People with short symptom duration of knee osteoarthritis benefit more from exercise therapy than people with longer symptom duration: an individual participant data meta-analysis from the OA trial bank.

OBJECTIVE: To investigate whether duration of knee symptoms influenced the magnitude of the effect of exercise therapy compared to non-exercise control interventions on pain and physical function in people with knee osteoarthritis (OA). METHOD: We undertook an individual participant data (IPD) meta-analysis utilizing IPD stored within the OA Trial Bank from randomised controlled trials (RCTs) comparing exercise to non-exercise control interventions among people with knee OA. IPD from RCTs were analysed to determine the treatment effect by considering both study-level and individual-level covariates in the multilevel regression model. To estimate the interaction effect (i.e., treatment x duration of symptoms (dichotomized)), on self-reported pain or physical function (standardized to 0-100 scale) a one-stage multilevel regression model was applied. RESULTS: We included IPD from 1767 participants with knee OA from 10 RCTs. Significant interaction effects between study arm and symptom duration (≤1 year vs >1 year, and ≤2 years vs>2 years) were found for short- (~3 months) (Mean Difference (MD) -3.57, 95%CI -6.76 to -0.38 and -4.12, 95% CI-6.58 to -1.66, respectively) and long-term (~12 months) pain outcomes (MD -8.33, 95%CI -12.51 to -4.15 and -8.00, 95%CI -11.21 to -4.80, respectively), and long-term function outcomes (MD -5.46, 95%CI -9.22 to -1.70 and -4.56 95%CI -7.33 to-1.80, respectively). CONCLUSIONS: This IPD meta-analysis demonstrated that people with a relatively short symptom duration benefit more from therapeutic exercise than those with a longer symptom duration. Therefore, there seems to be a window of opportunity to target therapeutic exercise in knee OA.

Development and proof of concept of a blended physiotherapeutic intervention for patients with non-specific low back pain.

OBJECTIVE: To develop a blended physiotherapeutic intervention for patients with non-specific low back pain (e-Exercise LBP) and evaluate its proof of concept. DESIGN: Focus groups with patients, physiotherapists, and eHealth and LBP experts were conducted to investigate values according to the development of e-Exercise LBP. Proof of concept was evaluated in a multicentre study. SETTING: Dutch primary care physiotherapy practices (n=21 therapists). PARTICIPANTS: Adults with non-specific LBP (n=41). INTERVENTION: e-Exercise LBP was developed based on clinical LBP guidelines and the focus groups, using the Center for eHealth Research Roadmap. Face-to-face physiotherapy sessions were integrated with a web application consisting of 12 information lessons, video-supported exercises and a physical activity module with the option to gradually increase individuals' level of physical activity. The intervention could be tailored to patients' risk of persistent disabling LBP, according to the STarT Back Screening Tool. MAIN OUTCOME MEASURES: Functional disability, pain, physical activity, sedentary behaviour and fear-avoidance beliefs, measured at baseline and 12 weeks. RESULTS: After 12 weeks, improvements were found in functional disability [Quebec Back Pain Disability Scale: mean difference (MD) -12.2/100; 95% confidence interval (CI) 8.3 to 16.1], pain (Numeric Pain Rating Scale: MD -2.8/10; 95% CI 2.1 to 3.6), subjective physical activity (Short Questionnaire to Assess Health Enhancing Physical Activity: MD 11.5minutes/day; 95% CI -47.8 to 24.8) and objective sedentary behaviour (ActiGraph: MD -23.0minutes/day; 95% CI -8.9 to 55.0). Small improvements were found in objective physical activity and fear-avoidance beliefs. The option to gradually increase physical activity was activated for six patients (15%). On average, patients received seven face-to-face sessions alongside the web application. CONCLUSIONS: The results of this study provide the first indication of the effectiveness of e-Exercise LBP, particularly for disability and pain among patients with LBP. Future studies will focus on end-user experiences and (cost-) effectiveness.

[Guideline 'The chronically ill and work']. / Richtlijn 'Chronisch zieken en werk'.

- The guideline 'The chronically ill and work' gives insight into disease-overarching factors and interventions that can promote or impede the participation in the work process of workers and those looking for work who have a chronic condition. - In particular, the guideline focuses on the role taken on by workers or those looking for work themselves during the process of keeping or resuming work. - The guideline gives recommendations for the daily practice of healthcare providers which are based on knowledge from disease-specific guidelines, the international literature and the experiences of healthcare providers, and workers and those looking for work with a chronic condition.

Influence of fermentation methods on neutral detergent fiber degradation parameters.

The effect of 3 fermentation methods, in situ (IS) in 4 lactating cows (average pH of 5.8), in vitro (IVn) with media pH of 6.8, or in vitro (IVa) with media pH adjusted to 6.0 using citric acid, on fiber degradation parameters was studied using feeds ground to different particle sizes. Corn silage (CS), grass silage (GS), barley grain (B), sugar beet pulp (BP), and rapeseed cake (RC) were ground using a shear mill. Silages were ground through 8-, 4-, 2-, or 1-mm screens, B and BP through 4-, 2-, or 1-mm screens, and RC through 2- or 1-mm screens. The amylase-treated NDF (aNDF) content of samples ground using a 1-mm screen was 399, 431, 197, 480, and 251 g/kg of DM for CS, GS, B, BP, and RC, respectively, but increased with increasing screen size. Materials were incubated for 0, 6, 12, 24, 48, and 96 h IS, IVn, or IVa. Inoculum for IVn and IVa was prepared as a composite from the cows used for IS. The potentially degradable aNDF (D(0)), indegradable aNDF (I), lag time (L), and fractional rate of degradation of potential degradable aNDF (k(d)) were estimated using PROC NLIN in SAS. Except for RC, fermentation methods affected most degradation parameters, especially k(d) and L. The IVn, IVa, and IS methods resulted in k(d) values of 0.291, 0.105, 0.080 h(-1) and 0.262, 0.107, 0.103 h(-1) for BP and RC, respectively, demonstrating a decreasing rate of degradation for these feeds when fermented under suboptimal pH. In CS, GS, and B, no difference was found in k(d) between the IVn and IVa methods, which suggests that differences in pH did not alter k(d) in vitro. The k(d) values obtained for CS, GS, and B were 0.058, 0.109, 0.168, and 0.028, 0.054, and 0.069 h(-1) for the IVn and IS methods, respectively, indicating that the IS method using cows fed at production levels can underestimate the potential rate of NDF degradation. Using the IVa method, L was 12.1, 9.1, 7.8, and 2.5 h for CS, GS, BP, and RC, respectively, which was higher than L obtained from the IVn and IS methods for all feeds except B, where L in all methods were near the parameter boundary of zero hour in NLIN. It was concluded that fermentation methods were more important than grinding screen size on estimates for feed aNDF degradation and that the individual aNDF degradation parameters for the 5 feeds were affected differently by fermentation methods.

Effect of transcutaneous electrical nerve stimulation characteristics on clinical pain.

We compared the effects of four treatment variables on the pain reduction produced by transcutaneous electrical nerve stimulation and attempted to establish indications for TENS based on patient history and pain evaluation items. Treatment variables were the therapist and the three TENS stimulus characteristics--pulse width, frequency, and amplitude. We randomly assigned 192 consecutive adult patients suffering from painful conditions to one of four physical therapists and one of 12 stimulus characteristic combinations. We used a standard evaluation form that included a visual analog scale (VAS) to evaluate pain. Patients were given a 30-minute trial using TENS, followed by reevaluation. The VAS line length change after treatment was the criterion score for comparison of stimulus characteristic effectiveness. Although pain was reduced greatly with TENS (p = .01), a four-way analysis of variance (pulse width, frequency, amplitude, and therapist) attributed little of the treatment effect to the treatment variables or their interactions (r2 = .101). The amplitude effect, however, was borderline (p = .056), and subthreshold stimulation proved more effective than stimulation to tolerance (p = .05). Extensive multiple linear regression analyses failed to provide indications for TENS based on patient information and pain evaluation items. Therefore, pain remains the only indication for TENS, and we recommend subthreshold rather than higher amplitude stimulation on the initial TENS trial.