Functional outcome measures for infantile Charcot-Marie-Tooth disease: a systematic review.

A functional outcome measure for infants (aged 0-3 years) with Charcot-Marie-Tooth (CMT) disease is needed for upcoming disease-modifying trials. A systematic review of outcome measures for infants with neuromuscular disorders was completed to determine if validated measures were available for the CMT infant population. We assessed 20,375 papers and identified seven functional outcome measures for infants with neuromuscular disorders. Six were developed and validated for spinal muscular atrophy (SMA). There were no CMT-specific outcome measures identified; however, one (motor function measure) assessed a range of neuromuscular disorders including 13 infants and children with CMT. The included studies exhibited "good" face, discriminant, convergent and concurrent validity, and reported excellent intra- and inter-rater reliability. No outcome measure was subjected to item response theory. Studies reported outcome measures comprising of 51 different items assessing six domains of function: reflexive movement, axial movement, limb movement, positioning, gross motor, and fine-motor skills. Scoring of items ranged from 2- to 7-point rating scales; and none were scaled to normative reference values to account for changes in growth and development. The SMA focus of most items is likely to produce ceiling effects and lack sensitivity and responsiveness for within and between types of CMT in infants. Nevertheless, several items across scales assessing distal strength, gross- and fine-motor function, could be included in the development of a composite functional outcome measure for infants with CMT to assess disease-modifying interventions.

Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium.

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Efficacy of a Sleep Quality Intervention in People With Low Back Pain: Protocol for a Feasibility Randomized Co-Twin Controlled Trial.

Poor sleep quality is highly prevalent in patients with low back pain (LBP) and is associated with high levels of pain, psychological distress, and physical disability. Studies have reported a bidirectional relationship between sleep problems and intensity of LBP. Accordingly, effective management of LBP should address sleep quality. In addition, genetics has been found to significantly affect the prevalence of both LBP and insomnia. Our study aims to establish the feasibility of a trial exploring the efficacy of a web-based sleep quality intervention in people with LBP, with the genetic influences being controlled for. 30 twins (15 complete pairs) with subacute or chronic LBP (>6 weeks) will be recruited from the Australian Twin Registry. Participants will be randomly assigned to one of the two groups with each twin within a pair receiving either an interactive web-based sleep intervention based on cognitive behavioral therapy principles (intervention) or a web-based education program (control) for 6 weeks. The feasibility of the trial will be investigated with regard to recruitment rate, feasibility of data collection and outcome measure completion, contamination of intervention, acceptability and experience of intervention, and sample size requirement for the full trial. Patient outcomes will be collected electronically at baseline, immediately post-treatment, and at 3-months' follow-up post-randomization. This trial employs a robust design that will effectively control for the influence of genetics on treatment effect. Additionally, this study addresses sleep quality, a significant but under-explored issue in LBP. Results will inform the design and implementation of the definitive trial.

Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis.

PURPOSE: Previous reviews have compared surgical to non-surgical management of sciatica, but have overlooked the specific comparison between surgery and physical activity-based interventions. METHODS: Systematic review using MEDLINE, CINAHL, Embase and PEDro databases was conducted. Randomised controlled trials comparing surgery to physical activity, where patients were experiencing the three most common causes of sciatica-disc herniation, spondylolisthesis and spinal stenosis. Two independent reviewers extracted pain and disability data (converted to a common 0-100 scale) and assessed methodological quality using the PEDro scale. The size of the effects was estimated for each outcome at three different time points, with a random effects model adopted and the GRADE approach used in summary conclusions. RESULTS: Twelve trials were included. In the short term, surgery provided better outcomes than physical activity for disc herniation: disability [WMD -9.00 (95 % CI -13.73, -4.27)], leg pain [WMD -16.01 (95 % CI -23.00, -9.02)] and back pain [WMD -12.44 (95 % CI -17.76, -7.09)]; for spondylolisthesis: disability [WMD -14.60 (95 % CI -17.12, -12.08)], leg pain [WMD -35.00 (95 % CI -39.66, -30.34)] and back pain [WMD -20.00 (95 % CI -24.66, -15.34)] and spinal stenosis: disability [WMD -11.39 (95 % CI -17.31, -5.46)], leg pain [WMD, -27.17 (95 % CI -35.87, -18.46)] and back pain [WMD -20.80 (95 % CI -25.15, -16.44)]. Long-term and greater than 2-year post-randomisation results favoured surgery for spondylolisthesis and stenosis, although the size of the effects reduced with time. For disc herniation, no significant effect was shown for leg and back pain comparing surgery to physical activity. CONCLUSION: There are indications that surgery is superior to physical activity-based interventions in reducing pain and disability for disc herniation at short-term follow-up only; but high-quality evidence in this field is lacking (GRADE). For spondylolisthesis and spinal stenosis, surgery is superior to physical activity up to greater than 2 years follow-up. Results should guide clinicians and patients when facing the difficult decision of having surgery or engaging in active care interventions. PROSPERO registration number : CRD42013005746.

2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains.

The Executive Committee of the International Ankle Consortium presents this 2016 position paper with recommendations for information implementation and continued research based on the paradigm that lateral ankle sprain (LAS), and the development of chronic ankle instability (CAI), serve as a conduit to a significant global healthcare burden. We intend our recommendations to serve as a mechanism to promote efforts to improve prevention and early management of LAS. We believe this will reduce the prevalence of CAI and associated sequelae that have led to the broader public health burdens of decreased physical activity and early onset ankle joint post-traumatic osteoarthritis. Ultimately, this can contribute to healthier lifestyles and promotion of physical activity.

Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains.

Lateral ankle sprains (LASs) are the most prevalent musculoskeletal injury in physically active populations. They also have a high prevalence in the general population and pose a substantial healthcare burden. The recurrence rates of LASs are high, leading to a large percentage of patients with LAS developing chronic ankle instability. This chronicity is associated with decreased physical activity levels and quality of life and associates with increasing rates of post-traumatic ankle osteoarthritis, all of which generate financial costs that are larger than many have realised. The literature review that follows expands this paradigm and introduces emerging areas that should be prioritised for continued research, supporting a companion position statement paper that proposes recommendations for using this summary of information, and needs for specific future research.

Elevated levels of GABA+ in migraine detected using (1) H-MRS.

γ-Aminobutyric acid (GABA) has been implicated in several pain conditions, yet no study has systematically evaluated GABA levels in migraine using (1) H-MRS. The accurate detection, separation and quantification of GABA in individuals with migraine could elucidate the role of this neurotransmitter in migraine pathophysiology. Such information may eventually be useful in the diagnosis and development of more effective treatments for migraine. The aims of this study were therefore to compare the concentration of GABA+ in individuals with migraine with that in asymptomatic individuals, and to determine the diagnostic potential of GABA+ in the classification of those with or without migraine. In this case-control study, GABA+ levels in the brain were determined in 19 participants with migraine and 19 matched controls by (1) H-MRS using Mescher-Garwood point-resolved spectroscopy (MEGA-PRESS) sequence. The diagnostic accuracy of GABA+ for the detection of migraine and the optimal cut-off value were determined by receiver operating characteristic analysis. GABA+ levels were significantly higher (p = 0.002) in those with migraine [median, 1.41 institutional units (IU); interquartile range, 1.31-1.50 IU] than in controls (median, 1.18 IU; interquartile range, 1.12-1.35 IU). The GABA+ concentration appears to have good accuracy for the classification of individuals with or without migraine [area under the curve (95% confidence interval), 0.837 (0.71-0.96); p < 0.001]. The optimal GABA+ cut-off value for migraine was 1.30 IU, with a sensitivity of 84.2%, specificity of 68.4% and positive likelihood ratio of +2.67. The outcomes of this study suggest altered GABA metabolism in migraine. These results add to the scarce evidence on the putative role of GABA in migraine and provide a basis to further explore the causal relationship between GABA+ and the pathophysiology of migraine. This study also demonstrates that GABA+ concentration has good diagnostic accuracy for migraine. These findings offer new research and practice directions for migraine diagnosis.

Diagnostic accuracy of clinical tests for ankle syndesmosis injury.

OBJECTIVE: Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests. DESIGN: Cross-sectional diagnostic accuracy study. SETTING: 9 clinics in two Australian cities. PARTICIPANTS: 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled. METHODS: Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests. RESULTS: The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004). CONCLUSIONS: Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific).

Heavy domestic, but not recreational, physical activity is associated with low back pain: Australian Twin low BACK pain (AUTBACK) study.

PURPOSE: To evaluate the association between domestic and recreational physical activity (PA) and low back pain (LBP) after adjusting for genetic and environmental influences. METHODS: Twins were recruited through the Australian twin registry. LBP prevalence and domestic (vigorous gardening/heavy yard work) and recreational (light walking, moderate/vigorous) PA were assessed by a validated questionnaire. Associations were analysed using a cross-sectional analysis of the complete sample of 486 twins, including a matched case-control analysis of 69 twin pairs discordant for LBP. Logistic regression and the lincom post-estimation method were used for the analysis. Odds ratios (OR) with 95 % confidence intervals (CIs) were calculated. RESULTS: The case-control analysis showed that LBP was significantly associated with heavy domestic PA (OR 2.88, 95 % CI 1.29-6.43), whereas no significant association was found with any form of recreational PA. The results of the lincom command indicated that being engaged in both heavy domestic and recreational PA (light walking or moderate/vigorous) was associated with a significantly increased probability of LBP compared with being engaged only in recreational PA (light walking or moderate/vigorous, ORs 3.48-4.22). Using the whole sample, we found weaker associations but in the same direction. CONCLUSIONS: We found evidence that heavy domestic PA is associated with an increased probability of LBP, and the combination of heavy domestic and recreational PA might increase the probability of LBP more so than heavy domestic or recreational PA alone. Associations being greater when using the co-twin case-control analysis indicate that genetic and environmental factors influence the relationship between PA and LBP, and demonstrate the value of a twin design.

A qualitative study of influences on older women's practitioner choices for back pain care.

BACKGROUND: Back pain is an increasingly prevalent health concern amongst Australian women for which a wide range of treatment options are available, offered by biomedical, allied health and complementary and alternative medicine (CAM) providers. Although there is an emerging literature on patterns of provider utilisation, less is known about the reasons why women with back pain select their chosen practitioner. In this paper we explore the influences on back pain sufferers' decision-making about treatment seeking with practitioners for their most recent episode of back pain. METHODS: Drawing on 50 semi-structured interviews with women aged 60-65 years from the Australian Longitudinal Study on Women's Health (ALSWH) who have chronic back pain, we focus on the factors which influence their choice of practitioner. Analysis followed a framework approach to qualitative content analysis, augmented by NVivo 9 qualitative data analysis software. Key themes were identified and tested for rigour through inter-rater reliability and constant comparison. RESULTS: The women identified four predominant influences on their choice of practitioner for back pain: familiarity with treatment or experiences with individual practitioners; recommendations from social networks; geographical proximity of practitioners; and, qualifications and credentials of practitioners. The therapeutic approach or evidence-base of the practices being utilised was not reported by the women as central to their back pain treatment decision making. CONCLUSIONS: Choice of practitioner appears to be unrelated to the therapeutic approaches, treatment practices or the scientific basis of therapeutic practices. Moreover, anecdotal lay reports of effectiveness and the 'treatment experience' may be more influential than formal qualifications in guiding women's choice of practitioner for their back pain. Further work is needed on the interpersonal, collective and subjective underpinnings of practitioner choice, particularly over time, in order to better understand why women utilise certain practitioners for back pain.

Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis.

OBJECTIVE: To determine the effectiveness of exercise and soft tissue massage either in isolation or in combination for the treatment of non-specific shoulder problems. METHODS: Database searches for articles from 1966 to December 2011 were performed. Studies were eligible if they investigated 'hands on' soft tissue massage performed locally to the shoulder or exercises aimed at improving strength, range of motion or coordination; non-surgical painful shoulder disorders; included participants aged 18-80 years and outcomes measured included pain, disability, range of motion, quality of life, work status, global perceived effect, adverse events or recurrence. RESULTS: Twenty-three papers met the selection criteria representing 20 individual trials. We found low-quality evidence that soft tissue massage was effective for producing moderate improvements in active flexion and abduction range of motion, pain and functional scores compared with no treatment, immediately after the cessation of treatment. Exercise was shown by meta-analysis to produce greater improvements than placebo, minimal or no treatment in reported pain (weighted mean=9.8 of 100, 95% CI 0.6 to 19.0) but these changes were of a magnitude that was less than that considered clinically worthwhile. Exercise did not produce greater improvements in shoulder function than placebo, minimal or no treatment (weighted mean=5.7 of 100, 95% CI -3.3 to 14.7). CONCLUSION: There is low-quality evidence that soft tissue massage is effective for improving pain, function and range of motion in patients with shoulder pain in the short term. Exercise therapy is effective for producing small improvements in pain but not in function or range of motion.

Transient swelling versus lymphoedema in the first year following surgery for breast cancer.

PURPOSE: The aim was to better understand the incidence, time course and risk factors for swelling in the arm on the side of surgery over the first year following surgery for breast cancer. METHOD: Women (n = 160) were assessed 1 month following surgery and then randomised to the exercise or control group. Reassessment occurred 3, 9 and 15 months following surgery. Potential risk factors for swelling included age, body mass index, side of surgery and surgical and medical treatments for their breast cancer, physical measures of shoulder range of motion and strength, inter-limb arm circumference difference and the group to which they were randomised. Swelling was determined using bioimpedance spectroscopy with reference to previously established cut-offs for lymphoedema. RESULTS: The number of women with swelling at 3, 9 and 15 months was 15, 15 and 13, respectively; however, at 15 months only 5/13 presented with swelling in either of the preceding assessments. The risk of swelling increased at 3, 9 and 15 months for each centimetre increase in the baseline inter-limb difference in sum of arm circumferences by 1.30, 1.17 and 1.14. In addition, risk of swelling at 3 months was 2.6 times greater for women in the control group; at 9 months, 7 times greater for women who had taxane-based chemotherapy; and at 15 months, the risk increased 1.16 times for each day the drain was in situ. CONCLUSION: Swelling in the first year is likely to be transient, and factors including exercise and taxane chemotherapy affect the risk of developing swelling.

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review.

OBJECTIVES: To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury. DESIGN: Systematic review. DATA SOURCES: An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information. STUDY SELECTION: Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard. RESULTS: The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests. CONCLUSIONS: This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

Upper limb progressive resistance training and stretching exercises following surgery for early breast cancer: a randomized controlled trial.

The aim of this study was to determine whether an exercise program, commencing 4-6 weeks post-operatively, reduces upper limb impairments in women treated for early breast cancer. Women (n = 160) were randomized to either an 8-week exercise program (n = 81) or to a control group (n = 79) following stratification for axillary surgery. The exercise program comprised a weekly session and home program of passive stretching and progressive resistance training for shoulder muscles. The control group attended fortnightly assessments but no exercises were provided. The primary outcome was self-reported arm symptoms derived from the EORTC breast cancer-specific questionnaire (BR23), scored out of 100 with a low score indicative of fewer symptoms. The secondary outcomes included physical measures of shoulder range of motion, strength, and swelling (i.e., lymphedema). Women were assessed immediately following the intervention and at 6 months post-intervention. The change in symptoms from baseline was not significantly different between groups immediately following the intervention or at 6 m post-intervention. The between group difference immediately following the intervention was 4 (95% CI -1 to 9) and 6 months post-intervention was 4 (-2 to 10). However, the change in range of motion for flexion and abduction was significantly greater in the exercise group immediately following the intervention, as was change in shoulder abductor strength. In conclusion, a supervised exercise program provided some, albeit small, additional benefit at 6 months post-intervention to women who had been provided with written information and reminders to use their arm. Both the groups reported few impairments including swelling immediately following the intervention and 6 months post-intervention. Notably, resistance training in the post-operative period did not precipitate lymphedema.

Rehabilitation for ankle fractures in adults.

BACKGROUND: Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008. OBJECTIVES: To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults. SEARCH METHODS: We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate. MAIN RESULTS: Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy. AUTHORS' CONCLUSIONS: There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Standardized measurement of recovery from nonspecific back pain.

OBJECTIVE: To propose standardized, patient-centered measures of recovery from nonspecific low back pain (LBP) in research, underpinned by an empirically derived concept of recovery and informed by expert opinion. DESIGN: Synthesis of literature reviews and expert panel opinion. SETTING: Primary care centers for the management of nonspecific LBP. PARTICIPANTS: Persons with nonspecific LBP. INTERVENTIONS: Conservative treatments for nonspecific LBP. MAIN OUTCOME MEASURES: Three phases of research were conducted. First, qualitative research that explored patients' perspectives of recovery from nonspecific LBP was reviewed. Second, measures of recovery used in LBP clinical trials during the past decade were investigated in a systematic review. Third, opinion was sought from an expert panel of clinicians and researchers about how to measure recovery from nonspecific LBP, in a workshop at the 10th International Forum for Primary Care Research in Low Back Pain. RESULTS: An empirically derived and patient-centered concept of recovery from nonspecific LBP was developed from the qualitative research phase. The systematic review conducted in the second study phase revealed that researchers have used vastly heterogeneous measures of LBP recovery in clinical trials during the past decade. Finally, the key conclusions of the LBP Forum workshop were (1) that appropriate patient-centered instruments to measure recovery include global measures and patient-specific measures; and (2) that the benefits of implementing the same recovery measures for acute and chronic LBP outweigh the disadvantages of using different measures. CONCLUSIONS: The results were synthesized to inform our recommendation that researchers consider adopting 2 instruments as standardized measures of recovery from nonspecific LBP, as an adjunct to the existing core set of LBP outcome measures. These instruments are an 11-point Global Back Recovery Scale, for a simple measure of global recovery, and the Patient-Generated Index of Quality of Life-Back Pain, to evaluate specific relevant dimensions of recovery. This recommendation has majority endorsement by members of the Australian National Health and Medical Research Council Acute Low Back Pain Review Group.

Prevalence and impact of chronic musculoskeletal ankle disorders in the community.

OBJECTIVE: To determine the point prevalence of chronic musculoskeletal ankle disorders in the community. DESIGN: Cross-sectional stratified (metropolitan vs regional) random sample. SETTING: General community. PARTICIPANTS: Population-based computer-aided telephone survey of people (N=2078) aged 18 to 65 years in New South Wales, Australia. Of those contacted, 751 participants provided data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Point prevalence for no history of ankle injury or chronic ankle problems (no ankle problems), history of ankle injury without residual problems, and chronic ankle disorders. Chronic musculoskeletal ankle disorders due to ankle sprain, fracture, arthritis, or other disorder compared by chi-square test for the presence of pain, weakness, giving way, swelling and instability, activity limitation, and health care use in the past year. RESULTS: There were 231 (30.8%) participants with no ankle problems, 342 (45.5%) with a history of ankle injury but no chronic problems, and 178 (23.7%) with chronic ankle disorders. The major component of chronic ankle disorders was musculoskeletal disorders (n=147, 19.6% of the total sample), most of which were due to ankle injury (n=117, 15.6% of the total). There was no difference among the arthritis, fracture, sprain, and other groups in the prevalence of the specific complaints, or health care use. Significantly more participants with arthritis had to limit activity than in the sprain group (Chi-square test, P=.035). CONCLUSIONS: Chronic musculoskeletal ankle disorders affected almost 20% of the Australian community. The majority were due to a previous ankle injury, and most people had to limit or change their physical activity because of the ankle disorder.

Use of complementary and alternative medicine by mid-age women with back pain: a national cross-sectional survey.

BACKGROUND: The use of complementary and alternative medicine (CAM) has increased significantly in Australia over the past decade. Back pain represents a common context for CAM use, with increasing utilisation of a wide range of therapies provided within and outside conventional medical facilities. We examine the relationship between back pain and use of CAM and conventional medicine in a national cohort of mid-aged Australian women. METHODS: Data is taken from a cross-sectional survey (n = 10492) of the mid-aged cohort of the Australian Longitudinal Study on Women's Health, surveyed in 2007. The main outcome measures were: incidence of back pain the previous 12 months, and frequency of use of conventional or CAM treatments in the previous 12 months. RESULTS: Back pain was experienced by 77% (n = 8063) of the cohort in the previous twelve month period. The majority of women with back pain only consulted with a conventional care provider (51.3%), 44.2% of women with back pain consulted with both a conventional care provider and a CAM practitioner. Women with more frequent back pain were more likely to consult a CAM practitioner, as well as seek conventional care. The most commonly utilised CAM practitioners were massage therapy (26.5% of those with back pain) and chiropractic (16.1% of those with back pain). Only 1.7% of women with back pain consulted with a CAM practitioner exclusively. CONCLUSIONS: Mid-aged women with back pain utilise a range of conventional and CAM treatments. Consultation with CAM practitioners or self-prescribed CAM was predominantly in addition to, rather than a replacement for, conventional care. It is important that health professionals are aware of potential multiple practitioner usage in the context of back pain and are prepared to discuss such behaviours and practices with their patients.

Segmental measurement of breast cancer-related arm lymphoedema using perometry and bioimpedance spectroscopy.

PURPOSE: To determine if bioimpedance spectroscopy (BIS) could detect localised lymphoedema of the arm and to compare BIS measurements with equivalent measures of limb volume by perometry. METHODS: Women with mild to severe upper limb lymphoedema (n = 29) and women with no history of lymphoedema (n = 11) participated. Commencing at the ulnar styloid of the wrist, 4 × 10 cm segment measurements were made of each arm using both BIS and perometry. RESULTS: Average BIS inter-limb ratios for the total arm and each arm segment were higher than comparable perometry measures in women with lymphoedema, but similar to perometry measures for women without lymphoedema. Limits of agreement analysis showed that the mean difference between methods varied according to segment measured, ranging from 8.5% for the uppermost segment of the arm to 16.6% for the forearm segment just below the elbow. For all limb segments, there was a positive bias towards BIS measurements, which increased as lymphoedema severity increased. CONCLUSION: BIS can be used for localised measurement of lymphoedema. Because it is specific to extracellular fluid, BIS is more sensitive to localised lymphoedema than perometry.