Trajectories of Pain and Function Outcomes up to 5 to 8 Years Following Total Knee Arthroplasty.

BACKGROUND: There appears to be substantial variability in outcomes > 2 years following total knee arthroplasty (TKA) that is masked by whole group analyses. The goal of the study was to identify trajectories of pain and function outcomes up to 5 to 8 years post-TKA and to identify baseline factors that are associated with different trajectories of recovery. METHODS: Baseline, 6-month, and 12-month pain and function data were collected in a previous study investigating predictors of outcome following primary TKA (n = 286), along with a variety of baseline predictor variables. The present study obtained pain and function data at 5 to 8 years following TKA in the same cohort (n = 201). Latent class linear mixed models were used to identify different classes of pain and functional trajectories over time. The extent to which differences across latent classes were explained by baseline predictor variables was determined. RESULTS: Three classes of pain and two classes of function trajectory were identified. While most patients (84% to 93%) followed a trajectory that showed an initial rapid gain following surgery that was sustained through 5 to 8 years, both pain and function included at least one trajectory class that showed a meaningful change after 12 months. No predictor variables were significantly associated with either the pain or function classes. CONCLUSIONS: Most patients follow a traditional trajectory of recovery in knee pain and function over 5 to 8 years. However, alternative trajectories are observed in an important minority of patients such that knee pain and function at 12 months after surgery does not always reflect outcomes at 5 to 8 years.

Robotic devices for paediatric rehabilitation: a review of design features.

Children with physical disabilities often have limited performance in daily activities, hindering their physical development, social development and mental health. Therefore, rehabilitation is essential to mitigate the adverse effects of the different causes of physical disabilities and improve independence and quality of life. In the last decade, robotic rehabilitation has shown the potential to augment traditional physical rehabilitation. However, to date, most robotic rehabilitation devices are designed for adult patients who differ in their needs compared to paediatric patients, limiting the devices' potential because the paediatric patients' needs are not adequately considered. With this in mind, the current work reviews the existing literature on robotic rehabilitation for children with physical disabilities, intending to summarise how the rehabilitation robots could fulfil children's needs and inspire researchers to develop new devices. A literature search was conducted utilising the Web of Science, PubMed and Scopus databases. Based on the inclusion-exclusion criteria, 206 publications were included, and 58 robotic devices used by children with a physical disability were identified. Different design factors and the treated conditions using robotic technology were compared. Through the analyses, it was identified that weight, safety, operability and motivation were crucial factors to the successful design of devices for children. The majority of the current devices were used for lower limb rehabilitation. Neurological disorders, in particular cerebral palsy, were the most common conditions for which devices were designed. By far, the most common actuator was the electric motor. Usually, the devices present more than one training strategy being the assistive strategy the most used. The admittance/impedance method is the most popular to interface the robot with the children. Currently, there is a trend on developing exoskeletons, as they can assist children with daily life activities outside of the rehabilitation setting, propitiating a wider adoption of the technology. With this shift in focus, it appears likely that new technologies to actuate the system (e.g. serial elastic actuators) and to detect the intention (e.g. physiological signals) of children as they go about their daily activities will be required.

A Gel Pad Designed to Measure Muscle Volume Using Freehand 3-Dimensional Ultrasonography.

We developed an innovative gel pad that covers the entire lower leg to remove artifacts due to the pressure of the transducer in freehand 3-dimensional ultrasonography. In comparison to the reference method in water, this study showed that this new method was valid (bias, 3.4 mL; limit of agreement, 7.7 mL for a volume of ≈220 mL) and reliable (coefficient of variation, <1.1%) for the measurement of gastrocnemius medialis muscle volume. Considering that it is easier to use than the water tank technique, it has much promise for volumetric measurement of many muscles.

Effects of worn and new footwear on plantar pressure in people with gout.

BACKGROUND: In clinical trials, good quality athletic shoes offer short-term improvements (two-months) in foot pain and disability in people with gout, but these improvements are not sustained over time. This may be due to wear and subsequent changes to the structural integrity of the shoe. The aim of this study was to examine the effects of wear on plantar pressures and footwear characteristics in shoes over six-months in people with gout. METHODS: Forty people with gout participated in a cross-sectional repeated measures study. Participants wore a pair of commercially available athletic footwear for six-months. Participants then attended a study visit where the worn footwear was compared with a new pair of the same model and size of footwear. Wear characteristics (upper, midsole, outsole) and plantar pressure were measured in the two footwear conditions. Wear characteristics were analysed using paired t-tests and Fisher's exact tests. Plantar pressure data were analysed using linear mixed models. RESULTS: Increases in medial midsole (P < 0.001), lateral midsole (P < 0.001) and heel midsole (P < 0.001) hardness were observed in the worn shoes. Normal upper wear patterns (P < 0.001) and outsole wear patterns (P < 0.001) were observed in most of the worn shoes. No differences in peak plantar pressures (P < 0.007) were observed between the two footwear conditions. Reduced pressure time integrals at the first metatarsophalangeal joint (P < 0.001), second metatarsophalangeal joint (P < 0.001) and hallux (P = 0.003) were seen in the worn shoes. CONCLUSIONS: The study found signs of wear were observed at the upper, midsole and outsole in the worn footwear after six-months. These changes to the structural properties of the footwear may affect forefoot loading patterns in people with gout.

Impaired Regulation of Submaximal Force after ACL Reconstruction: Role of Muscle Spindles.

Ongoing motor deficits are routinely present following anterior cruciate ligament (ACL) reconstruction, including the ability to regulate muscle force. While such deficits are known, it is unclear why this occurs. The goal of the current study was to investigate the potential influence of muscle spindle input on submaximal force regulation and muscle activity at the knee in people following ACL reconstruction. Fourteen participants (8 female) who were 6-24 months post-ACL reconstruction and 15 control participants (8 female) undertook submaximal force matching and force modulation tasks before and after 20 min of vibration applied to the patella tendon. Across all tasks, the ACL reconstruction participants were poorer at force matching (P=0.007). The effect of vibration was not significant in either group for the force matching tasks (P=0.06), although there was a reduction in maximum voluntary contraction post-vibration in the control group (P<0.001). The ACL reconstruction group also showed evidence of greater activation of the medial hamstring muscles in comparison to controls (P=0.04). Individuals who have undergone ACL reconstruction have a diminished ability to accurately match and regulate submaximal muscle force, but this does not appear to be related to impaired muscle spindle input. Neuromuscular retraining programs that involve force regulation tasks may be necessary to optimize rehabilitation after ACL reconstruction.

A Higher Grey Matter Density in the Amygdala and Midbrain Is Associated with Persistent Pain Following Total Knee Arthroplasty.

OBJECTIVE: The development of persistent pain following total knee arthroplasty (TKA) is common, but its underlying mechanisms are unknown. The goal of the study was to assess brain grey matter structure and its correlation with function of the nociceptive system in people with good and poor outcomes following TKA. SUBJECTS: Thirty-one people with LOW_PAIN (<3/10 on the numerical ratings scale [NRS]) at six months following TKA and 15 people with HIGH_PAIN (≥3/10 on the NRS) were recruited into the study. METHODS: Grey matter in key brain areas related to nociception was analyzed using voxel-based morphometry (VBM). Nociceptive facilitatory and inhibitory processes were evaluated using quantitative sensory testing (QST). QST scores and grey matter density in prespecified brain regions were compared between the LOW_PAIN and HIGH_PAIN groups. Regression analyses were used to analyze the associations between the grey matter and QST scores. RESULTS: There were no between-group differences in QST measures. In the VBM analysis, the HIGH_PAIN group had a higher grey matter density in the right amygdala, right nucleus accumbens, and in the periaqueductal grey (PAG), but lower grey matter density in the dorsal part of the left caudate nucleus. Grey matter density in the right amygdala and PAG correlated positively with temporal summation of pain. CONCLUSIONS: Persistent pain at six months after TKA is associated with a higher grey matter density in the regions involved in central sensitization and pain-related fear, which may contribute to the development of persistent pain after surgery.

Stretch reflex changes in ACL-deficient individuals and healthy controls during normal and surprise landings.

No studies in ACL-D individuals have examined neuromuscular adaptations during landing from a jump where an unexpected mechanical event changes the pre-programmed course of movement. The purpose of this study was to compare pre- and post-landing muscle activation in ACL-D individuals and uninjured controls during normal and surprise landings. Nineteen ACL-D and 17 uninjured volunteered. Participants performed repeated single leg landings from 30 and 15 cm heights. During 15 cm landings, a single surprise landing was performed where participants unexpectedly fell through a false surface at 15 cm to the solid floor a further 15 cm below. Electromyography (EMG) amplitude from vastus lateralis (VL), lateral hamstrings (LH), and soleus (Sol) was recorded. Pre-landing (-60 to 0 ms), post-landing short latency (31-60 ms), and post-landing medium latency (61-90 ms) periods were examined. Comparisons in EMG amplitudes were made across limbs (ACL-D, ACL intact, and control) in 30 cm landings. Additionally, the ratio of EMG amplitude in surprise:30 cm normal landings was analyzed. Post-landing LH EMG was reduced in the ACL-D compared to control limbs at short latencies (P < 0.05). Post-landing VL EMG was reduced in the ACL-D and ACL intact compared to the control limb at both latencies (P < 0.05). Surprise landings notably increased post-landing EMG in all muscles, across all limbs (P < 0.001). However, the gain in VL EMG was significantly greater in ACL-D and ACL intact limbs (P < 0.05). These changes in neuromuscular control of ACL-D individuals during expected and surprise landings may have important implications for rehabilitation, instability, and the risk of secondary injury.

Experimental knee pain impairs joint torque and rate of force development in isometric and isokinetic muscle activation.

PURPOSE: To investigate the effects of acute experimental knee joint pain on maximum force generation and rate of force development (RFD) of the quadriceps muscle during isometric and dynamic muscle activations. METHODS: The right knee of 20 healthy people was injected with hypertonic saline to create an acute pain experience. Measurements of maximum knee extensor torque during isometric, concentric, and eccentric contractions were undertaken using a Biodex dynamometer. The RFD was also examined during the isometric contractions. Quadriceps muscle activity was obtained using electromyography (EMG). The outcome measures were obtained at baseline, during pain, and after knee pain had resolved. RESULTS: Maximum joint torque and peak EMG were significantly reduced during pain, but there were no differences across the three types of contraction. The maximum RFD and rate of EMG rise were also reduced during pain, primarily at 50-100 ms post-contraction onset. The RFD and EMG rise were largely unaffected at later time periods following contraction onset (150-200 ms). CONCLUSIONS: Acute joint pain has a similar impact on isometric and isokinetic contractions despite differences in neural control strategies. Joint pain also impairs rapid muscle activation and the RFD. These findings are important for people with musculoskeletal pain as it likely contributes to impairments in joint function in these populations.

Orthostatic intolerance following hip arthroplasty: incidence, risk factors and effect on length of stay: A prospective cohort study.

BACKGROUND: Early postoperative mobilisation is important for enhanced recovery, but can be hindered by orthostatic intolerance, characterised by dizziness, nausea, vomiting, feeling of heat, blurred vision and ultimately syncope. Although the incidence of orthostatic intolerance following total hip arthroplasty has been identified, few studies have yet investigated potential risk factors for developing orthostatic intolerance after hip arthroplasty. OBJECTIVES: The aim of this study was to assess the incidence of orthostatic intolerance on the first postoperative day after total hip arthroplasty, potential predisposing risk factors for developing orthostatic intolerance and its effect on length of stay. DESIGN: A prospective observational study. SETTING: Tertiary hospital, Auckland, New Zealand, May to September 2015. PATIENTS: One hundred and seventeen consecutive patients undergoing unilateral total hip arthroplasty. Patients were excluded if they had revision surgery. MAIN OUTCOME MEASURES: Incidence of orthostatic intolerance during mobilisation on the first postoperative day. Significant peri-operative risk factors for developing orthostatic intolerance were identified using logistic regression. Length of stay was compared between orthostatic intolerant and orthostatic tolerant patients using the Mann-Whitney U-test. RESULTS: On the first postoperative day, 22% of patients failed mobilisation due to orthostatic intolerance. Factors independently associated with orthostatic intolerance were female sex; OR (95% CI), 3.11 (1.01 to 9.57), postoperative use of gabapentin; OR 3.55 (1.24 to 10.15) and high peak pain levels (≥5/10) during mobilisation; OR 4.05 (1.30 to 12.61). Overall, 78% of patients were correctly identified. The model was more accurate at predicting those who would not get orthostatic intolerance (89% correct), compared with those who did have orthostatic intolerance (39% correct). Length of stay was longer in patients with orthostatic intolerance (P = 0.019). CONCLUSION: Orthostatic intolerance is common after total hip arthroplasty. Optimising pain control prior to mobilisation and limiting gabapentin use may modify the risk of developing postoperative orthostatic intolerance. Although personalised recovery pathways appear attractive, at present, the ability to predict at-risk individuals is still limited.

Structural Brain Alterations Before and After Total Knee Arthroplasty: A Longitudinal Assessment.

Objective: Many studies have provided evidence of altered brain structure in chronic pain conditions, as well as further adaptations following treatment that are coincident with changes in pain. Less is known regarding how these structural brain adaptations relate to assessments of nociceptive processing. The current study aimed to investigate brain structure in people with knee osteoarthritis (OA) before and after total knee arthroplasty (TKA) and to investigate the relationships between these findings and quantitative sensory testing (QST) of the nociceptive system. Methods: Twenty-nine people with knee OA underwent magnetic resonance imaging (MRI) scans and QST before and six months after TKA and were compared with a pain-free control group (N = 18). MRI analyses involved voxel-based morphometry and fractional anisotropy. Results: Before TKA, there was reduced gray matter volume and impaired fractional anisotropy in areas associated with nociceptive processing, with further gray matter adaptations and improvements in fractional anisotropy evident after TKA. QST revealed increased nociceptive facilitation and impaired inhibition in knee OA that was reversed after TKA. There were minimal relationships found between MRI data and QST assessments or pain report. Conclusions: In people with end-stage knee OA, region-specific gray matter atrophy was detected, with further changes in gray matter volume and improvements in white matter integrity observed after joint replacement. Despite coincident alterations in nociceptive inhibition and facilitation processes, there did not appear to be any association between these functional assessments of the nociceptive system and changes in brain structure.

A Comparison of Walking Gait Following Mechanical and Kinematic Alignment in Total Knee Joint Replacement.

BACKGROUND: Although previous studies have compared radiological, pain, and function scores in kinematically aligned (KA) and mechanically aligned (MA) total knee arthroplasty (TKA), no previous studies have undertaken a three-dimensional (3D) gait analysis in these groups. This study compared kinematic and kinetic variables recorded during level walking in patients at least 2 years post-surgery who underwent an MA or KA procedure. METHODS: Utilizing a 9-camera motion analysis system, gait analysis was undertaken on 29 patients (MA = 15, KA = 14). A 9-camera motion analysis system was used to collect 3D kinematic data of the involved and uninvolved limbs during walking at a self-selected speed. Additionally, 3D ground reaction forces and moments during the stance phase were recorded, and an inverse dynamics approach was utilized to analyze these data. RESULTS: There were no significant differences in spatial-temporal variables between MA and KA groups (P > .05). Local minima and maxima for knee joint angles were not significantly different (P > .05) across involved and uninvolved legs and MA/KA groups in any of the 3 planes of motion. Principal component analysis revealed a significant difference (P < .05) in the transverse plane moment in late stance. No other significant differences were observed for knee, hip, or ankle joint moments. CONCLUSION: Differences in gait parameters across the KA and MA groups at 2 years post-surgery were insufficient to support either one of the operative procedures over the other.

Subconscious manipulation of pain expectation can modulate cortical nociceptive processing.

OBJECTIVE: To determine whether manipulation of the expectation of pain inhibition can enhance the efficacy of conditioned pain modulation in healthy participants METHODS: A conditioned pain modulation paradigm was used to investigate the effect of psychological manipulation of expectation on pain inhibition. In 19 healthy men, the lower limb nociceptive flexion reflex was elicited in isolation (test stimulus) and during application of 2 forms of conditioning stimuli. Following application of the first conditioning stimulus (CS1), the participants were informed that the subsequent conditioning stimulus (CS2) would elicit a greater amount of inhibition of test pain compared with the first. Lower limb flexion reflex size, perceived pain ratings of the test stimulus, and ratings of expected pain modulation were obtained for both test and conditioning protocols. RESULTS: The inhibition of perceived pain was significantly greater with CS2 compared with CS1; however, there was no significant difference in inhibition of nociceptive flexion reflex size or the participant's reported expectation of pain modulation between the 2 conditioning stimuli. DISCUSSION: As perceived pain inhibition was enhanced but flexion reflex size unchanged following the intervention, we suggest that the intervention gave rise to an inhibition of ascending nociceptive information at a supraspinal level resulting in reduced pain perception without influencing spinal level processing of nociceptive input. The finding that conditioned pain modulation can be enhanced is of relevance to clinical pain populations who commonly show impaired inhibition.

Progressive submaximal effort hamstring muscle endurance is reduced after reconstruction of the anterior cruciate ligament.

BACKGROUND: Endurance capability in the muscles controlling the knee is poorly understood post anterior cruciate ligament (ACL) reconstruction, despite many sporting activities requiring notable muscle endurance. The hamstring muscles, when active, provide important anatomical support to protect the reconstructed graft. In the absence of good hamstring endurance, fatigue may predispose individuals to re-injury. OBJECTIVE: To assess whether ACL reconstruction (ACLR) with a hamstring graft leads to reduced hamstring endurance 9-13 months post-surgery. STUDY DESIGN: A cross-sectional inter-limb comparison study was undertaken with participants 9-13 months after an ACLR with a hamstring graft, and a group of age, sex, and activity-matched controls. There were 22 participants in each group. METHOD: Submaximal hamstring endurance was measured using a progressive fatigue test on an isokinetic dynamometer at a joint angular velocity of 120°/second. The dependant variable was the maximum number of repetitions performed. Statistical comparisons were made across injured, uninjured and control group limbs. RESULTS: There was a significant (p < 0.05) deficit in hamstring endurance observed between the injured leg (mean: 111 repetitions, SD 49) and uninjured leg (mean: 136 repetitions, SD 67) of the ACL group, but not between the uninjured and control group legs (mean: 124 repetitions, SD 50). CONCLUSION: The 18% deficit in submaximal hamstring endurance across the ACL-reconstructed individual's limbs is indicative of a notable loss in muscle performance at 9-13 months post-surgery. These results provide initial evidence for supporting further research examining the inclusion of hamstring endurance training in ACL rehabilitation programmes post-surgery.

Comparing the lower limb tasks questionnaire to the Western Ontario and McMaster Universities Osteoarthritis Index: agreement, responsiveness, and convergence with physical performance for knee osteoarthritis patients.

OBJECTIVE: To compare the Lower Limb Tasks Questionnaire (LLTQ) with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in terms of agreement, responsiveness, and convergence. DESIGN: Cross-sectional with an exploratory repeated-measures subsample analysis. SETTING: Community-based seniors' centers and arthritis clinics. PARTICIPANTS: Individuals with symptomatic knee osteoarthritis (N=76) participated, with a subsample of 18 participants contributing to the pre- and postarthroplasty subanalysis. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Bland and Altman plots of agreement with 95% limits of agreement, statistical responsiveness, and standardized response mean (SRM) were calculated for LLTQ and WOMAC subscales. Both t tests and Wilcoxon rank-sum tests were used to examine changes in pre- and postarthroplasty self-reported function, 50-ft walk speed, stair ascent/descent speed, and isometric quadriceps strength. RESULTS: The agreement (bias) of the LLTQ activities of daily living (ADL) subscale when compared with the WOMAC physical function (PF) subscale was 1%±10% (mean ± SD), and the 95% limits of agreement were -19% to +22%. The statistical responsiveness of the WOMAC-PF and LLTQ ADL was 1.17 and -.63, respectively. The SRMs for these scales were .90 and -.61, respectively. The WOMAC-PF scores showed a notable improvement over the first 6 weeks postarthroplasty, while LLTQ ADL scores were unchanged. The objective measures of function were all significantly worse at 6 weeks. CONCLUSIONS: The LLTQ demonstrated adequate agreement with the WOMAC and acceptable responsiveness for use in place of the WOMAC in nonspecialized clinics. The LLTQ may more accurately represent functional status after total knee arthroplasty, but further study in larger samples is recommended.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain.

BACKGROUND: Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort. METHODS: Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O'Brien's test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests. RESULTS: Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84). CONCLUSIONS: In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

The effects of commercially available footwear on foot pain and disability in people with gout: a pilot study.

BACKGROUND: There is limited evidence on non-pharmacological interventions for gout. The aim of the study was to determine whether a footwear intervention can reduce foot pain and musculoskeletal disability in people with gout. METHODS: Thirty-six people with gout participated in a prospective intervention study over 8 weeks. Participants selected one of 4 pairs of shoes and thereafter wore the shoes for 8 weeks. The primary outcome was foot pain using a 100 mm visual analogue scale. Secondary outcomes related to function and disability were also analysed. RESULTS: The Cardio Zip shoe was selected by 58% of participants. Compared with baseline, overall scores for all shoes at 8-weeks demonstrated a decrease in foot pain (p = 0.03), general pain (p = 0.012), Health Assessment Questionnaire (HAQ)-II (p = 0.016) and Leeds Foot Impact Scale (LFIS) impairment subscale (p = 0.03). No significant differences were observed in other patient reported outcomes including patient global assessment, LFIS activity subscale, and Lower Limb Task Questionnaire subscales (all p > 0.10). We observed significant improvements between baseline measurements using the participants' own shoes and the Cardio Zip for foot pain (p = 0.002), general pain (p = 0.001), HAQ-II (p = 0.002) and LFIS impairment subscale (p = 0.004) after 8 weeks. The other three shoes did not improve pain or disability. CONCLUSIONS: Footwear with good cushioning, and motion control may reduce foot pain and disability in people with gout.

Biomechanical risk factors and mechanisms of knee injury in golfers.

Knee injuries in golf comprise approximately 8% of all injuries, and are considered to result from overuse, technical faults or a combination of those factors. This review examines factors involved in injury, including the structure of the knee joint, kinematics and kinetics of the golf swing, forces sustained by knee joint structures and the potential for joint injury as well as injury prevention strategies. The golf swing generates forces and torques which tend to cause internal or external rotation of the tibia on the femur, and these are resisted by the knee ligaments and menisci. Research has shown that both maximum muscle forces and the forces sustained during a golf swing are less than that required to cause damage to the ligaments. However, the complex motion of the golf swing, involving both substantial forces and ranges of rotational movement, demands good technique if the player is to avoid injuring their knee joint. Most knee injury in golf is likely related to joint laxity, previous injuries or arthritis, and such damage may be exacerbated by problems in technique or overuse. In addition to appropriate coaching, strategies to remedy discomfort include specific exercise programmes, external bracing, orthotics and equipment choices.

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care.

OBJECTIVES: Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort. METHODS: Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated. RESULTS: A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86-1.00; negative likelihood ratio: 0.00, 95% CI: 0.00-0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86-0.95; positive likelihood ratio 4.66, 95% CI: 2.34-8.74). DISCUSSION: Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation.

The effect of Tubigrip and a rigid belt on rectus abdominus diastasis immediately postpartum: A randomised clinical trial.

BACKGROUND: Rectus abdominis (RA) diastasis is a risk factor for abdominal muscle dysfunction and reduced quality of life postpartum. It is thought that supplementary abdominal supports might reduce the diastasis. However, there is limited research assessing the efficacy of abdominal supports/binding. OBJECTIVE: To determine the effects of Tubigrip and a rigid abdominal belt in reducing RA diastasis in the first eight weeks postpartum. DESIGN: Randomised clinical trial. METHODS: 62 women undertook ultrasound imaging to measure their RA diastasis prior to and after an eight week intervention wearing either Tubigrip or a rigid abdominal belt. Data analyses involved repeated measures ANOVA and correlational methods. RESULTS: The RA diastasis reduced by 46% from a mean 4.6 cm-2.5 cm over the eight week intervention period with no significant difference (p > 0.05) across groups. Women wore the Tubigrip for a significantly (p < 0.05) longer number of hours (Median: 278) compared to those in the belt group (Median: 81 h). The length of time that women wore Tubigrip or the belt was not associated with the percentage reduction in the RA diastasis (p > 0.05). There was no significant difference in the diastasis across vaginal and Caesarean section deliveries at baseline. There was a significant difference (p < 0.05) in the percent reduction of the RA diastasis across deliveries post-intervention (vaginal delivery mean: 48% vs C-section: 40%). CONCLUSION: There was no difference across groups post-intervention in the RA diastasis, and it is questionable whether either support improves upon that associated with natural healing alone.