Clinical Question:
Are balance exercises more effective at preventing ankle sprains than traditional strength and conditioning exercises among high school athletes?

Bottom Line:
A balance training program will significantly reduce the risk of ankle sprains in high school soccer and basketball players.

Reference:
McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 2006;34:1103-1111.

Study Design:
Randomized controlled trial (nonblinded)

Synopsis:
These researchers conducted a cluster randomized trial in which 55 high school soccer and basketball teams (523 girls, 242 boys) were randomized to either their usual strength and conditioning program or to a 5-phase balance program. Phases 1-4 each lasted 1 week and were completed prior to the start of their season. The fifth phase was a maintenance phase in which subjects performed the exercises 3 times each week for 10 minutes throughout the competitive season. The program began with open-eye training on the floor and increased in complexity, ending with closed-eye exercises on a balance board. Since the rate of ankle sprains is a function of exposures, the athletic trainers at the schools tracked all coach-directed competition, practice, or conditioning sessions. In addition to measuring the rate of ankle sprains (assessed via intention to treat), they determined severity on the basis of the number of days lost to sports: minor (1-7 days); moderate (8-21 days); severe (more than 21 days). To return to play, injured athletes needed: (1) approval by the athletic trainer and physician; (2) full ankle strength and pain-free range of motion; and (3) the ability to complete a series of functional activities similar to the demands of his or her individual sport. The intervention group sustained fewer sprains (6.1%, 1.13 per 1000 exposures) than the control group (9.9%, 1.87 per 1000 exposures). One would need to treat 26 high school soccer and basketball players with this program to prevent 1 sprain per season. The authors report that the program was more effective in preventing sprains in athletes with prior sprains, however, the study was not powerful enough to determine if the program was also effective in the primary prevention of sprains. There was no statistically significant difference in sprain severity, but the study lacked the power for this to be conclusive.

Clinical Question:
Is acupuncture more effective than placebo in decreasing symptoms in patients with fibromyalgia?

Bottom Line:
This study paradigm allows for controlled and blinded clinical trials of acupuncture. We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.

Reference:
Martin DP, Sletten CD, Williams BA, Berger IH. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc 2006;81:749-757.

Study Design:
Randomized controlled trial (single-blinded)

Synopsis:
To test the hypothesis that acupuncture improves symptoms of fibromyalgia. The authors conducted a prospective, partially blinded, controlled, randomized clinical trial of patients receiving true acupuncture compared with a control group of patients who received simulated acupuncture. All patients met American College of Rheumatology criteria for fibromyalgia and had tried conservative symptomatic treatments other than acupuncture. We measured symptoms with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at baseline, immediately after treatment, and at 1 month and 7 months after treatment. The trial was conducted from May 28, 2002, to August 18, 2003. Fifty patients participated in the study: 25 in the acupuncture group and 25 in the control group. Total fibromyalgia symptoms, as measured by the FIQ, were significantly improved in the acupuncture group compared with the control group during the study period (P = .01). The largest difference in mean FIQ total scores was observed at 1 month (42.2 vs 34.8 in the control and acupuncture groups, respectively; P = .007). Fatigue and anxiety were the most significantly improved symptoms during the follow-up period. However, activity and physical function levels did not change. Acupuncture was well tolerated, with minimal adverse effects.

Clinical Question:
What medical treatments are effective in the management of juvenile idiopathic arthritis?

Bottom Line:
Nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular injections of corticosteroids, methotrexate, and possibly biologic-modifiers are somewhat beneficial in the management of juvenile idiopathic arthritis (JIA), particularly oligoarthritis. Patients with polyarthritis and a positive rheumatoid factor respond poorly to medications and require aggressive individual management.

Reference:
Hashkes PJ, Laxer RM. Medical treatment of juvenile idiopathic arthritis. JAMA 2005;294:1671-84.

Study Design:
Systematic review

Synopsis:
The treatment of juvenile idiopathic arthritis (JIA) has changed markedly in the last 15 years. Many children with JIA are not treated by pediatric rheumatologists. To review the best evidence for the treatment of JIA. English-language trials of JIA between 1966 and 2005 were searched using MEDLINE, EMBASE, the Cochrane database, and abstracts from recent rheumatology and pediatric scientific meetings. Randomized controlled trials and open studies including at least 10 patients for medications without controlled trials. For studies after 1997, the American College of Rheumatology Pediatric 30 outcome measure was used to define patients as responders. For older studies, the primary response outcome measure defined by the authors was used. Thirty-four controlled studies were identified. Nonsteroidal anti-inflammatory drugs are effective only for a minority of patients, mainly those with oligoarthritis. Intra-articular corticosteroid injections are very effective for oligoarthritis. Methotrexate is effective for the treatment of extended oligoarthritis and polyarthritis and less effective for systemic arthritis. Sulfasalazine and leflunomide may be alternatives to methotrexate. Antitumor necrosis factor medications are highly effective for polyarticular course JIA not responsive to methotrexate but are less effective in systemic arthritis. There is a lack of evidence for the optimal treatment of systemic and enthesitis-related arthritis.