Physiological and psychological determinants of long-term diet-induced type 2 diabetes (T2DM) remission: A narrative review.

Type 2 diabetes mellitus (T2DM) is a highly prevalent metabolic disease, causing a heavy burden on healthcare systems worldwide, with related complications and anti-diabetes drug prescriptions. Recently, it was demonstrated that T2DM can be put into remission via significant weight loss using low-carbohydrate diets (LCDs) and very low-energy diets (VLEDs) in individuals with overweight and obesity. Clinical trials demonstrated remission rates of 25-77%, and metabolic improvements such as improved blood lipid profile and blood pressure were observed. In contrast, clinical trials showed that remission rate declines with time, concurrent with weight gain, or diminished weight loss. This review aims to discuss existing literature regarding underlying determinants of long-term remission of T2DM including metabolic adaptations to weight loss (e.g., role of gastrointestinal hormones), type of dietary intervention (i.e., LCDs or VLEDs), maintaining beta (ß)-cell function, early glycemic control, and psychosocial factors. This narrative review is significant because determining the factors that are associated with challenges in maintaining long-term remission may help in designing sustainable interventions for type 2 diabetes remission.

How can UK public health initiatives support each other to improve the maintenance of physical activity? Evidence from a cross-sectional survey of runners who move from Couch-to-5k to parkrun.

Physical activity improves physical and mental well-being and reduces mortality risk. However, only a quarter of adults globally meet recommended physical activity levels for health. Two common initiatives in the UK are Couch-to-5k (an app-assisted 9-week walk/run programme) and parkrun (a free, weekly, timed 5-km walk/run). It is not known how these initiatives are linked, how Couch-to-5k parkrunners compare to parkrunners, and the extent to which this influences their parkrun performance. The aims were to compare the characteristics and motives and to compare physical activity levels, parkrun performance and the impact of parkrun between Couch-to-5k parkrunners and parkrunners. Three thousand two hundred and ninety six Couch-to-5k parkrunners were compared to 55,923 parkrunners to explore age, sex, ethnicity, employment status, neighbourhood deprivation, motives, physical activity levels, parkrun performance and the impact of parkrun. Couch-to-5k parkrunners were slightly older, more likely to be female and work part-time, but similar in ethnicity, and neighbourhood deprivation compared with other parkrunners. Couch-to-5k parkrunners had different motives for participation and reported high levels of physical activity at registration, which remained to the point of survey completion. This group had slower parkrun times but, when registered for a year, completed a similar number of runs (11) per year. Larger proportions of Couch-to-5k parkrunners perceived positive impacts compared with other parkrunners and 65% of Couch-to-5k parkrunners reported improvements to their lifestyle. parkrun appears to be an effective pathway for those on the Couch-to-5k programme, and the promising positive association between the two initiatives may be effective in assisting previously inactive participants to take part in weekly physical activity.

"Couch-to-5k or Couch to Ouch to Couch!?" Who Takes Part in Beginner Runner Programmes in the UK and Is Non-Completion Linked to Musculoskeletal Injury?

Physical activity has mental and physical health benefits; however, globally, three-quarters of the population do not meet physical activity guidelines. The Couch-to-5k is a beginner runner programme aimed at increasing physical activity. However, this programme lacks an evidence base, and it is unclear who is attracted to the programme; running also has a high rate of musculoskeletal (MSK) injuries. The aims of this study were to identify the characteristics of people taking part and the incidence of MSK injuries as well as exploring the experiences of people who dropped out of a modified 9-week Couch-to-5k programme. A total of 110 runners (average age was 47.1 ± 13.7 years) participated in the study, which involved completion of questionnaires (running experience and footwear information, quality of life (EQ-5D-5L), physical activity level (IPAQ-short form), MSK injury history and knee condition (SNAPPS and KOOS-PS)) at the start, middle and end of the programme and collecting sociodemographic information (age, gender, social economic status, relationship status, education level), as well as body mass index, running experience, footwear information, quality of life, physical activity levels, MSK injuries and knee condition. Fifteen drop-outs were interviewed to explore experiences of the programme. Runners were mainly females (81.8%) with an average age 47.1 years, average body mass index of 28.1 kg.m2, mainly from high socio-economic levels, married and educated to degree level. In total, 64% of the sample had previous running experience and were classified as active. Half the sample self-reported pain/discomfort and 37.2% reported anxiety/depression at the start of the programme via the EQ-5D-5L scale. Self-reported health scores increased (p = 0.047) between baseline (73.1 ± 18.8 out of 100) and at the midpoint (81.2 ± 11.6), but there were no significant differences between any other time points (end point 79.7 ± 17.5, p > 0.05). Twenty-one injuries were reported during the programme (19%). Previous injury increased the risk of new injury (OR 7.56 95% CI from 2.06 to 27.75). Only 27.3% completed the programme. Three themes emerged from interviews; MSK injury, negative emotions linked to non-completion and design of the programme. The Couch-to-5k may not attract diverse inactive populations, but future work with larger sample sizes is needed to substantiate this finding. Dropping out was linked to MSK injury and progressive design, so future programmes should consider including injury prevention advice and more flexible designs.

Lower Limb Anthropometric Profiling in Professional Female Soccer Players: A Proof of Concept for Asymmetry Assessment Using Video Analysis.

The objective was to evaluate the clinical joint and limb measures in professional female soccer players. The study was a cross-sectional observational design. It was a preseason clinical setting. The inclusion criteria were outfield professional female soccer players, based in the UK, competing in the highest English league. The exclusion criteria included players who had had surgery in the last six months or had missed a single training session or match due to injury in the previous three months. In terms of the outcome measures, the dependent variables were the true limb length, ankle dorsiflexion, knee flexion and extension, hip flexion, extension, internal rotation and external rotation, and straight leg raise measured using video analysis software. Additionally, passive clinical knee and ankle stability tests were conducted. The independent variables were leg dominance and playing position (defender, midfielder, and attacker). For the results, all the ROM measurements demonstrated limb symmetry (p = 0.621). However, there were significant main effects of the playing position on the ankle dorsiflexion and hip internal rotation, with defenders demonstrating a significantly reduced range of motion in comparison to midfielders and attackers. A notable finding from the bilateral passive stability measures was that 38.3% of players exhibited ankle talar inversion instability when using a talar tilt. In conclusion, bilateral differences do not appear to be apparent in this population; however, positional differences may occur in the ankle and hip range of motion measures. A high proportion of this population may present with passive ankle inversion instability. Future research should consider whether this leads to a higher risk of injury in this population.

Running shoes for preventing lower limb running injuries in adults.

BACKGROUND: Lower-limb running injuries are common. Running shoes have been proposed as one means of reducing injury risk. However, there is uncertainty as to how effective running shoes are for the prevention of injury. It is also unclear how the effects of different characteristics of running shoes prevent injury. OBJECTIVES: To assess the effects (benefits and harms) of running shoes for preventing lower-limb running injuries in adult runners. SEARCH METHODS: We searched the following databases: CENTRAL, MEDLINE, Embase, AMED, CINAHL Plus and SPORTDiscus plus trial registers WHO ICTRP and ClinicalTrials.gov. We also searched additional sources for published and unpublished trials. The date of the search was June 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs involving runners or military personnel in basic training that either compared a) a running shoe with a non-running shoe; b) different types of running shoes (minimalist, neutral/cushioned, motion control, stability, soft midsole, hard midsole); or c) footwear recommended and selected on foot posture versus footwear not recommended and not selected on foot posture for preventing lower-limb running injuries. Our primary outcomes were number of people sustaining a lower-limb running injury and number of lower-limb running injuries. Our secondary outcomes were number of runners who failed to return to running or their previous level of running, runner satisfaction with footwear, adverse events other than musculoskeletal injuries, and number of runners requiring hospital admission or surgery, or both, for musculoskeletal injury or adverse event. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility and performed data extraction and risk of bias assessment. The certainty of the included evidence was assessed using GRADE methodology. MAIN RESULTS: We included 12 trials in the analysis which included a total of 11,240 participants, in trials that lasted from 6 to 26 weeks and were carried out in North America, Europe, Australia and South Africa. Most of the evidence was low or very low certainty as it was not possible to blind runners to their allocated running shoe, there was variation in the definition of an injury and characteristics of footwear, and there were too few studies for most comparisons. We did not find any trials that compared running shoes with non-running shoes. Neutral/cushioned versus minimalist (5 studies, 766 participants) Neutral/cushioned shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with minimalist shoes (low-certainty evidence) (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.59 to 1.01). One trial reported that 67% and 92% of runners were satisfied with their neutral/cushioned or minimalist running shoes, respectively (RR 0.73, 95% CI 0.47 to 1.12). Another trial reported mean satisfaction scores ranged from 4.0 to 4.3 in the neutral/ cushioned group and 3.6 to 3.9 in the minimalist running shoe group out of a total of 5. Hence neutral/cushioned running shoes may make little or no difference to runner satisfaction with footwear (low-certainty evidence). Motion control versus neutral / cushioned (2 studies, 421 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral / cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.92, 95% CI 0.30 to 2.81). Soft midsole versus hard midsole (2 studies, 1095 participants) Soft midsole shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with hard midsole shoes (low-certainty of evidence) (RR 0.82, 95% CI 0.61 to 1.10). Stability versus neutral / cushioned (1 study, 57 participants) It is uncertain whether or not stability shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral/cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.49, 95% CI 0.18 to 1.31). Motion control versus stability (1 study, 56 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with stability shoes because the quality of the evidence has been assessed as very low certainty (RR 3.47, 95% CI 1.43 to 8.40). Running shoes prescribed and selected on foot posture (3 studies, 7203 participants) There was no evidence that running shoes prescribed based on static foot posture reduced the number of injuries compared with those who received a shoe not prescribed based on foot posture in military recruits (Rate Ratio 1.03, 95% CI 0.94 to 1.13). Subgroup analysis confirmed these findings were consistent between males and females. Therefore, prescribing running shoes and selecting on foot posture probably makes little or no difference to lower-limb running injuries (moderate-certainty evidence). Data were not available for all other review outcomes. AUTHORS' CONCLUSIONS: Most evidence demonstrates no reduction in lower-limb running injuries in adults when comparing different types of running shoes. Overall, the certainty of the evidence determining whether different types of running shoes influence running injury rates was very low to low, and as such we are uncertain as to the true effects of different types of running shoes upon injury rates. There is no evidence that prescribing footwear based on foot type reduces running-related lower-limb injures in adults. The evidence for this comparison was rated as moderate and as such we can have more certainty when interpreting these findings. However, all three trials included in this comparison used military populations and as such the findings may differ in recreational runners.  Future researchers should develop a consensus definition of running shoe design to help standardise classification. The definition of a running injury should also be used consistently and confirmed via health practitioners. More researchers should consider a RCT design to increase the evidence in this area. Lastly, future work should look to explore the influence of different types or running shoes upon injury rates in specific subgroups.

The Landing Error Scoring System (LESS) and Lower Limb Power Profiles in Elite Rugby Union Players.

BACKGROUND: The Landing Error Scoring System (LESS) is a clinical test that assesses landing biomechanics during a drop-jump task. Performance measures such as jump height, power, contact time and reactive strength index are used commonly in athletic populations. Comparing results from the LESS against these performance measures has not been reported in elite rugby union. PURPOSE: To report i.) normative LESS scores for elite rugby union players ii.) correlations between LESS scores and performance measures and iii.) differences in performance measures between LESS scoring groups. A secondary purpose was to report the intra- and inter-rater reliability of the LESS test when used in elite rugby union players. # Study DesignCross-sectional design. METHODS: Thirty-six male, elite rugby union players participated. Each participant completed three trials of the LESS and performance measures were recorded concurrently using the OptojumpTM. LESS trials were scored independently by the authors. Statistical analyses were used to confirm reliability, data normality, and between group differences (p<0.05). RESULTS: The LESS test is a reliable testing tool in elite rugby union players (excellent intra- (ICC=0.96) and inter-rater (ICC=0.94) reliability). One player demonstrated an excellent LESS score, six players had good scores, eight players moderate scores and the majority of the group, 21 players, scored poorly. LESS scores were correlated to contact time (r = -0.461, p = 0.005) only. Participants with moderate to poor LESS scores (a score ≤5) produced greater power (p=0.036, η2 = 0.139), contact time (p=0.002, η2 = 0.268) and reactive strength index (p=0.016, η2 = 0.180). There were no differences in jump height (p=0.842) between players scoring excellent to good and moderate to poor. CONCLUSION: The results of the current study demonstrate excellent intra- and inter-rater reliability for the LESS, supporting its use as a clinical assessment tool in elite rugby union players. The majority of players presented with moderate to poor LESS scores, indicating an area of concern in this population. Participants scoring moderate to poor in the LESS recorded significantly higher power and reactive strength index, increased contact time but not jump height. This suggests participants with high-risk landing biomechanics may also produce higher performance measures, but these do not necessarily result in an improved jump height.

Screening Tools as a Predictor of Injury in Gymnastics: Systematic Literature Review.

BACKGROUND: Gymnastics requires a high level of physical ability and technical skill which utilises short sets of athleticism and artistry to perform complex and intense movements which can overload musculoskeletal tissues and result in acute injuries which can develop into chronic injuries. The aim of this systematic literature review was to investigate which screening tools predict injury in gymnasts and encompasses all genres, levels and ages. METHODS: An electronic search of seven databases from their inception until March 2021 was conducted. The databases were the Allied and Complementary Medicine Database, CINAHL, eBook Collection (EBSCOhost), MEDLINE, Cochrane Database of Systematic Reviews, SPORTDiscus and PEDro (the Physiotherapy Evidence Base). A combination of the following search terms was used: (1) Gymnastics AND injury AND Screening, (2) Screening AND Gymnastics and (3) Musculoskeletal AND Screening AND Gymnastics. These terms were searched in all text, abstract, title and subject terms. Studies were assessed using a 20-point scoring tool. RESULTS: The mean methodological quality score was 13.1 points (range 10-17 points). Range of motion, anthropometric and postural measurements, hypermobility, clinical diagnostic tests, movement screening tools, muscle strength, power and endurance were reported in the included studies. Some evidence existed for screening measurement of height and mass as taller and heavier gymnasts might be more susceptible to injury; however, the different methodologies utilised and lack of acknowledgment of confounding variables limit the clinical relevance of these findings. CONCLUSIONS: Height and mass should be recorded during the screening process. A lack of heterogeneity in study methodology prevented a meta-analysis. Studies were limited by a lack of prospective injury design, poor injury definition, self-reporting of injury and only 2 studies reported reliability of screening tools. Further research is required to determine the role of injury screening in gymnastics. Registration: The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42020218339.

Fear-related barriers to physical activity among adults with overweight and obesity: A narrative synthesis scoping review.

Physical activity is a health behavior contributing to successful weight management. Adults with overweight and obesity find it challenging to meet recommended activity guidelines because of a range of barriers, some of which are not yet fully understood. A barrier receiving limited consideration, compared with other literature within this field, is that of fear. The purpose of this scoping review was to establish the extent of literature on fear-related barriers to physical activity in adults with overweight or obesity and to identify gaps in this literature. The review followed the scoping review framework outlined by Arksey and O'Malley and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. The findings of the identified papers were charted thematically using a framework of fears and age group. In total, 34 studies were included that identified nine different fears related to barriers to activity in this population. However, only a small number of studies (n = 5) had explicitly intended to explore fear-related barriers. There were notable knowledge gaps including activity-related fear of pain and movement in adults under 45 years of age. There is a strong rationale to further explore these fears because they may restrict health promoting behavior.

Validation and utilisation of a digital version of the survey instrument for natural history, Aetiology and Prevalence of Patellofemoral pain studies (eSNAPPS).

OBJECTIVE: This study validated the newly adapted electronic SNAPPS (eSNAPPS) against the original paper SNAPPS. Subsequently, the study estimated the prevalence of PFP in running participants and spectators attending three mass-participant running events in the United Kingdom by using the eSNAPPS tool. DESIGN: This study had two parts. Firstly, a validation of the original paper version of the SNAPPS tool. Secondly, if validation was achieved, eSNAPPS was used in a prevalence study. PARTICIPANTS: A convenience sample of running participants and spectators aged 18-40 years attending the mass participation running events. MAIN OUTCOME MEASURE: The 12-month prevalence of PFP. RESULTS: eSNAPPS was valid in identifying those with PFP (ICC 0.99 for Overall agreement, p < 0.0001). In the prevalence study, a total of 1080 running participants and spectators completed the eSNAPPS. The overall prevalence of PFP was 17.4% (95%CI: 15.2%, 19.8%); 20.5% of males (16.5, 24.9) and 15.7% of females (13.1, 18.7) had PFP. Prevalence was 17.4% (15.2, 19.8) in spectators and 16.7% in running participants (14.5, 19.0). CONCLUSION: The overall PFP prevalence in this study was slightly smaller than those previously reported in the literature. Findings also show that there were similar prevalence estimates in spectators and running participants.

The Efficacy of Lower-Limb Screening Tests in Predicting PlayerLoad Within a Professional Soccer Academy.

CONTEXT: Training exposure has been associated with injury epidemiology in elite youth soccer, where lower-limb musculoskeletal screening is commonly used to highlight injury risk. However, there has been little consideration of the relationship between lower-limb screening and the loading response to soccer activities. OBJECTIVE: To quantify the efficacy of using screening tests to predict the loading elicited in soccer-specific activities and to develop a hierarchical ordering of musculoskeletal screening tests to identify test redundancy and inform practice. DESIGN: Correlational. SETTING: Professional soccer club academy. PARTICIPANTS: A total of 21 elite male soccer players aged 15.7 (0.9) years. INTERVENTION: Players completed a battery of 5 screening tests (knee to wall, hip internal rotation, adductor squeeze, single-leg hop, and anterior reach) and a 25-minute standardized soccer session with a Global Positioning System unit placed at C7 to collect multiplanar PlayerLoad data. MAIN OUTCOME MEASURES: Baseline data on each screening test, along with uniaxial PlayerLoad in the mediolateral, anteroposterior, and vertical planes. RESULTS: Stepwise hierarchical modeling of the screening tests revealed that dominant leg knee-to-wall distance was the most prevalent and powerful predictor of multiplanar PlayerLoad, accounting for up to 42% of variation in uniaxial loading. The adductor squeeze test was the least powerful predictor of PlayerLoad. Of note, one player who incurred a knee injury within 3 weeks of testing had shown a 20% reduction in knee-to-wall distance compared with peers, and elicited 23% greater PlayerLoad, supporting the hierarchical model. CONCLUSIONS: There was some evidence of redundancy in the screening battery, with implications for clinical choice. Hierarchical ordering and a concurrent case study highlight dominant leg knee-to-wall distance as the primary predictor of multiaxial loading in soccer. This has implications for the design and interpretation of screening data in elite youth soccer.

Screening Tools as a Predictor of Injury in Dance: Systematic Literature Review and Meta-analysis.

BACKGROUND: Dance involves movements of complexity and physical intensity which result in stress on the body. As a consequence, dancers are at risk of injury which can impact on their well-being. Screening tools are used for injury prevention to identify those dancers at risk of injury. The aim of this study was to investigate which screening tools can predict injury in dancers, encompassing all dance genres, levels and ages. METHODS: An electronic search of seven databases from their inception to December 2017 was conducted. The databases were the Allied and Complementary Medicine Database (AMED), CINAHL, eBOOK Collection (EBSCOhost), MEDLINE, Cochrane Database of Systematic Reviews, SPORTDiscus and PEDro: the Physiotherapy Evidence Base. The following search terms were used: (i) Dance AND injury AND Screening, (ii) Screening AND dance and (iii) Musculoskeletal AND Screening AND Dance. Studies were assessed using a 20-point scoring tool, and eligible studies were included in a meta-analysis. RESULTS: The mean methodological quality score was 12.2 points. Injured dancers had a significantly higher compensated turnout range of motion than non-injured dancers: pooled mean difference of compensated turnout (23.29°; 95% CI 14.85-31.73; P < 0.00001; I2 = 0%). Injured dancers had significantly greater functional turnout range of motion when compared to non-injured dancers: pooled mean difference of functional turnout (14.08°; 95% CI 7.09-21.07; P < 0.0001; I2 = 0%). There also some evidence for use of hip range of motion as a predictor of dance injury. CONCLUSIONS: Some evidence exists for the potential use of dance-specific positions as a predictor of injury. A number of studies were limited by a lack of prospective injury design, injury definition and self-reporting of injury.

Macrolide antibiotics for bronchiectasis.

BACKGROUND: Bronchiectasis is a chronic respiratory disease characterised by abnormal and irreversible dilatation and distortion of the smaller airways. Bacterial colonisation of the damaged airways leads to chronic cough and sputum production, often with breathlessness and further structural damage to the airways. Long-term macrolide antibiotic therapy may suppress bacterial infection and reduce inflammation, leading to fewer exacerbations, fewer symptoms, improved lung function, and improved quality of life. Further evidence is required on the efficacy of macrolides in terms of specific bacterial eradication and the extent of antibiotic resistance. OBJECTIVES: To determine the impact of macrolide antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS: We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted all searches on 18 January 2018. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of at least four weeks' duration that compared macrolide antibiotics with placebo or no intervention for the long-term management of stable bronchiectasis in adults or children with a diagnosis of bronchiectasis by bronchography, plain film chest radiograph, or high-resolution computed tomography. We excluded studies in which participants had received continuous or high-dose antibiotics immediately before enrolment or before a diagnosis of cystic fibrosis, sarcoidosis, or allergic bronchopulmonary aspergillosis. Our primary outcomes were exacerbation, hospitalisation, and serious adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of 103 records. We independently screened the full text of 40 study reports and included 15 trials from 30 reports. Two review authors independently extracted outcome data and assessed risk of bias for each study. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MDs) or standardised mean differences (SMDs). We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: We included 14 parallel-group RCTs and one cross-over RCT with interventions lasting from 8 weeks to 24 months. Of 11 adult studies with 690 participants, six used azithromycin, four roxithromycin, and one erythromycin. Four studies with 190 children used either azithromycin, clarithromycin, erythromycin, or roxithromycin.We included nine adult studies in our comparison between macrolides and placebo and two in our comparison with no intervention. We included one study with children in our comparison between macrolides and placebo and one in our comparison with no intervention.In adults, macrolides reduced exacerbation frequency to a greater extent than placebo (OR 0.34, 95% confidence interval (CI) 0.22 to 0.54; 341 participants; three studies; I2 = 65%; moderate-quality evidence). This translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 8). Data show no differences in exacerbation frequency between use of macrolides (OR 0.31, 95% CI 0.08 to 1.15; 43 participants; one study; moderate-quality evidence) and no intervention. Macrolides were also associated with a significantly better quality of life compared with placebo (MD -8.90, 95% CI -13.13 to -4.67; 68 participants; one study; moderate-quality evidence). We found no evidence of a reduction in hospitalisations (OR 0.56, 95% CI 0.19 to 1.62; 151 participants; two studies; I2 = 0%; low-quality evidence), in the number of participants with serious adverse events, including pneumonia, respiratory and non-respiratory infections, haemoptysis, and gastroenteritis (OR 0.49, 95% CI 0.20 to 1.23; 326 participants; three studies; I2 = 0%; low-quality evidence), or in the number experiencing adverse events (OR 0.83, 95% CI 0.51 to 1.35; 435 participants; five studies; I2 = 28%) in adults with macrolides compared with placebo.In children, there were no differences in exacerbation frequency (OR 0.40, 95% CI 0.11 to 1.41; 89 children; one study; low-quality evidence); hospitalisations (OR 0.28, 95% CI 0.07 to 1.11; 89 children; one study; low-quality evidence), serious adverse events, defined within the study as exacerbations of bronchiectasis or investigations related to bronchiectasis (OR 0.43, 95% CI 0.17 to 1.05; 89 children; one study; low-quality evidence), or adverse events (OR 0.78, 95% CI 0.33 to 1.83; 89 children; one study), in those receiving macrolides compared to placebo. The same study reported an increase in macrolide-resistant bacteria (OR 7.13, 95% CI 2.13 to 23.79; 89 children; one study), an increase in resistance to Streptococcus pneumoniae (OR 13.20, 95% CI 1.61 to 108.19; 89 children; one study), and an increase in resistance to Staphylococcus aureus (OR 4.16, 95% CI 1.06 to 16.32; 89 children; one study) with macrolides compared with placebo. Quality of life was not reported in the studies with children. AUTHORS' CONCLUSIONS: Long-term macrolide therapy may reduce the frequency of exacerbations and improve quality of life, although supporting evidence is derived mainly from studies of azithromycin, rather than other macrolides, and predominantly among adults rather than children. However, macrolides should be used with caution, as limited data indicate an associated increase in microbial resistance. Macrolides are associated with increased risk of cardiovascular death and other serious adverse events in other populations, and available data cannot exclude a similar risk among patients with bronchiectasis.

Knee joint position sense ability in elite athletes who have returned to international level play following ACL reconstruction: A cross-sectional study.

BACKGROUND: Following an ACL injury, reconstruction (ACL-R) and rehabilitation, athletes may return to play with a proprioceptive deficit. However, literature is lacking to support this hypothesis in elite athletic groups who have returned to international levels of performance. It is possible the potentially heightened proprioceptive ability evidenced in athletes may negate a deficit following injury. The purpose of this study was to consider the effects of ACL injury, reconstruction and rehabilitation on knee joint position sense (JPS) on a group of elite athletes who had returned to international performance. METHODS: Using a cross-sectional design ten elite athletes with ACL-R and ten controls were evaluated. JPS was tested into knee extension and flexion using absolute error scores. Average data with 95% confidence intervals between the reconstructed, contralateral and uninjured control knees were analyzed using t-tests and effect sizes. RESULTS: The reconstructed knee of the injured group demonstrated significantly greater angle of error scores when compared to the contralateral and uninjured control into knee flexion (p=0.0001, r=0.98) and knee extension (p=0.0001, r=0.91). There were no significant differences between the contralateral uninjured knee of the injured group and the uninjured control group. CONCLUSIONS: Elite athletes who have had an ACL injury, reconstruction, rehabilitation and returned to international play demonstrate lower JPS ability compared to control groups. It is unclear if this deficiency affects long-term performance or secondary injury and re-injury problems. In the future physical therapists should monitor athletes longitudinally when they return to play.

THE EFFECT OF CONSERVATIVELY TREATED ACL INJURY ON KNEE JOINT POSITION Sense.

BACKGROUND: Proprioception is critical for effective movement patterns. However, methods of proprioceptive measurement in previous research have been inconsistent and lacking in reliability statistics making it applications to clinical practice difficult. Researchers have suggested that damage to the anterior cruciate ligament (ACL) can alter proprioceptive ability due to a loss of functioning mechanoreceptors. The majority of patients opt for reconstructive surgery following this injury. However, some patients chose conservative rehabilitation options rather than surgical intervention. PURPOSE: The purpose of this study was to determine the effect of ACL deficiency on knee joint position sense following conservative, non-operative treatment and return to physical activity. A secondary purpose was to report the reliability and measurement error of the technique used to measure joint position sense, (JPS) and comment on the clinical utility of this measurement. STUDY DESIGN: Observational study design using a cross-section of ACL deficient patients and matched uninjured controls. METHODS: Twenty active conservatively treated ACL deficient patients who had returned to physical activity and twenty active matched controls were included in the study. Knee joint position sense was measured using a seated passive-active reproductive angle technique. The average absolute angle of error score, between 10 °-30 ° of knee flexion was determined. This error score was derived from the difference between the target and repositioning angle. RESULTS: The ACL deficient patients had a greater error score (7.9 °±3.6) and hence poorer static proprioception ability that both the contra-lateral leg (2.0 °±1.6; p = 0.0001) and the control group (2.6 °±0.9; p = 0.0001). The standard error of the mean (SEM) of this JPS technique was 0.5 ° and 0.2 ° and the minimum detectable change (MDC) was 1.3 ° and 0.4 ° on asymptomatic and symptomatic subjects respectively. CONCLUSION: This study confirms a static proprioceptive deficiency exists in the knee joint following ACL injury and rehabilitation, potentially due to a reduction in functioning mechanoreceptors in the ligament over time. The differences between the ACL deficient knee and the control group were above the SEMs and MDCs of the measurement which suggests clinical relevance. Longitudinal studies are needed to evaluate if patients who return to activity with a joint position sense deficiency develop secondary injuries. LEVELS OF EVIDENCE: Individual Cohort Study (2b).

The effects of knee direction, physical activity and age on knee joint position sense.

BACKGROUND: Previous research has suggested a decline in knee proprioception with age. Furthermore, regular participation in physical activity may improve proprioceptive ability. However, there is no large scale data on uninjured populations to confirm these theories. The aim of this study was to provide normative knee joint position data (JPS) from healthy participants aged 18-82years to evaluate the effects of age, physical activity and knee direction. METHODS: A sample of 116 participants across five age groups was used. The main outcome measures were knee JPS absolute error scores into flexion and extension, Tegner activity levels and General Practitioner Physical Activity Questionnaire results. RESULTS: Absolute error scores in to knee flexion were 3.6°, 3.9°, 3.5°, 3.7° and 3.1° and knee extension were 2.7°, 2.5°, 2.9°, 3.4° and 3.9° for ages 15-29, 30-44, 45-59, 60-74 and 75 years old respectively. Knee extension and flexion absolute error scores were significantly different when age group data were pooled. There was a significant effect of age and activity level on joint position sense into knee extension. Age and lower Tegner scores were also negatively correlated to joint position sense into knee extension. CONCLUSIONS: The results provide some evidence for a decline in knee joint position sense with age. Further, active populations may have heightened static proprioception compared to inactive groups. Normative knee joint position sense data is provided and may be used by practitioners to identify patients with reduced proprioceptive ability.

Criterion-related validity of knee joint-position-sense measurement using image capture and isokinetic dynamometry.

CONTEXT: Clinicians require portable, valid, and cost-effective methods to monitor knee joint-position-sense (JPS) ability. OBJECTIVE: To examine the criterion-related validity of image-capture JPS measures against an isokinetic-dynamometer (IKD) procedure. DESIGN: Random crossover design providing a comparison of knee JPS measures from image capture and IKD procedures. PARTICIPANTS: 10 healthy participants, 5 female, age 28.0 ± 13.29 y, mass 60.3 ± 9.02 kg, height 1.65 ± 0.07 m, and 5 male, 29.6 ± 10.74 y, mass 73.6 ± 5.86 kg, height 1.75 ± 0.07 m. MAIN OUTCOME MEASURES: The dependent variables were absolute error scores (AES) provided by 2 knee directions (flexion and extension). The independent variables were the method (image capture and IKD). RESULTS: There was no significant difference between clinical and IKD AES into knee-flexion data (P = .263, r = 0.55). There was a significant difference between clinical and IKD AES into knee-extension data (P = .016, r = .70). CONCLUSIONS: Analysis of photographic images to assess JPS measurements using knee flexion is valid against an IKD positioning method, but JPS measurements using knee extension may not be valid against IKD techniques. However, photo-analysis measurements provided a lower error score using knee-extension data and thus may provide an optimal environment to produce maximal knee JPS acuity. Therefore, clinicians do not need expensive equipment to collect representative JPS ability.

Interexaminer, intraexaminer and test-retest reliability of clinical knee joint-position-sense measurements using an image-capture technique.

CONTEXT: Knee joint-position sense (JPS) plays a critical role in controlled and stable joint movement. Poor ability to sense position of the knee can therefore increase risk of injury. There is no agreed consensus on JPS measurement techniques and a lack of reliability statistics on methods. OBJECTIVE: To identify the most reliable knee JPS measurement technique using image capture. DESIGN: Interexaminer, intraexaminer, and test-retest reliability of knee JPS measurements. SETTING: Biomechanics laboratory. PARTICIPANTS: 10 asymptomatic participants. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Relative and absolute error scores of knee JPS in 3 conditions (sitting, prone, active) through 3 ranges of movement (10-30°, 30-60°, 60-90°), into 2 directions (flexion and extension) using both legs (dominant and nondominant) collected during 15 trials and repeated 7 d after the first data collection. RESULTS: Statistical analysis by intraclass correlations revealed excellent interexaminer reliability between researchers (.98) and intraexaminer reliability within 1 researcher (.96). Test-retest reliability was highest in the sitting condition from a starting angle of 0°, target angle through 60-90° of flexion, using the dominant leg and absolute-error-score variables (ICC = .92). However, it was noted smallest detectable differences were a high percentage of mean values for all measures. CONCLUSIONS: The most reliable JPS measurement for asymptomatic participants has been identified. Practitioners should use this protocol when collecting JPS data during prescreening sessions. However, generalizability of findings to a class/group of clients exhibiting knee pathologies should be done with caution.