How Movement Is Assessed Matters. Changes in Forward Bending During Cognitive Functional Therapy Treatment for People With Chronic Low Back Pain.

OBJECTIVE: To investigate forward bending range of motion (ROM) and velocity in patients with low back pain who were receiving Cognitive Functional Therapy and determine (1) the amount and timing of change occurring at the trunk and pelvis (global angles), and lumbar spine (intersensor angle), and (2a) differences in changes between participants with and without sensor biofeedback, and (2b) participants with and without baseline movement limitation. DESIGN: Observational study. METHODS: Two hundred sixty-one participants attended Cognitive Functional Therapy treatment and wore sensors at the T12 and S2 spine levels while performing forward bending. Measures included ROM and velocity from both sensors, and the intersensor angle. Regression models estimated changes over time. Time-group interactions tested participants who were subgrouped by treatment and baseline movement. RESULTS: During the 90-day evaluation period, most change occurred in the first 21 days. Changes in ROM observed at T12 (3.3°, 95% CI: 1.0°, 5.5°; P = .001) and S2 (3.3°, 95% CI: 1.2°, 5.4°; P = .002) were similar. Intersensor angle remained similar (0.2°, 95% CI: -2.0°, -1.6°; P = .81). Velocity measured at T12 and S2, and the intersensor angle increased 8.5°/s (95% CI: 6.7°/s, 10.3°/s; P<.0001), 5.3°/s (95% CI: 4.0°/s, 6.5°/s; P<.0001), and 3.4°/s (95% CI: 2.4°/s, 4.5°/s; P<.0001), respectively, for 0 to 21 days. There were minimal differences in participants who received biofeedback. Larger increases occurred in participants with restricted ROM and slower velocity at baseline. CONCLUSION: During 0 to 21 days, we observed changes at the trunk and pelvis (especially in people with reduced ROM), and velocity changes across all measures (especially in people with baseline movement limitations). Biofeedback did not augment the changes. When targeting forward bending in people with low back pain, clinicians should monitor changes in velocity and global ROM. J Orthop Sports Phys Ther 2024;54(3):1-13. Epub 19 December 2023. doi:10.2519/jospt.2023.12023.

Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial.

BACKGROUND: Low back pain is the leading cause of years lived with disability globally, but most interventions have only short-lasting, small to moderate effects. Cognitive functional therapy (CFT) is an individualised approach that targets unhelpful pain-related cognitions, emotions, and behaviours that contribute to pain and disability. Movement sensor biofeedback might enhance treatment effects. We aimed to compare the effectiveness and economic efficiency of CFT, delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling low back pain. METHODS: RESTORE was a randomised, controlled, three-arm, parallel group, phase 3 trial, done in 20 primary care physiotherapy clinics in Australia. We recruited adults (aged ≥18 years) with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation. Exclusion criteria were serious spinal pathology (eg, fracture, infection, or cancer), any medical condition that prevented being physically active, being pregnant or having given birth within the previous 3 months, inadequate English literacy for the study's questionnaires and instructions, a skin allergy to hypoallergenic tape adhesives, surgery scheduled within 3 months, or an unwillingness to travel to trial sites. Participants were randomly assigned (1:1:1) via a centralised adaptive schedule to usual care, CFT only, or CFT plus biofeedback. The primary clinical outcome was activity limitation at 13 weeks, self-reported by participants using the 24-point Roland Morris Disability Questionnaire. The primary economic outcome was quality-adjusted life-years (QALYs). Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001396213. FINDINGS: Between Oct 23, 2018 and Aug 3, 2020, we assessed 1011 patients for eligibility. After excluding 519 (51·3%) ineligible patients, we randomly assigned 492 (48·7%) participants; 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedback mean difference -4·6 [-5·8 to -3·3]) for activity limitation at 13 weeks (primary endpoint). Effect sizes were similar at 52 weeks. Both interventions were also more effective than usual care for QALYs, and much less costly in terms of societal costs (direct and indirect costs and productivity losses; -AU$5276 [-10 529 to -24) and -8211 (-12 923 to -3500). INTERPRETATION: CFT can produce large and sustained improvements for people with chronic disabling low back pain at considerably lower societal cost than that of usual care. FUNDING: Australian National Health and Medical Research Council and Curtin University.

An Exploration of the Influence of Non-Biomechanical Factors on Lifting-Related LBP.

Objective: The primary objective was to compare non-biomechanical factors between manual workers with and without a history of LBP related to lifting. A secondary objective was to investigate associations between the change in pain intensity during repeated lifting (termed pain ramp) and non-biomechanical factors tested in the LBP group. Methods: Manual workers currently in lifting occupations with and without a history of lifting-related LBP were recruited (21 LBP and 20 noLBP) and took part in a repeated (100) lift task. A series of non-biomechanical factors, including psychological, work-related, lifestyle, whole health and psychophysical factors, were collected. Psychophysical factors (pressure pain thresholds (PPTs) and fatigue) were also measured at different time points. Associations between pain ramp during lifting and non-biomechanical factors were investigated with linear regression. Results: The LBP group reported worse perceived sleep quality, more musculoskeletal pain sites other than LBP and greater symptoms related to gastrointestinal complaints and pseudo-neurology compared to the group with no history of LBP. The group with LBP were also slightly more worried about the lifting task and felt more fatigued at the end of the lifting task. The feeling of fatigue during lifting was positively associated with pain ramp in the LBP group. Anxiety and gastrointestinal complaints were weakly negatively associated with pain ramp during lifting. Conclusions: The group differences of poorer perceived sleep, greater non-specific health complaints, slightly more worry about the lifting task and more perceived fatigue in the LBP group highlight the complex and multi-factorial nature of LBP related to lifting. The feeling of fatigue was positively associated with pain ramp in the LBP group, suggesting a close relationship with pain and fatigue during lifting that requires further exploration.

How do people with chronic pain explain their use, or non-use, of pain-related healthcare services? A qualitative study of patient experiences.

PURPOSE: This study aims to explore how people with chronic pain explain their use or non-use of pain-related healthcare services and their expectations of the healthcare provider, and explore how explanations and expectations vary between different levels of pain-related healthcare use. MATERIALS AND METHODS: We conducted 20 individual semi-structured interviews with purposely sampled adults between 39 and 77 years of age with chronic pain. All interviews were audio-recorded, transcribed and analysed using a thematical template analysis approach. RESULTS: Four key drivers for pain-related healthcare use were identified: (1) the healthcare system facilitates clinical pathways, (2) appraisal of pain-related healthcare initiatives influences future use, (3) autonomy, beliefs and values determine healthcare behaviour, and (4) recommendations from others impact healthcare behaviour. Comparing explanations across different pain-related healthcare user groups (high, medium and low) showed that perceived needs, beliefs and values, and appraisal of previous healthcare experiences differed between these groups. CONCLUSIONS: Beliefs, pain characteristics, recommendations, and the search for a diagnostic label, often initiate pain-related healthcare use. Healthcare is modified by two interconnected systems: (1) perceived needs, beliefs and values and (2) previous healthcare experiences. Differences related to these systems could explain some of the variance in pain-related healthcare use.Implications for RehabilitationDifferent use of pain-related healthcare services for people with chronic pain could be related to differences in perceived needs, beliefs and values and appraisal of previous healthcare.It may be helpful to explore the perceived needs and beliefs of those seeking healthcare due to chronic pain.Previous healthcare experiences may impact and should be explored.

Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain.

BACKGROUND: Physiotherapists trained to deliver biopsychosocial interventions for complex musculoskeletal pain problems often report difficulties in confidence and competency at the end of training. Cognitive Functional Therapy (CFT) is an individualized biopsychosocial intervention and understanding the facilitators and barriers to training in CFT will help inform future training programs. This study aimed to explore physiotherapists' and trainers' perceptions of the process of developing competency in CFT. METHODS: A cross-sectional qualitative design using interviews of 18 physiotherapists and two trainers investigated training in CFT for persistent LBP via reflexive thematic analysis. RESULTS: Physiotherapists reported undergoing a complex behavior change process during training. Four themes emerged: 1) Pre-training factors; 2) Behavior change process; 3) Physiotherapy culture and context; and 4) Confident competence and beyond. Key components included graduated practice exposure linked to experiential learning with feedback and clear competency guidelines. Pre-training and contextual factors were facilitators or barriers depending on the individual. Physiotherapists supported ongoing learning, even after competency was achieved. CONCLUSIONS: This study provides insight into the processes of change during progress toward competency in CFT. It highlights facilitators and barriers to competency including physiotherapy culture and the clinical environment. The study also describes important educational components, including experiential learning and clinical integration, which may be used to inform future post-graduate training.

Concurrent validity of DorsaVi wireless motion sensor system Version 6 and the Vicon motion analysis system during lifting.

BACKGROUND: Wearable sensor technology may allow accurate monitoring of spine movement outside a clinical setting. The concurrent validity of wearable sensors during multiplane tasks, such as lifting, is unknown. This study assessed DorsaVi Version 6 sensors for their concurrent validity with the Vicon motion analysis system for measuring lumbar flexion during lifting. METHODS: Twelve participants (nine with, and three without back pain) wore sensors on T12 and S2 spinal levels with Vicon surface markers attached to those sensors. Participants performed 5 symmetrical (lifting from front) and 20 asymmetrical lifts (alternate lifting from left and right). The global-T12-angle, global-S2-angle and the angle between these two sensors (relative-lumbar-angle) were output in the sagittal plane. Agreement between systems was determined through-range and at peak flexion, using multilevel mixed-effects regression models to calculate root mean square errors and standard deviation. Mean differences and limits of agreement for peak flexion were calculated using the Bland Altman method. RESULTS: For through-range measures of symmetrical lifts, root mean squared errors (standard deviation) were 0.86° (0.78) at global-T12-angle, 0.90° (0.84) at global-S2-angle and 1.34° (1.25) at relative-lumbar-angle. For through-range measures of asymmetrical lifts, root mean squared errors (standard deviation) were 1.84° (1.58) at global-T12-angle, 1.90° (1.65) at global-S2-angle and 1.70° (1.54) at relative-lumbar-angle. The mean difference (95% limit of agreement) for peak flexion of symmetrical lifts, was - 0.90° (-6.80 to 5.00) for global-T12-angle, 0.60° (-2.16 to 3.36) for global-S2-angle and - 1.20° (-8.06 to 5.67) for relative-lumbar-angle. The mean difference (95% limit of agreement) for peak flexion of asymmetrical lifts was - 1.59° (-8.66 to 5.48) for global-T12-angle, -0.60° (-7.00 to 5.79) for global-S2-angle and - 0.84° (-8.55 to 6.88) for relative-lumbar-angle. CONCLUSION: The root means squared errors were slightly better for symmetrical lifts than they were for asymmetrical lifts. Mean differences and 95% limits of agreement showed variability across lift types. However, the root mean squared errors for all lifts were better than previous research and below clinically acceptable thresholds. This research supports the use of lumbar flexion measurements from these inertial measurement units in populations with low back pain, where multi-plane lifting movements are assessed.

From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain.

BACKGROUND: Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes and how it relates to quantitative changes. METHODS: A mixed method study in the context of an existing single-case design involving 12 people with disabling non-specific LBP. Interviews were conducted before and after a 12-week physiotherapy-led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualized, quantitative measures of movement, posture, psychological factors, pain and activity limitation. RESULTS: Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterized the embodiment of 'nonconscious protection', while healthcare and societal messages prompted pain-related fear and 'conscious protection'. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention ('conscious non-protection'), but most returned to automatic, normal and fearless patterns ('nonconscious non-protection'), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures and less back muscle EMG accompanied positive changes in self-report factors. CONCLUSION: The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non-specific LBP. This involved a re-conceptualisation of movement and posture, from threatening, to therapeutic. SIGNIFICANCE: Findings from qualitative interviews before and after a Cognitive Functional Therapy intervention in 12 people with disabling low back pain highlighted an individualized recovery journey from conscious and nonconscious protection to conscious non-protection for some, and nonconscious non-protection for many. Pre and post-quantitative measures of movement, posture, psychological factors, pain and activity limitation integrated well with the qualitative findings. The findings suggest movement and posture may form part of a multidimensional pain schema.

Physiotherapists could detect changes of 12 degrees or more in single-plane movement when observing forward bending, squat or hand-over-head: A cross-sectional experiment.

BACKGROUND: The visual accuracy of physiotherapists to detect changes in dynamic joint angles is currently unknown. OBJECTIVE: To investigate (i) the smallest detectable change in movement that physiotherapists could visually observe, and (ii) whether visual accuracy was associated with the functional activity observed or characteristics of the physiotherapist. METHODS: Thirty-four physiotherapists viewed and rated videos of squat, hand-over-head, forward bend functional activities and an artificial test condition (a reference movement followed by subsequent movements showing random differences in peak angle from 0° to 15°, so 18 sets of paired videos per functional activity). They rated each range of movement (same/more/less) relative to the reference movement, while their visual tracking was continuously monitored. Accuracy was calculated (multilevel regression) using two thresholds - two correct out of three viewings (2/3) and three correct out of three viewings (3/3). RESULTS: More than 80% of physiotherapists were able to detect 9° difference using the 2/3 threshold and 12° using the 3/3 threshold. There was no association (p > 0.05) between visual accuracy and experience, sex, or movement type, except when viewing shoulder abduction compared with knee flexion using the 3/3 threshold. The only association between accuracy and visual tracking characteristics was for assessing lumbar flexion, where use of more visual fixation areas and a shorter fixation time per area were more accurate. CONCLUSION: Physiotherapists were consistently accurate at detecting changes of ≥12° in single-plane, low-speed functional activities. Visual accuracy was not explained by experience or sex, and rarely associated with functional activity type or visual fixation.

How Do People With Knee Osteoarthritis Conceptualize Knee Confidence? A Qualitative Study.

OBJECTIVE: Reduced knee confidence is common in people with knee osteoarthritis (OA) and is likely to influence how people with knee OA engage with movement and activities. However, there is conflicting evidence surrounding the association between confidence and function. This may be because knee confidence has been assessed via a single questionnaire item that was not developed for people with knee OA and thus may not provide an accurate or comprehensive assessment of confidence in this population. A better understanding of knee confidence could inform a more thorough assessment of the construct both in clinical and research contexts. Therefore, the aim of this study was to explore the meaning of knee confidence from the perspective of people with knee OA. METHODS: Fifty-one people with a clinical diagnosis of knee OA took part in a one-to-one semistructured interview. Interviews explored how each participant conceptualized knee confidence. Reflexive thematic analysis was selected as a flexible approach for identifying patterns of meaning across cases through a combination of data-driven and theory-informed coding of the transcribed data. RESULTS: People with knee OA conceptualized confidence with reference to 1 or more of 4 themes: (1) symptoms, (2) functional ability, (3) the internal structure of the knee, and (4) knowledge about knee OA and its management. Each conceptualization of confidence was associated with present and future concerns. CONCLUSION: Because people with knee OA conceptualize knee confidence in different ways, a single-item measure is unlikely to capture all of the aspects of this construct in this population. This may explain the conflicting evidence around the association between reduced knee confidence and function in people with knee OA. IMPACT: This study showed that a multi-item measure is needed to measure knee confidence in people with knee OA. Clinicians and researchers need to understand what knee confidence means to people with knee OA, because it is likely to influence how these individuals engage with movement and activities. Understanding this relationship can enable more targeted education and functional rehabilitation for people with knee OA.

GLA:D® Back Australia: a mixed methods feasibility study for implementation.

BACKGROUND: Practice-based guidelines recommend patient education and exercise as first-line care for low back pain (LBP); however, these recommendations are not routinely delivered in practice. GLA:D® Back, developed in Denmark to assist clinicians to implement guideline recommendations, offers a structured education and supervised exercise program for people with LBP in addition to a clinical registry to evaluate patient outcomes. In this study we evaluated the feasibility of implementing the GLA:D® Back program in Australia. We considered clinician and patient recruitment and retention, program fidelity, exploring clinicians' and patients' experiences with the program, and participant outcome data collection. METHODS: Clinicians (chiropractors and physiotherapists) were recruited and participated in a 2-day GLA:D® Back training course. Patients were eligible to participate if they had persistent or recurrent LBP. Feasibility domains included the ability to: (1) recruit clinicians to undergo training; (2) recruit and retain patients in the program; (3) observe program fidelity; and (4) perceive barriers and facilitators for GLA:D® Back implementation. We also collected data related to: (5) clinician confidence, attitudes, and behaviour; and (6) patient self-reported outcomes related to pain, disability, and performance tests. RESULTS: Twenty clinicians (8 chiropractors, 12 physiotherapists) participated in the training, with 55% (11/20) offering GLA:D® Back to their patients. Fifty-seven patients were enrolled in the program, with 67% (38/57) attending the final follow-up assessment. Loss to follow up was mainly due to the effects of the COVID-19 pandemic. We observed program fidelity, with clinicians generally delivering the program as intended. Interviews revealed two clinician themes related to: (i) intervention acceptability; and (ii) barriers and facilitators to implementation. Patient interviews revealed themes related to: (i) intervention acceptability; and (ii) program efficacy. At 3 months follow-up, clinicians demonstrated high treatment confidence and biomedical orientation. Patient outcomes trended towards improvement. CONCLUSION: GLA:D® Back implementation in Australia appears feasible based on clinician recruitment, program acceptability and potential benefits for patient outcomes from the small sample of participating clinicians and patients. However, COVID-19 impacted patient recruitment, retention, and data collection. To scale-up GLA:D® Back in private and public settings, further work is warranted to address associated barriers, and to leverage facilitators.

Predicting Knee Joint Kinematics from Wearable Sensor Data in People with Knee Osteoarthritis and Clinical Considerations for Future Machine Learning Models.

Deep learning models developed to predict knee joint kinematics are usually trained on inertial measurement unit (IMU) data from healthy people and only for the activity of walking. Yet, people with knee osteoarthritis have difficulties with other activities and there are a lack of studies using IMU training data from this population. Our objective was to conduct a proof-of-concept study to determine the feasibility of using IMU training data from people with knee osteoarthritis performing multiple clinically important activities to predict knee joint sagittal plane kinematics using a deep learning approach. We trained a bidirectional long short-term memory model on IMU data from 17 participants with knee osteoarthritis to estimate knee joint flexion kinematics for phases of walking, transitioning to and from a chair, and negotiating stairs. We tested two models, a double-leg model (four IMUs) and a single-leg model (two IMUs). The single-leg model demonstrated less prediction error compared to the double-leg model. Across the different activity phases, RMSE (SD) ranged from 7.04° (2.6) to 11.78° (6.04), MAE (SD) from 5.99° (2.34) to 10.37° (5.44), and Pearson's R from 0.85 to 0.99 using leave-one-subject-out cross-validation. This study demonstrates the feasibility of using IMU training data from people who have knee osteoarthritis for the prediction of kinematics for multiple clinically relevant activities.

Does intra-lumbar flexion during lifting differ in manual workers with and without a history of low back pain? A cross-sectional laboratory study.

Advice to limit or avoid a flexed lumbar curvature during lifting is widely promoted to reduce the risk of low back pain (LBP), yet there is very limited evidence to support this relationship. To provide higher quality evidence this study compared intra-lumbar flexion in manual workers with (n = 21) and without a history of LBP (n = 21) during a repeated lifting task. In contrast to common expectations, the LBP group demonstrated less peak absolute intra-lumbar flexion during lifting than the noLBP group [adjusted difference -3.7° (95%CI -6.9 to -0.6)]. The LBP group was also further from the end of range intra-lumbar flexion and did not use more intra-lumbar range of motion during any lift condition (both symmetrical and asymmetrical lifts and different box loads). Peak absolute intra-lumbar flexion was more variable in the LBP group during lifting and both groups increased their peak absolute intra-lumbar flexion over the lift repetitions. This high-quality capture of intra-lumbar spine flexion during repeated lifting in a clinically relevant cohort questions dominant safe lifting advice.Practitioner summary: Lifting remains a common trigger for low back pain (LBP). This study demonstrated that people with LBP, lift with less intra-lumbar flexion than those without LBP. Providing the best quality in-vivo laboratory evidence, that greater intra-lumbar flexion is not associated with LBP in manual workers, raising questions about lifting advice.

The Association Between Different Trajectories of Low Back Pain and Degenerative Imaging Findings in Young Adult Participants Within The Raine Study.

STUDY DESIGN: Case-control study. OBJECTIVE: Investigate the association between lumbar spine magnetic resonance imaging (MRI) findings and 5-year trajectories of low back pain (LBP) in young Australian adults. SUMMARY OF BACKGROUND DATA: The association between lumbar spine imaging findings and LBP remains unclear due to important limitations of previous research, such as a lack of clearly defined LBP phenotypes and inadequate controlling for age, which may substantially affect the association. METHODS: Seventy-eight "case" participants with a previously identified "consistent high disabling LBP" trajectory from age 17 to 22 years and 78 "control" participants from a trajectory with consistently low LBP over the same time period, matched for sex, body mass index, physical activity levels, and work physical demands, were identified from Gen2 Raine Study participants. At age 27, participants underwent a standardized lumbar MRI scan, from which 14 specific MRI phenotypes were identified. Primary analyses used unconditional logistic regression, adjusting for covariates used in the matching process, to investigate the relationship between presence of each imaging finding and being a case or control. Secondary analyses explored those relationships based on the number of spinal levels with each MRI finding. RESULTS: The odds for being a case compared with a control were higher in those with disc degeneration (Pfirrmann grade ≥ 3; OR = 3.21, 95% CI: 1.60-6.44; P = 0.001) or those with a herniation (OR = 1.90, 95% CI: 0.96-3.74; P - 0.065). We also found that the association became substantially stronger when either disc degeneration or herniation was present at two or more spinal levels (OR = 5.56, 95% CI: 1.97-15.70; P = 0.001, and OR = 5.85, 95% CI: 1.54-22.25; P = 0.009, respectively). The other investigated MRI findings were not associated with greater odds of being a case. CONCLUSION: Lumbar disc degeneration and herniation may be important contributors to disabling LBP in young adults. Further investigation of their potential prognostic and causal roles is indicated.Level of Evidence: 4.

Measurement of uni-planar and sport specific trunk motion using magneto-inertial measurement units: The concurrent validity of Noraxon and Xsens systems relative to a retro-reflective system.

BACKGROUND: There is a range of magneto-inertial measurement unit (MIMU) systems commercially available, however sensor specifications and fusion methods vary considerably between manufacturers. Such variability can influence the concurrent validity of MIMUs relative to reference standard measurement devices. Different MIMUs have been compared during static or low-velocity conditions, with higher-velocity movements assessed in robotic-based studies. However, there is a need for the concurrent validity of higher-velocity movements to be established in human-based studies. RESEARCH QUESTION: This study aimed to assess the concurrent validity of two commercial MIMU systems (Noraxon and Xsens), relative to a 'gold-standard' retro-reflective motion capture system, when measuring trunk angles during uni-planar range of motion (ROM) and cricket bowling, which involves high-speed, multi-planar movements. METHODS: For this criterion-based validity study, both MIMU systems incorporated comparable sensor specifications and employed Kalman filter sensor fusion algorithms. The MIMU based angles were compared with angles derived from concurrently captured three-dimensional retro-reflective data for 10 fast-medium bowlers. Statistical parametric mapping and root mean squared differences (RMSD) were computed for both MIMU systems. RESULTS: One-dimensional statistical parametric mapping showed no significant differences for angles from both MIMU systems when compared with retro-reflective based angle outputs. The MIMU systems produced ROM RMSDs between 1.4 ± 1.0° and 2.6 ± 1.5°. One system displayed RMSDs between 4.6 ± 1.4° and 7.4 ± 1.9° during bowling, indicating functionally relevant differences to retro-reflective derived angles. There were some small but statistically significant differences in RMSDs between the MIMU systems. SIGNIFICANCE: MIMU-based angle accuracy is poorer during high-speed, multi-planar movement than uni-planar tasks. Comparable MIMU systems can produce varying measurements during ROM and bowling tasks. It is likely that varying sample rates and sensor fusion algorithm parameters contributed to the differences.

What influences patient satisfaction after total knee replacement? A qualitative long-term follow-up study.

OBJECTIVES: To explore whether a conceptual model of patient satisfaction previously developed 1-2 years post-total knee replacement (TKR) is still relevant 3-4 years post-TKR. Specifically, (i) what is the stability in satisfaction levels 3-4 years post-TKR? and (ii) does the existing conceptual model of patient satisfaction after TKR apply at this later follow-up? DESIGN: A constructivist grounded theory qualitative follow-up study. The present study was theoretically governed by the findings of the initial qualitative inquiry. One-on-one semi-structured interviews were used to test the assumptions of the model developed from the findings of the previous study. SETTING: An urban Australian public hospital PARTICIPANTS: From 40 people who participated in the original study, 11 participants were purposively sampled based on their level of satisfaction and factors driving satisfaction as reported in their first interview. There were six women and five men, the average time since TKR was 3 years and 5 months, and the average age at time of interview was 77 years. RESULTS: Satisfaction levels were mostly stable with the exception of three participants; two transitioned in a positive direction; one in a negative direction. The meaning of satisfaction and the factors that influenced satisfaction were consistent with the original findings. However, beliefs relating to the influence of ageing on persistent knee symptoms and functional limitations were more dominant in the present study. CONCLUSIONS: The findings provide support for patient satisfaction being a multifactorial construct that is potentially modifiable over time. Clinicians may apply the conceptual model we have described to optimise satisfaction in patients up to 3-4 years post-TKR.

The Relationship Between Changes in Movement and Activity Limitation or Pain in People With Knee Osteoarthritis: A Systematic Review.

OBJECTIVE: To report whether changes in knee joint movement parameters recorded during functional activities relate to change in activity limitation or pain after an exercise intervention in people with knee osteoarthritis (OA). DESIGN: Etiology systematic review. LITERATURE SEARCH: Four databases (MEDLINE, Embase, CINAHL, and AMED) were searched up to January 22, 2021. STUDY SELECTION CRITERIA: Randomized controlled trials or cohort studies of exercise interventions for people with knee OA that assessed change in knee joint movement parameters (moments, kinematics, or muscle activity) and clinical outcomes (activity limitation or pain). DATA SYNTHESIS: A descriptive synthesis of functional activities, movement parameters, and clinical outcomes. RESULTS: From 3182 articles, 22 studies met the inclusion criteria, and almost all were of low quality. Gait was the only investigated functional activity. After exercise, gait parameters changed 26% of the time, and clinical outcomes improved 90% of the time. A relationship between group-level changes in gait parameters and clinical outcomes occurred 24.5% of the time. Two studies directly investigated an individual-level relationship, reporting only 1 significant association out of 8 correlations tested. CONCLUSION: Most studies reported no change in gait-related movement parameters despite improvement in clinical outcomes, challenging the belief that changing movement parameters is always clinically important in people with knee OA. J Orthop Sports Phys Ther 2021;51(10):492-502. doi:10.2519/jospt.2021.10418.

Functional calibration does not improve the concurrent validity of magneto-inertial wearable sensor-based thorax and lumbar angle measurements when compared with retro-reflective motion capture.

 Magneto-inertial measurement unit (MIMU) systems allow calculation of simple sensor-to-sensor Euler angles, though this process does not address sensor-to-segment alignment, which is important for deriving meaningful MIMU-based kinematics. Functional sensor-to-segment calibrations have improved concurrent validity for elbow and knee angle measurements but have not yet been comprehensively investigated for trunk or sport-specific movements. This study aimed to determine the influence of MIMU functional calibration on thorax and lumbar joint angles during uni-planar and multi-planar, sport-specific tasks. It was hypothesised that functionally calibrating segment axes prior to angle decomposition would produce smaller differences than a non-functional method when both approaches were compared with concurrently collected 3D retro-reflective derived angles. Movements of 10 fast-medium cricket bowlers were simultaneously recorded by MIMUs and retro-reflective motion capture. Joint angles derived from four different segment definitions were compared, with three incorporating functionally defined axes. Statistical parametric mapping and root mean squared differences (RMSD) quantified measurement differences one-dimensionally and zero-dimensionally, respectively. Statistical parametric mapping found no significant differences between MIMU and retro-reflective data for any method across bowling and uni-planar trunk movements. The RMSDs for the functionally calibrated methods and non-functional method were not significantly different. Functional segment calibration may be unnecessary for MIMU-based measurement of thorax and lumbar joint angles.

Trajectories of Musculoskeletal Healthcare Utilization of People with Chronic Musculoskeletal Pain - A Population-Based Cohort Study.

BACKGROUND AND AIM: Chronic musculoskeletal pain is common and associated with more general healthcare-seeking. However, musculoskeletal-related healthcare utilization is under-explored. This study aimed to explore, describe and profile trajectories of long-term musculoskeletal healthcare for people reporting chronic musculoskeletal pain. METHODS: This exploratory prognostic cohort study combined survey and national health register data from a representative group of adult Danes reporting chronic musculoskeletal pain (N = 2929). Trajectories of long-term musculoskeletal healthcare use were generated using latent class growth analysis. Types of healthcare-seeking, individual, sociodemographic, health, belief and work-related factors were used to describe and profile identified trajectories. RESULTS: We identified five distinct trajectories of long-term musculoskeletal healthcare utilization (low stable, low ascending, low descending, medium stable and high stable). The low stable trajectory group (no or almost no annual contacts) represented 39% of the sample, whereas the high stable trajectory group (consistent high number of annual contacts) represented 8%. Most healthcare-seeking was in primary healthcare settings (GP/physiotherapy/chiropractor). Opioid consumption was primarily in the high stable trajectory group, and surgery was rare. There were statistically significant differences across the five trajectory groups in individual, sociodemographic, health, belief and work-related profiles. CONCLUSION: Long-term use of musculoskeletal healthcare services varied in this chronic musculoskeletal pain population. Almost 40% coped without seeking care, whereas 8% had consistent high use of healthcare services. Chronic musculoskeletal pain was mostly managed in primary care settings, which aligns with musculoskeletal guidelines, as did the use of pain medication and surgery. People with different musculoskeletal healthcare trajectories had different individual, sociodemographic, health, belief and work-related profiles.

Only one fifth of young Australian adults have beliefs about medical imaging for low back pain that align with current evidence: A cross-sectional study.

BACKGROUND: Patients' perceptions/expectations may be a factor behind medical imaging referral rates. Few studies have investigated the beliefs that might drive expectations of medical imaging. OBJECTIVES: This study examined whether beliefs of young Australian adults with and without impactful low back pain (LBP) concerning medical scans for LBP align with current evidence. It also investigated if these beliefs were associated with clinical factors (history of impactful LBP, history of previous medical scans, LBP-related disability and the presence of leg pain) or sociodemographic factors (sex, education, income). DESIGN: Cross-sectional observational study. METHODS: 78 participants from the Raine Study with a history of impactful LBP and 85 participants with no history of impactful LBP completed a study-specific questionnaire with five statements concerning beliefs about medical imaging for LBP. All statements were not aligned with current evidence about the use of medical imaging in LBP management. RESULTS: Only 15-21% (n = 24-34) of the participants held beliefs that were aligned with current evidence. Participants with a university education had slightly more aligned beliefs compared to those whose highest education was completing secondary school. There was no difference in the beliefs of participants based on their history of impactful LBP, or other clinical or sociodemographic factors. CONCLUSION: As beliefs are likely to drive care-seeking behavior, it is notable that most participants' views about the role of medical imaging for LBP were not aligned with current evidence. Therefore, this suggests a need for community education, especially for those with lower education.