Publications by authors named "Jonas Bloch Thorlund"

33 Publications

A COgNitive FuncTional Therapy+ Pathway Versus an Interdisciplinary Pain Management Pathway for Patients with Severe Chronic Low Back Pain (CONFeTTI Trial): Protocol for a Pragmatic Randomized Controlled Trial.

Phys Ther 2021 May 17. Epub 2021 May 17.

Research Unit for General Practice, Department of Public Health, University of Southern Denmark.

Objective: Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe cLBP. Such programs are expensive, not easily accessible, and have limited effect and therefore new cost-effective strategies are warranted. Cognitive Functional Therapy (CFT) has shown promising results, but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial (RCT) is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed), is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care).

Methods: This pragmatic, two-arm, parallel-group RCT will randomly allocate patients (n = 176) aged 18 to 75 referred to an interdisciplinary pain center due to severe cLBP to one of two groups (1:1 ratio). Patients randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed) while patients randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual patient's situation, needs and resources. The primary outcome is the proportion of patients with an 8-point improvement in the Oswestry Disability Index (ODI) score at 12 months. Exploratory outcomes is change in ODI scores over time, and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D.

Impact: The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for patients with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.
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http://dx.doi.org/10.1093/ptj/pzab132DOI Listing
May 2021

Long-term follow-up after acute achilles tendon rupture - Does treatment strategy influence functional outcomes?

Foot (Edinb) 2021 Jun 13;47:101769. Epub 2021 Jan 13.

Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark; Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. Electronic address:

Background: Patients struggle to fully recover after an Achilles tendon rupture. Although several studies has investigated surgical and non-surgical treatment, the best treatment is still uncertain. The aim of this study was to investigate long-term patient-reported outcomes and objective measures 4 years after acute Achilles tendon rupture and compare whether outcomes differed between patients treated on basis of the previous regimen preferring surgical treatment and the new regimen preferring functional rehabilitation.

Methods: Achilles tendon Total Rupture Score (ATRS), number of re-ruptures and the objective measures; Achilles tendon resting angle, calf circumference, heel-rise height, and muscle endurance were measured at a 4-year follow-up. Patients were recruited from Aalborg University Hospital.

Results: Seventy-six patients were included (29% female). The mean ATRS was 71.4 (95% CI: 65.8 to 77.1) at 4 years follow-up. No difference in ATRS was observed between Previous regimen and New regimen at any timepoint (time x group interaction, (p=0.851). The injured side was still significantly impaired compared with the non-injured side in terms of all objective measures. Impairments in objective measures were not dependent on the preferred treatment strategy.

Conclusions: Patient reported impairments and objective functional deficits persist 4 years after an acute Achilles tendon rupture. No differences in patient reported outcome or objective measures at the 4 years follow-up was observed between the old treatment regimen preferring surgery compared with the new treatment regimen preferring functional rehabilitation.
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http://dx.doi.org/10.1016/j.foot.2020.101769DOI Listing
June 2021

Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis.

BMC Musculoskelet Disord 2021 Apr 26;22(1):389. Epub 2021 Apr 26.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Odense, Denmark.

Background: Joint hypermobility in athletes is associated with increased risk of knee injuries, but its role in relation to shoulder injuries has not been scrutinized. Therefore, our aim was to synthesize the evidence on the association between joint hypermobility and shoulder injuries in athletes.

Methods: Data sources were MEDLINE, CINAHL, EMBASE, and SPORTDiscus from inception to 27th February 2021. Eligibility criteria were observational studies of athletes (including military personnel), mean age ≥ 16 years, and with a transparent grouping of those with and without joint hypermobility. A broad definition of joint hypermobility as the exposure was accepted (i.e., generalised joint hypermobility (GJH), shoulder joint hypermobility including joint instability). Shoulder injuries included acute and overuse injuries, and self-reported pain was accepted as a proxy for shoulder injuries. The Odds Ratios (OR) for having shoulder injuries in exposed compared with non-exposed athletes were estimated using a random effects meta-analysis. Subgroup analyses were performed to explore the effect of sex, activity type, sports level, study type, risk of bias, and exposure definition. Risk of bias and the overall quality of evidence were assessed using, respectively, the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results: Among 6207 records, six studies were included with 2335 (range 118-718) participants (34.1% females; athlete mean age 19.9 years). Athletes with joint hypermobility were more likely to have shoulder injuries compared with athletes without joint hypermobility (OR = 3.25, 95% CI 1.64, 6.43, I = 75.3%; p = 0.001). Exposure definition (GJH, OR = 1.97, 95% CI 1.32, 2.94; shoulder joint hypermobility, OR = 8.23, 95% CI 3.63, 18.66; p = 0.002) and risk of bias (low, OR = 5.25, 95% CI 2.56, 10.8; high, OR = 1.6, 95% CI 0.78, 3.29; p = 0.024) had large impacts on estimates, while the remaining subgroup analyses showed no differences. The overall quality of evidence was low.

Conclusion: Joint hypermobility in athletes is associated with a threefold higher odds of having shoulder injuries, highlighting the need for prevention strategies in this population. However, due to low quality of evidence, future research will likely change the estimated strength of the association.

Protocol Registration: Open Science Framework registration osf.io/3wrn9.
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http://dx.doi.org/10.1186/s12891-021-04249-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077913PMC
April 2021

Cutoff Values to Interpret Short-term Treatment Outcomes After Arthroscopic Meniscal Surgery, Measured With the Knee Injury and Osteoarthritis Outcome Score.

J Orthop Sports Phys Ther 2021 06 30;51(6):281-288. Epub 2021 Jan 30.

Objective: To determine the proportions of patients who (1) perceived their symptoms to be satisfactory, (2) perceived their treatment to have failed, or (3) perceived that they improved to an important degree at 3 months after arthroscopic meniscal surgery; and to determine Knee injury and Osteoarthritis Outcome Score (KOOS) subscale scores corresponding to the Patient Acceptable Symptom State (PASS), treatment failure, and the minimal important change (MIC) for improvement.

Design: Prospective cohort study.

Methods: Patients from the Knee Arthroscopy Cohort Southern Denmark who had arthroscopic meniscal surgery were included. The PASS, treatment failure, and MIC improvement values were calculated for the KOOS subscales with anchor-based approaches, using the adjusted predictive modeling method. Subgroup analyses were performed by stratifying by age (40 years or younger versus older than 40 years) and surgery type.

Results: Six hundred fourteen patients (44% female; mean ± SD age, 50 ± 13 years) were included. At 3 months after arthroscopic meniscal surgery, 45% of patients perceived their symptoms to be satisfactory, 19% perceived the treatment to have failed, and 44% to 60% perceived that they had improved to an important degree across the 5 KOOS subscales (for PASS/treatment failure, respectively: pain, 74 and 60 points; symptoms, 72 and 61 points; function in activities of daily living, 81 and 68 points; sport and recreational function, 43 and 26 points; and knee-related quality of life, 52 and 40 points; for MIC improvement: pain, 12 points; symptoms, 8 points; function in activities of daily living, 12 points; sport and recreational function, 17 points; and knee-related quality of life, 9 points). The PASS values were 6 to 17 points higher for patients 40 years or younger compared to patients older than 40 years.

Conclusion: At 3 months after meniscal surgery, approximately half of the patients perceived their symptoms to have improved to an important degree, 4 in every 10 patients perceived their symptoms to be satisfactory, and 2 in every 10 patients perceived the treatment to have failed. .
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http://dx.doi.org/10.2519/jospt.2021.10149DOI Listing
June 2021

Critically appraised paper: Physical therapy was noninferior to partial meniscectomy for improving knee function in patients with nonobstructive meniscal tears [commentary].

J Physiother 2020 10 23;66(4):269. Epub 2020 Sep 23.

Department of Sports Science and Clinical Biomechanics, University of Southern, Odense, Denmark; Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.

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http://dx.doi.org/10.1016/j.jphys.2020.08.002DOI Listing
October 2020

Patients use fewer analgesics following supervised exercise therapy and patient education: an observational study of 16 499 patients with knee or hip osteoarthritis.

Br J Sports Med 2021 Jun 21;55(12):670-675. Epub 2020 Sep 21.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark.

Objectives: To investigate changes in analgesic use before and after supervised exercise therapy and patient education in patients with knee or hip osteoarthritis (OA).

Methods: We recruited 16 499 of 25 933 eligible patients (64%; mean age 64.9; SD 9.6; 73% women) from the Good Life with osteoArthritis in Denmark (GLA:D) registry. Change in proportions of analgesic users (categorised according to analgesic risk profile; opioids > non-steroidal anti-inflammatory drugs > paracetamol) was assessed from before to after an 8-week supervised exercise therapy and patient education programme targeting knee or hip OA pain and functional limitations.

Results: Patients reported 13.2 mm (95% CI 12.8 to 13.6) less pain (visual analogue scale 0-100 mm) at follow-up compared with baseline. The proportion of analgesic users reduced from 62.2% (95% CI 61.5 to 63.0) at baseline to 44.1% (95% CI 43.3 to 44.9) at follow-up (absolute change: 18.1% (95% CI 17.3 to 19.0)). Among patients using analgesics at baseline, 52% changed to a lower risk analgesic or discontinued analgesic use. The proportion of opioid users after the exercise therapy was 2.5% (95% CI 2.1 to 2.9) lower than baseline; this represents a relative reduction of 36%.

Conclusion: Among patients with knee or hip OA using analgesics, more than half either discontinued analgesic use or shifted to lower risk analgesics following an 8-week structured exercise therapy and patient education programme (GLA:D). These data encourage randomised controlled trial evaluation of whether supervised exercise therapy, combined with patient education, can reduce analgesic use, including opioids, among patients with knee and hip OA pain.
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http://dx.doi.org/10.1136/bjsports-2019-101265DOI Listing
June 2021

Power of Words: Influence of Preexercise Information on Hypoalgesia after Exercise-Randomized Controlled Trial.

Med Sci Sports Exerc 2020 11;52(11):2373-2379

Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr University Bochum, Bochum, GERMANY.

Purpose: Exercise increases pressure pain thresholds (PPT) in pain-free individuals, known as exercise-induced hypoalgesia (EIH). Positive preexercise information can elicit higher EIH responses, but the effect of positive versus negative preexercise information on EIH is unknown. The primary aim of this randomized controlled trial was to compare EIH at the exercising thigh muscle after an isometric squat exercise between individuals receiving positive versus negative preexercise information about the effect of exercise on pain. Secondary aims were to compare EIH at nonexercising muscles between groups, and to investigate the relationship between participants' expectations and EIH.

Methods: Eighty-three participants were randomly assigned to brief positive (n = 28), neutral (n = 28) or negative (n = 27) verbal information. The neutral information group was included in the study as a reference group. Pressure pain thresholds at the thigh and trapezius muscles were assessed before and after the intervention (i.e., preexercise information+squat exercise). Expectations of pain relief were assessed using a numerical rating scale (-10 [most negative] to 10 [most positive]).

Results: Change in quadriceps and trapezius PPT after the squat exercise showed a large difference between the positive and negative information groups (quadriceps, 102 kPa; 95% confidence interval, 55-150; effect size, 1.2; trapezius, 41 kPa; 95% confidence interval, 16-65; effect size:, 0.9). The positive information group had a 22% increase in quadriceps PPT whereas the negative information group had a 4% decrease. A positive correlation was found between expectations and increase in PPT.

Conclusions: Negative preexercise information caused hyperalgesia after the wall squat exercise, whereas positive or neutral preexercise information caused hypoalgesia. Positive preexercise information did not change the magnitude of EIH compared with neutral information.
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http://dx.doi.org/10.1249/MSS.0000000000002396DOI Listing
November 2020

Walking increases pain tolerance in humans: an experimental cross-over study.

Scand J Pain 2019 Oct 29;19(4):813-822. Epub 2019 Jun 29.

Pain Research Group, Pain Center, Odense University Hospital, Odense, Denmark.

Background And Aims: Exercise is commonly used as treatment for chronic pain with positive long-term effects on pain and pain-related disability. In pain-free subjects, hypoalgesia following an acute bout of exercise compared with a control condition has consistently been demonstrated also known as exercise-induced hypoalgesia (EIH). Walking exercise, a low intensity aerobic exercise, is frequently used in clinical practice as an easily applicable intervention for patients with chronic pain. Walking exercise is furthermore recommended as an effective treatment for patients with chronic musculoskeletal pain conditions to alleviate pain and reduce disability, however, the effect of walking on pain sensitivity is currently unknown. The aims of the present study were to investigate (1) the acute effect of walking on pain sensitivity, and (2) the relative (between-subjects) and absolute (within-subject) test-retest reliability of the hypoalgesic response across two sessions separated by 1 week.

Methods: In this randomised experimental cross-over study including two identical sessions, 35 pain-free subjects performed a standardized 6 min walking test and a duration-matched quiet rest condition in a randomized and counterbalanced order in each session. Before and after both conditions, handheld pressure pain thresholds (PPTs) were assessed at the thigh and shoulder, and pressure pain thresholds (cPPT) and pain tolerance (cPTT) were assessed with computer-controlled cuff algometry at the lower leg. Change in the pain sensitivity measures were analysed with repeated-measures ANOVAs, and test-retest reliability with intraclass correlation coefficients (ICC) and agreements in classification of EIH responders/non-responders between the two sessions.

Results: All subjects completed the walking conditions in both session 1 and session 2. The perceived intensity of walking assessed with rating of perceived exertion (RPE) and walking distance did not differ significantly between session 1 (distance: 632.5 ± 75.2 meters, RPE: 10.9 ± 1.9) and session 2 (distance: 642.1 ± 80.2 meters, RPE: 11.0 ± 2.4) ( > 0.11). Moreover, RPE showed excellent relative reliability with an ICC value of 0.95 [95%CI: 0.90-0.97]. Walking increased pain tolerance (mean difference: 2.6 kPa [95%CI: 0.5-4.9 kPa;  = 0.02]), but not pain thresholds compared with rest in both sessions. Hypoalgesia after walking demonstrated fair to good relative reliability (ICC = 0.61), however the agreement in classification of EIH responders/non-responders (absolute reliability) across sessions was low and not significant (κ = 0.19,  = 0.30).

Conclusions: Walking consistently increased pain tolerance but not pain thresholds compared with a duration-matched control condition with fair to good relative reliability between sessions. Based on classification of EIH responders/non-responders the absolute reliability between the two sessions was low indicating individual variance in the EIH response. Future studies should investigate the hypoalgesic effect of a walking exercise in a clinical pain population.
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http://dx.doi.org/10.1515/sjpain-2019-0070DOI Listing
October 2019

Wild goose chase - no predictable patient subgroups benefit from meniscal surgery: patient-reported outcomes of 641 patients 1 year after surgery.

Br J Sports Med 2020 Jan 11;54(1):13-22. Epub 2019 Jun 11.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Despite absence of evidence of a clinical benefit of arthroscopic partial meniscectomy (APM), many surgeons claim that subgroups of patients benefit from APM.

Objective: We developed a prognostic model predicting change in patient-reported outcome 1 year following arthroscopic meniscal surgery to identify such subgroups.

Methods: We included 641 patients (age 48.7 years (SD 13), 56% men) undergoing arthroscopic meniscal surgery from the Knee Arthroscopy Cohort Southern Denmark. 18 preoperative factors identified from literature and/or orthopaedic surgeons (patient demographics, medical history, symptom onset and duration, knee-related symptoms, etc) were combined in a multivariable linear regression model. The outcome was change in Knee injury and Osteoarthritis Outcome Score (KOOS) (average score of 4 of 5 KOOS subscales excluding the activities of daily living subscale) from presurgery to 52 weeks after surgery. A positive KOOS change score constitutes improvement. Prognostic performance was assessed using R statistics and calibration plots and was internally validated by adjusting for optimism using 1000 bootstrap samples.

Results: Patients improved on average 18.6 (SD 19.7, range -38.0 to 87.8) in KOOS. The strongest prognostic factors for improvement were (1) no previous meniscal surgery on index knee and (2) more severe preoperative knee-related symptoms. The model's overall predictive performance was low (apparent R=0.162, optimism adjusted R=0.080) and it showed poor calibration (calibration-in-the-large=0.205, calibration slope=0.772).

Conclusion: Despite combining a large number of preoperative factors presumed clinically relevant, change in patient-reported outcome 1 year following meniscal surgery was not predictable. This essentially quashes the existence of 'subgroups' with certain characteristics having a particularly favourable outcome after meniscal surgery.

Trial Registration Number: NCT01871272.
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http://dx.doi.org/10.1136/bjsports-2018-100321DOI Listing
January 2020

The association between smoking and knee osteoarthritis in a cohort of Danish patients undergoing knee arthroscopy.

BMC Musculoskelet Disord 2019 Apr 1;20(1):141. Epub 2019 Apr 1.

Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: It has been suggested that smoking is associated with reduced risk of knee osteoarthritis (OA). However, supplementary studies are needed to further investigate any such potential association. Thus, our aim was to examine the relationship between smoking and early or more established knee OA in a cohort of relatively young patients with meniscal tears.

Methods: This cross-sectional study included 620 participants from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing knee arthroscopy for a meniscal tear (mean age 49.2 (18.0-76.8) years). Recruitment of patients was performed between February 1, 2013, and January 31, 2015, at four different hospitals in Denmark. We defined early or more established knee OA as the combination of patient-reported frequent knee pain, degenerative meniscal tissue and presence of cartilage defects assessed by the operating surgeons. The relationship between smoking status and knee OA was examined by risk ratio (RR) with a 95% confidence interval (CI), estimated from logistic regression adjusted for age, sex, BMI, education, work status and level of physical activity.

Results: The prevalence of early or more established knee OA was 37.7% in current smokers and 45.0% in non-smokers. We found no statistically significant association between current smoking and knee OA (adjusted RR 1.09, 95% CI 0.91-1.30).

Conclusions: This study found no relationship between current smoking and early or more established knee OA in a cohort of patients undergoing arthroscopic meniscal surgery. Thus, the inverse association between smoking and knee OA that has been suggested by previous studies was not confirmed.
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http://dx.doi.org/10.1186/s12891-019-2518-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444863PMC
April 2019

Conundrum of mechanical knee symptoms: signifying feature of a meniscal tear?

Br J Sports Med 2019 Mar 31;53(5):299-303. Epub 2018 Aug 31.

Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden.

Background: Mechanical knee symptoms are often considered important in the decision to perform knee arthroscopy on the suspicion of a meniscal tear. We investigated if presence of a meniscal tear at knee arthroscopy in adults is associated with presence of preoperative self-reported mechanical knee symptoms.

Methods: We used data from Knee Arthroscopy Cohort Southern Denmark (KACS). KACS consists of patients aged 18 years or older referred to knee arthroscopy on the suspicion of a meniscal tear at four recruiting hospitals between 1 February 2013 and 31 January 2015. Of 1259 invited patients, 908 (72%) replied to the baseline questionnaire. With 91 patients excluded, the study sample consisted of 641 and 176 patients and a meniscal tear confirmed at surgery, respectively. Exposure was meniscal tear as determined by the knee surgeon during arthroscopy. Main outcomes were preoperative mechanical knee symptoms defined as self-reported catching/locking or self-reported inability to straighten knee fully.

Results: 55% of all patients reported symptoms of catching/locking and 47% were unable to straighten their knee fully. Preoperative mechanical symptoms were equally prevalent in patients and a meniscal tear (prevalence ratio catching/locking 0.89, 95% CI 0.77 to 1.03, and inability to straighten knee fully, prevalence ratio 1.02, 95% CI 0.84 to 1.23).

Interpretation: Patient-reported mechanical symptoms were equally common irrespective of presence or absence of a meniscal tear in patients undergoing arthroscopy for suspicion of a meniscal tear. Our findings suggest that mechanical knee symptoms have a limited value when considering indication for meniscal surgery.

Trial Registration Number: NCT01871272; Results.
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http://dx.doi.org/10.1136/bjsports-2018-099431DOI Listing
March 2019

Infographic. Exercise therapy for meniscal tears: evidence and recommendations.

Br J Sports Med 2019 Mar 23;53(5):315-316. Epub 2018 Jun 23.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

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http://dx.doi.org/10.1136/bjsports-2018-099492DOI Listing
March 2019

Patient-reported symptoms and changes up to 1 year after meniscal surgery.

Acta Orthop 2018 Jun 5;89(3):336-344. Epub 2018 Mar 5.

a Research Unit for Musculoskeletal Function and Physiotherapy , Department of Sports Science and Clinical Biomechanics , University of Southern Denmark , Odense.

Background and purpose - Detailed information on the symptoms and limitations that patients with meniscal tears experience is lacking. This study was undertaken to map the most prevalent self-reported symptoms and functional limitations among patients undergoing arthroscopic meniscal surgery and investigate which symptoms and limitations had improved most at 1 year after surgery. Patients and methods - Patients aged 18-76 years from the Knee Arthroscopy Cohort Southern Denmark (KACS) undergoing arthroscopic meniscal surgery were included in this analysis of individual subscale items from the Knee Injury and Osteoarthritis Outcome Score and 1 question on knee stability. Severity of each item was scored as none, mild, moderate, severe, or extreme. Improvements were evaluated using Wilcoxon's signed-rank test and effect size (ES). Results - The most common symptoms were knee grinding and clicking, knee pain in general, pain when twisting and bending the knee and climbing stairs (88-98%), while the most common functional limitations were difficulty bending to the floor, squatting, twisting, kneeling, and knee awareness (97-99%). Knee pain in general and knee awareness improved most 1 year after meniscal surgery (ES -0.47 and -0.45; p < 0.001), while knee instability and general knee difficulties improved least (ES 0.10 and -0.08; p < 0.006). Interpretation - Adults undergoing surgery for a meniscal tear commonly report clinical symptoms and functional limitations related to their daily activities. Moderate improvements were observed in some symptoms and functional limitations and small to no improvement in others at 1 year after surgery. These findings can assist the clinical discussion of symptoms, treatments, and patients' expectations.
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http://dx.doi.org/10.1080/17453674.2018.1447281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055776PMC
June 2018

Risk factors, diagnosis and non-surgical treatment for meniscal tears: evidence and recommendations: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

Br J Sports Med 2018 May 2;52(9):557-565. Epub 2018 Feb 2.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

This statement aimed at summarising and appraising the available evidence for risk factors, diagnostic tools and non-surgical treatments for patients with meniscal tears. We systematically searched electronic databases using a pragmatic search strategy approach. Included studies were synthesised quantitatively or qualitatively, as appropriate. Strength of evidence was determined according to the Grading of Recommendations Assessment Development and Evaluation framework. Low-quality evidence suggested that overweight (degenerative tears, k=3), male sex (k=4), contact and pivoting sports (k=2), and frequent occupational kneeling/squatting (k=3) were risk factors for meniscal tears. There was low to moderate quality evidence for low to high positive and negative predictive values, depending on the underlying prevalence of meniscal tears for four common diagnostic tests (k=15, n=2474). Seven trials investigated exercise versus surgery (k=2) or the effect of surgery in addition to exercise (k=5) for degenerative meniscal tears. There was moderate level of evidence for exercise improving self-reported pain (Effect Size (ES)-0.51, 95% CI -1.16 to 0.13) and function (ES -0.06, 95% CI -0.23 to 0.11) to the same extent as surgery, and improving muscle strength to a greater extent than surgery (ES -0.45, 95% CI -0.62 to -0.29). High-quality evidence showed no clinically relevant effect of surgery in addition to exercise on pain (ES 0.18, 95% 0.05 to 0.32) and function (ES, 0.13 95% CI -0.03 to 0.28) for patients with degenerative meniscal tears. No randomised trials comparing non-surgical treatments with surgery in patients younger than 40 years of age or patients with traumatic meniscal tears were identified. Diagnosis of meniscal tears is challenging as all clinical diagnostic tests have high risk of misclassification. Exercise therapy should be recommended as the treatment of choice for middle-aged and older patients with degenerative meniscal lesions. Evidence on the best treatment for young patients and patients with traumatic meniscal tears is lacking.
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http://dx.doi.org/10.1136/bjsports-2017-098429DOI Listing
May 2018

The effect of targeted exercise on knee-muscle function in patients with persistent hamstring deficiency following ACL reconstruction - study protocol for a randomized controlled trial.

Trials 2018 Jan 26;19(1):75. Epub 2018 Jan 26.

Orthopaedic Research Unit, Department of Orthopaedics and Traumatology, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark.

Background: Anterior cruciate ligament (ACL) reconstruction, using hamstring auto-graft is a common surgical procedure, which often leads to persistent hamstring muscle-strength deficiency and reduced function. The purpose of this randomized controlled trial (RCT) is to investigate the effect of a combined, progressive, strength and neuromuscular exercise intervention on knee muscle strength, functional capacity and hamstring muscle-tendon morphology in ACL-reconstructed patients with persistent hamstring muscle-strength deficiency compared with controls.

Methods/design: The study is designed as a multicenter, parallel-group RCT with balanced randomization (1:1) and blinded outcome assessments (level of evidence: II) and will be reported in accordance with the CONSORT Statement. Fifty ACL-reconstructed patients (hamstring auto-graft) with persistent limb-to-limb knee-flexor muscle-strength asymmetry at 12-24 months' post surgery, will be recruited through outpatient clinics and advertisements. Patients will be randomized to a 12-week progressive, strength and neuromuscular exercise group (SNG) with supervised training twice weekly or a control intervention (CON) consisting of a home-based, low-intensity exercise program. Outcome measures include between-group change in maximal isometric knee-flexor strength (primary outcome) and knee-extensor muscle strength, hamstring-to-quadriceps strength ratios of the leg that has been operated on and Knee injury and Osteoarthritis Outcome Score (KOOS) (secondary outcomes). In addition, several explorative outcomes will be investigated: The International Knee Documentation Committee Subjective Knee Form (IKDC), the Tegner Activity Score, rate of force development (RFD) for the knee flexors and extensors, tendon regeneration and potential muscle hypertrophy at graft harvest site evaluated by magnetic resonance imaging (MRI), postural control, kinetic/kinematic gait characteristics and knee-related functional capacity.

Discussion: This RCT is designed to investigate the effect of combined, progressive-resistance and neuromuscular exercises on knee-flexor/extensor strength, in the late rehabilitation phase following ACL reconstruction. Reduced hamstring strength represents a potential risk factor for secondary ACL rupture and accelerated progression of osteoarthritis. If deemed effective, the intervention paradigm introduced in this study may help to improve current treatment strategies in ACL-reconstructed patients.

Trial Registration: ClinicalTrials.gov, ID: NCT02939677 (recruiting). Registered on 20 October 2016.
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http://dx.doi.org/10.1186/s13063-018-2448-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787267PMC
January 2018

Study protocol for a randomised controlled trial of meniscal surgery compared with exercise and patient education for treatment of meniscal tears in young adults.

BMJ Open 2017 Aug 21;7(8):e017436. Epub 2017 Aug 21.

Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark.

Introduction: Arthroscopic surgery is a very common orthopaedic procedure. While several trials have investigated the effect of knee arthroscopy for middle-aged and older patients with meniscal tears, there is a paucity of trials comparing meniscal surgery with non-surgical treatment for younger adults. The aim of this randomised controlled trial (RCT) is to investigate if early arthroscopic surgery is superior to exercise therapy and education, with the option of later surgery if needed, in improving pain, function and quality of life in younger adults with meniscal tears.

Methods And Analysis: This is a protocol for a multicentre, parallel-group RCT conducted at six hospitals across all five healthcare regions in Denmark. 140 patients aged 18-40 years with a clinical history and symptoms consistent with a meniscal tear, verified on MRI, found eligible for meniscal surgery by an orthopaedic surgeon will be randomly allocated to one of two groups (1:1 ratio). Participants randomised to surgery will undergo either arthroscopic partial meniscectomy or meniscal repair followed by standard postsurgical care, while participants allocated to exercise and education will undergo a 12-week individualised, supervised neuromuscular and strengthening exercise programme and patient education. The primary outcome will be difference in change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, function in sports and recreation and quality of life (Knee Injury and Osteoarthritis Outcome Score (KOOS)) supported by the individual subscale scores allowing clinical interpretation. Alongside, the RCT an observational cohort will follow patients aged 18-40 years with clinical suspicion of a meniscal tear, but not fully eligible or declining to participate in the trial.

Ethics And Dissemination: Results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Regional Committees on Health Research Ethics for Southern Denmark.

Registration Details: ClinicalTrials.gov (NCT02995551).
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http://dx.doi.org/10.1136/bmjopen-2017-017436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724132PMC
August 2017

Knee extensor strength and body weight in adolescent men and the risk of knee osteoarthritis by middle age.

Ann Rheum Dis 2017 Oct 9;76(10):1657-1661. Epub 2017 May 9.

Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Faculty of Medicine, Lund University, Lund, Sweden.

Objectives: To assess the extent to which knee extensor strength and weight in adolescence are associated with knee osteoarthritis (OA) by middle age.

Methods: We studied a cohort of 40 121 men who at age 18 years in 1969/1970 underwent mandatory conscription in Sweden. We retrieved data on isometric knee extensor strength, weight, height, smoking, alcohol consumption, parental education and adult occupation from Swedish registries. We identified participants diagnosed with knee OA or knee injury from 1987 to 2010 through the National Patient Register. We estimated the HR of knee OA using multivariable-adjusted Cox proportional regression model. To assess the influence of adult knee injury and occupation, we performed a formal mediation analysis.

Results: The mean (SD) knee extensor strength was 234 (47) Nm, the mean (SD) weight was 66 (9.3) kg. During 24 years (median) of follow-up starting at the age of 35 years, 2049 persons were diagnosed with knee OA. The adjusted HR (95% CI) of incident knee OA was 1.12 (1.06 to 1.18) for each SD of knee extensor strength and 1.18 (1.15 to 1.21) per 5 kg of body weight. Fifteen per cent of the increase in OA risk due to higher knee extensor strength could be attributed to knee injury and adult occupation.

Conclusion: Higher knee extensor strength in adolescent men was associated with increased risk of knee OA by middle age, challenging the current tenet of low muscle strength being a risk factor for OA. We confirmed higher weight to be a strong risk factor for knee OA.
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http://dx.doi.org/10.1136/annrheumdis-2016-210888DOI Listing
October 2017

Trajectory of self-reported pain and function and knee extensor muscle strength in young patients undergoing arthroscopic surgery for meniscal tears: A systematic review and meta-analysis.

J Sci Med Sport 2017 Aug 21;20(8):712-717. Epub 2017 Feb 21.

Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark; Department of Rehabilitation, Copenhagen University Hospital, Denmark.

Objectives: To investigate the trajectory of patient reported pain and function and knee extensor muscle strength over time in young individuals undergoing arthroscopic meniscal surgery.

Design: Systematic review and meta-analysis METHODS: Six databases were searched up to October 13th, 2016.

Patients And Intervention: People aged 30 years or younger undergoing surgery for a meniscal tear.

Outcomes: and comparator: (1) Self-reported pain and function in patients undergoing meniscal surgery compared to a non-operative control group (2). Knee extensor strength in the leg undergoing surgery compared to a healthy control group or the contra-lateral leg. Methodological quality was assessed using the SIGN 50 guidelines.

Results: No studies were found on patient reported pain and function. Six studies, including 137 patients were included in the analysis on knee extensor muscle strength. Knee extensor muscle strength was impaired in the injured leg prior to surgery and was still reduced compared with control data up to 12 months after surgery (SMD: -1.16) (95% CI: -1.83; -0.49). All included studies were assessed to have a high risk of bias.

Conclusions: No studies were found comparing the trajectory of self-reported pain and function in patients undergoing arthroscopic surgery compared with non-operative treatments for young patients with meniscal tears. Knee extensor strength seemed to be impaired up to 12 months after surgery in young patients undergoing surgery for meniscal tears. The results of the present study should be interpreted with caution due to a limited number of available studies with high risk of bias including relatively few patients.
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http://dx.doi.org/10.1016/j.jsams.2017.02.004DOI Listing
August 2017

Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study.

BMJ 2017 Feb 2;356:j356. Epub 2017 Feb 2.

Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden.

Objectives:  To compare patient reported outcomes from before surgery to 52 weeks after surgery between individuals undergoing arthroscopic partial meniscectomy for traumatic meniscal tears and those for degenerative meniscal tears.

Design:  Comparative prospective cohort study.

Setting:  Four public orthopaedic departments in the Region of Southern Denmark. Participants were recruited between 1 February 2013 and 31 January 2014, and at one of the original four hospitals from 1 February 2014 to 31 January 2015.

Participants:  Individuals selected from Knee Arthroscopy Cohort Southern Denmark, aged 18-55, and undergoing arthroscopic partial meniscectomy for a traumatic or degenerative meniscal tear (defined by a combination of age and symptom onset).

Interventions:  Both participant groups underwent arthroscopic partial meniscectomy for a meniscal tear, with operating surgeons recording relevant information on knee pathology. Patient reported outcomes were recorded via online questionnaires.

Main Outcome Measures:  Primary outcome was the average between-group difference in change on four of five subscales of the knee injury and osteoarthritis outcome score (KOOS). The four subscales covered pain, symptoms, sport and recreational function, and quality of life (KOOS). A 95% confidence interval excluding differences greater than 10 KOOS points between groups was interpreted as absence of a clinically meaningful difference. Analyses adjusted for age, sex, and body mass index.

Results:  397 eligible adults (42% women) with a traumatic or degenerative meniscal tear (n=141, mean age 38.7 years (standard deviation 10.9); n=256, 46.6 years (6.4); respectively) were included in the main analysis. At 52 weeks after arthroscopic partial meniscectomy, 55 (14%) patients were lost to follow-up. Statistically, participants with degenerative meniscal tears had a significantly larger improvement in KOOS scores than those with traumatic tears (adjusted between-group difference -5.1 (95% confidence interval -8.9 to -1.3); P=0.008). In the analysis including KOOS score at all time points, a significant time-by-group interaction was observed in both the unadjusted (P=0.025) and adjusted analysis (P=0.024), indicating better self-reported outcomes in participants with degenerative tears. However, the difference between groups was at no time point considered clinically meaningful.

Conclusions:  These results question the current tenet that patients with traumatic meniscal tears experience greater improvements in patient reported outcomes after arthroscopic partial meniscectomy than patients with degenerative tears.Trial registration ClinicalTrials.gov identifier NCT01871272.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5421436PMC
http://dx.doi.org/10.1136/bmj.j356DOI Listing
February 2017

It is time to stop meniscectomy.

Br J Sports Med 2017 Mar 11;51(6):490-491. Epub 2017 Jan 11.

Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

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http://dx.doi.org/10.1136/bjsports-2016-097273DOI Listing
March 2017

Structural pathology is not related to patient-reported pain and function in patients undergoing meniscal surgery.

Br J Sports Med 2017 Mar 16;51(6):525-530. Epub 2016 Sep 16.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: The relationship between meniscal tears and other joint pathologies with patient-reported symptoms is not clear. We investigated associations between structural knee pathologies identified at surgery with preoperative knee pain and function in patients undergoing arthroscopic meniscal surgery.

Methods: This study included 443 patients from the Knee Arthroscopy Cohort Southern Denmark (KACS), a prospective cohort following patients 18 years or older undergoing arthroscopic meniscal surgery at 4 hospitals between 1 February 2013 and 31 January 2014. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), were obtained by online questionnaires prior to surgery. Knee pathology was assessed by the operating surgeons using a modified version of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears questionnaire, supplemented with information extracted from surgery reports. Following hypothesis-driven preselection of candidate variables, backward elimination regressions were performed to investigate associations between patient-reported outcomes and structural knee pathologies.

Results: Regression models only explained a small proportion of the variability in self-reported pain and function (adjusted R=0.10-0.12) and this association was mainly driven by age, gender and body mass index.

Conclusions: Specific meniscal pathology and other structural joint pathologies found at meniscal surgery were not associated with preoperative self-reported pain and function in patients with meniscal tears questioning inferences made about a direct relationship between these. Our findings question the role of arthroscopic surgery to address structural pathology as a means to improve patient-reported outcomes in patients having surgery for a meniscal tear.
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http://dx.doi.org/10.1136/bjsports-2016-096456DOI Listing
March 2017

Forward lunge knee biomechanics before and after partial meniscectomy.

Knee 2015 Dec 20;22(6):506-9. Epub 2015 Apr 20.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Patients following meniscectomy are at increased risk of developing knee osteoarthritis in the tibiofemoral compartment and at the patellofemoral joint. As osteoarthritis is widely considered a mechanical disease, it is important to understand the potential effect of arthroscopic partial meniscectomy (APM) on knee joint mechanics. The purpose of this study was to evaluate changes in knee joint biomechanics during a forward lunge in patients with a suspected degenerative meniscal tear from before to three months after APM.

Methods: Twenty-two patients (35-55 years old) with a suspected degenerative medial meniscal tear participated in this study. Three dimensional knee biomechanics were assessed on the injured and contralateral leg before and three months after APM. The visual analogue scale was used to assess knee pain and the Knee Injury Osteoarthritis Outcome Score was used to assess sport/recreation function and knee-related confidence before and after APM.

Results: The external peak knee flexion moment reduced in the APM leg compared to the contralateral leg (mean difference (95% CI)) -1.08 (-1.80 to -0.35) (Nm/(BW × HT)%), p = 0.004. Peak knee flexion angle also reduced in the APM leg compared to the contralateral leg -3.94 (-6.27 to -1.60) degrees, p = 0.001. There was no change in knee pain between the APM leg and contralateral leg (p=0.118). Self-reported sport/recreation function improved (p = 0.004).

Conclusions: Although patients self-reported less difficulty during strenuous tasks following APM, patients used less knee flexion, a strategy that may limit excessive patellar loads during forward lunge in the recently operated leg.
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http://dx.doi.org/10.1016/j.knee.2015.03.005DOI Listing
December 2015

Exploring the effect of space and place on response to exercise therapy for knee and hip pain--a protocol for a double-blind randomised controlled clinical trial: the CONEX trial.

BMJ Open 2015 Mar 27;5(3):e007701. Epub 2015 Mar 27.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Introduction: Context effects are described as effects of a given treatment, not directly caused by the treatment itself, but rather caused by the context in which treatment is delivered. Exercise is a recommended core treatment in clinical guidelines for musculoskeletal disorders. Although moderately effective overall, variation is seen in size of response to exercise across randomised controlled trial (RCT) studies. Part of this variation may be related to the fact that exercise interventions are performed in different physical environments, which may affect participants differently. The study aims to investigate the effect of exercising in a contextually enhanced physical environment for 8 weeks in people with knee or hip pain.

Methods And Analysis: The study is a double-blind RCT. Eligible participants are 35 years or older with persisting knee and/or hip pain for 3 months. Participants are randomised to one of three groups: (1) exercise in a contextually enhanced environment, (2) exercise in a standard environment and (3) waiting list. The contextually enhanced environment is located in a newly built facility, has large windows providing abundant daylight and overlooks a recreational park. The standard environment is in a basement, has artificial lighting and is marked by years of use; that is, resembling many clinical environments. The primary outcome is the participant's global perceived effect rated on a seven-point Likert scale after 8 weeks exercise. Patient-reported and objective secondary outcomes are included.

Ethics And Dissemination: The Regional Scientific Ethical Committee for Southern Denmark has approved the study. Study findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

Trial Registration Number: NCT02043613.
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http://dx.doi.org/10.1136/bmjopen-2015-007701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386269PMC
March 2015

Altered knee joint neuromuscular control during landing from a jump in 10-15 year old children with Generalised Joint Hypermobility. A substudy of the CHAMPS-study Denmark.

J Electromyogr Kinesiol 2015 Jun 6;25(3):501-7. Epub 2015 Mar 6.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Institute of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway.

Generalised Joint Hypermobility (GJH) is considered an intrinsic risk factor for knee injuries. Knee neuromuscular control during landing may be altered in GJH due to reduced passive stability. The aim was to identify differences in knee neuromuscular control during landing of the Single-Leg-Hop-for-Distance test (SLHD) in 25 children with GJH compared to 29 children without GJH (controls), all 10-15years. Inclusion criteria for GJH: Beighton score⩾5/9 and minimum one hypermobile knee. EMG was recorded from the quadriceps, the hamstring and the calf muscles, presented relative to Maximum Voluntary Electrical activity (MVE). There was no difference in jump length between groups. Before landing, GJH had 33% lower Semitendinosus, but 32% higher Gastrocnemius Medialis activity and 39% higher co contraction of the lateral knee muscles, than controls. After landing, GJH had 36% lower Semitendinosus activity than controls, all significant findings. Although the groups performed equally in SLHD, GJH had a Gastrocnemius Medialis dominated neuromuscular strategy before landing, plausibly caused by reduced Semitendinosus activity. Reduced Semitendinosus activity was seen in GJH after landing, but with no compensatory Gastrocnemius Medialis activity. Reduced pre and post-activation of the Semitendinosus may present a risk factor for traumatic knee injuries as ACL ruptures in GJH with knee hypermobility.
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http://dx.doi.org/10.1016/j.jelekin.2015.02.011DOI Listing
June 2015

Large regional differences in incidence of arthroscopic meniscal procedures in the public and private sector in Denmark.

BMJ Open 2015 Feb 24;5(2):e006659. Epub 2015 Feb 24.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Objectives: A recent study reported a large increase in the number of meniscal procedures from 2000 to 2011 in Denmark. We examined the nation-wide distribution of meniscal procedures performed in the private and public sector in Denmark since different incentives may be present and the use of these procedures may differ from region to region.

Setting: We included data on all patients who underwent an arthroscopic meniscal procedure performed in the public or private sector in Denmark.

Participants: Data were retrieved from the Danish National Patient Register on patients who underwent arthroscopic meniscus surgery as a primary or secondary procedure in the years 2000 to 2011. Hospital identification codes enabled linkage of performed procedures to specific hospitals.

Primary And Secondary Outcome Measures: Yearly incidence of meniscal procedures per 100,000 inhabitants was calculated with 95% CIs for public and private procedures for each region.

Results: Incidence of meniscal procedures increased at private and at public hospitals. The private sector accounted for the largest relative and absolute increase, rising from an incidence of 1 in 2000 to 98 in 2011. In 2011, the incidence of meniscal procedures was three times higher in the Capital Region than in Region Zealand.

Conclusions: Our study identified a large increase in the use of meniscal procedures in the public and private sector in Denmark. The increase was particularly conspicuous in the private sector as its proportion of procedures performed increased from 1% to 32%. Substantial regional differences were present in the incidence and trend over time of meniscal procedures.
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http://dx.doi.org/10.1136/bmjopen-2014-006659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342592PMC
February 2015

Author reply: To PMID 24800623.

Acta Orthop 2014 Dec;85(6):682-3

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December 2014

Knee Arthroscopy Cohort Southern Denmark (KACS): protocol for a prospective cohort study.

BMJ Open 2013 Oct 14;3(10):e003399. Epub 2013 Oct 14.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Meniscus surgery is a high-volume surgery carried out on 1 million patients annually in the USA. The procedure is conducted on an outpatient basis and the patients leave the hospital a few hours after surgery. A critical oversight of previous studies is their failure to account for the type of meniscal tears. Meniscus tears can be categorised as traumatic or non-traumatic. Traumatic tears (TT) are usually observed in younger, more active individuals in an otherwise 'healthy' meniscus and joint. Non-traumatic tears (NTT) (ie, degenerative tears) are typically observed in the middle-aged (35-55 years) and older population but the aetiology is largely unclear. Knowledge about the potential difference of the effect of arthroscopic meniscus surgery on patient symptoms between patients with traumatic and NTT is sparse. Furthermore, little is known about the natural time course of patient perceived pain, function and quality of life after meniscus surgery and factors affecting these outcomes. The aim of this prospective cohort study is to investigate the natural time course of patient-reported outcomes in patients undergoing meniscus surgery, with particular emphasis on the role of type of symptom onset.

Methods/design: This prospective cohort study enrol patients assigned for meniscus surgery. At the baseline (PRE surgery), patient characteristics are assessed using an email-based questionnaire also comprising several validated questionnaires assessing general health, knee-specific characteristics and patient's expectations of the surgery. Follow-up will be conducted at 12 and 52 weeks after meniscus surgery. The major outcomes will be differences in changes, from before to 52 weeks after surgery, in each of the five domains on the Knee injury and Osteoarthritis Outcome Score (KOOS) between patients undergoing surgery for traumatic compared with non-traumatic meniscus tears.

Dissemination: The study findings will be disseminated in peer-reviewed journals and presented at national and international conferences.

Trial Registration Number: ClinicalTrials.gov Identifier: NCT01871272.
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http://dx.doi.org/10.1136/bmjopen-2013-003399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3808767PMC
October 2013

Neuromuscular function during a forward lunge in meniscectomized patients.

Med Sci Sports Exerc 2012 Jul;44(7):1358-65

Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Objective: This study aimed to investigate differences in knee joint kinematics, ground reaction force kinetics and neuromuscular activity including muscle coactivation, and medial versus lateral muscle activity during a forward lunge between the operated and contralateral legs of meniscectomized patients. Such differences may represent early changes in neuromuscular function potentially contributing to the development of knee osteoarthritis.

Methods: Twenty-two unilaterally meniscectomized patients (15 men and 7 women; age = 45.4 ± 5.1 yr, height = 174.3 ± 7.1 cm, weight = 77.3 ± 15.4 kg (mean ± SD)) were investigated on their operated and contralateral legs during a forward lunge using synchronous goniometer, force plate, and EMG recording (vastus lateralis, vastus medialis, biceps femoris, and semitendinosus).

Results: During impact loading, an increased level of muscle coactivation (38.0% (29.8%-46.3%) vs 30.1% (23.6%-36.6%), P = 0.02; mean (95% confidence interval)), reduced range of motion (59.4° (54.5°-64.2°) vs 64.9 (60.8°-70.0°), P = 0.01), and increased loading rate (985% BW·s(-1) (653-1317% BW·s(-1)) vs 696% BW·s(-1) (525-868% BW·s(-1)), P = 0.01) were observed in the operated leg compared with the contralateral leg. In addition, different patterns of medial versus lateral neuromuscular activity were observed in the operated and contralateral legs, along with minor differences during the other phases of the forward lunge.

Conclusions: The findings of increased muscle coactivation, reduced range of motion, and increased loading rate in the operated compared with the contralateral leg support the hypothesis that meniscectomized patients demonstrate modulations in kinetics, kinematics, and neuromuscular activity, which may represent early changes in neuromuscular function that precede and affect development of knee osteoarthritis. The results also indicate that the forward lunge test is a sensitive measure to identify leg-to-leg differences in neuromuscular function after surgical interventions.
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http://dx.doi.org/10.1249/MSS.0b013e31824c315bDOI Listing
July 2012

Muscle strength and functional performance in patients at high risk of knee osteoarthritis: a follow-up study.

Knee Surg Sports Traumatol Arthrosc 2012 Jun 29;20(6):1110-7. Epub 2011 Oct 29.

Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.

Purpose: To investigate whether changes from 2 to 4 years post arthroscopic partial meniscectomy (APM) in mechanical muscle function and objectively measured function differ between the operated and contra-lateral leg of APM patients or compared with controls.

Methods: Twenty-two patients (age 46.6 ± 5.0, BMI 24.7 ± 2.9) and 25 controls (age 46.4 ± 5.2, BMI 25.1 ± 4.6) previously examined at ~2 years post APM were examined again at ~4 years post surgery for maximal knee extensor/flexor voluntary contraction (MVC) and rapid force capacity. Functional performance was assessed by the distance achieved during a one-leg hop test and the maximum number of knee bends performed in 30 s. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to evaluate self-reported outcomes.

Results: Overall changes from 2 to 4 years post APM did not differ in maximal muscle strength, rapid force capacity, and functional performance between the operated and contra-lateral leg of patients or control legs. However, secondary analysis showed a difference in change in knee extensor MVC resulting in a 6% difference between the operated and contra-lateral leg of patients at follow-up.

Conclusions: No differences in longitudinal changes were observed from 2 to 4 years post APM between patients and controls. The secondary finding of differential changes over time in knee extensor MVC between the operated and contra-lateral leg partly confirm our hypothesis that differences in muscle strength may evolve from 2 to 4 years post APM. This differential change may represent an initial sign of an evolving lower limb muscle asymmetry, which may play a role in the development of knee OA.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-011-1719-2DOI Listing
June 2012