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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.

Purpose. This qualitative study investigates possible differences in identified rehabilitation needs indicated by the usual intake procedures at a Multidisciplinary Rehabilitation Center (MRC) for visually impaired persons compared with those indicated by the use of a structured Dutch version [based on the International Classification of the Disability, Functioning and Health (ICF)] of the Activity Inventory (D-AI). Methods. Twenty patients who enrolled at the MRC received a D-AI assessment by telephone, in addition to the usual intake. All patients received usual care, based on rehabilitation needs identified by the usual intake procedure at the MRC. Rehabilitation needs identified at the MRC were obtained from patient files retrospectively and were compared with rehabilitation needs identified by the D-AI. Results. The mean number of rehabilitation needs reported in the patient files was 6.9 (±5.1) vs. 24.0 (±11.2) using the D-AI. Only 22.6% (±14.3) of the rehabilitation needs identified by the D-AI were present in the patient files; 79.3% (±28.2) of the rehabilitation needs reported in the patient files were identified by the D-AI. Overall agreement corrected for chance between both intake methods revealed a fair Cohen kappa of 0.27. Conclusions. At the MRC, more needs were revealed using the D-AI compared with the usual intake procedure. The systematic character of the D-AI prevents important topics being overlooked. In the usual intake, it was not clear whether needs were investigated from the patient's perspective. This may hamper (medical) communication and shared decision making about the rehabilitation program that needs to be followed. Moreover, using the unstructured information from the patient files makes it difficult to evaluate rehabilitation outcomes. With the D-AI, although an extensive overview of rehabilitation needs is produced, it remains difficult to focus on the most relevant needs. However, after assessment with the D-AI, all aspects of the ICF, Disability, and Health scheme can be discussed in a process of shared decision making, which leads to the final determination of rehabilitation goals. © 2012 American Academy of Optometry.

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.

BACKGROUND AND PURPOSE: Although the number of enhancing lesions is the typical outcome measure of choice in clinical trials in MS, a potentially more sensitive and statistically more powerful outcome measure is the volume of enhancing lesions. In this study, we assessed the distribution and statistical power of the volume of enhancing brain lesions as an outcome measure by means of their required sample size, and we compared the results with the number of enhancing lesions. MATERIAL AND METHODS: First, a literature search was performed to compare the effects of treatment on the number and volume of enhancing lesions. Then, a statistical model was proposed to describe the distribution of the volume of enhancing lesions in 2 datasets of patients with RRMS, and sample sizes for enhancing-lesion volume as primary outcome measure were calculated. RESULTS: A mixture of the binomial and Weibull distribution was determined to model enhancing-lesion volumes in patients. Sample size calculations for enhancing-lesion volumes showed that approximately 94 patients per arm would be required to detect a combination of 20% decrease in lesion volume and 20% increase in patients without enhancing lesions, whereas calculations for enhancing-lesion counts showed that approximately 129 patients would be required to detect a 50% decrease. CONCLUSIONS: The mixture of the binomial and Weibull distribution is a suitable approach in modeling new enhancing-lesion volumes in MS and yielded feasible sample size estimates for clinical trials, showing lesion volumes to be an advantageous outcome measure compared with lesion counts in terms of statistical power.

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.

Objective We developed the Determinants of Lifestyle Behavior Questionnaire (DLBQ) to measure determinants of lifestyle behavioral change according to the Theory of Planned Behavior (TPB) in adults at high risk of diabetes type 2 (T2DM) and cardiovascular diseases (CVD). The aim of the current study was to test the validity of the DLBQ. Methods From February to September 2008, a cross-sectional survey was conducted in the region West-Friesland (The Netherlands) among 622 adults, aged 30–50 years at high risk of T2DM or CVD participating in a lifestyle intervention trial. Structural equation modeling techniques were used for confirmatory factor analysis and to test correlations between the TPB constructs. Results The results demonstrate the factorial validity of the DLBQ in this population. The theoretical factor structure of the DLBQ is supported, and 41–56% of the variance in intentions to improve lifestyle behaviors is explained. Conclusions The DLBQ proves to be a valid instrument for measuring important determinants of the intention to change three lifestyle behaviors in adults at high risk of T2DM and CVD. Practice implications The identified ‘key-determinants’ of the TPB that seem to contribute to an increased intention to change behavior could be of value in designing future lifestyle interventions.

Background: Patient-reported outcome (PRO) scales are often used in multiple sclerosis (MS) research. Full understanding of items can be influenced by disease worsening, mood disturbances and cognitive problems of the MS patient. Earlier research with the Multiple Sclerosis Impact Scale (MSIS-29) showed that proxy respondents (i.e. partners of patients) can provide useful information. Objective: To determine agreement between patients and proxy respondents on different MS PRO scales. Methods: 139 Patients and partners completed the MSIS-29 (Physical and Psychological scale), Multiple Sclerosis Walking Scale (MSWS-12), Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ) and Guy’s Neurological Disability Scale (GNDS). We calculated the mean difference and intra-class correlation coefficients (ICC) on scale level and weighted kappas (κw) on item level. Results: On all scales, except MSNQ, the partner score was higher. ICCs were good for MSWS, GNDS and MSIS Physical, and moderate for MSNQ and MSIS Psychological. κw was excellent for MSWS items, fair to good for GNDS, MSIS Physical and MSIS Psychological items, and poor for MSNQ items. Conclusion: Partners of patients with MS can be a useful source of information for several PRO scales, especially when the focus is on physical functioning. For psychological functioning this seems to be less reliable.

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.

Background: The COSMIN checklist is a standardized tool for assessing the methodological quality of studies on measurement properties. It contains 9 boxes, each dealing with one measurement property, with 5-18 items per box about design aspects and statistical methods. Our aim was to develop a scoring system for the COSMIN checklist to calculate quality scores per measurement property when using the checklist in systematic reviews of measurement properties. Methods: The scoring system was developed based on discussions among experts and testing of the scoring system on 46 articles from a systematic review. Four response options were defined for each COSMIN item (excellent, good, fair, and poor). A quality score per measurement property is obtained by taking the lowest rating of any item in a box ("worst score counts"). Results: Specific criteria for excellent, good, fair, and poor quality for each COSMIN item are described. In defining the criteria, the "worst score counts" algorithm was taken into consideration. This means that only fatal flaws were defined as poor quality. The scores of the 46 articles show how the scoring system can be used to provide an overview of the methodological quality of studies included in a systematic review of measurement properties. Conclusions: Based on experience in testing this scoring system on 46 articles, the COSMIN checklist with the proposed scoring system seems to be a useful tool for assessing the methodological quality of studies included in systematic reviews of measurement properties. © The Author(s) 2011.

OBJECTIVES Training in and assessment of consultation skills are high on the agenda of vocational training institutes for postgraduate training. There is a need to establish valid and reliable instruments to assess consultation skills in authentic settings. We investigated the number of assessors and observations needed to achieve reliable assessments of the consultation skills of general practice trainees (GPTs) using a communication instrument (MAAS-Global) and either standardised patient (SP) encounters or videotaped real patient (RP) encounters. METHODS Eight teachers at the Vrije Universiteit (VU) University Medical Centre in Amsterdam attended a training course on the use of the MAAS-Global instrument, which they subsequently used to assess the consultation skills of 53 GPTs in 176 videotaped consultations (102 with SPs, 74 with RPs). All consultations were randomly allocated and assessed by two teachers independently. The reliability of the ratings was estimated using generalisability theory. RESULTS It was easier to obtain acceptable reliability using RP consultations than SP consultations. Two assessors and five consultations were required to achieve minimal reliability (generalisability coefficient 0.7) with RPs, whereas three assessors and 30 consultations were needed to achieve minimal reliability with SPs. CONCLUSIONS Inter-observer and context variability in the assessment of the consultation skills of GPTs remains high. To achieve acceptable levels of reliability, large samples of observations are required in both formats, but, interestingly, RP encounters require a smaller sample than SP encounters.

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.

Background: Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities. Methods: We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators. Results: Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference − 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents. Interpretation: Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care. Trial registration: www.controlled-trials.com trial register no. ISRCTN11076857.

A decline in everyday cognitive functioning is important for diagnosing dementia. Informant questionnaires, such as the informant questionnaire on cognitive decline in the elderly (IQCODE), are used to measure this. Previously, conflicting results on the IQCODEs ability to discriminate between Alzheimer's disease (AD), mild cognitive impairment (MCI), and cognitively healthy elderly were found. We aim to investigate whether specific groups of items are more useful than others in discriminating between these patient groups. Informants of 180 AD, 59 MCI, and 89 patients with subjective memory complaints (SMC) completed the IQCODE. To investigate the grouping of questionnaire items, we used a two-dimensional graded response model (GRM).The association between IQCODE, age, gender, education, and diagnosis was modeled using structural equation modeling. The GRM with two groups of items fitted better than the unidimensional model. However, the high correlation between the dimensions (r=.90) suggested unidimensionality. The structural model showed that the IQCODE was able to differentiate between all patient groups. The IQCODE can be considered as unidimensional and as a useful addition to diagnostic screening in a memory clinic setting, as it was able to distinguish between AD, MCI, and SMC and was not influenced by gender or education. (JINS, 2011, 17, 674–681)

Summary Vitamin D deficiency is very common in non-western immigrants. In this randomized clinical trial, vitamin D 800 IU/day or 100,000 IU/3 months were compared with advised sunlight exposure. Vitamin D supplementation was more effective than advised sunlight exposure in improving vitamin D status and lowering parathyroid hormone levels. Introduction Vitamin D deficiency (25-hydroxyvitamin D [25(OH)D]

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.

Contains fulltext : 88987.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Development and validation of a quick and easy screening tool for the early detection of undernourished residents in nursing homes and residential homes. DESIGN: Multi-center, cross sectional observational study. SETTING: Nursing homes and residential homes. PARTICIPANTS: The screening tool was developed in a total of 308 residents (development sample; sample A) and cross validated in a new sample of 720 residents (validation sample) consisting of 476 nursing home residents (Sample B1) and 244 residential home residents (sample B2). MEASUREMENTS: Patients were defined severely undernourished when they met at least one of the following criteria: BMI or= 5% unintentional weight loss in the past month and/or >or= 10% unintentional weight loss in the past 6 months. Patients were defined as moderately undernourished if they met the following criteria: BMI 20.1-22 kg/m2 and/or 5-10% unintentional weight loss in the past six months. The most predictive questions (originally derived from previously developed screening instruments) of undernourishment were selected in sample A and cross validated in sample B. In a second stage BMI was added to the SNAQRC in sample B. The diagnostic accuracy of the screening tool in the development and validation samples was expressed in sensitivity, specificity, and the negative and positive predictive value. RESULTS: The four most predictive questions for undernutrition related to: unintentional weight loss more than 6 kg during the past 6 months and more than 3 kg in the past month, capability of eating and drinking with help, and decreased appetite during the past month. The diagnostic accuracy of these questions alone was insufficient (Se=45%, Sp=87%, PPV=50% and NPV=84%). However, combining the questions with measured BMI sufficiently improved the diagnostic accuracy (Se=87%, Sp=82%, PPV=59% and NPV=95%). CONCLUSION: Early detection of undernourished nursing- and residential home residents is possible using four screening questions and measured BMI. 01 februari 2010

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.

Purpose: To examine the benefi ts of using near-isotropic single-slab three-dimensional (3D) magnetic resonance (MR) imaging for the creation of subtraction images and to evaluate their performance in the detection of active multiple sclerosis (MS) brain lesions in comparison with two-dimensional (2D) subtraction images. Materials and Methods: The study protocol was approved by the local ethics review board and all subjects gave written informed consent before investigation. Three-dimensional MR sequences, including double inversion-recovery, fl uid-attenuated inversion recovery, T2-weighted, and T1-weighted magnetization-prepared rapid acquisition gradient-echo (MP-RAGE), and corresponding 2D sequences were performed twice in 14 patients (eight women, six men; mean age, 37.6 years) with MS and nine age-matched healthy control subjects (three women, six men; mean age, 31.7 years). Active lesions were scored by two independent raters, followed by a consensus reading. Lesion counts were evaluated by using negative binomial regression; interrater agreement was evaluated by using intraclass correlation coefficient. Results: Three-dimensional subtraction images had less residual misregistration and fl ow artifacts and depicted higher numbers of active lesions with greater interobserver agreement compared with 2D subtraction images. Among the 3D sequences, MP-RAGE subtraction imaging enabled detection of a signifi cantly higher mean number of positive active MS lesions compared with 2D subtraction imaging (2.8 versus 1.7, P = .012), particularly infratentorial lesions (0.6 vs 0.1, P< .05), and a substantially higher (nonsignificant) mean number of small (< 3 mm) lesions (0.6 vs 0.1, P > .05). Conclusion: Three-dimensional subtraction imaging, after image registration, produced better image quality, leading to increased detection of active MS lesions with greater inter-observer agreement in comparison with 2D subtraction imaging; 3D MP-RAGE subtraction imaging represents a promising technique to increase sensitivity in ascertaining lesion dissemination in time and increase the power of MR imaging metrics for the evaluation of treatment effects in clinical trials. © RSNA, 2010.

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.

De Quality of Life in Late-Stage Dementia (QUALID) schaal is een meetinstrument om kwaliteit van leven te meten bij patienten met een ernstige dementie, door een interview met een verzorgende over de situatie in de afgelopen week. Wij interviewden verzorgenden van 48 ernstig dementerende patienten in twee verpleeghuizen in Nederland om de psychometrische eigenschappen van de Nederlandse vertaling van de QUALID te bepalen. De test-hertest betrouwbaarheid was goed, met een Concordantie Correlatie Coefficient (CCC) van 0,82 en een 95%-betrouwbaarheidsinterval van 0,70-0,90; de interbeoordelaars betrouwbaarheid was matig met een CCC van 0,49 (95%-betrouwbaarheidsinterval: 0,17-0,72). Er was een significante maar lage correlatie tussen de QUALID en geobserveerd onwelbevinden met de Discomfort Scale - Dementia of Alzheimer Type (DS-DAT) van 0,32 (betrouwbaarheidsinterval 0,04-0,56). De QUALID lijkt geschikt om kwaliteit van leven te meten bij patienten met een ernstige dementie als dezelfde observator iemand in de tijd volgt in longitudinaal onderzoek.

Objective: To provide a practical example showing how to relate measurement error to minimal important change (MIC) to estimate sample sizes required for detecting important changes in research, and to determine the usefulness of patient-reported outcomes (PROs) in daily clinical practice. Study Design and Setting: The standard error of measurement (SEM) can be calculated as a parameter of measurement error. MIC can be determined by taking the mean change in score on the questionnaire in the subgroup of patients that reported to be ‘‘a little better’’ or ‘‘better’’ on a global rating scale minus the mean change in score in the subgroup of patients that reported to be ‘‘not changed.’’ Based on SEM and MIC, formulas are presented that can be used to estimate sample sizes and to determine whether the questionnaire can be used to monitor changes in individual patients in daily clinical practice. Results: A fully worked-out example is presented, using Western Ontario and McMaster University Osteoarthritis Index data from a cohort of patients undergoing hip or knee replacement. Conclusion: We strongly recommend investigators to present the SEM and MIC of PROs and use these to estimate sample sizes for research and to determine the usefulness of these outcomes in daily clinical practice. 2008 Elsevier Inc. All rights reserved.

The aim of the study was to determine whether men and woman with equal tasks perform these tasks in the same way. Video recordings of 37 male and 43 female workers in six task groups were observed, from which data regarding frequency and duration of exposure to awkward postures were derived. These data were also compared to self-reported exposures. The results showed that when level, duration and frequency of exposure were analysed at the same time, men and women had slightly different exposure patterns. However, these differences were not found when duration and frequency were analysed separately. From the questionnaires it appeared that men and women generally report similar exposures, but they seemed to over-report their exposure compared to the observed exposures. It is concluded that gender differences in exposure to awkward postures within the same task were small at most and cannot explain the female excess in musculoskeletal symptoms.

Purpose To evaluate the psychometrics of the SF-36 Health Survey among Turkish and Moroccan ethnic minority populations in the Netherlands and to compare the results to those based on the indigenous Dutch population. Methods Data were derived from the Second Dutch National Survey of General Practice. In total, SF-36 data were available for 409 Turkish, 377 Moroccan, and 9,628 Dutch respondents. Language subgroup analyses were performed for the Turkish (n = 162) and Moroccan-Arabic (n = 52) versions of the SF-36. Psychometric properties were evaluated by descriptive statistics, factor analysis, internal consistency estimates, known-group comparisons, and differential item function (DIF) analysis. Results Low levels of missing SF-36 data were observed across all groups. Confirmatory factor analysis supported the hypothesized SF-36 scale structure for the Dutch and Turkish group, but high correlations between the MH and VT factors were observed in the Moroccan group. All Cronbach’s alpha coefficients were above 0.70, except for the Vitality scale in the Moroccan group and the Vitality and Social Functioning scales in the Moroccan-Arabic language subgroup. Known-groups validity was found across samples using age, sex, education, and comorbidity as grouping variables, but not marital status. Some evidence for DIF was found in both ethnic group samples. Conclusions The results generally support the use of the SF-36 for general population research among Turkish and Moroccan ethnic minorities in the Netherlands. Additional studies are needed to confirm the psychometrics of the questionnaire when used among these populations in other Western European countries.

Background: Physical activity such as walking may exert a positive impact on cognition and behaviour in older persons with dementia, but due to the frailty of the population it may be worthwhile to consider other motor activities as well. Objective: Examining the effects of]land motor activity on cognition, mood and the rest-activity rhythm in older persons with dementia. Methods: Sixty-one older nursing home residents with dementia (mean age 84.6 years) were randomly assigned to either a hand movement program (experimental) or read aloud program (control) for 30 min, 5 days a week, during 6 weeks. Neuropsychological tests, mood questionnaires, and actigraphy data were assessed at baseline, after 6 weeks, and again after 6 weeks. Apolipoprotein epsilon (ApoE) genotype was determined. Results: Scores on neuropsychological tests were combined and formed specific Cognitive domains. Symptoms of depression and anxiety formed the Mood domain. Actigraphy variables composed the Rest-activity domain. In mixed model analyses no significant group x time interactions were found on either the Cognitive, Mood or Rest-activity domains in the intention-to-treat analysis. in the per protocol analysis, that included people who attended at least 80% of the sessions, mood improved only in the experimental group. No significant time x group x ApoE interaction effects were found in either analysis. Conclusion: In older nursing home residents with dementia, increased attendance to the hand movement program appeared to have a positive effect on mood. Hand motor activity is a type of activity that can be applied at a large scale. (C) 2008 Elsevier B.V. All rights reserved.

STUDY DESIGN. Exploratory subgroup analysis in a randomized controlled trial (RCT). OBJECTIVE. To detect possible moderators in the effectiveness of a workplace intervention in a population of workers with sick leave due to sub acute nonspecific low back pain. SUMMARY OF BACKGROUND DATA. In a recently published RCT, a workplace intervention was effective on return to work, compared to usual care. Examining the heterogeneity of effect sizes within the population in this RCT (n = 196) can lead to information on the effectiveness of the intervention in subgroups of patients. METHODS. A subgroup analysis was performed by adding interaction terms to the statistical model. Before analysis the following possible moderators for treatment were identified: age, gender, pain, functional status, heavy work, and sick leave in the previous 12 months. Cox regression analyses were performed and survival curves were plotted. RESULTS. The interaction (P = 0.02) between age (dichotomized at the median value) and the workplace intervention indicates a modifying effect. The workplaceintervention is more effective for workers

Background A statistical distribution describing the number of new enhancing lesions seen on MRI in patients with MS is of great importance for improving the statistical methodology of clinical trials using new enhancing lesions as outcome measure. We examined whether there are superior alternatives for the currently proposed negative binomial (NB) distribution. Objective To determine the optimal statistical distribution describing new enhancing lesion counts from a selection of six conceivable models, and to assess the effect on the distribution of a treatment effect, varying follow-up duration and selection for activity at baseline. Methods The statistical NB, Poisson-Inverse Gaussian (P-IG), Poisson- Lognormal (P-LN), Neyman type A (NtA), Pólya-Aeppli (PA) and Zero Inflated Poisson (ZIP) distribution were fitted on new enhancing lesion data derived from one treated and two untreated cohorts of RRMS and relapsing SPMS patients and on subgroups of varying follow-up duration and selection for baseline activity. Measure of comparison was Akaike's information criterion (AIC). Results Both the subgroup analyses as well as a treatment had a noticeable effect on the distributional characteristics of new enhancing lesion counts. The NB distribution generally provided the most optimal fit, closely followed by the P-IG distribution and the P-LN distribution. Fits of the PA and NtA distribution were suboptimal, while the ZIP distribution was the least adequate for modelling new enhancing lesion counts. Conclusion The NB distribution is the optimal distribution for modelling new enhancing lesion counts, irrespective of the effect of treatment, follow-up duration or a baseline activity selection criterion.

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).

The aim of this study was to determine whether extended olfactory testing within a single olfactory task and/or across olfactory tasks increases diagnostic accuracy of olfactory testing in Parkinson's disease (PD). Olfactory function was assessed using an extended version of the "Sniffin' Sticks", comprising 32-item odor identification and discrimination tasks, and a detection threshold task in 52 PD patients and 50 controls, all aged between 49 and 78 years. ROC curves based on sensitivity and specificity estimates were used to compare the diagnostic accuracy of extended and combined olfactory testing. There was no significant difference in diagnostic accuracy between the 16-item and the 32-item versions of the odor identification or discrimination test. The single olfactory test that was best in discriminating between PD patients and controls was a 16-item odor identification test. A combination of the 16-item identification test and the detection threshold task had a significantly higher area under the curve than the 16-item odor identification test alone. In conclusion, extended testing across, and not within, olfactory tasks increases diagnostic accuracy of olfactory testing in PD. A combination of an odor detection threshold task and a 16-item odor identification test had the highest sensitivity and specificity in distinguishing between PD patients and controls.

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.

In recent clinical gait studies, the use of net energy cost (EC) outcomes has been recommended. This study assessed the comparative reproducibility of gross and net EC of walking in adults and children with locomotion disorders, using a portable system for gas-exchange. Furthermore, methodological considerations were proposed for improving the reproducibility of these outcomes. Assessment of reproducibility was made in adults with polio residuals (n = 14) versus healthy adults (n = 14), and in children with cerebral palsy (n = 13) versus healthy children (n = 10). There were four repeated measurement sessions on different days, with inter-session periods of 1 week. All the measurements had been conducted at the outpatient clinic between 2002 and 2004. Based on the Generalizability Theory for data-analysis, it was shown that there was less intra-subject variability in gross EC of walking compared to net EC of walking among adults and children with locomotion disorders, which was apparent from the lower standard error of measurement values. Data-analysis optimisation and study design adjustments were considered and presented in a decision scheme, to demonstrate that the reproducibility of net EC can substantially be increased. The use of gross EC, rather than net EC, in patients with locomotion disorders seems a more reproducible measure of walking efficiency. However, reproducibility of net EC can substantially be improved by careful standardization and using a multiple repetition design, as a result of which this outcome measure becomes suitable for detecting clinically relevant changes at the individual level. © 2007 Elsevier B.V. All rights reserved.

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.

Purpose: To establish the supplemental value of diffusion-weighted (DW) magnetic resonance (MR) imaging beyond conventional MR to predict clinical outcome after neonatal hypoxic ischemia (HI) at 2 years of age. Materials and Forty-six infants with neonatal HI were enrolled in this Methods: prospective study, after approval by the local ethical committee and informed consent of the parents. Neonatal MR imaging ranged from 1 to 45 days after birth. Apparent diffusion coefficient (ADC) was measured in 14 brain regions. DW and conventional images were qualitatively scored for abnormalities, resulting in cumulative scores and patterns of damage. Surviving infants were scored for motor outcome at the age of 2 years, and outcome was classified as poor if the motor score was less than 70 or in case of death. Analyses were performed for the whole group, with additional analyses for the early (0-4 days after birth) and late (>4 days after birth) imaging groups. Results: Twenty-five infants had a good outcome and 21 had a poor outcome. Only in the early imaging group, the infants with poor outcome had significantly lowered ADC values in several brain areas, with the posterior limb of the internal capsule being the most predictive (Wald score = 5.7; P = .017). Cumulative scores of DW imaging were the best predictor of poor motor outcome at the age of 2 years (Wald score = 7.2, P < .01). The basal ganglia and central cortex and the diffuse pattern of brain damage were highly associated with poor outcome (Fisher exact test = 29.8; P < .001). Conclusion: In neonatal HI, DW imaging is a useful additional MR technique to predict the motor outcome at 2 years. Local ADC values had a limited value. Recognition of the patterns of brain damage with DW and conventional MR imaging can be used as a diagnostic tool in neonatal HI. © RSNA, 2008.

Predictive developmental hypotheses play a crucial role in developmental theories. These hypotheses link early developmental behaviors or processes to later developmental outcomes. Empirical tests of predictive developmental hypotheses are generally based on standard regression models. It is argued that hierarchical linear models or longitudinal multilevel models offer a better alternative. A multivariate longitudinal model linking developmental data to a criterion is described and an application is given. The application, derived from attachment theory, pertains to the prediction of infant behavior in the Strange Situation. It is concluded that the proposed approach offers a valuable tool to the developmentalist, both from a theoretical and methodological point of view.

Background: The Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ) are frequently used questionnaires for pain-related fear, and the visual analogue scale (VAS) is for pain. Purpose: This study aims to determine the smallest detectable change (SDC) of these questionnaires in patients with acute low back pain (LBP), as well as ceiling and/or floor effects. Results: The SDC for the TSK (scoring range: 17-68) was 9.2 (95% CI: 8.4; 10.3). The estimated SDC was 9.4 (95% CI: 8.5; 10.6) and 12.7 (95% CI: 11.5; 14.1) for the FABQ physical activity subscale (scoring range: 0-24) and/or work subscale (scoring range: 0-42), respectively. For the VAS for pain (0-100 mm), the SDC turned out to be 36.2 mm (95% CI: 32.4; 41.0). The FABQ physical activity subscale and pain (VAS) seem to have considerable problems in detecting improvement and deterioration. The TSK appears to be able to detect improvement as well as deterioration. Conclusion: The SDCs of the (subscales of) questionnaires range from 18% to 40%. Floor and/or ceiling effects were detected for most scales, except the TSK total and the TSK activity avoidance subscale. These results should be considered when using these questionnaires as measures of therapeutic change in acute LBP.

This study assessed the effectiveness of a single intervention targeting work style and a combined intervention targeting work style and physical activity on the recovery from neck and upper limb symptoms. Computer workers with frequent or long-term neck and upper limb symptoms were randomised into the work style group (WS, n = 152), work style and physical activity group (WSPA, n = 156), or usual care group (n = 158). The WS and WSPA group attended six group meetings. All meetings focused on behavioural change with regard to body posture, workplace adjustment, breaks and coping with high work demands (WS and WSPA group) and physical activity (WSPA group). Pain, disability at work, days with symptoms and months without symptoms were measured at baseline and after 6 (T1) and 12 months (T2). Self-reported recovery was assessed at T1/T2. Both interventions were ineffective in improving recovery. The work style intervention but not the combined intervention was effective in reducing all pain measures. These effects were present in the neck/shoulder, not in the arm/wrist/hand. For the neck/shoulder, the work style intervention group also showed an increased recovery-rate. Total physical activity increased in all study groups but no differences between groups were observed. To conclude, a group-based work style intervention focused on behavioural change was effective in improving recovery from neck/shoulder symptoms and reducing pain on the long-term. The combined intervention was ineffective in increasing total physical activity. Therefore we cannot draw conclusions on the effect of increasing physical activity on the recovery from neck and upper limb symptoms. © 2007 International Association for the Study of Pain.

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.