A comprehensive MRI investigation to identify potential biomarkers of Osgood Schlatter disease in adolescents: A cross sectional study comparing Osgood Schlatter disease with controls

BACKGROUND

Osgood-Schlatter disease (OSD) is the most common knee pain complaint among adolescents playing sports. Despite this, there remains controversy over the pathophysiology and whether specific anatomical characteristics are associated with OSD.

PURPOSE

This study aimed to systematically and comprehensively characterize adolescents with OSD using magnetic resonance imaging (MRI) compared to pain-free controls, including both tissue abnormalities that may be associated with OSD, as well as anatomical characteristics. A secondary objective was to identify potential imaging biomarkers associated with pain.

STUDY DESIGN

Cross-sectional study.

METHODS

Adolescents with OSD and controls were recruited from 2020 to 2022. Following a clinical exam, demographics, pain, sports participation, and Tanner stage were collected. Knee MRI was conducted on the participants' most symptomatic knee (OSD) or the dominant leg (controls).

RESULTS

Sixty-seven adolescents (46 with OSD and 30 controls) were included. 80% of participants with OSD had at least one tissue alteration compared to 54% of controls. Compared to controls, OSD had 36.3 (95%CI 4.5 to 289.7) higher odds of bony oedema at the tibial tuberosity, and 32.7 (95%CI 4.1 to 260.6) and 5.3 (95%CI 0.6 to 46.2) higher odds of bony oedema at the  tibial epiphysis and metaphysis respectively. Participants with OSD also had higher odds of fluid/oedema at the patellar tendon (12.3 95%CI 3.3 to 46.6), and superficial infrapatellar bursitis (7.2).  Participants with OSD had a more proximal tendon attachment (mean tibial attachment portion difference, -0.05, 95% CI: -0.1 to 0.0, p = 0.02), tendon thickness (proximal mean difference, -0.09, 95% CI: -0.4 to 0.2, p = 0.04; distal mean difference, -0.6, 95% CI: -0.9 to -0.2, p = 0.01). Those with bony/tendon oedema had 1.8 points (95% CI: 0.3 to 3.2) higher pain on palpation than those without (t = -2.5, df = 26.6, p = 0.019), but there was no difference between these groups in a functional single leg pain provocation.

CONCLUSION

Adolescents with OSD present with tissue and structural abnormalities on MRI that differed from age-matched controls. The majority had findings in the patellar tendon and bone, which often co-occurred. However, a small proportion of OSD also presents without alterations. It appears these findings may be associated with clinical OSD-related pain on palpation of the tibial tuberosity.

CLINICAL RELEVANCE

Our highlight the pathophysiology on imaging, which has implications for understanding the mechanism and treatment of OSD.

Pain history and experimental pressure pain responses in adolescents: Results from a population-based birth cohort

BACKGROUND

Sensitized pain mechanisms are often reported in musculoskeletal pain conditions, but population-based paediatric studies are lacking. We assessed whether adolescents with musculoskeletal pain history had evidence of increased responsiveness to experimental pressure stimuli.

METHODS

Data were from 1496 adolescents of the Generation XXI birth cohort. Pain history was collected using the Luebeck Pain Questionnaire (self-reported at 13, parent-reported at 7 and 10 years). Two case definitions for musculoskeletal pain were considered: (1) cross-sectional-musculoskeletal pain lasting more than 3 months at age 13 and (2) longitudinal-musculoskeletal pain at age 13 with musculoskeletal pain reports at ages 7 and/or 10. Lower limb cuff pressure algometry was used to assess pain detection and tolerance thresholds, conditioned pain modulation effects (CPM, changes in thresholds in the presence on painful conditioning) and temporal summation of pain effects (TSP, changes in pain intensity to 10 phasic painful cuff stimulations).

RESULTS

Adolescents with musculoskeletal pain at age 13 plus a history of pain in previous evaluations (longitudinal definition) had lower pain tolerance thresholds compared to the remaining sample (40.2 v. 49.0 kPa, p = 0.02), but showed no differences in pain detection threshold, CPM effect and TSP effect. Pain sensitivity, CPM effects and TSP effects were not significantly different when the current pain only case definition (cross-sectional) was used.

CONCLUSIONS

Adolescents with current musculoskeletal pain who had a history of pain since childhood had lower tolerance to cuff stimulation. This may suggest long-standing musculoskeletal pain since childhood may contribute to sensitisation, rather than the presence of current pain only.

SIGNIFICANCE

Repeated musculoskeletal pain up to age 13 years may contribute to higher pain sensitivity (particularly lowered pressure pain tolerance) in the general adolescent population. This does not seem to be the case when reported pain experiences are recent or when the outcomes are temporal pain summation or CPM. In this community-based paediatric sample, the vast majority showed no sign of altered pain processing, but a small fraction may reveal some pain sensitization at 13 years of age.

Does children's healthcare seeking change after participation in a musculoskeletal study? A register-based study

BACKGROUND

Participating in research studies often involves interactions with healthcare professionals, potentially influencing the participant's future help-seeking behaviour. We investigated whether participating in the Childhood Health Activity and Motor Performance School Study - Denmark (CHAMPS) (2008-2014), which involved telephone consultations and clinical assessments by healthcare professionals with participants experiencing musculoskeletal complaints, changed frequency of contacts with primary public healthcare services among participants over the subsequent five-years-period, compared to non-participating children.

METHODS

Using Danish health register data from 1998 to 2020, we compared CHAMPS participant's and two control group's contacts with private physiotherapists, chiropractors (outside hospitals), and general practitioners: a random 10% sample of children from Denmark (National Controls), and a secondary local control group (Local Controls) during three periods: Before (1998-31.10.2008), during (01.11.2008-20.06.2014), and after (21.06.2014-31.12.2019) the CHAMPS-study. Separate multivariable Poisson regression models were used to assess the differences between groups for the outcome variables: contacts with physiotherapists, chiropractors, and general practitioners, and overall contacts.

RESULTS

Compared to National Controls, the CHAMPS-Group had fewer physiotherapy contacts before the study with an estimated mean of 0.01 vs 0.02 per person-year, and after (0.13 vs 0.18 per person-year), corresponding to a crude incidence rate ratio (IRR) of 0.69 (95% confidence intervals (CI): 0.58-0.83) after the study period. However, they had more chiropractor contacts before (0.05 vs 0.03), and after (0.21 vs 0.09) the study, with a crude IRR of 2.29 (95% CI: 1.93-2.71) after the study period. General practice contacts were equal for the CHAMPS-group compared to national controls (5.84 vs 5.84) before the study but reduced during and after (3.21 vs 3.71), with a crude IRR of 0.86 (95% CI: 0.83-0.90) after the study. Comparable patterns of contacts changes from before to after the study were observed between the CHAMPS-group and the Local Controls except for physiotherapy which was equal between the two groups after the study.

CONCLUSION

Our findings suggest that research studies involving systematic engagement with participants experiencing musculoskeletal complaints can influence subsequent healthcare-seeking behaviour. Future research should address the influence of health literacy, health education, and healthcare provider recommendations on healthcare decisions during such research studies.

The development of an informative leaflet for children and adolescents suffering from Osgood-Schlatter disease

The mainstay in the treatment of Osgood-Schlatter Disease (OSD) is guidance on activity modification alongside exercises. The purpose of this study was to create an informative leaflet for patients with OSD, based on evidence and stakeholders perspectives. A synthesis of the literature, including national reference work, clinical research, and systematic reviews informed the initial leaflet. Twelve children with OSD and four clinical experts provided feedback through semi-structured interviews. After incorporating stakeholder input, the leaflet 'Osgood-Schlatter-Information and guidance' was developed. This provides a resource to assist the provision of information and translation of the current evidence.

Exploring the pain and disability continuum in adolescents with non-traumatic anterior knee pain: a mediation analysis using individual participant data of prospective studies

OBJECTIVE

To use individual patient data (IPD) to investigate if the effect of pain on sports-related disability is mediated through physical (lower extremity isometric strength) or psychological (depression/anxiety and knee confidence) factors in adolescents with non-traumatic anterior knee pain.

METHODS

This study included four datasets from a previously harmonised IPD dataset. Prior to analysis, the protocol and analysis approach were predefined and published on Open Science Framework. Potential mediators were pre-sepcified as isometric knee and hip strengths, self-reported anxiety/depression and confidence in the knee, allmeasured at 12 weeks after baseline evaluation. Mediation analyses were undertaken using the CMAVerse package in RStudio using the regression-based approach to decompose the total effect of the exposure (pain at baseline evaluation) on the outcome (sports-related disability at 6 months) into the 'indirect effect' (the portion of the total effect acting through the mediators) and the 'direct effect'.

RESULTS

Two-hundred and seventy-nine adolescents with non-traumatic knee pain were included in the analysis. Median age was 13 (range 10-19), and 72% were women. Baseline pain was associated with sports-related disability at 6 months. There was no evidence of the association being mediated by any of the proposed mediators (total natural indirect effect for strength 0.01 (-1.14 to 1.80) and psychological factors 0.00 (-0.66 to 2.02)).

CONCLUSION

We found an effect of pain on sports-related disability at 6 months which appears to be independent of lower extremity muscle strength, or depression/anxiety and knee confidence in adolescents with non-traumatic anterior knee pain.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Do adolescents with Osgood-Schlatter display nociplastic pain manifestations compared to controls: A cross-sectional study

OBJECTIVES

Osgood-Schlatter disease is an overuse musculoskeletal pain condition. The pain mechanism is considered nociceptive, but no studies have investigated nociplastic manifestations. This study investigated pain sensitivity and inhibition evaluated through exercise-induced hypoalgesia in adolescents with and without Osgood-Schlatter.

DESIGN

Cross-sectional study.

METHODS

Adolescents underwent a baseline assessment comprising clinical history, demographics, sports participation, and pain severity rated (0-10) during a 45-second anterior knee pain provocation test, consisting of an isometric single leg squat. Pressure pain thresholds were assessed bilaterally at the quadriceps, tibialis anterior muscle, and the patella tendon before and after a three-minute wall squat.

RESULTS

Forty-nine adolescents (27 Osgood-Schlatter, 22 controls) were included. There were no differences in the exercise-induced hypoalgesia effect between Osgood-Schlatter and controls. Overall, an exercise-induced hypoalgesia effect was detected at the tendon only in both groups with a 48 kPa (95 % confidence interval 14 to 82) increase in pressure pain thresholds from before to after exercise. Controls had higher pressure pain thresholds at the patellar tendon (mean difference 184 kPa 95 % confidence interval 55 to 313), tibialis anterior (mean difference 139 kPa 95 % confidence interval 24 to 254), and rectus femoris (mean difference 149 kPa 95 % confidence interval 33 to 265). Higher anterior knee pain provocation severity was associated with lower exercise-induced hypoalgesia at the tendon (Pearson correlation = 0.48; p = 0.011) in participants with Osgood-Schlatter.

CONCLUSIONS

Adolescents with Osgood-Schlatter display increased pain sensitivity locally, proximally, and distally but similar endogenous pain modulation compared to healthy controls. Greater Osgood-Schlatter severity appears to be associated with less efficient pain inhibition during the exercise-induced hypoalgesia paradigm.

Development of a tool to support general practitioners to help adolescents with knee pain: an analysis using the Theoretical Domains Framework

AIM

Using the Theoretical Domains Framework (TDF) and COM-B model, this study aimed to determine the facilitators to a support tool for adolescent non-traumatic knee pain in general practice.

BACKGROUND

Many children and adolescents with non-traumatic knee pain consult their general practice. Currently, there are no tools to support general practitioners in the diagnosis and management of this group. There is a need to identify behavioural targets that would facilitate further development and implementation of such a tool.

METHODS

This study was designed as a qualitative study using focus group interviews with 12 medical doctors working in general practice. The semi-structured focus group interviews conducted online and followed an interview guide based on the TDF and COM-B model. Data were analysed via thematic text analysis.

FINDINGS

One of the biggest challenges from the general practitioner's perspective was how to manage and guide adolescents with non-traumatic knee pain. The doctors had doubts in their capability to diagnose knee pain and saw opportunity to help structure the consultation. The doctors felt motivated to use a tool but considered access a potential barrier. Increasing opportunity and motivation by creating access in the community among general practitioners was considered important. We identified several barriers and facilitators for a support tool for the management of adolescent non-traumatic knee pain in general practice. To align with user needs, future tools should support diagnostic workup, structure the consultation and be easily available among doctors working in general practice.

Maternal Well-Being and Stage of Behaviour Change during Pregnancy: A Secondary Analysis of the PEARS Randomised Controlled Trial

We aimed to determine whether early pregnancy well-being was associated with the stage of behaviour change during an antenatal lifestyle intervention using a secondary analysis of data from the Pregnancy Exercise and Nutrition Research Study (PEARS). Pregnant women (n = 277) with well-being data in early pregnancy were included. Maternal well-being was measured using the World Health Organisation Five-Item Well-Being Index. The intervention consisted of a mobile health (mHealth) phone application, supported by antenatal education and exercise, to prevent gestational diabetes in a population with overweight. Stage of behaviour change was measured in late pregnancy using a five-stage classification. Ordinal logistic regression was used to examine if well-being, the study group, or their interaction, were related to behaviour change. Maternal well-being (OR 1.03, 95% CI 1.01, 1.04, p < 0.01) and the study group (OR 2.25, 95% CI 1.44, 3.51, p < 0.01) both significantly influenced the positive stage of behaviour change. The probability of being at stage 5 increased from 43 to 92% as well-being increased from 0 to 100% and was higher in the intervention (53%) compared to the control (34%) group (p ≤ 0.01 (8.65, 29.27). This study demonstrates the potential importance of well-being in enabling women to engage with a healthy lifestyle, and the role that mHealth technology has in facilitating beneficial behaviour change.

Adaptation of a Danish online version of the Oxford Physical Activity Questionnaire (OPAQ) for secondary school students—a pilot study

Objective

To adapt and partly validate a Danish online version of the patient-reported outcome measure (PROM) Oxford Physical Activity Questionnaire (“OPAQ”) and evaluate mobile phones and tablets as data capturing tool to identify potential problems and deficiencies in the PROM prior to implementation in the full study.

Methods

The OPAQ was translated into Danish by a formalised forward-backward translation procedure. Face validity was examined by interviewing 12 school students aged 10–15, recruited from two Danish public schools. After modifications, the online version of the Danish OPAQ was pilot tested in a convenience sample of seven school students for 1 week. Simultaneous objective accelerometer data were captured during the registration period.

Results

No major challenges were identified when translating OPAQ. Based on the interviews, the Danish version of OPAQ was perceived to be easy to understand in general, and the questions were relevant for tracking activities during the week. Five of the 12 participants had difficulties with understanding the introductory question: “what is your cultural background” in the original OPAQ. The interviews revealed that the participants recalling 7 days forgot to record some of the physical activity they had done during the week, indicating issues with the weekly recall method.

After transforming to the online version, this was reported to be easy and quick to fill in (taking 1–3 min per day), and participants reported the daily design was helpful to remember activities. There was good correspondence between the online version and objective actigraphs with a tendency to underreport. Six participants reported 10–60 min less moderate to vigorous physical activity compared to the actigraphs, while one participant reported 3 min more.

Conclusion

Participants found the online OPAQ quick and easy to complete during a 1-week period. Completing daily rather than weekly may help limit issues with recall. Overall, there was good agreement between the objective actigraphs and the OPAQ, though the OPAQ tended to slightly underreport moderate to vigorous physical activity.

The Danish online version of OPAQ may be useful for capturing school students’ physical activity when objective measures are not feasible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01108-x.

Bio-psycho-social characteristics and impact of musculoskeletal pain in one hundred children and adolescents consulting general practice

Background

Eight percent of all child and adolescent general practice consultations are due to musculoskeletal conditions, with pain as the most frequent symptom. Despite the commonality of musculoskeletal pain, limited knowledge exists about care-seeking children and adolescents with musculoskeletal pain.

The purpose of this study was to describe characteristics of children and adolescents consulting their general practitioner with musculoskeletal pain.

Methods

This is a cross-sectional study based on baseline data from the child and adolescent musculoskeletal pain cohort study (ChiBPS), carried out in 17 Danish general practice clinics. Patients aged 8–19 years who had musculoskeletal pain when consulting their general practitioner were recruited. Participants completed a questionnaire on demographics, physical activity, pain impact, psychosocial factors, and expectations of their general practitioner. Descriptive statistics were used to summarize data. Normally distributed continuous data were described using mean and standard deviation while non-normally data were described using median and interquartile range (IQR).

Results

We included 100 participants (54% female, median age 13 [IQR: 12–16.5 years]). Frequent pain sites limiting activity were knee (56%), back (20%), ankle (19%), and neck (13%). Most participants (63%) consulted their general practitioner due to inability to use their body as usual, due to pain. Median pain duration at consultation was 5 months [IQR: 3 weeks-1 year]. More than a third were often/sometimes nervous (34%), worried or anxious (33%), and took pain medication (33%). Pain impeded ability to participate in sport activities at school (79%) and disturbed spare time activities (88%). Pain also made it difficult to concentrate for 58%, and to fall asleep for 38%. Only 38% expected a pain free long-term future.

Conclusion

This study demonstrates the bio-psycho-social impact of musculoskeletal pain in care-seeking children and adolescents. Demographics, pain characteristics, psychosocial characteristics, and physical characteristics should be included in addressing children and adolescents with musculoskeletal pain.

Trial registration

The ChiBPS study was pre-registered before participant recruitment (ClinicalTrials.gov Identifier: NCT03678922) date: 09.20.18.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01628-8.

Five-year follow-up of patients with knee osteoarthritis not eligible for total knee replacement: results from a randomised trial

OBJECTIVES

The main objective was to investigate 5-year outcomes in patients with knee osteoarthritis, randomised to one of two non-surgical treatments.

SETTING

Two outpatient clinics.

PARTICIPANTS

At baseline, 100 patients with radiographic and symptomatic knee osteoarthritis not found eligible for knee replacement (KR) were included. Main exclusion criteria were average score above 75 of the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales pain, symptoms, function of daily living and quality of life; KOOS₄ and average knee pain the previous week greater than 60 mm on a 100 mm visual analogue scale.

INTERVENTIONS

Patients were randomised to supervised non-surgical treatment consisting of patient education, supervised exercise, weight loss, insoles, and pain medication (the MEDIC treatment) or written advice. The 12-week MEDIC treatment included patient education, neuromuscular exercise, insoles and a dietary weight loss programme and/or pain medication if needed and written advice consisted of two leaflets.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 5-year mean change for KOOS₄. Secondary outcomes included KOOS subscales, self-reported health, usage of pain medication and self-reported physical activity.

RESULTS

Thirty-nine (78%) and 36 (72%) from the MEDIC and written advice groups responded at 5 years. There were no between-group differences in KOOS₄ (difference 5.3 (95% CI -1.5 to 12.1) or any secondary outcomes. However, the 95% CI included the minimal clinically important difference for the main outcome.Seventy-six percent of the MEDIC group and 66% of the written advice group experienced clinically important improvements in KOOS₄.Fifteen patients (30%) from the MEDIC group and 17 (34%) from the written advice group received KR in the index knee. Undergoing KR did not result in a statistically significant greater improvement in KOOS₄ (difference 6.1 (95% CI -1.1 to 13.4).

CONCLUSIONS

No statistically significant differences between supervised non-surgical treatment and written advice were demonstrated at 5 years. Most patients experienced clinically important improvements, irrespective of initial treatment strategy or KR.

TRIAL REGISTRATION NUMBER

NCT01535001; ClinicalTrials.gov.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

The 45-second anterior knee pain provocation test: A quick test of knee pain and sporting function in 10-14-year-old adolescents with patellofemoral pain

OBJECTIVE

To test 1) if the 45-second Anterior Knee Pain Provocation Test (AKPP-test) could differentiate between adolescents with patellofemoral pain (PFP) and pain-free controls and; 2) whether improvements in the AKPP-test over 12 weeks were associated with improvements in self-reported knee function and pain.

DESIGN

Prospective cohort.

PATIENTS

151 with PFP and 50 pain-free controls (age 10-14 years).

OUTCOMES

The AKPP-test was performed at baseline, 4- and 12-week follow-up. Pain and function were collected using Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

At baseline, the AKPP-test provoked pain to a median of 5 points (IQR: 3-7) on the 0-10 Numeric Pain Rating Scale in adolescents with PFP, compared to 0 (IQR 0-0) in controls. Higher pain during the AKPP-test was associated with worse KOOS-Sport/Rec (r = -0.33, P < 0.001), worse KOOS-Pain (r = -0.47, P < 0.001), and pain intensity (worst pain last 24 hours) (r = -0.39, P < 0.001) at baseline. Improvements in the AKPP-test over 12 weeks were associated with improvements in KOOS Pain (r = 0.48, P < 0.001) and KOOS Sport/Rec (r = 0.40, P < 0.001).

CONCLUSIONS

Improvements in the AKPP-test were associated with improvements in self-report knee pain and limitations in sports, suggesting the AKPP-test may be a clinically responsive test of knee pain and sporting function in adolescents with PFP.

Implementing the 27 PRISMA 2020 Statement items for systematic reviews in the sport and exercise medicine, musculoskeletal rehabilitation and sports science fields: the PERSiST (implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science) guidance

Poor reporting of medical and healthcare systematic reviews is a problem from which the sports and exercise medicine, musculoskeletal rehabilitation, and sports science fields are not immune. Transparent, accurate and comprehensive systematic review reporting helps researchers replicate methods, readers understand what was done and why, and clinicians and policy-makers implement results in practice. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and its accompanying Explanation and Elaboration document provide general reporting examples for systematic reviews of healthcare interventions. However, implementation guidance for sport and exercise medicine, musculoskeletal rehabilitation, and sports science does not exist. The Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science (PERSiST) guidance attempts to address this problem. Nineteen content experts collaborated with three methods experts to identify examples of exemplary reporting in systematic reviews in sport and exercise medicine (including physical activity), musculoskeletal rehabilitation (including physiotherapy), and sports science, for each of the PRISMA 2020 Statement items. PERSiST aims to help: (1) systematic reviewers improve the transparency and reporting of systematic reviews and (2) journal editors and peer reviewers make informed decisions about systematic review reporting quality.

Rapid and Laboratory SARS-CoV-2 Antibody Testing in High-Risk Hospital Associated Cohorts of Unknown COVID-19 Exposure, a Validation and Epidemiological Study After the First Wave of the Pandemic

Objective: We aimed to use SARS-CoV-2 antibody tests to assess the asymptomatic seroprevalence of individuals in high-risk hospital cohorts who's previous COVID-19 exposure is unknown; staff, and patients requiring haemodialysis or chemotherapy after the first wave.

Methods: In a single Center, study participants had five SARS-CoV-2 antibody tests done simultaneously; one rapid diagnostic test (RDT) (Superbio Colloidal Gold IgM/IgG), and four laboratory tests (Roche Elecsys® Anti-SARS-CoV-2 IgG [RE], Abbott Architect i2000SR IgG [AAr], Abbott Alinity IgG [AAl], and Abbott Architect IgM CMIA). To determine seroprevalence, only positive test results on laboratory assay were considered true positives.

Results: There were 157 participants, of whom 103 (65.6%) were female with a median age of 50 years (range 19–90). The IgG component of the RDT showed a high number of false positives (n = 18), was inferior to the laboratory assays (p < 0.001 RDT vs. AAl/AAr, p < 0.001 RDT vs. RE), and had reduced specificity (85.5% vs. AAl/AAr, 87.2% vs. RE). Sero-concordance was 97.5% between IgG laboratory assays (RE vs. AAl/AAr). Specificity of the IgM component of the RDT compared to Abbott IgM CMIA was 95.4%. Ten participants had positivity in at least one laboratory assay, seven (9.9%) of which were seen in HCWs. Two (4.1%) hematology/oncology (H/O) patients and a single (2.7%) haemodialysis (HD) were asymptomatically seropositive. Asymptomatic seroprevalence of HCWs compared to patients was not significant (p = 0.105).

Conclusion: HCWs (9.9%) had higher, although non-significant asymptomatic seroprevalence of SARS-CoV-2 antibodies compared to high-risk patients (H/O 4.1%, HD 2.7%). An IgM/IgG rapid diagnostic test was inferior to laboratory assays. Sero-concordance of 97.5% was found between IgG laboratory assays, RE vs. AAl/AAr.

Urinary biomarkers predict progression and adverse outcomes ofacute kidney injury in critical illness

BACKGROUND

Acute Kidney Injury (AKI) is common in hospitalized patients and is associated with high morbidity and mortality. The Dublin Acute Biomarker Group Evaluation (DAMAGE) Study is a prospective cohort study of critically ill patients (n = 717). We hypothesised that novel urinary biomarkers would predict progression of AKI and associated outcomes.

METHODS

The primary (diagnostic) analysis assessed the ability of biomarkers levels at the time of early Stage 1 or2 AKI to predict progression to higher AKI Stage, RRT or Death within 7 days of ICU admission. In the secondary (prognostic) analysis, we investigated the association between biomarker levels and RRT or Death within 30 days.

RESULTS

In total, 186 patients had an AKI within 7 days of admission. In the primary (diagnostic) analysis, eight of the 14 biomarkers were independently associated with progression. The best predictors were Cystatin C (aOR 5.2; 95% CI, 1.3-23.6), IL-18 (aOR 5.1; 95% CI, 1.8-15.7), Albumin (aOR 4.9; 95% CI, 1.5-18.3) and NGAL (aOR 4.6; 95% CI, 1.4-17.9). ROC and Net Reclassification Index analyses similarly demonstrated improved prediction by these biomarkers. In the secondary (prognostic) analysis of Stage 1-3 AKI cases, IL-18, NGAL, Albumin, and MCP-1 were also independently associated with RRT or Death within 30 days.

CONCLUSIONS

Among 14 novel urinary biomarkers assessed, Cystatin C, IL-18, Albumin and NGAL were the best predictors of Stage 1-2 AKI progression. These biomarkers, after further validation, may have utility to inform diagnostic and prognostic assessment and guide management of AKI in critically ill patients.

Is the Prognosis of Osgood-Schlatter Poorer Than Anticipated? A Prospective Cohort Study With 24-Month Follow-up

BACKGROUND

Osgood-Schlatter disease (OSD), an apophyseal injury of the tibial tuberosity, affects up to 1 in 10 adolescents. This condition has previously been assumed to be innocuous and to self-resolve with limited intervention.

PURPOSE

To investigate the 24-month prognosis of OSD and examine if ultrasound (US) classification is associated with outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study included a preregistered prospective cohort of 51 adolescents (aged 10-14 years) diagnosed with OSD who were evaluated for 24 months. The primary outcome at 24-month follow-up was whether participants continued to experience OSD-related knee pain. Baseline US scans were collected and characterized by OSD type (De Flaviis classification) as well as maturation of the tibial tuberosity. Secondary outcomes included sports participation, Knee injury and Osteoarthritis Outcome Score (KOOS) Sport/Recreation subscale, and health-related quality of life (European Quality of Life-5 Dimensions-Youth [EQ-5D-Y]). All participants were invited for re-examination by US at follow-up.

RESULTS

A total of 51 patients preregistered for the study, with 90% (n = 46) available at follow-up. Of these 46 participants, 37% (n = 17) still reported knee pain due to OSD. In this subgroup, the median duration since symptom onset was 42 months (interquartile range, 38-51 months). More than 1 in 5 participants reported stopping sport due to knee pain, and those who continued to experience knee pain reported significantly worse KOOS Sport/Recreation scores at follow-up compared with patients with no knee pain (mean 74 [95% CI, 63-84] vs 91 [95% CI, 85-97]). Participants with continued OSD-related pain also had lower health-related quality of life (mean difference in EQ-5D-Y, 0.11 [95% CI, 0.06-0.13]). Higher De Flaviis classification at baseline was significantly associated with an increased risk of knee pain at 2 years. Diagnostic US at follow-up demonstrated primarily tendon changes (thickening, positive Doppler signal), as well as an ununited ossicle in 32% of participants who underwent US scanning at follow-up.

CONCLUSION

Over one-third of the study participants had knee pain at 2-year follow-up, which was associated with lower sports related function and health related quality of life. This questions the assumption that all patients with OSD experience quick recovery. Participants without any changes on imaging at baseline were less likely to report pain at follow-up.

Development and validation of the Sorting non-trauMatIc adoLescent knEe pain (SMILE) tool - a development and initial validation study

BACKGROUND

Despite the commonality of adolescent knee pain, there are no tools to support medical doctors to correctly diagnose knee pain. This study aimed to develop and evaluate a support tool for diagnosing the most common types of non-traumatic adolescent knee pain.

METHOD

A systematic search on Medline identified the literature on clinical tests and diagnoses of adolescent knee pain. The search was supplemented by textbooks and transformed into a diagnostic flowchart based on onset, symptoms, and pain localisation. This tool was revised based on feedback from general practitioners and experts in sports medicine. The tool was evaluated on two separate days with blinded assessors. Overall, 27 participants (aged 10-17 years) with non-traumatic knee pain were included. All participants were diagnosed by medical doctors or medical students, without and with the use of the tool. Diagnoses were compared to a gold standard (expert clinician). An interview to inform optimisations of the tool was performed with the assessors. Percentage agreement with the gold standard, and Kappa statistic for interrater reliability were calculated.

RESULTS

The final tool improved diagnostic agreement with the gold standard from 22.7% (95% CI 10.3-35.1) to 77.3% (95% CI 64.9-89.7). Inter-rater reliability increased from poor agreement k = - 0.04 (95% CI, - 0.12-0.04) to moderate agreement k = 0.56 (95% CI, 0.40-0.72).

CONCLUSION

This simple diagnostic tool is quick to use and may assist doctors in diagnosing non-traumatic knee pain in adolescents.

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.

OP0084 CENTRAL MECHANISMS TRAIT PREDICTS PERSISTENT KNEE OSTEOARTHRITIS PAIN AT 24-MONTHS: DATA FROM THE OSTEOARTHRITIS INITIATIVE

Background:

In the UK, 10% of men and 18% of women over the age of 60 suffer from symptomatic osteoarthritis (OA), and rising. OA knee pain can worsen without significant radiographic changes and pain remains a major problem for up to 20% of patients after total knee joint replacement. Chronic knee OA pain is augmented by central pain mechanisms, including central sensitisation. Measures of the level of central involvement in pain could inform clinical decision making. Self-report characteristics of depression, anxiety, cognitive difficulties, catastrophizing, sleep disturbance, fatigue, and widespread pain distribution together contribute to a Central Mechanisms Trait which is associated with central sensitisation and OA knee pain

Objectives:

Using self-report questionnaire data from the Osteoarthritis Initiative Cohort Study (OAI) we aimed to evaluate the prognostic performance of baseline CMT for pain at 24-months.

Methods:

OAI participants with knee OA or at risk of knee OA with pain in the same knee at both index time point (48-months) and one year prior to that date were included (n=1984). Knee pain was measured using the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) pain sub-scale, by reference to the index knee (the knee with the highest WOMAC pain sub-scale score at baseline). Questionnaire items were selected to assess the 7 available characteristics identified by Akin-Akinyosoye et al.[1], from which a single CMT factor was calculated by confirmatory factor analysis. Anxiety, fatigue and cognitive difficulties were assessed by single items, depression and sleep disturbance represented by multiple items, and catastrophising by using the Coping Strategies Questionnaire – Catastrophising sub-scale. Pain distribution was defined as a sum of other painful joints at or below the hip. A CMT factor was derived from the 7 characteristics using confirmatory factor analysis. The association between the CMT factor score and 24-month pain (adjusted for baseline pain, radiographic OA (Kellgren-Lawrence (KL) scale) and demographic confounders) was investigated using generalised linear regression with a negative binomial link function.

Results:

At baseline, participants had a mean (SD) age 65(9) years, a BMI 29.6(5.1) kg/m2, 60% were female, 19.8% were African American, KL score was 1.92(1.35) indicating that the majority of the cohort had radiographic OA. Model diagnostics informed the CMT model, with the final model having an RMSEA of 0.073 (90%CI 0.070-0.076). Data were consistent with a single factor model for CMT. In the multivariable model, higher baseline CMT scores were significantly associated with 24-month WOMAC pain scores, with or without adjustment for baseline pain and other covariates, including KL score (multivariable model; std beta=0.173 (SE=0.027), p=0.004). Association of baseline CMT was of similar strength, and over and above association of KL score with 24-month pain (std beta=0.164 (SE=0.038), p=<0.001). Adjusted regression coefficients and associated p-values are shown in Table 1.

Table 1.

Adjusted regression coefficients for analysed variables against WOMAC pain at 24-months

VariablesStd beta (SE)PSex-0.096 (0.101)0.344Age, y-0.001 (0.006)0.881BMI, kg/m20.017 (0.010)0.088Index Knee Kellgren-Lawrence Score0.164 (0.038)<0.001CMT Factor Score0.173 (0.060)0.004Baseline Pain0.857 (0.035)<0.001

n=1421, rows in bold indicate significant association (p<0.05), associations adjusted for race and ethnicity

Conclusion:

CMT predicts worse pain prognosis with a similar magnitude to radiographic OA even after adjustment for other factors. A self-report tool which included items relevant to the characteristics included in the CMT may help to select people with OA knee pain with unfavourable pain prognosis. Poor outcomes related to central pain mechanisms or to joint structural damage might be amenable to treatments addressing central or peripheral pain mechanisms respectively.

References:

[1]Akin-Akinyosoye et al., PAIN, 2018. 159(6): p. 1035-1044.

Acknowledgements:

This abstract was prepared using an Osteoarthritis Initiative (OAI) public use data set and does not necessarily reflect the opinions or views of the OAI investigators, the NIH, or the private funding partners. The authors wish to thank the participants, principal investigators, co-investigators and staff of all the hospitals who have contributed data to the OAI. The OAI is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by the OAI Study Investigators. Private funding partners include Merck Research Laboratories; Novartis Pharmaceuticals Corporation, GlaxoSmithKline; and Pfizer, Inc. Private sector funding for the OAI is managed by the Foundation for the National Institutes of Health.

Disclosure of Interests:

Samuel Holden: None declared, Daniel McWilliams Grant/research support from: Pfizer and Eli Lilly, Stephanie Smith: None declared, David Walsh Consultant of: Pfizer, Eli Lilly, AbbVie and GlaxoSmithKline, Grant/research support from: Pfizer and Eli Lilly

Prognosis and transition of multi-site pain during the course of 5 years: Results of knee pain and function from a prospective cohort study among 756 adolescents

INTRODUCTION

Multi-site pain has not been investigated among adolescents suffering from knee pain. This study aimed to examine the trajectory of pain in adolescents with knee-pain, to determine if multi-site pain in adolescents together with other established prognostic factors (frequency of pain, sex, sports participation, Health Related Quality of Life (HRQoL)) was associated with five-year prognosis of knee-pain and function.

METHODS

This prospective cohort study included 504 adolescents with knee pain and 252 controls. At five-year follow-up, participants responded to an questionnaire which documented prescence and severity of knee pain and co-occurring pain.

RESULTS

At follow-up, 358 (71.0%) of those with knee-pain at baseline, and 182 (72.2%) controls responded. Female sex, low HRQoL, daily pain, and multi-site pain were associated with an increased odds of knee pain after 5 years (odds ratio: 1.41-3.37). Baseline multi-site pain was not associated with problems running at follow-up, whereas higher sports participation at baseline was associated with less problems running at follow-up (odd ratio 0.49). Among those with knee-pain at inclusion, the number of pain sites increased from a median of 2 (IQR 1-3) to 4 (IQR 2-6) at follow-up (P<0.05). Those with multi-site pain at follow-up score significantly worse in self-reported knee function, compared to those with one pain site only.

CONCLUSION

This study identified a set of factors that appeared to be associated with an increased risk of knee pain at five years follow up. Research is needed to understand and help direct treatment of adolescents with multi-site pain.

From intent to implementation: Factors affecting public involvement in life science research

Public involvement is key to closing the gap between research production and research use, and the only way to achieving ultimate transparency in science. The majority of life science research is not public-facing, but is funded by the public and impacts communities. We undertook an exploratory survey of researchers within the life sciences to better understand their views and perceived challenges to involving the public in their research. As survey response rate could not be determined, interpretation of the results must be cautious. We had a valid response cohort of n = 110 researchers, of whom 90% were primarily laboratory based. Using a mixed methods approach, we demonstrate that a top-down approach is key to motivate progression of life scientists from feeling positive towards public involvement to actually engaging in it. Researchers who viewed public involvement as beneficial to their research were more likely to have direct experience of doing it. We demonstrate that the systemic flaws in the way life sciences research enterprise is organised, including the promotion system, hyper-competition, and time pressures are major barriers to involving the public in the scientific process. Scientists are also apprehensive of being involuntarily involved in the current politicized climate; misinformation and publicity hype surrounding science nowadays makes them hesitant to share their early and in-progress research. The time required to deliberate study design and relevance, plan and build relationships for sustained involvement, provide and undertake training, and improve communication in the current research environment is often considered nonpragmatic, particularly for early career researchers. In conclusion, a top-down approach involving institutional incentives and infrastructure appears most effective at transitioning researchers from feeling positive towards public involvement to actually implementing it.

Early drain removal does not increase the rate of surgical site infections following an open transversus abdominis release

PURPOSE

Intraoperative drain placement during an open transversus abdominis release (TAR) is common practice. However, evidence detailing the optimal timing of drain removal is lacking. Surgical dogma teaches that drains should remain in place until output is minimal. This practice increases the risk of drain-associated complications (infection, pain, and skin irritation) and prolongs the burden of surgical drain maintenance. The objective of this study is to review infectious outcomes following TAR with early or late drain removal.

METHODS

Patients who underwent an open bilateral TAR from 1/2018 to 1/2020 were eligible for the study. Prior to 2019, one of the two intraoperative drains was left in place at discharge. In 2019, clinical practice shifted to remove both drains at hospital discharge irrespective of output. The rate of infectious morbidity was compared between the two cohorts.

RESULTS

A total of 184 patients were included: 89 late and 95 early drain removal. No differences in wound complications existed between the two cohorts: surgical site occurrence (SSO): 21.3% vs. 18.9% (p = 0.68); surgical site infection (SSI): 14.6% vs. 10.5% (p = 0.40); abscess: 8.9% vs. 4.2% (p = 0.20); seroma: 6.7% vs. 10.5% (p = 0.36); cellulitis: 14.6% vs. 8.4% (p = 0.19%); or SSO requiring procedural intervention (SSOPI): 5.6% vs. 5.2% (p = 0.92). Rates of antibiotic prescription and 30-day readmission were also similar (p = 0.69 and p = 0.89).

CONCLUSIONS

Early removal of abdominal wall surgical drains at discharge irrespective of drain output does not increase the prevalence of infectious morbidity following TAR. It is likely safe to remove all drains at discharge regardless of drain output.

Current management strategies in Osgood Schlatter: A cross-sectional mixed-method study

BACKGROUND

Osgood Schlatter disease (OSD) is the most common knee condition in adolescent athletes aged 9-16. Without evidence to guide clinical practice, it is unclear how OSD is managed. The aim of this study was to investigate how international healthcare professionals (general practitioners, physiotherapists, rheumatologists, sports and exercise medicine doctors, and orthopedic surgeons) diagnose and manage OSD.

METHODS

This mixed-method study used a convergent parallel design. A quantitative questionnaire and semi-structured interview covered prognosis, diagnosis, treatment, and return to play of adolescents with OSD. For quantitative data, those who reported likely/very likely considered "for" and unlikely/very unlikely "against" (for specific diagnostic/management strategy). Qualitative data analysis used a phenomenological approach.

RESULTS

Two hundred and fifty-one healthcare professionals completed the questionnaire. The most common diagnostic criterion was pain at the tibial tuberosity (97% for). The most common treatments were patient education (99%) and exercise therapy (92%). Other treatment options were more heterogeneous, for example, pain medication (31% for and 34% against). Managing training load (97%), pain intensity (87%), and psychological factors (86%) were considered the most important factors influencing the return to activities. Several themes emerged from the interviews (on N = 20) including imaging, pain management, family, and psychosocial factors influencing prognosis.

CONCLUSION

Diagnosis criteria of OSD were relatively well agreed upon, whereas the triangulation of qualitative and quantitative data showed heterogeneity of treatments. Psychosocial factors including family were highlighted as critical in the management of OSD.

Patients and clinicians managing patellofemoral pain should not rely on general web-based information

OBJECTIVE

To evaluate the credibility and accuracy of PFP-specific web-based content.

DESIGN

Cross-sectional evaluation of web-based information.

METHODS

The study protocol was registered with PROSPERO (CRD42018088671). Two search engines (Google and Bing) were used to search for websites offering information about PFP. Two reviewers assessed the websites for credibility-related and PFP-specific content. PFP-specific content was evaluated according to agreement with current international PFP consensus statements. Based on this, content was rated as (i) Accurate/Clearly described; (ii) Partially accurate/Description lacks clarity; (iii) Inaccurate/Misleading description; or (iv) Not mentioned.

RESULTS

After exclusion of duplicates, forty online websites were included in our analyses. 43% of websites did not mention their source of information, and 48% did not mention if the source material was peer-reviewed. Misleading/inaccurate information was most commonly found in the definition of PFP (20% websites) and clinical examination (15%). Twenty-two percent of websites recommended surgery as treatment. The item most frequently rated as accurate/clearly described was PFP terminology (87.5%).

CONCLUSION

This study highlights missing, inaccurate or poorly described web-based PFP information. Due to the commonality of PFP and potential for improving self-management, there is an urgent need to develop more accurate and comprehensive web-based patient education resources for PFP.

The Adolescent Knee Pain (AK-Pain) prognostic tool: protocol for a prospective cohort study

Background: One in three children and adolescents experience knee pain. Approximately one in two adolescents with knee pain will continue to experience pain even five years later and have low quality of life. The general practitioner (GP) is the first point of contact for children and adolescents with knee pain in Denmark. There is a variety of treatments being delivered in general practice, despite similar symptoms and patients' characteristics. This suggests a need to support the GPs in identifying those at high risk of a poor outcome early on, in order to better allocate resources. The aim of this study is to develop a user-friendly prognostic tool to support GPs' management of children and adolescents' knee pain. Methods: A preliminary set of items in the prognostic tool were identified using systematic reviews and meta-analysis of individual participant data. Following feedback from GPs and children and adolescents on the content and understanding, the tool was piloted and implemented in general practice. A cohort of approximately 300 children and adolescents (age 8-19 years old) is being recruited from general practices (recruitment period, July 2019 - June 2020). Clinically meaningful risk groups (e.g. low/medium/high) for the recurrence/persistence of knee pain (at 3 and 6 months) will be identified. Discussion: If successful, this prognostic tool will allow GPs to gain insights into the likely prognosis of adolescents with knee pain and subsequently provide the first building blocks towards stratified care, where treatments will be matched to the patients' prognostic profile. This has the potential to improve the recovery of children and adolescents from knee pain, to improve the allocation of resources in primary care, and to avoid the decline in physical activity and potential associated health and social consequences due to adolescent knee pain. Registration: Registered with ClinicalTrials.gov on 24 June 2019 (ID NCT03995771).

Long-term Prognosis and Impact of Osgood-Schlatter Disease 4 Years After Diagnosis: A Retrospective Study

Background:

Knee pain is common during adolescence, with Osgood-Schlatter disease (OSD) being the most frequent condition. Despite this, research regarding the long-term prognosis of OSD is limited.

Purpose:

To evaluate the prognosis 2 to 6 years after the diagnosis of OSD.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective cohort study included patients diagnosed with OSD at a single orthopaedic department between 2010 and 2016. Patients were contacted in 2018 and asked to complete a self-reported questionnaire regarding knee pain, knee function (Knee injury and Osteoarthritis Outcome Score [KOOS] Sports/Recreation subscale), Health-related quality of life (HRQoL) (youth version of EuroQol 5 dimensions 3 levels [EQ-5D-3L-Y]), and physical activity.

Results:

Out of 84 patients, 43 responded. Of these, 60.5% (n = 26) reported OSD-related knee pain at follow-up (median follow-up, 3.75 years). The median symptom duration was 90 months (interquartile range, 24-150 months) for those still experiencing knee pain, and 42.9% of these reported daily knee pain. Fifty-four percent with knee pain had reduced their sports participation compared with 35.3% of those without knee pain. KOOS Sports/Recreation subscale scores were significantly lower in those with knee pain compared with those without knee pain (53 [95% CI, 42-63] vs 85 [95% CI, 76-94], respectively). Participants with knee pain reported lower HRQoL (0.71 [95% CI, 0.57-0.84]) compared with those without knee pain (0.99 [95% CI, 0.97-1.00]).

Conclusion:

This study indicates that OSD may not always be self-limiting. The lower self-reported function and HRQoL in those with continued pain may be a consequence of impaired physical activity due to knee pain.

Comorbid insomnia, psychological symptoms and widespread pain among patients suffering from musculoskeletal pain in general practice: a cross-sectional study

OBJECTIVE

The aim of this study was to examine the association between musculoskeletal (MSK) pain, insomnia, anxiety and depressive symptoms in patients from general practice.

DESIGN

This is a cross-sectional study.

SETTING

This study was conducted in general practice in Denmark.

PARTICIPANTS

A consecutive sample of 390 general practice patients (aged 12 years or older) were included; 183 patients with MSK pain and 207 patients without MSK pain. To be included in the MSK pain group, participants with MSK pain were required to report MSK pain at least weekly during the preceding month, which had a negative impact on daily activities.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was insomnia evaluated by the Athens Insomnia Scale. The secondary outcomes were psychological symptoms assessed by the Hospital Anxiety and Depression Scale.

RESULTS

Patients with MSK pain had a significantly higher prevalence of insomnia (difference 25.5%, p<0.0001), anxiety (difference 24.3%, p<0.0001) and depressive symptoms (difference 11%, p<0.0001) compared with patients without MSK pain. Furthermore, patients with MSK pain and comorbid insomnia had significantly higher levels of anxiety and symptoms of depression compared with patients with MSK pain without insomnia (p<0.0001). These relationships remained robust when controlling for age, sex and body mass index in linear regression.

CONCLUSION

One in two patients in general practice report MSK pain. Comorbid MSK pain and insomnia are common and are associated with a higher prevalence of anxiety and depression. This highlights the importance of establishing the presence of insomnia and affective disorders as potentially modifiable factors during treatment of MSK pain in general practice.

Associations between number of pain sites and sleep, sports participation, and quality of life: a cross-sectional survey of 1021 youth from the Midwestern United States

BACKGROUND

Musculoskeletal pain in youth is common but little is known about the influence of the number of pain sites on pain characteristics. The objective of this study was to compare pain characteristics, quality of life, sleep, sport participation between adolescents without pain, those with single site pain, and those with multi-site pain and investigate the relationship between pain duration and number of pain sites.

METHODS

An online survey was sent via email to 7177 possible middle- and high-school students. The students completed a survey containing questions about their pain (including location, duration, intensity, frequency), health-related quality of life, sleep quantity and quality, and sports participation. Quantitative variables were analysed with one-way ANOVAs or t-tests and qualitative variables were analysed with Pearson Chi-squared tests. Relationships were investigated with a Pearson Correlation.

RESULTS

Of the respondents (n = 1021), 52.9% reported no pain, 17.2% reported pain in a single-site, and 29.9% reported pain in multiple sites. Those with multi-site pain reported significantly lower quality of life than both pain-free youth (p < 0.001) and those with single-site pain (p < 0.001); those with single-site pain had lower quality of life than pain-free youth (p < 0.001). Those with pain reported worse sleep than those without pain (P < 0.05). No differences in sport participation were found (p > 0.10). Those with multi-site pain reported greater intensity (p = 0.005) and duration (p < 0.001) than those with single-site pain. A positive, moderate, and significant correlation (r = 0.437, p < 0.001) was found between the pain duration and number of pain sites.

CONCLUSIONS

A large percentage of youth experience regular pain that affects their self-reported quality of life and sleep, with greater effects in those with multi-site pain.

Five-year prognosis and impact of adolescent knee pain: a prospective population-based cohort study of 504 adolescents in Denmark

OBJECTIVES

Investigate the prognosis of adolescent knee pain, and evaluate its impact on health, care-seeking and career choices 5 years later.

DESIGN

Pre-registered, prospective cohort study.

SETTING

Population-based cohort initiated in school setting.

PARTICIPANTS

From a cohort of 2200 adolescents aged 15-19 years in 2011, 504 reported knee pain on at least a monthly basis, and were followed prospectively in this cohort study, together with 252 controls who did not have knee pain in 2011.

MAIN OUTCOME MEASURES

Outcomes included the Pain and Symptoms subscales from the Knee injury and Osteoarthritis Outcome Score (KOOS), pain intensity measured with a Numeric Rating Scale, pain frequency, knee-related and health-related quality of life, sports participation, physical activity level, KOOS subscales: Function and Sport/recreation, quality of sleep, healthcare consultations, treatments received for their knee pain, the use of painkillers and impact on choice of job or career.

RESULTS

At follow-up, 358 (71.0%) from the knee pain group and 182 (72.2%) from the control group responded. Of note, 40.5% (95% CI: 35.4% to 45.6%) from the knee pain group reported knee pain 5 years later which was frequent and intense compared with 13.2% (95% CI: 8.2 to 18.1) of the control group. Those from the knee pain group still suffering from knee pain reported poorer physical health (13 points worse on KOOS Function and 30 points worse on KOOS Sport/recreation), stopped or reduced their sports participation because of knee pain (60%), reported worse sleep quality and worse knee-related and general quality of life. In terms of health behaviours, those still with knee pain reported more healthcare consultations. One-third used pain killers regularly, and 15% (95% CI: 12% to 20%) reported that knee pain influenced their choice of job or career.

CONCLUSION

Four out of every 10 adolescents with knee pain still experienced frequent and intense knee pain 5 years later, severe enough to impact health, health behaviours and career choices.

TRAIL REGISTRATION NUMBER

NCT02873143.

Conditioning pain modulation reduces pain only during the first stimulation of the temporal summation of pain paradigm in healthy participants

BACKGROUND

Pro-nociceptive and anti-nociceptive mechanisms are commonly assessed in clinical and experimental pain studies, but their potential interaction is not well understood.

OBJECTIVES

Investigate the effect of conditioning pain modulation (CPM) on temporal summation of pain (TSP).

METHODS

Twenty healthy participants underwent cuff algometry assessment on the lower legs to establish the pressure pain tolerance threshold (PTT). For the TSP assessment, ten stimuli at the level of the PTT were delivered by computerised cuff inflations (1-s stimulation, 1-s break) while participants rated pain intensity on a 10-cm electronic visual analogue scale (VAS). This TSP paradigm was then repeated with a simultaneous conditioning stimulus induced by a cuff on the contralateral leg, inflated to a constant pressure corresponding to 30% (mild), 70% (moderate) or 100% (severe) of the PTT. These were assessed in a randomised order, with a fifteen-minute break between tests. A final TSP test without conditioning was reassessed at the end (post-recording).

RESULTS

An interaction between stimuli (1-10) and repetition (p < 0.05) was found for VAS scores. VAS scores for the first stimulus were decreased during 30%, 70%, and 100% conditioning intensities, compared to baseline and post-recordings (p < 0.05). There was a significant increase in TSP during conditioning (p < 0.05). There were no significant differences between baseline and post-recordings for any stimuli (p > 0.05).

CONCLUSIONS

The current study indicates that mild to severe stimuli administered by cuff algometry does not modulate summation effect of temporal summation of pain, which could indicate that pain facilitatory mechanisms are more potent compared with pain inhibitory mechanisms.

SIGNIFICANCE

Current knowledge on the interaction effect of pro and anti-nociceptive paradigms are the lacking. The current study indicates that conditioning pain modulation does not modulate the summation effect of temporal summation of pain, when evaluated by computerized pressure algometry. This finding was independent of the mild, moderate and severe painful conditioning intensities.

Transparency in the eye region of an ostracod carapace ( Macrocypridina castanea, Myodocopida)

Many myodocopid ostracods are unusual in that they have well-developed compound eyes yet must view their environment through a shell. The cypridinid Macrocypridina castanea is relatively large among ostracods (about 5-10 mm) and is a pelagic predator. This species possess highly pigmented shells with a transparent region lying just above the eye. Here we examine the ultrastructure and transparency of this window using electron microscopy, serial-block face scanning electron microscopy and X-ray diffraction analysis and optical modelling. An internal, laminar stack was identified within the window region of the shell that formed a more regular half-wave reflector than in non-window regions, and where the distance between molecules in the chitin-protein fibrils decreases as compared to the non-window area. This results in excellent transmission properties-at around 99% transmission-for wavelengths between 350 and 630 nm due to its half-wave reflector organization. Therefore, blue light, common in the mid and deep sea, where this species inhabits, would be near-optimally transmitted as a consequence of the sub-micrometre structuring of the shell, thus optimizing the ostracod's vision. Further, pore canals were identified in the shell that may secrete substances to prevent microbial growth, and subsequently maintain transparency, on the shell surface. This article is part of the theme issue 'Bioinspired materials and surfaces for green science and technology'.

Sex differences in sagittal plane control emerge during adolescent growth: a prospective investigation

PURPOSE

Females athletes have a higher incidence of non-contact knee joint injuries compared to their male counterparts. This may be attributable to sex-specific differences in neuromuscular control, which arise during the pubertal growth spurt. The purpose of this longitudinal study was to assess the development of landing kinematics of adolescent male and female athletes during the adolescent growth-spurt.

METHODS

One hundred and eighty-four adolescent athletes (55% male, 45% female; mean age = 13 ± 0.3 years) participated. Testing was undertaken at baseline and then repeated at 6, 12, 18 and 24 months. Participants performed three drop vertical jump (DVJ) trials from a 31 cm box. Frontal and sagittal plane knee joint angles were recorded. The average measurement of the three jumps was used for analysis at each time point. To assess maturation status, participants were categorised according to their age from peak height velocity at baseline. Pre-initial contact knee flexion (pre-IC), peak knee flexion and knee valgus displacement were the dependant variables. The categorical independent variables were sex (male versus female) and time.

RESULTS

There was a significant sex*time interaction for pre-IC knee flexion, with males increasing knee flexion with time to a greater extent than females. There was no significant sex*time interaction for knee valgus displacement; although females displayed greater knee valgus displacement across all time points.

CONCLUSIONS

Adolescent male and female athletes display differing kinematic profiles across growth and development. This has clinical relevance for emphasising increased knee flexion, as well as decreasing abnormal frontal plane displacement in injury prevention programmes for adolescent females.

LEVEL OF EVIDENCE

II.

Point-of-Care Ultrasound in General Practice: A Systematic Review

PURPOSE

Ultrasound examinations are currently being implemented in general practice. This study aimed to systematically review the literature on the training in and use of point-of-care ultrasound (POCUS) by general practitioners.

METHODS

We followed the Cochrane guidelines for conduct and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. We searched the databases MEDLINE (via PubMed), EMBASE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials using the key words ultrasonography and general practice in combination and using thesaurus terms. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist.

RESULTS

We included in our review a total of 51 full-text articles. POCUS was applied for a variety of purposes, with the majority of scans focused on abdominal and obstetric indications. The length of training programs varied from 2 to 320 hours. Competence in some types of focused ultrasound scans could be attained with only few hours of training. Focused POCUS scans were reported to have a higher diagnostic accuracy and be associated with less harm than more comprehensive scans or screening scans. The included studies were of a low quality, however, mainly because of issues with design and reporting.

CONCLUSIONS

POCUS has the potential to be an important tool for the general practitioner and may possibly reduce health care costs. Future research should aim to assess the quality of ultrasound scans in broader groups of general practitioners, further explore how these clinicians should be trained, and evaluate the clinical course of patients who undergo scanning by general practitioners.

Which treatment is most effective for patients with patellofemoral pain? A protocol for a living systematic review including network meta-analysis

INTRODUCTION

Patellofemoral pain (PFP) affects 1 in every 14 adults. Many treatments for PFP have been evaluated, but the comparative effectiveness of all available treatments has never been examined. Network meta-analysis is the only design to study the comparative effectiveness of all available treatments in one synthesis. This protocol describes the methods for a systematic review including network meta-analysis to assess which treatment is most likely to be effective for patients with PFP.

METHODS AND ANALYSIS

The primary outcome measures of this network meta-analysis are the global rating of change scale at 6-12 weeks, 13-52 weeks and >52 weeks. The secondary outcome measures are patient-rated pain scales at 6-12 weeks, 13-52 weeks and >52 weeks. Completed published and unpublished randomised controlled trials with full-text reports are eligible for inclusion. We will search Embase, PubMed (including MEDLINE), CENTRAL, Scopus, Web of Science, and CINAHL, SPORTDiscus, OpenGrey, WorldCat, conference Proceedings and multiple trial registers for relevant reports. Two researchers will appraise the study eligibility and perform data extraction. Risk of bias will be assessed with the Cochrane Risk of Bias Tool V.2.0.Bayesian network meta-analyses will be constructed for global rating of change scale and patient-rated pain. Consistency between direct and indirect comparisons will be assessed. Between study variability will be explored, and a threshold analysis for the credibility of the network meta-analyses' conclusions will be performed.

ETHICS AND DISSEMINATION

Ethical approval is not required, as this study will be based on published data. The study commenced at 1 February 2018, and its expected completion date is 15 January 2019. Full publication of the work will be sought in an international peer-reviewed journal, as well as translational articles to disseminate the work to clinical practitioners.

PROSPERO REGISTRATION NUMBER

CRD42018079502.

The effect of isometric exercise on pain in individuals with plantar fasciopathy: A randomized crossover trial

Isometric exercise is commonly recommended for immediate pain relief in individuals suffering from lower limb tendinopathies, despite the limited evidence supporting its analgesic effect. Due to the similarities between plantar fasciopathy and tendinopathies, the aim of this trial was to investigate the acute effect of isometric exercise on pain, compared to isotonic exercise, or walking, in individuals with plantar fasciopathy. We recruited 20 individuals with plantar fasciopathy for this prospectively-registered, participant-blinded, randomized, superiority crossover trial (ClinicalTrials.gov: NCT03264729). Participants attended three exercise sessions (isometric, isotonic, or walking) in a randomized order, within a 2-week period. Both isometric and isotonic exercises were performed standing with the forefoot on a step bench, while walking was performed barefoot. The primary outcome was pain (measured on a 0-100-mm VAS) during a pain-aggravating activity. Secondary outcomes included pressure pain threshold (PPT) under the heel, and plantar fascia thickness (PFT). All outcomes were measured before and after each exercise session. There were no significant differences between the three exercises on pain (P = 0.753), PPTs (P = 0.837), or PFT (P = 0.718). Further, there was no change in pain from before to after any of the exercises (isometric exercise 2.7 mm [95% CI: -12.2; 6.8], isotonic exercise -3.4 mm [95% CI: -5.0; 11.8], or walking 1.6 mm [95% CI: -16.1; 12.9]). Contrary to expectations, isometric exercise was no better than isotonic exercise or walking at reducing pain in individuals with plantar fasciopathy. None of the exercises induced any systematic analgesic effect.

Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review

Objective

Evaluate effectiveness and harms of interventions for patellar tendon related pain in children and adolescents.

Design

Systematic review and meta-analysis.

Data sources

Medline via Pubmed, Embase via OVID, CINAHL via Ebsco, SportDiscus up until 24 November 2017 were searched.

Eligibility criteria for selecting studies

Inclusion criteria were (1) controlled or randomised controlled clinical trials (RCTs), (2) participants with diagnosis of patellar tendon related disorder, (3) participants≤18 years of age at enrolment and (4) published in a peer-reviewed English or Scandinavian language journal.

Results

Of 530 studies identified, eight were included after screening, with three included in data synthesis. To be included in data synthesis, we required studies to have included (and have data available for) a minimum of 10 participants under 18 years. All studies were rated as being at high risk of bias. For adolescents with patellar tendinopathy, one RCT compared eccentric exercises to usual care and found no difference between groups. In adolescents with Osgood-Schlatter disease (OSD), injection of local anaesthetic with dextrose proved superior to either usual care or local anaesthetic alone (three armed RCTs). In a retrospective case controlled study in adolescents with OSD, surgery provided no benefit over conservative management in terms of persistent symptoms and had a higher complication rate.

Conclusion

There is weak evidence to support the use of dextrose injection with local anaesthetic and no evidence to support the use of specific types of exercises to treat children/adolescents with OSD/patellar tendinopathy. Until further evidence arises, clinicians should include load modification and advise on a return to sport based on symptoms.

Exercise therapy, patient education, and patellar taping in the treatment of adolescents with patellofemoral pain: a prospective pilot study with 6 months follow-up

Background

Patellofemoral pain (PFP) is the most common knee condition among adolescents, with a prevalence of 6–7% resulting in reduced function and quality of life. Exercise therapy is recommended for treating PFP, but has only been tested in older adolescents (15–19 years). This pilot study aimed to investigate the adherence to, and clinical effects of, exercise and patient education in young adolescents (12–16 years), with PFP.

Methods

Twenty adolescents (16 females) with PFP were recruited from a population-based cohort to undergo a 3-month multimodal intervention. This comprised of a 30-min patient education and group-based exercise therapy. Exercises included supervised lower extremity strength exercises three times per week, in addition to similar home-based strength exercises. Outcomes included a 7-point global rating of change scale (ranging from “completely recovered” to “worse than ever”), the Knee injury and Osteoarthritis Outcome Score (KOOS), physical activity scale (PAS), weekly sports participation and health-related quality of life measured by European Quality of Life 5 dimensions Youth (EQ-5DY) and isometric knee and hip muscle strength. Pain was measured on a visual analogue scale (VAS), and satisfaction treatment was measured on a five-point Likert scale ranging from “highly satisfied” to “not satisfied at all”. These were collected at 3- and 6-month follow-ups. Adherence to supervised exercise was measured as session attendance, and adolescent self-reported adherence to home-based exercises.

Results

Adherence to the exercise therapy was poor, with adolescents participating in a median of 16 (IQR 5.5–25) out of 39 possible supervised training session. Five out of 18 adolescents had a successful outcome after both 3 and 6 months. There were no relevant changes in isometric muscle strength.

Conclusion

This was the first study to investigate adherence to, and clinical effects of, exercise therapy and patient education in young adolescents with patellofemoral pain. Adherence to the exercise therapy was low with little to no clinical effects making a full clinical trial impractical. Future studies need to explore how an intervention can be successfully tailored to young adolescents with patellofemoral pain to obtain good adherence while improving pain and function.

ACL rupture is a single leg injury but a double leg problem: too much focus on 'symmetry' alone and that's not enough!

The authors present their thoughts on the focus on targeting asymmetry in rehabilitation after ACL reconstruction, which they think may not be rich enough to identify deficits.