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Physio findings - 4 April 2012

Research that’s relevant to physio staff: Janet Wright reports on the latest clinical news.

Heavy rucksacks hurt young backs

Child health

A backpack may be kinder to a child’s spine than a lopsided shoulder bag. But the sheer weight pupils carry to school gives many of them back pain, a Spanish team reported last month.

The researchers studied all 1,403 school children aged from 12 to 17 years living in northern Galicia. More than six out of 10 of them carried bags weighing over a tenth of their own body weight.

Those carrying the heaviest bags were 50 per cent more likely to suffer back pain than those carrying the lightest bags.

They also had a 42 per cent higher risk of back pathology, although this last result was not statistically significant. Girls had more back pain than boys.

‘Carrying backpacks increases the risk of back pain and possibly the risk of back pathology,’ the team noted.

‘The prevalence of school children carrying heavy backpacks is extremely high. Preventive and educational activities should be implemented in this age group,’ the team concluded.

The lead  author is based at the Hospital da Costa, Burela, Galicia.

  • Rodríguez-Oviedo P et al. School children’s backpacks, back pain and back pathologies. Archives of Disease in Childhood 2012; doi:10.1136/archdischild-2011-301253

Evidence mounts against metal-on-metal implants

Hip replacement

Hip replacements are among surgery’s major success stories, restoring independence to thousands of people at risk of losing their mobility.

But recent large-scale studies published in leading medical journals have found that the newest are not necessarily the best.

Researchers pored through records of 402,051 operations in the National Joint Registry of England and Wales – the world’s largest register of hip replacements.

Their study, published in The Lancet, showed that women and younger people were most likely to need a further operation within the first five years, after the first implant caused pain or other problems.

The highest failure rate was found in metal-on-metal implants, in which both the ball and socket are replaced by metal parts. These were originally considered an improvement on older implants, as they were expected to last longer.

In the first five years, 6.2 per cent of metal-on-metal implants had failed, compared with 1.7 per cent of metal-on-plastic and 2.3 per cent of ceramic-on-ceramic.

Metal-on-metal hip implants are no longer popular in the UK, though they are still common in some other countries, including the US.

Only 673 were fitted here in 2011, down from 8,072 fitted in 2008. (One particular kind called ASR, that had a very high failure rate, was withdrawn from use in 2010 and wasn’t included in the Lancet study.)

The British Hip Society opposes the use of metal-on-metal implants, saying a lack of evidence means benefits outweigh the risks.

However, the Medicines and Healthcare products Regulatory Agency (MHRA) says they still have a role to play, especially for younger patients.

The risk of failure increased with the size of a metal-on-metal implant, said the team, from the universities of Bristol and Exeter and the Wrightington Hospital in Lancashire.

Each 1mm increase in head size was linked with a 2 per cent increase in the risk that the patient would need another operation. Ceramic implants, on the other hand, were more successful the larger they were.

On top of the failure risk, the MHRA warned in February that a particular kind of metal-to-metal implant could be harmful to the patient’s health.

Tiny slivers of metal had been found to break off large-head hip implants, in some cases. These fragments could enter a patient’s bloodstream, causing risks of neurological or musculoskeletal damage.

The MRHA said that the 49,000 people who had large-head metal-on-metal implants would need annual blood tests to check on this.

If anything showed up in the blood tests, or the patient reported symptoms, the MRHA recommends an MRI scan.

The Lancet report follows another large-scale study published in the BMJ in November. In the BMJ study, US and Australian researchers carried out a systematic review of clinical trials, observational studies and national registries. They analysed 18 studies covering 3,139 patients and more than 830,000 operations recorded by national registries.

They found that newer products – including metal-on-metal – were not necessarily better than more traditional implants.

‘Results do not indicate any advantage for metal-on-metal or ceramic-on-ceramic implants, compared with traditional metal-on-polyethylene or ceramic-on-polyethylene bearings,’ the team said.

Although one study showed ceramic-on-ceramic implants were less likely to fail, they said, the emerging evidence from national registries did not support these results.

  • Smith AJ et al. Failure rates of stemmed metal-on-metal hip replacements: analysis of data from the National Joint Registry of England and Wales. Lancet 2012; doi:10.1016/S0140-6736(12)60353-5
  • Sedrakyan A et al. Comparative assessment of implantable hip devices with different bearing surfaces: systematic appraisal of evidence.  BMJ 2011; 343 doi: 0.1136/bmj.d7434

Cochrane review backs cardiorespiratory training


Could fitness training reduce stroke survivors’ risk of death, dependence and disability? Researchers at the University of Edinburgh set out to find the answer.

They analysed 32 randomised trials comparing either cardiorespiratory training or resistance training, or both, with no intervention, a non-exercise intervention or usual care.

They also looked at the effects of training on other indicators such as mobility, physical function, quality of life and mood.

Their Cochrane review of trials involving 1,414 stroke patients found that cardiorespiratory fitness training can improve walking performance. But results were not clear enough to draw firm conclusions about any other effects.

‘There is sufficient evidence to incorporate cardiorespiratory training involving walking within post-stroke rehabilitation programmes to improve speed, tolerance and independence during walking,’ they concluded.

‘Further well-designed trials are needed to determine the optimal exercise prescription and identify long-term benefits.’

  • Brazzelli M et al. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2011; 11: doi: 10.1002/14651858.CD003316.pub4

Comments & conclusions

  • A Care Quality Commission report ‘Health care for disabled children and young people’ finds that primary care trusts (PCTs) rate their own services highly, but users challenge this assessment. PCTs said the average wait for a referral to a community physio was 6.9 weeks (range 1.2 – 23 weeks). Eleven PCTs did not know the length of waiting times and five said there were no disabled children or young people living in their area. Service-users’ experiences were overwhelmingly negative compared to the data supplied by PCTs.
  • Second or later operations on the anterior cruciate ligament (ACL) are three or four times more likely to fail than a first operation, say researchers, after analysing 21 studies. Two thirds of the 863 patients followed up for at least two years were male, average age 30. ‘A dramatically elevated failure rate was noted after revision ACL reconstruction,’ say the authors. Wright RW et al. Journal of Bone & Joint Surgery 2012; 94: 531-536 doi:10.2106/JBJS.K.00733


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