World J Orthop v67 2015 Aug 18 PMC4539476 World J Orthop 2015 Aug 18 67 528536 Published online 2015 Aug 18 doi 105312wjov6i7528 PMCID PMC4539476 Persistent postsurgical pain and neuropathic pain after total knee replacement Georgios I Drosos Triantafilia Triantafilidou Athanasios Ververidis Cristina Agelopoulou Theodosia Vogiatzaki and Konstantinos Kazakos Author information Article notes Copyright and License information Abstract AIM To study the prevalence of persistent postsurgical pain PPSP and neuropathic pain NP after total knee replacement TKR METHODS MEDLINE and Embase databases were searched for articles published until December 2014 in English language Published articles were included if they referred to pain that lasts at least 3 mo after primary TKR for knee osteoarthritis and measured pain with pain specific instruments Studies that referred to pain caused by septic reasons and implant malalignment were excluded Both prospective and retrospective studies were included and only 14 studies that match the inclusion criteria were selected for this review RESULTS The included studies were characterized by the heterogeneity on the scales used to measure pain and preoperative factors related to PPSP and NP The reported prevalence of PPSP and NP seems to be relatively high but it varies among different studies There is also evidence that the prevalence of postsurgical pain is related to the scale used for pain measurement The prevalence of PPSP is ranging at 6 mo from 16 to 39 and at 12 mo from 131 to 23 and even 38 of the patients The prevalence of NP at 6 mo postoperatively is ranging from 52 CONCLUSION No firm conclusions can be reached regarding the prevalence of PPSP and NP and the related factors due to the heterogeneity of the studies Keywords Total knee replacement Pain Chronic pain Neuropathic pain Postoperative pain Persistent postsurgical pain Core tip Persistent postsurgical pain PPSP is reported in a significant proportion of patients after total knee replacement This proportion varies between the different studies and different factors have been implicated including the instrument used to measure pain It is also obvious that in some of these patients the pain is neuropathic NP in origin or the NP pain coexists Nevertheless due to the heterogeneity of the studies mainly on the scales used to assess pain and preoperative factors we are unable to reach firm conclusions concerning the prevalence and the risk factors of PPSP pain after total knee replacement Additional studies Go to INTRODUCTION Total knee replacement TKR is a treatment of knee osteoarthritis to alleviate pain symptoms and improve mobility and physical functioning when other conservative treatments have failed 1 3 It is a very common and successful procedure since 1970s for late stage osteoarthritis and there is a continuously increasing number in demand for primary TKR performed worldwide each year 4 5 However not all patients are satisfied after TKR Pain after TKR is stronger determinant of satisfaction than function 6 An unfavorable pain outcome was seen in at least 80 and up to 265 of patients 7 and contribute to functional disability after TKR 6 8 10 Apart from the postsurgical pain that is a result of a specific cause some patients suffer from a persistent postsurgical pain PPSP with no specific origin that represents an important cause for patients dissatisfaction Although the cause of PPSP is not known it seems that some of the patients with PPSP after TKR suffer from neuropathic pain NP 11 The International Association for the Study of Pain IASP defines 1 as PPSP the pain that is being developed after surgery and exists beyond the time for normal healing and is present for at least 36 mo 12 and 2 NP is also defined by the IASP as the pain caused by a lesion or a disease of the somatosensory nervous system IASP website httpwwwiasppainorg 13 A wide variety of scorestools have been used in order to assess the outcome postoperatively Almost all scores or instruments either objective clinicianbased 14 or subjective patientreported 15 or disease specific 3 16 being used for the study of the outcome function and satisfaction after TKR include some kind of pain assessment 17 However a standard deﬁnition of pain severity at followup considered a difficult issue to be applied and the need to improve assessment and measurement of musculoskeletal pain in the clinical setting is recognized 18 The purpose of this study is to present a review of the existing literature concerning the existence of PPSP and NP after TKR for at least 3 mo including studies with main purpose the prevalence of the PPSP and NP after TKR using painspecific instruments and not through other scores or instruments measuring functional outcome Go to MATERIALS AND METHODS Literature search MEDLINE and Embase databases were searched for articles published until December 2014 The keywords TKR total knee arthroplasty chronic postoperative pain NP and synonyms were used to maximize the efﬁciency of the search Both prospective and retrospective studies were included Inclusion and exclusion criteria Published articles were included only if they referred to pain that lasts at least 3 mo after primary TKR and if the main reason of TKR was knee OA Studies were excluded if they were abstracts case studies reviews editorials and if they referred to pain caused by septic reasons and implant malalignment Studies that assessed a mixed cohort of patients eg knee and hip replacement patients were included in the review and only data relevant to the TKR patients were extracted Studies in other language than English were excluded A total of 112 articles were found Only 14 studies that match the inclusion criteria and measured pain with pain specific instruments were selected for this review Go to RESULTS PPSP after TKR Table Table1 1 Table 1 Total knee replacement and chronic persistent postsurgical pain Studies We identified 5 prospective 19 23 and 3 retrospective 9 24 25 studies Three of the studies found to have as primary aim the documentation of the existence and the prevalence of PPSP after TKR 19 20 25 while another one assessed PPSP retrospectively in patients after both TKR and THR 9 Factorsvariables related to PPSP Multiple variables have been considered to play an important role at persistent postoperative pain At times different aspects of risk factors have been examined In these studies preoperative factors that were examined were comorbidities 20 preoperative pain 19 20 and pain catastrophizing scores 20 21 But only one study found to quantify the effect of sex on postoperative pain outcomes 24 while another one assessed the relationship of PPSP and the Grade of knee osteoarthritis according to the scale of Kellgren and Lawrence 23 Quality of life pain and satisfaction were measured in depressed and nondepressed patients to identify differences that might exist in the scores 22 Pain scales or scores Pain intensity mainly was measured using validated patient reported measures of pain the most common were the Visual Analogue Scale VAS 19 25 which is a well evaluated tool the McGill pain questionnaire MpQ 9 20 the Knee Society Score 22 24 and the Numerical Rating Scale NRS 21 To cover the influence of psychological factors on TKR outcomes Pain Catastrophizing Scale PCS was used to measure pain catastrophizing 20 21 while the Twoitem Patient Health Questionnaire PHQ2 9 Geriatric Depression Scale 21 22 Medical Outcomes Study 36Item Short Form Health Mental Composite Score 22 and Anxiety Form of the State Trait Anxiety Inventory STAI 21 were used to measure depression and anxiety A recent study 25 evaluated the tools that used to measure pain intensity Knee injury and Osteoarthritis Outcome Score KOOS and VAS and how they affect the pain outcomes Pain assessment times and postoperative followup At the most of the studies there was a continuous followup Assessments took place preoperatively 19 21 25 and postoperatively at 1 mo 19 3 mo 19 20 6 mo 19 21 12 mo 19 22 23 25 and up to 1 year postoperatively 19 22 23 25 Prevalence of pain A significant reduction of pain after TKR was observed between preoperative scores and postoperative scores from 72 to 44 19 A further reduction was observed up to 3 mo postoperatively where pain reached a plateau 20 At 6 mo postoperatively pain at movements was found in 16 of patients 21 while pain at rest was significantly reduced in 5 of the patients 21 Others found PPSP in 184 of the patients at 6 mo 19 PPSP has been reported at 1 year postoperatively in 131 of the patients 19 while in another study 44 of the patients reported to had PPSP at a mean of 4 years after TKR 9 Interestingly in one study where the same patients were tested using two different scales at one year postoperatively the prevalence of PPSP was different in 25 of the patients using the KOOS and in 52 using the VAS 25 Factors related to PPSP Preoperative factors that affected pain scores were depression scores 9 19 affecting both preoperative and postoperative pain scores 22 early grade of osteoarthritis 23 number of comorbidities 20 and pain problems elsewhere 9 Gender didnt seemed to affect postoperative outcomes at all 24 A high correlation was found between preoperative pain catastrophizing scores and the existence of PPSP and its intensity 20 Which is in accordance with other reviews that is referred that patients pain catastrophizing might play an important role in chronic pain intensity 26 27 NP after TKR Table Table2 2 Table 2 Total knee replacement and neuropathic pain Studies The existence and prevalence of NP have been reported by a small number of studies 9 28 29 Three prospective studies 9 28 29 with the study population ranged from 77 to 120 patients and 1 retrospective study 9 with a number of 632 patients were designed for this purpose However other studies that aimed to evaluate specific treatments for NP recorded its prevalence too 30 Pain scales or scores Scores initially were used to establish the existence of pain in some of these studies These scores were MpQ 9 28 VAS 29 and NRS 30 Additionally NP was assessed by painDetect Questionnaire PDQ 9 29 Leeds Assessment of Neuropathic Symptoms and Signs scale 30 and MpQ 28 The contribution of depressions and anxietys presence and severity to the existence of NP were examined PHQ2 9 Beck Depression Inventory BDI 28 the Hospital Anxiety and Depression score 29 and the STAI 28 were used for this purpose Pain assessment times and postoperative followup Pain assessment at these studies took place preoperatively 29 30 and postoperatively at 35 d 29 6 wk 29 1 mo 28 at 3 6 and 9 mo 28 30 and up to 1 year postoperatively 9 29 NP prevalence A high correlation was found between VAS pain scores and NP at 3 mo 1 year and 3 years postop 29 Six weeks postoperatively a peak at the graph was observed with 27 having possible and 8 of the patients having likely NP At 3 mo that proportion reduced to 19 with possible and 4 with likely NP 29 Buvanendran et al 30 identified a rate of NP of 5 at 6 mo postoperatively while in another study 28 was found 13 of the patients having Complex Regional Pain Syndrome after TKR at both 3 and 6 mo It is reported that at mean 4 years after TKR 6 of the patients have pain of likely neuropathic origin 9 29 The use of perioperative pregabalin reduced the incidence of NP at 0 while placebo pregabalin didnt seem to reduce NP 30 Studies including TKR patients concerning the existence prevalence and etiology of NP Table Table3 3 Table 3 Studies including total knee replacement patients concerning the prevalence and etiology of neuropathic pain Studies A retrospective study assessed the existence and the preoperative predictors of NP in 632 TKR patients and 662 THR patients 9 and two prospective studies in 100 TKR patients and 89 patients after breast surgery 31 32 Another prospective study also examined the relationship between postoperative trajectories and NP in 112 TKR and UKR patients 33 Pain scales or scores Scores that used to assess NP were PDQ 9 and Diagnosing Neuropathic 4 31 33 Shortform McGill Pain Questionnaire 9 NRS 31 33 and Brief Pain Inventory 32 were used to define the existence of pain postoperatively Factors studied Preoperative factors of NP that were examined were depression 9 31 32 anxiety 31 33 pain catastrophizing 31 33 cognitive and emotional functioning 32 Depression was assessed with PHQ2 9 and 13item BDI 31 32 Spielberger STAI and PCS were used to assess anxiety and pain catastrophizing 31 33 Cognitive functioning was assessed with TrailMaking Test A B ReyOsterrieth Complex Figurecopy and immediate recall Coping Strategies Questionnaire and Brief Version of the Survey of Pain Attitudes 32 Pain assessment times and postoperative followup Assessments took place preoperatively 9 31 33 2 d postoperatively 31 32 at day 1 to 8 33 3 mo 31 33 6 mo 12 mo 32 and 3 to 4 years postoperatively 9 Factors Acute postoperative pain 31 cognitive functioning pain coping 32 emotional functioning 9 32 and problems of pain elsewhere 9 found to be predictors of PPSP and NP Prevalence Seventy five percent of the patients seemed to have NP preoperatively according to Attal et al 32 2014 while in another study NP seemed to appear on 307 of the patients 31 At 3 mo postoperatively NP ranged between 11 33 and 422 31 of the patients Six and 12 mo postoperatively patients with NP reduced at 32 and 26 respectively 32 At 3 to 4 years postoperatively only 6 of TKR patients had NP 9 Go to DISCUSSION The number of the 14 studies that used painspecific instruments to measure pain after TKR is small and studies that approach and record NP after TKR are much less According to these studies a significant proportion of patients have persistent postoperative pain for years after TKR and part of these patients suffer from pain of neuropathic origin Factors found to be related to persistent postoperative pain after TKR include emotional functioning such as depression and pain catastrophizing number of comorbidities and pain problems elsewhere and operations in knees with early grade of osteoarthritis Nevertheless due to the heterogeneity of the studies mainly on the scales used to assess pain and preoperative factors we are unable to reach firm conclusions concerning the prevalence and the risk factors of persistent postoperative pain after TKR Additional studies focused on the prevalence and risk factors related to persistent postoperative pain are needed Go to COMMENTS Background Persistentpostsurgical pain of unknown origin and neuropathic pain NP is considered a major underestimated problem for patients and for clinicians too There are several studies that measure pain with a wide variety of scorestools Research frontiers According to our acknowledgment this is the first review that analyses the prevalence of both persistent postsurgical pain PPSP and NP after total knee replacement TKR while pain is measured only with painspecific instruments Risk factors that might play an important role in the prediction and the prevalence of persistent postoperative pain were also analyzed Innovations and breakthroughs PPSP measured by pain specific instruments only by a few studies From this review it is obvious that postsurgical pain and NP exists in a significant proportion of patients for years after TKR Risk factors that might affect its prevalence and its intensity found to be emotional functioning such as depression and pain catastrophizing number of comorbidities and early grade of osteoarthritis Application Although it became recognizable the existence and the prevalence of PPSP and NP after TKR these studies did not lead us to firm conclusions There was mainly heterogeneity on the scales used to measured pain Thus further studies concerning the prevalence of PPSP and NP and their risk factors are needed with painspecific instruments Terminology PPSP is the pain that is being developed after surgery exists beyond the time for normal healing and is present for at least 36 mo NP is defined as the pain caused by a lesion or a disease of the somatosensory nervous system Peerreview This is a nice review article concerning postoperative knee pain after total knee arthroplasty Go to Footnotes Conflictofinterest statement All the authors declare that there is no conflict of interest for this work They have received no funds from any commercial party in relation to this work Data sharing statement It does not apply in this study OpenAccess This article is an openaccess article which was selected by an inhouse editor and fully peerreviewed by external reviewers It is distributed in accordance with the Creative Commons Attribution Non Commercial CC BYNC 40 license which permits others to distribute remix adapt build upon this work noncommercially and license their derivative works on different terms provided the original work is properly cited 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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PLoS One v1110 2016 PMC5049850 PLoS One 2016 1110 e0163917 Published online 2016 Oct 4 doi 101371journalpone0163917 PMCID PMC5049850 Strong or Weak Handgrip Normative Reference Values for the German Population across the Life Course Stratified by Sex Age and Body Height Nadia Steiber 1 2 Stefan Kiechl Editor Author information Article notes Copyright and License information Abstract Handgrip strength is an important biomarker of healthy ageing and a powerful predictor of future morbidity and mortality both in younger and older populations Therefore the measurement of handgrip strength is increasingly used as a simple but efficient screening tool for health vulnerability This study presents normative reference values for handgrip strength in Germany for use in research and clinical practice It is the first study to provide normative data across the life course that is stratified by sex age and body height The study used a nationally representative sample of test participants ages 1790 It was based on pooled data from five waves of the German SocioEconomic Panel 20062014 and involved a total of 11790 persons living in Germany providing 25285 observations Handgrip strength was measured with a Smedley dynamometer Results showed that peak mean values of handgrip strength are reached in mens and womens 30s and 40s after which handgrip strength declines in linear fashion with age Following published recommendations the study used a cutoff at 2 SD below the sexspecific peak mean value across the life course to define a weak grip Less than 10 of women and men aged 6569 were classified as weak according to this definition shares increasing to about half of the population aged 8090 Based on survival analysis that linked handgrip strength to a relevant outcome however a critically weak grip that warrants further examination was estimated to commence already at 1 SD below the groupspecific mean value Go to Introduction The strength of a persons handgrip measured with a dynamometer has come to be widely recommended as a simple but valid measure of overall muscle strength 1 and a central marker for the onset of sarcopenia 2 ie the ageassociated reduction of muscle function and strength from age 50 onwards 3 Low handgrip strength abbreviation HGS in the following tends to be associated with functional limitations and it is a powerful predictor of future disability physical health problems and cognitive decline 4 6 Low HGS was in fact found to be a better predictor of mortality than chronological age and systolic blood pressure 7 9 For these reasons gerontologists have suggested to measure HGS in clinical practice to allow for an early detection of a decline in muscle mass associated with morbidity and mortality risks 9 10 The measurement of HGS is a prime candidate for use in routine medical exams given the simplicity and low cost at which it helps to assess patients muscular fitness 2 The measurement of HGS has been proposed as a key component of frailty phenotypes and it was also suggested as a central biomarker of healthy ageing 7 For these reasons HGS is measured in a great number of ageing studies such as the US Health and Retirement Study HRS the Survey of Health Ageing and Retirement in Europe SHARE and the English Longitudinal Survey of Ageing ELSA The fact that most surveys that include measures of HGS only cover the population aged 50 and over limits life course research on HGS Studies show that healthrelated behaviours such as physical activity in midlife predict HGS at older ages 11 Moreover HGS in early old age ages 5668 has been shown to be associated with the probability of extreme longevity 12 Much less is known about levels of HGS earlier in life and its implications for future outcomes There is some evidence that low muscle strength among schoolaged youth is associated with cardiovascular and metabolic risk factors 13 supporting the view that routine screening of muscle strength should not be restricted to older ages and that reference values across the life course are needed The aim of this study is to provide normative reference values for HGS that allow for a comparison of HGS measurements in the clinical context and in other scientific studies with values that can be considered normal at certain ages The reference values are measured from a healthy reference population Since HGS measurements show a great deal of variation across geographical regions and national contexts 14 16 it is important to have regionspecific reference values In contrast to much of the previous work that tended to be based on small andor nonrepresentative convenience samples this study is based on a large random sample of test participants that is nationally representative The presented analyses are based on pooled data from five survey waves of the German SocioEconomic Panel 20062014 that provide more than 25 thousand measurements of HGS from test participants ages 1790 This study is among the first to provide normative data across the life course for young middleaged and older adultsthe very first studies providing life course data have recently been presented by Dodds et al 17 for the British context and by Peterson and Krishnan 18 for the US see also 19 This study is the first to provide such reference values for Germany and it is the first to provide reference values across the life course that are not only stratified by sex and age but also for body height Prior studies have in part normalized grip strength for body height or body weight 18 yet in most cases normative reference values are not presented for different population groups defined along such anthropometric measures However given the substantial share of the variance in HGS explained by body height over and above sex and age it is clearly important to stratify normative reference values for participants body height 20 Go to Prior Work A descriptive review of available studies providing reference values for HGS measurement shows that most of them draw on small nonrepresentative convenience samples of test participants see S1 Table Only three prior studies have presented nationally representative reference values covering the whole life course one for the British context 17 and two for the US American context 18 19 both using the same source of data The studies provide similar results showing that among men peak mean values of HGS of around 4952 kg are reached in the fourth decade of life whereas women reach their peak value of about 31 kg on average in the third or fourth decade of life In the seventh decade of life mean values drop to around 4142 kg among men and to 2526 kg among women see Panel A of S1 Table Other studies presenting reference values for broad age ranges covering larger parts of the life course see Panel B of S1 Table are typically based on small samples that are not representative of the countrys population Many of the studies draw on convenience samples recruited from various locations such as hospitals sports clubs universities senior residences or shopping malls 21 25 Moreover all of these studies are restricted to small sets of test participants at each given sex and age see also 26 Other studies are based on regional data 21 22 27 29 or on data collected in a diverse set of countries 30 Despite methodological limitations these studies do not tend to show radically different results compared to those from the nationally representative studies cf Panel A of S1 Table Based on a convenience sample of 720 participants collected in the US Peters and colleagues 24 show peak mean values of 49 kg for men and 29 kg for women values dropping in the seventh decade of life to 43 kg for men and 25 kg for women These results are remarkably close to those reported by Perna et al 19 drawing on the representative National Health and Nutrition Examination Study NHANES Reference values from the North West Adelaide Health Study 29 and from a Health Survey in Rio de Janeiro 28 show somewhat lower values for the respective regions of Australia and Brazil peak mean values of 47 kg for men in both studies a decline in mens seventh decade of life to 40 kg in Adelaide and to 37 kg in Rio Comparatively higher peak values are shown by studies drawing on convenience samples from Germanspeaking regions and Norway eg peak mean values of 54 kg for Bavarian men 56 kg for Germanspeaking Swiss men and 58 kg for Norwegian men The values for the seventh decade of life in these studies were also somewhat higher than those reported by 22 23 25 Finally a study of two cities near Madrid Spain suggests that mean values drop to 38 kg among men in their 60s Such national comparisons appear to corroborate prior research showing that handgrip tends to be stronger in Northern and Continental European countries than in Southern Europe 15 More robust conclusions can only be drawn based on nationally representative data Studies discussed in Panel B of S1 Table generally provide insufficient sample sizes for subgroups defined by sex and age and only allow for tentative conclusions Compared to the studies presented in Panel B studies that do not provide a life course perspective but that are based on sufficient sample sizes for older agegroups see Panel C of S1 Table are of greater value for robust interstudy comparisons A mediumscale study of the communitydwelling Japanese population aged 60 and above 31 estimates an average HGS of 38 kg for men aged 65 and of 32 kg for men aged 75 and thus values that are somewhat lower than those reported in studies of Caucasian populations living in Britain the US or Northern Europe for regional studies on Japan see also 32 33 A study on the Swedish province of Uppsala for instance suggests an average HGS of 41 kg for men aged 7476 The commonly found lower HGS among Asian compared to Caucasian men however does not appear to extend to women Aoyagi and colleagues 34 compare Japanese women living in Japan aged 6569 with Japanese and Caucasian women living in the US in the same age group They find the comparatively highest mean HGS in the native Japanese sample Finally three studies could be identified that provide reference values for certain population groups that are not only stratified by age and sex but also by body height see Panel D in S1 Table None of these studies provide reference values across the life course The largest of these studies presents values for the United Kingdom drawing on data from the UK Biobank and covers the age range 3973 20 The second study covers the Danish population aged 45 and above using data from three nationwide populationbased surveys 35 And the third one draws on data representative of the communitydwelling Irish population aged 5085 36 The studies corroborate the view that it is important to account for the height of test participants when evaluating their HGS against some reference value The Irish study suggests for instance that men aged 65 have an average HGS of 34 kg if they are less tall than 173 cm and of 38 kg if taller The British and the Danish studies were able to differentiate more than two height groups showing that average HGS increases by 24 kg for each 10 cm of body height with variations in the relation between HGS and body height by age To sum up published normative data for HGS are available from many countries Typically reference values are provided for different age and sex subgroups whereas only a handful of studies provide reference values for subgroups defined also along the lines of body height The majority of available studies furthermore pertain to a limited age range whereas only a small set of studies provide reference values for comprehensive age ranges that cover a large part of the life course The few studies taking a life course perspective report mean or median values of HGS for different sex and age groups and show a peak of HGS in the fourth decade of life followed by a gradual decline in HGS with agefor both sexes Although prior evidence suggests that normative values would need to be stratified not only for age and sex but also for body height 20 36 to date none of the available life course studies provides reference values for height subgroups This is the aim of the present study ie to provide reference values for a comprehensive age range 1790 and based on sufficient samples sizes for each age group and sex to provide values for height subgroups Many of the available studies but by far not all exclude persons with health limitations such as arthritis heart conditions inflammatory or neurological diseases There is however no standard procedure used to construct a healthy reference population At all events all of the available studies are naturally restricted to test participants who are in a state of health that allows them to take part in the study and to have their HGS measured with a dynamometer This typically excludes the institutionalized population The average health among test participants will thus be somewhat better compared to the general population Go to Data and Methods German SocioEconomic Panel This study uses anonymized secondary data collected by the German Institute for Economic Research DIW The data derive from the German SocioEconomic Panel SOEP a household panel study providing representative data for the German population since 1984 The SOEP is approved as being in accordance with the standards of the Federal Republic of Germany for lawful data protection The survey ethics are monitored by an independent advisory board at the DIW SOEP data are available free of charge as scientific use files In 2006 when HGS was first measured a random subsample of 5528 individuals out of 32304 survey respondents was selected to be assessed for HGS In 2008 the measure was repeated for the majority of the 2006 test participants longitudinal stability of 76 and from 1437 individuals HGS was measured for the first time in 2008 37 HGS was again measured in 2010 2012 and 2014 including both repeat testing longitudinal sample providing HGS measures at more than one age and testing on refresher samples measured for the first time in these years The HGS measurement included more than 5000 participants in each of the four measurement years annual response rates ranging between 95 and 97 Sample The sample is restricted to participants ages 1790 due to small sample sizes outside this age range For details on sample sizes in the chosen age range in the five measurement years see S2 Table In terms of anthropometric measures the sample is restricted to men who are between 160 and 200 centimetres tall and to women with a body height between 150 and 184 centimetres ie excluding 1 of participants Moreover it excludes 222 outliers identified from sexspecific regressions that model HGS as a function of age and body height in linear and quadratic form Those with standardized residuals of above 3 SD are removed from the sample 08 of participants In the aim to provide results for a healthy reference population the sample is restricted to those able to participate in the HGS test and attaining a value of at least 10 kg This threshold can easily be met by all reasonably healthy persons even at higher ages eg less than 2 of participants aged 8090 attain values below 10 kg Overall the lower bound on the HGS test result of 10 kg excludes 009 of measurements Finally the sample excludes those who score in the lowest 5 of the Physical Component Summary Scale PCS of the SF12 module in the SOEP which measures functional health and wellbeing based on twelve 38 39 It covers eight health domains that are summarized in two dimensions physical health PCS and mental health MCS The PCS accounts for physical functioning role limitations due to physical health problems bodily pain and general health perceptions The PCS score is zstandardized to a mean value of 50 and a SD of 10 the cutoff value to define the lowest 5 of the PCS is 30 The final sample for analysis involves 25285 observations Handgrip strength Handgrip strength in kilogrammes is measured with the Smedley S DynamometerTMM Tokio 100kg Prior research suggests that different dynamometer types and brands produce similar results ie reference values are robust to the dynamometer type used 17 and that values taken with a Smedley dynamometer very strongly correlate with those taken with the commonly used Jamar dynamometer 40 The examination procedure in SOEP foresees that two measures of HGS are taken from each hand Following published recommendations 1 37 the maximum value achieved with either hand is used as a summary measure of a persons isometric strength of the hand and forearm muscles This is a common choice of summary measure in prior research cf S1 Table yet it is worth mentioning that studies show similar results irrespective of whether they use average or maximum values achieved in multiple trials 41 Statistical analysis For the statistical analyses data from five waves of the SOEP are pooled resulting in 25285 HGS measurements from 11790 persons Following 17 all available data is used including values for individuals who had their HGS measured at more than one age Results are weighted In a first step simple means M standard deviations SD and median values p50 are presented for 14 age groups S3 Table Based on OLS regression analysis with age height and the variables square terms as predictors of HGS sexspecific life course profiles of HGS are estimated and graphically presented These profiles do not yet account for body height and thus allow for a definition of peak mean values for women and men that can be compared with prior studies In a second step agespecific height discount factors are calculated based on OLS regressions of HGS on age and body height and its squared term To allow for agespecific height stratification separate regressions are carried out for different age groups 1724 2535 4554 5564 6574 7584 8590 These regressions are then used to estimate mean HGS across seven height groups within each of the 14 age groups The results are presented as sexspecific reference values stratified by age and body height Finally cutoff values are defined to identify persons with a weak grip Such cutoff values have pragmatically been defined at 2 SD below the sexspecific peak mean value in prior research eg 17 A similar threshold has become a common criterion for the diagnosis of sarcopenia to allow for an early detection of declining muscle strength the European Working Group on Sarcopenia in Older Persons EWGSOP recommends cutoff points at 2 SD blow the mean value of HGS taken from a healthy and young reference population 2 To arrive at a more strongly evidencebased risk threshold that relates to a relevant outcome mortality information from the SOEP is utilized to model survival as a function of HGS More specifically these analyses draw on HGS measurements taken in 2006 and mortality information from a followup period of 8 years until the year 2014 HGS measurements are first standardized for age and body height The standardized measures of HGS are the zstandardized residuals derived from sexspecific OLS regressions of HGS in kg on age in years and body height in cm Subsequently the standardized HGS values are recoded into Go to Findings The estimated life course profiles of HGS show a slightly increasing curve up to peak values in midlife and a gradual decline in strength thereafter Fig 1 The mean peak value for men is about 54 kg ages 3049 for women it is about 345 kg ages 3544 Mean values drop to about 44 kg for men and 28 kg for women in the age group 6569 This drop in HGS between midlife and the second half of the seventh decade of life amounts to almost 1 SD in the male sample 1 SD pertains to 98 kg in the female sample to 68 kg More information about means SD and median values by age group is available from S3 Table Comparing these results with those presented in recent life course studies cf Panel A in S1 Table suggests that peak values reached in the German population 54 kg for men 345 kg for women are somewhat higher than those reached in the UK 52 and 31 kg respectively see 17 and the US 49 and 31 kg respectively see 19 Also the values for the seventh decade of life in the German population 44 kg for men 28 kg for women aged 6569 remain at a somewhat higher level compared to the UK 42 and 25 kg and the US 41 and 26 kg Similar values as the ones presented here are reported by 22 based on a small Bavarian convenience sample Fig 1 Life course profiles of handgrip strength for German women and men The prevalence of a weak grip defined by values that lie 2 SD below the sexspecific peak means see eg 17 is shown to increase with age Fig 2 Using this simple approach a weak grip was defined to start below 33 kg for men and below 21 kg for women Less than 10 of women and men aged 6569 are in this way classified as weak shares increasing to 23 of women and 29 of men aged 7579 and to about half of the population aged 8090 Interestingly the prevalence curves of a weak grip are very similar for both sexes Relaxing the definition using a cutoff at 1 SD below the sexspecific peak mean values weak grip would be defined to start already below 44 kg for men and 28 kg for women According to this definition around 20 of 5054 year olds would be classified as weak about half of the population aged 6569 and about three quarters of the population aged 7579 The vast majority of octogenarians have a weak grip 88 according to this alternative definition Fig 2 Share of individuals with a weak grip using 1 SD and 2 SD cutoffs Normative reference values for German men and women are shown in Tables Tables1 1 and and2 2 Values are reported for 14 age groups and within these for 7 groups defined by body height For example the reference value for 4044 year old women with a body height of 165169 cm is about 35 kg this value increases by about 1 kg for every 5 cm of additional height The relevance of body height for these reference values can be highlighted by the fact that a 20 cm difference in height among women amounts to a similar difference in HGS of about 4 kg as comparing women aged 4044 with those aged 5559 ie 15 years age Table 1 Normative Reference Values of Handgrip Strength for German Men Table 2 Normative Reference Values of Handgrip Strength for German Women The results of the survival analysis see Table 3 for sample distribution and Table 4 for results suggest that the mortality risk within 8 years of HGS measurement increases to a significant degree starting with HGS measurements that lie 115 SD below the groupspecific mean value using an age and heightstandardised measure of HGS Men whose HGS falls 115 SD below the mean value attained by their peers of the same age and height are found to have a 86 greater hazard to die within 8 years of the HGS test compared to the reference group HR 19 Also womens hazard shows a significant increase at 115 SD below the groupspecific mean value of HGS HR 26 This 1 SDthresholdwhich is much lower than the 2 SD cutoff commonly used in gerontological researchis thus used to define a critically weak handgrip that warrants closer examination given the presented evidence for an elevated mortality risk The estimated groupspecific risk thresholds in kg are shown in the last columns of Tables Tables1 1 and and2 2 For example for 6569 year old men with an average height of 175 cm mean HGS is estimated at 45 kg and the risk threshold at about 38 kg whereas for men in the age group 7579to take another examplethe estimated mean and threshold values in the same height group are 39 kg and 31 kg Table 3 Sample Distributions across Groups Defined by Age and HeightStandardized HGS Table 4 Cox Proportional Hazard Models with Age and HeightStandardized HGS as Categorical Predictor Go to Discussion The study presented nationally representative estimates of life course profiles in handgrip strength HGSa marker of muscle strength and predictor of future health risksfor Germany It was based on a large random sample of the noninstitutionalized population The data at hand provided the rare opportunity to develop normative values for HGS for large parts of the life course ages 1790 and the large sample sizecompared to most previous workmade it possible to report values stratified by sex age and body height The study showed inverted Ushaped life course profiles with mean peak values of about 54 kg for men and 345 kg for women and a gradual drop in mean HGS with age from the mid40s onwards By age 6569 average HGS has on average dropped by 1 SD to 44 kg for men and to 28 kg for women However the variance in HGS is substantial Using a common cutpoint in the literature to define a weak grip ie 2 SD or more below sexspecific peak mean values by age 7579 only about a quarter of the population would be classified as having a weak grip Such pragmatic cutoff values have been widely used in the literature typically without reference to empirical evidence for the usefulness of this specific threshold in terms of relevant outcomes such as increased risks for cardiovascular disease or mortality This study used survival analysis to provide such evidencebased thresholds The findings suggested that the threshold to define critically weak grip associated with elevated mortality risks is located already at values that lie 1 SD or more below the standardized mean HGS The reference values presented in this study are a valuable source of information in the clinical assessment of HGS and for comparison with studies from other countries The findings underscore the great importance of accounting for body height when evaluating measured HGS with some reference value The presented ageprofiles of HGS serve a particular purpose they are not indicative of ageing processes in terms of muscle strength Given changes in the health status of populations across cohorts ie older populations from more recent cohorts being less likely to be frail see Hörder et al 42 the ageprofiles of the provided references values may reflect cohort effects This would imply that the young of today are likely to show a less pronounced drop in HGS with age than suggested by the profiles crosssectional ageprofiles of HGS may for this reason overestimate individual decline Yet on the other hand studies on the older parts of any population are subject to selective attrition less healthy individuals being more likely to drop out due to morbidity and mortality crosssectional ageprofiles of HGS may for this reason underestimate individual decline In sum given potential differences between crosssectional and longitudinal HGS Go to Supporting Information S1 Table Overview of Prior Studies Providing Reference Values for Handgrip Strength Review restricted to studies published after the year 2000 and excluding studies with very low participant numbers Values given in pounds lbs or Newton have been transformed into whole kilogrammes to allow for comparability Abbreviations D dominant hand M mean values MD median values N no of test participants R right hand wo without PDF Click here for additional data file 93K pdf S2 Table Overview of Sample Sizes by Survey Year and Sex Sample SOEP 20062014 HGS test participants excluding those with HGS 10 kg those scoring in the lowest 5 of the PCS and outliers identified from regressions of HGS on age age2 height and height2 PDF Click here for additional data file 55K pdf S3 Table Mean and Median Values for HGS by Age Weighted Notes N 13120 women 12165 men Table presents weighted means and standard deviations SD and median values P50 The presented values are not standardized for height for information of mean height by sex and age see S4 Table denotes that the twofour values marked with a show no statistically significant difference PDF Click here for additional data file 63K pdf S4 Table Mean Body Height in Centimetres by Age Weighted Notes Overall sample size N 13120 women 12165 men PDF Click here for additional data file 58K pdf Go to Funding Statement European Research Council ERC2012AdG 323947ReAgeing The research leading to these results has received funding from the European Research Council under the European Unions Seventh Framework Programme FP720072013ERC grant agreement no ERC2012AdG 323947ReAgeing The funders had no role in study design data collection or analysis Go to Data Availability Data from the German SocioEconomic Panel SOEP are made available for scientific research by the German Institute for Economic Research DIW Contact edwidliampeos Go to References 1 Roberts HC Denison HJ Martin HJ Patel HP Syddall H Cooper C et al A review of the measurement of grip strength in clinical and epidemiological studies towards a standardised approach Age Ageing 2011 40 423429 doi 101093ageingafr051 PubMed 2 CruzJentoft AJ Baeyens JP Bauer JM Boirie Y Cederholm T Landi F et al Sarcopenia European consensus on definition and diagnosis report of the 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O O O O O O O O O O O O O O O O O O O O O O B O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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Development and validation of a clinical cancer genomic profiling test based on massively parallel DNA sequencing Frampton GM1 Fichtenholtz A Otto GA Wang K Downing SR He J SchnallLevin M White J Sanford EM An P Sun J Juhn F Brennan K Iwanik K Maillet A Buell J White E Zhao M Balasubramanian S Terzic S Richards T Banning V Garcia L Mahoney K Zwirko Z Donahue A Beltran H Mosquera JM Rubin MA Dogan S Hedvat CV Berger MF Pusztai L Lechner M Boshoff C Jarosz M Vietz C Parker A Miller VA Ross JS Curran J Cronin MT Stephens PJ Lipson D Yelensky R Author information 11 Foundation Medicine Cambridge Massachusetts USA 2 Comment in Nat Biotechnol 2013 Nov31119902 As more clinically relevant cancer genes are identified comprehensive diagnostic approaches are needed to match patients to therapies raising the challenge of optimization and analytical validation of assays that interrogate millions of bases of cancer genomes altered by multiple mechanisms Here we describe a test based on massively parallel DNA sequencing to characterize base substitutions short insertions and deletions indels copy number alterations and selected fusions across 287 cancerrelated genes from routine formalinfixed and paraffinembedded FFPE clinical specimens We implemented a practical validation strategy with reference samples of pooled cell lines that model key determinants of accuracy including mutant allele PMID 24142049 Publication Types Research Support NonUS Govt MeSH Terms DNA Copy Number Variations DNA Mutational Analysismethods Gene Frequency Humans Molecular Diagnostic Techniquesmethods Neoplasmsdiagnosis Neoplasmsgenetics Reproducibility of Results Sensitivity and Specificity Sequence Analysis DNAmethods Grant Support WT093855MAWellcome TrustUnited Kingdom

O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


AVAILABLE 7 DAYS A WEEK Manage My Policy Login Producer Login Member Insurers Login Independent Adjuster Login Third Party Administrator Login Vault Login Services Coverages Claims Catastrophes Approved Adjusters Underwriting Financial Member Insurers Policy FormsEndorsements Dynamic Web Information Producer Download Request Form Proudly Providing Coverage for the Citizens of North Carolina since 1969 IMPORTANT ANNOUNCEMENT CONTACT INFORMATION FOR UPDATE ON CLAIM STATUS To obtain the status of a claim with the NCIUA and your policy is Windstorm or Hail coverage only you will need to contact the Member Insurer that insures your policy and has excluded the windstorm or hail The Member Insurer is required to investigate and adjust the claim To obtain the status of a claim with the NCJUANCIUA and your policy is Full Peril including windstorm or hail you may call 919 8211299 or 18006627048 To better service the citizens of North Carolina the Associations have extended our normal operating hours NAMED STORMS FLORENCE HOW TO FILE A CLAIM AND OTHER PROCEDURES Policyholders Producers Member Insurers NONNAMED STORM LOSSES HOW TO FILE A CLAIM AND OTHER PROCEDURES Policyholders Producers Member Insurers BREAKING NEWS Updated November 29 2017 STORM TRACKER North Carolina Department of Insurance NCJUA MISSION The North Carolina Joint Underwriting Association NCJUA also known as the FAIR Fair Access to Insurance Requirements Plan is a tax exempt association of insurance companies licensed to write and engage in writing property insurance coverage in North Carolina The Association was created by law to act as a market of last resort to provide adequate basic property insurance to property owners having insurable property in North Carolina NCIUA MISSION The North Carolina Insurance Underwriting Association NCIUA also known as the Coastal Property Insurance Pool is a tax exempt association of insurance companies authorized to write and engage in writing essential property insurance coverage in North Carolina The Association was created by law to act as a market of last resort to provide adequate essential property insurance to property owners having insurable property in the Beach and Coastal Areas of North Carolina NCJUANCIUA does not provide Flood Insurance Please contact the National Flood Insurance Program through Flood Smart for Policy Information National Flood Insurance 18883799531 Storm Announcements Storm Announcements How to File a Claim and Other Named Storm Procedures Named Storm Alerts Important Links NCDOI North Carolina Department of Insurance NCHurriClaims North Carolina Department of Insurance NCRB North Carolina Rate Bureau NHC National Hurricane Center NFIP National Flood Insurance Program IBHS Insurance Institute for Business Home Safety

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

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Home Cruise Faq What Cancellation Policy Tours And Where Do I Cancel What is the cancellation policy on tours and where do I cancel You may modify or cancel excursions up to 48 hours prior to arrival in port without penalty Any exceptions are noted in the tour descriptions You may cancel an excursion by writing Cancel on the tickets and return them to the Shore Excursion Desk or Drop Box 48 hours prior to arrival in to port Related FAQs How do you contact someone on a cruise ship HowtoTiponaCruise What is the largest cruise ship Where does a cruise to nowhere go When is the best time to book a cruise How to book a cruise for a group What are the ways that I can book my tours Where do I find the meeting time and place for my tour What should I wear on tour Should I bring a towel with me on a tour Where do I pick them up What if I miss the cancellation deadline and do not want my tour Are we brought back to the ship following our tour I have a disability What excursions can I go on Is the speed of my connection the same as on land Can I access Skype or view streaming video onboard When do I need to settle my account What do I do if I lost something Is there an ATM on board What is the Freestyle Daily Where can I get one What is my onboard number What is the cost of the Phone and Messenger Package Can I place calls and send messages to another guest on the ship Can I place calls to my friends and family back home Will I incur roaming charges when making an onboard or offship call What number will display on the Caller ID when I place a call to a person offship Is there a voicemail Can I use the app when I go off the ship for example on an excursion When will my Phone and Messenger Package terminate Whom do I contact if I have a question or difficulties with the Cruise Norwegian App How does Freestyle Dining work What is your Restaurant Cancellation policy What is the Mandatory Life Boat Drill Do I have to attend the lifeboat drill even if I have cruised on Norwegian Cruise Line before What is my assembly station Should I wear my lifejacket when participating in the Life Boat Drill What is the timing of the mandatory safety drill Can I have an open flame

O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Home New To Cruising Countdown Cruise Countdown To Your Cruise LET US CALL YOU SIGN UP FOR SPECIAL OFFERS Excited about your cruise on Norwegian Great However before departure day there are some important mustdo items youll need take care of firstsee below Plus check out all the things you can prebook as well as other goodtoknow info 1 Planning A Cruise 2 Booking A Cruise 3 Cruise Countdown FIRST THINGS FIRST Before you depart you must be sure to have your cruise documentation including passports or visas if needed You can also CheckIn any time online up to 24 hours prior to sailing saving you lots of time at the pier To get to Online CheckIn and more things you can reserve before your cruise Log In to My NCL Go to the Vacation Summary section and follow the links to CheckIn Youll need personal info such as birth date address emergency contact info passport and document numbers for each guest Once Online CheckIn is complete for all guests in your stateroom and your cruise is paid in full you should be able to download your eDocs 30 days prior to sail date Make sure you bring a printed copy of your eDocs with you to the pier This will serve as your boarding pass If you booked your cruise reservation with a Travel Agent or an online travel website click the LOOKUP RESERVATION button located under the LogIn box Youll be asked your ship sail date and reservation number Watch the Video Get to Know My NCL Book things to do on board and on land Maximize every day and night of your cruise Before you set foot on board you can line up all your shore excursions specialty dining reservations entertainment spa appointments and more Having everything prearranged means less time coordinating and more time enjoying After all youre on vacation Log In to My NCL to Explore and Plan the possibilities Or check out the Cruise Calendar page to see a sampling of some Norwegian favorites Shore Excursions Many of our popular tours sell out quickly so be sure to reserve your must do Shore Excursion choices no later than two days before your cruise Log In to My NCL to see the excursions available on your itinerary Specialty Dining Starting 90 days prior to your sail date you can Log In to My NCL to reserve your specialty dining for every night of your cruise You can also make dinner reservations on board the ship Gifts More Celebrate a birthday anniversary or special occasion on board with flowers room decorations or gourmet treats Log In to My NCL and browse Gifts More to purchase bottles of wine onboard credits celebration packages What To Pack Many guests tend to take twice as much as they need Even though you only have to unpack once it makes things a lot easier for you if you plan ahead and pack accordingly Here are some tips to help you pack smart What to wear On Norwegian you can pretty much wear what you want when you want Go cruise casual smart casual or get alldecked out and look your best its totally your call Thats the freedom of Freestyle Cruising Dress for the destination Wherever youre going dressing in layers gives you the most options Also consider any shore excursions and pack appropriately including comfy walking shoes And be sure to pack a sweater the air conditioning can be chilly Dress for the event Our newest event Norwegians Night Out is the perfect opportunity to get dressed up for an evening of cocktails fine dining and great entertainment You may also want to pack an allwhite ensemble for our iconic White Hot Party Dont worry about bringing these For your convenience hairdryers and bath products are available in all staterooms Irons are available on request and laundry and dry cleaning services are available We also provide beach towels for you to use while in port Leave these at home Guests are not allowed to bring on board liquor firearms weapons of any kind ammunition explosive substances or any goods of a dangerous nature nor animals of any kind except service or guide animals Click here for more info HELPFUL TIPS DOWNLOADS Check out even more ways to make your first day on board and every day of your cruise vacation smooth sailing While youre on board youll receive the Freestyle Daily newsletter filled with the highlights in each port and the happenings on board that day PREPARE FOR YOUR CRUISE Already booked Make sure you read this useful information to prepare for your cruise Find tips on what to pack what to expect on departure day things to do onboard and more SHIP POCKET GUIDES Our handy ship pocket guides feature detailed deck plans helping you find your way around the ship Youll receive one at checkin but you can also download your pocket guide here Norwegian iCONCIERGE APP The iConcierge mobile app available on all ships except Norwegian Sky keeps you informed about everything going on aboard the ship Plus you can call chat with other guests during your cruise and even call friends back at home FLIGHT ASSISTANCE HOTLINE Get help with any flight delays or cancellations whether they are booked independently or through Norwegian Cruise Line Call 8004567179 or 3054682029 USEFUL INFORMATION Still have questions Click on some of our FAQ topics below to browse our Frequently Asked Questions Before You Cruise Children Accessibility Money Matters Need to Know While You Cruise Cruise Lingo

O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O