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

Background Limited walking ability is an important problem for patients with multiple sclerosis. A better understanding of how gait impairments lead to limited walking ability may help to develop more targeted interventions. Although gait classifications are available in cerebral palsy and stroke, relevant knowledge in MS is scarce. Objective The aims of this study were: (1) to identify distinctive gait patterns in patients with MS based on a combined evaluation of kinematics, gait features, and muscle activity during walking and (2) to determine the clinical relevance of these gait patterns. Design This was a cross-sectional study of 81 patients with MS of mild-to-moderate severity (Expanded Disability Status Scale [EDSS] median score=3.0, range=1.0–7.0) and an age range of 28 to 69 years. Method The patients participated in 2-dimensional video gait analysis, with concurrent measurement of surface electromyography and ground reaction forces. A score chart of 73 gait items was used to rate each gait analysis. A single rater performed the scoring. Latent class analysis was used to identify gait classes. Results Analysis of the 73 gait variables revealed that 9 variables could distinguish 3 clinically meaningful gait classes. The 9 variables were: (1) heel-rise in terminal stance, (2) push-off, (3) clearance in initial swing, (4) plantar-flexion position in mid-swing, (5) pelvic rotation, (6) arm-trunk movement, (7) activity of the gastrocnemius muscle in pre-swing, (8) M-wave, and (9) propulsive force. The EDSS score and gait speed worsened in ascending classes. Limitations Most participants had mild-to-moderate limitations in walking ability based on their EDSS scores, and the number of walkers who were severely limited was small. Conclusions Based on a small set of 9 variables measured with 2-dimensional clinical gait analysis, patients with MS could be divided into 3 different gait classes. The gait variables are suggestive of insufficient ankle push-off.

Prospective cohort, test-retest design.Directional preference (DP) with centralization (CEN) and DP without CEN are common pain-pattern responses assessed by Mechanical Diagnosis and Therapy (MDT). Although there is evidence that MDT can reduce pain and disability in the short term by treating the patient with direction-specific exercises concordant with the patient's DP, the mechanism responsible for this is unclear.To determine whether clinical signs of impaired spinal control improve immediately after eliciting a DP-with-CEN response or a DP-without-CEN response in patients with nonspecific low back pain.Participants underwent a standardized MDT assessment and were classified into the following pain-pattern subgroups: DP with CEN, DP without CEN, or no DP. Clinical signs of impaired spinal control were assessed pre-MDT assessment and post-MDT assessment by an independent examiner. Four spinal control tests were conducted: aberrant lumbar movements while bending forward, the active straight leg raise (ASLR) test, the Trendelenburg test, and the prone instability test. Differences in spinal control pre-MDT assessment and post-MDT assessment were calculated for the 3 pain-pattern subgroups and compared with chi-square tests. We hypothesized that a larger proportion of patients in the DP-with-CEN subgroup would exhibit improved spinal control than patients categorized as DP without CEN or no DP.Of 114 patients recruited, 51 patients (44.7%) were categorized as DP with CEN, 23 (20.2%) as DP without CEN, and 40 (35.1%) as no DP. Before MDT assessment, between 28.9% (Trendelenburg test) and 63.7% (ASLR test) of patients showed impaired spinal control. After MDT assessment, a larger proportion of patients in the DP-with-CEN subgroup (43%) showed improvement than those in the no-DP subgroup (7%) on aberrant lumbar movements (P = .02). Likewise, more patients in the DP-with-CEN subgroup (50%) improved on the ASLR test than those in the no-DP subgroup (8%, P.01) or the DP-without-CEN subgroup (7%, P = .01). Changes in Trendelenburg test and prone instability test outcomes did not reach statistical significance.Immediately following MDT assessment, a larger proportion of patients with a DP-with-CEN pain pattern showed improvement in clinical signs of spinal control compared to patients with a DP-without-CEN or no-DP pain pattern. The current study was registered in the Dutch trial registry at http://www.trialregister.nl/trialreg/index.asp (NTR4246).Therapy, level 2b.

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

Background Children with severe cerebral palsy (CP) (i.e. ‘non-speaking children with severely limited mobility’) are restricted in many domains that are important to the acquisition of language. Aims To investigate comprehension of spoken language on sentence type level in non-speaking children with severe CP. Methods & Procedures From an original sample of 87 non-speaking children with severe CP, 68 passed the pre-test (i.e. they matched at least five spoken words to the corresponding objects) of a specifically developed computer-based instrument for low motor language testing (C-BiLLT), admitting them to the actual C-BiLLT computer test. As a result, the present study included 68 children with severe CP (35 boys, 33 girls; mean age 6;11 years, SD 3;0 years; age range 1;9-11;11 years) who were investigated with the C-BiLLT for comprehension of different sentence types: phrases, simple active sentences (with one or two arguments) and compound sentences. The C-BiLLT provides norm data of typically developing (TD) children (1;6-6;6 years). Binomial logistic regression analyses were used to compare the percentage correct of each sentence type in children with severe CP with that in TD children (subdivided into age groups) and to compare percentage correct within the CP subtypes. Outcomes & Results Sentence comprehension in non-speaking children with severe CP followed the developmental trajectory of TD children, but at a much slower rate; nevertheless, they were still developing up to at least age 12 years. Delays in sentence type comprehension increased with sentence complexity and showed a large variability between individual children and between subtypes of CP. Comprehension of simple and syntactically more complex sentences were significantly better in children with dyskinetic CP than in children with spastic CP. Of the children with dyskinetic CP, 10-13% showed comprehension of simple and compound sentences within the percentage correct of TD children, as opposed to none of the children with spastic CP. Conclusion & Implications In non-speaking children with severe CP sentence comprehension is delayed rather than deviant. Results indicate the importance of following comprehension skills across all age groups, even beyond age 12 years. Moreover, the subtype of CP should be considered when establishing an educational programme for sentence comprehension, and augmentative and alternative communication support. In addition, educational programmes for children with severe CP should take into account the linguistic hierarchy of sentence comprehension when focusing on the input and understanding of spoken language comprehension.

Rugby Union ("rugby") participants have a higher than average risk of injury compared with participants of other popular team sports. BokSmart, a nationwide injury prevention program was launched in South Africa in mid-2009, with the goal of reducing catastrophic head/neck (serious) injuries in players. The program provides injury prevention information to coaches and referees. This study investigated if BokSmart has been associated with a reduction in these injuries. The BokSmart program collected data on all South African rugby-related serious injuries since 2008. Using a Poisson regression, injury numbers were compared pre-BokSmart (2008-2009) to the years post-implementation (2010-2013). Player numbers were assumed to be constant throughout this evaluation: junior = 529,483; senior = 121,663. In junior players, the "post-BokSmart" period had 2.5 less annual serious injuries than "pre-BokSmart" (incidence rate ratio: 0.6, 95% confidence interval: 0.5-0.7, P < 0.000). In contrast, there was no significant difference in these periods in seniors. The absence of effect in seniors may be a result of fewer players or of differences in effectiveness of BokSmart in this group--future studies should investigate these questions.

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

IMPORTANCE: Amyloid-β positron emission tomography (PET) imaging allows in vivo detection of fibrillar plaques, a core neuropathological feature of Alzheimer disease (AD). Its diagnostic utility is still unclear because amyloid plaques also occur in patients with non-AD dementia. OBJECTIVE: To use individual participant data meta-analysis to estimate the prevalence of amyloid positivity on PET in a wide variety of dementia syndromes. DATA SOURCES: The MEDLINE and Web of Science databases were searched from January 2004 to April 2015 for amyloid PET studies. STUDY SELECTION: Case reports and studies on neurological or psychiatric diseases other than dementia were excluded. Corresponding authors of eligible cohorts were invited to provide individual participant data. DATA EXTRACTION AND SYNTHESIS: Data were provided for 1359 participants with clinically diagnosed AD and 538 participants with non-AD dementia. The reference groups were 1849 healthy control participants (based on amyloid PET) and an independent sample of 1369 AD participants (based on autopsy). MAIN OUTCOMES AND MEASURES: Estimated prevalence of positive amyloid PET scans according to diagnosis, age, and apolipoprotein E (APOE) ε4 status, using the generalized estimating equations method. RESULTS: The likelihood of amyloid positivity was associated with age and APOE ε4 status. In AD dementia, the prevalence of amyloid positivity decreased from age 50 to 90 years in APOE ε4 noncarriers (86% [95% CI, 73%-94%] at 50 years to 68% [95% CI, 57%-77%] at 90 years; n = 377) and to a lesser degree in APOE ε4 carriers (97% [95% CI, 92%-99%] at 50 years to 90% [95% CI, 83%-94%] at 90 years; n = 593; P

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

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

STUDY DESIGN: A cross-sectional diagnostic accuracy study was conducted in 2 sessions.OBJECTIVE: It is important to know whether it is possible to accurately detect "specific findings" on lumbosacral magnetic resonance (MR) images and whether the results of different observers are comparable.SUMMARY OF BACKGROUND DATA: Health care providers frequently use magnetic resonance imaging in the diagnostic process of patients with low back pain. The use of MR scans is increasing. This leads to an increase in costs and to an increase in risk of inaccurately labeling patients with an anatomical diagnosis that might not be the actual cause of symptoms.METHODS: A set of 300 blinded MR images was read by medical radiologists, chiropractors, and chiropractic radiologists in 2 sessions. Each assessor read 100 scans in round 1 and 50 scans in round 2. The reference test was an expert panel.For all analyses, the magnetic resonance imaging findings were dichotomized into "specific findings" or "no specific findings." For the agreement, percentage agreement and κ values were calculated and for validity, sensitivity, and specificity. Sensitivity analysis was done for classifications A and B (prevalence of 31% and 57%, respectively).RESULTS: The intraobserver κ values for chiropractors, chiropractic radiologists, and medical radiologists were 0.46, 0.49, and 0.69 for A and 0.55, 0.75, and 0.64 for B, respectively.The interobserver κ values were lowest for chiropractors (0.28 for A, 0.37 for B) and highest for chiropractic radiologists (0.50 for A, 0.49 for B).The sensitivities of the medical radiologists, chiropractors, and chiropractic radiologists were 0.62, 0.71, and 0.75 for A and 0.70, 0.74, 0.84 for B, respectively.The specificities of medical radiologists, chiropractic radiologists, and chiropractors were 0.82, 0.77, and 0.70 for A and 0.74, 0.52, and 0.61 for B, respectively.CONCLUSION: Agreement and validity of MR image readings of chiropractors and chiropractic and medical radiologists is modest at best. This study supports recommendations in clinical guidelines against routine use of magnetic resonance imaging in patients with low back pain.LEVEL OF EVIDENCE: 3.

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

ObjectivesTo assess disease-free survival (DFS) in head and neck squamous cell carcinoma (HNSCC) treated with (chemo)radiotherapy ([C]RT).MethodsPretreatment MR-images of 78 patients were retrospectively studied. Apparent diffusion coefficients (ADC) were calculated with two sets of two b-values: 0–750s/mm2 (ADC750) and 0–1000s/mm2 (ADC1000). One observer assessed tumor volume on T1-WI. Two independent observers assessed ADC-values of primary tumor and largest lymph node in two sessions (i.e. without and with including CE-T1WI in image analysis). Interobserver and intersession agreement were assessed with intraclass correlation coefficients (ICC) separately for ADC750 and ADC1000. Lesion volumes and ADC-values were related to DFS using Cox regression analysis.ResultsMedian follow-up was 18 months. Interobserver ICC was better without than with CE-T1WI (primary tumor: 0.92 and 0.75–0.83, respectively; lymph node: 0.81–0.83 and 0.61–0.64, respectively). Intersession ICC ranged from 0.84 to 0.89. With CE-T1WI, mean ADC-values of primary tumor and lymph node were higher at both b-values than without CE-T1WI (P

Background: Low serum 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with insulin resistance, the metabolic syndrome, and type 2 diabetes. Because many non-Western immigrants in the Netherlands are vitamin D deficient, obese, and at high risk of diabetes, vitamin D supplementation may contribute to prevent diabetes and insulin resistance. Objective: We examined the effect of vitamin D supplementation on insulin sensitivity and b cell function in overweight, vitamin D‐ deficient, non-Western immigrants at high risk of diabetes. Design: The study was a 16-wk, randomized, placebo-controlled trial. A total of 130 non-Western immigrants with prediabetes (fasting glucose concentration .5.5 mmol/L or random glucose concentration from 7.8 to 11.1 mmol/L) and vitamin D deficiency (serum 25[OH]D concentration ,50 nmol/L) were randomly assigned after stratification by sex to receive either cholecalciferol (1200 IU/d) or a placebo for 16 wk. All participants received 500 mg Ca/d as calcium carbonate. The primary outcome was the difference in the area under the curve of insulin and glucose after a 75-g oral-glucose-tolerance test after 4 mo of treatment. Secondary outcomes were insulin-sensitivity variables, b cell‐function variables, and metabolic syndrome. Results: Mean serum 25(OH)D concentrations increased significantly in the vitamin D compared with placebo groups. After 4 mo of therapy, the mean between-group difference was 38 nmol/L (95% CI: 32.1, 43.9 nmol/L; P , 0.001). There was no significant effect on insulin sensitivity and b cell function. In a post hoc analysis, when patients with diabetes at baseline were excluded, a significant increase in the insulinogenic index was observed in participants who obtained a 25(OH)D concentration $60 nmol/L (P =0 .040). Conclusions: Vitamin D supplementation in non-Western vitamin D‐deficient immigrants with prediabetes did not improve insulin sensitivity or b cell function or change the incidence of metabolic syndrome. However, after the exclusion of diabetic subjects, an improvement in the insulinogenic index was observed in participants who obtained a 25(OH)D concentration $60 nmol/L. This trial was registered at trialregister.nl as NTR1827. Am J Clin Nutr 2014;100:152‐60.

Objective To examine the temporal evolution of spinal cord (SC) atrophy in multiple sclerosis (MS), and its association with clinical progression in a large MS cohort. Methods A total of 352 patients from two centres with MS (relapsing remitting MS (RRMS): 256, secondary progressive MS (SPMS): 73, primary progressive MS (PPMS): 23) were included. Clinical and MRI parameters were obtained at baseline, after 12 months and 24 months of follow-up. In addition to conventional brain and SC MRI parameters, the annualised percentage brain volume change and the annualised percentage upper cervical cord cross-sectional area change (aUCCA) were quantified. Main outcome measure was disease progression, defined by expanded disability status scale increase after 24 months. Results UCCA was lower in SPMS and PPMS compared with RRMS for all time points. aUCCA over 24 months was highest in patients with SPMS (-2.2% per year) and was significantly higher in patients with disease progression (-2.3% per year) than in stable patients (-1.2% per year; p=0.003), while annualised percentage brain volume change did not differ between subtypes (RRMS: -0.42% per year; SPMS -0.6% per year; PPMS: -0.46% per year) nor between progressive and stable patients (p=0.055). Baseline UCCA and aUCCA over 24 months were found to be relevant contributors of expanded disability status scale at month-24, while baseline UCCA as well as number of SC segments involved by lesions at baseline but not aUCCA were relevant contributors of disease progression. Conclusions SC MRI parameters including baseline UCCA and SC lesions were significant MRI predictors of disease progression. Progressive 24-month upper SC atrophy occurred in all MS subtypes, and was faster in patients exhibiting disease progression at month-24. © 2014 by the BMJ Publishing Group Ltd.

Background: Although communicating effectively with patients receiving palliative care can be difficult, it may contribute to maintaining or enhancing patients’ quality of life. Little is known about the effect of training general practitioners in palliative care–specific communication. We hypothesized that palliative care patients of general practitioners exposed to the ‘Availability, Current issues and Anticipation’ communication training programme would report better outcomes than patients of control general practitioners. Aim: To evaluate the effectiveness of the Availability, Current issues and Anticipation training programme for general practitioners on patient-reported outcomes. Design: In a controlled trial, general practitioners followed the Availability, Current issues and Anticipation programme or were part of the control group. Patients receiving palliative care of participating general practitioners completed the Palliative Care Outcome Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative, the Rest & Peace Scale, the Patient Satisfaction Questionnaire–III and the Availability, Current issues and Anticipation Scale, at baseline and 12 months follow-up. We analysed differences between groups using linear mixed models. Trial registration: ISRCTN56722368. Setting/participants: General practitioners who attended a 2-year Palliative Care Training Course in the Netherlands. Results: Questionnaire data were available for 145 patients (89 in intervention and 56 in control group). We found no significant differences over time between the intervention and control groups in any of the five outcome measures. Ceiling effects were observed for the Rest & Peace Scale, Patient Satisfaction Questionnaire–III and Availability, Current issues and Anticipation Scale. Conclusion: General practitioner participation in the Availability, Current issues and Anticipation training programme did not have a measurable effect on any of the outcomes investigated. Patients reported high levels of satisfaction with general practitioner care, regardless of group assignment. Future research might focus on general practitioners without special interest in palliative care.

tudy Design Prospective cohort study. Objective To report the clinical course of patients with MRI-confirmed lumbar disc herniation-related radicular noncentralizing pain who received transforaminal epidural steroid injections (TESIs) and mechanical diagnosis and therapy (MDT). Summary of Background Data Noncentralizing symptoms in patients with lumbar disc herniation are associated with poor outcome. Commonly used treatments for these patients include TESIs and MDT. No study has evaluated the outcome of combining both strategies. Methods Consecutive candidates for herniated lumbar disc surgery with noncentralizing chronic pain were eligible. Patients received TESIs followed by MDT. The primary outcomes were pain severity in the leg, disability (Roland–Morris Disability Questionnaire for Sciatica), and global perceived effect (GPE). Outcomes were measured at baseline, discharge, and 12 months. Linear mixed-models and McNemar's tests were used to analyze outcome data. Results Sixty-nine patients receive TESIs. After TESIs, symptoms were resolved completely in 11 patients (16%). In these patients, symptom resolution was maintained at 12 months. A second subgroup of 32 patients (46%) reported significantly less pain after TESIs and showed centralization with MDT reassessment (significant reductions in leg pain and disability [P

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

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

Aim Despite increasing interest in visual and hearing impairment in the older population, little attention has been paid to concurrent hearing and vision loss, also known as dual sensory loss. The aim of the present study was to investigate the prevalence of comorbid hearing disability and hearing aid ownership in visually impaired older adults. Methods In a cross-sectional survey, a self-report hearing disability screener was administered to 1396 visually impaired patients (aged ≥50 years) of outpatient low vision rehabilitation centers in the Netherlands and Belgium. Results Of all participants, 44.8% (95% CI 42.2–47.5) had insufficient or poor hearing; the prevalence increased quadratically with age. Of all dual sensory impaired participants, 31.2% in the Netherlands and 55.7% in Belgium did not own hearing aids. Conclusions The high prevalence of dual sensory loss calls for more awareness of related problems in these patients. Differences between the Netherlands and Belgium regarding hearing aid ownership might be due to different criteria used for hearing aid referral and insurance policies. For patients with dual sensory loss, specialized care implemented in low vision rehabilitation seems warranted. Geriatr Gerontol Int 2014; 14: 570–576.

PURPOSE: In the past, rehabilitation centers for the visually impaired used unstructured or semistructured methods to assess rehabilitation needs of their patients. Recently, an extensive instrument, the Dutch ICF Activity Inventory (D-AI), was developed to systematically investigate rehabilitation needs of visually impaired adults and to evaluate rehabilitation outcomes. The purpose of this study was to investigate the underlying factor structure and other psychometric properties to shorten and improve the D-AI. METHODS: The D-AI was administered to 241 visually impaired persons who recently enrolled in a multidisciplinary rehabilitation center. The D-AI uses graded scores to assess the importance and difficulty of 65 rehabilitation goals. For high-priority goals (e.g., daily meal preparation), the difficulty of underlying tasks (e.g., read recipes, cut vegetables) was assessed. To reduce underlying task items (>950), descriptive statistics were investigated and factor analyses were performed for several goals. The internal consistency reliability and test-retest reliability of the D-AI were investigated by calculating Cronbach α and Cohen (weighted) κ. Finally, consensus-based discussions were used to shorten and improve the D-AI. RESULTS: Except for one goal, factor analysis model parameters were at least reasonable. Internal consistency reliability was satisfactory (range, 0.74 to 0.93). In total, 60% of the 65 goal importance items and 84.4% of the goal difficulty items showed moderate to almost perfect κ values (≥0.40). After consensus-based discussions, a new D-AI was produced, containing 48 goals and less than 500 tasks. CONCLUSIONS: The analyses were an important step in the validation process of the D-AI and to develop a more feasible assessment tool to investigate rehabilitation needs of visually impaired persons in a systematic way. The D-AI is currently implemented in all Dutch rehabilitation centers serving all visually impaired adults with various rehabilitation needs. © 2013 American Academy of Optometry.

Background: In many retrospective studies and large clinical trials, high-resolution, good-contrast 3DT1 images are unavailable, hampering detailed analysis of brain atrophy. Ventricular enlargement then provides a sensitive indirect measure of ongoing central brain atrophy. Validated automated methods are required that can reliably measure ventricular enlargement and are robust across magnetic resonance (MR) image types. Aim: To validate the automated method VIENA for measuring the percentage ventricular volume change (PVVC) between two scans. Materials and Methods: Accuracy was assessed using four image types, acquired in 15 elderly patients (five with Alzheimer's disease, five with mild cognitive impairment, and five cognitively normal elderly) and 58 patients with multiple sclerosis (MS), by comparing PVVC values from VIENA to manual outlining. Precision was assessed from data with three imaging time points per MS patient, by measuring the difference between the direct (one-step) and indirect (two-step) measurement of ventricular volume change between the first and last time points. The stringent concordance correlation coefficient (CCC) was used to quantify absolute agreement. Results: CCC of VIENA with manual measurement was 0.84, indicating good absolute agreement. The median absolute difference between two-step and one-step measurement with VIENA was 1.01%, while CCC was 0.98. Neither initial ventricular volume nor ventricular volume change affected performance of the method. Discussion: VIENA has good accuracy and good precision across four image types. VIENA therefore provides a useful fully automated method for measuring ventricular volume change in large datasets. Conclusion: VIENA is a robust, accurate, and precise method for measuring ventricular volume change. Hum Brain Mapp 35:1101–1110, 2014. © 2013 Wiley Periodicals, Inc.

Introduction To counteract the recently observed increase in forearm fractures in children worldwide, an educational programme to improve fall skills was developed. In this 8-week programme children learned basic martial arts falling techniques in their physical education classes. In this study, the effectiveness of this educational programme to improve fall skills was evaluated. Methods A cluster randomised controlled trial was conducted in 33 primary schools. The intervention group received the educational programme to improve falling skills during their physical education (PE) classes whereas the control group received their regular PE curriculum. At baseline (October 2009) and follow-up (May 2010), a questionnaire was completed by the children about their physical activity behaviours. Furthermore, fall-related injuries were registered continuously during an entire school-year. Results A total of 36 incident injuries was reported in the intervention group, equalling an injury incidence density (IID) of 0.14 fall-related injuries per 1000 h of physical activity (95% CI 0.09 to 0.18). In contrast, 96 injuries were reported by the control group corresponding to an IID of 0.26 (95% CI 0.21 to 0.32). However, because intracluster correlation was high (ICC=0.46), differences in injury incidence were not statistically significant. When activity level was taken into account, a trend was shown suggesting that the ‘falling is a sport’ programme was effective in decreasing falling-related injury risk, but only in the least active children. Discussion and conclusion Although results did not reach significance because of strong clustering effects, a trend was found suggesting that a school-based educational programme to improve falling skills may be more beneficial for the prevention of falling-related injuries in children with low levels of habitual physical activity.

Background: Measuring impairments in “instrumental activities of daily living” (IADL) is important in dementia, but challenging due to the lack of reliable and valid instruments. We recently developed the Amsterdam Instrumental Activities of Daily Living Questionnaire (A-IADL-Q; note 1). We aim to investigate the diagnostic accuracy of the A-IADL-Q for dementia in a memory clinic setting. Methods: Patients visiting the Alzheimer Center of the VU University Medical Center with their informants between 2009 and 2011 were included (N = 278). Diagnoses were established in a multidisciplinary consensus meeting, independent of the A-IADL-Q scores. An optimal A-IADL-Q cutoff point was determined, and sensitivity and specificity were calculated. Area under the curves (AUCs) were compared between A-IADL-Q and “disability assessment of dementia” (DAD). The additional diagnostic value of the A-IADL-Q to Mini-Mental State Examination (MMSE) was examined using logistic regression analyses. Results: Dementia prevalence was 50.5%. Overall diagnostic accuracy based on the AUC was 0.75 (95% confidence interval [CI]: 0.70-0.81) for the A-IADL-Q and 0.70 (95% CI: 0.63-0.77) for the DAD, which did not differ significantly. The optimal cutoff score for the A-IADL-Q was 51.4, resulting in sensitivity of 0.74 and specificity of 0.64. Combining the A-IADL-Q with the MMSE improved specificity (0.94), with a decline in sensitivity (0.55). Logistic regression models showed that adding A-IADL-Q improved the diagnostic accuracy (Z = 2.55, P = .011), whereas the DAD did not. Conclusions: In this study, we showed a fair diagnostic accuracy for A-IADL-Q and an additional value in the diagnosis of dementia. These results support the role of A-IADL-Q as a valuable diagnostic tool.

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

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

UNLABELLED: Inflammatory mechanisms, like microglial activation, could be involved in the pathogenesis of Alzheimer's disease (AD). (R)-[(11)C]PK11195 (1-(2-chlorophenyl)-N-methyl-N-1(1-methylpropyl)-3-isoquinolinecarboxamide), a positron emission tomography (PET) ligand, can be used to quantify microglial activation in vivo. The purpose of this study was to assess whether increased (R)-[(11)C]PK11195 binding is present in AD and mild cognitive impairment (MCI), currently also known as "prodromal AD." METHODS: Nineteen patients with probable AD, 10 patients with prodromal AD (MCI), and 21 healthy control subjects were analyzed. Parametric images of binding potential (BP(ND)) of (R)-[(11)C]PK11195 scans were generated using receptor parametric mapping (RPM) with supervised cluster analysis. Differences between subject groups were tested using mixed model analysis, and associations between BP(ND) and cognition were evaluated using Pearson correlation coefficients. RESULTS: Voxel-wise statistical parametric mapping (SPM) analysis showed small clusters of significantly increased (R)-[(11)C]PK11195 BP(ND) in occipital lobe in AD dementia patients compared with healthy control subjects. Regions of interest (ROI)-based analyses showed no differences, with large overlap between groups. There were no differences in (R)-[(11)C]PK11195 BP(ND) between clinically stable prodromal AD patients and those who progressed to dementia, and BP(ND) did not correlate with cognitive function. CONCLUSION: Microglial activation is a subtle phenomenon occurring in AD.

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

Background: This study describes the validation of a new instrument measuring instrumental activities of daily living (IADL), the Amsterdam IADL Questionnaire© (a registered copyright of the Alzheimer Center of the VU University Medical Center). This informant-based tool aimed at detecting IADL problems in incipient dementia was previously found to have a high internal consistency and test-retest reliability. Methods: Patients and their informants who visited the Alzheimer Center of the VU University Medical Center were included in this study. Item response theory was used to estimate the individuals' trait levels as a measure of IADL disability. Construct validity was tested by correlating estimated trait levels with clinical and demographic measures using Pearson's or Kendall's τ correlation coefficients. Additionally, estimated trait levels between patients with and without dementia and between patients with early- and late-onset dementia were compared using independent t tests. Results: A total of 206 informants of patients completed the Amsterdam IADL Questionnaire. The correlations between estimated trait levels and other measures were in concordance with previously formed hypotheses. Patients diagnosed with dementia (n = 93) had higher estimated trait levels than patients without dementia (n = 96), Cohen's effect size, d = 1.04, t(187) = 7.1, p < 0.001. We found no differences between early- and late-onset dementia patients. Conclusions: Results suggest that the Amsterdam IADL Questionnaire is a reliable and valid instrument in the evaluation of dementia.

BACKGROUND: The surface area of scars is an important outcome parameter in scar assessment. It is often used to quantify the extent of scar features, such as pigmentation disturbances, hypertrophy, and contracture. Currently available techniques for measuring the surface area are known to be cumbersome or do not meet the basic clinimetric criteria (i.e., reliability and validity). Three-dimensional stereophotogrammetry is a technique that may improve the quality of surface area measurements. The aim of this study was to investigate the reliability and validity of three-dimensional stereophotogrammetry for measuring scar surface area. METHODS: In a cross-sectional study, two independent clinicians photographed and measured 50 scar areas of 32 patients using a handheld stereographic camera, to assess reliability. Subsequently, using planimetry, the scar surface was traced on a transparent sheet (considered the accepted standard) to assess validity. RESULTS: Three-dimensional stereophotogrammetry showed good reliability, with an intraclass correlation coefficient of 0.99 and a coefficient of variation of 6.8 percent. To visualize the differences between the two observers, data were plotted and the limits of agreement were calculated at 0 ± 0.19 × mean surface area. Also, excellent validity was found, with a concordance correlation coefficient of 0.99. CONCLUSION: This study showed that three-dimensional stereophotogrammetry is a reliable and valid tool for research purposes in the field of scar surface area measurements. Copyright © 2013 by the American Society of Plastic Surgeons.

Introduction Hereditary retinoblastoma survivors have an increased risk for cranio-facial second primary tumours (SPT), especially after treatment with external beam radiotherapy (EBRT). This multicentre study evaluates the clinical and imaging characteristics and outcomes of cranio-facial SPTs in irradiated retinoblastoma survivors. Patients and Methods Clinical and radiological data of 42 hereditary retinoblastoma patients with 44 second and third malignancies were reviewed. Radiological data included anatomic location and computed tomography (CT) and magnetic resonance (MR) characteristics. Cox regression and likelihood ratio chi-square test were used to evaluate differences in patients' survival rates. Results Cranio-facial SPTs were diagnosed at a median age of 13years. Histological types included osteosarcomas (43%), rhabdomyosarcomas (20%) (57% embryonal, 43% alveolar) and a variety of other types of SPT (37%). Predilection sites were: temporal fossa (39%), ethmoid sinus (23%), orbit (18%), maxillary sinus (16%) and intracranial dura mater (4%). Most of the osteosarcomas (78%) and rhabdomyosarcomas (80%) occurred in patients treated with EBRT in the first year-of-life. Treatment of SPTs with a microscopically complete surgical resection led to a significantly better 5-year overall survival (OS) ( P =0.017) and event-free survival (EFS) ( P =0.012) compared to patients treated without surgery or incomplete resection (OS: 83% versus 52%; EFS: 80% versus 47%). Conclusions Osteosarcomas and rhabdomyosarcomas are the most common cranio-facial SPTs in irradiated hereditary retinoblastoma survivors, which develop in specific locations and occur predominantly in patients irradiated in their first year-of-life. Microscopically complete surgical resection of SPTs is a major prognostic factor, suggesting the potential benefit of early detection by imaging.

Purpose: To assess the efficacy of client-centred occupational therapy (OT) according to a client-centred process framework, as compared to usual care OT, in patients with multiple sclerosis (MS). Method: A multicentre cluster randomised controlled trial with the institution (i.e. hospital or rehabilitation centre) as the unit of randomisation was performed. A total of 269 outpatients with MS, 13 hospitals and rehabilitation centres and 29 occupational therapists participated. Primary outcomes included measures of disability, participation and autonomy. Secondary outcomes included fatigue, generic health-related quality of life, quality and evaluation of therapy, therapy compliance and therapy frequency. Measurements were taken at baseline, four months and at eight months follow-up. Results: Primary outcome measures did not show significant differences between the two interventions. Secondary outcomes revealed significant differences in favour of the usual care OT on fatigue (physical scale and total scale) and health-related quality of life (bodily pain and vitality) at four months. After eight months only significant differences on mental health were found. Process outcomes (i.e. the information scale of therapy quality and the client-centredness of the organisation) were in favour of the client-centred intervention. Conclusion: Because the client-centred intervention resulted in no effects on the primary outcomes and small but negative effects on the secondary functional outcomes, we should seriously reconsider the application of client-centred practice.Implications for RehabilitationAn increasing number of interventions claim to incorporate client-centred practice. Client-centred practice is associated with improved satisfaction but the effects on functional health-related outcomes have not been fully evaluated.The findings of this study show that the process outcomes of therapy were in favour of the client-centred intervention, but no effects were found on the primary outcomes and negative effects on the secondary functional health outcomes.It is suggested that the implementation of client-centred practice should be adjusted in order to achieve optimal health outcomes. © 2013 Informa UK Ltd.

Study design Prospective cohort study. Background Although lumbar radiculopathy is regarded as a specific diagnosis, the most effective treatment strategy is unclear. Commonly used treatments include transforaminal epidural steroid injections (TESIs) and Mechanical Diagnosis & Therapy (MDT), but no studies have investigated the effectiveness of this combination. MDT differentiates pain centralization (C) from non-centralization (NC), which indicates good vs. poor prognostic validity respectively. Objective The main aims were 1) to determine changes in Mechanical Diagnosis and Therapy (MDT) pain response classifications after transforaminal epidural steroid injections (TESIs) in candidates for lumbar herniated disc surgery and 2) to evaluate differences in short and long term outcomes for patients with different pain response classifications. Methods Candidates for lumbar herniated disc surgery were assessed with a MDT protocol and their pain response classified as centralizing or peripheralizing. For this study,only patients were eligible who showed a peripheralizing pain response at intake. All patients then received TESIs and were reassessed and classified using the MDT protocol, into groups according to pain response (resolved, centralizing, peripheralizing with less pain and peripheralising with severe pain). After receiving targeted treatment based on pain response after TESIs, ranging from advice, MDT or surgery, follow-up assessments were completed at discharge and at 12 months. The primary outcomes were disability (Roland-Morris Disability Questionnaire [RMDQ] for Sciatica), pain severity in leg (visual analogue scale [VAS], 0-100) and global perceived effect (GPE). Linear mixed-models were used to determine between-groups differences in outcome. Results A total of 77 patients with lumbar disc herniation and peripheralizing symptoms were included. Patients received an average of 2 (SD 0.7) TESIs. After TESIs, 17 patients (22%) were classified as peripheralizing with continuing severe pain.These patients underwent surgery and were not further evaluated. Eleven (14%) patients were classified as resolved, 37 (48%) as centralizing with significant less pain, and 12 (16%) as peripheralizing with significant less pain. None of these patients underwent surgery. Resolved and centralizer subgroups had better outcomes in terms of VAS and RMDQ than the non-operated peripheralizers at discharge and at 12 months. The succes rates (GPE) for the resolved, centralizing, and peripheralizing with less pain patients were 100%, 100% and 33% respectively at short term, and 100%, 92% and 50% respectively at long term. Conclusion After TESIs, a peripheralizing pain pattern changed to resolved or centralizing in 62% of the patients. For the non-operated patients, those with a centralising pattern after TESIs reported better pain and disability outcomes than those with peripheralizing pattern at short and long term.

Background/Aims: Appropriate and timely screening instruments that sensitively capture the cognitive functioning of multiple sclerosis (MS) patients are the need of the hour. We evaluated newly derived regression-based norms for the Symbol Digit Modalities Test (SDMT) in a Dutch-speaking sample, as an indicator of the cognitive state of MS patients. Methods: Regression-based norms for the SDMT were created from a healthy control sample (n = 96) and used to convert MS patients' (n = 157) raw scores to demographically adjusted Z-scores, correcting for the effects of age, age2, gender, and education. Conventional and regression-based norms were compared on their impairment-classification rates and related to other neuropsychological measures. Results: The regression analyses revealed that age was the only significantly influencing demographic in our healthy sample. Regression-based norms for the SDMT more readily detected impairment in MS patients than conventional normalization methods (32 patients instead of 15). Patients changing from an SDMT-preserved to -impaired status (n = 17) were also impaired on other cognitive domains (p < 0.05), except for visuospatial memory (p = 0.34). Conclusions: Regression-based norms for the SDMT more readily detect abnormal performance in MS patients than conventional norms, identifying those patients at highest risk for cognitive impairment, which was supported by a worse performance on other neuropsychological measures.

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

BACKGROUND AND PURPOSE: Noninvasive evaluation of retinoblastoma treatment response has become more important due to increased use of eye-sparing treatments. We evaluated the relation between DCE-MR imaging and histopathologic parameters to determine the value of DCE-MR imaging in assessing tumor angiogenesis and prognostic features. MATERIALS AND METHODS: Fifteen consecutive patients with retinoblastoma (mean age, 24 months; range, 2–70 months) undergoing enucleation as the primary treatment (15 eyes) were scanned at 1.5T by using dedicated surface coils. Pretreatment DCE-MR imaging of the most affected eye was evaluated by 2 observers by using curve-pattern analysis, with the first 5 minutes of each curve and the full time-series described as κ 5min and κ 17min , respectively. Assessed histopathologic and immunologic parameters included optic nerve invasion, choroid invasion, MVD, tumor necrosis, and expression of VEGF and Flt-1. RESULTS: The median value of κ 5min was 1.28 (range, 0.87–2.07) and correlated positively with MVD ( P = .008). The median value of κ 17min was 1.33 (range, 0.35–3.08) and correlated negatively with tumor necrosis ( P = .002). Other histopathologic and immunohistopathologic parameters did not correlate with DCE-MR imaging parameters. Interobserver agreement was 0.53 for κ 5min and 0.91 for κ 17min . CONCLUSIONS: In retinoblastoma, the early phase of the DCE time curve positively correlates with MVD, while the presence of late enhancement is correlated with necrosis. Thus, the potential for DCE-MR imaging to noninvasively assess tumor angiogenesis and necrosis in retinoblastoma is promising and warrants further investigation.

Boorsma M, Frijters DHM, Knol DL, Ribbe ME, Nijpels G, Van Hout HPJ. Multidisciplinair zorgmodel in verzorgingshuizen. Huisarts Wet 2012;55(4):160-5.

Background Pain-related avoidance of activities is hypothesized to lead to lower muscle strength and thereby activity limitations. Negative affect (e.g., low vitality, depression) is thought to strengthen the tendency to avoid activities. Purpose The aim of this study was to assess the validity of this "avoidance model" in patients with early symptomatic knee osteoarthritis (OA). Methods Cross-sectional data (n=151) were used. The associations between pain, negative affect, avoidance, muscle strength, and activity limitations were modeled using structural equation modeling. Results Pain and negative affect were associated with lower muscle strength via avoidance (mediation by avoidance). Avoidance was associated with activity limitations via lower muscle strength (mediation by muscle strength). There were also direct associations between pain, negative affect, avoidance, muscle strength, and activity limitations. Conclusions The results support the validity of the avoidance model, which explains the associations between pain, negative affect, avoidance, muscle strength, and activity limitations in patients with early symptomatic knee OA. © The Society of Behavioral Medicine 2012.

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

The creatine transporter (CRTR) defect is a recently discovered cause of X-linked intellectual disability for which treatment options have been explored. Creatine monotherapy has not proved effective, and the effect of treatment with L-arginine is still controversial. Nine boys between 8 months and 10 years old with molecularly confirmed CRTR defect were followed with repeated (1)H-MRS and neuropsychological assessments during 4-6 years of combination treatment with creatine monohydrate, L-arginine, and glycine. Treatment did not lead to a significant increase in cerebral creatine content as observed with H(1)-MRS. After an initial improvement in locomotor and personal-social IQ subscales, no lasting clinical improvement was recorded. Additionally, we noticed an age-related decline in IQ subscales in boys affected with the CRTR defect.