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Study Design Randomized controlled trial. Background Low back pain is a common disorder. Patients with low back pain frequently have aberrant and pain-provocative movement patterns that often are addressed with motor control exercises. Objective To compare the effects of low-load motor control (LMC) exercise and those of a high-load lifting (HLL) exercise. Methods Seventy participants with recurrent low back pain, who were diagnosed with nociceptive mechanical pain as their dominating pain pattern, were randomized to either LMC or HLL exercise treatments. Participants were offered 12 treatment sessions over an 8-week period. All participants were also provided with education regarding pain mechanisms. Methods Participants were assessed prior to and following treatment. The primary outcome measures were activity (the Patient-Specific Functional Scale) and average pain intensity over the last 7 days (visual analog scale). The secondary outcome measure was a physical performance test battery that included 1 strength, 3 endurance, and 7 movement control tests for the lumbopelvic region. Results Both interventions resulted in significant within-group improvements in pain intensity, strength, and endurance. The LMC group showed significantly greater improvement on the Patient-Specific Functional Scale (4.2 points) compared with the HLL group (2.5 points) (P<.001). There were no significant between-group differences in pain intensity (P = .505), strength, and 1 of the 3 endurance tests. However, the LMC group showed an increase (from 2.9 to 5.9) on the movement control test subscale, whereas the HLL group showed no change (from 3.9 to 3.1) (P<.001). Conclusion An LMC intervention may result in superior outcomes in activity, movement control, and muscle endurance compared to an HLL intervention, but not in pain intensity, strength, or endurance.

Study design: Inter-rater reliability study. Background: Physiotherapists (PTs) use clinical tests including movement tests to identify faulty movement patterns. Aims: To investigate the inter-rater-reliability of active movement tests in the cervical spine, shoulder joint and scapulo-thoracic joint, and to describe the reasons for judgment of a positive test. Methodology: Four PTs, two experienced and two recently educated (novice), rated performance of five movement tests for 36 participants. Twenty-one of the participants were patients under treatment because of neck and/or shoulder problems, while 15 participants declared no problem from this region of the body. All tests were video recorded and the ratings were done by observing the video recordings. First, the PTs judged the tests as negative (the movement being ideally performed) or positive (the movement not being ideally performed). Then, the PTs described why the movements that they judged positive were not being ideally performed, using a predefined protocol, which represented different movement quality aspects. The inter-rater reliability was calculated for each test using Kappa statistics between the two experienced and the two novice PTs, respectively, and between each of the experienced and each of the novice PTs. Major findings: The experienced PTs had a higher inter-rater reliability than the novice PTs. The reasons for considering a movement test being positive differed highly between the (novice) PTs. Principal conclusion: This study supports previous studies concluding that the observation of active movement tests is reliable when assessed by experienced PTs. Novice PTs might benefit from further supervision.

Background: The main aim was to examine whether patients with persistent upper quadrant pain have higher end-point variability in goal directed pointing movements than pain-free controls when the pointing task is performed in total darkness and under full vision. An additional aim was to study associations between the magnitude of end-point variability and a clinical movement control test battery and self-rated functioning among patients.

Methods: Seventeen patients and 17 age- and gender-matched pain-free controls performed a pointing task that evaluated end-point variability of repetitive shoulder movements in horizontal adduction and abduction with full vision, and abduction with no visual information, completed a movement control test battery of neck and shoulder control tests and answered questionnaires.

Results: Patients had higher end point variability for horizontal abduction when performed with no visual information. For horizontal adduction the variability was higher, but only when it was controlled for movement time. No significant correlations were found between end-point variability and self-rated functioning, nor between end-point variability and neuromuscular control of the glenohumeral joint.

Conclusions: This study provides preliminary evidence that patients with persistent neck/shoulder pain can partly compensate proprioceptive deficits in goal-directed arm movement when visual feedback is present.

Bisphosphonates (BPs) are commonly used drugs in clinical practice. In this pilot study, we investigated whether bisphosphonate-related atypical femoral fractures (AFF) and osteonecrosis of the jaw (ONJ) occurred simultaneously in the same group of patients. Six ONJ patients were examined by an orthopedic surgeon and 5 AFF patients were examined by a dentist to look for manifestations of simultaneous occurrence of AFF in ONJ patients and vice versa. The required radiological investigations and previous medical and dental records were available. No simultaneous occurrence of AFF and ONJ was found in the examined patients. In this pilot study with limited sample size, no manifestations of simultaneous occurrence of AFF and ONJ were found. This could be an indication that these complications have different pathophysiologies and affect different subgroups of patients on long-term BP treatment.

Background: In situ fusion as salvage operation after calcaneal fractures has been used. In this retrospective investigation, a group of in situ fused patients is analyzed with long-term follow-up.

Methods: Twenty-nine patients with in situ single or multiple fusions performed between 1970 and 1990 were included. In 1998 these patients were examined with plain radiographs and computerized tomography (CT) scan of the affected foot. Also, a visual analogue score (VAS) for calcaneal fractures, short form health survey (SF-36), Olerud Molander score and American Orthopaedic Foot and Ankle society (AOFAS) hindfoot score were evaluated.

Results: The plain radiographs and CT scan showed severe remaining deformities in these patients. The outcome parameters were generally poor and correlated to the degree of remaining deformity.

Conclusions: Simple in situ fusion, without consideration of the deformity at hand, after a calcaneal fracture is not an adequate treatment and generally associated with poor outcome. (C) 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Purpose: The AOSpine classification divides thoracolumbar burst fractures into A3 and A4 fractures; nevertheless, past research has found inconsistent interobserver reliability in detecting those two fracture patterns. This systematic analysis aims to synthesize data on the reliability of discriminating between A3 and A4 fractures.

Methods: We searched PubMed, Scopus, and the Web of Science for studies reporting the inter- and intra-observer reliability of detecting thoracolumbar AO A3 and A4 fractures using computed tomography (CT). The search spanned 2013 to 2023 and included both primarily reliability and observational comparative studies. We followed the PRISMA guidelines and used the modified COSMIN checklist to assess the studies' quality. Kappa coefficient (k) values were categorized according to Landis and Koch, from slight to excellent.

Results: Of the 396 identified studies, nine met the eligibility criteria; all were primarily reliability studies except one observational study. Interobserver k values for A3/A4 fractures varied widely among studies (0.19-86). The interobserver reliability was poor in two studies, fair in one study, moderate in four studies, and excellent in two studies. Only two studies reported intra-observer reliability, showing fair and excellent agreement. The included studies revealed significant heterogeneity in study design, sample size, and interpretation methods.

Conclusion: Considerable variability exists in interobserver reliability for distinguishing A3 and A4 fractures from slight to excellent agreement. This variability might be attributed to methodological heterogeneity among studies, limitations of reliability analysis, or diagnostic pitfalls in differentiating between A3 and A4. Most observational studies comparing the outcome of A3 and A4 fractures do not report interobserver agreement, and this should be considered when interpreting their results.

Background: In obese patients, total hip arthroplasty (THA) can be technically demanding with increased perioperative risks. The aim of this prospective cohort study is to evaluate the effect of body mass index (BMI) on radiological restoration of femoral offset (FO) and leg length as well as acetabular cup positioning.

Methods: In this prospective study, patients with unilateral primary osteoarthritis (OA) treated with THA between September 2010 and December 2013 were considered for inclusion. The perioperative plain radiographs were standardised and used to measure the preoperative degree of hip osteoarthritis, postoperative FO, leg length discrepancy (LLD), acetabular component inclination and anteversion.

Results: We included 213 patients (74.5% of those considered for inclusion) with a mean BMI of 27.7 (SD 4.5) in the final analysis. The postoperative FO was improper in 55% and the LLD in 15%, while the cup inclination and anteversion were improper in 13 and 23% of patients respectively. A multivariable logistic regression model identified BMI as the only factor that affected LLD. Increased BMI increased the risk of LLD (OR 1.14, 95% CI 1.04 to 1.25). No other factors included in the model affected any of the primary or secondary outcomes.

Conclusion: Increased BMI showed a negative effect on restoration of post-THA leg length but not on restoration of FO or positioning of the acetabular cup. Age, gender, OA duration or radiological severity and surgeon’s experience showed no relation to post-THA restoration of FO, leg length or cup positioning.

Objective: The aim of this study was to assess the incidence and severity of kinesiophobia, and to determine the relationship between Tampa Scale of Kinesiophobia (TSK) scores, functional outcome and quality of life (QoL) 6-8 years after Total Hip Arthroplasty (THA).

Methods: 161 patients (78 male and 83 female) with unilateral primary osteoarthritis (OA) treated with THA between September 2010 and December 2013 were included in this study. Western Ontario and McMaster Universities Osteoarthritis (WOMAC) and EQ-5D scores were measured preoperatively. At 6-8 years follow-up, these scores were repeated and TSK scores were also measured. According to the TSK, patients were divided into two groups for further comparisons and analysis: without kinesiophobia (TSK-score ≤ 36) and with kinesiophobia (TSK-score >36).

Results: There were 99 patients (61.5%) with no kinesiophobia (TSK score ≤ 36, TSK mean 28.4, SD 4.7) and 62 patients (38.5%) with kinesiophobia (TSK score > 36, TSK mean 42.8, SD 5.3). Patients with and without kinesiophobia were not statistically different regarding age, sex or body mass index. (P = 0.20, P = 0.99, P = 0.22, respectively). In the group with no kinesiophobia, the mean 6-8 years WOMAC was 12.4 (SD 15.6), while the absolute delta (Δ) value between preoperative and 6-8 years WOMAC was 46.2 (SD 20.4), compared to the group with kinesiophobia where the mean 6-8 years WOMAC was 32.2 (SD 23.4), while the absolute delta (Δ) value between preoperative and 6-8 years WOMAC was 32.3 (SD 25.5): both P < 0.001. The group with no kinesiophobia had a mean 6-8 years EQ-5D of 0.81 (SD 0.22), while the absolute delta (Δ) value between preoperative and 6-8 years EQ-5D was 0.44 (SD 0.26), compared to the group with kinesiopho-bia where the mean 6-8 years EQ-5D was 0.57 (SD 0.23), while the absolute delta (Δ) value between preoperative and 6-8 years EQ-5D was 0.33 (SD 0.26): P < 0.001 and P = 0.03, respectively. TSK scores were associated with worse WOMAC and EQ-5D scores, higher proportion of dependence on walking aids and increased THArelated adverse events (all P < 0.05).

Conclusion: This study has shown us that there is a high incidence of kinesiophobia 6-8 years after surgery and treating kinesiophobia early after THA might improve the outcome.

Level of Evidence: Level IV, Therapeutic Study.

Background and purpose: Patients with focal cartilage lesions experience functional impairment. Results for biological treatments in the middle-aged patient is poor. Previous studies with focal prosthetic inlay resurfacing have shown a higher risk of conversion to total knee replacement at mid-term follow-up. A novel customized implant (Episealer, Episurf, Stockholm, Sweden) has been proposed to improve implant positioning and survival. The primary objective was to assess subjective-, objective function and implant survival at a minimum of five years after surgery.

Materials and methods: The inclusion criteria were patients aged 30–65 years with symptomatic focal chondral defects in the medial femoral condyle, International Cartilage Research Society grade 3 or 4 and failed conservative or surgical treatment. Minimum follow-up of 5 years. Clinical and radiologic assessments were made. Patient-reported outcome measurements at the latest follow-up were compared with the baseline data for the Knee injury and Osteoarthritis Outcome Score (KOOS), the EuroQoL (EQ-5D), the Tegner Activity Scale and a Visual Analog Scale of pain (VAS 0–10).

Results: Ten patients with the mean follow-up period of 75 months (60–86 months, SD 10) were included. Signs of osteoarthritis were seen in one patient (Ahlbäck 1). No cases with revision to knee replacement. VAS for pain and KOOS showed improvements that reached significance for VAS (p ≤ 0.001) and the KOOS subscores Pain (p = 0.01), ADL (p = 0.003), Sport and Recreation (p = 0.024) and Quality of Life (p = 0.003).

Conclusion: A good subjective outcome, a low risk of progression to degenerative changes and the need for subsequent surgery were seen at the mid-term follow-up with this customized focal knee-resurfacing implant.

Level of evidence: Prospective case series, level 4.

Aim: To evaluate the long-term clinical effectiveness of computed tomography (CT)-guided transforaminal cervical epidural steroid injection using an anterolateral approach for the treatment of cervical radiculopathy (CR) using well-established robust clinical scoring systems for neck pain and neck disability. Despite its widespread use, evidence to support the long-term benefit of routine cervical epidural steroid injection is currently very limited.

Materials and methods: This study included 113 patients with magnetic resonance imaging (MRI)-confirmed CR who underwent a steroid injection at a single cervical level via a unilateral transforaminal anterolateral approach. Pain was assessed quantitatively at pre-injection, 15 minutes post-injection, 1 month, 3 months, and at 1 year. Neck disability was assessed using the Oswestry Neck Disability Index (NDI) at pre-injection, 1 month, 3 months, and 1 year time points.

Results: Eighty patients completed the study. Sixty per cent reported reduced neck pain (mean pain reduction, 55%), which was clinically significant in 45% cases. Furthermore, 66% reported an improvement in neck disability (mean improvement, 51%), which was clinically significant for 56% patients. Clinically significant good outcomes in both neck pain and neck disability were evident from as early as 1-month, and importantly, were independent both of pre-treatment CR characteristics (including severity of pre-injection neck pain or disability) and of findings on pre-injection MRI imaging.

Conclusion: Transforaminal anterolateral approach CT-guided epidural steroid injection resulted in a clinically significant long-term improvement in both neck pain and disability for half of the present cohort of patients with unilateral single-level CR. This improvement was independent of the severity of the initial symptoms and pre-injection MRI findings.

Studies that objectively investigate patterns of everyday physical activity in relation to well-being and that use measures specific to older adults are scarce. This study aimed to explore objectively measured everyday physical activity and sedentary behavior in relation to a morale measure specifically constructed for older adults. A total of 77 persons (42 women, 35 men) aged 80 years or older (84.3 ± 3.8) wore an accelerometer device for at least 5 days. Morale was measured with the Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS scores were significantly positively associated with number of steps, time spent stepping, and time spent stepping at >75 steps per minute. Sedentary behavior did not associate with PGCMS. Promoting PA in the form of walking at any intensity–or even spending time in an upright position—and in any quantity may be important for morale, or vice versa, or the influence may be bidirectional.

Introduction: Self-rated health (SRH) offers insights into the evolving health demographics of an ageing population.

Aim: To assess change in SRH from old age to very old age and their associations with health and well-being factors, and to investigate the association between SRH and survival.

Methods: All participants in the MONICA 1999 re-examination born before 1940 (n = 1595) were included in the Silver-MONICA baseline cohort. The Silver-MONICA follow-up started in 2016 included participants in the Silver-MONICA baseline cohort aged 80 years or older. Data on SRH was available for 1561 participants at baseline with 446 of them also participating in the follow-up. The follow-up examination included a wide variety of measurements and tests.

Findings: Most participants rated their health as "Quite good" (54.5 %) at baseline. Over the study period, 42.6 % had stable SRH, 40.6 % had declined, and 16.8 % had improved. Changes in SRH were at follow-up significantly associated with age, pain, nutrition, cognition, walking aid use, self-paced gait speed, lower extremity strength, independence in activities of daily living, weekly physical exercise, outdoor activity, participation in organized activities, visiting others, morale, and depressive symptoms. SRH at baseline was significantly associated with survival (p < 0.05).

Conclusion: This study demonstrates associations between changes in SRH and a multitude of health- and wellbeing-related factors, as well as a relation between survival and SRH, accentuating their relevance within the ageing population.

Background and purpose: Roentgen stereometric analysis (RSA) cannot discern whether a single prosthesis is fixed or migrating below the detection level. Samples of patients usually show migration values that appear to be continuously distributed. Is there such continuity, or is there a dichotomy between stable and migrating prostheses? The hypothesis of a dichotomy has, to our knowledge, not been tested. We present an exploratory evaluation of such a dichotomy using a mixture distribution algorithm.

Methods: We analyzed the migration (as determined by RSA) of 147 cemented acetabular cups of 7 different designs by using a new set of algorithms for frequency distribution analysis called Rmix.

Results: We first analyzed a migration vector, regardless of direction. After 2 years there was a significant dichotomy between 2 lognormal subgroups within the sample. Although some types of cups were over‐represented in one of the subgroups, neither cup design, sex, nor operating department could explain the dichotomy into two groups, which appears to reflect the existence of two basically different types of behavior of the cups. We next analyzed the migration along the 3 axes in space, and found a similar dichotomy. During the second year, around 80% of the patients belonged to a distinct, normally distributed subgroup with a mean not different from 0 mm and a small variation. The remainder differed significantly from this subgroup and showed migration.

Interpretation: There is a dichotomy in migration pattern. During the second postoperative year, most cups belonged to a subpopulation that appeared stable. The remainder is probably at risk of loosening. For a single type of prosthesis, the relative size of the stable subgroup may be a good index of the expected performance. The possibility of detecting subgroups within a seemingly continuous sample might be useful in many fields of medicine.

Introduction: Periprosthetic femoral fractures (PFFs) following hip arthroplasty, especially Vancouver B2 and B3 fractures, present a challenge due to the association with a loose femoral stem, necessitating either open reduction and internal fixation or stem revision. This study aims to compare outcomes between uncemented and cemented stem revisions in managing Vancouver B2 and B3 fractures, considering factors such as hip-related complications, reoperations, and clinical outcome.

Methods: A retrospective cohort study was conducted at Danderyd Hospital, Sweden, from 2008 to 2022, encompassing operatively treated Vancouver B2 and B3 fractures. Patients were categorized into uncemented and cemented stem revision groups, with data collected on complications, revision surgeries, fracture healing times, and clinical outcomes.

Results: A total of 241 patients were identified. Significant differences were observed between the two groups in patient demographics, with the cemented group comprising older patients and more females. Follow up ranged from 1 to 15 years. Average follow up time was 3.9 years for the cemented group and 5.5 years for the uncemented group. The cemented stems demonstrated lower rates of dislocation (8.9% versus 22.5%, P = 0.004) and stem loosening (0.6% versus 9.3%, P = 0.004) than the uncemented method. Moreover, the cemented group exhibited shorter fracture healing times (11.4 weeks versus 16.7 weeks, P = 0.034). There was no difference in clinical outcome between groups. Mortality was higher in the cemented group.

Conclusions: This retrospective study indicates that cemented stem revision for Vancouver B2–3 fractures is correlated with lower dislocation and stem loosening rates, necessitating fewer reoperations and shorter fracture healing times compared with the uncemented approach. The cemented group had a notably higher mortality rate, urging caution in its clinical interpretation. Level of evidence III

PURPOSE: Periacetabular bone loss poses a considerable challenge in the longevity and stability of acetabular implants used in total hip arthroplasty (THA). Innovations in implant design, specifically the introduction of three-dimensional (3D) porous titanium constructs, might reduce bone resorption. The purpose of this study was to build upon our previous randomized controlled trial, which found no change in periacetabular bone loss between a 3D porous none-hydroxyapatite coated titanium cup and a standard porous hydroxyapatite coated cup over a two year follow-up period by extending the follow-up duration to ten years post-surgery.

METHODS: This was a single-centre, long-term follow-up study conducted over a ten year period in patients who had previously participated in a randomized controlled trial comparing a 3D porous titanium construct shell (PTC group) with a standard porous hydroxyapatite coated titanium shell (PC-group). The primary outcome measured was the change in bone mineral density (BMD) within four specific periacetabular zones, alongside overall bone loss, which was assessed through BMD in the lumbar spine at two, six and ten years postoperatively. Secondary outcomes included clinical outcome measures.

RESULTS: In total, 18 in the PTC and 20 in the PC group were analysed for the primary endpoint up to ten years. The mean bone mineral density in zones 1-4 was 3.7% higher in the PTC group than in the PC group at six years postoperatively and 12.0% higher at ten years. Clinical outcomes, and the frequency of adverse events did not differ between the groups.

CONCLUSIONS: The PTC group displayed superior long-term bone preservation compared to the PC group while maintaining similar clinical outcomes up to ten years postoperatively. Although with a small sample size, our findings suggest that porous titanium cups have the potential to minimize BMD loss around the cup which could contribute to improving THA outcomes and implant durability.

Iron is an essential micronutrient for oxygen transport and mitochondrial metabolism and is critical for physical performance. Compromised iron stores are more commonly found among athletes, and females are especially at risk. Iron deficiency is generally treated using oral iron supplements. However, only a small proportion of ingested iron is absorbed, necessitating higher intakes, which may result in adverse side effects, reduced compliance, and inefficient repletion of iron stores. The probiotic strainLactobacillus plantarum299v (Lp299v) significantly increases intestinal iron absorption in meal studies. The present study was conducted to explore the effects of 20 mg of iron with or without Lp299v on iron status, mood state, and physical performance. Fifty-three healthy non-anemic female athletes with low iron stores (ferritin < 30 mu g/L) were randomized, and 39 completed the study. Intake of Lp299v with iron for four weeks increased ferritin levels more than iron alone (13.6 vs. 8.2 mu g/L), but the difference between the groups was not significant (p= 0.056). The mean reticulocyte hemoglobin content increased after intake of Lp299v compared to control (1.5 vs. 0.82 pg) after 12 weeks, but the difference between the group was not significant (p= 0.083). The Profile of Mood States (POMS) questionnaire showed increased vigor with Lp299v vs. iron alone after 12 weeks (3.5 vs. 0.1,p= 0.015). No conclusive effects on physical performance were observed. In conclusion, Lp299v, together with 20 mg of iron, could result in a more substantial and rapid improvement in iron status and improved vigor compared to 20 mg of iron alone. A larger clinical trial is needed to further explore these findings as well as the impact of Lp299v on physical performance.

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies.

METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus.

RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains.

CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

Introduction: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements.

Methods: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51–74% agreement; strong consensus, 75–99% agreement; unanimous, 100% agreement.

Results: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus.

Conclusion: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. Level of evidence: Level V.

Prevention of hip fractures is of critical public health importance. In a cohort of adults from eight European countries, evidence was found that increased adherence to Mediterranean diet, measured by a 10-unit dietary score, is associated with reduced hip fracture incidence, particularly among men. INTRODUCTION: Evidence on the role of dietary patterns on hip fracture incidence is scarce. We explored the association of adherence to Mediterranean diet (MD) with hip fracture incidence in a cohort from eight European countries. METHODS: A total of 188,795 eligible participants (48,814 men and 139,981 women) in the European Prospective Investigation into Cancer and nutrition study with mean age 48.6 years (±10.8) were followed for a median of 9 years, and 802 incident hip fractures were recorded. Diet was assessed at baseline through validated dietary instruments. Adherence to MD was evaluated by a MD score (MDs), on a 10-point scale, in which monounsaturated were substituted with unsaturated lipids. Association with hip fracture incidence was assessed through Cox regression with adjustment for potential confounders. RESULTS: Increased adherence to MD was associated with a 7 % decrease in hip fracture incidence [hazard ratio (HR) per 1-unit increase in the MDs 0.93; 95 % confidence interval (95 % CI) = 0.89-0.98]. This association was more evident among men and somewhat stronger among older individuals. Using increments close to one standard deviation of daily intake, in the overall sample, high vegetable (HR = 0.86; 95 % CI = 0.79-0.94) and high fruit (HR = 0.89; 95 % CI = 0.82-0.97) intake was associated with decreased hip fracture incidence, whereas high meat intake (HR = 1.18; 95 % CI = 1.06-1.31) with increased incidence. Excessive ethanol consumption (HR high versus moderate = 1.74; 95 % CI = 1.32-2.31) was also a risk factor. CONCLUSIONS: In a prospective study of adults, increased adherence to MD appears to protect against hip fracture occurrence, particularly among men.

This study aimed to investigate the prevalence of having plans for the future among very old people and the factors associated with having such plans. A longitudinal population-based study with home visits for 85-, 90-, and ≥95-year-old participants in Sweden and Finland was used. Multivariate logistic regression and Cox proportional-hazards regression models with a maximum 5-year follow-up period were used. The prevalence of having plans for the future was 18.6% (174/936). More men than women and more people living in Sweden than in Finland had plans for the future. In multivariate models, having plans for the future was associated with speaking Swedish, being dentate, and living in the community in the total sample; speaking Swedish and being dentate among women; and speaking Swedish, having a lower Geriatric Depression Scale score, and urban residence among men. Having plans for the future was associated univariately, but not multivariately, with increased survival.

Objective: This pre-planned secondary analysis of geriatric interdisciplinary home rehabilitation, which was initially found to shorten the postoperative length of stay in hospital for older individuals following hip fracture, investigated whether such rehabilitation reduced the numbers of complications, readmissions, and total days spent in hospital after discharge during a 12-month follow-up period compared with conventional geriatric care and rehabilitation.

Design: Randomized controlled trial.

Setting: Geriatric department, participants' residential care facilities, and ordinary housing.

Subjects: Individuals aged ⩾70 years with acute hip fracture (n = 205) were included.

Intervention: Geriatric interdisciplinary home rehabilitation was individually designed and aimed at early discharge with the intention to prevent, detect, and treat complications after discharge.

Main measures: Complications, readmissions, and days spent in hospital were registered from patients' digital records and interviews conducted during hospitalization and at 3- and 12-month follow-up visits.

Results: No significant difference in outcomes was observed. Between discharge and the 12-month follow-up, among participants in the geriatric interdisciplinary home rehabilitation group (n = 106) and control group (n = 93), 57 (53.8%) and 44 (47.3%) had complications (P = 0.443), 46 (43.4%) and 38 (40.9%) fell (P = 0.828), and 38 (35.8%) and 27 (29.0%) were readmitted to hospital (P = 0.383); the median total days spent in hospital were 11.5 and 11.0 (P = 0.353), respectively.

Conclusion: Geriatric interdisciplinary home rehabilitation for older individuals following hip fracture resulted in similar proportions of complications, readmissions, and total days spent in hospital after discharge compared with conventional geriatric care and rehabilitation.

A randomized, controlled fall-prevention study including 199 patients operated on for femoral neck fracture reduced inpatient falls and injuries. No statistically significant effects of the intervention program could be detected after discharge. It seems that fall-prevention must be part of everyday life in fall-prone old people. Introduction This study evaluates whether a postoperative multidisciplinary, multifactorial fall-prevention program performed by a geriatric team that reduced inpatient falls and injuries had any continuing effect after discharge. The intervention consisted of staff education, systematic assessment and treatment of fall risk factors and vitamin D and calcium supplementation. Methods The randomized, controlled trial with a one-year follow-up at Umea University Hospital, Sweden, included 199 patients operated on for femoral neck fracture, aged >= 70 years. Results After one year 44 participants had fallen 138 times in the intervention group compared with 55 participants and 191 falls in the control group. The crude postoperative fall incidence was 4.16/1,000 days in the intervention group vs. 6.43/1,000 days in the control group. The incidence rate ratio was 0.64 (95% CI: 0.40-1.02, p = 0.063). Seven new fractures occurred in the intervention group and 11 in the control group. Conclusion A team applying comprehensive geriatric assessment and rehabilitation, including prevention and treatment of fall-risk factors, reduced inpatient falls and injuries, but no statistically significant effects of the program could be detected after discharge. It seems that fall-prevention must be part of everyday life in fall-prone elderly.

Disability due to low back pain is common. While evidence exist that exercise is effective in reducing pain and disability, it is still largely undetermined which kind of exercises that are most effective. The overall aim of this thesis was to evaluate and compare the effects of a high-load lifting exercise and individualized low-load motor control exercises for patients with nociceptive mechanical low back pain. A secondary aim was to evaluate which patients benefit from training with a high-load lifting exercise.

All four papers in this thesis were based on a randomized controlled trial including 70 participants with nociceptive mechanical low back pain as their dominating pain pattern. Participants were randomized into training with either a high-load lifting exercise (HLL), the deadlift, (n=35) or individualized low-load motor control exercises (LMC) (n=35). Both interventions included aspects of pain education. All participants were offered twelve sessions during an eight week period. The effects of the interventions were evaluated directly after and twelve months after the end of the intervention period. Outcome measures were pain intensity, activity, disability, physical performance, lumbo-pelvic alignment and lumbar multifidus muscle thickness.

There was a significant between-group effect in favour of the LMC intervention regarding improvements in activity, movement control tests and some tests of trunk muscle endurance. For pain intensity there were no significant differences between groups. A majority of participants in both intervention groups showed clinically meaningful improvements from baseline to two and twelve month follow-up regarding pain intensity and activity. There were no significant differences between HLL and LMC regarding the effect on lumbo-pelvic alignment or lumbar multifidus thickness. The participants who benefit the most from the HLL intervention were those with a low pain intensity and high performance in the Biering-Sørensen test at baseline.

The results of this thesis showed that the HLL intervention was not more effective than the LMC intervention. The LMC was in fact more effective in improving activity, performance in movement control tests and some tests of trunk muscle endurance, compared to the HLL intervention.

The results imply that the deadlift, when combined with education, could be considered as an exercise to produce clinically relevant improvements on pain intensity in patients who prefer a high-load exercise. However, before considering deadlift training, the results suggest that pain intensity and performance in the Biering-Sørensen test should be evaluated.

Fysisk träning är viktigt för en god hälsa och fungerar även som behandlingsform vid många sjukdomar, så även ländryggsbesvär. Styrketräning har visat sig vara en mer effektiv träningsform än till exempel aerob träning vid behandling av långvariga ländryggsbesvär. I dagsläget finns det ingen konsensus kring vilket det mest effektiva styrketräningsupplägget kan vara. Den vanligaste designen av styrketräningsprogram vid ländryggsbesvär tycks vara ett upplägg med syftet att förbättra styrkan/uthålligheten av ryggsträckarmuskulaturen och därigenom uppnå smärtlindring och funktionsförbättring. I en studie från Umeå universitet och Luleå tekniska universitet har träning av marklyft för patienter med långvariga ländryggsbesvär utvärderats. Marklyftsträningen förväntades öka deltagarnas bålstyrka samtidigt som den fokuserade på förbättring av rörelsekontroll kring såväl höft som ländrygg. När den åtta veckor långa träningsperioden var slut, visade det sig att gruppen som tränat marklyft hade ökat sin bålstyrka, minskat smärta, ökat funktionsförmåga och hälsorelaterad livskvalitet i samma omfattning som gruppen som tränade individanpassad träning av rörelsekontroll. Men de hade inte förbättrats lika mycket gällande rörelsekontroll eller vardagsfunktion. Vidare forskning pågår vid Umeå universitet om skador i samband med tung styrketräning samt lyftteknikens betydelse för skador och besvär vid tung styrketräning.

Recent studies have indicated that the deadlift exercise may be effective in decreasing pain intensity and increasing activity for most, but not all, patients with a dominating mechanical low back pain pattern. This study aimed to evaluate which individual factors measured at baseline could predict activity, disability, and pain intensity in patients with mechanical low back pain after an 8-week training period involving the deadlift as a rehabilitative exercise. Thirty-five participants performed deadlift training under the supervision of a physical therapist with powerlifting experience. Measures of pain-related fear of movement, hip and trunk muscle endurance and lumbopelvic movement control were collected at baseline. Measures of activity, disability and pain intensity were collected at baseline and at follow-up. Linear regression analyses were used to create models to predict activity, disability and pain intensity at follow-up. Results showed that participants with less disability, less pain intensity and higher performance on the Biering-Sørensen test, which tests the endurance of hip and back extensor muscles, at baseline benefit from deadlift training. The Biering-Sørensen test was the strongest predictor since it was included in all predictive models. Pain intensity was the next best predictor as it was included in two predictive models. Thus, for strength and conditioning professionals who use the deadlift as a rehabilitative exercise for individuals with mechanical low back pain, it is important to ensure that clients have sufficient back extensor strength and endurance and a sufficiently low pain intensity level to benefit from training involving the deadlift exercise.

Study Design: Randomized controlled trial

Objective: The aim of this study was to compare the effects of low-load motor control exercises and a high-load lifting exercise on lumbar multifidus thickness among patients with nociceptive mechanical low back pain.

Summary of Background Data: There is evidence that patients with low back pain may have a decreased size of the lumbar multifidus muscles with an asymmetry between left/right sides in the lower back. It has also been shown that low-load motor control training can affect this asymmetry; essentially, it is effective in equalizing side differences in lumbar multifidus muscle size. It is, however, not known whether a high-load exercise has the same effect.

Methods: Sixty-five participants diagnosed with nociceptive mechanical low back pain were included and randomized into low-load motor control exercises or a high-load lifting exercise, the deadlift. The lumbar multifidus thickness at the fifth lumbar vertebra was measured, using rehabilitative ultrasound imaging, at baseline and after a 2-month training period.

Results: There were no differences between interventions regarding effect on lumbar multifidus muscle thickness. However, the linear mixed model analysis showed a significant effect for asymmetry. The thickness of the lumbar multifidus muscle on the small side increased significantly compared to the large side in both intervention groups.

Conclusions: There was a difference in thickness of the lumbar multifidus muscles between sides. It seems that exercises focusing on spinal alignment may increase the thickness of the lumbar multifidus muscles on the small side, irrespective of exercise load.

Background Context Assessment of posture and lumbopelvic alignment is often the main focus in the classification and treatment of patients with low back pain (LBP). However, little is known regarding the effects of motor control interventions on objective measures of lumbopelvic alignment.

Purpose The primary aim of this study was to describe the variation of sagittal lumbopelvic alignment in patients with nociceptive mechanical LBP. The secondary aim was to compare the effects of a high-load lifting exercise (HLL) and low-load motor control exercises (LMC) on the change in lumbopelvic alignment with a special emphasis on patients with high and low degrees of lumbar lordosis (lu) and sacral angle (sa).

Study Design This study is a secondary analysis of a randomized controlled trial evaluating the effects of HLL and LMC.

Patient Sample Patients from the primary study, that is, patients categorized with nociceptive mechanical LBP, who agreed to participate in the radiographic examination were included (n=66).

Outcome Measures Lateral plain radiographic images were used to evaluate lumbopelvic alignment regarding the lumbar lordosis and the sacral angle as outcomes, with posterior bend as an explanatory variable.

Materials and Methods The participants were recruited to the study from two occupational health-care facilities. They were randomized to either the HLL or the LMC intervention group and offered 12 supervised exercise sessions. Outcome measures were collected at baseline and following the end of intervention period 2 months after baseline. Between- and within-group analyses of intervention groups and subgroups based on the distribution of the baseline values for the lumbar lordosis and the sacral angle, respectively (LOW, MID, and HIGH), were performed using both parametric and non-parametric statistics.

Results The ranges of values for the present sample were 26.9–91.6° (M=59.0°, standard deviation [SD]=11.5°) for the lumbar lordosis and 18.2–72.1° (M=42.0°, SD=9.6°) for the sacral angle. There were no significant differences between the intervention groups in the percent change of eitheroutcome measure. Neither did any outcome change significantly over time within the intervention groups. In the subgroups, based on the distribution of respective baseline values, LOWlu showed a significantly increased lumbar lordosis, whereas HIGHsa showed a significantly decreased sacral angle following intervention.

Conclusions This study describes the wide distribution of values for lumbopelvic alignment for patients with nociceptive mechanical LBP. Further research is needed to investigate subgroups of other types of LBP and contrast findings to those presented in this study. Our results also suggest that retraining of the lumbopelvic alignment could be possible for patients with LBP.

Introduction: Metabolic dysfunction-associated fatty liver disease (MAFLD)—a new definition for non-alcoholic fatty liver disease—reflects the impact of metabolic abnormalities on liver function. We assessed the diagnostic accuracy of biomarker-based scores for prediction of MAFLD in apparently healthy children.

Methods: This study included 144 children aged 9–11. MAFLD was recognized in 14 girls and 29 boys. Anthropometric indices, glycemia, insulin resistance, lipid profile, enzymes (ALT, AST, GGT, ALP), CRP, N-terminal propeptide of type I procollagen (P1NP) and collagen type I C-telopeptide (CTX-1) levels were measured. Fatty liver and hepatic steatosis index (FLI, HSI) and potential indicators of liver fibrogenesis: P1NP/ALP, P1NP/ALPxALT, P1NP/ALPxCRP were calculated.

Results: P1NP/ALPxALT and P1NP/ALPxCRP were significantly higher in subjects with MAFLD. FLI was a good, significant predictor of MAFLD occurrence, regardless of sex. In boys, P1NP/ALPxCRP was a comparable predictor as CRP (OR 1.14 vs. 1.17; p < 0.001). P1NP/ALPxCRP had better discrimination capability in boys (AUC = 0.79; p < 0.001). However, the use of this algorithm did not improve discriminatory power in comparison to CRP (AUC = 0.81; p < 0.001), but gave a better sensitivity for MAFLD prediction (86% vs. 59%).

Conclusions: We suggest that P1NP/ALPXCRP is a reliable tool for MAFLD prediction in routine pediatric practice.

Osteoporosis-related fracture is already today a major public health problem and the number of hip fractures is expected to double to 2030. Sweden has one of the highest hip fracture incidences worldwide. This may be explained by several factors: e.g. age, genetic, climatologic, geographic and a relative vitamin D deficiency, secondary to the limited sunlight exposure especially during winter months. Intrinsic and extrinsic factors contribute to a fracture, although a prior low energy fracture is one of the strongest predictors for a subsequent one and this should be a target for secondary fracture prevention in an orthopaedic setting.

Since 1993 all injured patients admitted to the emergency floor and all in-hospital fractures at Umeå University Hospital, Sweden, were registered according to the Injury Data Base, former EHLASS. There were 31,173 fracture events (one or more fractures at the same time), of which 13,931 were in patients’ ≥ 50 years old. The fracture database was co analyzed with the Northern Sweden Health and Disease Study cohort in a nested case-control study for investigations of associations between osteoporotic fracture and serum markers, lifestyle data, nutrition etc. We found that there were differences in fracture pattern depending on age and sex. Both injury mechanism and fracture site were strongly dependent of age. The most severe fragility fracture, hip fracture, had a decreasing incidence. However, the incidence curve was right-shifting leading to an increase, both in numbers and in incidence of hip fractures among the oldest female. To identify people at high risk for fractures, re-fracture patients are useful. No less than 21% of the fracture patients had suffered more than one fracture event, accounting for 38% of all fracture events. The total risk ratio for a subsequent fracture was 2.2 (2.1-2.3 95% CI). In males the highest risk for re fracture was in the age cohort 70-79 years (RR 2.7, 2.3-3.2 95% CI), in females > 90 years (RR 3.9, 3.2-4.8 95% CI). Another possible risk factor in this subarctic population is the lack of sunlight, leading to a vitamin D deficit. The overall adjusted risk of sustaining a hip fracture in this population was 2.7 (95%CI:1.3-5.4) in subjects with a serum 25 hydroxyvitamin D below 50 nmol/l. The association was, however, different according to age at baseline. Thus in subjects aged 60 years and above at baseline, the adjusted odds ratio of sustaining a hip fracture was 6.2 (1.2-32.5 95%CI) for the group of individuals with a serum 25OHD below 50 nmol/l, whereas no significant association was found in the youngest age group.

In the next 30 years the ongoing demographic changes will accelerate. The World War II baby boomers will cause an age quake. We can already see signs heralding a new fracture pattern: an increasing cohort of mobile but fragile elderly, with considerable co-morbidity is now at risk for fragility fractures. In fracture patients, clinical information is sufficient to pinpoint patients with a high risk for re-fractures. It is therefore clinically important to use the information provided by the fracture event. We suggest that trauma units and primary care units should screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients. Secondary prophylaxis and follow-up treatment after cardiovascular disorders are now a matter of course worldwide, but the screening for risk factors, in order to prevent a second fracture, is often neglected. This is one of the most important issues of fracture care in the future in order to improve general health.

Summary: In a study of a 12-year population-based injury register, Umeå, Sweden, we analyzed the fracture mechanisms and fracture pattern in men and women 50 years and older. Low-energy trauma was responsible for the major and costliest part of the fracture panorama, but the pattern differs between age groups.

Introduction: Osteoporosis-related fracture is a major health problem: the number of hip fractures is expected to double to 2030. While osteoporosis is one of many risk factors, trauma is almost always involved. Therefore, we analyzed injury mechanisms in patients aged over 50.

Methods: We registered injury mechanism, cause, diagnosis in all trauma patients at Umeå University hospital, Sweden. This population-based register (1993–2004) comprises a total of 113,668 injuries (29,189 fractures). Patients ≥50 years contributed to 13,279 fractures.

Results: Low-energy trauma (fall <1 m) caused 53% of all fractures ≥50 years and older. In those over 75 low-energy trauma caused >80%. The seasonal variation of fractures was maximally 25%. With increasing age, proximal fractures became more common, in both upper and lower extremities. Proximal locations predominate in older age groups.

Conclusions: Low-energy trauma was responsible for the largest and costliest part of the fracture panorama. In fact, almost all fractures in middle-aged and old people were caused by low-energy mechanisms; thus, most fractures in these patients have a fragility component, and the contribution of osteoporosis-related fractures is more important than previously thought. A better understanding of injury mechanisms also in low-energy trauma is a prerequisite for preventive interventions.

Background The number of hip fractures has doubled in the last 30–40 years in many countries. Age-adjusted incidence has been reported to be decreasing in Europe and North America, but is there a decreasing trend in all age groups? Patients and methods This population-based study included all hip-fracture patients over 50 years of age (a total of 2,919 individuals, 31% of whom were men) admitted to Umeå University Hospital, Sweden, from 1993 through 2005. Results The incidence of hip fracture declined between the periods 1993–1996 and 2001–2005: from 706 to 625 hip fractures per 105 women and from 390 to 317 hip fractures per 105 men. However, there was a 114% increase in the number of fractures in women aged 90 or older (12 and 25 hip fractures/year, respectively, in the two time periods). For the period 2001–05, women ≥ 90 years of age accounted for almost the same numbers of hip fractures as women aged 75–79 (27 fractures/year). The rate increased during this period, from 2,700 per 105 women to 3,900 per 105 women > 90 years. In men there were declining trends for both relative and absolute numbers. Interpretation Although age-adjusted incidence declined in the population > 50 years of age, absolute fracture rate and incidence increased in the very old. Women over 90 now have the same absolute number of hip fractures every year as women aged 75–79 years. There was a right-shift in hip fracture distribution towards the oldest old, probably due to an increased number of octo/nonagenarians, a new population of particularly frail old people that hardly existed earlier. Better health among septuagenarians may also have delayed the age at which fractures occurred. This changing pattern will strain orthopedic and geriatric resources even more.