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1.  A systematic review of musculoskeletal disorders among school teachers 
Background
Musculoskeletal disorders (MSD) represent one of the most common and most expensive occupational health problems in both developed and developing countries. School teachers represent an occupational group among which there appears to be a high prevalence of MSD. Given that causes of MSD have been described as multi-factorial and prevalence rates vary between body sites and location of study, the objective of this systematic review was to investigate the prevalence and risk factors for MSD among teaching staff.
Methods
The study involved an extensive search of MEDLINE and EMBASE databases in 2011. All studies which reported on the prevalence and/or risk factors for MSD in the teaching profession were initially selected for inclusion. Reference lists of articles identified in the original search were then examined for additional publications. Of the 80 articles initially located, a final group of 33 met the inclusion criteria and were examined in detail.
Results
This review suggests that the prevalence of self-reported MSD among school teachers ranges between 39% and 95%. The most prevalent body sites appear to be the back, neck and upper limbs. Nursery school teachers appear to be more likely to report suffering from low back pain. Factors such as gender, age, length of employment and awkward posture have been associated with higher MSD prevalence rates.
Conclusion
Overall, this study suggests that school teachers are at a high risk of MSD. Further research, preferably longitudinal, is required to more thoroughly investigate the issue of MSD among teachers, with a greater emphasis on the possible wider use of ergonomic principles. This would represent a major step forward in the prevention of MSD among teachers, especially if easy to implement control measures could be recommended.
doi:10.1186/1471-2474-12-260
PMCID: PMC3250950  PMID: 22087739
2.  Work-life conflict and musculoskeletal disorders: a cross-sectional study of an unexplored association 
Background
The health consequences of work-family or rather work-life conflict (WLC) have been studied by numerous researchers. The work-related causes of musculoskeletal disorders (MSD) are also well explored. And stress (at work) has been found to be a consequence of WLC as well as a cause of MSD. But very little is known about a potential association between WLC and MSD and the possible mediating role of stress in this relationship.
Methods
Survey data collected in 2007 among the workforces of four large companies in Switzerland were used for this study. The study population covered 6091 employees. As the exposure variable and hypothesized risk factor for MSD, WLC was measured by using a 10-item scale based on an established 18-item scale on work-family conflict. The outcome variables used as indicators of MSD were (low) back pain and neck/shoulder pain. Stress as the assumed intervening variable was assessed by a validated single-item measure of general stress perception. Correlation coefficients (r), standardized regression coefficients (β) and multiple adjusted odds ratios (OR) were calculated as measures of association.
Results
WLC was found to be quite strongly associated with MSD (β = .21). This association turned out to be substantially confounded by physical strain at work, workload and job autonomy and was considerably reduced but far from being completely eliminated after adjusting for general stress as another identified risk factor of MSD and a proven strong correlate of WLC (r = .44). A significant and relevant association still remained (β = .10) after having controlled for all considered covariates. This association could be fully attributed to only one direction of WLC, namely the work-to-life conflict. In subsequent analyses, a clear gradient between this WLC direction and both types of MSD was found, and proved to be consistent for both men and women. Employees who were most exposed to such work-to-life conflict were also most at risk and showed a fivefold higher prevalence rate (19%-42%) and also an up to sixfold increased relative risk (OR = 3.8-6.3) of suffering greatly from these types of MSD compared with the least exposed reference group showing very low WLC in this direction. Including stress in the regression models again reduced the strength of the association significantly (OR = 1.9-4.1), giving an indication for a possible indirect effect of WLC on MSD mediated by stress.
Conclusion
Future research and workplace interventions for the prevention of MSD need to consider WLC as an important stressor, and the MSD risk factor identified in this study.
doi:10.1186/1471-2474-12-60
PMCID: PMC3073966  PMID: 21410950
3.  Gender differences in disability after sickness absence with musculoskeletal disorders: five-year prospective study of 37,942 women and 26,307 men 
Background
Gender differences in the prevalence and occupational consequences of musculoskeletal disorders (MSDs) are consistently found in epidemiological studies. The study investigated whether gender differences also exist with respect to chronicity, measured as the rate of transition from sickness absence into permanent disability pension (DP).
Methods
Prospective national cohort study in Norway including all cases with a spell of sickness absence > eight weeks during 1997 certified with a MSD, 37,942 women and 26,307 men. The cohort was followed-up for five years with chronicity measured as granting of DP as the endpoint. The effect of gender was estimated in the full sample adjusting for sociodemographic factors and diagnostic distribution. Gender specific analyses were performed with the same explanatory variables. Finally, the gender difference was estimated for nine diagnostic subgroups.
Results
The crude rate of DP was 22% for women and 18% for men. After adjusting for all sociodemographic variables, a slightly higher female risk of DP remained. However, additional adjustment for diagnostic distribution removed the gender difference completely. Having children and working full time decreased the DP risk for both genders, whereas low socioeconomic status increased the risk similarly. There was a different age effect as more women obtained a DP below the age of 50. Increased female risk of chronicity remained for myalgia/fibromyalgia, back disorders and "other/unspecified" after relevant adjustments, whereas men with neck disorders were at higher risk of chronicity.
Conclusions
Women with MSDs had a moderately increased risk of chronicity compared to men, when including MSDs with a traumatic background. Possible explanations are lower income, a higher proportion belonging to diagnostic subgroups with poor prognosis, and a younger age of chronicity among women. When all sociodemographic and diagnostic variables were adjusted for, no gender difference remained, except for some diagnostic subgroups.
doi:10.1186/1471-2474-12-37
PMCID: PMC3046931  PMID: 21299856
4.  Work related musculoskeletal disorders amongst therapists in physically demanding roles: qualitative analysis of risk factors and strategies for prevention 
Background
Physiotherapy and occupational therapy are two professions at high risk of work related musculoskeletal disorders (WRMD). This investigation aimed to identify risk factors for WRMD as perceived by the health professionals working in these roles (Aim 1), as well as current and future strategies they perceive will allow them to continue to work in physically demanding clinical roles (Aim 2).
Methods
A two phase exploratory investigation was undertaken. The first phase included a survey administered via a web based platform with qualitative open response items. The second phase involved four focus group sessions which explored topics obtained from the survey. Thematic analysis of qualitative data from the survey and focus groups was undertaken.
Results
Overall 112 (34.3%) of invited health professionals completed the survey; 66 (58.9%) were physiotherapists and 46 (41.1%) were occupational therapists. Twenty-four health professionals participated in one of four focus groups. The risk factors most frequently perceived by health professionals included: work postures and movements, lifting or carrying, patient related factors and repetitive tasks. The six primary themes for strategies to allow therapists to continue to work in physically demanding clinical roles included: organisational strategies, workload or work allocation, work practices, work environment and equipment, physical condition and capacity, and education and training.
Conclusions
Risk factors as well as current and potential strategies for reducing WRMD amongst these health professionals working in clinically demanding roles have been identified and discussed. Further investigation regarding the relative effectiveness of these strategies is warranted.
doi:10.1186/1471-2474-12-24
PMCID: PMC3038991  PMID: 21266039
5.  Who seeks primary care for musculoskeletal disorders (MSDs) with physicians prescribing homeopathic and other complementary medicine? Results from the EPI3-LASER survey in France 
Background
There is a paucity of information describing patients with musculoskeletal disorders (MSDs) using complementary and alternative medicines (CAMs) and almost none distinguishing homeopathy from other CAMs. The objective of this study was to describe and compare patients with MSDs who consulted primary care physicians, either certified homeopaths (Ho) or regular prescribers of CAMs in a mixed practice (Mx), to those consulting physicians who strictly practice conventional medicine (CM), with regard to the severity of their MSD expressed as chronicity, co-morbidity and quality of life (QOL).
Methods
The EPI3-LASER study was a nationwide observational survey of a representative sample of general practitioners and their patients in France. The sampling strategy ensured a sufficient number of GPs in each of the three groups to allow comparison of their patients. Patients completed a questionnaire on socio-demographics, lifestyle and QOL using the Short Form 12 (SF-12) questionnaire. Chronicity of MSDs was defined as more than twelve weeks duration of the current episode. Diagnoses and co-morbidities were recorded by the physician.
Results
A total of 825 GPs included 1,692 MSD patients (predominantly back pain and osteoarthritis) were included, 21.6% in the CM group, 32.4% Ho and 45.9% Mx. Patients in the Ho group had more often a chronic MSD (62.1%) than the CM (48.6%) or Mx (50.3%) groups, a result that was statistically significant after controlling for patients' characteristics (Odds ratio = 1.43; 95% confidence interval (CI): 1.07 - 1.89). Patients seen by homeopaths or mixed practice physicians who were not the regular treating physician, had more often a chronic MSD than those seen in conventional medicine (Odds ratios were1.75; 95% CI: 1.22 - 2.50 and 1.48; 95% CI: 1.06 - 2.12, respectively). Otherwise patients in the three groups did not differ for co-morbidities and QOL.
Conclusion
MSD patients consulting primary care physicians who prescribed homeopathy and CAMs differed from those seen in conventional medicine. Chronic MSD patients represented a greater proportion of the clientele in physicians offering alternatives to conventional medicine. In addition, these physicians treated chronic patients as consulting rather than regular treating physicians, with potentially important impacts upon professional health care practices and organisation.
doi:10.1186/1471-2474-12-21
PMCID: PMC3034723  PMID: 21247493
6.  Aging enhances serum cytokine response but not task-induced grip strength declines in a rat model of work-related musculoskeletal disorders 
Background
We previously reported early tissue injury, increased serum and tissue inflammatory cytokines and decreased grip in young rats performing a moderate demand repetitive task. The tissue cytokine response was transient, the serum response and decreased grip were still evident by 8 weeks. Thus, here, we examined their levels at 12 weeks in young rats. Since aging is known to enhance serum cytokine levels, we also examined aged rats.
Methods
Aged and young rats, 14 mo and 2.5 mo of age at onset, respectfully, were trained 15 min/day for 4 weeks, and then performed a high repetition, low force (HRLF) reaching and grasping task for 2 hours/day, for 12 weeks. Serum was assayed for 6 cytokines: IL-1alpha, IL-6, IFN-gamma, TNF-alpha, MIP2, IL-10. Grip strength was assayed, since we have previously shown an inverse correlation between grip strength and serum inflammatory cytokines. Results were compared to naïve (grip), and normal, food-restricted and trained-only controls.
Results
Serum cytokines were higher overall in aged than young rats, with increases in IL-1alpha, IFN-gamma and IL-6 in aged Trained and 12-week HRLF rats, compared to young Trained and HRLF rats (p < 0.05 and p < 0.001, respectively, each). IL-6 was also increased in aged 12-week HRLF versus aged normal controls (p < 0.05). Serum IFN-gamma and MIP2 levels were also increased in young 6-week HRLF rats, but no cytokines were above baseline levels in young 12-week HRLF rats. Grip strength declined in both young and aged 12-week HRLF rats, compared to naïve and normal controls (p < 0.05 each), but these declines correlated only with IL-6 levels in aged rats (r = -0.39).
Conclusion
Aging enhanced a serum cytokine response in general, a response that was even greater with repetitive task performance. Grip strength was adversely affected by task performance in both age groups, but was apparently influenced by factors other than serum cytokine levels in young rats.
doi:10.1186/1471-2474-12-63
PMCID: PMC3072947  PMID: 21447183
7.  Prevalence and consequences of musculoskeletal symptoms in symphony orchestra musicians vary by gender: a cross-sectional study 
Background
Musculoskeletal symptoms are common in the neck, back, and upper limbs amongst musicians. Playing-related musculoskeletal disorders have been found to range from 32% to 87% with a tendency for female musicians to have more problems than males. Studies of musculoskeletal problems in instrumentalists have generally involved pre-professional musicians or populations comprising musicians of different levels. The objective of this study was therefore to investigate the prevalence, duration and consequences of musculoskeletal symptoms in professional symphony orchestra musicians.
Methods
A cross-sectional questionnaire study. The study population comprised of 441 musicians from six Danish symphony orchestras; 342 (78%) completed the questionnaire.
Results
During the last year 97% of the women and 83% of the men experienced symptoms in at least one of nine anatomic regions (neck, upper and lower back, shoulders, elbows, and hands and wrists). 86% of the women and 67% of the men experienced symptoms for more than seven days, while 63% of the women and 49% of the men had symptoms for more than 30 days. Woodwind players had a lower risk for musculoskeletal symptoms and a lower risk for the consequences. Among consequences were changed way of playing, reported by 73% of the musicians, difficulty in daily activities at home, reported by 55%, and difficulty in sleeping, reported by 49%. Their health behaviour included taking paracetamol as the most used analgesic, while physiotherapists and general practitioners were reported as the most consulted health care professionals concerning musculoskeletal problems.
Results regarding symptoms in six anatomic regions were compared to results for a sample of the general Danish workforce. Symptoms were more frequent in musicians and lasted longer than in the general workforce. This applied to both genders.
Conclusions
Within the last year most symphony orchestra musicians experienced musculoskeletal symptoms in the neck, back or upper extremities. The symptoms impacted on their level of function in and outside work and were reflected in their health behaviour. Generally women had a higher risk than men and woodwind players a lower risk than other instrumentalists. Finally, symptoms were more frequent and lasted longer in the musicians than in the general workforce.
doi:10.1186/1471-2474-12-223
PMCID: PMC3221643  PMID: 21978278
8.  Analysis of deep tissue hypersensitivity to pressure pain in professional pianists with insidious mechanical neck pain 
Background
The aim of this study was to investigate whether pressure pain hyperalgesia is a feature of professional pianists suffering from neck pain as their main playing-related musculoskeletal disorder.
Methods
Twenty-three active expert pianists, 6 males and 17 females (age: 36 ± 12 years) with insidious neck pain and 23 pianists, 9 males and 14 females (age: 38 ± 10 years) without neck pain the previous year were recruited. A numerical pain rate scale, Neck Disability Index, hand size and pressure pain thresholds (PPT) were assessed bilaterally over the C5-C6 zygapophyseal joint, deltoid muscle, the second metacarpal and the tibialis anterior muscle in a blinded design.
Results
The results showed that PPT levels were significantly decreased bilaterally over the second metacarpal and tibialis anterior muscles (P < 0.05), but not over C5-C6 zygapophyseal joint and deltoid muscle (P > 0.10), in pianists with neck pain as compared to healthy pianists. Pianists with neck pain had a smaller (P < 0.05) hand size (mean: 181.8 ± 11.8) as compared to pianists without neck pain (mean: 188. 6 ± 13.1). PPT over the tibialis anterior muscles was negatively correlated with the intensity of neck pain.
Conclusions
Our findings revealed pressure pain hypersensitivity over distant non-symptomatic distant points but not over the symptomatic areas in pianists suffering from neck pain. In addition, pianists with neck pain also had smaller hand size than those without neck pain. Future studies are needed to further determine the relevance of these findings in the clinical course of neck pain as playing-related musculoskeletal disorder in professional pianists.
doi:10.1186/1471-2474-12-268
PMCID: PMC3252288  PMID: 22111912
9.  Development of a brief multidisciplinary education programme for patients with osteoarthritis 
Background
Osteoarthritis (OA) is a prevalent progressive musculoskeletal disorder, leading to pain and disability. Patient information and education are considered core elements in treatment guidelines for OA; however, there is to our knowledge no evidence-based recommendation on the best approach, content or length on educational programmes in OA. Objective: to develop a brief, patient oriented disease specific multidisciplinary education programme (MEP) to enhance self-management in patients with OA.
Method
Twelve persons (80% female mean age 59 years) diagnosed with hand, hip or knee OA participated in focus group interviews. In the first focus group, six participants were interviewed about their educational needs, attitudes and expectations for the MEP. The interviews were transcribed verbatim and thereafter condensed.
Based on results from focus group interviews, current research evidence, clinical knowledge and patients' experience, a multidisciplinary OA team (dietist, nurse, occupational therapist, pharmacist, physical therapist and rheumatologist) and a patient representative developed a pilot-MEP after having attended a work-shop in health pedagogics. Finally, the pilot-MEP was evaluated by a second focus group consisting of four members from the first focus group and six other experienced patients, before final adjustments were made.
Results
The focus group interviews revealed four important themes: what is OA, treatment options, barriers and coping strategies in performing daily activities, and how to live with osteoarthritis. Identified gaps between patient expectations and experience with the pilot-programme were discussed and adapted into a final MEP. The final MEP was developed as a 3.5 hour educational programme provided in groups of 6-9 patients. All members from the multidisciplinary team are involved in the education programme, including a facilitator who during the provision of the programme ensures that the individual questions are addressed. As part of an ongoing process, a patient representative regularly attends the MEP and gives feedback concerning content and perceived value.
Conclusion
A MEP has been developed to enhance self-management in patients with OA attending a multidisciplinary OA outpatient clinic. The effectiveness of the MEP followed by individual consultations with members of the multidisciplinary team is currently evaluated in a randomised controlled trial with respect to patient satisfaction and functioning.
doi:10.1186/1471-2474-12-257
PMCID: PMC3262862  PMID: 22077985
10.  Course and prognosis of recovery for chronic non-specific low back pain: design, therapy program and baseline data of a prospective cohort study 
Background
There has been increasing focus on factors predicting the development of chronic musculoskeletal disorders. For patients already experiencing chronic non-specific low back pain it is also relevant to investigate which prognostic factors predict recovery. We present the design of a cohort study that aims to determine the course and prognostic factors for recovery in patients with chronic non-specific low back pain.
Methods/Design
All participating patients were recruited (Jan 2003-Dec 2008) from the same rehabilitation centre and were evaluated by means of (postal) questionnaires and physical examinations at baseline, during the 2-month therapy program, and at 5 and 12 months after start of therapy. The therapy protocol at the rehabilitation centre used a bio-psychosocial approach to stimulate patients to adopt adequate (movement) behaviour aimed at physical and functional recovery. The program is part of regular care and consists of 16 sessions of 3 hours each, over an 8-week period (in total 48 hours), followed by a 3-month self-management program. The primary outcomes are low back pain intensity, disability, quality of life, patient's global perceived effect of recovery, and participation in work. Baseline characteristics include information on socio-demographics, low back pain, employment status, and additional clinical items status such as fatigue, duration of activities, and fear of kinesiophobia. Prognostic variables are determined for recovery at short-term (5 months) and long-term (12 months) follow-up after start of therapy.
Discussion
In a routine clinical setting it is important to provide patients suffering from chronic non-specific low back pain with adequate information about the prognosis of their complaint.
doi:10.1186/1471-2474-12-252
PMCID: PMC3221649  PMID: 22047019
11.  Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study 
Background
Musculoskeletal disorders affect all racial and ethnic groups, including Hispanics. Because these disorders are not life-threatening, decision-making is generally preference-based. Little is known about whether Hispanics in the U.S. differ from non-Hispanic Whites with respect to key decision making preferences.
Methods
We assembled six focus groups of Hispanic and non-Hispanic White patients with chronic back or knee pain at an urban medical center to discuss management of their conditions and the roles they preferred in medical decision-making. Hispanic groups were further stratified by socioeconomic status, using neighborhood characteristics as proxy measures. Discussions were led by a moderator, taped, transcribed and analyzed using a grounded theory approach.
Results
The analysis revealed ethnic differences in several areas pertinent to medical decision-making. Specifically, Hispanic participants were more likely to permit their physician to take the predominant role in making health decisions. Also, Hispanics of lower socioeconomic status generally preferred to use non-internet sources of health information to make medical decisions and to rely on advice obtained by word of mouth. Hispanics emphasized the role of faith and religion in coping with musculoskeletal disability. The analysis also revealed broad areas of concordance across ethnic strata including the primary role that pain and achieving pain relief play in patients' experiences and decisions.
Conclusions
These findings suggest differences between Hispanics and non-Hispanic Whites in preferred information sources and decision-making roles. These findings are hypothesis-generating. If confirmed in further research, they may inform the development of interventions to enhance preference-based decision-making among Hispanics.
doi:10.1186/1471-2474-12-78
PMCID: PMC3098215  PMID: 21510880
12.  The effect of continuous ultrasound on chronic low back pain: protocol of a randomized controlled trial 
Background
Chronic non-specific low-back pain (LBP) is one of the most common and expensive musculoskeletal disorders in industrialized countries. Similar to other countries in the world, LBP is a common health and socioeconomic problem in Iran. One of the most widely used modalities in the field of physiotherapy for treating LBP is therapeutic ultrasound. Despite its common use, there is still inconclusive evidence to support its effectiveness in this group of patients. This randomised trial will evaluate the effectiveness of continuous ultrasound in addition to exercise therapy in patients with chronic LBP.
Methods and design
A total of 46 patients, between the ages 18 and 65 years old who have had LBP for more than three months will be recruited from university hospitals. Participants will be randomized to receive continuous ultrasound plus exercise therapy or placebo ultrasound plus exercise therapy. These groups will be treated for 10 sessions during a period of 4 weeks. Primary outcome measures will be functional disability and pain intensity. Lumbar flexion and extension range of motion, as well as changes in electromyography muscle fatigue indices, will be measured as secondary outcomes. All outcome measures will be measured at baseline, after completion of the treatment sessions, and after one month.
Discussion
The results of this trial will help to provide some evidence regarding the use of continuous ultrasound in chronic LBP patients. This should lead to a more evidence-based approach to clinical decision making regarding the use of ultrasound for LBP.
Trial registration
Netherlands Trial Register (NTR): NTR2251
doi:10.1186/1471-2474-12-59
PMCID: PMC3069953  PMID: 21406117
13.  Effectiveness of anodal transcranial direct current stimulation in patients with chronic low back pain: Design, method and protocol for a randomised controlled trial 
Background
Electrical stimulation of central nervous system areas with surgically implanted stimulators has been shown to result in pain relief. To avoid the risks and side effects of surgery, transcranial direct current stimulation is an option to electrically stimulate the motor cortex through the skull. Previous research has shown that transcranial direct current stimulation relieves pain in patients with fibromyalgia, chronic neuropathic pain and chronic pelvic pain. Evidence indicates that the method is pain free, safe and inexpensive.
Methods/Design
A randomised controlled trial has been designed to evaluate the effect of transcranial direct current stimulation over the motor cortex for pain reduction in patients with chronic low back pain. It will also investigate whether transcranial direct current stimulation as a prior treatment enhances the symptom reduction achieved by a cognitive-behavioural group intervention. Participants will be randomised to receive a series of 5 days of transcranial direct current stimulation (2 mA, 20 mins) or 20 mins of sham stimulation; followed by a cognitive-behavioural group programme. The primary outcome parameters will measure pain (Visual Analog Scale) and disability (Oswestry Disability Index). Secondary outcome parameters will include the Fear Avoidance Beliefs Questionnaire, the Funktionsfragebogen Hannover (perceived function), Hospital Anxiety Depression Scale, bothersomeness and Health Related Quality of Life (SF 36), as well as Patient-Perceived Satisfactory Improvement. Assessments will take place immediately prior to the first application of transcranial direct current stimulation or sham, after 5 consecutive days of stimulation, immediately after the cognitive-behavioural group programme and at 4 weeks, 12 weeks and 24 weeks follow-up.
Discussion
This trial will help to determine, whether transcranial direct current stimulation is an effective treatment for patients with chronic low back pain and whether it can further enhance the effects of a cognitive behavioural pain management programme. Trial registration: Current Controlled Trials ISRCTN89874874.
doi:10.1186/1471-2474-12-290
PMCID: PMC3339335  PMID: 22204615
14.  A strong association between non-musculoskeletal symptoms and musculoskeletal pain symptoms: results from a population study 
Background
There is a lack of knowledge about the pattern of symptom reporting in the general population as most research focuses on specific diseases or symptoms. The number of musculoskeletal pain sites is a strong predictor for disability pensioning and, hence, is considered to be an important dimension in symptom reporting. The simple method of counting symptoms might also be applicable to non-musculoskeletal symptoms, rendering further dimensions in describing individual and public health. In a general population, we aimed to explore the association between self-reported non-musculoskeletal symptoms and the number of pain sites.
Methods
With a cross-sectional design, the Standardised Nordic Questionnaire and the Subjective Health Complaints Inventory were used to record pain at ten different body sites and 13 non-musculoskeletal symptoms, respectively, among seven age groups in Ullensaker, Norway (n = 3,227).
Results
Results showed a strong, almost linear relationship between the number of non-musculoskeletal symptoms and the number of pain sites (r = 0.55). The number and type of non-musculoskeletal symptoms had an almost equal explanatory power in the number of pain sites reported (27.1% vs. 28.2%).
Conclusion
The linear association between the number of non-musculoskeletal and musculoskeletal symptoms might indicate that the symptoms share common characteristics and even common underlying causal factors. The total burden of symptoms as determined by the number of symptoms reported might be an interesting generic indicator of health and well-being, as well as present and future functioning. Research on symptom reporting might also be an alternative pathway to describe and, possibly, understand the medically unexplained multisymptom conditions.
doi:10.1186/1471-2474-12-285
PMCID: PMC3310803  PMID: 22176611
Epidemiology; Cross-sectional; General population; Musculoskeletal pain; Medically unexplained symptoms
15.  Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol 
Background
Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people, giving rise to pain and loss of function. Many people experience progressive worsening of the disease over time, particularly those with varus malalignment and increased medial knee joint load. Therefore, interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression. Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load. A neuromuscular exercise program, emphasising optimal alignment of the trunk and lower limb joints relative to one another, as well as quality of movement performance, while dynamically and functionally strengthening the lower limb muscles, may be able to reduce medial knee load. Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature. This randomised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading, pain and function in individuals with medial knee joint osteoarthritis. We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program.
Methods/Design
100 people with medial knee pain, radiographic medial compartment osteoarthritis and varus malalignment will be recruited and randomly allocated to one of two 12-week exercise programs: quadriceps strengthening or neuromuscular exercise. Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home. The primary outcomes are medial knee load during walking (the peak external knee adduction moment from 3D gait analysis), pain, and self-reported physical function measured at baseline and immediately following the program. Secondary outcomes include the external knee adduction moment angular impulse, electromyographic muscle activation patterns, knee and hip muscle strength, balance, functional ability, and quality-of-life.
Discussion
The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load, pain and physical function in people with medial knee osteoarthritis and varus malalignment.
Trial Registration
Australian New Zealand Clinical Trials Registry reference: ACTRN12610000660088
doi:10.1186/1471-2474-12-276
PMCID: PMC3247187  PMID: 22141334
16.  Neck exercises, physical and cognitive behavioural-graded activity as a treatment for adult whiplash patients with chronic neck pain: Design of a randomised controlled trial 
Background
Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.
Methods/Design
The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg - 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.
Discussion
The perspectives of this study are discussed, in addition to the strengths and weaknesses.
Trial registration
The study is registered in http://www.ClinicalTrials.gov identifier NCT01431261.
doi:10.1186/1471-2474-12-274
PMCID: PMC3266656  PMID: 22136113
17.  Amsterdam wrist rules: A clinical decision aid 
Background
Acute trauma of the wrist is one of the most frequent reasons for visiting the Emergency Department. These patients are routinely referred for radiological examination. Most X-rays however, do not reveal any fractures. A clinical decision rule determining the need for X-rays in patients with acute wrist trauma may help to percolate and select patients with fractures.
Methods/Design
This study will be a multi-center observational diagnostic study in which the data will be collected cross-sectionally. The study population will consist of all consecutive adult patients (≥18 years) presenting with acute wrist trauma at the Emergency Department in the participating hospitals.
This research comprises two components: one study will be conducted to determine which clinical parameters are predictive for the presence of a distal radius fracture in adult patients presenting to the Emergency Department following acute wrist trauma. These clinical parameters are defined by trauma-mechanism, physical examination, and functional testing. This data will be collected in two of the three participating hospitals and will be assessed by using logistic regression modelling to estimate the regression coefficients after which a reduced model will be created by means of a log likelihood ratio test. The accuracy of the model will be estimated by a goodness of fit test and an ROC curve. The final model will be validated internally through bootstrapping and by shrinking it, an adjusted model will be generated.
In the second component of this study, the developed prediction model will be validated in a new dataset consisting of a population of patients from the third hospital. If necessary, the model will be calibrated using the data from the validation study.
Discussion
Wrist trauma is frequently encountered at the Emergency Department. However, to this date, no decision rule regarding this type of trauma has been created. Ideally, radiographs are obtained of all patients entering one of the participating hospitals with trauma to the wrist. However, this is ethically and logistically not feasible and one could argue that patients, for whom no radiography is required according to their physician, are not suspected of having a distal radius fracture and thus are not part of the domain.
Trial registration
This study is registered at the Netherlands Trial Register (NTR 2544) and was granted permission by the Medical Ethical Committee of the Academic Medical Center Amsterdam on 06-01-2011.
doi:10.1186/1471-2474-12-238
PMCID: PMC3229467  PMID: 22004344
Clinical Decision Rule; Decision Rule; Diagnosis; Distal Radius Fractures; Radiography; Surgery; Trauma Surgery; Validation Study; Wrist Injury
18.  Implementation of neck/shoulder exercises for pain relief among industrial workers: A randomized controlled trial 
Background
Although leisure-time physical activity is important for health, adherence to regular exercise is challenging for many adults. The workplace may provide an optimal setting to reach a large proportion of the adult population needing regular physical exercise. This study evaluates the effect of implementing strength training at the workplace on non-specific neck and shoulder pain among industrial workers.
Methods
Cluster-randomized controlled trial involving 537 adults from occupations with high prevalence of neck and shoulder pain (industrial production units). Participants were randomized to 20 weeks of high-intensity strength training for the neck and shoulders three times a week (n = 282) or a control group receiving advice to stay physically active (n = 255). The strength training program followed principles of progressive overload and periodization. The primary outcome was changes in self-reported neck and shoulder pain intensity (scale 0-9).
Results
85% of the participants followed the strength training program on a weekly basis. In the training group compared with the control group, neck pain intensity decreased significantly (-0.6, 95% CI -1.0 to -0.1) and shoulder pain intensity tended to decrease (-0.2, 95% CI -0.5 to 0.1, P = 0.07). For pain-cases at baseline (pain intensity > = 3) the odds ratio - in the training group compared with the control group - for being a non-case at follow-up (pain intensity < 3) was 2.0 (95% CI 1.0 to 4.2) for the neck and 3.9 (95% CI 1.7 to 9.4) for the shoulders.
Conclusion
High-intensity strength training relying on principles of progressive overload can be successfully implemented at industrial workplaces, and results in significant reductions of neck and shoulder pain.
Trial registration
NCT01071980.
doi:10.1186/1471-2474-12-205
PMCID: PMC3188479  PMID: 21936939
19.  Test-retest of computerized health status questionnaires frequently used in the monitoring of knee osteoarthritis: a randomized crossover trial 
Background
To compare data based on touch screen to data based on traditional paper versions of questionnaires frequently used to examine patient reported outcomes in knee osteoarthritis patients and to examine the impact of patient characteristics on this comparison
Methods
Participants were recruited from an ongoing trial (http://ClinicalTrials.Gov Identifier: NCT00655941). 20 female participants, mean age 67 (SD 7), completed KOOS, VAS pain, function and patient global, SF-36, Physical Activity Scale, painDETECT, and the ADL Taxonomy. Patients were randomly assigned to one of two subgroups, completing either the paper or touch screen version first. Mean, mean differences (95% CI), median, median differences and Intraclass Correlation Coefficients (ICCs) were calculated for all questionnaires.
Results
ICCs between data based on computerized and paper versions ranged from 0.86 to 0.99. Analysis revealed a statistically significant difference between versions of the ADL Taxonomy, but not for the remaining questionnaires. Age, computer experience or education-level had no significant impact on the results. The computerized questionnaires were reported to be easier to use.
Conclusion
The computerized questionnaires gave comparable results to answers given on paper. Patient characteristics did not influence results and implementation was feasible.
doi:10.1186/1471-2474-12-190
PMCID: PMC3176488  PMID: 21851618
20.  Is the presence of Modic changes associated with the outcomes of different treatments? A systematic critical review 
Background
Modic changes (MCs) have been identified as a diagnostic subgroup associated with low back pain (LBP). The aetiology of MCs is still unknown and there is no effective treatment available. If MCs constitute a specific subgroup of LBP, it seems reasonable to expect different effects from different treatments. The objective of this systematic critical literature review was therefore to investigate if there is evidence in the literature that the presence of MCs at baseline is associated with a favourable outcome depending on the treatment provided for LBP.
Methods
The databases MEDLINE and EMBASE were searched for relevant articles from 1984 to December 2010. A checklist including items related to the research questions and quality of the articles was used for data extraction and quality assessment. Of the 1650 articles found, five (six studies) were included in this review but because the studies were so heterogeneous, the results have been reported separately for each study.
Results
The treatments studied were: lumbar epidural steroid injections (n = 1), lumbar intradiscal steroid injections (n = 2), lumbar disc replacement (n = 1), fusion surgery (n = 1) and exercise therapy (n = 1). One of the two studies investigating treatment with intradiscal steroid injections and the study investigating fusion surgery reported that MCs were positively associated with the outcomes of pain and disability. The other study on lumbar intradiscal steroid injections and the study on lumbar epidural steroid injections reported mixed results, whereas the study on lumbar disc replacement and the study on exercise therapy reported that MCs were not associated with the outcomes of pain and disability.
Conclusions
The available studies on the topic were too few and too heterogeneous to reach a definitive conclusion and it is therefore still unclear if MCs may be of clinical importance when guiding or prescribing the 'right' treatment for a patient with LBP.
doi:10.1186/1471-2474-12-183
PMCID: PMC3162945  PMID: 21831312
21.  Neck pain and postural balance among workers with high postural demands - a cross-sectional study 
Background
Neck pain is related to impaired postural balance among patients and is highly prevalent among workers with high postural demands, for example, cleaners. We therefore hypothesised, that cleaners with neck pain suffer from postural dysfunction. This cross-sectional study tested if cleaners with neck pain have an impaired postural balance compared with cleaners without neck pain.
Methods
Postural balance of 194 cleaners with (n = 85) and without (N = 109) neck pain was studied using three different tests. Success or failure to maintain the standing position for 30 s in unilateral stance was recorded. Participants were asked to stand on a force platform for 30 s in the Romberg position with eyes open and closed. The centre of pressure of the sway was calculated, and separated into a slow (rambling) and fast (trembling) component. Subsequently, the 95% confidence ellipse area (CEA) was calculated. Furthermore a perturbation test was performed.
Results
More cleaners with neck pain (81%) failed the unilateral stance compared with cleaners without neck pain (61%) (p < 0.01). However, the risk of failure in unilateral stance was statistically elevated in cleaners with concurrent neck/low back pain compared to cleaners without neck/low back pain (p < 0.01), whereas pain at only neck or only low back did not increase the risk. Impaired postural balance, measured as CEA (p < 0.01), rambling (p < 0.05) and trembling (p < 0.05) was observed among cleaners with neck pain in comparison with cleaners without neck pain in the Romberg position with eyes closed, but not with eyes open.
Conclusions
Postural balance is impaired among cleaners with neck pain and the current study suggests a particular role of the slow component of postural sway. Furthermore, the unilateral stance test is a simple test to illustrate functional impairment among cleaners with concurrent neck and low back pain.
Trial registration
ISRCTN96241850
doi:10.1186/1471-2474-12-176
PMCID: PMC3161921  PMID: 21806796
22.  Prevalence and anatomical location of muscle tenderness in adults with nonspecific neck/shoulder pain 
Background
Many adults experience bothersome neck/shoulder pain. While research and treatment strategies often focus on the upper trapezius, other neck/shoulder muscles may be affected as well. The aim of the present study is to evaluate the prevalence and anatomical location of muscle tenderness in adults with nonspecific neck/shoulder pain.
Methods
Clinical neck/shoulder examination at two large office workplaces in Copenhagen, Denmark. 174 women and 24 men (aged 25-65 years) with nonspecific neck/shoulder pain for a duration of at least 30 days during the previous year and a pain intensity of at least 2 on a modified VAS-scale of 0-10 participated. Exclusion criteria were traumatic injuries or other serious chronic disease. Using a standardized finger pressure of 2 kg, palpable tenderness were performed of eight anatomical neck/shoulder locations in the left and right side on a scale of 'no tenderness', 'some tenderness' and 'severe tenderness'.
Results
In women, the levator scapulae, neck extensors and infraspinatus showed the highest prevalence of severe tenderness (18-30%). In comparison, the prevalence of severe tenderness in the upper trapezius, occipital border and supraspinatus was 13-19%. Severe tenderness of the medial deltoid was least prevalent (0-1%). In men, the prevalence of severe tenderness in the levator scapulae was 13-21%, and ranged between 0-8% in the remainder of the examined anatomical locations.
Conclusions
A high prevalence of tenderness exists in several anatomical locations of the neck/shoulder complex among adults with nonspecific neck/shoulder pain. Future research should focus on several neck/shoulder muscles, including the levator scapulae, neck extensors and infraspinatus, and not only the upper trapezius.
Trial Registration
ISRCTN60264809
doi:10.1186/1471-2474-12-169
PMCID: PMC3161919  PMID: 21777478
23.  Is there a relationship between pain intensity and postural sway in patients with non-specific low back pain? 
Background
Increased center of pressure excursions are well documented in patients suffering from non-specific low back pain, whereby the altered postural sway includes both higher mean sway velocities and larger sway area. No investigation has been conducted to evaluate a relationship between pain intensity and postural sway in adults (aged 50 or less) with non-specific low back pain.
Methods
Seventy-seven patients with non-specific low back pain and a matching number of healthy controls were enrolled. Center of pressure parameters were measured by three static bipedal standing tasks of 90 sec duration with eyes closed in narrow stance on a firm surface. The perceived pain intensity was assessed by a numeric rating scale (NRS-11), an equal number of patients (n = 11) was enrolled per pain score.
Results
Generally, our results confirmed increased postural instability in pain sufferers compared to healthy controls. In addition, regression analysis revealed a significant and linear increase in postural sway with higher pain ratings for all included COP parameters. Statistically significant changes in mean sway velocity in antero-posterior and medio-lateral direction and sway area were reached with an incremental change in NRS scores of two to three points.
Conclusions
COP mean velocity and sway area are closely related to self-reported pain scores. This relationship may be of clinical use as an objective monitoring tool for patients under treatment or rehabilitation.
doi:10.1186/1471-2474-12-162
PMCID: PMC3146912  PMID: 21762484
24.  Inter-examiner reproducibility of tests for lumbar motor control 
Background
Many studies show a relation between reduced lumbar motor control (LMC) and low back pain (LBP). However, test circumstances vary and during test performance, subjects may change position. In other words, the reliability - i.e. reproducibility and validity - of tests for LMC should be based on quantitative data. This has not been considered before. The aim was to analyse the reproducibility of five different quantitative tests for LMC commonly used in daily clinical practice.
Methods
The five tests for LMC were: repositioning (RPS), sitting forward lean (SFL), sitting knee extension (SKE), and bent knee fall out (BKFO), all measured in cm, and leg lowering (LL), measured in mm Hg. A total of 40 subjects (14 males, 26 females) 25 with and 15 without LBP, with a mean age of 46.5 years (SD 14.8), were examined independently and in random order by two examiners on the same day. LBP subjects were recruited from three physiotherapy clinics with a connection to the clinic's gym or back-school. Non-LBP subjects were recruited from the clinic's staff acquaintances, and from patients without LBP.
Results
The means and standard deviations for each of the tests were 0.36 (0.27) cm for RPS, 1.01 (0.62) cm for SFL, 0.40 (0.29) cm for SKE, 1.07 (0.52) cm for BKFO, and 32.9 (7.1) mm Hg for LL. All five tests for LMC had reproducibility with the following ICCs: 0.90 for RPS, 0.96 for SFL, 0.96 for SKE, 0.94 for BKFO, and 0.98 for LL. Bland and Altman plots showed that most of the differences between examiners A and B were less than 0.20 cm.
Conclusion
These five tests for LMC displayed excellent reproducibility. However, the diagnostic accuracy of these tests needs to be addressed in larger cohorts of subjects, establishing values for the normal population. Also cut-points between subjects with and without LBP must be determined, taking into account age, level of activity, degree of impairment and participation in sports. Whether reproducibility of these tests is as good in daily clinical practice when used by untrained examiners also needs to be examined.
doi:10.1186/1471-2474-12-114
PMCID: PMC3116485  PMID: 21612650
25.  Clustering patients on the basis of their individual course of low back pain over a six month period 
Background
Several researchers have searched for subgroups in the heterogeneous population of patients with non-specific low back pain (LBP). To date, subgroups have been identified based on psychological profiles and the variation of pain.
Methods
This multicentre prospective observational study explored the 6- month clinical course with measurements of bothersomeness that were collected from weekly text messages that were sent by 176 patients with LBP. A hierarchical cluster analysis, Ward's method, was used to cluster patients according to the development of their pain.
Results
Four clusters with distinctly different clinical courses were described and further validated against clinical baseline variables and outcomes. Cluster 1, a "stable" cluster, where the course was relatively unchanged over time, contained young patients with good self- rated health. Cluster 2, a group of "fast improvers" who were very bothered initially but rapidly improved, consisted of patients who rated their health as relatively poor but experienced the fewest number of days with bothersome pain of all the clusters. Cluster 3 was the "typical patient" group, with medium bothersomeness at baseline and an average improvement over the first 4-5 weeks. Finally, cluster 4 contained the "slow improvers", a group of patients who improved over 12 weeks. This group contained older individuals who had more LBP the previous year and who also experienced most days with bothersome pain of all the clusters.
Conclusions
It is possible to define clinically meaningful clusters of patients based on their individual course of LBP over time. Future research should aim to reproduce these clusters in different populations, add further clinical variables to distinguish the clusters and test different treatment strategies for them.
doi:10.1186/1471-2474-12-99
PMCID: PMC3125255  PMID: 21586117

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