Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

BACKGROUND

There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy.

METHODS

We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion.

RESULTS

At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted.

CONCLUSIONS

Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.

The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations

OBJECTIVE

To develop clinical practice guidelines concerning individual and group exercise therapy for knee and/or hip osteoarthritis (OA).

METHOD

We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, to develop the guidelines.

RESULTS

Physical exercises are proposed for knee and hip OA. The benefit of individual exercises is low to moderate for pain, strength and ability to walk. The effectiveness is not maintained over time if the individual exercise program is not continued. The benefit of group exercise is also low to moderate for pain, strength, balance and ability to walk. There is no evidence of the superiority of one modality over the other (individual or group).

CONCLUSION

More randomised controlled trials with good methodology are needed to compare the effectiveness of individual versus group exercise therapy for knee and hip OA.

3-D scapular kinematics during arm elevation: effect of motion velocity

BACKGROUND

No three-dimensional (3-D) data exist on the influence of motion velocity on scapular kinematics. The effect of arm elevation velocity has been studied only in a two-dimensional setting.

METHODS

Thirty healthy subjects performed dominant (right) arm elevation in two planes, sagittal and frontal, and at slow and fast self-selected arm speed. Scapular orientation and humeral elevation were measured at 30 Hz recording frequency with use of a 6-degree-of-freedom electromagnetic system (Polhemus Fastraka). Motion was computed according to the International Society of Biomechanics standards. Scapular orientation was also determined with the arm held in different static positions.

FINDINGS

We obtained a full 3-D kinematic description of scapula achieving a reliable, complex 3-D motion during humeral elevation and lowering. The maximal sagittal arm elevation showed a characteristic "M"-shape pattern of protraction/retraction curve. Scapular rotations did not differ significantly between slow and fast movements. Moreover, protraction/retraction and tilt angular values did not differ significantly between static and dynamic tasks. However, scapular lateral rotation values differed between static and dynamic measurements during sagittal and frontal arm elevation. Lateral scapular rotation appears to be less in static than in dynamic measurement, particularly in the sagittal plane.

INTERPRETATION

Interpolation of statically recorded positions of the bones cannot reflect the kinematics of the scapula.

Les échelles d'incapacité fonctionnelle de l'épaule : revue systématique

OBJECTIVES

To identify all available shoulder disability questionnaires designed to measure physical functioning and to examine those with satisfactory clinimetric quality.

METHODS

We used the Medline database and the "Guide des outils de mesure de l'évaluation en médecine physique et de réadaptation" textbook to search for questionnaires. Analysis took into account the development methodology, clinimetric quality of the instruments and frequency of their utilization. We classified the instruments according to the International Classification of Functioning, Disability and Health.

RESULTS

Thirty-eight instruments have been developed to measure disease-, shoulder- or upper extremity-specific outcome. Four scales assess upper-extremity disability and 3 others shoulder disability. We found 6 scales evaluating disability and shoulder pain, 7 scales measuring the quality of life in patients with various conditions of the shoulder, 14 scales combining objective and subjective measures, 2 pain scales and 2 unclassified scales. Older instruments developed before the advent of modern measurement development methodology usually combine objective and subjective measures. Recent instruments were designed with appropriate methodology. Most are self-administered questionnaires.

CONCLUSION

Numerous shoulder outcome measure instruments are available. There is no "gold standard" for assessing shoulder function outcome in the general population.

Tête tombante fixée : efficacité d'une rééducation intensive

OBJECTIVES

To point out the diagnostic and etiologic context of neck extensor weakness and to consider orthopedic and rehabilitation treatment of dropped head syndrome.

METHODS

We report a case of a 68-year-old hospitalized woman with atypical and serious idiopathic neck extensor weakness who was treated by orthopedic measurements and intensive rehabilitation.

RESULTS

Our patient had progressive neck extensor weakness and total inflection of the cervico-cephalic axis over two years. Fixed and permanent contact of the chin and the sternum severely affected her ability to eat, and mandibular and sternal pressure ulcers developed. Cervical spine radiography revealed degenerative lesions. Other clinical and biological parameters were normal. Atypical idiopathic head drop was diagnosed because of painful and fixed head position. Rehabilitation consisted of cervical traction with a halo apparatus during eight weeks and an exercise programme based on cervical proprioception and muscular work. Orthopedic management consisted of cervical collar immobilization after cutaneous cicatrization. After ten weeks of treatment, the patient was able to raise her head and maintain it horizontally. Two years later, clinical results were stable.

DISCUSSION

Neck extensor weakness may be the presenting feature of several neuromuscular disorders. Generally, idiopathic dropped head syndrome appears to be the most likely diagnosis in patients with isolated neck extensor involvement. For our patient, clinical findings and cervical computed tomography showed important muscular weakness. However, painful passive extension and progressive stiffness of the neck do not represent the typical clinical course of idiopathic head drop. Neither degenerative lesions of the cervical spine nor other joint diseases can cause head drop. This case may result from the combined effects of idiopathic dropped head syndrome and cervical arthrosis. Orthopedic treatment and intensive rehabilitation had spectacular effects. Clinical management of head drop syndrome should always consist of orthopedic and rehabilitation treatment.

[Measurement of shoulder disability in the athlete: a systematic review]

OBJECTIVES

To identify all available shoulder disability questionnaires and to examine those that could be used for athlete.

METHODS

We systematically reviewed the literature in Medline using the keywords shoulder, function, scale, index, score, questionnaire, disability, quality of life, assessment, and evaluation. We searched for scales used for athletes with the keywords scale name AND (sport OR athlete). Data were completed by using the "Guide des Outils de Mesure et d'Evaluation en Médecine Physique et de Réadaptation" textbook. Analysis took into account the clinimetric quality of the instruments and the number of items specifically related to sports.

RESULTS

A total of 37 instruments have been developed to measure disease-, shoulder-specific or upper extremity specific outcome. Older instruments were developed before the advent of modern measurement methods. They usually combined objective and subjective measures. Recent instruments were designed with use of more advanced methods. Most are self-administered questionnaires. Fourteen scales included items assessing sport activity. Four of these scales have been used to assess shoulder disability in athlete. Six scales have been used to assess such disability but do not have specific items related to sports.

CONCLUSION

There is no gold standard for assessing shoulder outcome in the general population and no validated outcome instruments specifically for athletes. We suggest the use of ASES, WOSI and WORC scales for evaluating shoulder function in the recreational athletes. The DASH scale should be evaluated in this population. The principal criterion in evaluating shoulder function in the high level athlete is a return to the same level of sport performance. Further studies are required to identify measurement tools for shoulder disability that have a high predictive value for return to sport.

Chronicité, récidive et reprise du travail dans la lombalgie : facteurs communs de pronostic

OBJECTIVE

To determine the common risk factors of recurrence, chronicity and non return to work in low back pain.

MATERIAL AND METHOD

A systematic review of the literature was done by searches of Medline, Embase, Pascal, the Cochrane database and also in the unindexed literature. Keywords used were low back pain, chronic, risk factors, recurrence, predictive value of tests, prognosis, confounding factors. Studies were assessed by two readers using the ANAES (French Agency for Health Assessment) scale allowing classification into high-, moderate- and low-quality trials. The scientific evidence level of the identified risk factors depend on the methodological quality of the studies, the number of studies in agreement, the coherence of their results and their clinical relevance.

RESULTS

Fifty-four high quality studies were included. Several prognostic factors are common to the three described clinical situations. A history of low back pain (including the concept of pain severity, duration, disability, leg pain, related sickness leave and a history of spinal surgery), low level of job satisfaction and poor general health are highlighted with a strong level of evidence. Socioprofessionel and psychological factors including employment status, amount of wage, workers' compensation, and depression were found but with moderate level of evidence. Physical factors including lifting time per day and work postures were also found with moderate level of evidence.

CONCLUSION

This study confirm that several prognostic factors are commun to recurrence, chronicity and non return to work in low back pain. Early identification of these factors is important in understanding, and hopefully preventing, the recurrence or the progression to chronicity and disability in low back trouble.

[Development of rheumatoid arthritis functional handicap assessment questionnaire: preliminary study]

OBJECTIVE

To construct a handicap assessment questionnaire for rheumatoid arthritis and to determine if the concept of "participation" can replace the one of "handicap".

METHODS

Selection of daily life domains and items was based on the International Classification of Impairment Disability and Handicap "ICIDH" and on some others handicap epidemiological studies. The questionnaire was tested among rheumatoid arthritis patients. The relation between handicap and participation was investigated. Statistics analysis was performed with Systat.9 program. Spearman's correlation coefficient between 2 quantitative variables was examined.

RESULTS

Six among the 7 "ICIDH" domains were included in the questionnaire. Each of them was explored with many items. Forty-six items were included; each item was explored in 4 chapters:participation assessment with VAS (Visual Analogical Scale) before rheumatoid arthritis and during the study; difficulties: need of help, environment accessibility, patient's satisfaction, feeling of devalorization; patient's propositions;handicap assessment with VAS; other questions were added in some particular items. Thirty patients were included in the study (23 women), the average age was 51 years. Five patients didn't understand the meaning of "Handicap".This study allows us to eliminate 2 items, to add 2 others and to ameliorate 1 of them. Correlation between handicap and participation was moderate to bad.

CONCLUSION

This questionnaire allows to explore rheumatoid arthritis handicap. Each domain of the daily life can be assessed separately. The main difficulties are the length and the impossibility to be self-administered. Handicap and participation probably assess different concepts or are differently understood by patients.

Algo-functional assessment of knee osteoarthritis: comparison of the test-retest reliability and construct validity of the WOMAC and Lequesne indexes

OBJECTIVE

To assess and compare the test-retest reliability and the construct validity of the Lequesne and the French-Canadian version of the WOMAC indexes.

DESIGN

Patients with symptomatic knee osteoarthritis (OA) fulfilling the revised criteria of the American College of Rheumatology completed both the Lequesne and the French-Canadian version of the WOMAC indexes twice at a 3-h interval. Impairment outcome measures, patients' perceived discomfort in walking and handicap were recorded. For both questionnaires, an analysis was performed item by item. Repeatability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated using the Spearman rank correlation coefficient and a factor analysis was performed.

RESULTS

88 patients were included. Eight questions of the WOMAC section C and one question of the Lequesne index had insufficient psychometric properties. Although repeatability of questionnaires was fair to excellent (0.82, 0.68, 0.74, 0.95 for the WOMAC sections A, B, C and Lequesne index respectively), construct validity could not be demonstrated. Factor analysis of the WOMAC extracted five factors which differed from the a priori triple stratification. Factor analysis of the WOMAC section C extracted two factors explaining 71% of the variance which could not be clinically characterized. For the Lequesne index, expected convergent correlations were not always achieved. Three factors were extracted by factor analysis explaining 58% of the variance.

CONCLUSION

Despite their good test-retest reliability, the two composite indexes evaluated are not valid to assess the concept of functional disability induced by knee OA in a French population.

Responsiveness of the Cochin rheumatoid hand disability scale after surgery

OBJECTIVE

To assess the responsiveness of the Cochin functional disability scale for the rheumatoid hand after surgery.

METHOD

In a prospective study, patients with rheumatoid arthritis (RA) scheduled for surgery of the wrist and/or fingers were evaluated within 48 h before surgery and at least 6 months after surgery. Clinical outcome measures included duration of morning stiffness, total score for tenderness, total score for swelling, visual analogue scale score for pain in the hands and wrists, a score for overall mobility of the wrist and the fingers, grip and pinch strength, the Hand Functional Index (HFI), the Kapandji index and the Cochin scale. Responsiveness was assessed with the paired t-test, the effect size (ES), the standardized response mean (SRM) and the non-parametric Spearman rank correlation coefficient (r(S)).

RESULTS

Fifty patients (42 women) were evaluated twice at an interval of 7.16 +/- 2.10 months (mean +/- s.d.) (range 6-15 months). Thirty-six patients (72%) were very satisfied or satisfied with the results of surgery, seven (14%) were not satisfied or dissatisfied and seven (14%) were dissatisfied or very dissatisfied. The Cochin scale score improved at the second visit (P < 0.0001), with SRM and ES values of 0.66 and 0.58 respectively. The correlation of the change in Cochin score with patient overall satisfaction was r(S) = 0.40. Among the impairment measures, grip strength showed the best responsiveness (SRM = - 0.43, ES = - 0.36, correlation with patient overall satisfaction r(S) = 0.46). The change in Kapandji index had the best correlation (r(S) = 0.51) with patient overall satisfaction but its SRM and ES values were low (- 0.19 and - 0.10 respectively).

CONCLUSION

The Cochin scale is responsive and appropriate for the assessment of the effects of surgical treatments on disability in RA hands.

Reliability, validity, and sensitivity to change of the Cochin hand functional disability scale in hand osteoarthritis

OBJECTIVE

To assess the reliability, validity and sensitivity to change of the Cochin hand functional scale in hand osteoarthritis (OA).

BACKGROUND

The Cochin hand functional disability scale has been validated in rheumatoid arthritis.

DESIGN

Patients with hand OA according to Altman's criteria were included. Impairment outcome measures (VAS of pain, hand score of tenderness, clinical hand score of impairment, Kallman's radiographic scale), functional disability measures [Cochin scale, Revel's functional index (RFI), Dreiser's functional index (DFI)] and patients' perceived handicap (VAS) were recorded twice, at baseline and at a 6-month follow-up visit. Interobserver reliability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct (convergent and divergent) validity was investigated using the Spearman rank correlation coefficient and a factor analysis was performed. Sensitivity to change was assessed using the effect size (ES) and the standardized response mean (SRM), and the non-parametric Spearman rank correlation coefficient (r) was used to assess the correlation between quantitative variable changes and patient's overall opinion.

RESULTS

89 patients (8 males, mean age 63 years) were included. Interobserver reliability was excellent (ICC=0.96). The Bland and Altman method showed no systematic trend. Correlations of the Cochin scale score with RFI (r=0.86), DFI (r=0.87), VAS of handicap (r=0.67), VAS of pain (r=0.54), tenderness (r=0.51), clinical impairment (r=0.32), and Kallman's radiographic scale (r=0.13) indicated a good construct validity. Factor analysis extracted four main factors, accounting for 65% of the total variance. 51 patients were evaluated at the 6-month visit. The Cochin scale score had worsened with SRM and ES values of -0.26 and -0.17 respectively. Changes in the score had one of the highest correlation (r=0.47) with the patient's overall opinion.

CONCLUSION

The Cochin hand functional disability scale which was first developed to assess the rheumatoid hand can be used to evaluate functional disability in hand OA.

The ability of the Cochin rheumatoid arthritis hand functional scale to detect change during the course of disease

OBJECTIVE

To assess changes measured with the Cochin rheumatoid arthritis (RA) hand functional disability scale during the course of the disease.

METHODS

A cohort study evaluating outcome measure responsiveness in RA was conducted in a referral center. Ambulatory or hospitalized patients with RA according to the 1987 American College of Rheumatology (formerly the American Rheumatism Association) criteria were evaluated twice. Clinical measures included Cochin's scale, Revel's functional index, hand functional index, visual analog scale of patient-perceived handicap, visual analog scale of pain in hands and wrists, total score of swelling, total score of tenderness, and morning stiffness duration. Responsiveness was assessed by the effect size (ES) and the standardized response mean (SRM). The nonparametric Spearman rank correlation coefficient (r) was used to assess the correlation between two quantitative variable changes.

RESULTS

Fifty-five patients (44 women) were evaluated twice at an interval of 15.4 +/- 1.4 months (mean +/- SD) (range 13-18 months). The Cochin scale total score had worsened at the second visit (95% confidence interval for mean differences -5.16, 0.73). Its SRM and ES values were -0.20 and -0.15, respectively. Changes in the score had the highest correlation (r = 0.58) with changes in the patient-perceived handicap, while it had only fair or little correlation with changes in the disease activity measures. The factor 2 scale subscore significantly worsened and had the highest values of SRM and ES (SRM = -0.40 and ES = -0.31).

CONCLUSION

The Cochin scale can detect small but meaningful changes in RA hand disability.