk of bias scoring using the Cochrane RoB tool 2 and/or the Consensus Health Economic Criteria list. GRADE was used to assess the level of certainty of the evidence. RESULTS: In total 2510 records were screened, and 4 studies on 3 original RCTs with 216 participants were included. Low certainty evidence (1 study) showed that combined lifestyle interventions were not superior to usual care for physical functioning, pain and lifestyle outcomes. Compared to usual care, moderate certainty evidence showed that healthcare (-$292, 95%CI: 872; -33), medication (-$30, 95% CI -65; -4) and absenteeism costs (-$1000, 95%CI: 3573; -210) were lower for the combined lifestyle interventions. CONCLUSION: There is low certainty evidence from 3 studies with predominantly small sample sizes, short follow-up and low intervention adherence that combined lifestyle interventions are not superior to physical functioning, pain and lifestyle outcomes compared to usual care, but are likely to be cost-effective.

Development of radiological knee osteoarthritis in patients with knee complaints.

OBJECTIVES: It is currently impossible to identify which patients with knee complaints presenting to the general practitioner will develop knee osteoarthritis (OA) pathology at a later stage. This study examines the determinants for developing OA pathology on x-ray in patients with knee complaints but no radiological OA at baseline in the painful knee. METHODS: Data from the prospective Rotterdam cohort study (including subjects aged ≥55 years) were used. Analysis was performed on 623 subjects with knee complaints at baseline and their data at 6-year follow-up (T1; n=607) and at 11-year follow-up (T2; n=457). At baseline, none had radiological OA (rOA=Kellgren and Lawrence (KL) grade ≥2) in the painful joint. At follow-up, predictors for rOA were determined using multivariate ordinal logistic regression analysis. RESULTS: At T1, 8.5% of the group had developed knee rOA and, by T2, this had increased to 23%. Determinants remaining significant in the multivariate analysis were female gender (OR 1.95, 95% CI 1.15 to 3.36), other joint complaints (OR 2.22, 95% CI 1.12 to 4.35) and KL grade 1 at baseline in the painful knee joint (OR 7.14, 95% CI 4.55 to 11.1). All outcomes are adjusted for all included determinants. CONCLUSION: The best predictors of development of knee rOA are a combination of female gender, other joint complaints and KL grade 1 in the painful joint. KL grade 1 in combination with knee pain should be considered as early OA in patient management.

Association between spinal morning stiffness and lumbar disc degeneration: the Rotterdam Study.

OBJECTIVE: To explore the associations between spinal morning stiffness and lumbar disc degeneration (LDD). DESIGN: Data from a cross-sectional general population-based study (Rotterdam Study-I) were used. Intervertebral disc spaces and osteophytes of people aged ≥55 years were scored on lumbar lateral radiographs (L1-2 through L5-S1 was scored). Logistic regression analysis was used to explore associations between spinal morning stiffness and two definitions of LDD (i.e., 'narrowing' and 'osteophytes'). Spinal morning stiffness combined with low back pain and its association with LDD was also analyzed. Similar analyses were performed for knee and hip pain, morning stiffness in the legs, and radiographic knee and hip osteoarthritis (OA) in order to compare these associations with those of LDD. All analyses were adjusted for age, gender, and body mass index (BMI). RESULTS: Lumbar lateral radiographs were scored for 2,819 participants. Both definitions of LDD were associated with spinal morning stiffness: adjusted odds ratio (aOR) 1.3; 95% confidence interval (CI): 1.1-1.6 for 'osteophytes' and aOR 1.8; 95% CI: 1.4-2.2 for 'narrowing'. Both the odds ratios increased when spinal morning stiffness was combined with low back pain: aOR 1.5; 95% CI: 1.1-2.0 for 'osteophytes' and aOR 2.5; 95% CI: 1.9-3.4 for 'narrowing'. When morning stiffness in the legs was combined with knee or hip pain, the associations with radiographic knee or hip OA were: aOR 3.0; 95% CI: 2.1-4.1 for knee OA and aOR 3.1; 95% CI: 1.9-5.0 for hip OA. CONCLUSIONS: Reported spinal morning stiffness is associated with LDD. The associations increased when we combined spinal morning stiffness with low back pain. The magnitude of the association for the definition 'narrowing' is similar to the association between morning stiffness in the legs and knee or hip OA.

Impact of different descriptions of the Kellgren and Lawrence classification criteria on the diagnosis of knee osteoarthritis.

OBJECTIVES: Although the Kellgren and Lawrence (K&L) criteria for defining radiological osteoarthritis are widely used in epidemiological and clinical studies, the authors previously documented the existence of five different versions of these criteria. This study identifies the impact of the use of alternative versions of the K&L criteria and evaluates which description has the highest association with knee complaints. METHODS: Two readers scored most radiographs of the knees of participants of the Rotterdam Study with the original K&L description (90%). In addition, each alternative description was used in a random part (20%) of the radiographs. The authors calculated reproducibility of all descriptions, and compared sensitivity and specificity of the alternative descriptions for three cut-off points with the original description as reference standard (K&L≥1, K&L≥2 and K&L≥3). The authors calculated κ statistics to compare agreement between the original and alternative descriptions, and evaluated the association with knee complaints. RESULTS: The dataset comprises radiographs of knees of 3071 people. For cut-off K&L≥1 all four alternatives classified more people as having osteoarthritis than the original description; κ was low, and sensitivity and specificity were moderate to good. For cut-offs K&L≥2 and K&L≥3 there was little difference in the number of cases and κ, sensitivity and specificity were good to perfect. The original description and alternative 3 showed the strongest association with knee complaints. CONCLUSIONS: The different descriptions of the K&L criteria have impact on the classification of osteoarthritis in the lowest grade (K&L≥1). All descriptions have strengths and weaknesses. It depends on the purpose which is the best description.

NSAIDs vs acetaminophen in knee and hip osteoarthritis: a systematic review regarding heterogeneity influencing the outcomes.

OBJECTIVE: To identify sources of heterogeneity (statistical, methodological, and clinical) in studies evaluating non-steroidal anti-inflammatory drugs (NSAIDs) vs acetaminophen in patients with knee and hip osteoarthritis (OA) to elucidate variations in outcomes. METHOD: A database search (1966 to January 2010) was made for (randomized) controlled trials ((R)CTs) comparing NSAIDs vs acetaminophen in knee and hip OA. Extracted data included baseline demographic/clinical characteristics, outcomes at follow-up, and characteristics of study design. Heterogeneity was examined with subgroup analyses by exploring changes in effect size and with I(2) of Higgins. Pain measures were expressed as standardized mean differences. RESULTS: 15 RCTs, including 21 comparisons of NSAIDs and acetaminophen were included. Statistical heterogeneity was absent (Cochran's Q-test=14.11; I(2)=0; P=0.78). Moderate clinical heterogeneity was found for comparisons which included both hip and knee OA vs knee OA only (I(2)=51; P=0.09). NSAIDs seemed slightly more effective than acetaminophen if more patients with hip OA were included. However, the pooled effect sizes of comparisons with knee OA vs both knee and hip OA are equal. Low clinical heterogeneity was found for comparisons with low dosage of acetaminophen, normal dosage of NSAIDs, and moderate pain intensity at baseline. Low methodological heterogeneity was found for comparisons with a short duration. CONCLUSION: Future trials should present the results of hip and knee OA separately, as moderate clinical heterogeneity was found. There might be differences in effectiveness of NSAIDs vs acetaminophen in patients with hip vs knee OA. No significant methodological and statistical heterogeneity was found in studies evaluating NSAIDs vs acetaminophen.

A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain.

The objective of this review was to determine the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP). Existing Cochrane reviews for the four interventions were screened for studies fulfilling the inclusion criteria. Then, the literature searches were updated. Only randomized controlled trials on adults (≥18 years) with chronic (≥12 weeks) non-specific LBP and evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work) were included. The GRADE approach was used to determine the quality of evidence. A total of 17 randomized controlled trials was included: NSAIDs (n = 4), antidepressants (n = 5), and opioids (n = 8). No studies were found for muscle relaxants; 14 studies had a low risk of bias. The studies only reported effects on the short term (<3 months). The overall quality of the evidence was low. NSAIDs and opioids seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo, in patients with non-specific chronic low back pain; opioids seem to have a small effect in improving function for a selection of patients who responded with an exacerbation of their symptoms after stopping their medication. However, both types of medication show more adverse effects than placebo. There seems to be no difference in effect between antidepressants and placebo in patients with non-specific chronic LBP.

Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review.

BACKGROUND: A variety of therapeutic interventions is available for restoring motion and diminishing pain in patients with frozen shoulder. An overview article concerning the evidence for the effectiveness of these interventions is lacking. OBJECTIVE: To provide an evidence-based overview regarding the effectiveness of conservative and surgical interventions to treat the frozen shoulder. METHODS: The Cochrane Library, PubMed, Embase, Cinahl and Pedro were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently selected relevant studies, assessed the methodological quality and extracted data. A best-evidence synthesis was used to summarise the results. RESULTS: Five Cochrane reviews and 18 RCTs were included studying the effectiveness of oral medication, injection therapy, physiotherapy, acupuncture, arthrographic distension and suprascapular nerve block (SSNB). CONCLUSIONS: We found strong evidence for the effectiveness of steroid injections and laser therapy in short-term and moderate evidence for steroid injections in mid-term follow-up. Moderate evidence was found in favour of mobilisation techniques in the short and long term, for the effectiveness of arthrographic distension alone and as an addition to active physiotherapy in the short term, for the effectiveness of oral steroids compared with no treatment or placebo in the short term, and for the effectiveness of SSNB compared with acupuncture, placebo or steroid injections. For other commonly used interventions no or only limited evidence of effectiveness was found. Most of the included studies reported short-term results, whereas symptoms of frozen shoulder may last up to 4 years. High quality RCTs studying long-term results are clearly needed in this field.

Diagnostic ultrasound in patients with shoulder pain: An inter-examiner agreement and reliability study among Dutch physical therapists.

STUDY DESIGN: A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care. BACKGROUND: musculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears. OBJECTIVES: To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain. METHODS: Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's). RESULTS: Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy. CONCLUSIONS: Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.