Low back pain is one of the most common causes of permanent functional impairment 47 and is recognized as a key cost driver in the medical system. 11 Anatomical structures of the lumbar spine, such as the intervertebral discs, ligaments, facet joints, or musculature, may cause low back pain. 6,7,30,38 However, others view this model of a peripheral pain generator in a critical light and propose other causes of pain, including neurophysiological, psychological, and social factors. 28,42,46

IMPORTANCE Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy. OBJECTIVE To explore clinical outcomes associated with exercise training before and after hip arthroplasty. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Google Scholar were searched from their inception to March 2020. Reference lists of included trials and related reviews were also searched. STUDY SELECTION Randomized clinical trials of land-based exercise interventions before or after total hip arthroplasty were included. DATA EXTRACTION AND SYNTHESIS This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was independently performed in duplicate. Random-effects meta-analyses with restricted maximum likelihood were performed for pooling the data. MAIN OUTCOMES AND MEASURES The primary prespecified outcome was self-reported physical function. Secondary prespecified outcomes were self-reported pain intensity, quality of life, gait speed, lower body muscle strength, lower body flexibility, anxiety, hospital length of stay, and adverse events. RESULTS A total of 32 randomized clinical trials with 1753 patients were included in the qualitative synthesis, and 26 studies with 1004 patients were included in the meta-analysis. Compared with usual care or no or minimal intervention, postoperative exercise training was not associated with improved self-reported physical function, with a moderate level of certainty, at 4 weeks

ObjectiveCompare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.DesignLiving systematic review and meta-analysis.Data sourcesSix databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.Eligibility criteriaRandomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.Data synthesisBayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.ResultsOf 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.ConclusionsThere is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.PROSPERO registration numberCRD42021256537.

Background The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations. Objective To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity. Methods A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models. Results The participants’ (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%. Conclusions The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.

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Zusammenfassung Einleitung Die Behandlung einer vorderen Kreuzbandruptur wird nach wie vor kontrovers diskutiert. Insbesondere die Frage: Konservative oder operative Versorgung? steht dabei im Mittelpunkt. Für die Beantwortung dieser Frage werden häufig Folgeschäden wie die Entwicklung einer posttraumatischen Arthrose, Sekundärschäden am Meniskus oder Knorpel und auch die Partizipation im Sport herangezogen. Sollten zwischen den einzelnen Behandlungsoptionen bedeutsame Unterschiede bezüglich dieser Parameter bestehen, so wären die Ergebnisse für die Entwicklung evidenzbasierter Behandlungspfade von hoher Bedeutung. Ziel dieser Arbeit war es daher, die Entwicklung einer Gonarthrose nach einer Ruptur des vorderen Kreuzbandes und der entsprechenden Behandlung (konservativ oder operativ) zu evaluieren. Material und Methoden Zur Beantwortung der Fragestellung wurde eine systematische Literaturrecherche in der Medline über Pubmed, der Cochrane Library und in CINAHL durchgeführt. Die Recherche wurde im Januar 2020 durchgeführt und im Januar 2021 wiederholt. Eingeschlossen wurden ausschließlich systematische Reviews mit einem minimalen Nachuntersuchungszeitraum von 10 Jahren. Untersuchte Kohorten umfassten Patienten mit einer entweder konservativ oder operativ versorgten Ruptur des vorderen Kreuzbandes. Die Diagnose Arthrose wurde entweder radiologisch (anerkannte Scores) oder klinisch (Schmerz und Funktionseinschränkung) gestellt. Passende Übersichtsarbeiten wurden mit dem AMSTAR-2-Fragebogen einer qualitativen Bewertung unterzogen. Ergebnisse Die Literaturrecherche ermittelte zunächst n = 42 Übersichtsarbeiten, von denen 14 Arbeiten inkludiert werden konnten. Nach der Volltextprüfung und der qualitativen Bewertung verblieben zur Auswertung der Ergebnisse lediglich n = 2 systematische Reviews. Die Ergebnisse beider Arbeiten zeigen unpräzise Daten mit einer großen Variabilität. Es kann aber mit großer Wahrscheinlichkeit davon ausgegangen werden, dass das Risiko für die Entwicklung einer Gonarthrose nach einer Ruptur des vorderen Kreuzbandes erhöht ist. Eine Reduktion der Inzidenz der Gelenkdegeneration durch eine Rekonstruktion des vorderen Kreuzbandes ist nicht nachweisbar, genauso wenig wie ein Unterschied bei einem direkten Vergleich zwischen konservativer und operativer Versorgung. Schlussfolgerung Patienten mit einer vorderen Kreuzbandruptur tragen mit hoher Wahrscheinlichkeit ein größeres Risiko für eine progressive Gelenkdegeneration. Ein pauschaler protektiver Effekt einer Kreuzbandplastik ist in den ausgewerteten Arbeiten nicht nachweisbar. Aus diesem Grund sollten innerhalb der Entscheidungsfindung über operative versus konservative Versorgung andere Faktoren wie die funktionelle Instabilität noch höher bewertet werden.

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