One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial.

OBJECTIVES: To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms. METHODS: A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis. RESULTS: One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042). CONCLUSION: High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings. TRIAL REGISTRATION NUMBER: NCT03869307.

Exercise into pain in chronic rotator cuff related shoulder pain: a prospective single-group feasibility study.

OBJECTIVES: This study evaluated the feasibility of exercising into pain in rotator cuff related shoulder pain (RCRSP), data collection procedures, feedback from physiotherapists and patients, and clinically important changes in patient-reported outcome measures (PROMs). DESIGN: Unblinded non-randomised single-group study. SETTING: Physiotherapy clinic in Belgium. PARTICIPANTS: Twelve patients with unilateral RCRSP for minimum 3 months, aged 18-65 years. INTERVENTIONS: Twelve weeks of four individualised exercises, with nine physiotherapist-led sessions with pain ratings 4-7 out of 10 on a verbal Numeric Pain Rating Scale for 9 weeks and then pain ratings 0-2 for 3 weeks. Every physiotherapy session included 15 min of manual therapy. Non-supervised exercises were: 2×/week in weeks with physiotherapy session, 3×/week in weeks without physiotherapy session. OUTCOME MEASURES: Primary: adherence, where patients were considered adherent with 78% (7/9 sessions) attendance for supervised sessions and 81% (22/27 sessions) completion for non-supervised exercises, and Shoulder Pain and Disability Index (SPADI); secondary: fear-avoidance behaviour, fear of pain, physical outcomes (strength, range of motion, scapular dyskinesis); others: ultrasound (US) imaging outcomes (acromionhumeral distance, supraspinatus tendon thickness, occupation ratio), global perceived effect (GPE). PROMs were collected via online survey, except for the GPE (via closed envelope). US measures were taken after physical measures. RESULTS: Adherence and adverse effects were analysed in patients who had the possibility to attend minimum seven supervised sessions (n=8): 88% of them adhered to supervised sessions, 50% to non-supervised exercises; none of them withdrew from the study, three of them obtained individual clinically important improvements in SPADI score above 20 points. The measurement protocol of physical and ultrasonographic outcomes took around 60 min. CONCLUSIONS: Adherence to supervised sessions was satisfactory, the adherence to non-supervised exercises must be improved. Data collection procedures were feasible to perform, but some changes are recommended. TRIAL REGISTRATION NUMBER: NCT04154345.

Psychological factors and symptom duration are associated with exercise-based treatment effect in people with hypermobile shoulders: A secondary analysis of a randomised controlled trial.

BACKGROUND: Shoulder symptoms are common in patients with hypermobility spectrum disorders (HSD), but few studies focus on identifying factors associated with treatment effects. AIM: To identify baseline and clinical characteristics associated with a better outcome 16 weeks after starting an exercise-based treatment in patients with HSD and shoulder symptoms. DESIGN: Exploratory secondary analysis of data from a randomised controlled trial. METHOD: Self-reported treatment outcome was reported as change between baseline and follow-up after 16 weeks of high-load or low-load shoulder strengthening. Multiple linear and logistic regressions were used to investigate associations of patient expectations of treatment effect, self-efficacy, fear of movement, and symptom duration with change in shoulder function, shoulder pain, quality of life, and patient reported health change. All regression models were performed firstly with adjustments for covariates (age, sex, body mass index, hand dominance, treatment group, and baseline score of the outcome variable) and secondly with additional adjustments for exposure variables. RESULTS: Expectations of complete recovery were associated with an increased odds of perceiving an important improvement in physical symptoms after a 16-week exercise-based treatment program. Higher self-efficacy at baseline seemed to be associated with improved shoulder function, shoulder pain and quality of life. A higher fear of movement seemed to be associated with increased shoulder pain and decreased quality of life. A longer symptom duration was associated with decreased quality of life. CONCLUSION: Expectations of complete recovery, higher self-efficacy, lower fear of movement and shorter symptom duration seem to be important for better treatment outcomes.

Reliability of coracohumeral distance and subcoracoid tendons in subacromial pain syndrome.

This study investigated the intra-rater reliability of a novice ultrasound (US) examiner and the inter-rater reliability of two examiners (novice, expert) in the measures of coracohumeral distance at rest (CHD) and at 60° of elevation without (CHD60) or with weights (CHD60w), tendon thickness of the long head of the biceps (LHB) and subscapularis (SCP). Twenty-one patients with subacromial pain syndrome (SAPS) and 20 asymptomatic participants were included. Intra and inter-rater reliability were tested with intraclass-correlation-coefficient (ICC), differences between raters were analyzed with Bland-Altman plots. Intra-rater reliability for CHD, CHD60 and CHD60w was excellent (ICC = 0.97-0.98) in asymptomatic participants, and good-to-excellent (0.88-0.93) in SAPS, while intra-rater reliability for LHB and SCP was good-to-excellent in asymptomatic participants (0.88-0.97) and in SAPS (0.90-0.92). Inter-rater reliability for CHD, CHD60 and CHD60w was moderate-to-good (0.70-0.90) in asymptomatic participants and good (0.85-0.87) in SAPS, in contrast inter-rater reliability for LHB and SCP was poor in asymptomatic participants (0.10-0.46) and poor-to-moderate (0.49-0.61) in SAPS. Bland-Altman plots revealed systematic and/or proportional bias for tendons' thickness. A novice showed good-to-excellent intra-rater reliability in all US measures, whereas in comparison to an expert a novice can measure reliably CHD, CHD60 and CHD60w, but not LHB and SCP, where more training is recommended.

Subacromial space measured by ultrasound imaging in asymptomatic subjects and patients with subacromial shoulder pain: an inter-rater reliability study.

BACKGROUND: Acromiohumeral distance (AHD) and supraspinatus tendon thickness (STT) measured by ultrasound (US) can be combined in the occupation ratio (OR). Inter-rater reliability on these subacromial measures depends on the US experience of raters and on the subject status, differing between asymptomatic or patients with subacromial shoulder pain (SSP). OBJECTIVE: To evaluate inter-rater reliability between two raters with different US experience (experienced examiner and novice examiner). METHODS: In total, 20 asymptomatic subjects (controls) and 21 patients with SSP were examined on one shoulder. Inter-rater reliability was evaluated with intraclass correlation coefficient (ICC). RESULTS: ICC for controls was good for AHD at rest and at 60° (0.76-0.77), moderate for STT and AHD at 60° with weights (0.53-0.72), while OR was poorly reliable (below 0.44). ICC for SSP was moderate for AHD at rest and at 60°, STT, OR at rest and at 60° (0.52-0.74) and poor for AHD at 60° with weights and OR at 60° with weights (0.33-0.36). Bland-Altman plots showed systematic bias. CONCLUSION: Inter-rater reliability varied largely from poor to good between two examiners with different US experience. Clinicians might use the US as additional tool for detecting the subacromial structures, but a structured training including also symptomatic subjects is suggested. Researchers may further investigate the OR in matched case-control studies, and an overall agreement phase is recommended before starting the inter-rater reliability phase.

Physical impairments among adults in Denmark: a register-based study.

BACKGROUND: Knowledge of the prevalence and socio-demographic characteristics of physical impairments is limited. This study aimed to determine the prevalence of physical impairments among adults in Denmark, both in total and according to nine common diagnostic subgroups, describe the socio-demographic and socio-economic profile, and compare the data with those of the general adult population. METHODS: This descriptive, cross-sectional, register-based study evaluated the general socio-demographic and socio-economic variables, including sex, age, geographical region, origin, educational level, occupation, marital status, and disability level, of adults with physical impairments extracted by diagnosis from the Danish National Patient Register and Statistics Denmark by 31 December 2018. These data were compared with those of the general adult population in Denmark extracted from Statistics Denmark by January 2019. RESULTS: In total, 606,857 adults with physical impairments were identified. Of the nine selected diagnoses, osteoarthritis (69.4%) was the most prevalent, followed by acquired brain injury (29.0%), rheumatoid arthritis (6.7%), multiple sclerosis (2.6%), spinal cord injury (1.5%), cerebral palsy (1.2%), amputation (0.7%), muscular dystrophy (0.5%), and poliomyelitis (< 0.1%). There were large variations in the socio-demographic and socio-economic profile between the nine diagnostic subgroups. The adults with physical impairments were more often women, were older, were less often immigrants and employed adults, had a lower educational level, and were more commonly married than the general adult population. Only the geographical region did not differ. CONCLUSION: The nine subgroups with diagnoses related to the musculoskeletal system represent 13% of the adult Danish population. The socio-demographic and socio-economic profile varied largely between the nine diagnostic subgroups, and almost all variables differed significantly between adults with physical impairments and the general adult population in Denmark. These findings reveal patterns and trends on socio-demographic and socio-economic variables essential for future planning at a societal level, including the healthcare and social sectors.

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme.

INTRODUCTION: Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups. METHODS: Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months. RESULTS: 115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group. CONCLUSION: For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

Self-Reported Measures Have a Stronger Association With Dizziness-Related Handicap Compared With Physical Tests in Persons With Persistent Dizziness.

Background: Associations between dizziness-related handicap and a variety of self-reported measures have been reported. However, research regarding associations between dizziness-related handicap and aspects of functioning that includes both physical tests and self-reported measures is scarce. Objective: The purpose of the study was to describe the variations in signs and symptoms in people with persistent dizziness using physical tests and self-reported outcomes across three severity levels of the Dizziness Handicap Inventory (DHI) and investigate their associations with the DHI. Method: Participants with persistent dizziness (n = 107) were included in this cross-sectional study. The participants underwent (1) physical tests (gait tests, grip strength, body flexibility, and movement-induced dizziness) and completed questionnaires regarding (2) psychological measures (Mobility Inventory of Agoraphobia, Body Sensation Questionnaire, Agoraphobic Cognitions Questionnaire, and Hospital Depression and Anxiety Questionnaire), and (3) fatigue, dizziness severity, and quality of life (Chalders Fatigue Scale, Vertigo Symptom Scale-Short Form, and EQ visual analog scale), in addition to the DHI. Data were presented by descriptive statistics for three DHI severity levels (mild, moderate, and severe). A multiple linear backward regression analysis was conducted for each group of measures in relation to the DHI total score, with additional analyses adjusting for age and sex. Based on these results, significant associations were tested in a final regression model. Results: With increasing severity levels of DHI, the participants demonstrated worse performance on most of the physical tests (preferred and fast gait velocity, dizziness intensity after head movements), presented with worse scores on the self-reported measures (avoidance behavior, fear of bodily sensation, fear of fear itself, psychological distress, fatigue, dizziness severity, quality of life). After adjusting for age and sex, significant associations were found between total DHI and avoidance behavior, psychological distress, dizziness severity, and quality of life, but not with any of the physical tests, explaining almost 56% of the variance of the DHI total score. Conclusion: There was a trend toward worse scores on physical tests and self-reported measurements with increasing DHI severity level. The DHI seems to be a valuable tool in relation to several self-reported outcomes; however, several signs and symptoms may not be detected by the DHI, and thus, a combination of outcomes should be utilized when examining patients with persistent dizziness.

The association between number of shoulder diagnoses and positive clinical tests with self-reported function and pain: A cross-sectional study of patients with hypermobile joints and shoulder complaints.

BACKGROUND: Patients with hypermobility spectrum disorder (HSD) and shoulder complaints may suffer from symptoms related to shoulder instability, laxity, and hypermobility. It is currently unknown whether having a more complex clinical status with several diagnoses (i.e., anterior instability (AI), multidirectional instability (MDI), and/or symptomatic localised shoulder hypermobility (LSH), relates to higher functional impairments and pain. OBJECTIVES: To investigate the associations between either ≤1, 2, or 3 clinical shoulder diagnoses (AI, MDI, and LSH) or the number (0-10) of positive clinical shoulder tests with shoulder function using the western Ontario shoulder instability index (WOSI, 0-2100, 0 = best) and pain intensity using numerical pain rating scale (NPRS, 0-10, 10 = worse). DESIGN: Exploratory cross-sectional study. METHOD: From a randomised controlled trial, baseline data from 100 participants with HSD and shoulder complaints for at least three months were included. Associations were investigated using linear regression models, adjusted for age, sex, body mass index, and hand dominance. RESULTS: Compared with having ≤1 diagnosis, neither participants with two (WOSI 76.9, 95% CI -136.3, 290.0; NPRS 0.3, 95% CI -0.9, 1.5) nor three (WOSI 35.5, 95% CI -178.5, 249.6; NPRS 0.1, 95% CI -1.1, 1.3) clinical shoulder diagnoses had significantly worse shoulder function or pain. Likewise, the number of positive clinical shoulder tests was not associated with function (WOSI -20.8 95%CI (-55.3, 13.7)) or pain (NPRS -0.1 95%CI (-0.2, 0.1)). CONCLUSIONS: In participants with HSD and shoulder complaints, having more additional shoulder diagnoses or increased number of positive shoulder tests were not related to functional impairments or pain intensities.

Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial.

OBJECTIVES: To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms. METHODS: A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression. RESULTS: 93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%). CONCLUSION: High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events. TRIAL REGISTRATION NUMBER: NCT03869307.

Comparison of Shoulder Kinematics and Muscle Activation of Female Elite Handball Players With and Without Pain-An Explorative Cross-Sectional Study.

Non-traumatic shoulder injuries are common in team handball. However, many athletes continue to throw, despite pain in the shoulder. This study investigated upper body kinematics and muscle activation while throwing in female elite handball players with and without shoulder pain. Thirty female elite team handball players, 15 with pain (age 22.2 ± 2.9 yrs.) and 15 without pain (age 20.4 ± 2.6 yrs.) performed five standing throws in which joint kinematics and muscle activity were measured in the following muscles: pectoralis major, infraspinatus, serratus anterior, latissimus dorsi, and upper-, middle-, and lower trapezius. The main findings revealed that peak joint angles and angular velocities were not different between groups; however, group differences were observed in earlier timing of position and longer time spent in maximal shoulder extension and external shoulder rotation in the pain group compared with the no pain group. The pain group also revealed a significant lower muscle peak activity in the serratus anterior during the cocking phase compared to the no pain group. After the cocking phase and at ball release, the groups had similar activation. In conclusion, the present study showed group differences in appearance and time spent in maximal humerus extension and external rotation and a different serratus anterior muscle peak activity between elite handball players playing with and without shoulder pain, which are identified as possible mechanisms of adaptation to avoid pain.

Clinical Characteristics of 100 Patients With Hypermobility Spectrum Disorders and Shoulder Complaints With or Without Mechanical Symptoms: A Cross-sectional Study.

OBJECTIVE: To describe the clinical characteristics of patients with hypermobility spectrum disorders (HSD) and shoulder complaints with or without mechanical symptoms, and to compare characteristics between these groups. DESIGN: A cross-sectional study. SETTING: Primary care. PARTICIPANTS: One-hundred patients with HSD and shoulder complaints for at least 3 months were included from primary care (N=100). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical history, self-reported (shoulder pain and function, discomfort due to other symptoms, fatigue, fear of movement, quality of life) and objective (strength, range of motion, proprioception) characteristics were collected by physiotherapists. Mechanical symptoms (yes/no) were defined as self-reported shoulder instability, subluxation, and/or laxity. RESULTS: Sixty-seven reported mechanical symptoms. Patients in both groups reported impairments related to shoulder pain, function, fatigue, fear of movement, and quality of life. Patients with mechanical symptoms were younger (mean, 35.1 years [95% CI, 32.3-37.9 years] vs 43.3 years [95% CI, 38.4-48.1 years]), had longer symptom duration (median, 46 months [95% CI, 36-66 months] vs 24 months [95% CI, 9-56 months]), reported a previous shoulder dislocation (25% [95% CI, 16-37] vs 3% [95% CI, 0-16]), experienced that their shoulder was loose (64% [95% CI, 52-76] vs 15% [95% CI, 5-32]), and reported discomfort due to other symptoms (odds ratio, 1.48 [95% CI, 1.17-1.87]). Furthermore, a larger proportion had received supplemental treatment (analgesic medication, steroid injection/surgery). CONCLUSIONS: Both groups with HSD and shoulder complaints presented with substantial shoulder-related impairments. Two-thirds reported mechanical symptoms, were younger, and more severely impaired than those without mechanical symptoms. These findings highlight the importance of managing mechanical shoulder symptoms to fully address the patients' impairments.

Assessment of shoulder rotation strength, muscle co-activation and shoulder pain in tetraplegic wheelchair athletes - A methodological study.

Objective: To develop a feasible protocol for testing maximum shoulder rotation strength in tetraplegic wheelchair athletes, and investigate concurrent validity of maximum isometric handheld dynamometer (HHD) towards maximum isokinetic dynamometer (ID) strength measurements; secondly, to study shoulder muscle activation during maximum shoulder rotation measurements, and the association between shoulder strength and shoulder pain.Design: Descriptive methodological.Setting: Danish Wheelchair Rugby (WCR) association for WCR tetraplegic athletes from local WCR-clubs.Participants: Twelve adult tetraplegics.Interventions: N/A.Outcome measures: Wheelchair User's Shoulder Pain Index (WUSPI) and Visual Analog Scale (VAS) measured shoulder pain, isometric HHD and ID (60°/s) measured maximum internal (IR) and external (ER) shoulder rotation strength. Surface Electromyography normalized to maximum EMG measured muscle activity (mm Infraspinatus and Latissimus Dorsi) during maximum shoulder rotation strength.Results: Concurrent validity of isometric HHD towards ID showed Concordance Correlation Coefficients of left and right arms 0.90 and 0.86 (IR), and 0.89 and 0.91 (ER), with no difference in muscle activity between isometric HHD and ID, but larger co-activation during ER. There was no association between shoulder strength and pain, except for significantly weak negative associations between ID and pain during ER for left and right arms (P = 0.03; P = 0.04).Conclusion: Standardized feasible protocol for tetraplegic wheelchair athletes for measuring maximum shoulder rotation strength was established. Isometric HHD is comparable with ID on normalized peak torques and muscle activity, but with larger co-activation. Strength was not clearly associated with shoulder pain.

Treatment of shoulder pain in people with spinal cord injury who use manual wheelchairs: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis OBJECTIVES: The objective was to summarise prior research regarding the efficacy of active physiotherapy interventions and prevention strategies on shoulder pain, decreased physical function and quality of life in people with a spinal cord injury (SCI). METHODS: A systematic literature search was conducted in CENTRAL, EMBASE (via Ovid), CINAHL and MEDLINE (via Ovid). Randomised controlled trials investigating effects of active physiotherapy interventions on shoulder pain, physical function and quality of life were included. Further, prospective cohort studies investigating effects of active physiotherapy interventions in prevention of shoulder pain and reduced physical function were included. Mean difference (MD) for pain (15 items on a 0-10 scale) and standardised mean difference (SMD) for physical function were summarised in a random effects meta-analysis. RESULTS: Four studies on treatment (totalling 167 participants), and no studies on prevention were included. Significant and clinically meaningful improvements on shoulder pain (MD 19.06, 95% CI 5.72-32.40; I2 = 65%) (scale 0-150) and physical function (SMD 0.61, 95% CI 0.27-0.94; I2 = 0%) were found for active physiotherapy interventions. Only one study included quality of life, making meta-analysis inappropriate. CONCLUSIONS: Evidence from a sparse number of studies supports active physiotherapy interventions to decrease shoulder pain and increase physical function in people with SCI who use a manual wheelchair. No studies met the criteria for prevention, highlighting a lack of research investigating prevention of shoulder pain and decreased physical function and quality of life.

Supervised, Heavy Resistance Training Is Tolerated and Potentially Beneficial in Women with Knee Pain and Knee Joint Hypermobility: A Case Series.

Introduction: Adults with generalised joint hypermobility including knee joint hypermobility (GJHk) report more knee joint symptoms when compared to adults without GJHk. There is no consensus on best practice for symptom management. For instance, controversy exists regarding the appropriateness and safety of heavy resistance training as an intervention for this specific group. This case series aims to describe a supervised, progressive heavy resistance training program in adults with GJHk and knee pain, the tolerability of the intervention, and the outcomes of knee pain, knee-related quality of life, muscle strength, proprioception, and patellar tendon stiffness through a 12-week period. Materials and Methods: Adults with GJHk and knee pain were recruited to perform supervised, progressive heavy resistance training twice a week for 12 weeks. The main outcome was the tolerability of the intervention. Secondary outcomes were knee pain during a self-nominated activity (VASNA); Knee injury and Osteoarthritis Outcome Score (KOOS); Tampa Scale of Kinesiophobia (TSK); maximal quadriceps voluntary isometric contraction and rate of torque development; 5 repetition maximum strength in five different leg exercises; single leg hop for distance; knee proprioception and patellar tendon stiffness. Results: In total, 16 women (24.2 years, SD 2.5) completed at least 21/24 training sessions. No major adverse events were observed. On average, VASNA decreased by 32.5 mm (95% CI 21.4-43.6), in addition to improvements in KOOS and TSK scores. These improvements were supported by an increase in all measures of lower extremity muscle strength, knee proprioception, and patellar tendon stiffness. Conclusion: Supervised heavy resistance training seems to be well tolerated and potentially beneficial in young women with GJHk and knee pain.

Six weeks of intensive rehearsals for the Swan Lake ballet shows ultrasound tissue characterization changes of the Achilles tendons in dancers.

The objective was to investigate, first, whether six weeks of intensive ballet dance exposure is associated with structural and clinical changes in the Achilles tendon; second, the importance of demographics, self-reported Achilles pain, and generalized joint hypermobility (GJH). Data were collected at baseline and at six weeks' follow-up, using Achilles tendon ultrasound tissue characteristics (UTC) as primary outcome (percentage distribution of echo-type I-IV: type I = intact and aligned bundles, type II = discontinuous/wavy bundles, type III = fibrillar, and type IV = amorphous cells/fluid). Secondary outcomes included clinical signs of Achilles tendinopathy, Achilles tendon pain during single-leg heel raise, self-reported symptoms (VISA-A questionnaire), and GJH. Sixty-three ballet dancers (aged 18-41) participated. From baseline to follow-up, UTC echo-type I decreased significantly (ß = -3.6, p = 0.001; 95% CI: -5.8;-1.4), whereas echo-type II increased significantly (ß = 3.2, p < 0.0001, 95% CI: 1.6;4.8). Furthermore, a significant effect of limb (left limb showed decreased echo-type I and increased echo-type III + IV) and sex (women showed decreased echo-type I and increased in type II) was found. No significant changes in the remaining secondary outcomes were found. Ballet dancers showed structural changes in UTC, corresponding to a decreased echo-type I distribution after six weeks of rehearsing for Swan Lake ballet. No changes in self-reported symptoms, clinical signs of Achilles tendinopathy, and single-leg heel raise test were seen from pre- to post-rehearsal. Thus, UTC changes in the Achilles tendon seem to appear earlier than clinical signs of tendinopathy.

Fitness for all: how do non-disabled people respond to inclusive fitness centres?

BACKGROUND: Representation of people with disabilities in fitness centres is lacking, despite initiatives to promote inclusion mainly in the UK and USA. Success creating these inclusive spaces is mixed and few were crafted taking into account attitudes and biases of non-disabled co-members. Inclusive fitness centres have not gained much attention in Denmark, and the campaign 'Fitness for All - fitness for people with physical disabilities' was initiated. The aim of this study was shaped by two key questions; 1) what is the ideal fitness space from the perception of non-disabled fitness users? and 2) how might their dis/ableist attitudes negate inclusion in three future pilot inclusive fitness centres across Denmark? METHOD: Three focus groups involving 5-7 (total n = 18) adult non-disabled participants were conducted. Aged ranged between 19 and 75 years, both men and women were involved, with fitness centre experiences ranging from 0 to 20+ years. Interviews were transcribed and analysed using Malterud's four-step method of systematic text condensation. RESULTS: Of most importance was a pleasant atmosphere which should make them feel welcome and comfortable. Good social relations within the space were also highly valued. Participants welcomed people with physical disabilities but predicted many challenges with an inclusive fitness centre and expressed unconscious ableist attitudes. CONCLUSION: The current study adds essential knowledge regarding how non-disabled people perceive the ideal inclusive fitness centre. A welcoming and inviting atmosphere is essential whereas social skills, ableism, ignorance, and preconceptions are important barriers that may hinder inclusion of participants with disabilities in inclusive fitness centres.

Barriers to, and Facilitators of, Exercising in Fitness Centres among Adults with and without Physical Disabilities: A Scoping Review.

Fitness centres are an obvious arena for performing physical activity for the general population but representation of adults with physical disabilities (AwPD) is lacking. To increase possibilities for AwPD to exercise in fitness centres together with adults without physical disabilities (AwoPD), the aim of this study was to identify, synthesise, and compare barriers to, and facilitators of, exercising in fitness centres for each group. A scoping review was conducted and data extraction of the barriers and facilitators was performed independently by two researchers on six categories of contextual factors based on the framework of Di Blasi: (1) The fitness centre setting; (2) The fitness centre user characteristics; (3) The fitness instructor/staff characteristics; (4) The fitness centre user-instructor/management relationship; and (5) The fitness/exercise characteristics. An extra category, (6) Other relationships, was added. The PRISMA Extension for Scoping Reviews was used for reporting. Of the 102 included papers, only 26 (25%) of the papers were on AwPD, which focused mainly on physical barriers (category 1: inaccessible settings). In contrast, the remaining 76 papers involving AwoPD focused primarily on facilitators (category 2: motivational factors and exercising effects). In categories 3-6, the two groups had similar results, as both groups preferred skilled instructors, a welcoming and comfortable fitness centre environment, an ability to exercise at their preferred type and level, and good social connections. Since most data were based on AwoPD, more studies on actual experiences from AwPD are needed, to reveal the facilitators/motivational factors for fitness centre use.

Supervised Training Compared With No Training or Self-training in Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE: To study the effects of supervised training in adults with subacromial pain syndrome. DATA SOURCES: Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020. STUDY SELECTION: Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up. DATA EXTRACTION: Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE). DATA SYNTHESIS: Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes. CONCLUSIONS: Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome.

Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis.

BACKGROUND: Joint hypermobility in athletes is associated with increased risk of knee injuries, but its role in relation to shoulder injuries has not been scrutinized. Therefore, our aim was to synthesize the evidence on the association between joint hypermobility and shoulder injuries in athletes. METHODS: Data sources were MEDLINE, CINAHL, EMBASE, and SPORTDiscus from inception to 27th February 2021. Eligibility criteria were observational studies of athletes (including military personnel), mean age ≥ 16 years, and with a transparent grouping of those with and without joint hypermobility. A broad definition of joint hypermobility as the exposure was accepted (i.e., generalised joint hypermobility (GJH), shoulder joint hypermobility including joint instability). Shoulder injuries included acute and overuse injuries, and self-reported pain was accepted as a proxy for shoulder injuries. The Odds Ratios (OR) for having shoulder injuries in exposed compared with non-exposed athletes were estimated using a random effects meta-analysis. Subgroup analyses were performed to explore the effect of sex, activity type, sports level, study type, risk of bias, and exposure definition. Risk of bias and the overall quality of evidence were assessed using, respectively, the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Among 6207 records, six studies were included with 2335 (range 118-718) participants (34.1% females; athlete mean age 19.9 years). Athletes with joint hypermobility were more likely to have shoulder injuries compared with athletes without joint hypermobility (OR = 3.25, 95% CI 1.64, 6.43, I2 = 75.3%; p = 0.001). Exposure definition (GJH, OR = 1.97, 95% CI 1.32, 2.94; shoulder joint hypermobility, OR = 8.23, 95% CI 3.63, 18.66; p = 0.002) and risk of bias (low, OR = 5.25, 95% CI 2.56, 10.8; high, OR = 1.6, 95% CI 0.78, 3.29; p = 0.024) had large impacts on estimates, while the remaining subgroup analyses showed no differences. The overall quality of evidence was low. CONCLUSION: Joint hypermobility in athletes is associated with a threefold higher odds of having shoulder injuries, highlighting the need for prevention strategies in this population. However, due to low quality of evidence, future research will likely change the estimated strength of the association. PROTOCOL REGISTRATION: Open Science Framework registration osf.io/3wrn9.