Maarten H Moen’s research while affiliated with Bergman Clinics and other places

Objective To establish the prevalence of mental health symptoms (MHSs) among Dutch elite athletes and their coaches, to examine the association between potential contributing factors and MHS among Dutch elite athletes and their coaches and to explore the view and needs of Dutch elite athletes and their coaches regarding mental health resources and support. Methods A cross-sectional study was conducted by distributing an electronic questionnaire based on validated screening questionnaires for the assessment of MHS. Results In total, 156 athletes (55% female) and 95 coaches (79% male) across various sports participated in this study. The most prevalent MHS among athletes and coaches were distress (73% and 41%) and alcohol misuse (52% and 53%). Adverse life events showed an association with anxiety, depression, sleep disturbance, alcohol misuse and disordered eating while severe injuries showed an association with distress and sleep disturbance in elite athletes. Among coaches, no significant associations were found between potential contributing factors and MHS. 60% of the athletes and 60% of the coaches (totally) agreed that they could openly address their mental health issues within their sport while 53% of the athletes and 41% of the coaches (totally) agreed a need for increased attention regarding mental health/guidance in their sport. Conclusions MHSs are prevalent among Dutch elite athletes and coaches. Recent adverse life events and severe injuries have a potential intersection with MHS in elite athletes. There is a need for increased attention regarding mental health/guidance among Dutch elite athletes and coaches within their sport so that subsequent treatment/support can be provided.

Objectives Studies identifying clinical and MRI reinjury risk factors are limited by relatively small sample sizes. This study aimed to examine the association between baseline clinical and MRI findings with the incidence of hamstring reinjuries using a large multicentre dataset. Methods We merged data from four prospective studies (three randomised controlled trials and one ongoing prospective case series) from Qatar and the Netherlands. Inclusion criteria included patients with MRI-confirmed acute hamstring injuries (<7 days). We performed multivariable modified Poisson regression analysis to assess the association of baseline clinical and MRI data with hamstring reinjury incidence within 2 months and 12 months of follow-up. Results 330 and 308 patients were included in 2 months (31 (9%) reinjuries) and 12 months (52 (17%) reinjuries) analyses, respectively. In the 2-month analysis, the presence of discomfort during the active knee extension test was associated with reinjury risk (adjusted risk ratio (ARR) 3.38; 95% CI 1.19 to 9.64). In the 12 months analysis, the time to return to play (RTP) (ARR 0.99; 95% CI 0.97 to 1.00), straight leg raise angle on the injured leg (ARR 0.98; 95% CI 0.96 to 1.00), the presence of discomfort during active knee extension test (ARR 2.52; 95% CI 1.10 to 5.78), the extent of oedema anteroposterior on MRI (ARR 0.74; 95% CI 0.57 to 0.96) and myotendinous junction (MTJ) involvement on MRI (ARR 3.10; 95% CI 1.39 to 6.93) were independently associated with hamstring reinjury. Conclusions Two clinical findings (the presence of discomfort during active knee extension test, lower straight leg raise angle on the injured leg), two MRI findings (less anteroposterior oedema, MTJ involvement) and shorter time to RTP were independently associated with increased hamstring reinjury risk. These findings may assist the clinician to identify patients at increased reinjury risk following acute hamstring injury. Trial registration numbers NCT01812564 ; NCT02104258 ; NL2643; NL55671.018.16

Background: Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis. Purpose: To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks. Study design: Randomized controlled trial; Level of evidence, 1. Methods: In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks. Results: Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures. Conclusion: For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections. Registration: NTR7261 (Netherlands Trial Register).

Introduction There is a lack of effective non-surgical interventions for ankle osteoarthritis. Platelet-rich plasma (PRP) injections are widely used and reported to be beneficial for knee osteoarthritis. We evaluated the efficacy of PRP injections in the management of ankle osteoarthritis. Materials and Methods In this six-center stratified, block-randomised, double-blind, placebo-controlled trial design we randomly assigned 100 patients to two treatment groups: PRP versus Placebo (saline) injected intra-articular. Patients had talocrural joint space narrowing. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) score at 26 weeks follow-up. Secondary outcome measures included multiple Patient Related Outcome Measures assessing pain, function and quality of life. Results A total of 48 patients were randomized to the PRP-group and 52 patients to the placebo-group. No patients were lost to follow-up for the primary outcome. Compared to baseline, the mean AOFAS score improved by 10 points in the PRP group (from 63 to 73 points; 95% CI: 6 to 14; p<0.001) and 11 points in the placebo group (from 64 to 75 points; 95% CI: 7 to 15; p<0.001). The adjusted between-group difference over 26 weeks was -1 point (95% CI, -6 to 3; p=0.56). No between group differences were seen for any of the secondary outcome measures. There was one serious adverse events in each group unrelated to the study intervention. Conclusion In patients with ankle (talocrural) osteoarthritis intra-articular PRP injections compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks.

Objective To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions. Methods Patients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity. Results Twenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008). Conclusion In a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Importance Approximately 3.4% of adults have ankle (tibiotalar) osteoarthritis and, among younger patients, ankle osteoarthritis is more common than knee and hip osteoarthritis. Few effective nonsurgical interventions exist, but platelet-rich plasma (PRP) injections are widely used, with some evidence of efficacy in knee osteoarthritis. Objective To determine the effect of PRP injections on symptoms and function in patients with ankle osteoarthritis. Design, Setting, and Participants A multicenter, block-randomized, double-blinded, placebo-controlled clinical trial performed at 6 sites in the Netherlands that included 100 patients with pain greater than 40 on a visual analog scale (range, 0-100) and tibiotalar joint space narrowing. Enrollment began on August 24, 2018, and follow-up was completed on December 3, 2020. Interventions Patients were randomly assigned (1:1) to receive 2 ultrasonography-guided intra-articular injections of either PRP (n = 48) or placebo (saline; n = 52). Main Outcomes and Measures The primary outcome was the validated American Orthopaedic Foot and Ankle Society score (range, 0-100; higher scores indicate less pain and better function; minimal clinically important difference, 12 points) over 26 weeks. Results Among 100 randomized patients (mean age, 56 years; 45 [45%] women), no patients were lost to follow-up for the primary outcome. Compared with baseline values, the mean American Orthopaedic Foot and Ankle Society score improved by 10 points in the PRP group (from 63 to 73 points [95% CI, 6-14]; P < .001) and 11 points in the placebo group (from 64 to 75 points [95% CI, 7-15]; P < .001). The adjusted between-group difference over 26 weeks was −1 ([95% CI, –6 to 3]; P = .56). One serious adverse event was reported in the placebo group, which was unrelated to the intervention; there were 13 other adverse events in the PRP group and 8 in the placebo group. Conclusions and Relevance Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis. Trial Registration Netherlands Trial Register: NTR7261

Objective Stem cell therapy is increasingly used for knee osteoarthritis (KOA). We aimed to review the evidence of autologous mesenchymal stem cell therapy on pain, function and severity on imaging in KOA. Design Systematic review of randomised controlled trials (RCTs). Eligibility criteria RCTs evaluating autologous mesenchymal stem cell (MSC) therapy on patient-reported outcome measures and disease severity. Data sources Seven databases were searched until 31 December 2020. Risk of bias and data synthesis Risk of bias was assessed using the ROB V.2. We used Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of the evidence. Data were synthesised descriptively. Results Fourteen RCTs were included. A total of 408 patients with KOA received MSC therapy derived from bone marrow, adipose tissue or activated peripheral blood. After 1 year, 19 of 26 (73%) clinical outcome measures improved with MSCs compared with control. In the MSC group, patients improved by 1.8–4.4 points on the Visual Analogue Scale (0–10) and 18–32 points of the Knee Osteoarthritis Outcome Score (0–100). Four studies showed better disease severity on imaging after MSC compared with control at 1 year. Ten of 14 (71%) RCTs were at high risk of bias on all outcomes. No serious adverse events were reported after MSC therapy during a maximum of 4 years follow-up. Conclusion We found a positive effect of autologous MSC therapy compared with control treatments on patient-reported outcome measures, and disease severity. The certainty of this evidence was low to very low. PROSPERO registration number CRD42019120506

Objective: Our aim was to assess the effects of adding arch-support foot-orthoses (ASFO) to a multimodal therapeutic intervention on the perception of pain and improvement of recovery from medial tibial stress syndrome (MTSS) in recreational runners. Design: A prospective randomized controlled trial. Setting: Sport training and medical centers. Participants: Fifty female recreational runners with MTSS were randomized into 2 groups. Interventions: Runners either received ASFO or sham flat noncontoured orthoses. Both groups received a multimodal therapeutic intervention, including ice massage, ankle muscle exercises, and extracorporeal shockwave therapy. Main outcome measures: Pain during bone pressure using a numerical Likert scale (0-10), MTSS severity using an MTSS scale, perceived treatment effect using the global rating of change scale, and quality of life using the short Form-36 questionnaire were determined at week 6, 12, and 18. Results: Pain intensity and MTSS severity were lower, and the perceived treatment effect and physical function were better in the ASFO than in the sham flat noncontoured orthoses group at week 6 and week 12. Cohen's dz effect size for between-group differences showed a medium difference. However, arch-support foot-orthoses did not add to the benefits of multimodal therapeutic intervention on pain, MTSS severity and perceived treatment effect at week 18. Conclusions: Adding ASFO to a therapeutic intervention leads to an earlier diminishment of pain and MTSS severity, and improved PF and perceived therapeutic effects.

Objectives Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuries. Study design Case-control study. Methods We used MRI STIR to measure intramuscular signal intensity in patients with clinically diagnosed hamstring injuries at two time points: at injury and RTP. At injury, we calculated the association of MRI STIR signal intensity with the time to RTP and reinjury risk. At RTP, the association of MRI STIR signal intensity and reinjury risk and the change in MRI STIR signal intensity over time on reinjury risk was evaluated. Results 51 patients were included. We found increased MRI STIR signal intensity: (1) at time of injury not to be associated with time to RTP, (2) at time of injury to be associated with a slightly lower risk for reinjury: odds 0.986 (0.975 – 0.998, p = 0.02) and (3) at RTP not to be associated with reinjury risk. (4) We found no association between the change in MRI STIR signal intensity over time and reinjury risk. Conclusion Increased MRI STIR signal intensity at injury has no value in time to RTP prognosis, but is associated with a reduced reinjury risk.

OBJECTIVES: The primary objectives of the study were to (i) establish the 12-month incidence and comorbidity of symptoms of mental health disorders (distress, anxiety/depression, sleep disturbance, alcohol misuse, disordered eating) among Dutch former elite athletes and (ii) explore the potential relationship with the stressors involuntary retirement, recent life events, career dissatisfaction. The secondary objective was to investigate whether the incidence of symptoms of mental health disorders and their potential relationship with stressors are related to duration since retirement. METHODS: An observational prospective cohort study with a 12-month follow-up was conducted among Dutch former elite athletes. Symptoms of mental health disorders and potential stressors were assessed using validated questionnaires. RESULTS: A total of 282 participants were included at baseline and 193 completed follow-up. The incidence ranged from 7% for alcohol misuse to 28% for anxiety/depression. Comorbidity of two or three symptoms of mental health disorders was reported in 7% and 4%, respectively. Adverse life events were significantly related to disordered eating (RR = 1.30, 95%CI = 1.05-1.61), while career dissatisfaction also showed a significant relationship with disordered eating (RR = 3.98, 95%CI = 1.32-11.99) and sleep disturbance (RR = 3.23, 95%CI = 1.10-9.51). The stressor involuntary retirement did not have a significant relationship with any symptoms of mental health disorders. The effect of duration since retirement seemed to be most present in the first 15 years since athletic career retirement in the plotted graphs. CONCLUSIONS: The 12-month incidence of symptoms of mental health disorders ranged from 7% to 28% and comorbidity of symptoms of mental health disorders was present in 12%. Adverse life events and career dissatisfaction only increased the risk of certain symptoms of mental health disorders. Duration since retirement might affect the incidence of symptoms of mental health disorders and its relationship with stressors in the first 15 years.