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Rehabilitation is an essential aspect of symptomatic and supportive treatment for people with multiple sclerosis (MS). The number of randomised controlled trials (RCTs) for rehabilitation interventions in MS has increased over the last two decades. The design, conduct and reporting quality of some of these trials could be improved. There are, however, some specific challenges that researchers face in conducting RCTs of rehabilitation interventions, which are often ‘complex interventions’. This paper explores some of the challenges of undertaking robust clinical trials in rehabilitation. We focus on issues related to (1) participant selection and sample size, (2) interventions – the ‘dose’, content, active ingredients, targeting, fidelity of delivery and treatment adherence, (3) control groups and (4) outcomes – choosing the right type, number, timing of outcomes, and the importance of defining a primary outcome and clinically important difference between groups. We believe that by following internationally accepted RCT guidelines, by developing a critical mass of MS rehabilitation ‘trialists’ through international collaboration and by continuing to critique, challenge, and develop RCT designs, we can exploit the potential of RCTs to answer important questions related to the effectiveness of rehabilitation interventions.

Background: High tibial osteotomy (HTO) is increasingly used in young and physically active patients with knee osteoarthritis. These patients have high expectations, including return to sport (RTS). By retaining native knee structures, a return to highly knee-demanding activities seems possible. However, evidence on patient-related outcomes, including RTS, is sparse. Also, time to RTS has never been described. Furthermore, prognostic factors for RTS after HTO have never been investigated. These data may further justify HTO as a surgical alternative to knee arthroplasty. Purpose: To investigate the extent and timing of RTS after HTO in the largest cohort investigated for RTS to date and to identify prognostic factors for successful RTS. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients with HTO, operated on between 2012 and 2015, received a questionnaire. First, pre- and postoperative sports participation questions were asked. Also, time to RTS, sports level and frequency, impact level, the presymptomatic and postoperative Tegner activity score (1-10; higher is more active), and the postoperative Lysholm score (0-100; higher is better) were collected. Finally, prognostic factors for RTS were analyzed using a logistic regression model. Covariates were selected based on univariate analysis and a directed acyclic graph. Results: We included 340 eligible patients of whom 294 sufficiently completed the questionnaire. The mean follow-up was 3.7 years (± 1.0 years). Out of 256 patients participating in sports preoperatively, 210 patients (82%) returned to sport postoperatively, of whom 158 (75%) returned within 6 months. We observed a shift to participation in lower-impact activities, although 44% of reported sports activities at final follow-up were intermediate- or high-impact sports. The median Tegner score decreased from 5.0 (interquartile range [IQR], 4.0-6.0) presymptomatically to 4.0 (IQR, 3.0-4.0) at follow-up ( P < .001). The mean Lysholm score at follow-up was 68 (SD, ± 22). No significant differences were found between patients with varus or valgus osteoarthritis. The strongest prognostic factor for RTS was continued sports participation in the year before surgery (odds ratio, 2.81; 95% CI, 1.37-5.76). Conclusion: More than 8 of 10 patients returned to sport after HTO. Continued preoperative sports participation was associated with a successful RTS. Future studies need to identify additional prognostic factors.

The dominant notion that exercise is medicine puts a strong normative emphasis on individual responsibility for participation in sport and physical activity. The aim of this article was to explore how people with type 2 diabetes, a condition strongly linked to lifestyle behaviour both in origin and in management, translate this notion into their daily life. Based on a critical narrative analysis of stories of 18 Dutch people diagnosed with type 2 diabetes collected between 2012 and 2016, we found a range of meanings given to sport and physical activity. In addition, almost all respondents seemed to subscribe to the notion of exercise as medicine on a general level, either quite explicitly or in more subtle ways, for example, elicited by the interview setting. However, they employed different strategies to negotiate with the translation of this notion into their daily life, ranging from (almost) total acceptance to resistance. In addition, nearly all stories revealed mostly negative experiences with care and professional support regarding the uptake or continuation of sport or physical activity participation after diagnosis.

The collective involvement of patients and clients in health care organizations is valued in our Western society. In practice, giving form to this involvement seems to be a complex process. In this paper we present our learning experiences with a process of enhancing the involvement of older people in a residential care home in the Netherlands, by using a participatory action research approach, called PARTNER. This approach is inspired by responsive evaluation and developed for the context of long-term care. We use concepts of Habermas’ theory to understand what happens when trying to create communicative spaces through dialogue. Our learning history shows that the involvement of residents is not an easy task, because power issues are at stake. System values seem to dominate the lifeworld and expert knowledge seems to be more valued than expressed emotions and narratives of residents. Researchers who use participatory action research must be aware of these issues of power, often hidden in language and discourse. Dialogue can be a vehicle to enhance mutual understanding, when attention is paid to underlying values, assumptions and meanings of all people. Then, the gap between system and lifeworld can be bridged and communicative spaces can be opened up.

Background: Responsiveness and the minimal important change (MIC) are important measurement properties to evaluate treatment effects and to interpret clinical trial results. The International Knee Documentation Committee (IKDC) Subjective Knee Form is a reliable and valid instrument for measuring patient-reported knee-specific symptoms, functioning, and sports activities in a population with meniscal tears. However, evidence on responsiveness is of limited methodological quality, and the MIC has not yet been established for patients with symptomatic meniscal tears. Purpose: To evaluate the responsiveness and determine the MIC of the IKDC for patients with meniscal tears. Study Design: Cohort study (design); Level of evidence 2. Methods: This study was part of the ESCAPE trial: a noninferiority multicenter randomized controlled trial comparing arthroscopic partial meniscectomy with physical therapy. Patients aged 45 to 70 years who were treated for a meniscal tear by arthroscopic partial meniscectomy or physical therapy completed the IKDC and 3 other questionnaires (RAND 36-Item Health Survey, EuroQol-5D-5L, and visual analog scales for pain) at baseline and 6-month follow-up. Responsiveness was evaluated by testing predefined hypotheses about the relation of the change in IKDC with regard to the change in the other self-reported outcomes. An external anchor question was used to distinguish patients reporting improvement versus no change in daily functioning. The MIC was determined by the optimal cutoff point in the receiver operating characteristic curve, which quantifies the IKDC score that best discriminated between patients with and without improvement in daily function. Results: Data from all 298 patients who completed baseline and 6-month follow-up questionnaires were analyzed. Responsiveness of the IKDC was confirmed in 7 of 10 predefined hypotheses about the change in IKDC score with regard to other patient-reported outcome measures. One hypothesis differed in the expected direction, while 2 hypotheses failed to meet the expected magnitude by 0.02 and 0.01 points. An MIC of 10.9 points was calculated for the IKDC of middle-aged and older patients with meniscal tears. Conclusion: This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscal tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population.

Summary Family Group Conferencing as deployed in child care might be useful in elderly care to strengthen older adults’ social networks and self-mastery. When Family Group Conferencing was implemented for older adults in the Netherlands, social workers were reluctant to refer. To discover reasons for this reluctance, we examined social workers’ views and attitudes concerning Family Group Conferencing for their clients. Findings In an initial exploratory study, we distributed a survey among social workers who worked with older adults and were informed about Family Group Conferencing, followed by three focus groups of social workers with and without Family Group Conferencing experience. We also held semi-structured individual interviews with social workers and an employee of the Dutch Family Group Conferencing foundation. The respondents were positive about Family Group Conferencing, but hesitant about referring their older clients. Reasons were: they were already working with their clients’ social networks; they feared losing control over the care process; and they wondered how they could motivate their clients. They also reported that their clients themselves were reluctant, because they seemed to fear that Family Group Conferencing would lose them self-mastery, and they did not want to burden their social networks. Applications Our findings indicate that implementing Family Group Conferencing in elderly care is a complicated and slow process, partly because social workers have little experience with Family Group Conferencing. To facilitate social workers it might be necessary to offer them more guidance, in a joint process with the Family Group Conferencing foundation. One might also experiment with alterations to the Family Group Conferencing model, for example, by focusing less on family networks and more on reciprocity.

BackgroundDiagnosing capitellar osteochondritis dissecans (OCD) can be difficult, causing delay in treating young athletes. The main aim of this retrospective diagnostic study was to determine which radiological technique is preferred to identify and classify elbow OCD.MethodsWe identified young patients who underwent elbow arthroscopy because of symptomatic OCD. We included all patients who had pre-operative radiographs, a computed tomography (CT) scan and magnetic resonance imaging (MRI) available. We assessed whether the osteochondral lesion could be identified using the various imaging modalities. All lesions were classified according to previous classifications for X-ray, CT and MRI, respectively. These results were compared with findings at arthroscopy.ResultsTwenty-five patients had pre-operative radiographs as well as CT scans and MRI. In six patients, the lesion was not visible on standard X-ray. In 20 patients, one or two loose bodies were found during surgery, consistent with an unstable lesion. Pre-operatively, this was seen on 11 X-rays, 13 MRIs and 18 CT scans.ConclusionsCapitellar OCD lesions are not always visible on standard X-rays. A CT appears to be the preferred imaging technique to confirm diagnosis of OCD. Loose bodies are often missed, especially on standard X-rays and MRIs.

Background: Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores. Methods: This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score. Results: Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure. Conclusions: Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI. Level of Evidence: Level IV, case series

Objectives: The aims of this article are to (1) determine whether and to what extent general perceived health and quality of supervision predict voluntary early retirement pension (VERP) and (2) assess whether quality of supervision modifies the association between general perceived health and VERP. Methods: Employees aged 49–64 years who participated in the Danish Work Environment Cohort Study in 2000 were selected. Their questionnaire data about health and work were linked to register data on social transfer payments, among others VERP, from 2001 to 2012 in the Danish Register for Evaluation of Marginalization ( N=1167). Cox proportional hazards analyses were performed to identify the prospective association of general perceived health and quality of supervision on VERP. Relative excess risks due to interaction (RERIs) were calculated to assess whether quality of supervision modified the association between health and VERP. Results: Employees with poor health at baseline had an increased risk of VERP during follow-up (hazard ratio [HR]=1.23; 95% confidence interval [CI] 1.02–1.49). Quality of supervision at baseline was not associated to VERP during follow-up (HR=1.04; 95% CI 0.90–1.21). There was no statistically significant interaction of poor health and poor quality of supervision with regard to risk of VERP (RERI=−0.33; 95% CI −1.79 to 1.14). Conclusions: This study did not support the notion that quality of supervision buffers the association between poor health and VERP. Future research is needed to determine whether other aspects of supervision, for example supervisors’ opportunities to effectuate workplace adjustments, may modify the association of poor health and VERP.

Uterine disorders are often presented with overlapping symptoms. The microvasculature holds specific information important for diagnosing uterine disorders. Conventional sonography is an established diagnostic technique in gynecology, but is limited by its inability to image the microvasculature. Contrast-enhanced ultrasound (CEUS), is capable of imaging the microvasculature by means of intravascular contrast agents; that is, gas-filled microbubbles. We provide a literature overview on the use of CEUS in diagnosing myometrial and endometrial disorders, that is, fibroids, adenomyosis, leiomyosarcomas and endometrial carcinomas, as well as for monitoring and enhancing the effectiveness of minimally invasive therapies. A systematic literature search with quality assessment was performed until December 2020. In total 34 studies were included, published between 2007 and 2020.The results entail a description of contrast-enhancement patterns obtained from healthy tissue and from malignant and benign tissue; providing a first base for potential diagnostic differentiation in gynecology. In addition it is also possible to determine the degree of myometrial invasion in case of endometrial carcinoma using CEUS. The effectiveness of minimally invasive therapies for uterine disorders can safely and accurately be assessed with CEUS. In conclusion, the abovementioned applications of CEUS are promising and it is worth further exploring its full potential for gynecology by designing innovative and methodologically high-quality clinical studies. ispartof: ULTRASONIC IMAGING vol:43 issue:5 pages:239-252 ispartof: location:England status: published

This cross-sectional study investigated whether physical activity, social cohesion, and loneliness mediate the association between time spent visiting green spaces and perceived mental health and vitality. Questionnaire data were collected from 3,948 residents from 124 neighborhoods across four European cities. Multilevel linear regression analysis revealed positive, but weak, associations between time spent visiting green space and Medical Outcome Study Short Form (SF-36) mental health and vitality score, which suggest small mental health benefits. Single mediation analyses showed that different indicators of physical activity (total, during leisure time, and walking during leisure time), social cohesion, and loneliness were mediators. Multiple mediation analyses showed that physical activity during leisure time and loneliness may explain about 25% of the relationship. The unmediated part of the association suggests that other mediators may explain the association. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by European Community’s Seventh Framework Programme (FP7/2007-2013; Grant/Award Number: 282996).

In this article the authors challenge contemporary epistemological research within educational settings. After a reconciliation of the current models which treat epistemological beliefs as static and mechanical, the authors present a teaching experience to illustrate their enactivist view that epistemological beliefs should be conceptualized as fluid and dynamic constructs, emerging in web-like configurations. Answers to epistemological questions unfold within the interstices and mutual interactions between people and their environment. Boundaries between student—teacher, individual—community, cognition—bodily experience are becoming blurred. From this enactivist perspective the researcher's role changes considerably. Instead of determining teachers' personal traits and epistemological make-up, the researcher should sensitize teachers to the subtle ways epistemological beliefs are enmeshed within their day-to-day professional lives, focusing on the complex fabric of the teaching practice.

It is not uncommon that nurses are unable to meet the normative expectations of chronically ill patients. The purpose of this article is to describe and illustrate Walker’s expressive-collaborative view of morality to interpret the normative expectations of two women with multiple sclerosis. Both women present themselves as autonomous persons who make their own choices, but who also have to rely on others for many aspects of their lives, for example, to find a new balance between work and social contacts or to find work. We show that their narratives of identity, relationship and value differ from the narratives that others use to understand and identify them. Since identities, relationships and values give rise to normative expectations, in both cases there is a conflict between what the women expect of their caregivers and vice-versa. The narratives also show that two similar persons with multiple sclerosis may need very different care. This implies that nurses caring for such persons should listen carefully to their stories and reflect on their own perceptions of self.

Displacement transducers were placed across the anterior and posterior tibiofibular ligaments of 17 fresh cadaver (78.4±6.7 years old at death) lower extremities. Displacements induced by various clinical tests (squeeze, fibula translation, Cotton, external rotation, and anterior drawer) were measured with the ankle ligaments intact and after sequential sectioning of the anterior tibiofibular ligament, anterior deltoid ligament, and posterior tibiofibular ligament. None of the syndesmotic stress tests could distinguish which ligaments were sectioned. Furthermore, the small displacements measured during the stress tests (with the exception of the external rotation test) suggest it is unlikely that the displacement induced in injured syndesmoses can be clinically differentiated from normal syndesmoses. Therefore, pain, rather than increased displacement, should be considered the outcome measure of these tests.

Aversiveness of loud sounds is a frequent complaint by hearing aid users, especially when fitted bilaterally. This study investigates whether loudness summation can be held responsible for this finding. Two aspects of loudness summation should be taken into account: spectral loudness summation for broadband signals and binaural loudness summation for signals that are presented binaurally. In this study, the effect of different symmetrical hearing losses was studied. Measurements were obtained with the widely used technique of Adaptive Categorical Loudness Scaling. For large bandwidths, spectral loudness summation for hearing-impaired listeners was found to be greater than that for normal-hearing listeners, both for monaurally and binaurally presented signals. For binaural loudness summation, the effect of hearing loss was not significant. In all cases, individual differences were substantial.

There is lack of a systematic approach concerning how to select an adequate hearing aid and how to evaluate its efficacy with respect to the personal needs of rehabilitation. The goal of this study was to examine the applicability and added value of two widely used self-reporting questionnaires in relation to the evaluation of hearing aid fitting. We analyzed responses, pre- and postfitting, from 1,319 subjects who completed the Client Oriented Scale of Improvement (COSI) and a slightly adapted version of the Amsterdam Inventory for Auditory Disability and Handicap (in Dutch: AVAB). Most COSI responses were at or near the maximum possible score. Results show a close relation between COSI’s degree of change and final ability (Spearman’s rho = 0.71). Both AVAB and COSI showed a significant effect of hearing aid experience, but—in contrast to AVAB—COSI did not show a significant effect of the degree of hearing loss. In addition, a Friedman test showed significant differences between six dimensions of auditory functioning for both AVAB and COSI, although post hoc analysis revealed that for COSI, the dimension speech in quiet explained most variation between dimensions. In conclusion, the effects of hearing loss were more salient in AVAB, while both AVAB and COSI showed differences regarding hearing aid experience. Combining the advantages of both methods results in a detailed evaluation of hearing aid rehabilitation. Our results therefore suggest that both methods should be used in a complementary manner, rather than separately.

Background: The Action Research Arm (ARA) test is a performance test of upper extremity motor function which consists of 19 items divided into four hierarchical subtests. This multidimensionality has not yet been tested empirically. Objective: To investigate the dimensionality of the ARA test. Design: Cross-sectional study involving a sample of 63 chronic stroke patients. Methods: A Mokken scale analysis was performed. Results: The Mokken scale analysis revealed one strong unidimensional scale containing all 19 items, of which the scalability coefficient H was 0.79, while H per item ranged from 0.69 to 0.86. The reliability coefficient rho equalled 0.98, indicating a very high internal consistency. A subset of 15 out of 19 items showed an invariant hierarchical item-ordering. Conclusion: The ARA test is a unidimensional scale. The use of subtests, as proposed in the original description of the instrument, is not supported by the present findings. The 15-item scale presented here can be used for adaptive testing, i.e. using only a selected subset of items based on prior knowledge about the patient's abilities, thus minimizing testing time.

Qualitative health researchers have recently begun to experiment with narrative forms of knowledge representation, often incorporating postmodern theory and related constructivist epistemology. However, misunderstanding of these ideas may lead to rejection of, or lack of interest in, these unconventional texts, which in turn might impede the use of narrative forms in the health sciences. The author’s aim is to “open up” the provocative domain of ideas about knowledge representation and explain how the forms operate. Two texts are described with respect to narrative plotting, author’s stance, character building, voices, and rhetorical tropes: Troubling the Angels, Patti Lather and Chris Smithies’s account of support groups for women living with HIV/AIDS, and The Social Meaning of Surgery, Nicolas Fox’s description and sociological analysis of daily life in the operating theater. Other examples of emerging forms are integrated and made relevant to the substantive texts chosen for analysis.

Objective: Subluxation of the shoulder after stroke can be measured according to the method described by Van Langenberghe and Hogan. Methods: To evaluate the reliability of this method, the shoulder radiographs of 25 patients were available for this study. Two independent raters each assessed these radiographs twice. Results: The intrarater reliability was good: percentage of agreement was 88 and 84%, weighted κ, 0.69 [95% confidence interval (CI), 0.38-1 0] and 0.78 (95% CI, 0.60-0.95) for raters 1 and 2, respectively. The interrater reliability was poor: percentage of agree ment was 36 and 28%, κ, 0.11 (95% CI, 0.0-0.31) and 0.09 (95% CI, 0.0-0.23) in sessions 1 and 2, respectively. Subsequently the original method was adjusted by com bining two categories (no subluxation and beginning subluxation) into one ("no clin ically important subluxation"). Conclusions: After this adjustment of the categories, the interrater reliability improved [percentage of agreement, 72%, and κ, 0.49 (95% CI, 0.18-0.80)], but did not reach acceptable values. Key Words: Hemiplegic shoul der pain—Subluxation—Measurement.