Risk factors for pelvic girdle pain postpartum and pregnancy related low back pain postpartum; a systematic review and meta-analysis.

BACKGROUND: Although pelvic girdle pain postpartum and pregnancy related low back pain postpartum (combined and named PGPP in this study) have a natural favourable course, there is a subgroup of women who have persistent complaints. The objective of this study was to identify personal-, (pre)pregnancy-, obstetric-, and child related risk factors on PGPP by means of a systematic literature review and meta-analysis. METHODS: Literature searches of PubMed, EMBASE, CINAHL and Cochrane up to October 2018 were conducted. Prospective cohort studies in English or Dutch describing three or more risk factors for PGPP were included. We assessed articles for inclusion and risk of bias. Studies with high risk of bias were excluded from data extraction. Data was extracted and checked for accuracy confirming to the CHARMS-checklist. Homogeneous variables were pooled. RESULTS: Twelve full text studies were assessed. Seven studies were excluded due to high risk of bias. Data was extracted from five studies. Multivariate analysis was not possible due to heterogeneity in included risk factors as well as outcome measures on risk factor per study. Pooled univariate significant risk factors on PGPP were: a history of low back pain, pre-pregnancy body mass index >25, pelvic girdle pain in pregnancy, depression in pregnancy, and a heavy workload in pregnancy. No significant obstetric and child related risk factors were reported. CONCLUSIONS: Risk factors on PGPP have been identified. Since multivariate analysis was not possible the outcome should be treated with care, because interaction between risk factors could not be analysed.

Cognitive behavioral therapy or graded exercise therapy compared with usual care for severe fatigue in patients with advanced cancer during treatment: a randomized controlled trial.

BACKGROUND: Cancer-related fatigue remains a prevalent and burdensome symptom experienced by patients with advanced cancer. Our aim was to assess the effects of cognitive behavioral therapy (CBT) or graded exercise therapy (GET) on fatigue in patients with advanced cancer during treatment with palliative intent. PATIENTS AND METHODS: A randomized controlled trial was conducted from 1 January 2013 to 1 September 2017. Adult patients with locally advanced or metastatic cancer who reported severe fatigue during treatment [Checklist Individual Strength, subscale fatigue severity (CIS-fatigue) ≥35] were accrued across nine centers in The Netherlands. Patients were randomly assigned to either 12 weeks of CBT or GET, or usual care (1 : 1: 1, computer-generated sequence). Primary outcome was CIS-fatigue at 14 weeks. Secondary outcomes included fatigue measured with the European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC-QLQ-C30), quality of life, emotional functioning, physical functioning, and functional impairments at baseline, 14, 18, and 26 weeks. RESULTS: Among 134 participants randomized, the mean age was 63 (standard deviation 9) years and 77 (57%) were women. Common diagnoses included: breast (41%), colorectal (28%), and prostate cancer (17%). A total of 126 participants completed assessment at 14 weeks. Compared with usual care, CBT significantly reduced fatigue [difference -7.2, 97.5% confidence interval (CI) -12.7 to -1.7; P = 0.003, d = 0.7], whereas GET did not (-4.7, 97.5% CI -10.2 to 0.9; P = 0.057, d = 0.4). CBT significantly reduced EORTC-QLQ-C30 fatigue (-13.1, 95% CI -22.1 to -4.0; P = 0.005) and improved quality of life (10.2, 95% CI 2.4 to 17.9; P = 0.011) and physical functioning (7.1, 95% CI 0.5 to 13.7; P = 0.036) compared with usual care. Improvement in emotional functioning and decrease in functional impairments failed to reach significance. GET did not improve secondary outcomes compared with usual care. CONCLUSIONS: Among advanced cancer patients with severe fatigue during treatment, a CBT intervention was more effective than usual care for reducing fatigue. Following GET, patients reported lower fatigue, but results were not significant, probably due to a smaller sample size and lower adherence than anticipated. TRIAL REGISTRATION: Netherlands National Trial Register, identifier: NTR3812.

Development of a standard set of outcome measures for non-specific low back pain in Dutch primary care physiotherapy practices: a Delphi study.

PURPOSE: To develop a clinical standard set of outcome measures that are accepted for relevance and feasibility by stakeholders and useful for (a) interaction between patient and the professional, e.g. shared decision-making in goal-setting, monitoring and feedback based on outcomes, (b) internal quality improvement, and (c) external transparency in patients with non-specific low back pain (NSLBP) in primary care physical therapy. METHODS: We used a consensus-driven modified RAND-UCLA Delphi method in seven steps with panellists (patients, representatives of patient and physiotherapy associations, researchers, policy makers, health insurers): (1) literature search, (2) first online survey, (3) patient interviews, (4) an experts meeting, (5) a consensus meeting, (6) second online survey, and (7) final approval of an advisory board. Steps 1-4 resulted in potential outcome measures. In the consensus meeting after discussion panellists voted for inclusion per measure. In the second online survey the final standard set was rated on relevance and feasibility on a 9-point Likert scale; when the median score was ≥ 7, the standard set was accepted and finally approved. RESULTS: Thirteen draft outcome measures were rated and discussed, and finally, six outcome measures were accepted. The standard set includes the Quebec Back Pain Disability Scale, Oswestry Disability Index, Patient-Specific Functional Scale, Numeric Pain Rating Scale, Global Perceived Effect (GPE-DV), and the STarT Back Screening Tool (SBT). CONCLUSION: This study presents a standard set of outcome measures for patients with NSLBP in primary care physiotherapy accepted for relevance and feasibility by stakeholders. The standard set is currently used in daily practice and tested on validity and reliability in a pilot study. These slides can be retrieved under Electronic Supplementary Material.

Explicit and implicit motor sequence learning in children and adults; the role of age and visual working memory.

This study investigated explicit and implicit motor learning, and the influence of visual working memory (VWM) and age. Sixty children and 28 adults learned a nine-button sequence task explicitly and implicitly. Performance in explicit and implicit learning improved with age. Learning curves were similar across ages for implicit learning. In explicit learning, learning curves differed across ages: younger children started slower, but their learning rate was higher compared to older children. Learning curves were similar across VWM scores, but performance in explicit learning was positively influenced by VWM scores. Further research and implications for education and rehabilitation are discussed.

qLessons learned from patients with access to an online self-management enhancing program for RA patients: Qualitative analysis of interviews alongside a randomized clinical trial.

OBJECTIVE: This study aims to explain the earlier findings of a Randomized Controlled Trial (RCT), which showed that rheumatoid arthritis (RA) patients did not benefit from an online self-management program. Moreover, less patients than expected used the program. METHODS: As part of an explorative RCT, patients were interviewed to explore their (non) usage of the program. Purposive sampling (n = 21) was used to select patients from four groups of patients (n = 49): 1) non-users; 2) low users; 3) high users basic; 4) high users plus. RESULTS: The program supported only a small group of patients because: 1) not all patients were motivated to use the program, 2) patients had no clear expectation or had differing expectations of the program, 3) there was a mismatch between individual patients' support needs and the needs included in the program, 4) reminders were only sent to fill in the diaries for pain and fatigue, not to use the program modules. CONCLUSION: This study offers insights in the (non-) usage of online programs and how usage could be increased in practice. PRACTICAL IMPLICATIONS: Health professionals should be involved in the implementation of this online programs and should inform patients what the program could bring them.

Fatigue affects quality of movement more in ACL-reconstructed soccer players than in healthy soccer players.

PURPOSE: Athletes who meet return to play (RTP) criteria after anterior cruciate ligament reconstruction (ACLR) rehabilitation still have a substantially increased risk of second ACL injury. One of the contributing factors to this increased risk could be that the RTP criteria are often not tested in an ecologically valid environment and in a fatigued state. The purpose of this cross-sectional case-control study was to investigate the influence of neuromuscular fatigue on both movement quantity and quality in fully-rehabilitated soccer players after ACLR and to compare them with healthy soccer players. METHODS: ACL-reconstructed soccer players (n = 14) and healthy soccer players (n = 19) participated in the study and were matched by playing level and training hours. RTP measurements were performed on the soccer field, in both a non-fatigued and fatigued state. The RTP measurements focussed on both movement quantity (hop tests) and quality [countermovement jump with a Landing Error Scoring System (LESS) score]. RESULTS: Movement quantity did not differ between ACL-reconstructed and healthy soccer players, both expressed in absolute values and the LSI-D/ND (calculated as dominant/non-dominant*100%). However, movement quality decreased more in the ACL-reconstructed soccer players in the fatigued state compared to the non-fatigued state. CONCLUSIONS: Ideally, RTP measurements should focus on movement quality and should be conducted on the soccer field in a fatigued state, creating an ecologically valid environment. The LSI-D/ND can be used as an outcome parameter for RTP measurements of movement quantity and should be at least 95%. LEVEL OF EVIDENCE: Therapeutic, Level III.

Learning New Letter-like Writing Patterns Explicitly and Implicitly in Children and Adults.

A handwriting task was used to test the assumption that explicit learning is dependent on age and working memory, while implicit learning is not. The effect of age was examined by testing both, typically developing children (5-12 years old, n = 81) and adults (n = 27) in a counterbalanced within-subjects design. Participants were asked to repeatedly write letter-like patterns on a digitizer with a non-inking pen. Reproduction of the pattern was better after explicit learning compared to implicit learning. Age had positive effects on both explicit and implicit learning; working memory did not affect learning in either conditions. These results show that it may be more effective to learn writing new letter-like patterns explicitly and that an explicit teaching method is preferred in mainstream primary education.

Social participation of people with cognitive problems and their caregivers: a feasibility evaluation of the Social Fitness Programme.

OBJECTIVE: We developed a tailor-made intervention aimed at improving social participation of people with cognitive problems and their caregivers. This programme consists of an integration of healthcare and welfare interventions: occupational therapy, physiotherapy and guidance by a welfare professional. This article describes the feasibility evaluation of this Social Fitness Programme. METHODS: Feasibility in terms of acceptability, demand, implementation, practicability and limited efficacy was evaluated based on experiences from professionals (programme deliverers), people with cognitive problems and their caregivers (programme recipients). We used qualitative research methods (focus group discussions, interviews, collection of treatment records) and applied thematic analyses. RESULTS: The intervention was feasible according to stakeholders, and limited efficacy showed promising results. However, we found feasibility barriers. First, an acceptability barrier: discussing declined social participation was difficult, hindering recruitment. Second, a demand barrier: some people with cognitive problems lacked motivation to improve declined social participation, sometimes in contrast to their caregivers' wishes. Third, implementation and practicability barriers: shared decision-making, focusing the intervention and interdisciplinary collaboration between healthcare and welfare professionals were suboptimal during implementation. DISCUSSION: Although this intervention builds upon scientific evidence, expert opinions and stakeholder needs, implementation was challenging. Healthcare and welfare professionals need to overcome obstacles in their collaboration and focus on integrated intervention delivery. Also, they need to find ways to (empower caregivers to) motivate people with cognitive problems to participate socially. After modifying the intervention and additional training of professionals, a consecutive pilot study to assess feasibility of the research design and outcome measures is justified. Copyright © 2017 John Wiley & Sons, Ltd.

Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice.

The purpose of this retrospective cohort study was to (a) describe the clinical presentation of femoroacetabular impingement (FAI) and hip labral pathology; (b) describe the accuracy of patient history and physical tests for FAI and labral pathology as confirmed by hip arthroscopy. Patients (18-65 years) were included if they were referred to a physical therapist to gather pre-operative data and were then diagnosed during arthroscopy. Results of pre-operative patient history and physical tests were collected and compared to arthroscopy. Data of 77 active patients (mean age: 37 years) were included. Groin as main location of pain, the Anterior Impingement test (AIT), Flexion-Abduction-External Rotation (FABER) test, and Fitzgerald test had a high sensitivity (range 0.72-0.91). Sensitivity increased when combining these tests (0.97) as either groin as main location of pain and a positive FABER test or a positive AIT and a positive FABER test were the shortest most sensitive combinations. The results of this study point out that in clinical practice absence of groin as main location of pain combined with a negative FABER test or the combination of a negative AIT and a negative FABER test are suggested to rule out the diagnosis of symptomatic FAI and/or labral pathology.

Can mastication in children with cerebral palsy be analyzed by clinical observation, dynamic ultrasound and 3D kinematics?

The aim of this study was to explore the feasibility of the Mastication Observation and Evaluation (MOE) instrument, dynamic ultrasound and 3D kinematic measurements to describe mastication in children with spastic cerebral palsy and typically developing children. Masticatory movements during five trials of eating a biscuit were assessed in 8 children with cerebral palsy, spastic type (mean age 9.08years) and 14 typically developing children (mean age 9.01years). Differences between trials were tested (t-test) and the mastication of individual children with cerebral palsy was analyzed. MOE scores ranged from 17 to 31 (median 24) for the children with cerebral palsy and from 28 to 32 (median 31) for the typically developing children. There was an increased chewing cycle duration, a smaller left-right and up-down tongue displacement and larger anterior mandible movements for the trials (n=40) of cerebral palsy children (p<0.000 for all comparisons) compared to the trials of typically developing children (n=70). The MOE captures differences in mastication between individual children with cerebral palsy. The MOE items 'jaw movement' and 'fluency and coordination' showed the most similarity with the objective measurements. Objective measurements of dynamic ultrasound and 3D kinematics complemented data from the MOE instrument.

Development of an Age Band on the ManuVis for 3-Year-Old Children with Visual Impairments.

AIM: To compare fine motor performance of 3-year-old children with visual impairment with peers having normal vision, to provide reference scores for 3-year-old children with visual impairment on the ManuVis, and to assess inter-rater reliability. METHOD: 26 children with visual impairment (mean age: 3 years 7 months (SD 3 months); 17 boys) and 28 children with normal vision (mean age: 3 years 7 months (SD 4 months); 14 boys) participated in the study. The ManuVis age band for 3-year-old children comprised two one-handed tasks, two two-handed tasks, and a pre-writing task. RESULTS: Children with visual impairment needed more time on all tasks (p < .01) and performed the pre-writing task less accurately than children with normal vision (p < .001). Children aged 42-47 months performed significantly faster on two tasks and had better total scores than children aged 36-41 months (p < .05). Inter-rater reliability was excellent (Intra-class Correlation Coefficient = 0.96-0.99). CONCLUSIONS: The ManuVis age band for 3-year-old children is appropriate to assess fine motor skills, and is sensitive to differences between children with visual impairment and normal vision and between half-year age groups. Reference scores are provided for 3-year-old children with visual impairment to identify delayed fine motor development.

How Well Do Randomized Controlled Trials Reflect Standard Care: A Comparison between Scientific Research Data and Standard Care Data in Patients with Intermittent Claudication undergoing Supervised Exercise Therapy.

OBJECTIVE: The aim of the present study was to assess the degree and impact of patient selection of patients with intermittent claudication undergoing supervised exercise therapy in Randomized Controlled Trials (RCTs) by describing commonly used exclusion criteria, and by comparing baseline characteristics and treatment response measured as improvement in maximum walking distance of patients included in RCTs and patients treated in standard care. METHODS: We compared data from RCTs with unselected standard care data. First, we systematically reviewed RCTs that investigated the effect of supervised exercise therapy in patients with intermittent claudication. For each of the RCTs, we extracted and categorized the eligibility criteria and their justifications. To assess whether people in RCTs (n = 1,440) differed from patients treated in daily practice (n = 3,513), in terms of demographics, comorbidity and walking capacity, we assessed between group-differences using t-tests. To assess differences in treatment response, we compared walking distances at three and six months between groups using t-tests. Differences of ≥15% were set as a marker for a clinically relevant difference. RESULTS: All 20 included RCTs excluded large segments of patients with intermittent claudication. One-third of the RCTs eligibility criteria were justified. Despite, the numerous eligibility criteria, we found that baseline characteristics were largely comparable. A statistically significant and (borderline) clinically relevant difference in treatment response after three and six months between trial participants and standard care patients was found. Improvements in maximum walking distance after three and six months were significantly and clinically less in trial participants. CONCLUSIONS: The finding that baseline characteristics of patients included in RCTs and patients treated in standard care were comparable, may indicate that RCT eligibility criteria are used implicitly by professionals when referring patients to standard physiotherapy care. The larger treatment response reported in standard physiotherapy care compared to clinical trials, might suggest that scientific studies underestimate the benefits of supervised exercise therapy in patients with intermittent claudication.

Physical therapy aimed at self-management versus usual care physical therapy after hip arthroscopy for femoroacetabular impingement: study protocol for a randomized controlled trial.

BACKGROUND: Femoroacetabular impingement has been recognized as a common cause of hip pain and dysfunction, especially in athletes. Femoroacetabular impingement can now be better treated by hip arthroscopy but it is unclear what postoperative rehabilitation of hip arthroscopy should look like. Several rehabilitation protocols have been described, but none presented clinical outcome data. These protocols also differ in frequency, duration and level of supervision. We developed a rehabilitation protocol with supervised physical therapy which showed good clinical results and is considered usual care in our treatment center. However, it is unknown whether, due to the relatively young age and low complication rate of hip arthroscopy patients, rehabilitation based on self-management might lead to similar results. The aims of this pilot study are (1) to determine feasibility and acceptability of the self-management intervention, (2) to obtain a preliminary estimate of the difference in effect between physical therapy aimed at self-management versus usual care physical therapy in patients who undergo hip arthroscopy for femoroacetabular impingement. METHODS/DESIGN: Thirty participants (aged 18-50 years) scheduled for hip arthroscopy will be included and randomized (after surgery) to either self-management or usual care physical therapy in this assessor-blinded randomized controlled trial. After surgery, the self-management group will perform a home-based exercise program three times a week and will receive physical therapy treatment once every 2 weeks for 14 weeks. The usual care group will receive physical therapy treatment twice a week for 14 weeks and will perform an additional home-based exercise program once a week. Assessment will occur preoperatively and at 6, 14, 26 and 52 weeks after surgery. Primary outcomes are feasibility, acceptability and preliminary effectiveness. Feasibility and acceptability will be determined by the willingness to enroll, recruitment rate, adherence to treatment, patient satisfaction, drop-out rate and adverse events. Preliminary effectiveness will be determined using the following outcomes: the International Hip Outcome Tool 33 and hip functional performance as measured with the Single Leg Squat Test 14 weeks after surgery. DISCUSSION: The results of this study will be used to help decide on the need, feasibility and acceptability of a large-scale randomized controlled trial. TRIAL REGISTRATION: This protocol was registered with the Dutch Trial Registry (NTR5168) on 8 May 2015.

Assessment of mastication in healthy children and children with cerebral palsy: a validity and consistency study.

The aim of this study was to develop the Mastication Observation and Evaluation instrument for observing and assessing the chewing ability of children eating solid and lumpy foods. This study describes the process of item definition and item selection and reports the content validity, reproducibility and consistency of the instrument. In the developmental phase, 15 experienced speech therapists assessed item relevance and descriptions over three Delphi rounds. Potential items were selected based on the results from a literature review. At the initial Delphi round, 17 potential items were included. After three Delphi rounds, 14 items that regarded as providing distinctive value in assessment of mastication (consensus >75%) were included in the Mastication Observation and Evaluation instrument. To test item reproducibility and consistency, two experts and five students evaluated video recordings of 20 children (10 children with cerebral palsy aged 29-65 months and 10 healthy children aged 11-42 months) eating bread and a biscuit. Reproducibility was estimated by means of the intraclass correlation coefficient (ICC). With the exception of one item concerning chewing duration, all items showed good to excellent intra-observer agreement (ICC students: 0.73-1.0). With the exception of chewing duration and number of swallows, inter-observer agreement was fair to excellent for all items (ICC experts: 0.68-1.0 and ICC students: 0.42-1.0). Results indicate that this tool is a feasible instrument and could be used in clinical practice after further research is completed on the reliability of the tool.

Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis.

This is the first meta-analysis focusing on elderly patients with mobility problems, physical disability and/or multi-morbidity. The aim of this study is to assess the effect of physical exercise therapy on mobility, physical functioning, physical activity and quality of life. A broad systematic literature search was performed in the databases PubMed, CINAHL, Embase, PEDro and The Cochrane Library. Relevant study characteristics were reviewed and meta-analyses using standardized mean differences (SMDs) were performed. The results show that physical exercise therapy has a positive effect on mobility (SMD final value: 0.18; 95% CI: 0.05, 0.30; SMD change value: 0.82; 95% CI: 0.54, 1.10) and physical functioning (SMD final value: 0.27; 95% CI: 0.08, 0.46; SMD change value: 2.93; 95% CI: 2.50, 3.36). High-intensity exercise interventions seem to be somewhat more effective in improving physical functioning than low-intensity exercise interventions (SMD final value: 0.22; 95% CI: -0.17, 0.62; SMD change value: 0.38; 95% CI: -0.48, 1.25). These positive effects are of great value for older adults who are already physically impaired. The effect on physical activity and quality of life was not evident and no definite conclusions on the most effective type of physical exercise therapy intervention can be drawn.

Improvement of fine motor skills in children with visual impairment: an explorative study.

In this study we analysed the potential spin-off of magnifier training on the fine-motor skills of visually impaired children. The fine-motor skills of 4- and 5-year-old visually impaired children were assessed using the manual skills test for children (6-12 years) with a visual impairment (ManuVis) and movement assessment for children (Movement ABC), before and after receiving a 12-sessions training within a 6-weeks period. The training was designed to practice the use of a stand magnifier, as part of a larger research project on low-vision aids. In this study, fifteen children trained with a magnifier; seven without. Sixteen children had nystagmus. In this group head orientation (ocular torticollis) was monitored. Results showed an age-related progress in children's fine-motor skills after the training, irrespective of magnifier condition: performance speed of the ManuVis items went from 333.4s to 273.6s on average. Accuracy in the writing tasks also increased. Finally, for the children with nystagmus, an increase of ocular torticollis was found. These results suggest a careful reconsideration of which intervention is most effective for enhancing perceptuomotor performance in visually impaired children: specific 'fine-motor' training or 'non-specific' visual-attention training with a magnifier.

Exercise training improves physical fitness and vascular function in children with type 1 diabetes.

Children with type 1 diabetes mellitus (DM1) show endothelial dysfunction and mild artery wall thickening compared to their age-matched healthy peers. In this study, we examined the effect of 18-week exercise training on physical fitness and vascular function and structure in children with DM1. We examined physical fitness, brachial artery endothelial function [flow-mediated dilation (FMD)], common carotid artery diameter, wall thickness and wall-to-lumen ratio before and after 18-week exercise training in children with DM1 (n = 7). Physical fitness, measured as maximal oxygen consumption, improved after training (p = 0.039). Brachial artery FMD improved from 7.5 ± 4.2 to 12.4 ± 5.2 (p = 0.038). Carotid artery diameter, wall thickness and wall-to-lumen ratio did not change significantly (p = 0.26, 0.53 and 0.27, respectively). We showed that exercise training in children with DM1 effectively reverses endothelial dysfunction and improves physical fitness. These data emphasize the important role for physical activity in the management of DM1.

Outcome instruments to measure frailty: a systematic review.

Frailty is one of the greatest challenges for healthcare professionals. The level of frailty depends on several interrelated factors and can change over time while different interventions seem to be able to influence the level of frailty. Therefore, an outcome instrument to measure frailty with sound clinimetric properties is needed. A systematic review on evaluative measures of frailty was performed in the databases PubMed, EMBASE, Cinahl and Cochrane. The results show numerous instruments that measure the level of frailty. This article gives a clear overview of the content of these frailty instruments and describes their clinimetric properties. Frailty instruments, however, are often developed as prognostic instruments and have also been validated as such. The clinimetric properties of these instruments as evaluative outcome measures are unclear.

Successful use of albuterol in a patient with central core disease and mitochondrial dysfunction.

Albuterol, a selective beta-adrenergic agonist, has been used experimentally in combination with exercise therapy in a few inherited neuromuscular disorders to increase muscle strength and muscle volume . We report on a 9-year-old boy with central core disease and mitochondrial dysfunction due to compound heterozygous RYR1 mutations receiving albuterol treatment for 1 year. Throughout the period of albuterol administration, the patient underwent an aerobic exercise regime of training sessions three times a week that lasted 20 min each. No side effects of albuterol use were seen. Significant clinical progress, including self care, sitting up, raising arms above the shoulders, independent feeding, and better speech and writing were observed compared with minimal development of these abilities in the previous years on physiotherapy. Improved forced expiratory volume in 1 s (FEV1) score was detected and increased muscle strength was noted: progress was measured using various functional tests and assessment scales. The only complication observed was a mild progression of the joint contractures, possibly due to an unbalance between the flexor and extensor musculature. In general, in this pilot study in a complex case of metabolic myopathy our patient has shown promising results following albuterol treatment and aerobic exercise therapy.

Participation and risk-taking behaviour in sports in children with haemophilia.

The aim of this study was to investigate participation in sports activities and risk-taking behaviour in children with haemophilia and the relationship to personal and health related factors. Ninety-nine children (mean age 12.6 years) completed questionnaires regarding participation in sports and physical education, medication, health related quality of life, and perceived motor competence. Furthermore, weight, height, active range of motion, pain, and muscle strength were assessed. Based on a risk exposure factor (REF) we defined subgroups with low, medium, and high risk when participating in sport. Most children participate in sport five times a week (mean 140 min per week), and little absence during school sports was reported. In general, prophylaxis was not tailored to sport activities. Boys with haemophilia preferred other sports than their Dutch contemporaries. The top-5 being soccer, swimming, tennis, gymnastics, and cardio-fitness for the former; soccer, gymnastics, tennis, hockey, and swimming for the latter. Significant differences between the low risk group and both other groups were found for sport intensity, total energy expenditure (EE) and average risk factor (ARF), however the medium and high-risk groups did not differ in ARF. REF and sport participation increased associated with increasing interest in athletic and motor activities. No significant differences were found between REF groups regarding age, Z-BMI, Z-AROM, Z-Muscle force, and the presence of painful joints. As in normal peers motivation to participate in sport depends upon the enthusiasm and interest, in children with haemophilia choice of sports differs, probably related to sport advice.