BACKGROUND/AIMS:The prognosis of traumatic dental injuries (TDI) of permanent teeth depends on several factors related to the injury, patient characteristics, management, and follow-up protocols. When such injuries affect both hard dental tissues and the periodontium ("combination injuries"), the risk of adverse healing complications increases. However, a significant knowledge gap exists regarding the factors associated with their etiopathogenesis. Therefore, this systematic review aimed to evaluate the prognosis of traumatized permanent teeth affected by combination injuries. METHODS:An a priori protocol was registered in PROSPERO. A search strategy based on the research question was prepared, and the search was performed on PubMed, EMBASE, Web of Science, and Scopus on December 4, 2026. An additional grey literature search and reference search were also performed. Clinical studies reporting outcomes of permanent teeth with combination injuries and a follow-up greater than six months were included. Data extraction, risk of bias assessment, and meta-analysis were performed. The certainty of evidence was evaluated using GRADE. RESULTS:The electronic search of databases revealed 8190 records. Titles and abstracts of 4445 of them were evaluated, resulting in 177 studies for full-text screening. Finally, 10 of them could qualify for inclusion in the systematic review, and one more study was identified from reference searching. The incidence of pulp necrosis was high, with a pooled incidence of 42% (95% CI: 33%-52%, I2 = 87%) in teeth with crown fracture and luxation and 33% (95% CI: 26%-41%, I2 = 16.2%) in teeth with the combination of uncomplicated crown fracture and subluxation. Teeth with mature root development had a significantly higher risk of pulp necrosis (risk ratio = 1.70; 95% CI: 1.15-2.48). Other complications were less frequently reported. The overall certainty of evidence was very low. CONCLUSIONS:The pooled incidence of pulp necrosis among permanent teeth with combination injuries was 39%. Greater severity of luxation injury in any combination and mature status of the root showed a significantly higher risk of pulp necrosis and healing complications. The evidence base for the prognosis of combination injuries showed very low certainty, indicating the need for future studies addressing the limitations observed in the review.

BACKGROUND:Combination injuries or multiple traumatic dental injuries (TDI) affecting a single permanent tooth are clinically significant but remain underrecognized. Although the global prevalence of TDI is well documented, the epidemiology of combination injuries has not been clearly established. This systematic review and meta-analysis aimed to assess the prevalence and patterns of combination injuries in traumatized permanent teeth. METHODS:A review protocol was registered in PROSPERO (CRD1245967). Comprehensive searches of PubMed, EMBASE, Web of Science, and Scopus were conducted without language or date restrictions on December 4, 2025. Observational studies done in clinical settings involving patients older than 6 years with TDI in permanent teeth and reporting combination injuries were included. Two authors independently performed screening, data extraction, and risk of bias assessment using the Joanna Briggs Institute checklist. Random-effects meta-analyses were performed to estimate pooled prevalence and proportions of specific injury combinations. The certainty of evidence was evaluated using the GRADE framework. RESULTS:Thirty studies from 20 countries were included. Among 34,382 traumatized permanent teeth, 7161 presented with combination injuries. Reported prevalence ranged from 2.36% to 48.28%, with a pooled prevalence of 14% (95% CI: 11%-19%; I2 = 98.2%). Denmark demonstrated the highest pooled prevalence among countries represented by multiple studies. The most frequently reported combinations were enamel-dentin fracture with subluxation (25%) and enamel-dentin fracture with concussion (17%). Reporting terminology varied considerably, and many studies did not explicitly document combination injuries. While most studies had a low risk of bias, the overall certainty of evidence was very low. CONCLUSIONS:The pooled prevalence of combination injuries was 14%, with the highest country-specific prevalence reported in Denmark, and the most common pattern being enamel-dentin fracture combined with subluxation. Considerable variation in reporting terminology and the very low certainty of evidence highlight an urgent need for standardized nomenclature, calibrated diagnostic protocols, and well-designed studies to accurately capture the complexity of these injuries.

BACKGROUND/AIMS:Traumatic dental injuries (TDIs) can result in complications that may manifest long after the initial injury. Long-term follow-up is essential. Registration systems must be easy to use. This study aimed to describe and validate a simple registration system for clinician-important TDI outcomes as an index. MATERIALS/METHODS:The clinical and radiological outcome findings were formulated with five digits in line with the Eden Baysal Dental Trauma Index. Twenty-five experts (n = 15 in a primary expert panel and n = 10 in a feedback panel) from seventeen countries participated in the validation process using the e-Delphi method. After two rounds to reach consensus, the second version of the proposed system was presented to the feedback group. The revised post-feedback version was re-evaluated by the primary experts. All experts commented freely and answered four questions on the system's use using a three-point Likert-scale. RESULTS:The approved name of the proposed system is "Eden Dental Trauma Outcome Index". The first digit reports the success of the restoration, and the second digit reports the healing type of root fracture. Coding the first two digits changed from Roman to Arabic numerals after the first round. The third digit records the external root resorption type with capitalised first letters of the two words describing the type. The fourth digit reports the maturity of the apex with lowercase first letters. The fifth digit records pulp status with Arabic numerals. Codes for unclear situations and tooth loss were added to all digits in the final version. All experts in the primary panel and 83.3% in the feedback panel reported that the index is practical but needs experience. CONCLUSION:After four validation rounds, the "Eden Dental Trauma Outcome Index" for reporting clinician-important outcomes was approved for face and content validity and external validity.

BACKGROUND/AIM:Alveolar bone process fractures in preschool children are not well documented in the literature. Alveolar process fractures are located very close to primary teeth and permanent tooth germs. This study investigates the risk of healing complications following alveolar process fractures in the primary dentition and potential sequelae in the permanent dentition. MATERIALS AND METHODS:A retrospective cohort study was conducted involving 21 patients with 49 primary teeth involved in an alveolar fracture. The follow-up protocol included clinical and radiographic examinations at specified intervals up to the age of 6 years. Healing complications in the primary teeth such as pulp necrosis, pulp canal obliteration, ankylosis, infection-related resorption and premature tooth loss were examined. Sequelae in the permanent dentition was also registered when the permanent incisors had erupted. RESULTS:Over a 3-year follow-up, the incidence of premature tooth loss was 51.2% [95% CI: 34.1%-68.4%], pulp canal obliteration was 42.5% [95% CI: 27.1%-57.8%], and pulp necrosis was 8.9% [95% CI: 0.6%-17.3%] following an alveolar process fracture. No cases of ankylosis were observed. Sequelae in the permanent dentition primarily included demarcated opacities and hypoplasia with a risk estimated at 24% [95% CI: 13%-39%] and 9% [95% CI: 2%-21%] respectively. CONCLUSION:Alveolar process fractures in primary dentition are associated with several healing complications in the primary teeth. Although the likelihood of severe complications in the permanent dentition is low, young children are still susceptible to developing sequelae in their permanent teeth. These results highlight the importance of awareness of dental injuries following alveolar process bone fractures in the primary dentition.

This systematic review aimed to evaluate the evidence related to the occurrence of pulp necrosis and related complications in permanent anterior teeth with lateral luxation. It was envisaged to address the ambiguity related to the recommendation for pulp extirpation in teeth with mature root apex. An a priori protocol was formulated as per the best practices of evidence-based medicine and registered in PROSPERO. A comprehensive search was performed electronically in PubMed, LILACS, Web of Science, EMBASE, Scopus, and Cochrane on July 10,2023 without any restriction of language or year of publication. The screening of titles and abstracts and later the full-text articles were performed. Later, the data extraction was performed by using a self-designed sheet, risk of bias (ROB) assessment was done, meta-analysis was performed, and the GRADE approach was used to assess the quality of evidence. The qualitative synthesis was performed on 13 studies done from 1985 to 2020 in hospital settings. There was variability in the minimum and total observation periods, sample sizes, and characteristics of the sample population. The overall pooled prevalence of pulp necrosis was found to be 57% (95% CI: 42, 72%). It was 12% (95% CI: 8%, 18%, I2 = 0%) in immature teeth, and 58% (95% CI: 42, 73%, I2 = 86%) in mature teeth. The pooled prevalence of EIRR was found to be 11% (95% CI: 4, 27%, I2 = 95%) with greater risk in teeth with mature root apex (RR: 1.26, 95% CI: 1.12, 1.42, I2 = 0%). The ROB was moderate or high in nine studies and the GRADE of evidence was very low in 14 of 15 outcomes. There are greater chances of pulp necrosis in teeth with lateral luxation, especially with mature apex. However, it can still be less than 60% in most cases with the prevalence of EIRR less than 20%. Hence, an absolute recommendation for endodontic intervention in mature teeth with lateral luxation must be interpreted with slight caution.

BACKGROUND/AIM:Primary teeth are frequently affected by traumatic dental injuries. Root fractures are rare and have a reported incidence of 2% in the primary dentition. Hence, there is limited evidence on this topic. This study aims to evaluate the risk of healing complications in primary teeth with root fracture and to identify possible sequelae in the permanent dentition following root fracture in the primary dentition.MATERIALS AND METHODS:A retrospective analysis of a cohort of 53 patients with 74 root fractured primary teeth. The standard follow-up program included clinical and radiographic examination after 4 weeks, 8 weeks, 6 months, and 1 year after the trauma and when the patient was 6 years of age. The following complications were registered: pulp necrosis (PN), pulp canal obliteration (PCO), ankylosis with replacement root resorption (ARR), infection-related root resorption (IRR), premature tooth loss (PTL), and repair-related resorption (RRR).STATISTICS:The Kaplan-Meier and Aalen-Johansen estimators were employed. The level of significance was 5%.RESULTS:A total of 74 teeth were included. 42 teeth were extracted at the initial examination. Risks estimated after 3 years: PTL 45.9% [95% CI: 28.8-63.0], PCO 12.9% [95% CI: 2.3-23.4], PN 14.9% [95% CI: 3.9-25.9], RRR 2.6% [95% CI: 0.0-7.5]. No teeth showed ARR or IRR. All complications were diagnosed within the first year. Most common sequelae in the permanent dentition was demarcated opacities, with an estimated risk of 20% [95% CI: 8.2-41.3].CONCLUSIONS:There is a low risk of healing complications following a root fracture in the primary dentition. Root fractures often result in early extraction of the coronal fragment. The remaining apical fragment will undergo a physiological resorption. Aside from opacities, there is a low risk of sequelae in the permanent dentition.

Dental trauma is complex, as it includes a wide range of different injury types with each type requiring specific considerations. It constitutes the fifth-most prevalent disease, and nearly 900 million individuals from 7 to 65 years of age are affected. The Dental Trauma Guide (DTG) project was initiated by Dr. Jens Andreasen in 2008 with the intention that all dentists around the world should be able to get access to the best available evidence regarding diagnosis, treatment, and prognosis for a patient with dental trauma within a few minutes. The DTG has been a global success, and today, 40,000 colleagues visit the DTG website every year. The website displays the treatment guidelines developed by the International Association of Dental Traumatology as well as visualized with film animations to make it easy and appealing for the users. The dentist can connect to the DTG Copenhagen database to compare his/her case with similar cases from the database, providing guidance to emergency treatment. Furthermore, DTG provides prognosis estimates for each individual injury type, as well as prognosis estimates for teeth with combinations of fracture and luxation injuries. Today, the DTG is a nonprofit organization with the aim of improving the level of care for dental trauma patients worldwide. Therefore, the DTG team has decided to offer free access for students at all dental schools in India.

BACKGROUND/AIM:There are few long-term clinical follow-up studies on human teeth replanted immediately or after storage in a suitable storage medium prior to replantation. This study aimed to assess the risk of ankylosis in avulsed human teeth replanted immediately or after storage in physiological media for a short time. MATERIAL:Data from 116 patients with 145 replanted avulsed permanent teeth were selected from a comprehensive dental trauma database in Copenhagen University Hospital. The following teeth were selected: Group 1 comprised 36 teeth replanted immediately (dry time <6 min; wet time <6 min). Group 2 comprised 61 teeth replanted after physiologic storage media (saliva and saline) (dry time <6 min; wet time >5 min; wet time ranged from 7 to 170 min, and mean wet time was 59 min). Group 3 (control) included 48 teeth replanted after dry storage (dry time > 60 min). METHOD:Clinical and radiographic registrations were carried out according to a standardized protocol; follow-up ranged from 7 months to 23 years. Ankylosis was diagnosed by percussion test and radiographs and related to the conditions prior to replantation and stage of root development. RESULTS:The overall risk of ankylosis was 17.2% [95% CI: 4.61; 29.79] for immediately replanted teeth, 55.3% [95% CI: 42.54; 68.00] for teeth stored in physiologic media before replantation, and 85.7% [95% CI: 75.70; 95.73] for teeth stored dry more than 1 h. Mature teeth showed a significantly higher risk of ankylosis than immature teeth. CONCLUSION:This clinical long-term study has verified earlier experimental studies showing that immediate reimplantation has the lowest risk of ankylosis. Physiologic storage media are good alternatives that also reduce the risk of ankylosis compared to dry storage, where ankylosis is more likely although not always seen. Mature teeth are significantly more likely to develop ankylosis.

Background Atrial fibrillation negatively impacts physical fitness and health-related quality of life. We recently showed that 3 months of physiotherapist-led exercise-based cardiac rehabilitation improves physical fitness and muscle function in elderly patients with permanent atrial fibrillation and concomitant diseases. Little is, however, known about the consequences for physical fitness, physical activity level, and health-related quality of life after ending the rehabilitation period. Methods Prospective 3 months follow-up study of 38 patients out of 40 eligible (10 women) who, as part of a randomized controlled trial, had completed a 3 months physiotherapist-led cardiac rehabilitation resulting in improved physical fitness,. In the current study, the participants were instructed to refrain from exercise for 3 months after completion of the rehabilitation period. Primary outcome measure was physical fitness measured as highest achieved workload using an exercise tolerance test. Secondary outcome measures were muscle function (muscle endurance tests), physical activity level (questionnaire and accelerometer), and health-related quality of life, (Short Form-36), as in the preceding intervention study. We used the Wilcoxon Signed Rank test to analyse differences between the end of rehabilitation and at follow-up. The effect size was determined using Cohen's d . Results Exercise capacity and exercise time significantly decresead between end of rehabilitation and at follow-up (p < .0001 for both). A significant reduction in shoulder flexion repetitions (p = .006) was observed as well as reduced health-related quality of life in the Short Form-36 dimensions Physical Function (p = .042), Mental Health (p = .030), and Mental Component Score (p = .035). There were, however, no changes regarding objective and subjective physical activity measurements. Conclusion In older patients with permanent atrial fibrillation, previously achieved improvements from physiotherapist-led exercise-based cardiac rehabilitation in physical fitness and muscle function were lost, and health-related quality of life was impaired after ending the rehabilitation period. A strategy for conserving improvements after a rehabilitation period is essential.

An accurate, clear, and easy-to-use traumatic dental injury (TDI) classification and definition system is a prerequisite for proper diagnosis, study, and treatment. However, more than 50 classifications have been used in the past. The ideal solution would be that TDIs are adequately classified within the International Classification of Diseases (ICD), endorsed by the World Health Organization (WHO). TDI classification provided by the 11th Revision of the ICD (ICD-11), released in 2018, and previous Revisions, failed to classify TDIs satisfactorily. Therefore, in December 2018, a proposal was submitted by Dr's Stefano Petti, Jens Ove Andreasen, Ulf Glendor, and Lars Andersson, to the ICD-11, asking for a change of the existing TDI classification. Proposal #2130 highlighted the TDI paradox, the fifth most frequent disease/condition neglected by most public health agencies in the world, and the limits of ICD-11 classification. Namely, injuries of teeth and periodontal tissues were located in two separate blocks that did not mention dental/periodontal tissues; infraction, concussion, and subluxation were not coded; most TDIs lacked description; and tooth fractures were described through bone fracture descriptions (e.g., comminuted, compression, and fissured fractures). These limitations led to TDI mis-reporting, under-reporting, and non-specific reporting by untrained non-dental healthcare providers. In addition, no scientific articles on TDIs, present in PubMed, Scopus, and Web-of-Science, used the ICD classification. Proposal #2130 suggested to adopt the Andreasen classification, the most widely acknowledged classification used in dental traumatology. The Proposal was reviewed by two WHO teams, two scientific Committees, one WHO Collaborating Center, and the Department of Non-Communicable Disease Prevention at WHO headquarters, and it underwent two voting sessions. In March 2022, the Andreasen classification was accepted integrally. A new entity was generated, called NA0D, "Injury of teeth or supporting structures" (https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1413338122). Hopefully, this will contribute to increasing the public awareness, and the dental profession's management, of TDIs.

Like most dentists, I first heard the name Jens Andreasen when I was a dental student in the 1970s, but little did I realize, or even imagine, back then the influence that Jens had already had on our profession and especially on the subject of dental traumatology, as well as how that influence would grow on me over the ensuing years. In the 1980s, I had the great fortune to study endodontics under the mentorship of Geoffrey Heithersay in Adelaide, Australia. Geoff and Jens were great friends. Geoff often talked about Jens with insights into his work and papers before they had been published because of their personal friendship. As I became more and more interested in dental traumatology, my admiration for Jens increased exponentially. Then, in 2007, when I was dean of the dental school in Perth, Western Australia, I invited Jens to be a visiting professor. He spent 2 wonderful weeks with our staff and graduate and undergraduate students—what an opportunity that was for everyone here! Jens was incredibly generous with his time, not just during that visit but for his entire career. He lectured all over the world and with multiple visits to many places.

AIMS AND OBJECTIVESThe aims of this study were to compare the anesthetic effect of a lidocaine/prilocaine (L/P) topical anesthetic with placebo on pain from needle sticks and to compare the anesthetic effect of the L/P topical anesthetic with an infiltrative anesthetic on pain from orthodontic miniscrew placement.MATERIALS AND METHODSPain elimination was analyzed from two interventions: (a) needle stick and (b) miniscrew insertion. When assessing pain from needle stick, one side of the mandible received 2.5% lidocaine/2.5% prilocaine topical anesthetic, and the other side received placebo. When evaluating pain from miniscrew placement, one side of the mandible received L/P topical anesthetic and the other side received infiltrative anesthetic. The findings were recorded on a Visual Analogue Scale after needle stick and after miniscrew placement. Subjective assessment was analyzed by a questionnaire.RESULTSThe L/P topical anesthetic significantly eliminated the pain from needle stick (Mann-Whitney test of medians, 29.0 vs 0.0, respectively, p<0.001). However, the injection anesthetic eliminated the pain from the miniscrew placement better than the L/P topical anesthetic (Mann-Whitney test of medians, 0.0 vs 5.5, respectively, p<0.001). Eighty percent of the subjects felt more comfortable with L/P topical anesthetic than injection anesthetic. Pain from needle stick pain was reported to be the most uncomfortable part of the study.CONCLUSIONThe L/P topical anesthetic efficiently eliminated pain from needle stick. The L/P topical anesthetic did not completely eliminate pain from miniscrew placement as the injection anesthesia, but it did reduce pain to tolerable levels.CLINICAL SIGNIFICANCEL/P topical anesthetics can significantly eliminate pain from needle stick injections, and L/P topical anesthetics can reduce pain from orthodontic miniscrew placement to tolerable levels.

The life and professional contributions to dental traumatology of Dr Jens Ove Andreasen are described in terms of his research, writing, teaching, and leadership.

BACKGROUND/AIM:The survival of an avulsed tooth highly depends on the emergency management. The aim of this study was to evaluate the risk of ankylosis for avulsed human teeth stored in saliva preceded by various dry storage conditions prior to replantation.MATERIAL AND METHODS:Data include 74 patients (54 male and 20 female) with 89 avulsed and replanted teeth (16 immature teeth, 73 mature teeth). Patient ages ranged from 6 to 36 years (median: 13.0 years). All teeth were stored in saliva before replantation. Treatment and follow-up were performed according to a standardized procedure. Follow-up periods ranged from 7 months to 20 years (mean 5.3 years). The risk of ankylosis over time was estimated by the Aalen-Johansen method in relation to the length of dry storage and the stage of root development. The effect of risk factors (root development and length of dry time) on the risk of ankylosis was analysed by Cox regression analysis.RESULTS:For mature teeth, dry storage for 5 min or less before saliva storage resulted in a 47.4% (95% confidence interval (CI): 32.8-60.7) ankylosis rate. When dry storage was >5 min and <20 min, the risk of ankylosis was 76.8% (95% CI: 45.7-91.5). When dry storage exceeded 20 min prior to saliva storage, ankylosis increased to 89.3% (95% CI: 68.0-96.7). Ankylosis also increased with increasing saliva storage time. Specifically, one additional minute of wet time increased the ankylosis hazard rate (HR) by approximately 1% (CI = [0%, 2%], p = .052). Teeth with mature root development were significantly more frequently affected by ankylosis than teeth with immature root development (HR: 2.4 (95% CI: 1.0-5.5), p = .04).CONCLUSION:Temporary storage in saliva should be encouraged if an avulsed permanent tooth cannot be immediately replanted or a suitable storage medium such as milk or saline is not immediately available at the place of the accident.

This study was undertaken to investigate the integration of titanium micro-implants installed in conjunction with previously dentin-grafted areas and to study the morphological appearance, mineral content, and healing pattern of xenogenic EDTA-conditioned dentin blocks and granules grafted to cavities in the tibial bone of rabbits. Demineralized and non-demineralized dentin blocks and granules from human premolars were implanted into cavities prepared on the lateral aspects of the tibias of rabbits. After a healing period of six months, micro-implants were installed at each surgical site. Histological examinations were carried out after 24 weeks. Characterization of the EDTA-conditioned dentin blocks was performed by means of light microscopy, dental X-rays, scanning electron microscopy, and energy dispersive X-ray analysis (EDX). No implants were found to be integrated in direct contact with the dentin particles or blocks. On the EDTA-conditioned dentin surface, the organic marker elements C and N dominated, as revealed by EDX. The hydroxyapatite constituents Ca and P were almost absent on the dentin surface. No statistically significant difference was observed between the EDTA-conditioned and non-demineralized dentin, as revealed by BIC and BA. The bone-inductive capacity of the dentin material seemed limited, although demineralization by means of EDTA indicated higher BIC and BA values in conjunction with the installed implants in the area. A 12 h EDTA treatment did not fully decalcify the grafts, as revealed by X-ray analysis.

The life and professional contributions to dental traumatology of Dr. Jens Ove Andreasen are described in terms of his research, writing, teaching, and leadership.

BACKGROUND/AIMS:Traumatic dental injuries (TDI) are complex problems where lack of proper care may result in serious complications. The need to improve the management of TDI is a frequently addressed concern. Methods of improvement in their diagnosis and management are continuously evolving. The interactive Internet tool, the Dental Trauma Guide (DTG), helps to simplify diagnostic and management dilemmas. However, it is not a freely available tool. The aim of the current study was to assess the knowledge and diagnostic skills of undergraduate dental students with access to the DTG compared with students without such access, in order to validate and promote this tool in dental education.MATERIALS AND METHODS:Two groups of students were randomly selected where one group of final year dental undergraduate students were exposed to lectures, demonstrations, discussions and tutorials on the management of TDI according to the standard undergraduate curriculum in Sri Lanka. Another test group of 21 students were provided with access to DTG during their training in paediatric dentistry. At the end of the study period, students were assessed on their knowledge of TDI using MCQs (Multiple Choice Questions) and OSCEs (Objective Structured Clinical Examination), based on the DTG.RESULTS:The students with access to the DTG were more knowledgeable in providing the correct answers to three out of the seven OSCE questions. Evaluation based on the MCQs did not reveal a significant difference (p = .913). However, users of the DTG showed a statistically significant difference with better overall knowledge based on their answers (p = .028). Following this period of evaluation, all of the students were provided with access to the DTG to supplement their learning experience.CONCLUSION:The Dental Trauma Guide is a useful supplementary tool for undergraduate students to arrive at a correct diagnosis and treatment plan for TDI.

Abstract Background: Atrial fibrillation negatively impact physical fitness and health-related quality of life in patients. We recently showed that physiotherapist-led exercise-based cardiac rehabilitation improves physical fitness in patients with permanent atrial fibrillation, however little is known about the effect of detraining after finishing an exercise period. The purpose of the study was to examine the impact of 3 months of detraining on physical fitness, physical activity level and health-related quality of life among patients with permanent atrial fibrillation, after ending a randomized comparison of physiotherapist-led exercise-based cardiac rehabilitation versus physical activity on prescription.Methods: Prospective 3-month follow-up study after a randomized multi-centre study. Of the 87 patients completing the intervention study, 80 (92%) participated in the detraining part (22 women; age 74 ± 5 years), 38 from the physiotherapist-led exercise-based cardiac rehabilitation group and 42 from the physical activity on prescription group. All patients were asked to refrain from organised exercise during the 3-months period of detraining. The primary outcome measure was maximal exercise capacity using an exercise tolerance test. Secondary outcomes measures were muscle function, physical activity level, and health-related quality of life using a muscle endurance tests, Short Form-36, and physical activity assessments (questionnaire and accelerometer), as in the intervention study. We used the Mann-Whitney U-test and X2 test to analyse differences between the groups, and Cohen’s d to determine the effect size. A mixed effect model analysis was used to identify predictors of change in physical fitness.Results: Compared to the physical activity on prescription, physiotherapist-led exercise-based cardiac rehabilitation showed a significantly decreased exercise capacity (−9 ± 11 vs. −2 ± 12 W, P < .0001), reduction in shoulder flexion repetitions (−4 ± 8 vs. 2 ± 7 repetitions, P = .001), and reduced health-related quality of life in the Short Form-36 dimension Role Emotional (−13 ± 39 vs. 6 ± 27 points, P = .006). Conclusion: In elderly patients with permanent atrial fibrillation detraining negatively impacted previously achieved improvements from physiotherapist-led exercise-based cardiac rehabilitation in physical fitness and reduce health-related quality of life. The importance of continued exercise is emphasized and should be part of the strategy. Retrospectively registred in ClinicalTrials.gov Identifier: NCT02493400. First posted July 9, 2015

The aim of this multicenter randomized controlled trial was to compare physiotherapist-led exercise-based cardiac rehabilitation (PT-X) with physical activity on prescription (PAP) with regard to physical fitness, physical activity, health-related quality of life (HR-QoL), and metabolic risk markers in patients with permanent atrial fibrillation. Ninety six patients (28 women), age 74 (5) years, and ejection fraction >= 45% were randomized. An exercise tolerance test (primary outcome measure), muscle endurance tests, HR-QoL, physical activity assessments (questionnaire and accelerometer), and blood sampling were performed. The PT-X consisted of 60-minute group sessions and home-based exercise, both twice a week. The PAP consisted of 40 minutes of active walking, 4 times a week. Eighty seven patients completed the study. Exercise tolerance (maximum exercise capacity) improved significantly after PT-X (n = 40) but not after PAP (n = 47) (16 vs -3 W; P < .0001). Muscle endurance also improved after PT-X: shoulder flexion left arm (7 vs -1 repetition; P < .001), heel-lift right leg (4 vs 1 repetition; P < .05), left leg (4 vs -1 repetition; P < .001), and shoulder abduction (17 vs -4 s; P < .010). PAP significantly increased energy expenditure. Health-related quality of life and lab-tests did not differ. PT-X improved physical fitness in patients with permanent atrial fibrillation.