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1.  Low back pain and widespread pain predict sickness absence among industrial workers 
Background
The prevalence of musculoskeletal disorders (MSD) in the aluminium industry is high, and there is a considerable work-related fraction. More knowledge about the predictors of sickness absence from MSD in this industry will be valuable in determining strategies for prevention. The aim of this study was to analyse the relative impact of body parts, psychosocial and individual factors as predictors for short- and long-term sickness absence from MSD among industrial workers.
Methods
A follow-up study was conducted among all the workers at eight aluminium plants in Norway. A questionnaire was completed by 5654 workers at baseline in 1998. A total of 3320 of these participated in the follow-up study in 2000. Cox regression analysis was applied to investigate the relative impact of MSD in various parts of the body and of psychosocial and individual factors reported in 1998 on short-term and long-term sickness absence from MSD reported in 2000.
Results
MSD accounted for 45% of all working days lost the year prior to follow-up in 2000. Blue-collar workers had significantly higher risk than white-collar workers for both short- and long-term sickness absence from MSD (long-term sickness absence: RR = 3.04, 95% CI 2.08–4.45). Widespread and low back pain in 1998 significantly predicted both short- and long-term sickness absence in 2000. In addition, shoulder pain predicted long-term sickness absence. Low social support predicted short-term sickness absence (RR = 1.28, 95% CI 1.11–1.49).
Conclusions
Reducing sickness absence from MSD among industrial workers requires focusing on the working conditions of blue-collar workers and risk factors for low back pain and widespread pain. Increasing social support in the work environment may have effects in reducing short-term sickness absence from MSD.
doi:10.1186/1471-2474-4-21
PMCID: PMC200978  PMID: 12956891
sickness absence; musculoskeletal disorders; low back pain; widespread pain; blue-collar workers; social support
2.  The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery 
Background
The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale, scored 0 (no disability) to 100. The main purpose of this study was to assess the longitudinal construct validity of the DASH among patients undergoing surgery. The second purpose was to quantify self-rated treatment effectiveness after surgery.
Methods
The longitudinal construct validity of the DASH was evaluated in 109 patients having surgical treatment for a variety of upper-extremity conditions, by assessing preoperative-to-postoperative (6–21 months) change in DASH score and calculating the effect size and standardized response mean. The magnitude of score change was also analyzed in relation to patients' responses to an item regarding self-perceived change in the status of the arm after surgery. Performance of the DASH as a measure of treatment effectiveness was assessed after surgery for subacromial impingement and carpal tunnel syndrome by calculating the effect size and standardized response mean.
Results
Among the 109 patients, the mean (SD) DASH score preoperatively was 35 (22) and postoperatively 24 (23) and the mean score change was 15 (13). The effect size was 0.7 and the standardized response mean 1.2.
The mean change (95% confidence interval) in DASH score for the patients reporting the status of the arm as "much better" or "much worse" after surgery was 19 (15–23) and for those reporting it as "somewhat better" or "somewhat worse" was 10 (7–14) (p = 0.01). In measuring effectiveness of arthroscopic acromioplasty the effect size was 0.9 and standardized response mean 0.5; for carpal tunnel surgery the effect size was 0.7 and standardized response mean 1.0.
Conclusion
The DASH can detect and differentiate small and large changes of disability over time after surgery in patients with upper-extremity musculoskeletal disorders. A 10-point difference in mean DASH score may be considered as a minimal important change. The DASH can show treatment effectiveness after surgery for subacromial impingement and carpal tunnel syndrome. The effect size and standardized response mean may yield substantially differing results.
doi:10.1186/1471-2474-4-11
PMCID: PMC165599  PMID: 12809562
3.  Is undergraduate physiotherapy study a risk factor for low back pain? A prevalence study of LBP in physiotherapy students 
Background
Following reports of high prevalence of low back pain (LBP) in young physiotherapists [17-22], we investigated whether LBP was a problem for undergraduate physiotherapy students.
Method
Physiotherapy students enrolled in one Australian tertiary institution completed a validated self-administered questionnaire in April 2001, seeking information on LBP prevalence (lifetime, 12 month, one-month, one-week), and its risk factors. The survey incorporated the Nordic back questionnaire, questions on common risks for LBP, and purpose-built questions regarding educational exposures. Univariate logistic regression models were applied to test associations.
Results and Discussion
72% students responded. LBP prevalence was 69% (lifetime), 63% (12-month), 44% (one-month), 28% (one-week). The risk of LBP increased significantly for students once they completed first year. Being aged 20 or 21 years (final year students) was significantly associated with all measures of LBP, compared with the youngest students. Exposure to tertiary study of greater than two years was associated with lifetime, 12 month and one-month LBP prevalence. Spending more than 20 hours in the past month 'sitting looking down' was significantly associated with one-month LBP prevalence. Similar exposure to 'treating patients' was significantly associated with one-month and one-week LBP prevalence.
Conclusions
Physiotherapy students should be alerted to the likelihood of LBP and is potential causes during their training, so that they enter the workforce with reduced risk of LBP. The potential for other undergraduate students to suffer LBP should also be considered.
doi:10.1186/1471-2474-4-22
PMCID: PMC270026  PMID: 14536021
Low back pain; physiotherapy students; risk factors
4.  Inter-examiner reliability of the diagnosis of cervical pillar hyperplasia (CPH) and the correlation between CPH and spinal degenerative joint disease (DJD) 
Background
Cervical pillar hyperplasia (CPH) is a recently described phenomenon of unknown aetiology. Its clinical importance is poorly understood at the present time; therefore, the objective of this study was to determine (1) the inter-examiner reliability of detecting CPH and (2) if there is a clinically important correlation (r > 0.4) between the number of cervical spine levels showing signs of degenerative joint disease (DJD) and CPH.
Methods
The sample consisted of 320 radiographs of human male and female subjects who ranged from 40 to 79 years of age. The inter-examiner reliability of assessing the presence/absence of pillar hyperplasia was evaluated on 50 neutral lateral radiographs by two examiners using line drawings and it was quantified using the kappa coefficient of concordance. To determine the presence/absence of hyperplastic pillars as well as the presence/absence of DJD at each intervertebral disc and zygapophysial joint, 320 AP open mouth, AP lower cervical and neutral lateral radiographs were then examined. The unpaired t-test at the 5% level of significance was performed to test for a statistically significant difference between the number of levels affected by DJD in patients with and without hyperplasia. The Spearman's rho at the 5% level of significance was performed to quantify the correlation between DJD and age.
Results
The inter-examiner reliability of detecting cervical pillar hyperplasia was moderate with a kappa coefficient of 0.51. The unpaired t-test indicated that there was no statistically significant difference (p > 0.05) between the presence/absence of cervical pillar hyperplasia and the number of levels affected by DJD in an age-matched population, regardless of whether all elements were considered together, or the discs and facets were analyzed separately. A Spearman correlation rank of 0.67 (p < 0.05) suggested a moderately strong correlation between the number of elements (i.e. discs/facets) affected, and the age of the individual.
Conclusion
Cervical pillar hyperplasia is a reasonable concept that requires further research. Its evaluation is easy to learn and acceptably reliable. Previous research has suggested that CPH may affect the cervical lordosis, and therefore, alter biomechanics which may result in premature DJD. This current study, however, indicates that, globally, CPH does not appear to be related to the development of DJD.
doi:10.1186/1471-2474-4-28
PMCID: PMC324408  PMID: 14678560
5.  From evidence to best practice in the management of fractures of the distal radius in adults: working towards a research agenda 
Background
Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. We report our work towards evidence-based and patient-centred care for adults with these injuries.
Methods
We developed a systematic programme of research that built on our systematic review of the evidence of effectiveness of treatment interventions for these fractures. We devised schemata showing 'typical' care pathways and identified over 100 patient management questions. These depicted the more important decisions taken when progressing along each care pathway. We compiled a comprehensive document summarising the evidence available for each decision point from our reviews of randomised trials of treatment interventions. Using these documents, we undertook a formal and structured consultation process involving key players, including a patient representative, to obtain their views on the available evidence and to establish a research agenda. The resulting feedback was then processed and interpreted, using systematic methods.
Results
Some evidence from 114 randomised trials was available for 31 of the 117 patient management questions. However, there was sufficient evidence to base some conclusions of effectiveness for particular interventions in only five of these.
Though only 60% of those approached responded, the responses received from the consultation group were often comprehensive and provided important insights into treatment practice and policy. There was a clear acceptance of the aims of the project and, aside from some suggestions for the more explicit inclusion of secondary prevention and management of complications, of the care pathways scheme. Though some respondents stressed that randomised trials were not always appropriate, there was no direct overall criticism of the evidence document and underlying processes. We were able to identify important core themes that underpin management decisions and research from the feedback of the consultation exercise.
Conclusions
Overall, this project is an important advance towards evidence-based and patient-centred management of adults with distal radial fractures. It exposes the serious deficiency in the available evidence but also provides a template for further action. As well as being a valuable basis for viewing and informing current practice, the insights gained from this project should inform a future research agenda.
doi:10.1186/1471-2474-4-27
PMCID: PMC317324  PMID: 14641927
6.  Cost effectiveness of a multi-stage return to work program for workers on sick leave due to low back pain, design of a population based controlled trial [ISRCTN60233560] 
Background
To describe the design of a population based randomized controlled trial (RCT), including a cost-effectiveness analysis, comparing participative ergonomics interventions between 2–8 weeks of sick leave and Graded Activity after 8 weeks of sick leave with usual care, in occupational back pain management.
Methods
Design
An RCT and cost-effectiveness evaluation in employees sick-listed for a period of 2 to 6 weeks due to low back pain. Interventions used are 1. Communication between general practitioner and occupational physician plus Participative Ergonomics protocol performed by an ergonomist. 2. Graded Activity based on cognitive behavioural principles by a physiotherapist. 3. Usual care, provided by an occupational physician according to the Dutch guidelines for the occupational health management of workers with low back pain. The primary outcome measure is return to work. Secondary outcome measures are pain intensity, functional status and general improvement. Intermediate variables are kinesiophobia and pain coping. The cost-effectiveness analysis includes the direct and indirect costs due to low back pain. The outcome measures are assessed before randomization (after 2–6 weeks on sick leave) and 12 weeks, 26 weeks and 52 weeks after first day of sick leave.
Discussion
The combination of these interventions has been subject of earlier research in Canada. The results of the current RCT will: 1. crossvalidate the Canadian findings in an different sociocultural environment; 2. add to the cost-effectiveness on treatment options for workers in the sub acute phase of low back pain. Results might lead to alterations of existing (inter)national guidelines.
doi:10.1186/1471-2474-4-26
PMCID: PMC317323  PMID: 14629775
Low back pain; Graded Activity; Participative Ergonomics; Return to work; Randomized Controlled Trial; Cost-effectiveness; Occupational health
7.  Primary subcutaneous cyst hydatic disease in proximal thigh: an unusual localisation: a case report 
Background
Musculoskeletal hydatidosis is very rare and represents 1% – 5.4% of all cases of echinococcosis. On clinical basis, infection mimics a soft-tissue tumor, and the preoperative radiological diagnosis is very important to avoid biopsy.
Case Presentation
We report an unusual case of primary subcutaneous hydatidosis in proximity to vastus lateralis muscle. It was diagnosed according to the computed tomography appearance, clinical and pathological findings. A 43 year old female patient was admitted with a history of pain at proximal thigh for the last 30 days. On physical examination, a mass which was 4 × 5 cm in diameter, painful and erythamatous, was palpated over greater trochanter. Sedimentation rate was 40 mm in the first hour. CT (Computed Tomography) scan demonstrated, a soft tissue mass with central cystic component in the subcutaneous tissue near vastus lateralis muscle.
Histopathological examination of the specimen revealed a pericystic structure, which consisted of connective tissue and scattered hyaline cells showing a necrotic basophilic structure that resembled a cuticular membrane. Treatment with high dose albendazole was conducted for 4 weeks.
Conclusions
This case illustrates that echinococcal disease should be considered in the differential diagnosis of every cystic mass in every anatomic location, especially when they occur in areas where the disease is endemic.
doi:10.1186/1471-2474-4-25
PMCID: PMC281003  PMID: 14604436
Cyst Hydatic; Vastus lateralis muscle.
8.  Pain and disability reported in the year following a distal radius fracture: A cohort study 
Background
Distal radius fractures are a common injury that cause pain and disability. The purpose of this study was to describe the pain and disabilities experienced by patients with a distal radius fracture in the first year following fracture.
Methods
A prospective cohort study of 129 patients with a fracture of the distal radius was conducted. Patients completed a Patient-rated Wrist Evaluation at their baseline clinic visit and at 2, 3, 6 and 12 months following their fracture. The frequency/severity of pain and disabilities reported was described at each time point.
Results
The majority of patients experienced mild pain at rest and (very) severe high levels of pain with movement during the first two-months following distal radius fracture. This time is also associated with (very) severe difficulty in performing specific functional activities and moderate to severe difficulty in four domains of usual activity. The majority of recovery occurred within six-months, but symptoms persisted for a small minority of patients at one-year following fracture. Patients had the most difficulty with carrying ten pounds and pushing up from a chair. Resumption of usual personal care and household work preceded, and was more complete, than work and recreational participation.
Conclusions
This study demonstrated that the normal course of recovery following a distal radius fracture is one where severe symptoms subside within the first two-months and the majority of patients can be expected to have minimal pain and disability by six-months following fracture. This information can be used when planning interventions and assessing whether the progress of a patient is typical of other patients.
doi:10.1186/1471-2474-4-24
PMCID: PMC270028  PMID: 14588078
9.  Postural stability is altered by the stimulation of pain but not warm receptors in humans 
Background
It is now recognized that large diameter myelinated afferents provide the primary source of lower limb proprioceptive information for maintaining an upright standing position. Small diameter afferents transmitting noxious stimuli, however, can also influence motor behaviors. Despite the possible influence of pain on motor behaviors, the effects of pain on the postural control system have not been well documented.
Methods
Two cutaneous heat stimulations (experiment 1: non-noxious 40 degrees C; experiment 2: noxious 45 degrees C) were applied bilaterally on the calves of the subject with two thermal grills to stimulate A delta and C warm receptors and nociceptors in order to examine their effects on postural stability. The non-noxious stimulation induced a gentle sensation of warmth and the noxious stimulation induced a perception of heat pain (visual analogue scores of 0 and 46 mm, respectively). For both experiments, ten healthy young adults were tested with and without heat stimulations of the lower limbs while standing upright on a force platform with eyes open, eyes closed and eyes closed with tendon co-vibration of tibialis anterior and triceps surae muscles. The center of pressure displacements were analyzed to examine how both stimulations affected the regulation of quiet standing and if the effects were exacerbated when vision was removed or ankle proprioception perturbed.
Results
The stimulation of the warm receptors (40 degrees C) did not induce any postural deterioration. With pain (45 degrees C), subjects showed a significant increase in standard deviation, range and mean velocity of postural oscillations as well as standard deviation of the center of pressure velocity. The effects of heat pain were exacerbated when subjects had both their eyes closed and ankle tendons vibrated (increased standard deviation of the center of pressure velocity and mean velocity of the center of pressure).
Conclusions
A non-noxious stimulation (40 degrees C) of the small diameter afferents is not a sufficiently intense sensory stimulation to alter the control of posture. A painful stimulation (45 degrees C) of the skin thermoreceptors, however, yielded a deterioration of the postural control system. The observed deteriorating effects of the combined stimulation of nociceptors and Ia afferents (when ankle tendons were vibrated) could result from the convergence of these afferents at the spinal level. This could certainly lead to the hypothesis that individuals suffering from lower limb pain present alterations of the postural control mechanisms; especially populations already at risk of falling (for example, frail elderly) or populations suffering from concomitant lower limb pain and sensory deficits (for example, diabetic polyneuropathy).
doi:10.1186/1471-2474-4-23
PMCID: PMC270027  PMID: 14565854
10.  Fatty metamorphosis and other patterns in fibrous dysplasia 
Background
Interpretation of small biopsy fragments from suspected lesions of fibrous dysplasia with unusual clinical and / or radiological features may be challenging due to wide histomorphological spectrum of stromal appearances. Awareness of these variations should improve diagnostic confidence.
Methods
We retrospectively studied 26 cases of fibrous dysplasia (F- 19, M- 7; Ages ranged from 10 to 53 years) with confirmed diagnosis. The sites of the lesions were skull bones (9), humerus (1), femur (8), tibia (2), fibula (3), talus (1), mandible (1), and maxilla (1).
Results
Different stromal patterns, variably admixed with the classical pattern, were observed in 58%(15/26) of the cases. 20%(3/15) of these had more than one pattern. Focal fatty metamorphosis as groups of fat cells in the central portion of the lesion in the stroma of fibrous dysplasia between osseous trabeculae was observed in 23%(6/26) cases. Other patterns included myxoid stroma in 16%(4/26), collagenization of stroma in 12%(3/26), stroma rich pattern (with paucity of trabeculae) in 12%(3/26), foci of few foam cells in 23% (6/26), and calcified spherules in 12%(3/26). Focal osteoblastic rimming of trabeculae was observed only in 4%(1/26).
Conclusions
Various stromal variations and previously unreported fatty metamorphosis were frequently observed in fibrous dysplasia.
doi:10.1186/1471-2474-4-20
PMCID: PMC200977  PMID: 12946277
Fibrous dysplasia; Bone tumors; Bone neoplasms; Osteoblastic rimming; Ground glass radiology; Fatty metamorphosis
11.  Remission of Behcet's disease with anti-tumor necrosis factor monoclonal antibody therapy: a case report 
Background
Behcet's disease (BD) is a chronic relapsing multisystem inflammatory disorder with mucocutaneous, ocular, articular, vascular, gastrointestinal and central nervous system manifestations. Tumor necrosis factor (TNF)-alpha is believed to play a pivotal role in BD. Therapeutic blockade of the activity of TNF has been successfully given in a short course of therapy with favorable effects in patients with BD refractory to conventional immunosuppressive drugs. We aimed to find out whether a 12-month treatment with infliximab, a chimeric monoclonal antibody to TNF-alpha, had any beneficial effect in reducing relapses of a patient with long-standing BD refractory to conventional immunosuppressive drugs.
Case presentation
A 54 year-old-woman with a 35-year history of BD with orogenital ulcerations, arthritis in the right knee and retinal lesions compatible with vasculitis received infliximab, 5 mg/kg by a two-hour intravenous infusion. Symptoms improved within 24 hours and eight days later the genital and oral ulcers healed as well as the arthritis in the right knee subsided. The retinal infiltrates completely resolved within 10 days. The infusions were repeated at weeks 2, 6, 14, 22 and then every 8 weeks. The patient was able to return to her domestic daily life. No exacerbation of the mucocutaneous ocular or arthritic symptoms occurred during the treatment period.
Conclusions
Previous studies have suggested that infliximab given in a short course of treatment is effective in inducing remission of severe mucocutaneous, gastrointestinal and ocular manifestations of BD. Our patient received a 12-month infliximab treatment showing a favorable effect on remission of BD manifestations.
The long-term infliximab treatment appears as a new therapeutic option for patients with active BD who failed to respond to conventional immunosuppressive agents.
doi:10.1186/1471-2474-4-19
PMCID: PMC194711  PMID: 12946278
Behcet's disease; infliximab; tumor necrosis factor alpha.
12.  Advice or exercise for chronic whiplash disorders? Design of a randomized controlled trial 
Background
Whiplash-associated disorder (or "whiplash") is a common condition incurring considerable expense in social and economic terms. A lack of research on effective therapy for patients with chronic whiplash associated disorders prompted the design of the current study. The primary aim of this randomised controlled trial is to determine the effects of a physical activity program for people with chronic (symptoms of > 3 months duration) whiplash. A secondary aim is to determine if pain severity, level of disability and fear of movement/(re)injury predict response to a physical activity program.
Methods / Design
This paper presents the rationale and design of a randomised controlled trial examining the effects of advice and individualized sub-maximal exercise programs in the treatment of whiplash associated disorders.
Discussion
This paper highlights the design, methods and operational aspects of a significant clinical trial in the area of whiplash and chronic pain.
doi:10.1186/1471-2474-4-18
PMCID: PMC194710  PMID: 12932301
Whiplash; Exercise; Advice; Therapy; Neck Pain; Disability.
13.  The design of a valid and reliable questionnaire to measure osteoporosis knowledge in women: the Osteoporosis Knowledge Assessment Tool (OKAT) 
Background
Osteoporosis knowledge is an important contributor to improving exercise and calcium intake behaviour. However, there are few validated instruments for measuring osteoporosis knowledge levels. The aim of this study was to design a valid and reliable instrument to measure osteoporosis knowledge in Australian women.
Methods
A 20 item instrument with true, false and don't know responses was drafted, based on the Osteoporosis Australia Osteoporosis Prevention and Self-management course and the information leaflet "Understanding Osteoporosis". The scoring range was 1 to 20. This was administered to a 467 randomly-selected, healthy women aged 25–44 years. Questionnaire performance was assessed by Flesch reading ease, index of difficulty, Ferguson's sigma, inter-item and item-total correlations, Cronbach's alpha and principal component factor analysis.
Results
Flesch reading ease was higher than desirable at 45, but this was due to the use of the word osteoporosis in many items. Of the individual items 17 had an index of difficulty less than 0.75. The questionnaire had a Ferguson's sigma of 0.96, a Cronbach's alpha of 0.70 and factor analysis consistent with only one factor (osteoporosis knowledge) being measured. Levels of osteoporosis knowledge were low with a mean score of 8.8 out of 20 which suggests the OKAT may be sensitive to change.
Conclusions
The OKAT for measuring osteoporosis knowledge has good psychometric properties in Australian 25–44 year old females. While it should be applicable to other Caucasian populations, this will require confirmation by further research.
doi:10.1186/1471-2474-4-17
PMCID: PMC183834  PMID: 12877751
14.  Elevated levels of β-catenin and fibronectin in three-dimensional collagen cultures of Dupuytren's disease cells are regulated by tension in vitro 
Background
Dupuytren's contracture or disease (DD) is a fibro-proliferative disease of the hand that results in the development of scar-like, collagen-rich disease cords within specific palmar fascia bands. Although the molecular pathology of DD is unknown, recent evidence suggests that β-catenin may play a role. In this study, collagen matrix cultures of primary disease fibroblasts show enhanced contraction and isometric tension-dependent changes in β-catenin and fibronectin levels.
Methods
Western blots of β-catenin and fibronectin levels were determined for control and disease primary cell cultures grown within stressed- and attached-collagen matrices. Collagen contraction was quantified, and immunocytochemistry analysis of filamentous actin performed.
Results
Disease cells exhibited enhanced collagen contraction activity compared to control cells. Alterations in isometric tension of collagen matrices triggered dramatic changes in β-catenin and fibronectin levels, including a transient increase in β-catenin levels within disease cells, while fibronectin levels steadily decreased to levels below those seen in normal cell cultures. In contrast, both fibronectin and β-catenin levels increased in attached collagen-matrix cultures of disease cells, while control cultures showed only increases in fibronectin levels. Immunocytochemistry analysis also revealed extensive filamentous actin networks in disease cells, and enhanced attachment and spreading of disease cell in collagen matrices.
Conclusion
Three-dimensional collagen matrix cultures of primary disease cell lines are more contractile and express a more extensive filamentous actin network than patient-matched control cultures. The elevated levels of β-catenin and Fn seen in collagen matrix cultures of disease fibroblasts can be regulated by changes in isometric tension.
doi:10.1186/1471-2474-4-16
PMCID: PMC183833  PMID: 12866952
15.  Discordant effect of body mass index on bone mineral density and speed of sound 
Background
Increased BMI may affect the determination of bone mineral density (BMD) by dual X-ray absorptiometry (DXA) and speed of sound (SOS) measured across bones. Preliminary data suggest that axial SOS is less affected by soft tissue. The purpose of this study is to evaluate the effect of body mass index (BMI) on BMD and SOS measured along bones.
Methods
We compared axial BMD determined by DXA with SOS along the phalanx, radius and tibia in 22 overweight (BMI > 27 kg/m2), and 11 lean (BMI = 21 kg/m2) postmenopausal women. Serum bone specific alkaline phosphatase and urinary deoxypyridinoline excretion determined bone turnover.
Results
Mean femoral neck – but not lumbar spine BMD was higher in the overweight – as compared with the lean group (0.70 ± 0.82, -0.99 ± 0.52, P < 0.00001). Femoral neck BMD in the overweight – but not in the lean group highly correlated with BMI (R = 0.68. P < 0.0001). Mean SOS at all measurement sites was similar in both groups and did not correlate with BMI. Bone turnover was similar in the two study groups.
Conclusions
The high BMI of postmenopausal women may result in spuriously high BMD. SOS measured along bones may be a more appropriate means for evaluating bones of overweight women.
doi:10.1186/1471-2474-4-15
PMCID: PMC183832  PMID: 12864923
16.  Balance in single-limb stance in healthy subjects – reliability of testing procedure and the effect of short-duration sub-maximal cycling 
Background
To assess balance in single-limb stance, center of pressure movements can be registered by stabilometry with force platforms. This can be used for evaluation of injuries to the lower extremities. It is important to ensure that the assessment tools we use in the clinical setting and in research have minimal measurement error. Previous studies have shown that the ability to maintain standing balance is decreased by fatiguing exercise. There is, however, a need for further studies regarding possible effects of general exercise on balance in single-limb stance. The aims of this study were: 1) to assess the test-retest reliability of balance variables measured in single-limb stance on a force platform, and 2) to study the effect of exercise on balance in single-limb stance, in healthy subjects.
Methods
Forty-two individuals were examined for test-retest reliability, and 24 individuals were tested before (pre-exercise) and after (post-exercise) short-duration, sub-maximal cycling. Amplitude and average speed of center of pressure movements were registered in the frontal and sagittal planes. Mean difference between test and retest with 95% confidence interval, the intraclass correlation coefficient, and the Bland and Altman graphs with limits of agreement, were used as statistical methods for assessing test-retest reliability. The paired t-test was used for comparisons between pre- and post-exercise measurements.
Results
No difference was found between test and retest. The intraclass correlation coefficients ranged from 0.79 to 0.95 in all stabilometric variables except one. The limits of agreement revealed that small changes in an individual's performance cannot be detected. Higher values were found after cycling in three of the eight stabilometric variables.
Conclusions
The absence of systematic variation and the high ICC values, indicate that the test is reliable for distinguishing among groups of subjects. However, relatively large differences in an individual's balance performance would be required to confidently state that a change is real. The higher values found after cycling, indicate compensatory mechanisms intended to maintain balance, or a decreased ability to maintain balance. It is recommended that average speed and DEV 10; the variables showing the best reliability and effects of exercise, be used in future studies.
doi:10.1186/1471-2474-4-14
PMCID: PMC166283  PMID: 12831402
17.  Osteoporosis in Canadian adult cystic fibrosis patients: A descriptive study 
Background
Cystic fibrosis is the most common fatal autosomal recessive genetic disease in the Caucasian population. Osteoporosis is increasingly being recognised as an important complication in people with cystic fibrosis.
Methods
A descriptive study of adult cystic fibrosis patients receiving care at a Canadian tertiary care hospital was conducted to evaluate the prevalence of osteoporosis, the prevalence of non-vertebral fractures, and the change in bone mineral density during the course of a year. Data on bone mineral density were obtained for 40 adult cystic fibrosis patients by reviewing dual x-ray absorptiometry scans taken at baseline (when annual scans became standard clinical practice) and one year prior to baseline. Data on prevalent fractures were obtained by reviewing all available patient charts. Clinical and laboratory data were collected from an existing clinic database.
Results
Over half of the 40 patients had reduced T- and Z-scores at baseline. For the 27 patients who had data available one year prior to baseline, total hip and lumbar spine bone mineral density had decreased by 3.04% and 0.86% after one year while total body bone mineral density had not changed significantly. Four prior non-vertebral fractures were reported in three patients (1,146 patient-years).
Conclusion
This study confirms that osteoporosis is a significant problem in adult cystic fibrosis patients, and constitutes the first published evidence of cystic fibrosis bone disease in Canadians.
doi:10.1186/1471-2474-4-13
PMCID: PMC198278  PMID: 12823863
18.  The postural effects of load carriage on young people – a systematic review 
Background
Spinal pain in young people is a significant source of morbidity in industrialised countries. The carriage of posterior loads by young people has been linked with spinal pain, and the amount of postural change produced by load carriage has been used as a measure of the potential to cause tissue damage. The purpose of this review was to identify, appraise and collate the research evidence regarding load-carriage related postural changes in young people.
Methods
A systematic literature review sought published literature on the postural effects of load carriage in young people. Sixteen databases were searched, which covered the domains of allied health, childcare, engineering, health, health-research, health-science, medicine and medical sciences. Two independent reviewers graded the papers according to Lloyd-Smith's hierarchy of evidence scale. Papers graded between 1a (meta-analysis of randomised controlled trials) and 2b (well-designed quasi-experimental study) were eligible for inclusion in this review. These papers were quality appraised using a modified Crombie tool. The results informed the collation of research evidence from the papers sourced.
Results
Seven papers were identified for inclusion in this review. Methodological differences limited our ability to collate evidence.
Conclusions
Evidence based recommendations for load carriage in young people could not be made based on the results of this systematic review, therefore constraining the use of published literature to inform good load carriage practice for young people.
doi:10.1186/1471-2474-4-12
PMCID: PMC194855  PMID: 12809561
19.  Hip disability and osteoarthritis outcome score (HOOS) – validity and responsiveness in total hip replacement 
Background
The aim of the study was to evaluate if physical functions usually associated with a younger population were of importance for an older population, and to construct an outcome measure for hip osteoarthritis with improved responsiveness compared to the Western Ontario McMaster osteoarthritis score (WOMAC LK 3.0).
Methods
A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) was constructed to assess patient-relevant outcomes in five separate subscales (pain, symptoms, activity of daily living, sport and recreation function and hip related quality of life). The HOOS contains all WOMAC LK 3.0 questions in unchanged form. The HOOS was distributed to 90 patients with primary hip osteoarthritis (mean age 71.5, range 49–85, 41 females) assigned for total hip replacement for osteoarthritis preoperatively and at six months follow-up.
Results
The HOOS met set criteria of validity and responsiveness. It was more responsive than WOMAC regarding the subscales pain (SRM 2.11 vs. 1.83) and other symptoms (SRM 1.83 vs. 1.28). The responsiveness (SRM) for the two added subscales sport and recreation and quality of life were 1.29 and 1.65, respectively. Patients ≤ 66 years of age (range 49–66) reported higher responsiveness in all five subscales than patients >66 years of age (range 67–85) (Pain SRM 2.60 vs. 1.97, other symptoms SRM 3.0 vs. 1.60, activity of daily living SRM 2.51 vs. 1.52, sport and recreation function SRM 1.53 vs. 1.21 and hip related quality of life SRM 1.95 vs. 1.57).
Conclusion
The HOOS 2.0 appears to be useful for the evaluation of patient-relevant outcome after THR and is more responsive than the WOMAC LK 3.0. The added subscales sport and recreation function and hip related quality of life were highly responsive for this group of patients, with the responsiveness being highest for those younger than 66.
doi:10.1186/1471-2474-4-10
PMCID: PMC161815  PMID: 12777182
20.  Diagnostic properties of nerve conduction tests in population-based carpal tunnel syndrome 
Background
Numerous nerve conduction tests are used for the electrodiagnosis of carpal tunnel syndrome (CTS), with a wide range of sensitivity and specificity reported for each test in clinical studies. The tests have not been assessed in population-based studies. Such information would be important when using electrodiagnosis in epidemiologic research. The purpose of this study was to compare the diagnostic accuracy of various nerve conduction tests in population-based CTS and determine the properties of the most accurate test.
Methods
In a population-based study a questionnaire was mailed to a random sample of 3,000 persons. Of 2,466 responders, 262 symptomatic (numbness/tingling in the radial fingers) and 125 randomly selected asymptomatic responders underwent clinical and electrophysiologic examinations. A standardized hand diagram was administered to the symptomatic persons. At the clinical examination, the examining surgeon identified 94 symptomatic persons as having clinically certain CTS. Nerve conduction tests were then performed on the symptomatic and the asymptomatic persons by blinded examiners. Analysis with receiver operating characteristic (ROC) curves was used to compare the diagnostic accuracy of the nerve conduction tests in distinguishing the persons with clinically certain CTS from the asymptomatic persons.
Results
No difference was shown in the diagnostic accuracy of median nerve distal motor latency, digit-wrist sensory latency, wrist-palm sensory conduction velocity, and wrist-palm/forearm sensory conduction velocity ratio (area under curve, 0.75–0.76). Median-ulnar digit-wrist sensory latency difference had a significantly higher diagnostic accuracy (area under curve, 0.80). Using the optimal cutoff value of 0.8 ms for abnormal sensory latency difference shown on the ROC curve the sensitivity was 70%, specificity 82%, positive predictive value 19% and negative predictive value 98%. Based on the clinical diagnosis among the symptomatic persons, the hand diagram (classified as classic/probable or possible/unlikely CTS) had high sensitivity but poor specificity.
Conclusions
Using the clinical diagnosis of CTS as the criterion standard, nerve conduction tests had moderate sensitivity and specificity and a low positive predictive value in population-based CTS. Measurement of median-ulnar sensory latency difference had the highest diagnostic accuracy. The performance of nerve conduction tests in population-based CTS does not necessarily apply to their performance in clinical settings.
doi:10.1186/1471-2474-4-9
PMCID: PMC156649  PMID: 12734018
21.  Does simvastatin stimulate bone formation in vivo? 
Background
Statins, potent compounds that inhibit cholesterol synthesis in the liver have been reported to induce bone formation, both in tissue culture and in rats and mice. To re-examine potential anabolic effects of statins on bone formation, we compared the activity of simvastatin (SVS) to the known anabolic effects of PTH in an established model of ovariectomized (OVX) Swiss-Webster mice.
Methods
Mice were ovariectomized at 12 weeks of age (T0), remained untreated for 5 weeks to allow development of osteopenia (T5), followed by treatment for 8 weeks (T13). Whole, trabecular and cortical femoral bone was analyzed by micro-computed tomography (micro CT). Liquid chromatography/mass spectrometry (LC/MS) was used to detect the presence of SVS and its active metabolite, simvastatin β-hydroxy acid (SVS-OH) in the mouse serum.
Results
Trabecular BV/TV at T13 was 4.2 fold higher in animals treated with PTH (80 micro-g/kg/day) compared to the OVX-vehicle treated group (p < 0.001). However, the same comparison for the SVS-treated group (10 mg/kg/day administered by gavage) showed no significant difference (p = NS). LC/MS detected SVS and SVS-OH in mouse serum 20 minutes after gavage of 100 mg SVS. A serum osteocalcin assay (OC) demonstrated that neither bone formation nor osteoblast activity is significantly enhanced by SVS treatment in this in vivo study.
Conclusions
While PTH demonstrated the expected anabolic effect on bone, SVS failed to stimulate bone formation, despite our verification by LC/MS of the active SVS-OH metabolite in mouse serum. While statins have clear effects on bone formation in vitro, the formulation of existing 'liver-targeted' statins requires further refinement for efficacy in vivo.
doi:10.1186/1471-2474-4-8
PMCID: PMC156891  PMID: 12718758
22.  Magnesium deficiency: effect on bone mineral density in the mouse appendicular skeleton 
Background
Dietary magnesium (Mg) deficiency in the mouse perturbs bone and mineral homeostasis. The objective of the present study was to evaluate bone mineral density of the femur in control and Mg-deficient mice.
Methods
BALB/c mice aged 28 days at study initiation were maintained on a normal or Mg deficient (0.0002% Mg) diet, and at time points 0, 2, 4 or 6 weeks bones were harvested for bone mineral density analysis. Peripheral quantitative computed tomography (pQCT) was used to assess the trabecular metaphyseal compartment and the cortical midshaft.
Results
Although mean total bone density of the femoral midshaft in Mg deficient mice did not differ significantly from controls throughout the study, the trabecular bone compartment showed significantly decreased mineral content after 4 (p < 0.001) and 6 weeks (p < 0.001) of Mg depletion.
Conclusions
This study demonstrates the profound effect of Mg depletion on the trabecular compartment of bone, which, with its greater surface area and turnover, was more responsive to Mg depletion than cortical bone in the appendicular skeleton of the mouse.
doi:10.1186/1471-2474-4-7
PMCID: PMC155646  PMID: 12702215
23.  Revision and complication rates in 654 Exeter total hip replacements, with a maximum follow-up of 20 years 
Background
Iceland's geographical isolation with a stable and small population gives a rare opportunity for follow-up studies of medical interventions. Total hip replacements (THR) have been done at FSA Central Hospital in Akureyri, Iceland since 1982 with the Exeter hip implant being in use from the beginning.
Methods
Hospital records for all patients operated on with THR between 1982 and the end of 1999 were reviewed and the patients were followed until the end of 2001. Information was gathered regarding the indication for primary surgery, the reason for revision if needed, as well as that of any complications. Survival statistics were used to calculate the cumulative revision rate.
Results
The mean age at primary THR was 68.4 years for males and 68.8 years for females. 654 primary THRs were done; of which 571 (87 %) were due to osteoarthritis. 37 of the primary arthroplasties had been revised before the end of year 2001.
Conclusion
We have in this unique 2–20 year study of 654 THRs with no loss to follow-up for the patients, found revision rates that conform with the large Swedish THR registry. Complication rates in general are in agreement with that reported for other comparable patient groups, while infection rates appear lower.
doi:10.1186/1471-2474-4-6
PMCID: PMC153516  PMID: 12659648
24.  Validation and reproducibility of computerised cell-viability analysis of tissue slices 
Background
The identification of live cells using membrane integrity dyes has become a frequently used technique, especially with articular cartilage and chondrocytes in situ where tissue slices are used to assess cell recovery as a function of location. The development of a reproducible computerised method of cell evaluation would eliminate many variables associated with manual counting and significantly reduce the amount of time required to evaluate experimental results.
Methods
To validate a custom computerised counting program, intra-person and inter-person cell counts of nine human evaluators (three groups – unskilled, novice, and experienced) were compared with repeated pixel counts of the custom program on 15 digitised images (in triplicate) of chondrocytes in situ stained with fluorescent dyes.
Results
Results indicated increased reproducibility with increased experience within evaluators [Intraclass Correlation Coefficient (ICC) range = 0.67 (unskilled) to 0.99 (experienced)] and between evaluators [ICC = 0.47 (unskilled), 0.85 (novice), 0.93 (experienced)]. The computer program had perfect reproducibility (ICC = 1.0). There was a significant relationship between the average of the experienced evaluators results and the custom program results (ICC = 0.77).
Conclusions
This study demonstrated that increased experience in cell counting resulted in increased reproducibility both within and between human evaluators but confirmed that the computer program was the most reproducible. There was a good correlation between the intact cell recovery determined by the computer program and the experienced human evaluators. The results of this study showed that the computer counting program was a reproducible tool to evaluate intact cell recovery after use of membrane integrity dyes on chondrocytes in situ. This and the significant decrease in the time used to count the cells by the computer program advocate its use in future studies because it has significant advantages.
doi:10.1186/1471-2474-4-5
PMCID: PMC153524  PMID: 12659649
cell counting; computerised viability assessment; chondrocytes; reproducibility; tissue slices
25.  Computer aided vertebral visualization and analysis: a methodology using the sand rat, a small animal model of disc degeneration 
Background
The purpose of this study is to present an automated system that analyzes digitized x-ray images of small animal spines identifying the effects of disc degeneration. The age-related disc and spine degeneration that occurs in the sand rat (Psammomys obesus) has previously been documented radiologically; selected representative radiographs with age-related changes were used here to develop computer-assisted vertebral visualization/analysis techniques. Techniques presented here have the potential to produce quantitative algorithms that create more accurate and informative measurements in a time efficient manner.
Methods
Signal and image processing techniques were applied to digitized spine x-ray images the spine was segmented, and orientation and curvature determined. The image was segmented based on orientation changes of the spine; edge detection was performed to define vertebral boundaries. Once vertebrae were identified, a number of measures were introduced and calculated to retrieve information on the vertebral separation/orientation and sclerosis.
Results
A method is described which produces computer-generated quantitative measurements of vertebrae and disc spaces. Six sand rat spine radiographs illustrate applications of this technique. Results showed that this method can successfully automate calculation and analysis of vertebral length, vertebral spacing, vertebral angle, and can score sclerosis. Techniques also provide quantitative means to explore the relation between age and vertebral shape.
Conclusions
This method provides a computationally efficient system to analyze spinal changes during aging. Techniques can be used to automate the quantitative processing of vertebral radiographic images and may be applicable to human and other animal radiologic models of the aging/degenerating spine.
doi:10.1186/1471-2474-4-4
PMCID: PMC154090  PMID: 12659650

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