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OBJECTIVE: To assess the effectiveness of individualized physiotherapy in combination with rigid taping compared with individualized physiotherapy alone in patients with subacromial pain syndrome.DESIGN: A prospective randomized trial with concealed allocation.PATIENTS: A total of 140 patients between 18 and 65 years of age from primary physiotherapy settings.METHODS: The intervention group received individualized physiotherapy and shoulder taping. The control group received individualized physiotherapy only. Primary outcomes were: pain intensit (numerical rating scale) and functioning (Simple Shoulder Test). Secondary outcomes were: global perceived effect and patient-specific complaints. Data were collected at baseline, and at 4, 12 and 26 weeks' follow-up.RESULTS: During the 6-month follow-up period multilevel analysis showed a significant difference between groups favouring the control group on pain intensity (p = 0.02), but not on functioning. Regarding secondary outcomes, a significant difference between groups was found favouring the intervention group for global perceived effect (p = 0.02), but not for patient-specific complaints.CONCLUSION: Rigid shoulder taping, as used in this study, cannot be recommended for improving physiotherapy outcomes in people with subacromial pain syndrome.

Aim To determine if psychosocial factors are associated with outcome in patients with neck pain or low back pain. Methods In a prospective, multi-center chiropractic practice-based cohort study in Belgium and The Netherlands, 917 patients, of which 326 with neck pain and 591 with low back pain, completed self-administered questionnaires at baseline, following the second visit, and at 1, 3, 6 and 12 months. Psychosocial factors assessed at baseline were: distress, depression, anxiety and somatization via the Four Dimensional Symptom Questionnaire, patient's beliefs regarding the effect of physical activity and work on their complaint via the Fear Avoidance Beliefs Questionnaire, and social support via the Feij social support scale. Primary outcome measures were perceived recovery, pain intensity, and functional status which was measured with the Neck Disability Index and Oswestry Disability Index. A univariable regression analysis to estimate the relation between each psychological variable and outcome was followed by a multivariable multilevel regression analysis. Results There were no differences in baseline patient characteristics between the patient population from Belgium and the Netherlands. Somatization scores are consistently associated with perceived recovery, functional status and pain for both neck pain and low-back pain. Depression was associated with poorer functioning in patients with LBP. There was a small association between fear and function and pain for patients with neck pain or low-back pain. Conclusion Somatization was the only variable consistently found to be associated with diminished perceived recovery, higher degree of neck or low back disability, and increased neck or low back pain.

Background and aims To identify relations between brain abnormalities and spoken language comprehension, MRI characteristics of 80 nonspeaking children with severe CP were examined. Methods MRI scans were analysed for patterns of brain abnormalities and scored for specific MRI measures: white matter (WM) areas; size of lateral ventricles, WM abnormality/reduction, cysts, subarachnoid space, corpus callosum thinning and grey matter (GM) areas; cortical GM abnormalities, thalamus, putamen, globus pallidus and nucleus caudatus and cerebellar abnormalities. Language comprehension was assessed with a new validated instrument (C-BiLLT). Results MRI scans of 35 children were classified as a basal ganglia necrosis (BGN) pattern, with damage to central GM areas; in 60% of these children damage to WM areas was also found. MRI scans of 13 children were classified as periventricular leukomalacia (PVL) with little concomitant damage to central GM areas, 13 as malformations and 19 as miscellaneous. Language comprehension was best in children with BGN, followed by malformations and miscellaneous, and was poorest in PVL. Linear regression modelling per pattern group (malformations excluded), with MRI measures as independent variables, revealed that corpus callosum thinning in BGN and parieto-occipital WM reduction in PVL were the most important explanatory factors for poor language comprehension. No MRI measures explained outcomes in language comprehension in the miscellaneous group. Conclusions Comprehension of spoken language differs between MRI patterns of severe CP. In children with BGN and PVL differences in language comprehension performance is attributed to damage in the WM areas. Language comprehension was most affected in children with WM lesions in the subcortical and then periventricular areas, most characteristic for children with PVL.

BACKGROUND AND PURPOSE: DWI is typically performed with EPI sequences in single-center studies. The purpose of this study was to determine the reproducibility of ADC values in the head and neck region in healthy subjects. In addition, the reproducibility of ADC values in different tissues was assessed to identify the most suitable reference tissue. MATERIALS AND METHODS: We prospectively studied 7 healthy subjects, with EPI and TSE sequences, on 5 MR imaging systems at 3 time points in 2 institutions. ADC maps of EPI (with 2 b-values and 6 b-values) and TSE sequences were compared. Mean ADC values for different tissues (submandibular gland, sternocleidomastoid muscle, spinal cord, subdigastric lymph node, and tonsil) were used to evaluate intra- and intersubject, intersystem, and intersequence variability by using a linear mixed model. RESULTS: On 97% of images, a region of interest could be placed on the spinal cord, compared with 87% in the tonsil. ADC values derived from EPI-DWI with 2 b-values and calculated EPI-DWI with 2 b-values extracted from EPI-DWI with 6 b-values did not differ significantly. The standard error of ADC measurement was the smallest for the tonsil and spinal cord (standard error of measurement = 151.2 × 10(−6) mm/s(2) and 190.1 × 10(−6) mm/s(2), respectively). The intersystem difference for mean ADC values and the influence of the MR imaging system on ADC values among the subjects were statistically significant (P < .001). The mean difference among examinations was negligible (ie

Objectives Dual sensory loss (DSL; concurrent vision and hearing loss) negatively affects quality of life. As speechreading is hampered, use of hearing aids (HAs) is important for older adults with DSL. However, due to vision loss, use of small and complex HAs is assumed to be difficult. An integrative DSL protocol that addresses rehabilitative care for older adults with DSL, including proper HA use, was implemented in low vision rehabilitation centers. The present study aims to evaluate the effectiveness of the DSL protocol among HA owners on HA outcomes (i.e., HA use, benefit, satisfaction with HAs, and hearing with HAs). Design In a randomized controlled trial, the DSL protocol was compared to a waiting list control group among clients (aged ≥50 years) of low vision rehabilitation centers with DSL. The International Outcome Inventory for Hearing Aids (IOI-HA) and the HA Fitting Questionnaire (HAFQ) were administered at baseline and 3 months follow-up. Participants (n = 128) were randomly allocated to either the intervention (n = 63) or control group (n = 65). Results Intention-to-treat analyses showed a near significant effect on IOI-HA Residual problems (effect size, 0.35; p = 0.063). Per-protocol analyses showed similar (nonsignificant) results on the main outcomes, and a ceiling effect was found on the HAFQ. Significant effects were found in subgroups of patients: among patients with low HAFQ scores (HAFQ-Use: effect size = 0.56, p = 0.046; HAFQ-Hearing with HAs: effect size = 0.64, p = 0.019), male participants (effect size = 0.80; p = 0.003), and those with moderate hearing loss (effect size = 0.72; p = 0.028), significantly better IOI-HA scores were found in the intervention group at 3 months follow-up. Conclusions Although the per-protocol and subgroup analyses need to be interpreted with caution, DSL patients who experience HA difficulties could benefit from the DSL protocol by making better use of their HAs. The increasing prevalence and impact of DSL on a person's independence and social participation call for more awareness of concurrent sensory impairments in both low vision and audiology rehabilitation. Interdisciplinary training for rehabilitation professionals could be an important step, followed by integration of vision and hearing services using the DSL protocol.

Introduction This study aimed to investigate the sensitivity to change over time of a new informant-based instrument to assess instrumental activities of daily living (IADL) during the course of dementia: the Amsterdam IADL Questionnaire© (A-IADL-Q). Methods Participants (n = 102) were patients and their informants who visited the Alzheimer Center of the VU University Medical Center. Linear mixed models with random effects were used to relate longitudinal change on the A-IADL-Q to diagnosis and to longitudinal change in cognitive measures. Results We found longitudinal change on the A-IADL-Q to differ between diagnosis (P = .003), with dementia patients showing the fastest rate of decline (P < .001). In addition, we found longitudinal change on the A-IADL-Q to be related to longitudinal change in cognitive measures (global cognition: P < .001; memory: P = .024; executive functioning: P = .028). Discussion Findings indicate the A-IADL-Q is sensitive to change over time in IADL functioning and can be used in evaluating treatment effects and assessing individual disease progress.

Purpose: To assess the intra- and inter-rater reliability of a standardized protocol for measuring proximal tibia and distal femur bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA).Methods: Ten able-bodied individuals (7 males) participated in this study. During one measurement session, the knee of each participant was scanned twice by rater 1 using DXA. Both scans were analyzed twice by rater 1 as well as once by a second rater. Intraclass correlation coefficients (ICCs), standard error of measurements (SEMs) and smallest detectable differences (SDDs) were calculated for the outcome measures proximal tibia and distal femur BMD. A decision study was performed to determine the effect of study protocol adjustments (i.e. increasing the number of scan repetitions, or scan analyses by the same rater) on SEM and SDD values.Results: High intra- and inter-rater ICCs (0.97-0.98) were found for both proximal tibia and distal femur BMD. Low SEMs (0.017-0.028 g/cm(2)) and SDDs (0.047-0.077 g/cm(2)) were found, with a slightly better result for proximal tibia BMD. Increasing the number of scan analyses by the same rater did not markedly reduce SEM and SDD values, while increasing the number of scan repetitions did.Conclusions: Proximal tibia and distal femur BMD can be reliably assessed with this method. (C) 2013 IPEM. Published by Elsevier Ltd. All rights reserved.

PURPOSE Consultations for forefoot pain are frequent in primary care, but scientific support of treatment options is scarce. The purpose of this study is to investigate the effect of podiatric treatment vs standardized advice on proper shoe characteristics and fit of shoes by means of an information leaflet for people aged 50 years and older with forefoot pain in primary care. METHODS In this randomized controlled trial, 205 participants aged 50 years and older with hindering nontraumatic forefoot pain have been recruited at their general practitioner’s office. Exclusion criteria were treatment of forefoot problem of less than 6 months’ duration before inclusion, rheumatoid arthritis, and diabetic neuropathy or having pain considered not to be musculoskeletal (eg, warts). Participants received shoe advice by means of an information leaflet or podiatric care. Foot pain, foot-related dysfunction, general health, and social participation were assessed by means of questionnaires every 3 months for 1 year. Using multilevel analysis, we analyzed results at the level of (1) outcome measures, (2) the individual, and (3) the general practitioner. RESULTS No differences were found between the 2 treatment groups. Both intervention groups showed an improvement over time in foot pain and foot-related dysfunction. CONCLUSION This study found that shoe advice provided to patients consulting their general practitioner for forefoot pain and symptom relief resulted in outcomes similar to treatment outcomes in patients consulting a podiatrist. Based on these results, primary care physicians should be cautious when referring a patient to a podiatrist; instead, they should start by providing advice on proper characteristics and fit of shoes.

Background: Testosterone concentrations in normally cycling women are assumed to be elevated around the time of ovulation. The clinical relevance of changing testosterone concentrations during the menstrual cycle, however, is unclear. Poor performance of current direct immunoassays for testosterone at low concentrations confounds this issue. Therefore, our objective was to assess daily testosterone fluctuation during the menstrual cycle by a thoroughly validated isotope dilution-liquid chromatography-Tandem mass spectrometry (ID-LC-MS/MS) method and to evaluate whether an ARCHITECT® 2nd Generation Testosterone fully automated immunoassay is equally suited for this purpose. Methods: Testosterone was measured in serum obtained daily during the menstrual cycle of 25 healthy women, characterized by biochemical and physical examination. Results: Performance of the ID-LC-MS/MS method was concordant with a published reference method (y = 1.007x - 0.056 nmol/L; r = 0.9998). Comparison of the immunoassay to ID-LC-MS/MS yielded y = 1.095x + 0.104 nmol/L (r = 0.9031). Overall, testosterone concentrations were higher mid-cycle, but a peak was not discernible in each individual. Apart from a persistent positive bias, the immunoassay measured the same testosterone profiles as the ID-LC-MS/MS method. The reference interval in women was 0.30-1.69 nmol/L (8.7-48.7 ng/dL) for ID-LC-MS/MS and 0.50-2.00 nmol/L (14.4-57.7 ng/dL) for the immunoassay. Conclusion: The elevation of mid-cycle testosterone concentrations is statistically significant, although not clinically relevant since day-To-day variation is higher and independent of the menstrual cycle. In this light, a single testosterone measurement might not be reflective of the overall testosterone status in an individual. Measurements obtained using the 2nd generation immunoassay gave comparable results across the menstrual cycle. © 2012 Elsevier Inc. All rights reserved.

Objective: To determine the content, structural, and construct validity of the Dutch version of the Neck Disability Index (NDI). Study Design and Setting: To assess content validity, 11 neck pain experts and 10 patients commented on the construct, comprehensiveness, and relevance of the NDI. Structural validity was assessed by item factor analysis (FA) and item response theory modeling using the generalized partial credit model. Differential item functioning (DIF) analysis for gender was examined. Pearson correlation coefficient with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was calculated to assess construct validity. Results: In addition to a suboptimal translation, we found a lack of consensus on the construct the NDI intends to measure. Experts and patients suggested that the NDI measures more than physical functioning. Unidimensionality of the NDI could not be confirmed. DIF analysis for gender showed DIF for the headache item. The goodness-of-fit statistics for FA with one factor were satisfactory when the item ‘‘concentration’’ was omitted. A correlation of 0.75 with the DASH was found supporting construct validity. Conclusion: It is questionable whether in research the NDI should be the instrument of choice for use as a primary outcome measure. Definition of the construct to be measured is a prerequisite for the assessment of validity. 2013 Elsevier Inc. All rights reserved.

Purpose: Fatigue is a complex, multidimensional construct. Most questionnaires measuring fatigue do not meet the standards for good measurement properties. Therefore, the Neurological Fatigue Index for multiple sclerosis (NFIMS) is recently developed using thorough methods. The aim of this study was to develop and validate the Dutch version of the NFI-MS. Methods: The original English version of the NFI-MS was translated into Dutch using a forward-backward procedure. Reliability (intraclass correlation coefficient (ICC) and standard error of measurement (SEM)) were assessed for the summary score and the four subscale scores separately. Construct validity was assessed by testing hypotheses about expected correlations between the NFI-MS and other constructs (e.g. impact on functioning and depression) and expected differences on NFI scores between groups defined on the basis of disease type and work status. Results: The reliability analyses (n = 118) showed that the ICC was 0.78 (NFI-MS summary) and ranged from 0.75 to 0.83 for the four subscales and the SEM was 2.5 (NFI-MS summary) and ranged from 1.1 to 2.2 for the four subscales. For construct validity (n = 136), 50 out of the 57 expected hypotheses were confirmed (88 %). Conclusion: The present study shows that the Dutch version of the NFI-MS is a reliable and valid self-report questionnaire for measuring fatigue in Dutch patients with MS. © Springer Science+Business Media Dordrecht 2013.

The objective of this study was to evaluate whether self-reported knee instability is associated with activity limitations in patients with knee osteoarthritis (OA), in addition to knee pain and muscle strength. A cohort of 248 patients diagnosed with knee OA was examined. Self-reported knee instability was defined as the perception of any episode of buckling, shifting, or giving way of the knee in the past 3 months. Knee pain was assessed using a numeric rating scale, and knee extensor and flexor strength were measured using an isokinetic dynamometer. Activity limitations were measured by using the Western Ontario and McMasters Universities Osteoarthritis Index physical function questionnaire, the timed Get Up and Go, and the timed stair climbing and three questionnaires evaluating walking, climbing stairs, and rising from a chair. Other potential determinants of activity limitations were also collected, including joint proprioception, joint laxity, age, sex, body mass index (BMI), disease duration, and radiographic disease severity. Regression analyses evaluated the effect of adding self-reported knee instability to knee pain and muscle strength, when examining associations with the activity limitations measures. Self-reported knee instability was common (65 %) in this cohort of patients with knee OA. Analyses revealed that self-reported knee instability is significantly associated with activity limitations, even after controlling for knee pain and muscle strength. Joint proprioception, joint laxity, age, sex, BMI, duration of complaints, and radiographic severity did not confound the associations. In conclusion, self-reported knee instability is associated with activity limitations in patients with knee OA, in addition to knee pain and muscle strength. Clinically, self-reported knee instability should be assessed in addition to knee pain and muscle strength.

PURPOSE. In addition to performance-based measures, visionrelated quality of life (QOL) and other subjective measures of psychosocial functioning are considered important outcomes of training in the visually impaired. In a multicenter, masked, randomized controlled trial, subjective effects of training in the use of closed-circuit televisions (CCTV) were investigated. METHODS. Patients (n ¼ 122) were randomized either to a treatment group that received usual delivery instructions from the supplier combined with concise outpatient training, or to a control group that received delivery instructions only. Subjective outcomes were the Low Vision Quality-of-Life Questionnaire (LVQOL), EuroQOL 5 Dimensions, Adaptation to AgeRelated Vision Loss (AVL), and the Center of Epidemiologic Studies Depression scales. Linear mixed models were used to investigate treatment effects. Differential effects of patient characteristics were studied by implementing higher order interactions into the models. RESULTS. From baseline to follow-up, all patients perceived significantly less problems on the reading and fine work dimension (-28.8 points; P < 0.001) and the adaptation dimension (-4.67 points; P ¼ 0.04) of the LVQOL. However, no treatment effect was found based on the intention-to-treat analysis. CONCLUSIONS. This study demonstrated the effect of receiving and using a CCTV on two vision-related QOL dimensions; however, outpatient training in the use of CCTVs had no additional value. (trialregister.nl number, NTR1031.) (Invest Ophthalmol Vis Sci. 2012;53:3645‐3652) DOI:10.1167/ iovs.11-9226

Aims In a time of controversy regarding the use of echocardiography for assessment of left ventricular (LV) dyssynchrony and prediction of response to cardiac resynchronization therapy (CRT), this meta-analysis aimed to evaluate the feasibility and reliability of LV dyssynchrony assessment by three-dimensional echocardiography (3DE), determine clinically useful reference values in healthy subjects and heart failure patients, and examine the accuracy of 3DE to predict response to CRT. Methods and results A total of 73 studies that evaluated the assessment of LV dyssynchrony by 3DE were eligible. The systolic dyssynchrony index (SDI) for 16 segments, being the predominant 3DE dyssynchrony parameter, was used for data pooling. Results demonstrated that LV dyssynchrony assessment by 3DE is feasible in 94% of studied subjects [95% confidence interval (CI): 92-95%)]. Pooled estimates of intraclass correlation coefficients (ICC) and limits of agreement (LoA) demonstrated that SDI has good interobserver (ICC: 0.92, LoA: 4.07%) and intraobserver reliability (ICC: 0.95, LoA: 2.10%). Reference values of SDI in healthy subjects, heart failure patients in general, and patients eligible for CRT were 2.7±0.9%, 9.8±3.9%, and 10.7±3.6%, respectively. Meta-regression analysis demonstrated that reference values of SDI in healthy subjects significantly differed between different software [1.80% (95% CI: 0.55-3.05%), P < 0.001]. In patients eligible for CRT, SDI had good accuracy to predict treatment response with a weighted mean cut-off value of 9.8% and pooled estimates for sensitivity and specificity of 93% (95% CI: 89-97%) and 75% (95% CI: 58-93%), respectively. Conclusion 3DE is a feasible and reliable tool for assessment of LV dyssynchrony and may have additional value to current selection criteria for accurate prediction of response to CRT. © The Author 2012.

STUDY DESIGN: A randomized controlled trial.OBJECTIVE: To assess the effectiveness of Delitto's classification-based treatment approach compared with usual physical therapy care in patients with subacute or chronic low back pain.SUMMARY OF BACKGROUND DATA: No trial has evaluated this approach in patients with subacute and chronic low back pain.METHODS: Before randomization, all patients were classified by research physical therapists according to a modified version of Delitto's classification-based system. Randomization was computer-generated, with centralized allocation concealment. The statistician and the physical therapists were unblinded. Patients and assistants who collected follow-up questionnaires were blinded. Follow-up assessments were completed at 8, 26, and 52 weeks. The primary analysis was performed according to the intention-to-treat principle, using multilevel analysis. The main outcomes were global perceived effect, disability (Oswestry Disability Index, 0-100), and pain intensity (Numerical Rating Scale, 0-10). Secondary outcomes were quality of life, fear-avoidance beliefs, and psychosocial status. RESULTS.: A total of 156 patients were included (classification-based group, n = 74; usual physical therapy group, n = 82). There were no statistically significant differences between the treatment groups for any of the outcomes at any of the follow-up time points. After 8 weeks, patients in the classification-based group had greater global perceived effect scores; adjusted odds ratio of 1.01 (95% confidence interval [CI], 0.31 to 3.28), and higher adjusted Oswestry Disability Index and Numerical Rating Scale scores; mean adjusted differences of 0.48 points (95% CI, -4.59 to 3.63) and 0.49 points (95% CI, -1.34 to 0.37) respectively, but all differences were statistically nonsignificant.CONCLUSION: The classification-based system used in this study was not effective for improving physical therapy care outcomes in a population of patients with subacute and chronic low back pain.

OBJECTIVES: To investigate whether problems in instrumental activities of daily living (IADL) can add to conventionally used clinical measurements in helping to predict a diagnosis of dementia at 1- and 2-year follow-up. DESIGN: Multicenter prospective cohort study. SETTING: Memory clinics in Europe. PARTICIPANTS: Individuals aged 55 and older without dementia. MEASUREMENTS: IADLs were measured using pooled activities from five informant-based questionnaires. Structural equation modeling (SEM) was used to investigate the relation between IADLs and dementia. Age, sex, education, depression, and cognitive measures (Mini-Mental State Examination and verbal memory) were included in the model. RESULTS: Five hundred thirty-one participants had baseline and 1-year follow-up assessments; 69 (13.0%) of these had developed dementia at 1-year follow-up. At 2-year follow- up, 481 participants were seen, of whom 100 (20.8%) had developed dementia. Participants with IADL disabilities at baseline had a higher conversion rate (24.4%) than participants without IADL disabilities (16.7%) (chisquare = 4.28, degrees of freedom = 1, P =.04). SEM showed that IADL disability could help predict dementia in addition to the measured variables at 1-year follow-up (odds ratio (OR) = 2.20, 95% confidence interval (CI) = 1.51-3.13) and 2-year follow-up (OR = 2.11, 95% CI = 1.33-3.33). CONCLUSION: IADL disability is a useful addition to the diagnostic process in a memory clinic setting, indicating who is at higher risk of developing dementia at 1- and 2-year follow-up. J Am Geriatr Soc 59: 2273-2281, 2011.

OBJECTIVE: To identify subgroups or phenotypes of knee osteoarthritis (OA) patients based on similarities of clinically relevant patient characteristics, and to compare clinical outcomes of these phenotypes.METHODS: Data from 842 knee OA patients of the Osteoarthritis Initiative were used. A cluster analysis method was performed, in which clusters were formed based on similarities in 4 clinically relevant, easily available variables: severity of radiographic OA, lower extremity muscle strength, body mass index, and depression. Univariable and multivariable regression analyses were used to compare phenotypes on clinical outcomes (pain and activity limitations), taking into account possible confounders.RESULTS: Five phenotypes of knee OA patients were identified: "minimal joint disease phenotype," "strong muscle phenotype," "nonobese and weak muscle phenotype," "obese and weak muscle phenotype," and "depressive phenotype." The "depressive phenotype" and "obese and weak muscle phenotype" showed higher pain levels and more severe activity limitations than the other 3 phenotypes.CONCLUSION: Five phenotypes based on clinically relevant patient characteristics can be identified in the heterogeneous population of knee OA patients. These phenotypes showed different clinical outcomes. Interventions may need to be tailored to these clinical phenotypes.

Introduction: Within the labour force workers without an employment contract represent a vulnerable group. In most cases, when sick-listed, these workers have no workplace/employer to return to. Therefore, the aim of this study was to evaluate the effectiveness on return-to-work of a participatory return-to-work program compared to usual care for unemployed workers and temporary agency workers, sick-listed due to musculoskeletal disorders. Methods: The workers, sick-listed for 2-8 weeks due to musculoskeletal disorders, were randomly allocated to the participatory return-to-work program (n = 79) or to usual care (n = 84). The new program is a stepwise procedure aimed at making a consensus-based return-to-work plan, with the possibility of a temporary (therapeutic) workplace. Outcomes were measured at baseline, 3, 6, 9 and 12 months. The primary outcome measure was time to sustainable first return-to-work. Secondary outcome measures were duration of sickness benefit, functional status, pain intensity, and perceived health. Results The median duration until sustainable first return-to-work was 161 days in the intervention group, compared to 299 days in the usual care group. The new return-to-work program resulted in a non-significant delay in RTW during the first 90 days, followed by a significant advantage in RTW rate after 90 days (hazard ratio of 2.24 [95% confidence interval 1.28-3.94] P = 0.005). No significant differences were found for the measured secondary outcomes. Conclusions The newly developed participatory return-to-work program seems to be a promising intervention to facilitate work resumption and reduce work disability among temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders. © The Author(s) 2011.

Summary Background No consensus exists on the validity of the sentinel-lymph-node procedure for assessment of nodal status in patients with colorectal cancer. We aimed to assess the diagnostic performance of this procedure. Methods We searched Embase and PubMed databases for studies published before March 20, 2010. Eligible studies had a prospective design, a sample size of at least 20 patients, and reported the rate of sentinel-lymph-node positivity. Individual patient data were requested for localisation and T-stage stratification. A subset of reports with high methodological quality was selected and analysed. Findings We identified 52 eligible studies, which included 3767 sentinel-lymph-node procedures (2961 [78·6%] colon and 806 [21·4%] rectal carcinomas). Most tumours 2339 (62·1%) were stage T3 or T4. 1887 (50·1%) of patients were male, 1880 (49·9%) female. Mean overall weighted-detection rate was 0·94 (95% CI 0·92–0·95), at a pooled sensitivity of 0·76 (0·72–0·80) with limited heterogeneity (χ 2 =286·08, degrees of freedom=51; p=0·003). A mean weighted upstaging of 0·15 (95% CI 0·12–0·19) was noted. Individual patient data were available from 19 studies that included 1168 patients. Analysis of these data showed no significant difference in sensitivity between colon (0·86 [95% CI 0·83–0·90]) and rectal cancer (0·82 [0·77–0·88]; p=0·23). Also, there was no dependency of sensitivity on T stage for both colon (pT1: 0·79 [95% CI 0·73–0·84], pT2: 0·76 [0·62–0·90], pT3: 0·73 [0·59–0·87], pT4: 0·73 [0·53–0·93]) and rectal cancer (T1 or T2: 0·81 [0·52–0·94] vs T3 or T4: 0·80 [0·51–0·93]). The subgroup of eight studies with high methodological quality showed a mean detection rate of 0·96 (95% CI 0·90–0·99) for colonic tumours and 0·95 (0·75–0·99) for rectal tumours, and a mean sensitivity of 0·90 (95% CI 0·86–0·93) for colonic tumours and 0·82 (0·60–0·93) for rectal tumours. Interpretation The sentinel-lymph-node procedure shows a low sensitivity, regardless of T stage, localisation, or pathological technique. For every patient diagnosed with colon or rectal cancer without clinical evidence of lymph-node involvement or metastatic disease, this procedure in addition to conventional resection should be considered, since the prognostic information provided by this technique could be clinically significant. Funding Cancer Center Amsterdam Foundation, Amsterdam, Netherlands.

Background: Cortical lesions (CLs) occur frequently in multiple sclerosis (MS), but only few CLs are observed on conventional magnetic resonance imaging (MRI). Why some CLs are visible and others are not is currently unknown. Here, we investigated whether CLs that are visible on conventional MRI differ from MRI-invisible CLs in terms of underlying histopathology and quantitative MRI (qMRI) measures. Methods: A total of 16 brain slices from 10 patients with chronic MS were analysed histopathologically and with conventional and qMRI. A region-of-interest approach was used to compare MRI-visible CLs with MRI-invisible CLs. Results: Although under-powering cannot be completely excluded in this study, MRI-visible CLs did not seem to differ from MRI-invisible CLs in terms of histopathology or qMRI measures. They were, however, significantly larger than their invisible counterparts (mean 13.3 ± 1.7 mm2 versus 6.9 ± 1.3 mm2; p = 0.001). Furthermore, the number of MRI-visible lesions correlated with the overall number of CLs in the brain slice ( r = 0.96, p Conclusion: MRI visibility of CLs is determined by lesion size, and not by any distinctive underlying pathology. Visible CLs are associated with a higher total cortical lesion load, which suggests that when CLs in patients with MS become detectable on MRI, they merely represent ‘the tip of the pathological iceberg’.

Objectives: This study investigated the effectiveness of the Stay@Work participatory ergonomics programme to reduce workers9 exposure to psychosocial and physical risk factors. Methods: 37 departments (n=3047 workers) from four Dutch companies participated in this cluster randomised controlled trial; 19 (n=1472 workers) were randomised to an intervention group (participatory ergonomics) and 18 (n=1575 workers) to a control group (no participatory ergonomics). During a 6 h meeting guided by an ergonomist, working groups devised ergonomic measures to reduce psychosocial and physical workload and implemented them within 3 months in their departments. Data on psychosocial and physical risk factors for low back pain and neck pain were collected at baseline and after 6 months. Psychosocial risk factors were measured using the Job Content Questionnaire and physical risk factors using the Dutch Musculoskeletal Questionnaire. Intervention effects were studied using multilevel analysis. Results: Intervention group workers significantly increased on decision latitude (0.29 points; 95% CI 0.07 to 0.52) and decision authority (0.16 points; 95% CI 0.04 to 0.28) compared to control workers. However, exposure to awkward trunk working postures significantly increased in the intervention group (OR 1.86; 95% CI 1.15 to 3.01) compared to the control group. No significant differences between the intervention and control group were found for the remaining risk factors. After 6 months, loss to follow-up was 35% in the intervention group and 29% in the control group.Conclusion: Participatory ergonomics was not effective in reducing exposure to psychosocial and physical risk factors for low back pain and neck pain among a large group of workers. Trial registration: ISRCTN27472278.

Objective: To investigate the impact of a higher magnetic field strength of 3 Tesla (T) on the detection rate of cortical lesions in multiple sclerosis (MS) patients, in particular using a dedicated double inversion recovery (DIR) pulse sequence. Methods: Thirty-four patients with clinically isolated syndromes or definite MS were included. All patients underwent magnetic resonance imaging (MRI) at 1.5 T and 3 T, including T2-weighted turbo spin echo (TSE), fluid-attenuated inversion recovery (FLAIR) and DIR sequences. All images were analysed for focal lesions categorised according to their anatomical location. Results: The total number of detected lesions was higher at 3 T across all pulse sequences. We observed significantly higher numbers of lesions involving the cortex at 3 T using a DIR sequence. DIR at 3 T showed 192% more pure intracortical (p

Background When making decisions, children with oppositional defiant disorder (ODD) are thought to focus on reward and ignore penalty. This is suggested to be associated with a state of low psychophysiological arousal. Methods This study investigates decision making in 18 children with oppositional defiant disorder and 24 typically developing control subjects. Children were required to choose between three alternatives that carried either frequent small rewards and occasional small penalties (advantageous), frequent large rewards and increasing penalties (seductive), or frequent small rewards and increasing penalties (disadvantageous). Penalties in the seductive and disadvantageous alternatives increased either in frequency or magnitude in two conditions. Heart rate (HR) and skin conductance responses to reinforcement were obtained. Results In the magnitude condition, children with ODD showed an increased preference for the seductive alternative (carrying large rewards); this was not observed in the frequency condition. Children with ODD, compared with typically developing children, displayed greater HR reactivity to reward (more HR deceleration) and smaller HR reactivity to penalty. Correlation analyses showed that decreased HR responses to penalty were related to an increased preference for large rewards. No group differences were observed in skin conductance responses to reward or penalty. Conclusions The findings suggest that an increased preference for large rewards in children with ODD is related to a reduced cardiac reactivity to aversive stimuli. This confirms notions of impaired decision making and altered reinforcement sensitivity in children with ODD and adds to the literature linking altered autonomic control to antisocial behavior.

STUDY DESIGN: A randomized clinical trial. OBJECTIVE: To compare the effectiveness of a behavioral graded activity program with manual therapy in patients with subacute (4-12 weeks) nonspecific neck pain. SUMMARY OF BACKGROUND DATA: Neck pain is a common complaint, for which many conservative therapies are available in primary care. There is strong evidence for manual therapy in combination with exercises. Psychosocial factors are also believed to play a role in chronic pain. The evidence of the effectiveness of a program focused on these factors is still unknown. METHODS: A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. Manual therapy consists of specific spinal mobilization techniques and exercises. Primary outcomes were global perceived effect, the Numerical Rating Scale for pain and the Neck Disability Index. Secondary outcomes were the Tampa Scale for Kinesiophobia, the 4 Dimensional Symptom Questionnaire, and the Pain Coping and Cognition List. Measurements were carried out at baseline and 6, 13, 26, and 52 weeks after randomization. Data are analyzed according to the intention-to-treat principle, using multilevel analysis. RESULTS: The success rates at 52 weeks, based on the GPE were 89.4% for the BGA program and 86.5% for MT. This difference was not statistically significant. For pain and disability, a difference was found in favor of the BGA program; mean difference for pain = 0.99 (95% CI 0.15-1.83) and mean difference for NDI = 2.42 (95% CI 0.52-4.32). All other differences between the interventions in the primary and secondary outcomes were not statistically significant. CONCLUSION: Based on this trial it can be concluded that there are only marginal, but not clinically relevant, differences between a BGA program and MT. Spine (Phila Pa 1976) ispartof: Spine vol:35 issue:10 pages:1017-1024 ispartof: location:United States status: published

Medical Education 2010:44: 156–164 Context This study aimed to assess if an additional patient feedback training programme leads to better consultation skills in general practice trainees (GPTs) than regular communication skills training, and whether process measurements (intensity of participation in the programme) predict the effect of the intervention. Methods We carried out a controlled trial in which two sub-cohorts of GPTs were allocated to an intervention group (n = 23) or a control group (n = 30), respectively. In 2006, allocated first-year GPTs in the VU University Medical Centre attended a patient feedback training programme in addition to the regular communication skills training. The control group attended only regular communication skills training. Trainees were assessed by simulated patients who visited the practices and videotaped the consultations at baseline and after 3 months. The videotapes were randomly assigned to eight trained staff members. The MAAS-Global Instrument (range 0–6) was used to assess (a change in) trainee consultation skills. Results were analysed using a multi-level, linear mixed-model analysis. Results Data on 50 GPTs were available for the follow-up analysis. Both intervention group and control group GPTs improved their consultation skills: mean MAAS-Global scores for all participants were 3.29 (standard deviation [SD] 0.75) at baseline and 3.54 (SD 0.66) at follow-up (P = 0.047). The improvement in MAAS-Global scores in the intervention group did not differ significantly from the improvement in the control group. The analysis showed a trend for intensity of participation in the patient feedback programme to predict greater improvement in MAAS-Global scores. Discussion Although the baseline scores were already in the high range, consultation skills in both groups improved significantly. This is reassuring for current teaching methods. The patient feedback programme did not improve consultation skills more than regular communication skills training. However, a subgroup of GPTs who participated intensively in the programme did improve their consultation skills further in comparison with the less motivated subgroup.

Objective: Lack of consensus on taxonomy, terminology, and definitions has led to confusion about which measurement properties are relevant and which concepts they represent. The aim was to clarify and standardize terminology and definitions of measurement properties by reaching consensus among a group of experts and to develop a taxonomy of measurement properties relevant for evaluating health instruments. Study Design and Setting: An international Delphi study with four written rounds was performed. Participating experts had a background in epidemiology, statistics, psychology, and clinical medicine. The panel was asked to rate their (dis)agreement about proposals on a five-point scale. Consensus was considered to be reached when at least 67% of the panel agreed. Results: Of 91 invited experts, 57 agreed to participate and 43 actually participated. Consensus was reached on positions of measurement properties in the taxonomy (68e84%), terminology (74e88%, except for structural validity [56%]), and definitions of measurement properties (68e88%). The panel extensively discussed the positions of internal consistency and responsiveness in the taxonomy, the terms ‘‘reliability’’ and ‘‘structural validity,’’ and the definitions of internal consistency and reliability. Conclusions: Consensus on taxonomy, terminology, and definitions of measurement properties was reached. Hopefully, this will lead to a more uniform use of terms and definitions in the literature on measurement properties. 2010 Elsevier Inc. All rights reserved.

Objective: Determining "minimally important change" (MIC) facilitates the interpretation of change scores on multi-item instruments. This article focuses on how MIC values should be interpreted when applied to individual patients. Study Design and Setting: The MIC value of a hypothetical questionnaire "Q" was determined in a sample of 400 patients who improved and 100 patients who did not improve, using the receiver operating characteristic (ROC) method, and three methods to quantify the uncertainty. Results: The MIC value on questionnaire Q was 10.5. Firstly, the 95% confidence interval (CI) of the MIC value (for questionnaire Q: 5.6-14.2) quantifies the uncertainty of the estimation of the MIC value. Secondly, "how sure we are that this MIC value holds for every patient" is quantified by the values for sensitivity (74%) and specificity (91%). Thirdly, the smallest detectable change (SDC) on questionnaire Q is calculated (16.0) to consider whether the MIC value (10.5) falls outside or within the measurement error. Conclusion: For application in clinical research and practice, MIC values are always considered at the individual level, but determined in groups of patients. The interpretation comes with different forms of uncertainty. To appreciate the uncertainty, knowledge of the underlying distributions of change scores is indispensable. © 2010 Elsevier Inc. All rights reserved.

BACKGROUND AND PURPOSE: Recent postmortem studies in MS brain suggest that the severity of changes in DAWM can be measured by using quantitative MR imaging. This study aimed to characterize DAWM in vivo by using 4 quantitative MR imaging measures and to explore differences between MS disease types. MATERIALS AND METHODS: In 17 patients with chronic MS (7 PP, 10 SP), quantitative MR imaging was performed at 1.5T, yielding whole-brain voxelwise maps of T1, MTR, ADC, and FA. ROIs were placed to obtain values for DAWM, NAWM, and WM lesions. A general linear mixed-model analysis was used to compare T1, MTR, ADC, and FA between tissue types and disease types. RESULTS: Values of T1, MTR, ADC, and FA for DAWM were intermediate to those observed in NAWM and WM lesions. In patients with SPMS, DAWM was significantly different from both WM lesions and NAWM regarding all 4 measures, while in patients with PPMS, DAWM differed significantly from NAWM regarding T1, MTR, and FA and from lesions only regarding FA. Most interesting, DAWM differed between disease types: DAWM in patients with SPMS exhibited significantly higher T1 and lower MTR than did DAWM in patients with PPMS. CONCLUSIONS: In vivo T1, MTR, ADC, and FA reflect the variable severity of pathologic changes in DAWM in MS. Moreover, these quantitative MR imaging measures suggest that DAWM may differ between PPMS and SPMS.

The aim was to determine if psychological factors favourably influence the short and long-term outcome of patients with sub-acute neck pain in terms of global perceived recovery, pain, using a Numerical Rating Scale (NRS) and functional disability, using the Neck Disability Index (NDI). This study was conducted within the framework of a randomised clinical trial comparing two types of conservative therapy in 146 patients with sub-acute neck pain. Multilevel techniques were used for data-analysis. The short and long term results for the three outcomes were very diverse. The sub-scales of the used questionnaires, i.e. the Pain Coping and Cognition List (PCCL), and the 4 Dimensional Symptom Questionnaire (4DSQ), did not contribute significantly to all of the multilevel models. Only the factor 'fear of movement' was consistently and significantly present in the univariable analysis for all outcomes at both follow-up measurements. The explained variance in the short term ranged from 16% to 30%, and from 6% to 34% in the long term. This can be considered to be low. We conclude that all psychological factors showed a considerable variation on the specific measurement and time point used. Only 'fear of movement' consistently impedes short term and long term recovery. Further prognostic research is needed to achieve more consistent results. © 2009 Elsevier Ltd. All rights reserved.

Background: Being unable to read is a major problem for visually impaired patients. Since distance visual acuity (VA) does not adequately reflect reading ability, it is important to also evaluate near VA. The Radner Reading Charts (RRCs) are available to measure patients' reading performance. The present study tested the inter-chart and test-retest reliability of the RRCs in Dutch low-vision patients (i.e., visual acuity ≥0.3 logMAR) with various eye disorders. Methods: Thirty-eight patients read the three RRCs in random order. Then, about 1 month after the initial measurements, a test-retest procedure was performed in 15 of the 38 patients. Tested variables were reading acuity (logRAD), logRAD score, logRAD/logMAR ratio, maximum reading speed (MRS), and critical print size (CPS). Both MRS and CPS were calculated in two different ways. To determine the variability, a mixed-model analysis was used. Results: For all variables, the largest part of the variance was explained by the individual subject (86-89%) whereas the chart accounted for only 0-0.78% of the variability. Therefore, the inter-chart and test-retest reliability was high, except for the CPS which had a poor to moderate reliability (31-62%) when calculated in the two different ways. Conclusions: The inter-chart and test-retest results showed high reliability in patients with low vision due to various diseases; therefore, the charts are feasible to determine effects in large groups. © 2010 Springer-Verlag.

Purpose The aim of this study was to improve the quality and applicability of the 6 Dutch scales of the Communication Profile for the Hearing Impaired (CPHI; Demorest & Erdman, 1986, 1987, 1988) using item response theory (IRT). IRT modeling can produce precise, valid, and relatively brief instruments, resulting in minimal response burden (Edelen & Reeve, 2006). Method We investigated (a) whether items fit to the graded response model (GRM; Samejima, 1969) using Stone and Zhang’s (2003) procedure to test goodness of fit and (b) whether items showed differential item functioning (DIF) with the IRT log-likelihood ratio approach for 5 group variables: gender, age, living arrangement, use of hearing aids, and degree of hearing impairment. We investigated the magnitude of DIF by calculating the maximum difference between expected item scores for subgroups of the group variables of items showing DIF. Results In a cross-sectional study, 408 consecutive individuals with hearing impairment completed the Dutch CPHI scales. Twelve items were deleted because of misfit to GRMs, 14 items showed uniform DIF, and 2 showed nonuniform DIF. Five items showing DIF were deleted due to large magnitude of DIF. The short form of the Dutch CPHI scales contains 35 items. Conclusions DIF analyses showed that the short form was relatively free of DIF with respect to the 5 group variables. Hence, there is no need to make adjustments for the calculation of subgroup scores.

A systematic review of measurement properties of health-status instruments is a tool for evaluating the quality of instruments. Our aim was to appraise the quality of the review process, to describe how authors assess the methodological quality of primary studies of measurement properties, and to describe how authors evaluate results of the studies. Literature searches were performed in three databases. One hundred and forty-eight reviews were included. The purpose of included reviews was to identify health status instruments used in an evaluative application and to report on the measurement properties of these instruments. Two independent reviewers selected the articles and extracted the data. Reviews were often of low quality: 22% of the reviews used one database, the search strategy was often poorly described, and in many cases it was not reported whether article selection (75%) and data extraction (71%) was done by two independent reviewers. In 11 reviews the methodological quality of the primary studies was evaluated for all measurement properties, and of these 11 reviews only 7 evaluated the results. Methods to evaluate the quality of the primary studies and the results differed widely. The poor quality of reviews hampers evidence-based selection of instruments. Guidelines for conducting and reporting systematic reviews of measurement properties should be developed. © 2009 The Author(s).

Objective: To determine the validity of varus-valgus motion as a measure of knee joint stability by establishing the relationship of varus-valgus motion with muscle strength, joint proprioception, joint laxity and skeletal alignment in patients with knee osteoarthritis (OA). Methods: Sixty-three patients with OA of the knee were tested. Varus-valgus motion was determined with a video-based optoelectronic gait analysis system. Muscle strength was measured using a computer-driven isokinetic dynamometer. Proprioceptive acuity was assessed by establishing the joint motion detection threshold in the anterior-posterior direction. Laxity was assessed using a device which measures the passive angular deviation of the knee in the frontal plane. Alignment was assessed using a goniometer. Regression analyses were performed to assess the relationship between varus-valgus motion, muscle strength, joint proprioception, joint laxity and skeletal alignment. Result: Varus-valgus motion was not related to muscle strength, joint proprioception, joint laxity and skeletal alignment. Conclusions: Knee joint stability cannot be measured as varus-valgus motion. Rather, a number of independent factors seem to contribute to the process of stabilization of the knee joint. © 2007 Osteoarthritis Research Society International.

Study design.: Prospective, multicenter, cohort study. Objective.: To examine which clinical and sociodemographic baseline variables can predict a favorable outcome in subjects with neck pain treated by chiropractors. Summary of background data.: Relatively little is known on predictors of neck pain, particularly for those subjects undergoing chiropractic care. No previous study has examined predictors of outcome for subjects with neck pain by modeling the trajectories of subjects in a longitudinal design. Methods.: All new, consecutive patients, between 18 and 65 years of age with neck pain of any duration, who had not undergone chiropractic or manual therapy in the prior 3 months, were recruited. Questionnaires were administered at the first 3 visits, and at 3 and 12 months. In all, 29 putative prognostic baseline variables were evaluated. Multivariate multilevel longitudinal regression analyses were conducted using neck pain, neck disability, and perceived recovery as outcomes. Results.: In total, 529 patients fulfilled the inclusion criteria. The response rate at 12-months was 92%. In the multivariate analyses, 14 (48%) of the prognostic variables examined were retained in at least one of the models. Shorter duration of neck pain at the first visit was the only variable retained in all 3 final regression models. The following were predictive of a favorable outcome for any 2 of the 3 outcome measures examined: intermittent neck pain, those not on sick-leave or receiving workers compensation at baseline, a higher level of education, less tiredness, higher expectations that the treatment would be beneficial, lack of morning pain, and worse perceived general health. Conclusion.: On the basis of the patient's history, the clinician can identify a number of determinants, which are predictive of a favorable outcome. Shorter duration of neck pain at the first visit was the only variable consistently found to be predictive of a favorable outcome for all 3 outcome measures examined. © 2008, Lippincott Williams & Wilkins.

Objective: Hypercortisolism is associated with muscle weakness. This study examines the relationship between cortisol and physical performance in older persons. Design/patients: The study was conducted within the Longitudinal Aging Study Amsterdam (LASA), an ongoing cohort study in a population-based sample of healthy older persons in the Netherlands. Data from the second (1995/1996) and fourth (2001/2002) cycle were used pertaining to 1172 (65-88 years) and 884 (65-94 years) men and women, respectively. Measurements: Physical performance was measured by adding up scores on the chair stands, tandem stand and walk test (range 0-12). In the second cycle serum total and calculated free cortisol were assessed; in the fourth cycle evening salivary cortisol was assessed. Regression analysis (stratified for sex, adjusted for age, body mass index, alcohol use, physical activity and region) was performed to examine the cross-sectional relationship between cortisol and physical performance. Results: Women with higher calculated free cortisol scored less well on physical performance (b = -0.28 per SD higher cortisol, P = 0.016), which was mainly explained by poorer performance on the tandem stand (OR = 1.32 for a lower score per SD higher cortisol, P = 0.003). Men with higher salivary cortisol scored less well on physical performance (b = -0.90 in the highest vs. the lowest quartile, P = 0.008), which was mainly explained by poorer performance on the chair stands and walk test (OR = 1.88, P = 0.020 and OR = 1.81, P = 0.027, respectively, in the highest vs. the lowest quartile). Conclusion: Physical performance is negatively associated with high cortisol levels in older persons. © 2007 The Authors.

PURPOSE: Instead of applying the usual longitudinal methods to assess the outcome of low-vision rehabilitation services in terms of vision-related quality of life, a three-level Item Response Theory (IRT) method was proposed.METHODS: The translated Vision-Related Quality of Life Core Measure (VCM1) and Low Vision Quality Of Life (LVQOL) questionnaires were used in a nonrandomized follow-up study among elderly patients (n = 296) referred to two different low-vision rehabilitation services in the Netherlands. Factor analysis was performed on the matrix of polychoric correlations to investigate (uni-)dimensionality and to prepare both questionnaires for the multilevel IRT analyses. A statistical model, which was characterized by a graded response model for rating scales, was developed. Threshold and item difficulty parameters and group by time-specific mean fixed effects were estimated. Random individual effects were predicted. Measurement invariance across occasions was tested.RESULTS: The VCM1 and the LVQOL "reading and fine work" dimension showed item parameter drift. In the multidisciplinary rehabilitation center patients, deterioration was found on the "mobility" dimension after 1 year and improvement was found on "adjustment" and "visual (motor) skills" after 5 months (p < 0.05). Patients in both low-vision services showed improvement on the "reading small print" subscale at both follow-up time points (p < 0.05).CONCLUSIONS: Except for improvement in "reading small print," low-vision rehabilitation services did not seem to contribute substantially to any other dimensions of vision-related quality of life. The results showed a change in only a limited number of individual patients. However, with regard to the field of low-vision rehabilitation, the proposed IRT method seemed to be successful in the follow-up of individuals. IRT specific software was unnecessary. The data did not have to be complete and the use of cumulative logits made the proposed IRT method an economical and efficient approach. Because of item parameter drift, the VCM1 was difficult to interpret. The use of multilevel IRT models with longitudinal data and dependent observations is recommended.

The prioritisation of patients on waiting lists is ascribed high potential for diminishing the consequences of waiting times for elective surgery. However, consistent evidence is lacking about which factors determine patient priority and it is unclear whether different stakeholders have different opinions on this issue. This study, conducted in the Netherlands, investigates the judgements of patients, laypersons (i.e. patients on other waiting lists), and physicians on the priority of patients on waiting lists. Participants were former patients with varicose veins (N=82), inguinal hernia (N=86), and gallstones (N=89), 101 surgeons, 95 occupational physicians, and 65 general practitioners. Each participant judged the priority of paper vignettes of patients with varicose veins, inguinal hernia, and gallstones. The vignettes were designed according to conjoint analysis methodology and described the physical symptoms, the psychological distress, the social limitations, and impairments in work of patients. Multilevel regression analysis of the responses showed that all groups made significant distinctions in patient priority depending on the severity of each characteristic in the vignettes. The physical symptoms and impairments in work had on average the highest impact on priority, but the summed impact of non-physical factors exceeded that of the physical symptoms. The different groups of participants appraised only the importance of the physical symptoms differently, but opinions on priority varied widely within each group. Whereas the high level of agreement between the different groups would facilitate the acceptance and the implementation of explicit prioritisation of patients on the waiting list, the high inter-individual variation signifies that consensus criteria for prioritisation are needed to warrant equity and transparency in care provision.

Objective: This study describes both positive clinical outcomes and adverse events in patients treated for neck pain by a chiropractor. Methods: This study was a prospective, multicenter, observational cohort study. Patients with neck pain of any duration who fulfilled the inclusion criteria were recruited in a practice-based study. Data were collected on the patients and from the chiropractors at baseline, the first 3 visits, and at 3 and 12 months. Clinical outcome measures included (1) neck pain in the 24 hours preceding the visit, (2) neck disability, (3) treatment satisfaction, (4) global assessment, and (5) adverse events. Recovery was defined as "completely improved" or "much better" using the global assessment scale. An adverse event was defined as either a new related complaint or a worsening of the presenting or existing complaint by >30% based upon an 11-point numerical rating scale. Results: In all, 79 chiropractors participated, recruiting 529 subjects, representing 4891 treatment consultations. Follow-up was possible for 90% and 92%, respectively, at 3 and 12 months. Most patients had chronic, recurrent complaints; mild to moderate disability of the neck; and a mild amount of pain at baseline; and two thirds had sought previous care for the presenting complaint in the preceding 6 months. Adverse events after any of the first 3 treatments were reported by 56%, and 13% of the study population reported these events to be severe in intensity. The most common adverse events affected the musculoskeletal system or were pain related, whereas symptoms such as tiredness, dizziness, nausea, or ringing in the ears were uncommon (

Background In animals, strong evidence exists for an association between testosterone and aggression. In humans, and particularly in children and adolescents, findings have been less consistent. Previous research has suggested that this may partly be due to moderating effects of other factors, e.g., hormones. This study aims to investigate the moderating effect of cortisol on the relationship between testosterone and subtypes of aggression in delinquent male adolescents. Methods Participants were 103 boys (mean age 13.7) referred to a delinquency diversion program. Testosterone and cortisol levels were determined from saliva samples collected during resting conditions and related to self-report scores on overt and covert aggression. Results Linear regression analyses revealed a significant interaction between cortisol and testosterone in relation to overt aggression, with a significant positive relationship between testosterone and overt aggression in subjects with low cortisol levels but not in subjects with high cortisol levels. Using the same model for covert aggression, no significant effects of testosterone, cortisol, or testosterone × cortisol interaction were found. Conclusions These results indicate a moderating effect of cortisol on the relationship between testosterone and overt aggression in delinquent male adolescents. Implications and directions for future research are discussed.

Objectives Multi-item questionnaires are frequently used to measure outcomes in randomized controlled trials (RCTs) in patients with sciatica. Knowing the minimaly important change (MIC) values for these instruments will facilitate interpretation of change scores. MIC values have been shown to be dependent on baseline values. The question is whether they also depend on the type of intervention. To estimate the MIC of the Roland Morris Disability Questionnaire (modified 23 item version) (RMDQ) and of intensity of leg pain measured by a Visual Analogue Scale (VAS) in patients with sciatica and to assess to what extent MIC values depend on type of intervention and on baseline values. Study Design and Setting This is a secondary analysis of RCT data of the effects of early surgery vs. prolonged conservative treatment in patients with sciatica. Baseline and 8-week data were used to assess MIC of the RMDQ-23 and VAS leg pain. We used the receiver operator characteristic (ROC) method to assess the MIC. Global Perceived Recovery (rated 8 weeks after baseline) was used as anchor. Subgroups were created based on type of treatment and baseline severity. Results The MIC value of the RMDQ-23 for the total group of sciatica patients was 7.5. The values were 8.1 and 6.9 for surgery and conservative treatment, respectively. For high and low baseline values, the MICs were 9.0 and 4.9, respectively, irrespective of treatment received. The MIC values of the VAS leg pain were 34.4 for the total group. For surgery and conservative treatment, the MIC values were 38.5 and 30.4, respectively, whereas for groups with high and low baseline values, MIC values of 53.5 and 17.2 were found. Conclusion The MIC values of the RMDQ-23 and VAS leg pain were found to be highly dependent on their baseline values, although the type of intervention appeared to influence the MIC value only slightly.

BACKGROUND: Successful management of workers on sick leave due to low back pain depends on the identification by the occupational physician of modifiable prognostic factors in the early phase of sick-leave. The prognostic value of factors which influence the course of low back pain and return to work in occupational health care is unclear.METHODS: Secondary data analysis in a cohort of 299 workers on sick leave between 3 and 6 weeks due to low back pain was applied. We investigated the association of a broad set of prognostic indicators related to characteristics of worker, job, low back pain and psychosocial issues on return to work lasting at least 4 weeks (lasting-RTW) and minimally 1 day of first return to work (first-RTW). Relationships were studied using Cox regression analysis and covered a follow-up period of 12 months. The explained variation of the models was also calculated.RESULTS: The median time to return to work using lasting-RTW and first-RTW was 76 and 71 days respectively. In addition to individual analysis of potential predictive factors a backward selection procedure resulted in the following multivariable model: self-predicted timing of return to work, pain intensity, job satisfaction, social support, pain radiation, expectations of treatment succes of the occupational physician. Similar results were found for first-RTW. The explained variance of the multivariate model of lasting-RTW was 18%.CONCLUSIONS: Factors concerning the expectations and beliefs of the worker affected the RTW process. Knowledge of these factors by the occupational physician in the early phase of low back pain and sick-leave may contribute to solutions to promote return to work.

Background and purpose When evaluating the outcome after total knee arthroplasty (TKA), increasing emphasis has been put on patient satisfaction and ability to perform activities of daily living. To address this, the forgotten joint score (FJS) for assessment of knee awareness has been developed. We investigated the validity and reliability of the FJS. Patients and methods A Danish version of the FJS questionnaire was created according to internationally accepted standards. 360 participants who underwent primary TKA were invited to participate in the study. Of these, 315 were included in a validity study and 150 in a reliability study. Correlation between the Oxford knee score (OKS) and the FJS was examined and test-retest evaluation was performed. A ceiling effect was defined as participants reaching a score within 15% of the maximum achievable score. Results The validity study revealed a strong correlation between the FJS and the OKS (intraclass correlation coefficient (ICC) = 0.81, 95% CI: 0.77–0.85; p < 0.001). The test-retest evaluation showed almost perfect reliability for the FJS total score (ICC = 0.91, 95% CI: 0.88–0.94) and substantial reliability or better for individual items of the FJS (ICC? 0.79). We found a high level of internal consistency (Cronbach’s? = 0.96). The ceiling effect for the FJS was 16%, as compared to 37% for the OKS. Interpretation The FJS showed good construct validity and test-retest reliability. It had a lower ceiling effect than the OKS. The FJS appears to be a promising tool for evaluation of small differences in knee performance in groups of patients with good clinical results after TKA.

Cortisol has been implicated in psychobiological explanations of antisocial behavior. This study measured basal salivary cortisol in a sample of 25 children (age range 6 to 12 years) selected to vary in levels of antisocial behavior. Regression analyses were used to predict cortisol concentrations from parent- and teacher-reported symptoms. Parent-reported symptoms did not predict basal cortisol. Teacher-reported conduct disorder (CD) symptoms explained 38% of the variance in the cortisol concentrations, with high symptom severity associated with low cortisol. When a distinction was made between aggressive and non-aggressive CD symptoms, aggressive CD symptoms were more clearly related to low cortisol than non-aggressive CD symptoms. In contrast to previous research, no evidence was found for a mediating role of anxiety symptoms in the relationship between CD and cortisol. The results support biologically based models of antisocial behavior in children that involve reduced autonomic activity.

To assess diagnostic accuracy of preoperatively performed magnetic resonance (MR) imaging for detection of tumor extent in a large patient population with histopathologically proved retinoblastoma.Local ethics committee approval and informed consent were not required for retrospective review of patients' images and records. Fifty-eight eyes in 28 girls (mean age, 21 months; range, 2-59 months) and 28 boys (mean age, 24 months; range, 2-76 months) with retinoblastoma were retrospectively reviewed by one radiologist on unenhanced T1-weighted, dual-echo T2-weighted, and gadolinium-enhanced T1-weighted MR images. MR imaging parameters such as growth pattern, anterior chamber hyperintensity, and involvement of choroid, ciliary body, optic nerve, sclera, orbital fat, and pineal gland were determined. Tumor volume was measured and correlated to metastatic risk factors. Imaging and pathologic findings were compared. Statistical analysis was performed by using logistic regression with log likelihood ratio chi(2) test or Fisher exact test.Choroidal invasion was suspected with MR imaging in 21 eyes; findings were false-positive in 13 eyes and false-negative in three (73% sensitivity, 72% specificity, 72% accuracy). Anterior chamber hyperintensity on T1-weighted MR images obtained after contrast agent administration correlated well with clinical presence of reactive neovascular processes. MR imaging findings were true-positive in 21 of 32 eyes with proved prelaminar optic nerve invasion (66% sensitivity) and false-positive in one (96% specificity, 79% accuracy). Postlaminar optic nerve invasion was correctly detected in two eyes; in two other eyes, this metastatic risk factor was missed (50% sensitivity, 100% specificity, 97% accuracy). Scleral and extrascleral tumor invasion were correctly excluded in all eyes. Tumor volume was statistically associated with prelaminar optic nerve invasion (P = .001) and choroidal invasion (P = .031).MR imaging is accurate for tumor staging and detection of metastatic risk factors; detection of intraocular tumor infiltration remains difficult. Tumor volume, measured with MR imaging, was associated with prelaminar optic nerve and choroidal involvement.

Background We investigated the pattern of disease progression in the asymptomatic, mild cognitive impairment (MCI), and dementia stage of Alzheimer's disease (AD). Methods We selected 284 subjects with AD pathology, defined as abnormal levels of amyloid beta 1–42 (Aβ1–42) in cerebrospinal fluid (CSF). Disease outcome measures included six biomarkers and five cognitive markers. We compared differences in baseline measures and decline over 4 years between the AD stages and tested whether these changes differed from subjects, without AD pathology (N = 132). Results CSF Aβ1–42 reached the maximum abnormality level in the asymptomatic stage and tau in the MCI stage. The imaging and cognitive markers started to decline in the asymptomatic stage, and decline accelerated with advancing clinical stage. Conclusion This study provides further evidence for a temporal evolution of AD biomarkers. Our findings may be helpful to determine stage specific outcome measures for clinical trials.

Purpose: We developed the Arm Function in Multiple Sclerosis Questionnaire (AMSQ) to measure arm and hand function in MS, based on existing scales. We aimed at developing a unidimensional scale containing enough items to be used as an itembank. In this study, we investigated reliability and differential item functioning of the Dutch version. Method: Patients were recruited from two MS Centers and a Dutch website for MS patients. We performed item factor analysis on the polychoric correlation matrix, using multiple fit-indices to investigate model fit. The graded response model, an item response theory model, was used to investigate item goodness-of-fit, reliability of the estimated trait levels (θ), differential item functioning, and total information. Differential item functioning was investigated for type of MS, gender, administration version, and test length. Results: Factor analysis results suggested one factor. All items showed p-values of the item goodness-of-fit statistic above 0.0016. The reliability was 0.95, and no items showed differential item functioning on any of the investigated variables. Conclusion: AMSQ is a unidimensional 31-item questionnaire for measuring arm function in MS. Because of a well fit in a graded response model, it is suitable for further development as a computer adaptive test. ▸ Implications for Rehabilitation • A new questionnaire for arm and hand function recommended in people with multiple sclerosis (AMSQ). • Scale characteristics make the questionnaire suitable for use in clinical practice and research. • Good reliability. • Further development as a computer adaptive test to reduce burden of (repetitive) testing in patients is feasible.

ObjectiveWe aimed to identify barriers for meeting the fruit, vegetable and fish guidelines in older Dutch adults and to investigate socio-economic status (SES) differences in these barriers. Furthermore, we examined the mediating role of these barriers in the association between SES and adherence to these guidelines.DesignCross-sectional.SettingLongitudinal Aging Study Amsterdam (LASA), the Netherlands.SubjectsWe used data from 1057 community-dwelling adults, aged 55–85 years. SES was measured by level of education and household income. An FFQ was used to assess dietary intake and barriers were measured with a self-reported lifestyle questionnaire.ResultsOverall, 48·9 % of the respondents perceived a barrier to adhere to the fruit guideline, 40·0 % for the vegetable and 51·1 % for the fish guideline. The most frequently perceived barriers to meet the guidelines were the high price of fruit and fish and a poor appetite for vegetables. Lower-SES groups met the guidelines less often and perceived more barriers. The association between income and adherence to the fruit guideline was mediated by ‘perceiving any barrier to meet the fruit guideline’ and the barrier ‘dislike fruit’. The association between income and adherence to the fish guideline was mediated by ‘perceiving any barrier to meet the fish guideline’ and the barrier ‘fish is expensive’.ConclusionsPerceived barriers for meeting the dietary guidelines are common in older adults, especially in lower-SES groups. These barriers and in particular disliking and cost concerns explained the lower adherence to the guidelines for fruit and fish in lower-income groups in older adults.