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BackgroundThere is a need for better interpretation of orthopedic treatment effects. Patient-reported outcome measures (PROMs) are already commonly used for patient evaluation. PROMs can be used to determine treatment effects in research as well as in clinical settings by calculating change scores, with pre- and post-treatment evaluation. The smallest detectable change (SDC) and minimal important change (MIC) are two important benchmarks for interpreting these change scores. The purpose was to determine the SDC and the MIC for four commonly used shoulder-related PROMs: Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand (DASH and QuickDASH), and the Oxford Shoulder Score (OSS).MethodsA cohort of 164 consecutive patients with shoulder problems visiting an orthopedic outpatient clinic completed the SST, DASH, and the OSS at their first visit and 6 months after operative or non-operative treatment. The SDC was calculated with a test re-test protocol (0–2 weeks). For the MIC, change scores (0–6 months of evaluation) were calculated in seven subgroups of patients, according to an additional self-administered ranking of change over time (anchor-based mean change technique). The MIC is defined as the average score of the ‘slightly improved’ group according to the anchor. The QuickDASH was computed from the DASH.ResultsThe SDC of the SST was 2.8, DASH 16.3, QuickDASH 17.1, and OSS 6.0. The MIC change score for the SST was 2.2, DASH 12.4, QuickDASH 13.4, and OSS 6.0.ConclusionThis study shows that on an individual patient-based level, when taking into account SDC and MIC, the change score should exceed 2.8 points for the SST, 16.3 points for the DASH, 17.1 points for the QuickDASH, and 6.0 points for the OSS to have a clinically relevant change on a PROM, which is not due to measurement error.

AIM To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength training on muscle strength and mobility in children with cerebral palsy (CP).METHOD Fifty-one children with spastic uni-and bilateral CP; (29 males, 22 females; mean age 10y 5mo, SD 1y 10mo, range 6y 0mo-13y 10mo; Gross Motor Function Classification System levels I-III) were randomized to the intervention group (n=26) or the control group (n=25, receiving usual care). The intervention group trained for 12 weeks, three times a week, on a five-exercise circuit, which included a leg-press and functional exercises. The training load progressively increased based on the child's maximum level of strength, determined by the eight-repetition maximum. Muscle strength (measured with hand-held dynamometry and a six-repetition maximum leg-press test), mobility (measured with the Gross Motor Function Measure, two functional tests, and a mobility questionnaire), and spasticity (measured by the appearance of a catch) were evaluated before, during, directly after, and 6 weeks after the end of training by two blinded research assistants.RESULTS Directly after training, there was a statistically significant effect (p<0.05) on muscle strength (knee extensors +12% [0.56N ⁄ kg; 95% confidence interval {CI} 0.13-0.99]; hip abductors +11% [0.27N ⁄ kg; 95% CI 0.00-0.54]; total +8% [1.30N ⁄ kg; 95% CI 0.56-2.54]; six-repetition maximum +14% [14%; 95% CI 1.99-26.35]), but not on mobility or spasticity. A detraining effect was seen after 6 weeks.INTERPRETATION Twelve weeks of functional PRE strength training increases muscle strength up to 14%. This strength gain did not lead to improved mobility.Cerebral palsy (CP) describes a group of disorders in the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing brain. 1 It is the most common cause of movement disability in childhood. Children with CP may experience a variety of impaired muscle functions, such as spasticity, muscle weakness, and loss of selective motor control. Although all impaired muscle functions limit the performance of daily life activities and participation in a child with CP, a recent study has shown that muscle weakness showed a stronger association with mobility limitations in children with CP than spasticity. 2 Strength training for these children is, therefore, expected to improve or maintain their mobility.Until recently, strength training in children with CP was discouraged as it was assumed that it would increase spasticity. However, this was not supported by the results of earlier uncontrolled studies which showed that strength training can improve lower-limb muscle strength in children with CP without increasing spasticity. 3,4 Although studies have shown there to be sufficient evidence for its effectiveness on muscle strength, these effects are probably overestimated because of the low methodological quality of the studies. 5,6 The few uncontrolled studies that have evalua...

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity‐dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords ‘spasticity’, ‘child’, and‘cerebral palsy’, to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time–consuming clinical scoring system.

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BackgroundPatients undergoing total knee arthroplasty (TKA) often experience strength deficits both pre- and post-operatively. As these deficits may have a direct impact on functional recovery, strength assessment should be performed in this patient population. For these assessments, reliable measurements should be used. This study aimed to determine the inter- and intrarater reliability of hand-held dynamometry (HHD) in measuring isometric knee strength in patients awaiting TKA.MethodsTo determine interrater reliability, 32 patients (81.3% female) were assessed by two examiners. Patients were assessed consecutively by both examiners on the same individual test dates. To determine intrarater reliability, a subgroup (n = 13) was again assessed by the examiners within four weeks of the initial testing procedure. Maximal isometric knee flexor and extensor strength were tested using a modified Citec hand-held dynamometer. Both the affected and unaffected knee were tested. Reliability was assessed using the Intraclass Correlation Coefficient (ICC). In addition, the Standard Error of Measurement (SEM) and the Smallest Detectable Difference (SDD) were used to determine reliability.ResultsIn both the affected and unaffected knee, the inter- and intrarater reliability were good for knee flexors (ICC range 0.76-0.94) and excellent for knee extensors (ICC range 0.92-0.97). However, measurement error was high, displaying SDD ranges between 21.7% and 36.2% for interrater reliability and between 19.0% and 57.5% for intrarater reliability. Overall, measurement error was higher for the knee flexors than for the knee extensors.ConclusionsModified HHD appears to be a reliable strength measure, producing good to excellent ICC values for both inter- and intrarater reliability in a group of TKA patients. High SEM and SDD values, however, indicate high measurement error for individual measures. This study demonstrates that a modified HHD is appropriate to evaluate knee strength changes in TKA patient groups. However, it also demonstrates that modified HHD is not suitable to measure individual strength changes. The use of modified HHD is, therefore, not advised for use in a clinical setting.

ObjectiveThe objective of this systematic review of the literature was to identify the predictors of functional outcome after total hip arthroplasty (THA).MethodA systematic literature search in Web of Science, CINAHL, EMBASE and PubMed was conducted on 23 June 2015. The articles were selected based on their quality, relevance and measurement of the predictive factor. The level of evidence of all studies was determined using the GRADE rating scheme.ResultsThe initial search resulted in 1092 citations. After application of the inclusion and exclusion criteria, 33 articles met our eligibility criteria and were graded. Included studies were classified as level of evidence low (11), moderate (17) or high (5). Of the included studies, 18 evaluated body mass index (BMI), 17 evaluated preoperative physical functions, 15 evaluated age, 15 evaluated gender and 13 evaluated comorbidity. There was strong evidence suggesting an association between BMI, age, comorbidity, preoperative physical functions and mental health with functional outcome after THA. There was weak evidence suggesting an association between quadriceps strength and education with functional outcome after THA. The evidence was inconsistent for associations with gender and socioeconomic status and functional outcome following THA. We found limited evidence suggesting that alcohol consumption, vitamin D insufficiency and allergies were predictors of functional outcome following THA.ConclusionsWe have identified multiple predictors of functional outcome after THA, which will enable general practitioners and orthopaedic surgeons to better predict the improvement in physical functioning for their patients with THA. They can use this information to provide patient-specific advice regarding the referral for THA and the expected outcomes after THA. Further research with consistent measurement tools, outcomes and duration of follow-up across studies is needed to confirm the influence of these factors.

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