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Lower limb muscle dysfunction is a key driver for impaired physical capacity and frailty status, both characteristics of sarcopenia. Sarcopenia is the key pathway between frailty and disability. Identifying biological markers for early diagnosis, treatment, and prevention may be key to early intervention and prevention of disability particularly mobility issues. To identify biological markers associated with lower limb muscle (dys)function in adults with sarcopenia, a systematic literature search was conducted in AMED, CINAHL, Cochrane Library, EMBASE, Medline, PubMed, Scopus, SPORTDiscus, and Web of Science databases from inception to 17 November 2021. Title, abstract, and full-text screening, data extraction, and methodological quality assessment were performed by two reviewers independently and verified by a third reviewer. Depending on available data, associations are reported as either Pearson's correlations, regression R2 or partial R2 , P value, and sample size (n). Twenty eligible studies including 3306 participants were included (females: 79%, males: 15%, unreported: 6%; mean age ranged from 53 to 92 years) with 36% in a distinct sarcopenic subgroup (females: 73%, males: 19%, unreported: 8%; mean age range 55-92 years). A total of 119 biomarkers were reported, categorized into: genetic and microRNAs (n = 64), oxidative stress (n = 10), energy metabolism (n = 18), inflammation (n = 7), enzyme (n = 4), hormone (n = 7), bone (n = 3), vitamin (n = 2), and cytokine (n = 4) markers) and seven lower limb muscle measures predominately focused on strength. Seven studies reported associations between lower limb muscle measures including (e.g. power, force, and torque) and biomarkers. In individuals with sarcopenia, muscle strength was positively associated with free testosterone (r = 0.40, P = 0.01; n = 46). In analysis with combined sarcopenic and non-sarcopenic individuals, muscle strength was positively associated with combined genetic and methylation score (partial R2  = 0.122, P = 0.03; n = 48) and negatively associated with sarcopenia-driven methylation score (partial R2  = 0.401, P < 0.01; n = 48). Biomarkers related to genetics (R2  = 0.001-0.014, partial R2  = 0.013-0.122, P > 0.05; n = 48), oxidative stress (r = 0.061, P > 0.05; n ≥ 77), hormone (r = 0.01, ρ = 0.052 p > 0.05, n ≥ 46) and combined protein, oxidative stress, muscle performance, and hormones (R2  = 22.0, P > 0.05; n ≥ 82) did not report significant associations with lower limb muscle strength. Several biomarkers demonstrated associations with lower limb muscle dysfunction. The current literature remains difficult to draw clear conclusions on the relationship between biomarkers and lower limb muscle dysfunction in adults with sarcopenia. Heterogeneity of biomarkers and lower limb muscle function precluded direct comparison. Use of international classification of sarcopenia and a set of core standardized outcome measures should be adopted to aid future investigation and recommendations to be made.

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BACKGROUND: Foot impairments in early rheumatoid arthritis are common and lead to progressive deterioration of lower limb function. A gait rehabilitation programme underpinned by psychological techniques to improve adherence, may preserve gait and lower limb function. This study evaluated the feasibility of a novel gait rehabilitation intervention (GREAT Strides) and a future trial. METHODS: This was a mixed methods feasibility study with embedded qualitative components. People with early (< 2 years) rheumatoid arthritis (RA) and foot pain were eligible. Intervention acceptability was evaluated using a questionnaire. Adherence was evaluated using the Exercise Adherence Rating Scale (EARS). Safety was monitored using case report forms. Participants and therapists were interviewed to explore intervention acceptability. Deductive thematic analysis was applied using the Theoretical Framework of Acceptability. For fidelity, audio recordings of interventions sessions were assessed using the Motivational Interviewing Treatment Integrity (MITI) scale. Measurement properties of four candidate primary outcomes, rates of recruitment, attrition, and data completeness were evaluated. RESULTS: Thirty-five participants (68.6% female) with median age (inter-quartile range [IQR]) 60.1 [49.4-68.4] years and disease duration 9.1 [4.0-16.2] months), were recruited and 23 (65.7%) completed 12-week follow-up. Intervention acceptability was excellent; 21/23 were confident that it could help and would recommend it; 22/23 indicated it made sense to them. Adherence was good, with a median [IQR] EARS score of 17/24 [12.5-22.5]. One serious adverse event that was unrelated to the study was reported. Twelve participants' and 9 therapists' interviews confirmed intervention acceptability, identified perceptions of benefit, but also highlighted some barriers to completion. Mean MITI scores for relational (4.38) and technical (4.19) aspects of motivational interviewing demonstrated good fidelity. The Foot Function Index disability subscale performed best in terms of theoretical consistency and was deemed most practical. CONCLUSION: GREAT Strides was viewed as acceptable by patients and therapists, and we observed high intervention fidelity, good patient adherence, and no safety concerns. A future trial to test the additional benefit of GREAT Strides to usual care will benefit from amended eligibility criteria, refinement of the intervention and strategies to ensure higher follow-up rates. The Foot Function Index disability subscale was identified as the primary outcome for the future trial. TRIAL REGISTRATION: ISRCTN14277030.

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OBJECTIVES: The objectives were to evaluate the methodological and reporting quality of ultrasound (US) studies of Achilles enthesitis in people with psoriatic arthritis (PsA), to identify the definitions and scoring systems adopted and to estimate the prevalence of ultrasound features of Achilles enthesitis in this population. METHODS: A systematic literature review was conducted using the AMED, CINAHL, MEDLINE, ProQuest and Web of Science databases. Eligible studies had to measure US features of Achilles enthesitis in people with PsA. Methodological quality was assessed using a modified Downs and Black Quality Index tool. US protocol reporting was assessed using a checklist informed by the European League Against Rheumatism (EULAR) recommendations for the reporting of US studies in rheumatic and musculoskeletal diseases. RESULTS: Fifteen studies were included. One study was scored as high methodological quality, 9 as moderate and 5 as low. Significant heterogeneity was observed in the prevalence, descriptions, scoring of features and quality of US protocol reporting. Prevalence estimates (% of entheses) reported included hypoechogenicity [mean 5.9% (s.d. 0.9)], increased thickness [mean 22.1% (s.d. 12.2)], erosions [mean 3.3% (s.d. 2.5)], calcifications [mean 42.6% (s.d. 15.6)], enthesophytes [mean 41.3% (s.d. 15.6)] and Doppler signal [mean 11.8% (s.d. 10.1)]. CONCLUSIONS: The review highlighted significant variations in prevalence figures that could potentially be explained by the range of definitions and scoring criteria available, but also due to the inconsistent reporting of US protocols. Uptake of the EULAR recommendations and using the latest definitions and validated scoring criteria would allow for a better understanding of the frequency and severity of individual features of pathology.

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OBJECTIVE: The aim was systematically to identify and evaluate factors related to fatigue in individuals with hip and/or knee OA. METHODS: A systematic literature search was conducted using AMED, CINAHL, MEDLINE, ProQuest and Web of Science Core Collections databases. Inclusion criteria comprised cross-sectional, case-control or longitudinal studies on patients with a diagnosis of hip and/or knee OA that included self-reported fatigue measures. Study quality was assessed using the National Heart, Lung and Blood Institute quality appraisal tool, and factors were synthesized within a bio-behavioural framework. Study designs and quality were combined to determine current evidence levels using best evidence synthesis grading. The full review protocol is available from PROSPERO (PROSPERO 2019: CRD42019138571). RESULTS: Twenty-four studies were included, of which 19 were high, 4 moderate and 1 low quality. There was strong evidence of an association between poor self-reported physical function and high depressive symptoms with higher fatigue. Moderate evidence of an association was found between severe pain, high numbers of co-morbidities and low physical activity levels with higher fatigue. There was moderate or limited evidence of no association between most sociodemographic factors and radiographic OA severity with fatigue. CONCLUSION: Targets for fatigue management might include improving physical function, reducing depressive symptoms, pain and co-morbidities, and increasing physical activity levels. There is a need for more rigorous longitudinal studies to understand the causal effect of fatigue determinants within the hip and knee OA populations.

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BACKGROUND: Individuals with knee osteoarthritis (OA) demonstrate impairments in muscle function (i.e. muscle weakness, high muscle co-activation believed to have detrimental effects on joint integrity). Women with knee OA exhibit poorer health outcomes than men. Sex and muscle function are known risk factors for knee OA. It is unclear how these risk factors are associated with muscle function in knee OA and the implications for disease aetiology. RESEARCH QUESTION: How does sex and knee osteoarthritis disease status relate to muscle function, specifically strength and muscle co-activation, during walking, stair negotiation and sit-to-walk activities. METHODS: A cross-sectional study assessed muscle co-activation in 77 individuals with knee OA (mean[SD], 62.5[8.1] years; 48/29 women/men) and 18 age-matched controls (62.5[10.4] years; 9/9 women/men), during a series of walking, stair ascent and descent and sit-to-walk activities. Muscle strength of the knee extensors and flexors was assessed using maximal voluntary isometric contractions (MVIC). Electromyography was recorded from the vastus lateralis/medalis, rectus femoris, biceps femoris, semitendinosus, medial/lateral gastrocnemius normalised to MVIC. Multiple regression assessed the relationship between sex, disease status, and muscle strength on muscle co-activation. RESULTS: Individuals with knee OA were weaker than controls, had higher hamstrings-quadriceps and medial-lateral co-activation for specific phases of gait. Women were weaker than men with higher muscle co-activation across all activities. Sex and muscle weakness, but not age or disease status predicted high muscle co-activation. SIGNIFICANCE: High muscle co-activation was associated with female sex and muscle weakness regardless of disease status and age. High muscle co-activation is believed to be a compensatory mechanism for muscle weakness to maintain a certain level of function. High muscle co-activation is also thought to have detrimental effects on cartilage and joint integrity this may explain high muscle co-activation in women with muscle weakness and contribute to increased risk of incidence and progression of knee OA in women.

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AIM: The aim of the study was to identify sociodemographic, disease-related, physical and mental health-related determinants of fatigue at 2-year follow-up in individuals with symptomatic knee osteoarthritis (OA). METHODS: A longitudinal analysis of participants with symptomatic knee OA from the Multicenter Osteoarthritis Study (MOST) was conducted to identify predictors of fatigue at 2-year follow-up. Participants self-reported fatigue at baseline for the first time in the MOST cohort and at follow-up using a 0-10 visual analog scale. At baseline, questionnaires on sociodemographics, disease-related symptoms, physical and mental health factors were completed. Data were analyzed using linear regressions with a backwards elimination approach. RESULTS: Of the 2330 individuals in the MOST cohort at baseline, 576 had symptomatic knee OA and of these, 449 with complete fatigue values at baseline and follow-up were included in this analysis. Minimally important fatigue change (ie, worsening [≥1.13], no change [<0.82 or <1.13] and improvement [≥-0.82]) from baseline to follow-up were unequal within the population (34.5%, 26.9%, 38.5%; χ2 [2, N = 449] = 9.32, P = .009). The multiple linear regression showed that baseline fatigue (unstandardized coefficient [Β] = 0.435; 95% confidence interval [CI] 0.348-0.523, P < .001), slow gait speed (Β = -1.124; 95% CI -1.962 to -0.285, P = .009), depressive symptoms (Β = 0.049; 95% CI 0.024-0.075, P < .001) and higher numbers of comorbidities (Β = 0.242; 95% CI 0.045-0.439, P = .016) were significant predictors of greater fatigue at follow-up. CONCLUSION: Fatigue is strongly associated with physical- and mental-related health factors. Individualized treatments that include combined psychological and physical function rehabilitation might be modalities for fatigue management.

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OBJECTIVE: Muscle co-activation has been shown to be elevated in individuals with knee osteoarthritis (OA) during gait. Comparisons of muscle co-activation across different activities of daily living such as stair negotiation have yet to be explored. The aim of this study was to explore muscle co-activation across different activities of daily living in patients with knee OA. METHODS: Muscle co-activation was assessed in 77 symptomatic knee OA patients (mean ± SD age 62.5 ± 8.1 years, body mass index 29.4 ± 6.0 kg/m2 , and sex 48:29 female:male) using electromyography (EMG), during a series of walking, stair negotiation (ascent, descent), and sit-to-walk activities. EMG was recorded from 7 sites, mediolateral gastrocnemius, biceps femoris, semitendinosus, vastus lateralis/medialis, and rectus femoris, and normalized to maximal voluntary isometric contraction. Correlation was used to assess the consistency of co-activation across activities. Repeated-measures analysis of variance assessed the muscle combination by activity differences. RESULTS: Muscle co-activation was highest during stair ascent. When comparing muscle combinations within the same activity, we found that correlations ranged from r = 0.003 to r = 0.897, of which 80% of the combinations were significant. Between activities, muscle co-activation was significantly different (P < 0.05). Mediolateral muscle co-activation was higher than hamstrings/quadriceps across activities. CONCLUSION: Two muscle co-activation strategies were observed during activities of daily living in patients with knee OA to maintain stability. Muscle co-activation was higher during more challenging activities, particularly when the joint was accepting load. Mediolateral muscle co-activation was higher than hamstrings/quadriceps, so that mediolateral co-activation was thought to be a stabilization mechanism, while hamstrings/quadriceps co-activation responds to knee flexion moments, suggesting that different muscle combinations may have different roles in responding to joint demand.

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OBJECTIVE: (1) To select a limited number of performance-based tests that are reliable, show improvement in physical functioning after tumor necrosis factor inhibitor (TNFi) therapy in patients with ankylosing spondylitis (AS), and generate information equivalent to the full set of tests, and (2) are feasible for use in daily clinical practice. METHODS: Eight performance-based tests were evaluated. To eliminate redundant testing, the tests that showed adequate reliability, the highest standardized response mean (SRM), and the largest proportion of patients with an improved performance-based physical functioning were selected. The selected tests were combined into a new criterion for improvement in physical functioning (AS Performance-based Improvement; ASPI). The number and percentage of improved patients identified with the ASPI and identified with the full set of performance tests were compared. RESULTS: Reliability for all tests was adequate to excellent (ICC 0.73-0.96). The tests for bending, putting on socks, and getting up from the floor had the highest SRM (0.52-0.74) and showed the largest proportion of improved patients after TNFi therapy. The combination of these 3 tests was feasible in daily clinical practice and showed improved physical functioning after TNFi therapy in 67% of the patients. CONCLUSION: The 3 selected tests are recommended for use in daily practice because they generate information comparable to the full set. They are reliable and feasible, and the combination of these tests showed improved physical functioning after TNFi therapy in 67% of the patients. Evaluation of physical functioning might be improved by adding these tests to other AS outcome measures.

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OBJECTIVE: It has been hypothesized that pain and low vitality lead to an increase in avoidance of activities in persons with early symptomatic knee osteoarthritis (OA), and that avoidance of activities leads to an increase in activity limitations. The present study aimed to evaluate these hypotheses. METHODS: Baseline, 2-year, and 5-year followup data of 828 participants from the Cohort Hip and Cohort Knee Study with early symptomatic knee OA were used. Autoregressive generalized estimating equations and linear regression models were used to analyze the longitudinal and cross-sectional associations between self-reported knee pain, vitality, pain-related avoidance of activities, and activity limitations. The models were adjusted for the covariates age, sex, education level, body mass index, comorbidity, radiographic severity, and hip pain. RESULTS: In longitudinal analyses, knee pain and vitality predicted a subsequent increase in avoidance of activities. Pain-related avoidance of activities predicted a subsequent increase in activity limitations; however, this relationship lost statistical significance (P = 0.089) after adjustment for covariates. Cross-sectional analyses showed strong relationships between knee pain, low vitality, pain-related avoidance of activities, and activity limitations at all time points. CONCLUSIONS: In persons with early symptomatic knee OA, knee pain and low vitality lead to a subsequent increase in avoidance of activities. Pain-related avoidance of activities is related to activity limitations at inception of symptoms, but also years later. Therefore, it can be recommended to monitor and target avoidance of activities at various stages of the disease.

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PURPOSE: To explore the associations between (improvement in) fatigue and (improvement in) clinical and cognitive factors in patients with chronic widespread pain (CWP), participating in multidisciplinary rehabilitation treatment. METHODS: Data were used from baseline, 6 and 18 months of follow-up during a prospective cohort study of 120 CWP patients who completed multidisciplinary rehabilitation treatment. Cross-sectional and longitudinal relationships were analyzed between fatigue, clinical (i.e. pain, interference of pain and depression) and pain related cognitive factors (i.e. negative emotional cognitions, active cognitive coping, and control and chronicity beliefs). RESULTS: Higher levels of pain, interference of pain, depression, negative emotional cognitions, and negative control and chronicity beliefs were associated with a higher level of fatigue. Improvement in depression was related to improvement in fatigue. CONCLUSIONS: In CWP patients, worse clinical status, and dysfunctional pain-related cognitions are associated with a higher level of fatigue. Our results suggest that improvement in depression might be a mechanism of improvement in fatigue. Furthermore, improvement in fatigue seems to be independent of improvement in pain related cognitions. Targeting fatigue in multidisciplinary pain treatment may need specific strategies. IMPLICATIONS FOR REHABILITATION: Improvement in depression may be a mechanism of change to improve the level of fatigue in CWP. Improvement in dysfunctional (pain related) cognitions seems to be independent of improvement in fatigue. Targeting fatigue in multidisciplinary treatment may need specific strategies (e.g. additional interventions focusing on reducing fatigue and specific attention to improvement of sleep).

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BACKGROUND: Altered foot function is common in individuals with rheumatoid arthritis. Plantar pressure distributions during gait are regularly assessed in this patient group; however, the association between frequently reported magnitude-based pressure variables and clinical outcomes has not been clearly established. Recently, a novel approach to the analysis of plantar pressure distributions throughout stance phase, the dynamic plantar loading index, has been proposed. This study aimed to assess the utility of this index for measuring foot function in individuals with rheumatoid arthritis. METHODS: Barefoot plantar pressures during gait were measured in 63 patients with rheumatoid arthritis and 51 matched controls. Additionally, 15 individuals with rheumatoid arthritis had in-shoe plantar pressures measured whilst walking in standardized footwear for two conditions: shoes-only; and shoes with prescribed custom foot orthoses. The dynamic plantar loading index was determined for all participants and conditions. Patient and control groups were compared for significant differences as were the shod and orthosis conditions. FINDINGS: The patient group was found to have a mean index of 0.19, significantly lower than the control group's index of 0.32 (p>0.001, 95% CI [0.054, 0.197]). No significant differences were found between the shoe-only and shoe plus orthosis conditions. The loading index was found to correlate with clinical measures of structural deformity. INTERPRETATION: The dynamic plantar loading index may be a useful tool for researchers and clinicians looking to objectively assess dynamic foot function in patients with rheumatoid arthritis; however, it may be unresponsive to changes caused by orthotic interventions in this patient group.

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OBJECTIVE: To test whether knee stabilization therapy, prior to strength/functional training, may have added value in reducing activity limitations only in patients with knee osteoarthritis who have knee instability and (i) low upper leg muscle strength, (ii) impaired knee proprioception, (iii) high knee laxity, or (iv) frequent episodes of knee instability. DESIGN: Subgroup analyses in a randomized controlled trial comparing 2 exercise programmes (with/without knee stabilization therapy) (STABILITY; NTR1475). PATIENTS: Participants from the STABILITY-trial with clinical knee osteoarthritis and knee instability (n = 159). METHODS: Effect modification by upper leg muscle strength, knee proprioception, knee laxity, and patient-reported knee instability were determined using the interaction terms "treatment group subgroup factor", with the outcome measures WOMAC physical function (primary), numeric rating scale pain and the Get up and Go test (secondary). RESULTS: Effect modification by muscle strength was found for the primary outcome (p = 0.01), indicating that patients with greater muscle strength tend to benefit more from the experimental programme with additional knee stabilization training, while patients with lower muscle strength benefit more from the control programme. CONCLUSION: Knee stabilization therapy may have added value in patients with instability and strong muscles. Thus it may be beneficial if exercises target muscle strength prior to knee stabilization.

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The avoidance model in patients with knee and hip osteoarthritis (OA) hypothesizes that pain and psychological distress lead to avoidance of activities, and thereby to muscle weakness and activity limitations. This paper systematically reviews the scientific evidence for the validity of this avoidance model. A qualitative data synthesis was used to identify levels of evidence. Sixty studies were included. In knee OA, strong evidence was found that avoidance of activities is associated with activity limitations via muscle weakness (mediation by muscle weakness), strong evidence was found for an association between muscle weakness and activity limitations, and weak evidence was found that pain and psychological distress are associated with muscle weakness via avoidance of activities (mediation by avoidance). In hip OA, weak evidence was found for mediation by muscle weakness; and strong evidence was found for an association between muscle weakness and activity limitations. More research is needed on the consecutive associations between pain or psychological distress, avoidance of activities and muscle weakness, and to confirm causal relationships.

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OBJECTIVE: Despite beneficial effects on communication and process measures, client-centred practice has been shown to result in poor functional outcomes. To examine a potential explanation for poor functional outcomes, this paper aims to assess whether in client-centred therapy more time is spent on diagnostic consultation and less time on actual treatment compared to usual care. METHOD: A multicentre cluster randomised controlled trial was performed. Thirteen hospitals and rehabilitation centres, 29 therapists and 269 outpatients with multiple sclerosis participated. Measurements included an inventory of diagnostic and treatment goals, the number of sessions, therapy duration and therapy intensity. RESULTS: In client-centred therapy, more sessions were used for diagnostic consultation (10.9% points difference, p = 0.030); the time needed to formulate the first treatment goal was longer (11.4 days difference, p = 0.041); there was a tendency towards more goals directed to diagnostic issues (0.69 goals difference, p = 0.056), spending more hours on indirect issues (1.16 h difference, p = 0.051) and towards a longer total therapy period (1.56 months difference, p = 0.058) than in usual care. CONCLUSION: Client-centred therapy resulted in more intensive diagnostic evaluation and less intensive treatment. This suggests that client-centred therapy should be adjusted towards a more proportional distribution of time devoted to diagnostic evaluation versus actual treatment.

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OBJECTIVE: The aim of this study was to identify independent predictors of pain at the MTP joints in patients with PsA. METHODS: Thirty-four consecutive patients with PsA (mean age 45.3 years, 65% female, mean disease duration 9.9 years) and 22 control participants (mean age 37.9 years, 64% female) underwent clinical and US examination to determine the presence of pain, swelling, synovitis, erosions, effusions and submetatarsal bursae at the MTP joints. Mean barefoot peak plantar pressures were determined at each MTP joint. Levels of pain, US-determined pathology and peak pressures were compared between groups. Binary logistic regression was used to identify demographic, clinical examination-derived, US-derived and plantar pressure predictors of pain at the MTP joints in the PsA group. RESULTS: The presence of pain, deformity, synovitis, erosions (P < 0.001) and submetatarsal bursae and peak plantar pressure at MTP 3 (P < 0.05) were significantly higher in the PsA group. MTP joint pain in PsA was independently predicted by high BMI, female gender and the presence of joint subluxation, synovitis and erosion. CONCLUSION: These results suggest local inflammatory and structural factors, together with systemic factors (gender, BMI), are predominantly responsible for painful MTP joints in PsA, with no clear role for plantar pressure characteristics.

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BACKGROUND: The Western Ontario Shoulder Instability Index (WOSI) is a disease-specific shoulder questionnaire to measure quality of life in patients with shoulder instability. The aim of the present study was to translate the WOSI into Dutch and assess its principal measurement properties. METHODS: The WOSI was translated into Dutch according to guidelines in the literature. Fifty-two shoulder instability patients completed the questionnaire twice within 2 weeks. We assessed internal consistency (Cronbach's alpha), test-retest reliability [Intraclass Correlation Coefficient (ICC)], standard error of measurement (SEM), smallest detectable change (SDC) and reliable change index. The Bland-Altman analysis was applied to assess test-retest agreement and floor and ceiling effects were calculated. RESULTS: Cronbach's alpha was 0.95 for the total WOSI score (range 0.88-0.95 for the 4 domains). ICC for the total WOSI score was 0.91 (range 0.79-0.90 for domains), SEM was 130.6 for the total WOSI score resulting in a SDC of 362.0, which is 17.3 % of the maximum obtainable score of 2100. Bland-Altman analysis showed no systematic differences or consistent bias between the two assessments. We observed no relevant floor and ceiling effects. CONCLUSION: The results of the present study suggest the Dutch version of the WOSI is a reliable tool for clinical assessment and scientific evaluation. It shows high values for Cronbach's alpha and ICC implying excellent internal consistency and good test-retest reliability.

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OBJECTIVE: To evaluate the contribution of improvement in negative emotional cognitions, active cognitive coping, and control and chronicity beliefs to the outcome of multidisciplinary treatment in patients with chronic widespread pain. DESIGN: Prospective cohort study. PATIENTS: A total of 120 subjects diagnosed with chronic widespread pain, who completed a multidisciplinary pain programme. METHODS: Data from baseline, 6 months and 18 months follow-up measurements were analysed. Longitudinal relationships were analysed between changes in cognitions and outcome, using generalized estimated equations. Outcome domains included: pain, interference of pain in daily life, depression, and global perceived effect. Cognitive domains included: negative emotional cognitions, active cognitive coping and control and chronicity beliefs. RESULTS: Improvements in negative emotional cognitions were associated with improvements in all outcome domains, in particular with improvement in interference of pain with daily life and depression (between baseline and 6 months, and 6 and 18 months). Improvements in active cognitive coping were associated with improvements in interference of pain in daily life (between baseline and 6 months). Improvements in control and chronicity beliefs were associated with improvements in pain and depression (between 6 and 18 months). CONCLUSION: Improvement in negative emotional cognitions seems to be a key mechanism of change in multidisciplinary treatment of chronic widespread pain. Improvement in active cognitive coping and improvement in control and chronic timeline beliefs may also constitute mechanisms of change, although the evidence is less strong.

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OBJECTIVE: A prospective study was conducted in order to establish whether AS patients, who are defined as non-responders after 3 months of anti-TNF therapy, show improvement on performance-based tests of physical functioning. METHODS: At baseline and 3 months after the start of anti-TNF therapy, AS patients completed seven performance-based tests of physical functioning, questionnaires on self-reported physical functioning (BASFI) and disease activity (BASDAI), and a pain and a global patient assessment. The concordance between ≥ 20% intra-individual improvement on the performance-based test of physical functioning and (i) response to anti-TNF therapy [Assessment of SpondyloArthritis International Society 20% (ASAS20) response] and (ii) ≥ 20% intra-individual improvement on self-reported physical functioning (BASFI) was assessed. RESULTS: One hundred AS patients were included, of which 82 patients completed all tests at both time points. After 3 months of anti-TNF therapy, 27 (32.9%) patients were categorized as non-responders according to the ASAS20 response criteria. Improvement in performance-based physical functioning was seen in 13 of the 27 non-responders (48.1%) (i.e. n = 13/82 = 15.9% of the total group). Furthermore, 30 (36.6%) patients showed no improvement on self-reported physical functioning (BASFI). However, 17 of the 30 (56.7%) patients did improve on the performance-based tests of physical functioning (i.e. n = 17/82 = 20.7% of the total group). CONCLUSION: After 3 months of anti-TNF therapy, performance-based tests of physical functioning showed improvement in 48.1% of the ASAS20 non-responders. With these performance-based tests, new information on outcome after anti-TNF therapy can be generated. Using performance-based tests alongside the BASFI could have additional value in the evaluation of outcomes for patients receiving anti-TNF therapy.

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Despite the widespread use of customised foot orthoses (FOs) for the pronated foot type there is a lack of reliable information on the dose-response effect on lower limb mechanics. This study investigated these effects in subjects with normal and pronated foot types. Customised FOs were administered to 12 participants with symptomatic pronated foot type and 12 age and gender matched controls. A computer-aided design (CAD) software was used to design nine FOs per participant with dose incrementally changed by varying only the rearfoot post angle. This was done in 2° increments from 6° lateral to 10° medial posting. A 3D printing method was used to manufacture the FOs. Quantification of the dose-response effect was performed using three-dimensional gait analyses for selected rearfoot and knee kinematics and kinetics. Under these experimental conditions, significant and linear effects of posting were seen for the peak (p<0.001) and mean (p<0.001) rearfoot eversions, peak (p=0.003) and mean (p<0.001) ankle eversion moments and peak (p=0.017) and mean (p=0.005) knee adduction moment variables. Group effects were observed for the peak (p=0.007) and mean (p=0.007) forefoot abduction and for the peak (p=0.007) knee adduction moment. A significant interaction between posting and group was seen for internal tibial rotation (p=0.004). These data indicate that a dose-response effect, with a linear trend for both the rearfoot and knee, exists for customised FOs used to treat pronated foot type.

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PURPOSE: To assess the efficacy of client-centred occupational therapy (OT) according to a client-centred process framework, as compared to usual care OT, in patients with multiple sclerosis (MS). METHOD: A multicentre cluster randomised controlled trial with the institution (i.e. hospital or rehabilitation centre) as the unit of randomisation was performed. A total of 269 outpatients with MS, 13 hospitals and rehabilitation centres and 29 occupational therapists participated. Primary outcomes included measures of disability, participation and autonomy. Secondary outcomes included fatigue, generic health-related quality of life, quality and evaluation of therapy, therapy compliance and therapy frequency. Measurements were taken at baseline, four months and at eight months follow-up. RESULTS: Primary outcome measures did not show significant differences between the two interventions. Secondary outcomes revealed significant differences in favour of the usual care OT on fatigue (physical scale and total scale) and health-related quality of life (bodily pain and vitality) at four months. After eight months only significant differences on mental health were found. Process outcomes (i.e. the information scale of therapy quality and the client-centredness of the organisation) were in favour of the client-centred intervention. CONCLUSION: Because the client-centred intervention resulted in no effects on the primary outcomes and small but negative effects on the secondary functional outcomes, we should seriously reconsider the application of client-centred practice. IMPLICATIONS FOR REHABILITATION: An increasing number of interventions claim to incorporate client-centred practice. Client-centred practice is associated with improved satisfaction but the effects on functional health-related outcomes have not been fully evaluated. The findings of this study show that the process outcomes of therapy were in favour of the client-centred intervention, but no effects were found on the primary outcomes and negative effects on the secondary functional health outcomes. It is suggested that the implementation of client-centred practice should be adjusted in order to achieve optimal health outcomes.

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