People with osteoarthritis (OA) suffer from joint degeneration and pain as well as difficulty performing daily activities. Joint contact forces (JCF) are important for understanding individual joint loading, however, these contact force cannot be directly measured without instrumented implants. Musculoskeletal modeling is a tool for estimating JCF without the need for surgery. The results from these models can be very different due to different approaches used in the development of a model that was used for simulation. Therefore, the first purpose of this study was to develop and validate a musculoskeletal model in which lower extremity JCF were calculated at the hip, knee, and ankle in 10 participants with hip OA (H-OA) and 10 healthy control participants using OpenSim 4.0 [simtk.org, 23]. The generic gait2392 model was scaled to participant demographics, then the inverse kinematics (IK) solution and kinetic data were input into the Residual Reduction Algorithm (RRA) to reduce modeling errors. Kinematic solutions from RRA were used in the Computed Muscle Control (CMC) tool to compute muscle forces, then JCF were estimated using the Joint Reaction Analysis tool. Validation included JCF comparisons to published data of similar participant samples during level walking, and movement simulation quality was assessed with residual forces and moments applied at the pelvis, joint reserve actuators, and kinematic tracking errors. The computed JCFs were similar to the overall trends of published JCF results from similar participant samples, however the values of the computed JCFs were anywhere from 0.5 times body weight (BW) to 3BW larger than those in published studies. Simulation quality assessment resulted in low residual forces and moments, and low tracking errors. Most of the reserve actuators were small as well, besides pelvis rotation and hip rotation. The computed JCF were then used in the second portion of this study to determine the effect of group and side on JCF during both the weight acceptance and push-off phases of level walking. It was determined that there was a significant difference in the knee and ankle JCF during the weight acceptance portion of stance phase and at all joints during the push-off phase when comparing the H-OA and control groups on the affected limb. A significant interaction between group and limb was found for the peak hip JCF timing (% stance) during the push-off portion of the stance phase (p=0.009). These results demonstrate that H-OA participants experience an earlier peak hip JCF during propulsion on their affected limb. Based on previous research in OA that has examined spatiotemporal measures, this finding suggests that H-OA participants may use step or stride length changes as a strategy to decrease or limit pain and loading on the affected limb. Knowledge of potential JCF differences in H-OA participants, such as timing of the peaks in either portion of the stance phase, could provide useful insight to clinicians and therapists to make decisions on how to proceed with treatment or rehabilitation programs. / Master of Science / People with osteoarthritis suffer from joint degeneration and pain as well as difficulty performing daily activities, like walking. It is important to understand the forces and loading within individual joints. Musculoskeletal modeling is one way that researchers can estimate these joint contact forces (JCF) without needing a joint replacement implant that can measure these forces. When it comes to modeling simulations, there is a wide variety of results. Therefore, the first purpose of this study was to develop and validate a musculoskeletal model in which JCFs were calculated at the hip, knee, and ankle in 10 participants with hip osteoarthritis and 10 healthy adults. Validation of the model was completed through a comparison between computed results and published data of similar participant samples during level walking. The computed results were similar to the overall trends of published JCF results, however the numerical values themselves were larger than those in published studies. The computed JCFs were then used in the second portion of this study to determine how the two groups and limbs differ during level walking. There was a significant difference in the knee and ankle JCF during the first half of the stance phase and in all joints during the second half of stance when comparing the two groups. The hip osteoarthritis participants also experience an earlier peak hip JCF during the second half of stance phase on their affected limb. This finding suggests that hip osteoarthritis participants may change the way they take a step as a strategy to decrease or limit pain and loading on the affected limb. Knowledge of potential JCF differences, such as timing of the peaks in either portion of the stance phase, could provide useful insight to clinicians and therapists to make decisions on how to proceed with treatment or rehabilitation programs.

Author: Barbora Říhová Title: Kinematic Analysis of Gait in Patients with Hip Osteoarthrosis Objectives: The aim of this thesis was to analyse the gait patterns in probands with Stage III osteoarthritis of the hip joint, to compare these patterns with published norms and to confirm a set of pre-established hypotheses. Method: The thesis was designed as a case study, the purpose of which was to observe changes in the pelvis and trunk extension during gait, associated with significant degenerative changes in the hip joint. A total of 9 probands with Stage III osteoarthritis of the hip joint (6 females, 3 males) took part in the study. A complete physiotherapy assessment was carried out as part of the study. The temporal gait parameters were used to measure the probands' walking speed and relative stance phase duration. The following variables were measured in the frontal plane: lateral displacement of the pelvis and trunk toward the stance limb (cm) and pelvic obliquity toward the swing limb (degrees). A 3D motion analysis and evaluation of kinematic parameters were carried out using the Qualisys motion capture system device consisting of 6 infrared cameras. Gait was measured at different walking speeds during a 10-second time frame and the data was subsequently subtracted from a minimum of 5 gait...

京都大学 / 0048 / 新制・課程博士 / 博士(人間健康科学) / 甲第17981号 / 人健博第10号 / 新制||人健||1(附属図書館) / 80825 / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 坪山 直生, 教授 椎名 毅, 教授 松田 秀一 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

京都大学 / 0048 / 新制・論文博士 / 博士(人間健康科学) / 乙第13033号 / 論人健博第2号 / 新制||人健||3(附属図書館) / 32991 / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 坪山 直生, 教授 黒木 裕士, 教授 妻木 範行 / 学位規則第4条第2項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

A osteoartrite do quadril é uma grande causa de incapacidade da população idosa. A doença é caracterizada pela deterioração da cartilagem articular, perda do espaço cartilaginoso, esclerose do osso subcondral e presença de osteofitos. O teste Timed Up And Go (TUG) tem sido considerado como uma das ferramentas para avaliar a função do membro inferior, mobilidade e risco de quedas. O presente estudo visa determinar a influência da amplitude de movimento (ADM) do quadril no resultado do teste TUG em pacientes com osteoartrite de quadril, visto que há poucos estudos sobre o tema. Fizeram parte do estudo um total de 40 indivíduos divididos em dois grupos, 20 indivíduos no grupo controle e 20 no grupo de osteoartrite de quadril (grupo OA) com idade entre 40 e 75 anos. Para a inclusão dos indivíduos no grupo OA, utilizamos os critérios clínicos do American College of Rheumatology e para graduar a intensidade do comprometimento articular utilizamos a classificação de Tönnis. Os critérios de exclusão foram a presença de cirurgia prévia no membro inferior, fratura prévia no membro inferior, osteoartrite bilateral, dor lombar, obesidade mórbida, pacientes com estado geral comprometido por doenças sistêmicas graves, comprometimento cognitivo ou comprometimento neurológico. Através de um goniômetro examinadores independentes realizaram a medida de ADM ativa do quadril e com um cronômetro digital o tempo do teste TUG. Foi aplicado o Questionário de Western Ontario Universities (WOMAC) e a escala visual analógica de dor (EVA). Realizou-se a somatória da ADM de todos os movimentos do quadril e através do coeficiente de correlação de Pearson observamos a associação linear entre as variáveis ADM total ativa do quadril e tempo do teste TUG, nos grupos controle e OA. Nos resultados a ADM total ativa do quadril e o tempo do TUG do grupo OA apresentaram uma correlação negativa e moderada (r = - 0,69; p < 0,0001) porém no grupo controle observou-se fraca correlação (r = -0,08; p = 0,46). Os dados do estudo demonstram uma moderada correlação entre o tempo do TUG e a ADM total ativa do quadril em indivíduos com OA. Porém, mais estudos são necessários para determinar todas as variáveis que influenciam o resultado do teste. / Hip osteoarthritis is a major cause of disability in the elderly population. The disease is characterized by deterioration of articular cartilage, loss of cartilaginous space, sclerosis of subchondral bone and presence of osteophytes. The Timed Up And Go (TUG) test has been considered as one of the tools for assessing lower limb function, mobility, and risk of falls. The present study aims to determine the influence of the range of motion (ROM) on the TUG test result in patients with hip osteoarthritis, since there are few studies on the subject. A total of 40 individuals were divided into two groups, 20 in the control group and 20 in the group of hip osteoarthritis (OA group) aged between 40 and 75 years. For the inclusion of the individuals in the OA group we used the clinical criteria of the American College of Rheumatology and to grade the severity of the joint degeneration we used the Tönnis classification. Exclusion criteria were the presence of previous surgery on the lower limb, previous lower limb fracture, bilateral osteoarthritis, low back pain, morbid obesity, patients with poor general condition due to severe systemic diseases, cognitive impairment or neurological impairment. With a goniometer independent examiners performed the measurement of active ROM of the hip and with a digital timer the TUG test time. Western Ontario Universities Questionnaire (WOMAC) and visual analogue pain scale (VAS) were applied. We performed the summation of the ROM of all hip movements and through the Pearson correlation coefficient we observed the linear association between the active total ROM of the hip and the time of the TUG test in the control and OA groups. In the results, the total active ROM of the hip and the TUG time of the OA group presented a negative and moderate correlation (r = -0.64; p <0.0001), but in the control group there was a weak correlation (r = -0.08; p =0.46) . Data from the study demonstrate a moderate correlation between TUG time and total active ROM in subjects with OA. However, more studies are needed to determine all the variables that influence the test result.

L’arthrose est la maladie articulaire la plus fréquente pouvant être responsable d’une perte d’autonomie et d’un handicap fonctionnel majeur. Du fait du vieillissement de la population et de la prévalence de l’obésité, le nombre de personnes ayant une arthrose des membres inférieurs va augmenter dans les années à venir et entrainer une explosion des dépenses de santé. La cohorte « Knee and Hip OsteoArthritis Long-term Assessment » (KHOALA) est une cohorte française multicentrique représentative de patients atteints d’arthrose symptomatique de hanche et/ou de genou.Les objectifs de ce projet étaient d’établir une revue de la littérature sur les conséquences économiques de l'arthrose de hanche et/ou du genou. Puis à partir de la cohorte KHOALA, nous avons décrit la consommation de soins ; identifié les facteurs associés aux trajectoires d'utilisation des ressources de santé et estimé les coûts annuels totaux. Enfin nous avons réalisé une analyse systématique de la littérature sur les analyses coût-efficacité des anti-arthrosiques d’action lente et de l’acide hyaluronique intra articulaire dans l’arthrose de genoux.La revue systématique a objectivé une hétérogénéité des couts totaux par patient (de 0,7 à 12 k€/an). Les données de KHOALA ont démontré que la majorité des patients consultait son médecin généraliste et une minorité de patients consultait un spécialiste. Le seul facteur clinique indépendant prédictif des consultations des professionnels de la santé était l'état de santé mentale. Le coût total annuel moyen par patient sur la période d'étude de 5 ans était de 2180 ± 5 305 €. En France, les coûts médians pourraient atteindre 2 milliards € / an (IQR 0,7–4,3). / Osteoarthritis is the most common joint disease that can be responsible for a loss of autonomy and a major functional disability. With the aging of the population and the prevalence of obesity, the number of people with lower limb osteoarthritis will increase in the coming years and lead to an explosion of health spending. The "Knee and Hip OsteoArthritis Long-term Assessment" cohort (KHOALA) is a representative French multicenter cohort of patients with symptomatic hip and / or knee osteoarthritis.The aims of this thesis were to provide an overview of the economic consequences of hip and knee osteoarthritis worldwide. Then from the KHOALA cohort, we described health care resources use in the KHOALA cohort, we identified factors associated with trajectories of healthcare use and we estimated the annual total costs. Finally, we conducted a systematic review of the literature on the cost effectiveness of intra-articular hyaluronic acid and disease-modifying osteoarthritis drugs used in the treatment of knee OA.The systematic review showed a heterogeneity of the total costs per patient (from 0.7 to 12 k € / year). KHOALA data showed that primary care physicians have a central role in osteoarthritis care, mental health state was the only independent predictive factor of healthcare professional consultations. The mean annual total cost per patient over 5 years was 2180 ± 5,305 €. In France, median annual total costs would be approximately 2 billion €/year (IQR 0.7-4.3).

Bakgrund: Artros är en av de ledande orsakerna till funktionshinder hos äldre vuxna. Träning är en grundsten i vanlig artrosbehandling, men vid uteblivna resultat kan protesoperation vara nödvändig. Träning inför höftprotesoperation kan minska dekonditionering och ge gynnsamma postoperativa utfall, men träningsupplägg och dos har inte undersökts tillräckligt noggrant för att säkerställa bäst effekt. Syfte: Att genom en systematisk litteraturstudie kartlägga hur preoperativ träning genomförts inför höftprotesoperation och dess påverkan på postoperative smärta och funktion. Metod: Sökningar genomfördes i databaserna CINAHL, PubMed, Cochrane och Web of Science för att identifiera relevanta artiklar. Grovsållning av artikelnamn och abstrakt utfördes individuellt av författarna i programmet “Rayyan”. Potentiellt relevanta artiklar lästes i fulltext innan dess relevans bedömdes. Därefter skedde granskningar av metodologisk kvalitet och forskningsetiken av inkluderade studier. Resultat: Tio RCT-studier inkluderades. Preoperativa interventioner bestod av styrketräning, konditionsträning, flexibilitetsträning, postural kontroll eller funktionell träning. Interventionerna och doseringen var olika tydligt beskrivna och utförda och med varierande effekt på både smärta och funktion. På grund av studiernas metodologiska brister användes endast fyra studier som underlag för slutsatser kring träningsupplägg och dos. Slutsats: Få studier har säkerställt tydlighet i träningsprogrammen, att träningen bygger på evidensbaserad rekommendation, progression och följsamhet. Frekvens och volym verkar till viss del kompensera för utebliven intensitet / Background: Osteoarthritis is one of the leading causes of disability among older adults. Exercise is a cornerstone in regular osteoarthritis treatment, but sometimes a joint replacement may be necessary. Training prior to hip replacement surgery can reduce patient deconditioning and produce positive postoperative results, but the type of training and dosage hasn’t been researched regarding best possible effects. Purpose: Through a systematic literature study survey the types of preoperative training used for hip replacement surgery and present results for postoperative pain and function. Method: Searches were conducted in the databases CINAHL, PubMed, Cochrane and Web of Science to identify relevant articles. Titles and abstracts were screened individually by the authors in the program “Rayyan”. Potentially relevant articles were read in full text. A review and examination regarding methodological quality and ethics of the included articles was conducted. Results: Ten RCT-studies were included. Preoperative interventions consisted of strength training, endurance training, flexibility training, postural control or functional training. Descriptions of interventions and dosage were at varying levels of detail. The effects on pain and function also varied. Due to insufficient methodological quality only four studies were used for conclusions regarding training intervention and dose. Conclusion: Few studies have clearly defined exercise programs, and lack evidence-based recommendations, progressive overload and compliance. Frequency and volume seem to partially compensate for lack of exercise intensity.

INTRODUÇÃO: a doença de Legg-Calvé-Perthes (DLCP) é a causa da osteoartrose de quadril em menos de 5% dos casos com indicação de artroplastia total do quadril (ATQ). Por isso, poucos estudos descrevem os resultados clínicos e radiológicos da ATQ nessa situação, em que deformidades no fêmur proximal e no acetábulo tornam a cirurgia um desafio técnico. MÉTODO: neste estudo tipo caso-controle, foram revisados os prontuários de pacientes admitidos num hospital público universitário de referência para serem submetidos à ATQ por osteoartrose primária ou secundária à DLCP entre 2008 e 2015, utilizando um determinado modelo de prótese não cimentada de um mesmo fabricante. Os pacientes foram convocados para análise clínica e radiográfica. Indivíduos com ATQ por osteoartrose secundária à DLCP foram comparados a um grupo controle de pacientes com osteoartrose primária quanto a dor e função por meio do questionário de Lequesne. Foram também avaliadas as seguintes variáveis radiográficas: inclinação lateral do componente acetabular em relação à pelve, offset femoral e posicionamento do componente femoral em relação ao canal femoral. As avaliações radiográficas no pós-operatório imediato e na última consulta de seguimento foram comparadas. O tempo cirúrgico, o tamanho dos componentes protéticos utilizados e as complicações decorrentes do ato cirúrgico foram comparados nos dois grupos. RESULTADOS: no período do estudo, foram analisados 22 pacientes no grupo estudo (25 quadris) e 22 pacientes (25 quadris) do grupo controle, que foram comparados. Os dois grupos eram homogêneos quanto a lateralidade, sexo, tempo de cirurgia, tempo de seguimento e tamanho dos componentes utilizados. Os pacientes do grupo controle, com osteoartrose primária, tinham idade superior aos do grupo estudo. Ocorreram quatro fraturas periprotéticas femorais intraoperatórias no grupo com sequela da DLCP e nenhuma no grupo com osteoartrose primária (p = 0,050). A avaliação clínica e funcional mostrou maior comprometimento no grupo de pacientes com sequela da DLCP (p = 0,002). As medidas angulares de inclinação lateral acetabular foram semelhantes entre os dois grupos. Tanto no pós-operatório imediato quanto no final do seguimento, os componentes femorais estavam posicionados significativamente mais em valgo para o grupo com sequela da DLCP quando comparados ao grupo controle (com p = 0,008 no pós-operatório imediato e p = 0,002 no seguimento final). A medida do offset femoral lateral não teve diferenças significativas entre os grupos. Em nenhum dos casos dos grupos estudados houve infecção, luxação ou lesão neurológica decorrentes do ato cirúrgico. Não foi indicada ou realizada nenhuma cirurgia de revisão em ambos os grupos. CONCLUSÕES: há risco aumentado de fratura femoral periprotética intraoperatória e resultados clínico-funcionais piores em pacientes com osteoartrose secundária à sequela da DLCP submetidos a ATQ sem cimento convencional do que em pacientes com osteoartrose primária do quadril. Os componentes femorais da ATQ sem cimento convencional tendem a ser implantados mais em valgo no canal femoral nos casos motivados por osteoartrose secundária à sequela da DLCP comparados aos casos motivados por osteoartrose primária do quadril / INTRODUCTION: Legg-Calvé-Perthes disease (LCPD) is the cause of hip osteoarthrosis in less than 5% of cases with an indication of total hip arthroplasty (THA). For that reason, few studies describe the clinical and radiological results of THA in this situation, in which proximal femur and acetabulum deformities make surgery a technical challenge. METHODS: In this case-control study, the medical records of patients admitted to a public university reference hospital to undergo THA due to primary osteoarthrosis or to LCPD sequelae between 2008 and 2015, using a cementless prosthesis from the same manufacturer, were reviewed. Patients were recruited for clinical and radiographic analysis. Individuals with osteoarthrosis secondary to LCPD were compared to a control group of patients with primary osteoarthrosis regarding pain and function using the Lequesne questionnaire. The following radiographic variables were also evaluated: acetabular component inclination in relation to the pelvis, femoral offset, and femoral component position in relation to the femoral canal. Evaluations in the immediate postoperative period and at the last follow-up visit were compared. The surgical time, the size of the prosthetic components used and the complications resulting from the surgical procedure were studied and compared between groups. RESULTS: During the study period, 22 patients in the study group (25 hips) were compared to 22 patients (25 hips) in the control group. The two groups were homogeneous regarding the laterality, sex, surgery time, follow-up time and size of the prosthetic components used. Patients in the control group, with primary osteoarthrosis, were older than those in the study group. There were four intraoperative femoral periprosthetic fractures in the group with LCPD sequelae and none in the primary osteoarthrosis group (p = 0.050). The clinical and functional evaluation showed greater impairment in the group of patients with LCPD sequelae (p = 0.002). Angular measures of acetabular inclination were similar between the two groups. Both in the immediate postoperative period and at the end of the follow-up, the femoral components were positioned significantly more in valgus for the LCPD sequelae group when compared to the control group (p = 0.008 in the immediate postoperative period and 0.002 in the final follow-up). The measurement of the lateral femoral offset was similar between the groups. In none of the cases of the studied groups, there was infection, dislocation or neurological injury resulting from the surgical act. No revision surgery was indicated or performed in both groups. CONCLUSIONS: There is an increased risk of intraoperative periprosthetic femoral fracture and worse clinical-functional results in patients with osteoarthrosis secondary to LCPD sequelae undergoing conventional cementless THA than in patients with primary hip osteoarthrosis. The femoral components of the cementless THA tend to be implanted more in valgus in the femoral canal in the cases of osteoarthrosis secondary to the sequelae of the LCPD compared to cases of primary hip osteoarthrosis

Background Osteoarthritis (OA) of the hip is a common disease among elderly adults and its prevalence increases with age. Hip OA is presumed to be a group of diseases resulting in the same pathological pathway, but its etiology is not completely understood. The major symptoms are joint pain, joint stiffness, impaired range of motion, and muscle weakness resulting in increased levels of physical disability (PD) and reduced quality of life. Besides the impairments of the individual subject a heavy economic burden goes along with the disease and is expected to increase due to aging societies in western countries throughout the upcoming years. Exercise therapy (ET), including elements to strengthen the hip muscles, is a common treatment in hip OA and considered to reduce pain and PD. Currently, there is only silver-level scientific evidence regarding the effectiveness of ET in hip OA due to a limited number of high quality studies. Furthermore, the optimal content and dosage, as well as the mode of delivery of ET need to be evaluated. This doctoral thesis deals with three specific aspects of hip muscle strength (HMS) in patients with hip OA: the precision of measuring HMS, training HMS, and the relevance of HMS to physical disability (PD). Three studies and one study protocol provide the scientific program of this thesis, referring to these aspects of HMS. Methods The first study (S1) investigated the reproducibility of isokinetic and isometric HMS measures in patients with hip OA. 16 subjects with unilateral or bilateral hip OA and 13 healthy subjects were tested twice, 7 days apart. A subpopulation of 11 hip OA patients was tested a third time to evaluate familiarization to these measurements. The standard error of measurement (SEM) served as the reproducibility outcome parameter. The second study (S2) investigated the feasibility of strengthening exercises and their effect on HMS in hip patients. 36 participants from an institutional training group for hip patients were allocated randomly to an intervention or control group. While the intervention group completed an eight-week progressive home-based strengthening exercise program (PHSEP) in addition to the weekly institutional supervised group-based exercise therapy (ISET), the control group continued weekly ISET, only. Exercise logs were used to monitor adherence, pain, and the applied exercise intensity of the PHSEP. Before and after the intervention period, HMS was determined using isokinetic concentric and isometric HMS measurements. Additionally, health-related quality of life was assessed by the SF36 questionnaire. These two studies served as a basis for developing strength-specific aspects of a study design for a randomized controlled trial (RCT), which was in progress at the writing of this thesis. This RCT addresses the above-mentioned lack of scientific evidence about the effectiveness of ET in hip OA. A study protocol (P1) describes this RCT, which evaluates the effectiveness of ET on pain and PD in patients with hip OA. 217 patients with hip OA were recruited from the community and allocated to one of the four groups: (1) exercise group, n = 70 (2) non-intervention group, n = 70, (3) “Sham” ultrasound group, n = 70, and (4) ultrasound group, n = 7. The main outcome measure is the change in the subscale bodily pain of the SF36. Secondary outcomes are PD assessed by the SF36 and the WOMAC questionnaire, isometric HMS, several gait variables and postural control. Finally, the relationship of HMS and PD in hip OA was investigated in a third (cross-sectional) study (S3). A stepwise regression model was applied with data from 149 subjects suffering from hip OA. The outcome variable was the self-reported physical disability, assessed with the physical function subscale of the WOMAC questionnaire. Age, gender, body mass index BMI , HMS, pain, stiffness, and range of motion were included in the statistical model as associated factors of PD. Results The results of S1 showed high variability in HMS measurements between days. The highest SEM values, indicating poorest reproducibility, were obtained for hip extension, followed by hip adduction and hip flexion measures, while the smallest values were found for hip abduction measures. Lower reproducibility occurred in patients with hip OA in comparison to healthy controls during the isometric measures of hip abduction, adduction, and flexion. Reproducibility of 11 hip OA patients was lower for the second test sequence (test-day 2 and 3) than for the first test sequence (test-day 1 and 2). The findings of S2 indicated high exercise adherence (99%) of the intervention group to the applied PHSEP. Furthermore, exercise logs reported that pain resulting from the PHSEP was low. HMS improved about 7-11% in comparison to the control group. The SF36 variables did not change throughout the exercise period. In S3, the statistical model revealed stiffness, pain, and HMS to be significant factors of self-reported physical disability in hip OA. Conclusion In conclusion, the precision of several HMS measures may be affected by hip OA and clinicians should be aware of a higher measurement error in patients with hip OA under isometric test conditions than for healthy subjects. A familiarization measurement may be an approach to diminish the measurement error. The applied PHSEP amended to an ISET is feasible for hip patients to carry out and can be applied to improve HMS. Furthermore, a significant cross-sectional relationship between HMS and PD has been evaluated, indicating that HMS may be an important factor to stimulate during exercise therapy in hip OA. The upcoming results of the RCT (P1) described in the study protocol will help to reduce the shortcomings in scientific evidence regarding the effectiveness of strengthening exercise regimes to reduce pain and PD in patients with hip OA. / Hintergrund Coxarthrose ist eine weit verbreitete Krankheit in der älteren Bevölkerung westlicher Industrienationen. Die Bedeutung und Zahl der Neuerkrankungen nehmen mit steigendem Lebensalter zu. Schmerz, Steifheit, Bewegungseinschränkungen und Muskelschwäche zählen zu den Leitsymptomen dieser Krankheit, die sich in einer zunehmenden körperlichen Funktionseinschränkung und eingeschränkten Lebensqualität der Patienten äußern. Neben der Bedeutung für die betroffenen Patienten selbst wachsen in westlichen Industrienationen aufgrund der demographischen Entwicklung hin zu einer alternden Gesellschaft der Druck und die finanzielle Belastung auf die Renten- und Gesundheitssysteme. Die Sporttherapie wird häufig in frühen Stadien der Krankheit eingesetzt und zählt zu den konservativen Therapieverfahren. Nach aktuellem Stand der Wissenschaft scheinen sporttherapeutische Interventionen mit Trainingselementen zur Kräftigung der hüftumgebenden Muskulatur sinnvoll. Dennoch wurde die Wirksamkeit von Sporttherapie bei Coxarthrose bisher nur in einzelnen Studien nachgewiesen (Silver-level Evidence). Es fehlen qualitativ hochwertige randomisierte Kontrollgruppenstudien (RCTs). Zudem ist bislang ungeklärt, wie ein optimales Trainingsprogramm bei Coxarthrose hinsichtlich der Inhalte, Dosierung und Durchführungsmodalität zu gestalten ist, um Schmerz und körperliche Funktionseinschränkungen bestmöglich zu therapieren. Vor diesem Hintergrund beschäftigt sich die vorliegende Dissertation mit drei Aspekten der Hüftmuskelkraft bei Patienten mit Coxarthrose. Drei entsprechende Studien, die in vier wissenschaftlichen Artikeln aufgearbeitet wurden, bilden den wissenschaftlichen Schwerpunkt der Arbeit. Methode Die erste Studie (S1) befasst sich mit der Messgenauigkeit von Hüftkraftmessungen bei Coxarthrosepatienten. Unter diesem Aspekt wurden isometrische und isokinetische Kraftmessgrößen an der Hüfte bei 16 Coxarthrosepatienten und 13 gesunden Personen zwei Mal im Abstand von sieben Tagen erhoben. Bei einer Teilstichprobe von 11 Coxarthrosepatienten wurden die Messungen ein drittes Mal durchgeführt, um mögliche Gewöhnungseffekte zu evaluieren. Der Standard Error of Measurement (SEM) wurde verwendet, um den Messfehler zu quantifizieren. Die zweite Studie (S2) greift einen weiteren Aspekt auf, der sich auf das Training der Hüftmuskelkraft bei Hüftpatienten bezieht. Hier wurde die Machbarkeit eines ergänzenden Heimtrainingsprogramms zur Kräftigung der hüftumgebenden Muskulatur evaluiert sowie mögliche Auswirkungen auf die Hüftmuskelkraft untersucht. 36 Teilnehmer einer Hüftsportgruppe mit Coxarthrose und/oder einer Total-Endoprothese (TEP) wurden randomisiert in zwei Untersuchungsgruppen aufgeteilt. Während die Patienten der Kontrollgruppe im Untersuchungszeitraum weiterhin wöchentliche institutionelle sporttherapeutische Trainingseinheiten wahrnahmen, führten die Patienten der Interventionsgruppe zusätzlich Heimtrainingseinheiten zur Kräftigung der Hüftmuskeln durch. Vor und nach der Intervention wurden isometrische und isokinetische Maximalkraftmessungen durchgeführt. Die Patienten der Trainingsgruppe haben ein Trainingstagebuch geführt, um die Teilnahme am Heimtrainingsprogramm und mögliche Schwierigkeiten damit zu dokumentieren. Der SF36 Fragebogen wurde eingesetzt, um die gesundheitsbezogene Lebensqualität im Verlauf zu kontrollieren. Die Erkenntnisse der beiden beschriebenen Studien wurden verwendet, um kraftspezifische Aspekte eines Studiendesigns zu entwickeln. Dieses Studiendesign entspricht einem RCT und soll die Effektivität eines sporttherapeutischen Trainingskonzepts hinsichtlich Schmerzreduktion und Verbesserung der körperlichen Funktionsfähigkeit überprüfen. 217 Hüftarthrosepatienten werden rekrutiert und randomisiert auf eine der folgenden Untersuchungsgruppen aufgeteilt: (1) Trainingsgruppe, n = 70 (2) Kontrollgruppe ohne Intervention, n = 70, (3) “Schein” Ultraschallgruppe, n = 70, und (4) Ultraschallgruppe, n = 7. Die primäre Zielgröße ist Veränderung in der Subskala „Körperliche Schmerzen“ des SF36-Fragebogens. Sekundäre Zielgrößen sind Schmerz und Körperliche Funktionsfähigkeit aus dem WOMAC-Fragebogen, weiteren Subskalen des SF36-Fragebogens, isometrische Hüftmuskelkraft, verschiedene Variablen des Gangs und posturale Kontrolle. Die Bedeutung der Hüftmuskelkraft auf die alltagsrelevante körperliche Funktionsfähigkeit stellt den dritten Aspekt dieser Dissertation dar und wurde in Studie 3 (S3), einer Querschnittsuntersuchung an 149 Coxarthrosepatienten behandelt. Ziel der Studie war die Untersuchung des Zusammenhangs verschiedener Variablen und der alltagsbezogenen körperlichen Funktionsfähigkeit. In einem statistisches Modell wurde die Beziehung zwischen den Variablen: Hüftmuskelkraft, Body Mass Index (BMI), Alter, Geschlecht, Schmerz, Steifheit und Beweglichkeit der Hüfte und der Subskala „Körperliche Funktionsfähigkeit“ des WOMAC-Fragebogens als Maß für die alltagsbezogene körperlichen Funktionsfähigkeit berechnet. Ergebnisse In der ersten Studie (S1) wurden die größten Messfehler in den Messgrößen Hüftextension ermittelt. Danach folgten die Messgrößen Hüftadduktion und -flexion. Der geringste Messfehler wurde für Hüftabduktion ermittelt. Unter isometrischen Bedingungen wurden in den Kraftmessgrößen Hüftabduktion, -adduktion und -flexion bei Coxarthrosepatienten größere Messfehler quantifiziert als bei gesunden Personen. Zudem war die Reproduzierbarkeit in der ersten Test-Sequenz (Messtag 1 und 2) im Vergleich zur zweiten Test-Sequenz reduziert (Messtag 2 und 3). In der zweiten Studie (S2) konnte gezeigt werden, dass das verwendete Heimtrainingsprogramm sicher und selbstständig von den Hüftpatienten durchgeführt werden konnte. Die Trainingstagebücher ließen auf eine nahezu hundertprozentige Teilnahme am ergänzenden Heimtrainingsprogramm schließen und zeigten außerdem, dass das Heimtrainingsprogramm keine schmerzverursachende Wirkung hatte. Nach der Intervention war die Kraft der hüftumgebenden Muskulatur im Vergleich zur Kontrollgruppe um 7-9% gesteigert. Befunde hinsichtlich einer veränderten Lebensqualität konnten nicht registriert werden. Das statistische Modell, das in der dritten Studie (S3) eingesetzt wurde, erkannte Schmerz, Steifheit und Hüftmuskelkraft als die drei bedeutsamsten Faktoren für die alltagsbezogene körperliche Funktionsfähigkeit bei Patienten mit Coxarthrose. Schlussfolgerungen Kraftmessungen an der Hüfte scheinen erheblichen Tagesschwankungen ausgesetzt zu sein. Bei Coxarthrosepatienten und gesunden Personen scheint sich die Wiederholbarkeit von isokinetischen Kraftmessungen zu ähneln. Unter isometrischen Testbedingungen muss mit höheren Messfehlern bei Coxarthrosepatienten gerechnet und entsprechend bei der Interpretation von Ergebnissen berücksichtigt werden. Eine Gewöhnungsmessung kann den Messfehler reduzieren, birgt allerdings einen erheblich höheren finanziellen und personellen Aufwand. Das ergänzende Heimtrainingsprogramm wurde von den Patienten gut angenommen, so dass lediglich kleinere Modifikationen vorgenommen werden mussten, um es in dem geplanten RCT zu evaluieren. Zudem konnte gezeigt werden, dass die Hüftmuskelkraft zu den drei bedeutsamsten Faktoren zählt, die Einfluss auf die alltagsbezogene körperliche Funktionsfähigkeit bei Patienten mit Coxarthrose haben können. Ob diese Beziehung tatsächlich kausaler Natur ist, werden zukünftige Verlaufsstudien aufzeigen, in denen gezielt solche Faktoren der alltagsrelevanten körperliche Funktionsfähigkeit durch sporttherapeutische Maßnahmen modifiziert werden. Die ausstehenden Ergebnisse des RCT sollen die noch unzureichende wissenschaftliche Beweislage bezüglich der Wirksamkeit sporttherapeutischer Interventionen bei Coxarthrose verbessern. Dabei soll gezeigt werden, ob und in welchem Maß eine Schmerzreduktion und Verringerung der körperlichen Funktionseinschränkung erzielt werden kann.

Sammanfattning   Syfte och frågeställningar Syftet med denna studie var att sammanställa kvalitet på och resultat av studier som undersökt om långdistanslöpning ger artros i höft-, knä- eller fotleder. Finns det vetenskaplig evidens för att långdistanslöpning ger artros i höft-, knä- eller fotleder? Vilka styrkor och svagheter har de studier som försökt utröna om samband finns mellan långdistanslöpning och artros i höft-, knä- eller fotleder?   Metod Sökning av litteratur utfördes i PubMed, CINAHL, Cochrane Library och PEDro. Detta resulterade i att tio artiklar inkluderades för närmare granskning och sammanställning. Utifrån artiklarnas sammantagna bevisvärde poängsattes och graderades artiklarna efter evidensnivå enligt Statens Beredning för medicinsk Utvärderings (SBU) granskningsmallar för kohortstudier med kontrollgrupper.   Resultat Endast en av tio studier visar ett positivt samband mellan långdistanslöpning och artros i höft-, knä- eller fotleder, i detta fall höftledsartros. Studierna har ingen tydlig och gemensam definition över vad långdistanslöpning är. De granskade studierna använder sig av olika mätmetoder för att bedöma leddegenerationen, både av självrapportering och av olika diagnostiska kriterier för artros. Alla studier har inslag av selektionsbias.   Slutsats En indikation på att det inte finns ett vetenskapligt stöd för att långdistanslöpning ger höft-, knä- eller fotledsartros hos människor. Studierna har brister i hantering av confounders och selektionsbias och bedöms vara av låg eller medelhög kvalitet. / Abstract   Aim The purpose of this study was to compile the quality and results of studies that examined if long-distance running gives osteoarthritis of the hip, knee or ankle joints. Is there scientific evidence that long-distance running gives osteoarthritis of the hip, knee or ankle? What strengths and weaknesses of the studies attempted to determine if the link between long-distance running and osteoarthritis of the hip, knee or ankle joints.   Method Search of the literature was performed in PubMed, CINAHL, Cochrane Library, and PEDro. This resulted in ten articles that were included for further review and compilation. Based on the articles combined probative value was scored and graded articles for level of evidence according to the National Council on Technology Evaluation (SBU) examination templates for cohort studies with control groups.   Results Only one of the ten studies showed a positive association between long distance running and osteoarthritis of the hip, knee or ankle joints, in this case hip joint. The studies have not a clear and common definition of what long-distance running is. The studies reviewed use different metrics to assess joint degeneration, both by self-report and of different diagnostic criteria for osteoarthritis. All studies have an element of selection bias.   Conclusion An indication that there is no scientific evidence that long-distance running gives hip, knee or ankle osteoarthritis in humans. The studies were inadequate handling of confounders and selection bias and judged to be of low or medium quality.