Physiotherapy Post Lumbar Discectomy: Prospective Feasibility and Pilot Randomised Controlled Trial

Objectives

To evaluate: acceptability and feasibility of trial procedures; distribution of scores on the Roland Morris Disability Questionnaire (RMDQ, planned primary outcome); and efficient working of trial components.

Design and Setting

A feasibility and external pilot randomised controlled trial (ISRCTN33808269, assigned 10/12/2012) was conducted across 2 UK secondary care outpatient physiotherapy departments associated with regional spinal surgery centres.

Participants

Consecutive consenting patients aged >18 years; post primary, single level, lumbar discectomy.

Interventions

Participants were randomised to either 1:1 physiotherapy outpatient management including patient leaflet, or patient leaflet alone.

Main Outcome Measures

Blinded assessments were made at 4 weeks post surgery (baseline) and 12 weeks post baseline (proposed primary end point). Secondary outcomes included: Global Perceived Effect, back/leg pain, straight leg raise, return to work/function, quality of life, fear avoidance, range of movement, medication, re-operation.

Results

At discharge, 110 (44%) eligible patients gave consent to be contacted. 59 (54%) patients were recruited. Loss to follow up was 39% at 12 weeks, with one site contributing 83% losses. Mean (SD) RMDQ was 10.07 (5.58) leaflet and 10.52 (5.94) physiotherapy/leaflet at baseline; and 5.37 (4.91) leaflet and 5.53 (4.49) physiotherapy/leaflet at 12 weeks. 5.1% zero scores at 12 weeks illustrated no floor effect. Sensitivity to change was assessed at 12 weeks with mean (SD) change -4.53 (6.41), 95%CI -7.61 to -1.44 for leaflet; and -6.18 (5.59), 95%CI -9.01 to -3.30 for physiotherapy/leaflet. RMDQ mean difference (95%CI) between change from baseline to twelve weeks was 1.65(-2.46 to 5.75). Mean difference (95%CI) between groups at 12 weeks was -0.16 (-3.36 to 3.04). Participant adherence with treatment was good. No adverse events were reported.

Conclusions

Both interventions were acceptable, and it is promising that they both demonstrated a trend in reducing disability in this population. A randomised controlled trial, using a different trial design, is needed to ascertain the effectiveness of combining the interventions into a stepped care intervention and comparing to a no intervention arm. Findings will guide design changes for an adequately powered randomised controlled trial, using RMDQ as the primary outcome.

Trial Registration

ISRCTN registry 33808269     

Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial

Objectives To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain.Design Multicentre randomised controlled trial.Setting 15 secondary care orthopaedic and rehabilitation centres across the United Kingdom.Participants 349 participants aged 18-55 with chronic low back pain of at least one year''s duration who were considered candidates for spinal fusion.Intervention Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy.Main outcome measure The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure.Results 176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was –4.1 (95% confidence interval –8.1 to –0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures.Conclusions Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.     

Effect of two randomised exercise programmes on bone mass of healthy postmenopausal women.

The effect of two structured exercise programmes on the bone mass of 48 healthy postmenopausal white women aged 50-62 was studied after one year. Volunteers were randomised to group 1 (control), group 2 (aerobic exercise), or group 3 (aerobic and strengthening exercises). Before and after the training programme each subject had evaluations of bone mass (determined by neutron activation analysis and expressed as calcium bone index) and maximum oxygen uptake attained on a multistage exercise treadmill test. After one year both exercise groups had higher levels of fitness and greater bone mass than controls. Mean values (2 SEM) for changes in the calcium bone index were -0.011 (0.037), 0.039 (0.035), and 0.066 (0.036) for groups 1, 2, and 3, respectively. Analysis of variance on the observed data and analysis of covariance adjusting changes to the initial mean value for the whole group showed significant differences between each exercise group and the controls but no difference between the exercise groups themselves. Both exercise groups showed a significant improvement in maximum oxygen uptake. This study suggests that exercise may modify bone loss in healthy postmenopausal women.     

Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis. Canadian Erythropoietin Study Group.

OBJECTIVE--To determine whether recombinant human erythropoietin improves the quality of life and exercise capacity of anaemic patients receiving haemodialysis. DESIGN--A double blind, randomised, placebo controlled study. SETTING--Eight Canadian university haemodialysis centres. PATIENTS--118 Patients receiving haemodialysis aged 18-75 with haemoglobin concentrations less than 90 g/l, no causes of anaemia other than erythropoietin deficiency, and no other serious diseases. INTERVENTIONS--Patients were randomised to three groups to receive placebo (n = 40), erythropoietin to achieve a haemoglobin concentration of 95-110 g/l (n = 40), or erythropoietin to achieve a haemoglobin concentration of 115-130 g/l (n = 38). Erythropoietin was given intravenously thrice weekly, initially at 100 units/kg/dose. The dose was subsequently adjusted to achieve the target haemoglobin concentration. All patients with a serum ferritin concentration less than 250 micrograms/l received oral or intravenous iron for one month before the study and as necessary throughout the trial. MAIN OUTCOME MEASURES--Scores obtained with kidney disease questionnaire, sickness impact profile, and time trade off technique; and results of six minute walk test and modified Naughton stress test. RESULTS--The mean (SD) haemoglobin concentration at six months was 74 (12) g/l in patients given placebo, 102 (10) g/l in those in the low erythropoietin group, and 117 (17) g/l in those in the high erythropoietin group. Compared with the placebo group, patients treated with erythropoietin had a significant improvement in their scores for fatigue, physical symptoms, relationships, and depression on the kidney disease questionnaire and in the global and physical scores on the sickness impact profile. The distance walked in the stress test increased in the group treated with erythropoietin, but there was no improvement in the six minute walk test, psychosocial scores on the sickness impact profile, or time trade off scores. There was no significant difference in the improvement in quality of life or exercise capacity between the two groups taking erythropoietin. Patients taking erythropoietin had a significantly increased diastolic blood pressure despite an increase in either the dose or number of antihypertensive drugs used. Eleven of 78 patients treated with erythropoietin had their sites of access clotted compared with only one of 40 patients given placebo. CONCLUSIONS--Patients receiving erythropoietin were appreciably less fatigued, complained of less severe physical symptoms, and had moderate improvements in exercise tolerance and depression compared with patients not receiving erythropoietin. At the doses used in this trial there was a higher incidence of hypertension and clotting of the vascular access in patients treated with erythropoietin.     

Opiate withdrawal: inpatient versus outpatient programmes and preferred versus random assignment to treatment.

The relative effectiveness of an inpatient and an outpatient withdrawal programme for opiate addicts was studied. Forty five men and 15 women (mean age 26.13 (SD 5.12) years) took part in the study, all of whom were voluntary patients at the drug dependence clinic of the Maudsley Hospital in London between 1984 and 1985. Subjects were asked if they were prepared to accept either inpatient or outpatient withdrawal, and those who were willing to do so were assigned randomly to the randomised outpatient group or the randomised inpatient group. Those who expressed a strong preference were assigned, as appropriate, to the preferred outpatient group or the preferred inpatient group. Addicts in the inpatient group were more likely to achieve complete withdrawal (25 out of 31, 81%) than those in the outpatient group (five out of 29, 17%). This difference could not be attributed to pretreatment factors related to drugs or to social or psychological differences between the groups. These results have clinical and policy implications for the treatment of opiate addicts.     

Influence of oral magnesium supplementation on cardiac events among survivors of an acute myocardial infarction.

OBJECTIVE--To investigate the effect of long term oral magnesium treatment on incidence of cardiac events among survivors of an acute myocardial infarction. DESIGN--Double blind, placebo controlled parallel study in which patients were randomised to treatment or placebo. SETTING--Two coronary care units and corresponding outpatient clinics. SUBJECTS--468 survivors of an acute myocardial infarction (289 men and 178 women) aged 31-92. INTERVENTIONS--One tablet of 15 mmol magnesium hydroxide or placebo daily for one year. MAIN OUTCOME MEASURES--Incidences of reinfarction, sudden death, and coronary artery bypass grafting in one year. RESULTS--There was no significant difference between treatment and placebo groups in the incidence of each of the three cardiac events, but when the events were combined and drop outs were excluded from calculations there was a significantly higher incidence of events in the treatment group (56/167 v 33/153; relative risk 1.55 (95% confidence interval 1.07 to 2.25); p = 0.02). When the timing of events was incorporated by means of a Kaplan-Meier plot the treatment group showed a significantly higher incidence of events whether drop outs were included or excluded (p < 0.025). CONCLUSION--Long term oral treatment with 15 mmol magnesium daily doses not reduce the incidence of cardiac events in survivors of an acute myocardial infarction and, indeed, seems to increase the risk of developing a cardiac event. Consequently, this treatment cannot be recommended as secondary prophylaxis for such patients.     

Preventing childhood obesity: two year follow-up results from the Christchurch obesity prevention programme in schools (CHOPPS)

Objective To assess the long term effects of an obesity prevention programme in schools.Design Longitudinal results after a cluster randomised controlled trial.Setting Schools in southwest England.Participants Of the original sample of 644 children aged 7-11, 511 children were tracked and measurements were obtained from 434 children three years after baseline.Intervention The intervention was conducted over one school year, with four sessions of focused education promoting a healthy diet and discouraging the consumption of carbonated drinks.Main outcome measures Anthropometric measures of height, weight, and waist circumference. Body mass index (BMI) converted to z scores (SD scores) and to centile values with growth reference curves. Waist circumference was also converted to z scores (SD scores).Results At three years after baseline the age and sex specific BMI z scores (SD scores) had increased in the control group by 0.10 (SD 0.53) but decreased in the intervention group by −0.01 (SD 0.58), with a mean difference of 0.10 (95% confidence interval −0.00 to 0.21, P=0.06). The prevalence of overweight increased in both the intervention and control group at three years and the significant difference between the groups seen at 12 months was no longer evident. The BMI increased in the control group by 2.14 (SD 1.64) and the intervention group by 1.88 (SD 1.71), with mean difference of 0.26 (−0.07 to 0.58, P= 0.12). The waist circumference increased in both groups after three years with a mean difference of 0.09 (−0.06 to 0.26, P=0.25).Conclusions These longitudinal results show that after a simple year long intervention the difference in prevalence of overweight in children seen at 12 months was not sustained at three years.     

和中平逆方治疗肝胃郁热型反流性食管炎临床研究

目的:观察和中平逆方治疗肝胃郁热型反流性食管炎的临床疗效。方法:选择60例经内镜检查及中医辨证确诊为肝胃郁热型的反流性食管炎患者,分为中药治疗组、西药对照组,每组各30例,均以8周为一疗程,疗程结束后进行疗效比较。结果:两组临床症状疗效,治疗组总有效率为96.67%,对照组为96.66%,两组比较无显著性差异(P>0.05);内镜疗效,治疗组总有效率为73.33%,对照组为73.33%,两组比较无显著性差异(P>0.05);肝胃郁热证候疗效,治疗组总有效率为96.67%,对照组为76.67%,两组比较有显著性差异(P<0.05)。结论:1.和中平逆方对反流性食管炎的症状、食管黏膜炎症改善均有明显疗效;2.和中平逆方对肝胃郁热型反流性食管炎中医证候的改善优于奥美拉唑肠溶胶囊。     

Randomised study of long term outcome after epidural versus non-epidural analgesia during labour

ObjectiveTo determine whether epidural analgesia during labour is associated with long term backache.DesignFollow up after randomised controlled trial. Analysis by intention to treat.SettingDepartment of obstetrics and gynaecology at one NHS trust.Participants369 women: 184 randomised to epidural group (treatment as allocated received by 123) and 185 randomised to non-epidural group (treatment as allocated received by 133). In the follow up study 151 women were from the epidural group and 155 from the non-epidural group.ResultsThere were no significant differences between groups in demographic details or other key characteristics. The mean time interval from delivery to interview was 26 months. There were no significant differences in the onset or duration of low back pain, with nearly a third of women in each group reporting pain in the week before interview. There were no differences in self reported measures of disability in activities of daily living and no significant differences in measurements of spinal mobility.ConclusionsAfter childbirth there are no differences in the incidence of long term low back pain, disability, or movement restriction between women who receive epidural pain relief and women who receive other forms of pain relief.

What is already known on this topic

Previous research has suggested an association between epidural analgesia during labour and low back painIt is not known whether this association is causal

What this study adds

This long term follow up study found no evidence of a causal link between epidural analgesia during labour and low back pain     

Effectiveness of a geriatric day hospital.

OBJECTIVE: To determine whether there is a difference in the quality of life between elderly patients managed in a day hospital and those receiving conventional care. DESIGN: Randomized controlled trial; assessment upon entry to study and at 3, 6 and 12 months afterward. SETTING: Geriatrician referral-based secondary care. PATIENTS: A total of 113 consecutively referred elderly patients with deteriorating functional status believed to have rehabilitation potential; 55 were assessed and treated by an interdisciplinary team in a day hospital (treatment group), and 58 were assessed in an inpatient unit or an outpatient clinic or were discharged early with appropriate community services (control group). OUTCOME MEASURES: Barthel Index, Rand Questionnaire, Global Health Question and Geriatric Quality of Life Questionnaire (GQLQ). MAIN RESULTS: Eight study subjects and four control subjects died; the difference was insignificant. Functional status deteriorated over time in the two groups; although the difference was not significant there was less deterioration in the control group. The GQLQ scores indicated no significant difference between the two groups in the ability to perform daily living activities and in the alleviation of symptoms over time but did show a trend favouring the control group. The GQLQ scores did indicate a significant difference in favour of the control group in the effect of treatment on emotions (p = 0.009). CONCLUSION: The care received at the day hospital did not improve functional status or quality of life of elderly patients as compared with the otherwise excellent geriatric outpatient care.     

Partial medial meniscectomy and rotational differences at the knee during walking

Loss of meniscal function due to injury or partial meniscectomy is common and represents a significant risk factor for premature osteoarthritis. The menisci can influence the transverse plane movements (anterior–posterior (AP) translation and internal–external (IE) rotation) of the knee during walking. While walking is the most frequent activity of daily living, the kinematic differences at the knee during walking associated with the meniscal injury are not well understood. This study examined the influence of partial medial meniscectomy (PMM) on the kinematics and kinetics of the knee during the stance phase of gait by testing the differences in anterior–posterior translation, internal–external rotation, knee flexion range of movement, peak flexion/extension moments, and adduction moments between the PMM and healthy contralateral limbs. Ten patients (45±9 years old, height 1.75±0.06 m, weight 76.7±13.5 kg) who had undergone partial medial meniscectomy (33±100 months post-op) in one limb with a healthy contralateral limb were tested during normal walking. The contralateral limb was compared to a matched control group and no differences were found. The primary kinematic difference was a significantly greater external rotation (3.2°) of the tibia that existed through stance phase, with 8 of 10 subjects demonstrating the same pattern. The PMM subjects also exhibited significantly lower peak flexion and extension moments in their PMM limbs. The altered rotational position found likely results in changes of tibio-femoral contact during walking and could cause the type of degenerative changes found in the articular cartilage following meniscal injury.     

UKA与TKA治疗膝关节内侧单间室骨性关节炎的临床对比

目的:探究膝关节单髁置换术(UKA)与全膝关节置换术(TKA)治疗膝关节内侧单间室骨性关节炎的临床治疗效果。方法:将2011年4月-2015年7月期间因膝关节单间室骨性关节炎入院接受治疗的89例患者纳入本研究,随机分为研究组和对照组,研究组44例,行UKA手术,对照组45例,采用TKA手术方式治疗。对两组患者进行术后随访,对比临床治疗效果。结果:两组术前均有明显膝关节疼痛,术后膝关节疼痛均明显改善,组间差别无显著统计学意义(X2=1.323,P=0.2500.05);术后膝关节屈曲角度、HSS评分相对于术前均显著改善,研究组术后膝关节屈曲角度(111.2±18.8)度高于对照组的(98.6±14.7)度,差异有统计学意义(P0.05);HSS评分(87.6±13.7)分高于对照组的(73.2±16.8)分,差异有统计学意义(P0.05);研究组膝关节屈曲至90度时间比对照组短,数据差异有统计学差异(t=-2.303,P=0.0240.05)。结论:膝关节内侧单间室骨性关节炎采用UKA与TKA均能取得一定临床效果,减轻患者痛苦,改善膝关节功能,但UKA临床疗效较好,手术创伤较小,术后恢复较快。     

Prospective randomised controlled trial of methods of call and recall for cervical cytology screening.

OBJECTIVE--To discover whether systematic methods of call and recall are more effective than a non-systematic method and to see which of the two systematic methods was more effective. DESIGN--Prospective randomised controlled trial over a year. SETTING--One group general practice. PATIENTS--416 Women over 35 eligible for a smear test who had never had a cervical smear test or in whom a smear test was overdue (previous test more than five years before). INTERVENTIONS--One group received written invitations to have a smear taken. The second group had their notes tagged so that the doctor would remind them (when they attended for another reason) to have a smear test. No special intervention was made in the third group. MAIN OUTCOME MEASURE--Performance of a cervical smear test during the year of the study. RESULTS--32% (45/140) of the screened group, 27% (39/142) of the tagged group, and 15% (20/134) of the control group had a smear test during the year. The percentage of women having a smear test in the screened group was not significantly different from that in the tagged group, but the percentages in the two groups were significantly different from that in the control group. Whether a woman had had a previous smear test significantly affected the uptake of the invitation to have a smear test independently of the method of invitation. CONCLUSIONS--The systematic methods of call and recall were more effective than a non-systematic method. There was no significant difference between the two systematic methods (sending letters or tagging the notes) at one year.     

Efficacy of tacrine and lecithin in mild to moderate Alzheimer's disease: double blind trial.

OBJECTIVE--To assess the efficacy of tacrine and lecithin in treating Alzheimer''s disease over nine months. DESIGN--Double blind randomised controlled trial. SETTING--Outpatients clinic of university department of geriatric medicine. SUBJECTS--53 subjects (26 women, 27 men) with probable Alzheimer''s disease. 41 completed the dose finding phase and were randomised to treatment. 32 (14 tacrine, 18 placebo) completed nine months'' treatment. INTERVENTIONS--Lecithin and tacrine or lecithin and placebo for 36 weeks. MAIN OUTCOME MEASURES--Scores on neuropsychological tests sensitive to deficits in the cholinergic system; mini-mental state score; behaviour change; mood; functional state; and stress in carers. RESULTS--The tacrine and placebo groups were similar except that the tacrine group had a longer duration of disease (mean 5.4 v 2.5 years in placebo group; P = 0.003). Only 17 of the 32 patients could tolerate the maximum dose of tacrine (100 mg). No significant difference was found between the groups for any of the tests after nine months'' treatment except for the digit backwards test, which is insensitive to cholinergic deficit. Analysis of subjects taking the maximum dose of tacrine and of subjects with mild dementia also found no differences. CONCLUSIONS--Tacrine produces no clinically relevant improvement over 36 weeks at the doses tolerated by these patients.     

Fluorescent microsphere method is suitable for chronic bone blood flow measurement: a long-term study after meniscectomy in rabbits.

The fluorescent microsphere (FM) method is considered a reliable technique to determine regional bone blood flow (RBBF) in acute experiments. In this study, we verified the accuracy and validity of this technique for measurement of RBBF in a long-term experiment and examined RBBF after meniscectomy. Twenty-four anesthetized female New Zealand white rabbits (3 groups, each n = 8) received consecutive left ventricular injections of FM in defined time intervals after meniscectomy: group 1 from preoperation to 3 wk postoperation; group 2 from 3 to 7 wk postoperation; and group 3 from 7 to 11 wk postoperation. To test the precision of the FM method, two FM species were injected simultaneously at the first and last measurement. After the experiment, humeri, femora, tibiae, and reference organs (kidney, lung, brain) were removed and dissected according to standardized protocols. Fluorescence was determined in each reference blood and tissue sample, and blood flow values were calculated. Blood flow in kidney, lung, and brain revealed no significant difference between right and left side and remained unchanged during the observation period, thus excluding errors due to shunting and dislodging of spheres in our experiments. Comparison of relative bone blood flow values obtained by simultaneously injected FM showed an excellent correlation at the first and last injection, indicating valid RBBF measurements in long-term experiments. We found a significant increase in RBBF 3 wk after meniscectomy in the right tibial condyles compared with the nonoperated left side. Similar changes were found in the femoral condyles. RBBF in other regions of tibia, femur, and humerus revealed no significant differences between right- and left-sided bone samples of the same region. Our results demonstrate that the FM method is valid for measuring RBBF in long-term experiments. In addition, we were able to demonstrate that meniscectomy leads to an increase in RBBF in the tibial condyles at a very early stage. This increase might be caused by stress-induced alterations of the subchondral bone.     

关节镜下不同术式治疗盘状半月板的临床疗效研究

目的:比较分析关节镜下不同术式治疗盘状半月板的临床效果。方法:选取盘状半月板患者85例,其中完全型盘状半月板47例,行完全切除术(A组)23例,行部分切除成形术(B组)24例;不完全性盘状半月板38例,行完全切除术(C组)20例,行部分切除成形术(D组)18例。术后随访观察,膝关节功能评价分别采用国际膝关节文献委员会膝关节评估表(the international knee documentation committee knee evaluation form,IKDC)和Lysholm评分进行。结果:78例患者均得到有效随访。随访时间12-18个月,平均(16.2±3.4)月。术前各组各评分均无显著差异(P0.05)。完全型盘状半月板中,A组术后IKDC和Lysholm评分分别为(92.9±9.7)分、(93.4±8.6)分,优良率为91.3%(21/23),均显著优于B组[(83.5±8.4)分、(82.7±9.2)分、70.8%(17/24)](P0.05)。C组和D组术后各指标比较无显著差异(P0.05)。结论:关节镜下不同术式治疗盘状半月板均可获得较为满意的疗效,但对于完全型盘状半月板而言,采取完全切除术治疗的患者较部分切除成形术者术后疗效具有一定优势。     

Randomised controlled trial of interferon alfa (lymphoblastoid interferon) in chronic non-A non-B hepatitis.

OBJECTIVE--To determine the effect of low dose interferon alfa (human lymphoblastoid interferon) on aminotransferase activities in chronic non-A non-B hepatitis. DESIGN--Prospective randomised controlled parallel group study of active treatment versus no treatment carried out over 16 weeks and preceded by baseline measurements at weeks 8 and 4 and time zero. SETTING--HEPATOLOGY outpatient clinics in secondary referral centres. PATIENTS--Fourteen adults with histologically proved chronic hepatitis and persistently raised aminotransferase activities for six months or more. INTERVENTIONS--Seven patients randomised to receive interferon alfa 5 megaunits (MU) daily for one week, reducing to 5 MU thrice weekly for seven weeks, then 3 MU thrice weekly for eight weeks. Controls not treated. END POINT--Control of hepatic enzyme activity in chronic non-A non-B hepatitis. MEASUREMENTS AND MAIN RESULTS--Serum aspartate aminotransferase activity remained raised in controls (mean increase in study period 23.4 U/l) but fell rapidly to normal in the treated group (mean decrease 106.4 U/l). In four cases values were normal by eight weeks and in five cases by 16 weeks. Only minor side effects were recorded (fever, myalgia), which became less common as treatment progressed. CONCLUSIONS--Continuous low dose interferon alfa reduces aspartate aminotransferase activity to normal in most patients with chronic non-A non-B hepatitis and may prevent progression to cirrhosis.     

Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomised controlled trial and patient preference study

Objective To determine whether older patients with chronic knee pain should be advised to use topical or oral non-steroidal anti-inflammatory drugs (NSAIDs).Design Randomised controlled trial and patient preference study.Setting 26 general practices.Participants People aged ≥50 with knee pain: 282 in randomised trial and 303 in preference study. Interventions Advice to use topical or oral ibuprofen.Primary outcome measures WOMAC (Western Ontario and McMaster Universities) osteoarthritis index, major and minor adverse effects.Results Changes in global WOMAC scores at 12 months were equivalent. In the randomised trial the difference (topical minus oral) was two points (95% confidence interval −2 to 6); in the preference study, it was one point (−4 to 6). There were no differences in major adverse effects in the trial or study. The only significant differences in secondary outcomes were in the randomised trial. The oral group had more respiratory adverse effects (17% v 7%,95% confidence interval for difference −17% to −2%), the change in serum creatinine was 3.7 mmol/l less favourable (0.9 µmol/l to 6.5 µmol/l); and more participants changed treatments because of adverse effects (16% v 1%, −16% to −5%). In the topical group more participants had chronic pain grade III or IV at three months, and more participants changed treatment because of ineffectiveness.Conclusions Advice to use oral or topical preparations has an equivalent effect on knee pain over one year, and there are more minor side effects with oral NSAIDs. Topical NSAIDs may be a useful alternative to oral NSAIDs.Trial registration ISRCTN 79353052.     

Comparison of outpatient and inpatient spa therapy in knee osteoarthritis

Osteoarthritis (OA) is a common condition that impacts many people worldwide and involves weight-bearing joints, resulting in chronic pain. In this study, we aimed to compare the effectiveness of inpatient and outpatient physical therapy modalities and spa combination treatments on pain and functional status in patients with knee osteoarthritis. Seventy-four patients diagnosed with primary knee osteoarthritis were included in this study. The patients were randomized into two groups, inpatient (n?=?37) and outpatient (n?=?37) physical therapy. All patients received a physical therapy program (superficial heater + deep heater + transcutaneous electrical nerve stimulation) for 2 weeks and spa therapy. All cases were evaluated clinically, laboratory, and radiographically. In order to evaluate pain and functional status, the Visual Analogue Scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC), and Timed Up and Go (TUG) test were used before and after treatment. There was no significant difference between the two groups in the TUG test and WOMAC scores (p?>?0.05). However, a significant difference was found in VAS scores in favor of the outpatient group (p?<?0.05). As a result, although there was a significant improvement in pain scores in the outpatient group, multicenter studies with larger patient groups may provide more evidence.

     

Comparative evaluation of ropivacaine and lidocaine as dental pulp anaesthesia

Root canal therapy linked to pulpal diseases or trauma is common in modern dental care. The 2% Lidocaine which is considered as the gold standard has some drawbacks in pulpal anaesthesia. Ropivacaine has beneficial anaesthetic effects on pulpal anaesthesia. Therefore, it is of interest to compare and evaluate the pulpal aesthetic effect using 0.5% Ropivacaine and 2% Lidocaine in symptomatic irreversible pulpitis. A double blinded randomized controlled clinical trial consisting of 110 lower molar and premolar tooth with irreversible pulpitis cases for root canal therapy were selected and randomly divided into 2 groups. Group A: 2% lidocaine with epinephrine and Group B: 0.5% ropivacaine. The pulp sensibility tests with heat test, cold test and electric pulp test were completed. The preoperative pain score was measured with Visual Analogue Scale (VAS) pain scale. The classical inferior alveolar nerve block (IANB) technique was administered to all patients by a single operator. Subjects were asked for lip numbness and presence or absence of lip numbness. Postoperative pain scores were recorded during access opening and on placing files in the canal. There is no statistical difference between the groups during pre operative conditions. The mean pain scores within group A and group B is recorded. The difference was found to be statistically significant with p value ≤ 0.05. Significant difference between the mean values after and before the treatment is observed. However, there is no statistical significance between the mean pain scores between the access and pulp. The 0.5% Ropivacaine and 2% Lidocaine with epinephrine does not have any significant difference during access opening. However, 0.5% Ropivacaine groups were effective while placing the file in the canal. Thus, 0.5% Ropivacaine showed better results even though it was not statistically significant for further consideration in this context.