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Background and purpose: Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.Materials and methods: We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.Results: 4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).Conclusion: The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies. Background and purpose: Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review.Materials and methods: We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work.Results: 4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence).Conclusion: The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.

Background and purpose: Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates post total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. This systematic review aimed to update the evidence on the influence of hip precautions on early recovery following THA.Materials and methods: We performed systematic searches for published randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL from 2016 to July 2022. Two reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within three months of surgery. Other outcomes were long-term risk of dislocation, reoperation, levels of self-reported function, quality of life, pain, performance-based assessment of function, and time to return to work.Results: 4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCT: risk ratio (RR): 1.8, 95% confidence interval (CI) 0.6 - 5.2; NRS: RR: 0.9, CI 0.3 - 2.5). Certainty in the evidence for the low. For all other outcomes, no differences were found with moderate to very low certainty in the evidence.Interpretation: The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA. However, the results are likely to change with higher-quality studies.

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion.

Purpose To report completeness of registered surgeries in the Danish hip arthroscopy registry (DHAR) and proportion of patients completing patient-reported outcome measures (PROMs) prior to surgery and at 1-year follow-up. Patients and Methods Completeness was determined as the number of surgeries registered in DHAR in comparison with the number of surgeries registered in the Danish National Patient Registry database (DNPR). The number of patients self-reporting pre-surgical PROMs was compared to the total number of surgeries registered in DHAR. Further, we evaluated potential differences in baseline characteristics between the groups of responders and non-responders at 1-year follow-up. Patient characteristics included age, sex, activity levels measured by the hip sports activity scale (HSAS), and PROMs (Copenhagen Hip and Groin Outcome Score, EQ-5D-3L and general hip status). Age was stratified in three groups (

Acetabular retroversion is associated with femoroacetabular impingement syndrome (FAIS). Anterior pelvic tilt enhances risk of FAIS.To investigate feasibility and change in patient-reported symptoms of a home-based exercise intervention in patients with acetabular retroversion and excessive anterior pelvic tilt, in comparison with a prior control period.Prospective intervention study.Patients (18-40 years) not eligible for surgery, with radiographic signs of acetabular retroversion and excessive anterior pelvic tilt were recruited. An 8-week control period was followed by an 8-week training period. The home-based intervention consisted of education and exercises for core stability, muscle strengthening and stretching for reducing anterior pelvic tilt. Feasibility assessments were dropout (≤10%), adherence (≥75% of sessions), exercise-related pain, and adverse events. Primary outcome was change in the Copenhagen Hip and Groin Outcome Score (HAGOS) pain-subscale. Pelvic tilt was measured by EOS scanning.Forty-two patients (93% female, mean age 22.2 ± 4.2 years) were included. Dropout rate was 7% and satisfactory adherence was demonstrated by 85%. Exercise-related pain and adverse events were acceptable. Between-period mean change score for HAGOS-PAIN was 5.2 points (95% CI: -0.3-10.6) and -1.6° (95% CI: -3.9-0.7) of anterior pelvic tilt. Patients responding positively (≥10 points) (n = 10, 26%), had pre-exercise moderate pain (HAGOS-PAIN 47.5-70 points).Current exercise intervention was feasible. However, we found no clinically relevant changes in self-reported hip-related pain or anterior pelvic tilt. Post hoc responder analysis revealed that patients with moderate pain at baseline might benefit from this exercise.

Background A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. Objectives We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. Global summit The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. Systematic review of the literature We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. Results We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. Conclusion Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

BackgroundPatients with symptomatic acetabular retroversion is reported having reduced functional ability and quality of life but little is known about the effect of non-surgical interventions.Purpose/Aim of StudyTo investigate feasibility and change in patient-reported symptoms of a home-based exercise intervention in patients with acetabular retroversion and excessive anterior pelvic tilt, in comparison with a prior control period.Materials and MethodsPatients with symptomatic acetabular retroversion and excessive anterior pelvic tilt were included. Following an 8-week control period, patients were instructed to follow an 8-week targeted (3 times/week) progressive home-based exercise intervention. Feasibility assessment included; dropout, acceptable adherence (≥75% of sessions), exercise-related pain, and adverse events. Primary outcome was change in the Copenhagen Hip and Groin Outcome Score (HAGOS) pain subscale. Secondary outcomes included change in remaining HAGOS subscales, EQ-5D-3L questionnaire, and pelvic tilt measured by EOS® scanning.Findings / ResultsForty-two patients (39 women) (median [interquartile range (IQR)], 20.5 [19 - 25 years]) were included. Three patients were lost to follow-up (one regretting participating during the control period, one during the intervention period and one patient was lost at follow-up). Adherence to exercise sessions was 85%. Exercise-related pain and adverse events were acceptable. Between-period mean change score for the HAGOS-PAIN subscale was 5.2 points (95% confidence interval [CI]:[-0.3 – 10.6] and -1.6 degree [-3.9 – 0.7]) of anterior pelvic tilt. Additionally, patients who responded positively (≥ minimal clinically important difference) to the exercise intervention (n = 10, 26%), all had a pre-exercise HAGOS-PAIN score between 47.5 to 70 points.ConclusionsCurrent exercise intervention was feasible. However, no clinical relevant changes in self-reported hip-related pain, function, quality of life, nor anterior pelvic tilt were found. Post-hoc responder analysis revealed that patients with moderate pain at baseline might benefit from current exercise.

ObjectiveTo estimate knee osteoarthritis (OA) risk following anterior cruciate ligament (ACL), meniscus or combined ACL and meniscus injury.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, Embase, SPORTDiscus, CINAHL and Web of Science until November 2018.Eligibility criteria for selecting studiesProspective or retrospective studies with at least 2-year follow-up including adults with ACL injury, meniscal injury or combined injuries. Knee OA was defined by radiographs or clinical diagnosis and compared with the contralateral knee or non-injured controls.Study appraisal and synthesisRisk of bias was assessed using the SIGN50 checklist. ORs for developing knee OA were estimated using random effects meta-analysis.Results53 studies totalling ∼1 million participants were included: 185 219 participants with ACL injury, mean age 28 years, 35% females, 98% surgically reconstructed; 83 267 participants with meniscal injury, mean age 38 years, 36% females, 22% confirmed meniscectomy and 73% unknown; 725 362 participants with combined injury, mean age 31 years, 26% females, 80% treated surgically. The OR of developing knee OA were 4.2 (95% CI 2.2 to 8.0; I2=92%), 6.3 (95% CI 3.8 to 10.5; I2=95%) and 6.4 (95% CI 4.9 to 8.3; I2=62%) for patients with ACL injury, meniscal injury and combined injuries, respectively.ConclusionThe odds of developing knee OA following ACL injury are approximately four times higher compared with a non-injured knee. A meniscal injury and a combined injury affecting both the ACL and meniscus are associated with six times higher odds compared with a non-injured knee. Large inconsistency (eg, study design, follow-up period and comparator) and few high-quality studies suggest that future studies may change these estimates.Clinical relevancePatients sustaining a major knee injury have a substantially increased risk of developing knee OA, highlighting the importance of knee injury prevention programmes and secondary prevention strategies to prevent or delay knee OA development.PROSPERO registration number CRD42015016900

INTRODUCTION: Acetabular retroversion (AR) is a variant of hip dysplasia,1 enhancing the risk of pincer-morphology femoroacetabular impingement syndrome (FAIS).2 FAIS is associated with pain,3 reduced level of function,4 decreased health-related quality of life,5 and early development of hip osteoarthritis (OA).6, 7 Symptoms may be exacerbated by anterior pelvic tilt (APT)8 as it functionally increases anterosuperior femoral head cover.1, 9, 10 Currently, the standard treatment for symptomatic AR is an invasive anteverting periacetabular osteotomy.11 Exercise aiming at reducing APT may be a less-invasive alternative treatment strategy. However, the impact of a targeted exercise intervention in patients with symptomatic AR, and excessive APT is unknown. RESEARCH QUESTION: What is the change in patient-reported symptoms and pelvic tilt in patients with AR and excessive APT of an 8-week targeted progressive home-based exercise intervention compared with a prior control period?METHODS: The sample size was n=36 patients (age 18-40 years) not eligible for surgery, with radiographic signs of AR on an anterior/posterior radiograph in standing position. Patients were recruited from Odense University Hospital outpatient clinic (Denmark) from November 2018 to December 2019. Exclusion criteria were; pelvic-tilt-ratio greater than 0.512 (the height of the obturator foramen divided by the height of the lesser pelvis) indicating posterior pelvic tilt, radiographic sign of hip OA, related surgery, and a body mass index (BMI) above 35. The intervention consisted of education, activity modification, stretching for posterior pelvic tilt mobility, strengthening muscles for tilting the pelvis posteriorly, improving body core stability, and pelvic movement control three times per week. The primary outcome was change in the Copenhagen Hip and Groin Outcome Score (HAGOS) pain subscale. Secondary outcomes included change in pelvic tilt in standing position measured by EOS® scanning, as the angle between a horizontal line and a line connecting the upper border of the symphysis with the sacral promontory.13RESULTS: Forty-two patients (39 women) (median [interquartile range], 20.5 [19 – 25 years] were included. Three patients were lost to follow-up. Between-period mean change scores were 5.2 points (95% confidence interval [CI]: [-0.3 – 10.6]), for the HAGOS-PAIN subscale and -1.6 degrees [-3.9 – 0.7] of anterior pelvic tilt. DISCUSSION: No statistical or clinically relevant changes in self-reported hip-related pain and APT were found. However, post-hoc responder analysis revealed that patients with moderate pain at baseline benefited from exercise. Patients had an excessive APT of 74° ±8 (mean ±SD) at baseline, which is 14° more than the defined neutral pelvic tilt.13 The current study is limited by a short and unsupervised training period, and measuring static pelvic tilt only. Future results from three-dimensional gait analysis will provide answers to whether patients' ability to dynamically tilt their pelvis posteriorly has changed.REFERENCES: 1. Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br. 1999;81(2):281-8.2. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-86.3. Langlais F, Lambotte JC, Lannou R, Gedouin JE, Belot N, Thomazeau H, et al. Hip pain from impingement and dysplasia in patients aged 20-50 years. Workup and role for reconstruction. Joint Bone Spine. 2006;73(6):614-23.4. Rylander JH, Shu B, Andriacchi TP, Safran MR. Preoperative and postoperative sagittal plane hip kinematics in patients with femoroacetabular impingement during level walking. Am J Sports Med. 2011;39 Suppl:36S-42S.5. Clohisy JC, Baca G, Beaule PE, Kim YJ, Larson CM, Millis MB, et al. Descriptive epidemiology of femoroacetabular impingement: a North American cohort of patients undergoing surgery. Am J Sports Med. 2013;41(6):1348-56.6. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003(417):112-20.7. Giori NJ, Trousdale RT. Acetabular retroversion is associated with osteoarthritis of the hip. Clin Orthop Relat Res. 2003(417):263-9.8. Riviere C, Hardijzer A, Lazennec JY, Beaule P, Muirhead-Allwood S, Cobb J. Spine-hip relations add understandings to the pathophysiology of femoro-acetabular impingement: A systematic review. Orthop Traumatol Surg Res. 2017;103(4):549-57.9. Dandachli W, Ul Islam S, Richards R, Hall-Craggs M, Witt J. The influence of pelvic tilt on acetabular orientation and cover: a three-dimensional computerised tomography analysis. Hip Int. 2013;23(1):87-92.10. Ross JR, Nepple JJ, Philippon MJ, Kelly BT, Larson CM, Bedi A. Effect of Changes in Pelvic Tilt on Range of Motion to Impingement and Radiographic Parameters of Acetabular Morphologic Characteristics. Am J Sports Med. 2014.11. Siebenrock KA, Schaller C, Tannast M, Keel M, Buchler L. Anteverting periacetabular osteotomy for symptomatic acetabular retroversion: results at ten years. J Bone Joint Surg Am. 2014;96(21):1785-92.12. Schwarz T, Benditz A, Springorum HR, Matussek J, Heers G, Weber M, et al. Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios. Arch Orthop Trauma Surg. 2018.13. Tannast M, Murphy SB, Langlotz F, Anderson SE, Siebenrock KA. Estimation of pelvic tilt on anteroposterior X-rays--a comparison of six parameters. Skeletal Radiol. 2006;35(3):149-55.

BACKGROUND: Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately.OBJECTIVE: To describe pain location and pain distribution in primary care patients with clinical and radiographic confirmed hip OA.METHODS: Primary care patients with unilateral clinical and radiographic hip OA living on the island of Funen, Denmark were recruited from primary care to participate in a randomized clinical trial. At baseline, patients recorded pain intensity using an 11-box numeric rating scale and the distribution of hip pain using a manikin displaying three separate views: front, back and lateral. Pain drawings were analysed using a template to determine the most frequent pain locations and distribution of pain.RESULTS: Pain drawings were completed by 109 patients of which 108 (99%) were valid. The mean age of patients was 65 (SD 9) years and 44% were females. The mean pain intensity was 5.4 (SD 2.0). A total of 77% had marked the greater trochanter area, 53% the groin area, 42% the anterior/lateral thigh area, 38% the buttock area, 17% the knee and 15% the lower leg area. No patients marked pain exclusively in the areas of the knee, posterior thigh or lower leg.CONCLUSION: The most common pain locations of patients with hip OA presenting to primary care are the greater trochanter, groin, thigh and buttock areas. No patients recorded pain exclusively in the knee or lower leg.

s / Osteoarthritis and Cartilage 24 (2016) S63eS534 S495 therapy, chiropractic, and CAM are becoming more common among younger generations. 852 END-FEEL ASSESSMENT OF HIP JOINT DYSFUNCTION AND PAIN AT FULL RANGE OF MOTION IN PATIENTS WITH HIP OSTEOARTHRITISeA RELIABILITY STUDY E. Poulsen y, S. Overgaard zy, H.W. Christensen x, J. Hartvigsen yx. yUniv. of Southern Denmark, Odense, Denmark; zOdense Univ. Hosp., Odense, Denmark; xNordic Inst. of Chiropractic and Clinical Biomechanics

Objective The purposes of this study were to measure the prevalence of clinical and radiographic hip osteoarthritis (OA) and first-time diagnosis of hip OA in consecutive patients presenting to chiropractic practices in Denmark and to report the components of the initial treatment rendered by the chiropractic practitioner. Methods A total of 2000 patient records and 1000 radiographs were reviewed retrospectively in 20 chiropractic clinics throughout Denmark. Information obtained included patients' primary complaint, physical examination and radiographic findings of hip OA, and treatment. Subsequently, the 20 clinics participated in a prospective survey where they collected equivalent information over a 2-week period. Results Retrospective review of records revealed that 1.4% of patients in Danish chiropractic practice had signs of clinical hip OA. Of these, 59% demonstrated radiographic signs of hip OA. Prospective data collection revealed that 3.4% of new patients had signs of clinical hip OA. Fifty-four percent of these demonstrated radiographic signs of hip OA, and of these 70% were diagnosed as having OA of the hip for the first time. Initial treatment involved manual treatment and advice on over-the-counter pain medication and/or supplements. Of all 1000 retrospectively reviewed radiographs in patients 40 years or older, 19.2% demonstrated radiographic signs of hip OA. Conclusion Osteoarthritis of the hip is diagnosed and managed in primary care chiropractic practice in Denmark; however, it is likely underdiagnosed. In those newly presenting to chiropractic practitioners, first-time diagnosis with clinical and radiographic signs of hip OA appears to be common.

Medical device companies report the performance of their products through actuarial survival curves. Analyses are based on “passive” databases. For pacemakers, a significant number of explanted devices may not be reported to manufacturers. Thus, expiant information is lost. High rates of underreporting of failures could result. Therefore, performance curves could indicate better survival rates than those that are actually occurring. Samples of closely-followed patients called active samples are used to adjust survival curves for underreported failures. Through simulations, this paper shows a need for a larger sample size for active components and what degree of underreporting failures would be necessary to assure better estimates using adjustments rather than estimates that ignore adjustments. The issues in this paper have a much broader context as pharmaceutical companies increasingly rely on medical devices to monitor patients ’ health or deliver drugs. This can also apply to survival cunes for adverse events in Phase 4 clinical trials.

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Background Assessment of range of motion (ROM) and muscle strength is fundamental in the clinical diagnosis of hip osteoarthritis (OA) but reproducibility of these measurements has mostly involved clinicians from secondary care and has rarely reported agreement parameters. Therefore, the primary objective of the study was to determine the inter-rater reproducibility of ROM and muscle strength measurements. Furthermore, the reliability of the overall assessment of clinical hip OA was evaluated. Reporting is in accordance with proposed guidelines for the reporting of reliability and agreement studies (GRRAS). Methods In a university hospital, four blinded raters independently examined patients with unilateral hip OA; two hospital orthopaedists independently examined 48 (24 men) patients and two primary care chiropractors examined 61 patients (29 men). ROM was measured in degrees (deg.) with a standard two-arm goniometer and muscle strength in Newton (N) using a hand-held dynamometer. Reproducibility is reported as agreement and reliability between paired raters of the same profession. Agreement is reported as limits of agreement (LoA) and reliability is reported with intraclass correlation coefficients (ICC). Reliability of the overall assessment of clinical OA is reported as weighted kappa. Results Between orthopaedists, agreement for ROM ranged from LoA [-28–12 deg.] for internal rotation to [-8–13 deg.] for extension. ICC ranged between 0.53 and 0.73, highest for flexion. For muscle strength between orthopaedists, LoA ranged from [-65–47N] for external rotation to [-10 –59N] for flexion. ICC ranged between 0.52 and 0.85, highest for abduction. Between chiropractors, agreement for ROM ranged from LoA [-25–30 deg.] for internal rotation to [-13–21 deg.] for flexion. ICC ranged between 0.14 and 0.79, highest for flexion. For muscle strength between chiropractors, LoA ranged between [-80–20N] for external rotation to [-146–55N] for abduction. ICC ranged between 0.38 and 0.81, highest for flexion. Weighted kappa for the overall assessment of clinical hip OA was 0.52 between orthopaedists and 0.65 between chiropractors. Conclusions Reproducibility of goniometric and dynamometric measurements of ROM and muscle strength in patients with hip OA is poor between experienced orthopaedists and between experienced chiropractors. Orthopaedists and chiropractors can to a moderate degree differentiate between hips with or without osteoarthritis.

Background The biomechanical relationship between the hip and low back is well described and impairment of hip range of motion is thought to affect lumbar spine function, possibly leading to increased loading and subsequent symptoms. However therapy for low back pain (LBP) patients is commonly directed solely to the low back area overlooking possible hip impairment. Case description A 56-year-old male recreational golfer presented with a chronic golf-related low back complaint. Previous conservative therapy targeting the spine did not result in complete symptom relief. A working diagnosis of L4–S1 facet joint irritation and lower lumbar segmental instability secondary to bilateral hip ROM impairment was established. A trial of therapy strictly addressing the hip ROM impairments was initiated and following 2 treatment sessions, a complete resolution of symptoms was achieved and maintained at a 2-month follow-up. Discussion This case demonstrated a complete and rapid relief of un-resolving low back pain with a management strategy focused on hip ROM impairments. Clinicians should remember to look beyond the local area of complaint and appreciate the interdependent nature of the musculoskeletal system.

Background Hip osteoarthritis is a common and chronic condition resulting in pain, functional disability and reduced quality of life. In the early stages of the disease, a combination of non-pharmacological and pharmacological treatment is recommended. There is evidence from several trials that exercise therapy is effective. In addition, single trials suggest that patient education in the form of a hip school is a promising intervention and that manual therapy is superior to exercise. Methods/Design This is a randomized clinical trial. Patients with clinical and radiological hip osteoarthritis, 40-80 years of age, and without indication for hip surgery were randomized into 3 groups. The active intervention groups A and B received six weeks of hip school, taught by a physiotherapist, for a total of 5 sessions. In addition, group B received manual therapy consisting of joint manipulation and soft-tissue therapy twice a week for six weeks. Group C received a self-care information leaflet containing advice on "live as usual" and stretching exercises from the hip school. The primary time point for assessing relative effectiveness is at the end of the six weeks intervention period with follow-ups after three and 12 months. Primary outcome measure is pain measured on an eleven-point numeric rating scale. Secondary outcome measures are the hip dysfunction and osteoarthritis outcome score, patient's global perceived effect, patient specific functional scale, general quality of life and hip range of motion. Discussion To our knowledge this is the first randomized clinical trial comparing a patient education program with or without the addition of manual therapy to a minimal intervention for patients with hip osteoarthritis. Trial registration ClinicalTrials NCT01039337

The project aimed at describing and analysing word processing integrated into the students' writing of school compositions using a process-oriented approach in the teaching of English at intermediate level in the classroom. The project may be characterised as an exploratory, qualitatively-oriented study with a pyramid-structured design in which various layers of information are collected. Initial analysis of 3 years of data has started and some preliminary conclusions have been arrived at. In general, the students did little planning and frequently changed from one process level to another. Formulation was done at clause, phrase or word level if possible, or a switch into Danish took place and reversion to English did not occur until the formulation had been agreed. The spell checker trapped about 80% of spelling mistakes but students did not always use the correct form suggested, and if a correct solution was not offered, students rarely tried to solve the problem in other ways. In an examination, the spell checker would have been able to trap about half of the errors, but no reliable generalisations can be made at this stage.

A safe technique useful in the preparation of spores, pollen, dinoflagellate cysts, acritarchs and other acid-insoluble microfossils is described. The technique utilizes a macerationtank for hydrofluoric acid treatment of palynological samples. The hydrofluoric acid is conducted to and from the macerationtank along tubing. Tests of the method are discussed and the macerationtank is described. Some techniques in subsequent preparation are mentioned. These include heavy-liquid separation, oxidation, ethanol water separation (modified), swirling (modified), ultrasonic treatment, filtration.

Our objective was to evaluate the effects of darbepoetin alfa (Aranesp) on hemoglobin and transfusions in anemic patients with cancer undergoing chemotherapy, and the impact of age, sex, baseline hemoglobin, chemotherapy type, and tumor type. Patients were randomized to one of three darbepoetin alfa groups based on average weekly dose (1.5 microg/kg, 1.5 to 2.25 microg/kg, and2.25 microg/kg) or to placebo. Dose response was evaluated for change in hemoglobin, hemoglobin and hematopoietic responses, and red blood cell transfusion rates. Hazard ratios for the incidence of hemoglobin response and transfusions were calculated. Adverse events and antibody formation were assessed. Treatment effects were observedfor all hemoglobin end points and incidence of transfusion. The incidence of hematopoietic response among the darbepoetin alfa dose groups ranged from 46% (95% confidence interval [CI] = 33%-60%) to 74% (95% CI = 66%-81%) and increased with higher darbepoetin alfa dose. Patients receiving darbepoetin alfa were more likely to exhibit a hemoglobin response and less likely to require a transfusion, compared with placebo, irrespective of the patient characteristics examined. No increased risk of adverse events and no development of neutralizing antibodies were observed with darbepoetin alfa use. Darbepoetin alfa increased the likelihood of a hemoglobin response and decreased the need for transfusions in cancer patients with chemotherapy-induced anemia.

Accumulation rates of cadmium, the amount of food ingested and assimilated, the amount of oxygen consumed and changes in dry flesh weight have been measured in Mytilus edulis L. exposed to 0, 10 and 100 ppb cadmium for 17 d in aquaria with seawater flowing continously and at constant algal concentration. The accumulation rates were linear at 10 and 100 ppb, amounting to 0.58 and 8.89 ppm d-1, respectively. Body loads up to 150 ppm caused no effects on either clearance, ingestion, assimilation, respiration, or growth. High net growth efficiencies between 55–59% were obtained, indicating near optimal experimental conditions. It is suggested that the setup and experimental procedure provide an excellent tool in the study of accumulation and sublethal effects of environmental pollutants in suspension feeding bivalves.

Summary Objective To investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI). Methods In a single-center university hospital setting, a total of 118 patients with clinical and radiographic unilateral hip osteoarthritis (OA) from primary care were randomized into one of three groups: PE, PE plus MT or MCI. The PE was taught by a physiotherapist involving five sessions. The MT was delivered by a chiropractor involving 12 sessions and the MCI included a home stretching program. Primary outcome was self-reported pain severity on an 11-box numeric rating scale (NRS) immediately following a 6-week intervention period. Patients were followed for 1 year. Results Primary analysis included 111 patients (94%). In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points (95% confidence interval (CI) 0.9–2.9) was achieved. Effect size (Cohen's d) for the PE + MT minus the MCI was 0.92 (95% CI 0.41–1.42). Number needed to treat for PE + MT was 3 (95% CI 2–7). No difference was found between the PE and MCI groups, with mean difference 0.0 (95% CI −1.0 to 1.0). At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained. Conclusions For primary care patients with OA of the hip, a combined intervention of MT and PE was more effective than a MCI. PE alone was not superior to the MCI. Trial registration clinicaltrials.gov NCT01039337.

Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis 'musculoskeletal chest pain' in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.