Depression as a prognostic factor for lumbar spinal stenosis outcomes: a systematic review.

PURPOSE: Lumbar spinal stenosis (LSS) is associated with increased levels of psychological distress, including depression; however, the prognostic value of depression remains unclear. The purpose of this systematic review was to synthesize the evidence on the prognostic value of depression for a range of outcomes in patients with LSS. METHODS: Inclusion criteria were prospective cohort studies that investigated depression in patients diagnosed with LSS. Searches were conducted in 7 databases. Critical appraisal, data extraction, and judgement of cumulative evidence were conducted independently by two reviewers. A meta-analysis was not conducted due to a lack of unique cohorts for each outcome, varying follow-up times, and differences in measurements for both prognostic factors and outcomes. RESULTS: Twenty-three articles were included. There was evidence for an association between preoperative depression and postoperative disability and symptom severity outcomes for patients with LSS. Odds ratios ranged from 1.15 to 2.94 for postoperative disability and 1.16-1.20 for symptom severity at various follow-up times. Using GRADE, evidence supporting depression as a prognostic factor for these LSS outcomes was deemed to be of moderate quality. Similarly strong evidence suggested depressive symptoms are of no prognostic value for postoperative walking capacity. CONCLUSION: Depression appears to have small to moderate prognostic value for LSS outcomes, with the strongest evidence for postoperative disability and symptom severity. The prognostic value of depression for LSS outcomes should be further explored using standardized measures in additional cohorts, including patients managing their condition conservatively, who have been neglected in related research.

Measurement properties of cervical joint position error in people with and without neck pain: a systematic review and narrative synthesis.

INTRODUCTION: Proprioception can be impaired in people with neck pain. The cervical joint position sense test, which measures joint position error (JPE), is the most common test used to assess neck proprioception. The aim of this systematic review was to assess the measurement properties of this test for the assessment of people with and without neck pain. METHODS: This systematic review was registered prospectively on Prospero (CRD42020188715). It was designed using the COSMIN guidelines and reported in line with the PRISMA checklist. Two reviewers independently searched Medline, Embase, SportDiscus, and CINAHL Plus databases from inception to the 24th July 2022 with an update of the search conducted until 14th of October 2023. The COSMIN risk of bias checklist was used to assess the risk of bias in each study. The updated criteria for good measurement properties were used to rate individual studies and then the overall pooled results. The level of evidence was rated by two reviewers independently using a modified GRADE approach. RESULTS: Fifteen studies were included in this review, 13 reporting absolute JPE and 2 reporting constant JPE. The measurement properties assessed were reliability, measurement error, and validity. The measurement of JPE showed sufficient reliability and validity, however, the level of evidence was low/very low for both measurement properties, apart from convergent validity of the constant JPE, which was high. CONCLUSION: The measure of cervical JPE showed sufficient reliability and validity but with low/very low levels of evidence. Further studies are required to investigate the reliability and validity of this test as well as the responsiveness of the measure.

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology.

BACKGROUND: Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs. OBJECTIVE: To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students. METHODS: Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein's diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes). RESULTS: For all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant's clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection). CONCLUSIONS: Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

A single bout of prior resistance exercise attenuates muscle atrophy and declines in myofibrillar protein synthesis during bed-rest in older men.

Impairments in myofibrillar protein synthesis (MyoPS) during bed rest accelerate skeletal muscle loss in older adults, increasing the risk of adverse secondary health outcomes. We investigated the effect of prior resistance exercise (RE) on MyoPS and muscle morphology during a disuse event in 10 healthy older men (65-80 years). Participants completed a single bout of unilateral leg RE the evening prior to 5 days of in-patient bed-rest. Quadriceps cross-sectional area (CSA) was determined prior to and following bed-rest. Serial muscle biopsies and dual stable isotope tracers were used to determine rates of integrated MyoPS (iMyoPS) over a 7 day habitual 'free-living' phase and the bed-rest phase, and rates of acute postabsorptive and postprandial MyoPS (aMyoPS) at the end of bed rest. Quadriceps CSA at 40%, 60% and 80% of muscle length significantly decreased in exercised (EX) and non-exercised control (CTL) legs with bed-rest. The decline in quadriceps CSA at 40% and 60% of muscle length was attenuated in EX compared with CTL. During bed-rest, iMyoPS rates decreased from habitual values in CTL, but not EX, and were significantly different between legs. Postprandial aMyoPS rates increased above postabsorptive values in EX only. The change in iMyoPS over bed-rest correlated with the change in quadriceps CSA in CTL, but not EX. A single bout of RE attenuated the decline in iMyoPS rates and quadriceps atrophy with 5 days of bed-rest in older men. Further work is required to understand the functional and clinical implications of prior RE in older patient populations. KEY POINTS: Age-related skeletal muscle deterioration, linked to numerous adverse health outcomes, is driven by impairments in muscle protein synthesis that are accelerated during periods of disuse. Resistance exercise can stimulate muscle protein synthesis over several days of recovery and therefore could counteract impairments in this process that occur in the early phase of disuse. In the present study, we demonstrate that the decline in myofibrillar protein synthesis and muscle atrophy over 5 days of bed-rest in older men was attenuated by a single bout of unilateral resistance exercise performed the evening prior to bed-rest. These findings suggest that concise resistance exercise intervention holds the potential to support muscle mass retention in older individuals during short-term disuse, with implications for delaying sarcopenia progression in ageing populations.

Predictors of poor outcome following lumbar spinal fusion surgery: a prospective observational study to derive two clinical prediction rules using British Spine Registry data.

PURPOSE: Lumbar spinal fusion surgery (LSFS) is common for lumbar degenerative disorders. The objective was to develop clinical prediction rules to identify which patients are likely to have a favourable outcome to inform decisions regarding surgery and rehabilitation. METHODS: A prospective observational study recruited 600 (derivation) and 600 (internal validation) consecutive adult patients undergoing LSFS for degenerative lumbar disorder through the British Spine Registry. Definition of good outcome (6 weeks, 12 months) was reduction in pain intensity (Numerical Rating Scale, 0-10) and disability (Oswestry Disability Index, ODI 0-50) > 1.7 and 14.3, respectively. Linear and logistic regression models were fitted and regression coefficients, Odds ratios and 95% CIs reported. RESULTS: Lower BMI, higher ODI and higher leg pain pre-operatively were predictive of good disability outcome, higher back pain was predictive of good back pain outcome, and no previous surgery and higher leg pain were predictive of good leg pain outcome; all at 6 weeks. Working and higher leg pain were predictive of good ODI and leg pain outcomes, higher back pain was predictive of good back pain outcome, and higher leg pain was predictive of good leg pain outcome at 12 months. Model performance demonstrated reasonable to good calibration and adequate/very good discrimination. CONCLUSIONS: BMI, ODI, leg and back pain and previous surgery are important considerations pre-operatively to inform decisions for surgery. Pre-operative leg and back pain and work status are important considerations to inform decisions for management following surgery. Findings may inform clinical decision making regarding LSFS and associated rehabilitation.

Prognostic factors for outcome following lumbar spine fusion surgery: a systematic review and narrative synthesis.

PURPOSE: The objective of this study was to identify and evaluate the value of prognostic factors related to disability, pain and quality of life (QoL) for adult patients undergoing lumbar spine fusion surgery (LSFS). METHODS: Two reviewers independently searched the literature, assessed eligibility, extracted data and assessed risk of bias and certainty of evidence. Key electronic databases were searched [PubMed, CINAHL, EMBASE, MEDLINE, PEDro and ZETOC] using pre-defined terms [e.g. LSFS] to 20/9/2020; with additional searching of journals, reference lists and unpublished literature. Prospective cohort studies with ≥ 12-month follow-up after LSFS were included. Narrative synthesis was based on recommendations by Cochrane Consumers and Communication Review Group. The GRADE tool enabled assessment of certainty of evidence. Prognostic factors and outcome were analysed and summarised when examined in ≥ 2 studies and when results pointed in the same direction in ≥ 75% of studies. RESULTS: Sixteen studies (n = 8388, 2 low and 14 high risk of bias) were included with 39 prognostic factors identified. There is low certainty evidence that higher pre-operative severity of leg pain predicts greater improvement of leg pain and that pre-operative working predicts less post-operative disability both at 1-2-year follow-up. Other found associations were of very low certainty evidence. CONCLUSION: No moderate to high certainty evidence exists. Use of leg pain and pre-operative working may be valuable predictors of outcome to inform clinical decision-making and advice regarding LSFS surgery. There is need for adequately powered low-risk-of-bias prospective observational studies to further investigate candidate prognostic factors.

The influence of spinal position on imaging findings: an observational study of thoracolumbar spine upright MRI in elite gymnasts.

PURPOSE: To investigate whether upright magnetic resonance imaging (MRI) has a role in defining thoracolumbar spine pathology in elite gymnastics. METHODS: A prospective cross-sectional observational study of National Senior and Junior Artistic gymnasts in three MRI positions (standard supine, upright flexed and extended positions). Two specialist musculoskeletal radiologists independently analysed images with neutral as a baseline with the effects of flexion and extension reported in line with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. RESULTS: Forty (18 males) gymnasts aged 13-24 years with a mean (SD) of 32 (5.3) training hours per week consented with 75% showing MRI abnormalities. Degenerative disc disease (DDD) was evident in 55% participants with vertebral end plate (VEP) changes in 42.5%. Spondylolysis was present in 40% with an additional 17% showing chronic bilateral complete L5 pars defects. 23% participants demonstrated different MRI findings in upright flexion compared to neutral. CONCLUSION: Findings suggest a high levels of MRI abnormalities in elite gymnastics including altered disc morphology and posterior element abnormalities. High prevalence of T11/12 DDD and VEP changes reflects the thoracolumbar junction being a transition zone. Upright MRI and varying spine position offer promise for enhanced visualisation of posterior element abnormalities.

Immediate patient perceptions following lumbar spinal fusion surgery: semi-structured multi-centre interviews exploring the patient journey and experiences of lumbar fusion surgery (FuJourn).

PURPOSE: To understand the patient journey to Lumbar Spinal Fusion Surgery (LSFS) and patients' experiences of surgery. METHODS: Qualitative study using interpretive phenomenological analysis. Adult participants following LSFS were recruited from 4 UK clinical sites using purposive sampling to ensure representation of key features (e.g. age). Semi-structured interviews informed by a piloted topic guide developed from the literature were audio-recorded and transcribed verbatim. Framework analysis for individual interviews and then across participants (deductive and inductive) identified emerging themes. Trustworthiness of data analyses was enhanced using multiple strategies (e.g. attention to negative cases). RESULTS: Four emerging themes from n = 31 patients' narratives were identified: decision for surgery, coping strategies, barriers to recovery and recovery after surgery. Decision for surgery and recovery after surgery themes are distinguished by the point of surgery. However, barriers to recovery and coping strategies are key to the whole patient journey encompassing long journeys to surgery and their initial journey after surgery. The themes of coping strategies and barriers to recovery were inter-related and perceived by participants as parallel concepts. The 4 multifactorial themes interacted with each other and shaped the process of an individual patient's recovery. Factors such as sporadic interventions prior to surgery, time-consuming wait for diagnosis and surgery and lack of information regarding recovery strongly influenced perceptions of outcome. CONCLUSION: Patient driven data enables insights to inform research regarding surgery/rehabilitation through depth of understanding of the patient journey. Awareness of factors important to patients is important; ensuring that patient-driven data informs research and patient care.

Exploring the barriers and facilitators to non-medical prescribing experienced by pharmacists and physiotherapists, using focus groups.

BACKGROUND: Non-medical prescribing (NMP) was introduced into the United Kingdom to enhance patient care and improve access to medicines. Early research indicated that not all non-medical prescribers utilised their qualification. A systematic review described 15 factors influencing NMP implementation. Findings from a recent linked Delphi study with independent physiotherapist and pharmacist prescribers achieved consensus for 1 barrier and 28 facilitators. However, item ranking differed for pharmacist and physiotherapist groups, suggesting facilitators and barriers to NMP differ depending on profession. The aim of this study was to further explore the lived experiences of NMP by pharmacists and physiotherapists. METHOD: Study design and analytical approach were guided by Interpretative Phenomenology Analysis principles. Focus groups (November and December 2020) used the 'Zoom®ï»¿' virtual platform with pharmacist and physiotherapist prescribers. Each focus group followed a topic guide, developed a priori based on the Delphi study results, and was audio recorded digitally. Transcripts underwent thematic analysis and data were visualised using a concept map and sunburst graph, and a table of illustrative quotes produced. Research trustworthiness was enhanced through critical discussion of the topic guide and study findings by the research group and by author reflexivity. The study is reported in line with COREQ guidelines. RESULTS: Participants comprised three physiotherapists and seven pharmacists. Five themes were identified. The most frequently mentioned theme was 'Staff', and the subtheme 'Clinical team', describing the working relationship between participants and team members. The other themes were 'Self', 'Governance', 'Practical aspects' and 'Patient care'. Important inter-dependencies were described between themes and subthemes, for example between 'Governance' and 'Quality and Safety'. Differences were highlighted between the professions, some relating to the way each profession practises (for example decision making), others to the way the prescribing role had been established (for example administration support). CONCLUSIONS: The key finding of collaborative working with the clinical team emphasises its impact on successful implementation of NMP. Themes may be inter-dependent, and inter-profession differences were identified. Specifically designed prescribing roles were beneficial for participants. For full NMP benefits to be realised all aspects of such roles must be fully scoped, before recruiting or training non-medical prescribers.

MRI features of ERSA (exercise-related signal abnormality) lesions in professional soccer players.

OBJECTIVE: This study aims to describe the prevalence, anatomy and morphology of ERSA (exercise-related signal abnormality) lesions, a previously undescribed pattern of muscle signal changes on MRI in professional soccer players with suspected acute thigh muscle injury. METHODS: A multicenter retrospective review was performed of 287 MRIs of professional soccer players referred for suspected acute thigh injury from August 2017 to February 2020. MR images were reviewed for muscle signal abnormalities corresponding to a peritendinous ovoid region or a subfascial ring of faint increased signal on fluid-sensitive MR images. Imaging features including anatomical site, morphology, and craniocaudal length were recorded. Concomitant acute muscle injury was graded in accordance with the British Athletics Muscle Injury Classification (BAMIC). RESULTS: ERSA lesions comprising a peritendinous ovoid region, a subfascial ring, or both, were identified in 40 muscles across 31/287 studies (10.8%). These lesions had a mean length of 15.8 cm and were predominantly located in the proximal or mid-portions of muscles. Affected muscles were rectus femoris (n = 22), adductor longus (n = 11), semitendinosus (n = 6) and biceps femoris (n = 1). 21/31 studies (67.7%) had a BAMIC grade 1-4 injury in a separate muscle, which were largely (81%) in a separate anatomic compartment or contralateral. CONCLUSION: ERSA lesions were evident on MRI in 10.8% of our cohort of professional soccer players referred for suspected acute thigh muscle injury. Characteristic morphology and the longitudinal length (mean 15.8 cm) distinguish ERSA lesions from recognized patterns of acute muscle injury.

Assessing moderate-to-vigorous physical activity in hip and knee osteoarthritis using accelerometers: Implications of different patterns and cut-points for health and well-being.

OBJECTIVE: This cross-sectional study explored how using age-specific and non-age-specific cut-points to assess moderate-to-vigorous physical activity (MVPA) measured by GT3X accelerometers affected bouted and total volume MVPA associations with health and well-being. METHODS: MVPA correlations with physical function, BMI, joint pain, quality of life, anxiety and depression were tested. Steiger's z compared the strength of these correlations for each pair of cut-points. RESULTS: A total of 109 adults with hip/knee osteoarthritis [M= 63.8 years (±10.58), 63.3% women] participated. Applying age-specific cut-points resulted in significantly more time classified as MVPA (76/9.5min total volume/bouted) compared to non-age-specific (38.8/7min total volume/bouted). Only total volume MVPA correlations differed significantly as a function of cut-points for self-reported function, quality of life, anxiety and depression (p ≤ .05). For age-specific cut-points, more time spent in MVPA was associated with a worse psychological profile. DISCUSSION: Applying age-specific cut-points for MVPA assessment in older adults with lower limb OA had implications for MVPA associations with health and well-being when total volume, but not bouted, MVPA was considered. Age-specific total volume MVPA needs further understanding regarding patterns and affective responses it comprises. Bouted MVPA is an important pattern for MVPA accrual, but probably not an applicable PA target for many patients.

Outcomes Evaluating Quality of Life and Their Measurement Properties in Early-onset Scoliosis: A Systematic Review.

INTRODUCTION: Early-onset scoliosis (EOS) is a spinal deformity affecting children under the age of 10. Understanding the impact of EOS on quality of life can be achieved through appropriate patient/carer-reported outcome measures (PROMs). The aim of this systematic review was to identify, evaluate and summarize the evidence for the measurement properties of health-related quality of life (HR-QoL) outcome measures in the EOS population. METHODS: A 2-stage search methodology was conducted across the PubMed, MEDLINE, EMBASE, EMCARE, PsychINFO, and CINAHL databases. Search 1 identified PROMs used to evaluate the quality of life in EOS, and search 2 identified studies of the measurement properties of these PROMs. Two reviewers performed searching, study screening and selection and assessed studies for risk of bias using the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. One reviewer performed data extraction. Evidence for each measurement property per PROM was summarized and evaluated using a modified GRADE approach. RESULTS: Search 1 identified 19 (10 disease-specific, 9 generic) PROMs that have been used to assess HR-QoL or a relevant domain in the EOS population. Search 2 identified only one PROM (the 24-item Early-Onset Scoliosis Questionnaire, EOSQ) with eligible studies (n=4) evaluating measurement properties. There is low-quality evidence for sufficient content validity, very low-quality evidence for sufficient reliability and low-quality evidence for sufficient criterion validity, specifically regarding the pulmonary function domain) of the EOSQ. Construct validity and responsiveness were rated as indeterminate. There were no studies on measurement error. CONCLUSIONS: Our search strategy found that measurement properties have only been evaluated for one PROM, the EOSQ. There is low-quality evidence for sufficient measurement properties for the EOSQ in patients under the age of 10 with EOS. Further research is needed to improve the quality of evidence for EOSQ measurement properties and investigate other PROMs in this population. LEVEL OF EVIDENCE: Level II.

[Pain modulation through exercise : Exercise-induced hypoalgesia in physiotherapy]. / Schmerzmodellierung durch Bewegung : Bewegungsinduzierte Hypoalgesie in der Physiotherapie.

Exercise prescription is a central tenet of physiotherapy. One of the numerous benefits of exercise is its influence on endogenous pain modulation. Exercise-induced hypoalgesia (EIH) refers to a short-term change in pain sensitivity following an acute bout of exercise. Interest in this phenomenon has grown considerably with over 150 articles published, including four systematic reviews in 2020 alone.This narrative review provides an overview of EIH including a definition and summary of the underlying mechanisms and mediating factors. Recent systematic reviews assessing EIH in people with and without musculoskeletal complaints were evaluated using AMSTAR2. Review findings confirm the presence of EIH. For asymptomatic people, confidence in the evidence was low to very low due to high heterogeneity of included studies, risk of bias, and study eligibility. For people with pain, there is very low confidence, at best, that subgroups or isometric exercise show altered EIH. Despite the growing body of evidence, challenges within the available evidence due to its complex nature are highlighted. Recommendations regarding outcome measures and exercise parameters are required, and further understanding of reliability and validity of EIH is needed. There is a demand to further elucidate these parameters and contextual factors to advance our understanding of EIH. Additional clinical research, especially in patient populations, is required to then provide implications for rehabilitation.

Prediction of walking ability following posterior decompression for lumbar spinal stenosis.

PURPOSE: Following surgery for lumbar spinal stenosis (LSS) up to 40% of people report persistent walking disability. This study aimed to identify pre-operative factors that are predictive of walking ability post-surgery for LSS. METHODS: An observational cohort study was conducted using data from the British Spine Registry (2017-2018) of adults (≥ 50 years) with LSS, who underwent ≤ 2 level posterior lumbar decompression. Patients receiving fixation or who had previous lumbar surgery were excluded. Walking ability was assessed by a single item on the Oswestry Disability Index and dichotomised into poor/good outcome. Multivariable regression models were performed. RESULTS: 14,485 patients were identified. Pre-operatively 30% patients reported poor walking ability, this decreased to 8% at 12 months follow-up. Predictors associated with poor walking ability at 12 months were: increasing age (≥ 75 years OR 1.54, 95% CI 1.07, 2.18), BMI ≥ 35 kg/m2 (OR 1.52, 95% CI 1.00, 2.30), severity of leg pain (OR 1.10, CI 95% 1.01, 1.21), disability (OR 1.01, 95% CI 1.01, 1.02) and quality of life (OR 0.72, 95% CI 0.56, 0.89). Pre-operative maximum walking distance (OR 1.10, 95% CI 1.05, 1.25) and higher education (OR 0.90, 95% CI 0.80, 0.96) were associated with reduced risk of poor walking ability at 12 months; p < 0.05. Depression, fear of movement and symptom duration were not associated with risk of poor outcome. CONCLUSION: Older age, obesity, greater pre-operative pain and disability and lower quality of life are associated with risk of poor walking ability post-operatively. Greater pre-operative walking and higher education are associated with reduced risk of poor walking ability post-operatively. Patients should be counselled on their risk of poor outcome and considered for rehabilitation so that walking and surgical outcomes may be optimised.

Utilising the perspectives of patients with lower-limb osteoarthritis on prescribed physical activity to develop a theoretically informed physiotherapy intervention.

BACKGROUND: Lower-limb osteoarthritis (OA) causes high levels of pain and disability. Physiotherapists are the primary healthcare provider of non-pharmacological treatments, and incorporate strategies to optimise physical activity (PA) to aid patients with lower-limb OA to moderate their clinical symptoms. However, patients with lower-limb OA have low adherence to PA recommendations both during treatment and after discharge. This study aimed to use knowledge of identified barriers and facilitators to physiotherapy prescribed PA (during treatment and post-discharge) to develop a theoretically informed intervention to optimise adherence to PA for patients with lower-limb OA during treatment and post-discharge. METHODS: 1) A purposive sample of 13 patients with lower-limb OA participated in semi-structured interviews following physiotherapy treatment. Inductive analysis identified themes/subthemes reflecting barriers and facilitators to physiotherapist prescribed PA, which were organised deductively according to personal factors, treatment and post-discharge phases. 2) Themes/subthemes were mapped onto the theoretical domains framework (TDF). 3) Behaviour change techniques (BCTs) were coded from the key identified domains and a theoretically informed physiotherapy intervention addressing barriers and using facilitators, was developed. RESULTS: Themes of patient confidence, mind-set, motivation, OA symptoms and PA experiences were primary personal factors that influenced PA adherence; with the TDF domain 'Beliefs about capabilities' most important to target. During treatment, the theme of routine formation was the major driver of personal factors; and primarily influenced by developing a positive physiotherapist-patient relationship. Post-discharge, physical factors, psychosocial factors and ongoing access to resources were important themes influencing PA maintenance. 'Environmental context and resources' and 'social influences' emerged as the key TDF domains to target during treatment and post-discharge. The proposed theoretically informed intervention included 26 BCTs delivered across conceptual phases of adoption, routine formation, and maintenance. CONCLUSION: A theoretically informed physiotherapy intervention was proposed to optimise PA adherence in patients with lower-limb OA. The included BCTs primarily target patients' perceived beliefs about their capabilities, by developing a PA routine during treatment and facilitating appropriate psychosocial support and access to resources for PA maintenance post-discharge. The feasibility of delivering the intervention in clinical practice will now be evaluated.

MRI findings of tibialis anterior friction syndrome: a mimic of tibial stress injury.

OBJECTIVE: To describe a distinct constellation of MRI demonstrated soft tissue abnormalities centred around the tibialis anterior tendon in a subset of patients presenting as suspected tibial stress injury. MATERIALS AND METHODS: A retrospective review was performed of the clinical and MRI imaging findings from 5 selected patients referred for MRI with suspected tibial stress injury. MRI studies at presentation of each case were systematically reviewed for peritendinous fluid, tibialis anterior tendon change, tibialis anterior muscle and myotendinous junction oedema, periosteal oedema over the tibia and tibial marrow oedema. RESULTS: All 5 cases were athletes (3 soccer players, 2 runners) of between 20 and 40 years of age. On MRI, all 5 cases demonstrated peritendinous fluid around an intact tibialis anterior tendon. This fluid was maximal at the junction of mid and distal thirds of the lower leg, and extended down to the superior extensor retinaculum, with a mean cranio-caudal length of 13 cm (range 8-17 cm). Associated oedema was present in the surrounding subcutaneous tissue, tibial periosteum and distal tibialis anterior musculotendinous junction. CONCLUSION: Peritendinous fluid around an intact tibialis anterior tendon over the mid-to-distal third tibia, with surrounding subcutaneous, periosteal and tibialis anterior myotendinous junction oedema is demonstrable on MRI in a subset of patients presenting as suspected tibial stress injury. A friction syndrome of tibialis anterior between the superior extensor retinaculum and the anterior tibia is proposed as the aetiology of this entity.

Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise.

BACKGROUND: Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. METHODS: A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. RESULTS: Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were "Training and retention of specialist staff", "Health education/awareness of injury severity", "Geographical coverage of referral trauma centres", and "Lack of protocol for bypass to referral centres". The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. CONCLUSION: Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study.

BACKGROUND: Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain. METHODS: A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated. RESULTS: Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants. CONCLUSIONS: Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.

Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis.

BACKGROUND: Low back-related leg pain (LBLP) is a challenge for healthcare providers to manage. Neuropathic pain (NP) is highly prevalent in presentations of LBLP and an accurate diagnosis of NP in LBLP is essential to ensure appropriate intervention. In the absence of a gold standard, the objective of this systematic review was to evaluate the diagnostic utility of patient history, clinical examination and screening tool data for identifying NP in LBLP. METHODS: This systematic review is reported in line with PRISMA and followed a pre-defined and published protocol. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro and PubMed databases, key journals and the grey literature were searched from inception to 31 July 2019. Eligible studies included any study design reporting primary diagnostic data on the diagnostic utility of patient history, clinical examination or screening tool data to identify NP in LBLP, in an adult population. Two independent reviewers searched information sources, assessed risk of bias (QUADAS-2) and used GRADE to assess overall quality of evidence. RESULTS: From 762 studies, 11 studies were included. Nine studies out of the 11 were at risk of bias. Moderate level evidence supports a cluster of eight signs (age, duration of disease, paroxysmal pain, pain worse in leg than back, typical dermatomal distribution, worse on coughing/sneezing/straining, finger to floor distance and paresis) for diagnosing lumbosacral nerve root compression, demonstrating moderate/high sensitivity (72%) and specificity (80%) values. Moderate level evidence supports the use of the StEP tool for diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values. CONCLUSIONS: Overall low-moderate level evidence supports the diagnostic utility of patient history, clinical examination and screening tool data to identify NP in LBLP. The weak evidence base is largely due to methodological flaws and indirectness regarding applicability of the included studies. The most promising diagnostic tools include a cluster of 8 patient history/clinical examination signs and the StEP tool. Low risk of bias and high level of evidence diagnostic utility studies are needed, in order for stronger recommendations to be made.

The Extent of Pain Is Associated With Signs of Central Sensitization in Patients With Hip Osteoarthritis.

BACKGROUND: Central sensitization may be present in some patients with hip osteoarthritis (OA), often reflected as widespread pain. We examine the association between pain extent with signs of central sensitization and other clinical and psychological features in patients with hip OA. METHODS: Thirty patients with hip OA were recruited for this cross-sectional observational study. Participants completed pain drawings on a digital tablet, which displayed frontal and dorsal views of the body. The pain extent (%) for each participant was determined by combining the frontal and dorsal pixels shaded and dividing by the total pixels of the body chart area. Participants completed patient-reported outcome measures to assess for signs and symptoms of central sensitization and psychosocial factors. Quantitative sensory testing including pain pressure thresholds (PPTs) and thermal pressure thresholds was performed at points anatomically local and distant from the hip. RESULTS: Women had significantly greater pain extent (6.71%) than men (2.65%) (z = -2.76, P < 0.01). Across all participants, increased pain extent was significantly associated with higher scores on the Widespread Pain Index (r2  = 0.426, P < 0.05), painDETECT questionnaire (r2  = 0.394, P < 0.05), and Pain Catastrophizing Scale (r2  = 0.413, P < 0.05), and with lower PPTs at the thenar eminence (r2  = -0.410, P < 0.05), vastus lateralis (r2  = -0.530, P < 0.01), vastus medialis (r2  = 0.363, P < 0.05), and greater trochanter (r2  = -0.373, P < 0.05). CONCLUSIONS: Greater pain extent was associated with several measures of signs and symptoms of central sensitization in patients with hip OA. These results support the utility of the pain drawing for identifying signs of central sensitization in patients with hip OA.