A critical appraisal of web-based information on shoulder pain comparing biomedical vs. psychosocial information.

BACKGROUND: Websites have become a primary way for patients to access health-related information, which allows patients to not only understand their condition better but also to engage in better decision making with their health care provider. However, this can be a double-edged sword, as information patients access may not be of high quality, easily readable, or could be biased based on website authorship. This study examines the readability and content quality of common websites about shoulder pain, with a specific focus on biomedical vs. psychosocial information. METHODS: The Flesch reading-ease score (FRES) and Flesch-Kincaid grade level (FKGL) instruments were used to assess website readability. Health on the net code of conduct (HONcode) certification and the DISCERN tool were used to evaluate the reliability and quality of information. Lastly, shoulder-specific content quality and focus was gauged using a Shoulder-specific Website Appraisal Tool (SWAT) created for this study. A systematic search protocol was used to identify popular shoulder injury websites. The websites were identified using 5 search terms (shoulder pain, shoulder muscle pain, shoulder impingement, shoulder rotator cuff pain, and shoulder pain diagnosis) across 5 English-speaking regions (United States, Canada, United Kingdom, Australia, and New Zealand) using the Google search engine. The top 10 websites for each term and region combination were included and combined, yielding 41 original websites for appraisal; several (6) websites were omitted as duplicates, behind paywalls, or nontext (video) for a total of 35 websites appraised. RESULTS: On average, the FRES shoulder pain websites readability was 55.37, which is categorized as "fairly difficult" to read, and a seventh- or eighth-grade reading level based on the FKGL. For trustworthiness and bias, 57% (20 of 35) of the websites were HONcode certified. The quality of health care information using the DISCERN score averaged 50.92%. Examining shoulder-specific content quality, the average SWAT score was 10.54 out of 14 possible points, with only 1 website reporting information on psychosocial aspects of shoulder pain. CONCLUSIONS: This study suggests that shoulder pain websites present information that is at too high of a reading level for public consumption, has a strong bias toward biomedical causes of shoulder pain, and would benefit from implementation of website screening tools to improve evidence-based content.

Immediate and six-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction on knee kinematics and kinetics: a cross-over laboratory and randomised clinical trial.

BACKGROUND: Elastic knee sleeves are often worn following anterior cruciate ligament reconstruction (ACLR) but their effects on movement patterns are unclear. AIM: To determine the immediate and six-week effects of wearing a knee sleeve on biomechanics of the knee during a step-down hop task. METHODS: Using a cross-over design, we estimated sagittal plane knee kinematics and kinetics and stance duration during a step-down hop for 31 participants (age 26.0 [SD 6.6] years, 15 women) after ACLR (median 16 months post-surgery) with and without wearing a knee sleeve. In a subsequent randomised clinical trial, participants in the 'Sleeve Group' (n = 9) then wore the sleeve for 6 weeks at least 1 h daily, while a 'Control Group' (n = 9) did not wear the sleeve. We used statistical parametric mapping to compare (1) knee flexion/extension angle and external flexion/extension moment trajectories between three conditions at baseline (uninjured side, unsleeved injured side and sleeved injured side); (2) within-participant changes for knee flexion angles and external flexion/extension moment trajectories from baseline to follow-up between groups. We compared discrete flexion angles and moments, and stance duration between conditions and between groups. RESULTS: Without sleeves, knee flexion was lower for the injured than the uninjured sides during mid-stance phase. When wearing the sleeve on the injured side, knee flexion increased during the loading phase of the stance phase. Discrete initial and peak knee flexion angles increased by (mean difference, 95% CIs) 2.7° (1.3, 4.1) and 3.0° (1.2, 4.9), respectively, when wearing the knee sleeve. Knee external flexion moments for the unsleeved injured sides were lower than the uninjured sides for 80% of stance phase, with no change when sleeved. The groups differenced for within-group changes in knee flexion trajectories at follow-up. Knee flexion angles increased for the Control group only. Stance duration decreased by 22% for the Sleeve group from baseline to follow-up (-89 ms; -153, -24) but not for the Controls. CONCLUSIONS: Application of knee sleeves following ACLR is associated with improved knee flexion angles during hop landing training. Longer term (daily) knee sleeve application may help improve hop stance duration, potentially indicating improved hop performance. TRIAL REGISTRATION: The trial was prospectively registered with the Australia New Zealand Clinical Trials Registry No: ACTRN12618001083280, 28/06/2018. ANZCTR.

Sport concussion assessment in New Zealand high school rugby players: a collaborative approach to the challenges faced in primary care.

PRIMARY OBJECTIVE: To describe the collaborative development of a New Zealand Rugby Concussion Assessment (NZRCA) for primary care and to provide normative baseline data from a representative group of high school rugby players. METHODS: This study, conducted over the 2018 and 2019 community rugby season where players were baseline tested during the pre- or start of season period. RESULTS: Data were collected from 1428 players (males n = 1121, females n = 307) with a mean age of 15.9 ± 1.4 years. The mean ± SD symptom severity score was 11.3 ± 8.6, the mean number of endorsed symptoms was 8.5 ± 5.3 and the percentage feeling "normal" was 80.2 ± 15.3%. Only 5.3% of players reported no symptoms at baseline. The most common reported were: 'distracted easily' (72.5%), 'forgetful' (68.5%), and 'often tired' (62.6%). None of the participants achieved a perfect score for the SAC50. The majority of participants (89.7%) passed the tandem gait test with a time of 12.2 ± 1.7 seconds. Age, gender, and ethnicity were associated with NZRCA performance; albeit weakly. CONCLUSION: This study provides normative reference values for high-school rugby players. These data will aid healthcare providers in their identification of suspected concussion in the absence of individualized baselines.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community.

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

Association Between Knee Moments During Stair Navigation and Participant-Related Factors in Individuals With Anterior Cruciate Ligament Reconstruction: A Cross-Sectional Study.

CONTEXT: Altered knee joint mechanics may be related to quadriceps muscle strength, time since surgery, and sex following anterior cruciate ligament reconstruction (ACLR). The aim of this study was to investigate the association between knee moments, with participant-related factors during stair navigation post-ACLR. DESIGN: Cross-sectional study. METHODS: A total of 30 participants (14 women) with ACLR, on average 7.0 (SD 4.4) years postsurgery were tested during stair ascent and descent in a gait laboratory. Motion capture was conducted using a floor-embedded force plate and 11 infrared cameras. Quadriceps concentric and eccentric muscle strength was measured with an isokinetic dynamometer at 60°/s, and peak torques recorded. Multiple regression analyses were performed between external knee flexion and adduction moments, respectively, and quadriceps peak torque, sex, and time since ACLR. RESULTS: Higher concentric quadriceps strength and female sex accounted for 55.7% of the total variance for peak knee flexion moment during stair ascent (P < .001). None of the independent variables accounted for variance in knee adduction moment (P = .698). No significant associations were found for knee flexion and adduction moments during for stair descent. CONCLUSION: Higher quadriceps concentric strength and sex explains major variance in knee flexion moments during stair ascent. The strong association between muscle strength and external knee flexion moments during stair ascent indicate rehabilitation tailored for quadriceps may optimize knee mechanics, particularly for women.

Immediate and 6-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction: a cross-over laboratory and randomised clinical trial.

BACKGROUND: Rehabilitation following anterior cruciate ligament (ACL) reconstructions is based mainly on comprehensive progressive exercise programmes using a multi-dimensional approach. Elastic knee sleeves may be useful adjuncts to rehabilitation. The aim of this study was to determine the immediate and 6-week effects of wearing a knee sleeve on person-reported outcomes and function in participants who had undergone an ACL reconstruction and who had residual self-reported functional limitations. METHODS: Individuals with ACL reconstruction in the previous 6 months to 5 years were recruited. Immediate effects of a commercially-available elastic knee sleeve on single-leg horizontal hop distance were explored using a cross-over design. Following this first session, participants were randomised into a Control Group and a Sleeve Group who wore the sleeve for 6 weeks, at least 1 h daily. Outcome measures for the randomised clinical trial (RCT) were the International Knee Documentation Classification Subjective Knee Form (IKDC-SKF) score, the single-leg horizontal hop distance, and isokinetic quadriceps and hamstring peak torque. Linear mixed models were used to determine random effects. Where both limbs were measured at multiple time points, a random measurement occasion effect nested within participant was used. RESULTS: Thirty-four individuals (16 women) with ACL reconstruction completed the cross-over trial. Hop distance for the injured side during the sleeve condition increased by 3.6 % (95 % CI 0.4-6.8 %, p = 0.025). There was no evidence of differential changes between groups for the IKDC-SKF (Sleeve Group n = 15; Control Group n = 16; p = 0.327), or relative improvement in the injured side compared to the uninjured side for the physical performance measures (Sleeve Group n = 12, Control Group n = 12; three-way interaction p = 0.533 [hop distance], 0.381 [quadriceps isokinetic peak torque], and 0.592 [hamstring isokinetic peak torque]). CONCLUSIONS: Single-leg hop distance of the ACL reconstructed side improved when wearing a knee sleeve. Wearing the knee sleeve over 6 weeks did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group. TRIAL REGISTRATION: The trial was prospectively registered with the Australia New Zealand Clinical Trials Registry No: ACTRN12618001083280 , 28 June 2018.

Baseline concussion assessment performance of community-based senior rugby players: a cross-sectional study.

OBJECTIVE: To report pre-season baseline concussion assessment performance among senior rugby players and explore associations between assessment performance and player demographics. DESIGN: A cross-sectional study using the New Zealand Rugby Concussion Assessments (NZRCA), comprising symptom, cognitive and dynamic coordination assessments was conducted in the 2018-2019 season. METHODS: Players' baseline assessments were characterised using descriptive statistics; effect sizes (ES) and t-tests were used to explore associations between player demographic characteristics and NZRCA performance. RESULTS: A total of 733 players (11.4% female) aged between 16 and 52 years completed the NZRCA. The median (range) value for symptom severity, endorsed symptoms and "percentage normal" was respectively, 5 (0-40), 5 (0-21) and 90% (30-100%). A perfect standardised assessment of concussion score was achieved by one participant; seven achieved ≥27/30 for immediate recall, and 22 achieved a perfect delayed recall score. Most participants (n = 674, 92%) passed the tandem gait test. Associations between NZRCA performance and gender, concussion history, and Pasifika ethnicity were observed with effect sizes ranging from small (0.18) to large (0.70). Six hundred and twenty-three (85%) participants reported at least one symptom. CONCLUSIONS: The results from this study could help support decision-making by clinicians, improving the management of concussions in the community setting.

Between-Day Reliability of Scapular Locator for Measuring Scapular Position During Arm Elevation in Asymptomatic Participants.

OBJECTIVE: The aim of this study was to assess the between-day reliability of the scapular locator for measuring scapular rotations during arm elevation in patients without shoulder pain/conditions/disorders. METHODS: Twenty-three asymptomatic individuals were measured during 2 sessions separated by 24 hours. One observer measured scapular position with a scapular locator while participants held their arms at 30°, 60°, 90°, and 120° elevation in the scapular plane. Three trials were performed for each arm position. RESULTS: At 30°, between-day intraclass correlation coefficients (ICCs) for all scapular rotations were poor (ICC 0.10-0.40). At higher arm elevations (60°, 90°, and 120°), ICCs ranged from 0.73 to 0.93 for scapular upward rotation, 0.80 to 0.87 for posterior tilt, and 0.37 to 0.62 for scapular internal rotation. For all scapular rotations, the standard error of measurement was less than 6°, and the smallest detectable difference ranged from 11° to 18°. CONCLUSION: The findings indicate good to excellent reliability for measuring scapular upward/downward rotation and anterior/posterior tilt between 60° and 120° of shoulder elevation in the scapular plane. However, low reliability was found for all scapular rotations at 30° elevation, and for scapular internal rotation at higher arm elevation.

Maximizing Participation During Walking in Children With Disabilities: Is Response to Unpredictability Important?

Walking ability is one of the primary components of human motor function, and interventions aimed at improving walking ability are common in physical therapy, particularly in children. One element encountered in a participatory, or natural, environment is unpredictability, defined as the presence of an unexpected obstacle, stimulus, or alteration of the environmental conditions. Little research has assessed the influence of unpredictability on biomechanical adaptations to walking in children who are developing typically or children with motor disabilities. A variety of impairments may result in an inadequate response to unpredictability, and we propose that there may be a relationship between response to an unpredictable visual cue and mobility-based participation.

Shoulder muscle activity during the modified dynamic relocation test and side-lying shoulder external rotation: a cross-sectional study on asymptomatic individuals.

OBJECTIVES: (1) to compare activity levels between monitored muscles during the dynamic relocation test (DRT); (2) to assess changes in muscle activation variability over 10 trials; (3) to assess within-muscle difference activity levels between the DRT and the unloaded side-lying shoulder external rotation exercise. METHODS: This is a cross-sectional, laboratory-based, repeated measures study. Thirty asymptomatic individuals performed the DRT and unloaded side-lying external rotation. The order of exercises was randomized. Superficial electromyography was used for recording the supraspinatus, infraspinatus, middle deltoid, posterior deltoid, pectoralis major, and latissimus dorsi muscles. The main outcome measures were mean muscle activity, expressed as % of maximal isometric voluntary contraction. RESULTS: We found significant between-muscles differences in activity (Ft = 14.11, p < 0.001) during the DRT. Post hoc analysis suggested between-trial variability did not change over the 10 trials, (F = 18.2, p < 0.001). Within-muscle comparisons between the DRT and side-lying shoulder external rotation suggested significant differences between these exercises (F = 32.37, p < 0.001). CONCLUSIONS: considering the monitored muscles, supraspinatus, infraspinatus, pectoralis major, and latissimus dorsi are the main muscles contracting during the DRT. Of all monitored muscles, supraspinatus muscle was the only one presenting higher activity levels during the DRT when compared to the unloaded side-lying shoulder external rotation.

The "glass shoulder": Patients' lived experiences of a traumatic shoulder dislocation - A qualitative study.

BACKGROUND: Anterior shoulder dislocations have a high recurrence rate, often necessitating stabilizing surgery, with residual long-term fear of reinjury. OBJECTIVES: To explore patients' experiences of anterior shoulder dislocations in relation to their lives, well-being, fear of reinjury, and future perspectives. DESIGN: Qualitative study. METHODS: We interviewed fourteen individuals (median age 27.5 yrs, range 21-40; two women) with traumatic anterior glenohumeral dislocation within 5 years, with or without past stabilizing surgery. We analysed data using Interpretive Description. RESULTS: We constructed three main themes. (1) Downward wellness spiral: The injury shattered their lives, influencing their self-identity and -confidence. Sleep disturbances added to stress levels, loss, depression and grief. The re-injury risk could lead to social isolation. (2) Out of arm's reach: Recurrences led to frustration as the prior surgery and rehabilitation appeared to have been unsuccessful, having to start again. Support from healthcare providers and whanau/family was crucial to regain trust in the body. (3) Obligatory compromise: Over time, some individuals accepted the re-injury risk, learnt to heed warning signals, or compromised by avoiding specific social and recreational activities, changing their sports or to other roles in their preferred sport, and adapting work-related and daily tasks. CONCLUSION: Participants described in-depth socio-emotional responses following shoulder dislocations. Most participants described an ongoing interplay between fear and confidence in their shoulder. Healthcare provider support and professional relationship, on-going shoulder-related strengthening, and risk mitigation strategies were important to facilitate and maintain confidence and self-efficacy, and to re-consider and adjust the participant's goals when needed.

Strategies for knee stabilising and pivot-shift avoidance in a step-down and cross-over task observed sub-acutely after anterior cruciate ligament reconstruction.

BACKGROUND: Individuals with a recent anterior cruciate ligament reconstruction may demonstrate an altered movement strategy for protecting the knee and maintaining stability. Altered knee movement might lead to abnormal intra-articular load, potentially contributing to early knee osteoarthritis onset. A protective strategy may be particularly evident during active tasks that induce a pivot-shift manoeuvre, such as a step-down and cross-over task. In this study, we investigated whether knee joint mechanics and muscle activity differed between participants early (∼3 months) following reconstruction (n = 35) to uninjured controls (n = 35) during a step-down and cross-over task with a 45° change-of-direction. METHODS: We used motion capture, force plates and surface electromyography to compare time-normalised curves of sagittal and transverse-plane knee mechanics and muscle activity during the cross-over phase between groups using functional t-tests. We also compared knee mechanics between sides within the injured group and compared discrete outcomes describing the cross-over phase between groups. FINDINGS: Compared to controls, the injured participants had greater knee flexion angle and moment, lower internal rotation moment, more preparatory foot rotation of the pivoting leg, a smaller cross-over angle, and a longer cross-over phase for both the injured and uninjured sides. The injured leg also had greater biceps femoris and vastus medialis muscle activity compared to controls and different knee mechanics than the uninjured leg. INTERPRETATION: Individuals with anterior cruciate ligament reconstruction showed a knee-stabilising and pivot-shift avoidance strategy for both legs early in rehabilitation. These results may reflect an altered motor representation and motivate considerations early in rehabilitation.

Unintended consequences - A qualitative exploration of baseline testing in community rugby concussion management.

OBJECTIVES: Understanding key stakeholders' perceptions around the value of baseline testing, as well as barriers or facilitators experienced as part of the process, may assist with the decision-making process of whether to implement baseline testing in community sport. This study explored coaches', players' and physiotherapists' perceptions of the perceived value, barriers and facilitators of baseline testing as part of New Zealand Rugby's (NZR) community concussion initiative. DESIGN: The study employed a pragmatic, qualitative descriptive design. METHODS: Semi-structured interviews were used to explore participants' perceptions. In total, 73 individual interviews were conducted. The sample consisted of 36 players, 13 coaches and 24 physiotherapists involved in NZR's concussion management pathway. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. RESULTS: In terms of perceived value, baseline testing was reported to play a role in i) facilitating a positive concussion culture; ii) positive perceptions of rugby and player safety and iii) enhancing concussion management as part of the pathway. Barriers and facilitators of the baseline testing process included i) stakeholder buy-in as critical driver of the process and ii) contextual and operational factors. Although contextual and operational challenges exist, these participants, as key stakeholders in the process, perceived the value of baseline testing to be more important than the barriers experienced. CONCLUSIONS: The value of baseline testing extends beyond concussion assessment and management, by enhancing community concussion awareness, attitudes and player safety. The findings of this study may assist in the decision-making process around inclusion of pre-season baseline testing in community rugby.

Validity and reliability of the Spineangel lumbo-pelvic postural monitor.

OBJECTIVE: to determine the reliability and the concurrent validity of the Spineangel lumbo-pelvic postural monitoring device. METHODS: the dynamic lumbo-pelvic posture of 25 participants was simultaneously monitored by the Spineangel and Fastrak devices. Participants performed six different functional tasks in random order. Within-task, within-session and between-day intraclass correlation coefficients (ICC(3,1), ICC(3,5), ICC(2,5), respectively) reliability were calculated for Spineangel measurements. Concurrent validity of the Spineangel was assessed by means of a Bland and Altman plot and by means of Pearson's correlation coefficient and paired t-test. RESULTS: within-task, within-session and between-day ICC for the Spineangel were found to be excellent (>0.93). The Spineangel and Fastrak pelvic measurements were found to have a good correlation (R = 0.77). CONCLUSION: the Spineangel is a reliable and valid device for monitoring general lumbo-pelvic movements when clipped on the belt or waistband of workers' clothing during various occupational activities. PRACTITIONER SUMMARY: The Spineangel can be used for assessing lumbo-pelvic posture during work or daily-life activities. This device was found to provide reliable and valid measurements for lumbo-pelvic movements. Further research is required to determine whether the use of this device is clinically relevant for patients presenting with low back pain.

Physiotherapists' attitudes and beliefs about self-management as part of their management for low back pain.

BACKGROUND: Perceptually, there is a discrepancy between research evidence and clinical physiotherapy practice for supporting self-management in people with low back pain (LBP). OBJECTIVE: This study aimed to explore physiotherapists' understanding of LBP; ascertain their knowledge of self-management concepts; and explore their attitudes and beliefs about supporting self-management for LBP within present physiotherapy practice in private and hospital settings. DESIGN: Interpretive Description qualitative methodology, involving in-depth data interpretation to clinical practice, was used. METHODS: Semi-structured interviews with physiotherapists throughout New Zealand were conducted via video conferencing. Data was analysed and themes were defined. RESULTS: Seventeen physiotherapists (24-65 years old), with between one and 40+ years of experience, participated. Four main themes were defined: 1) Evolving understanding of LBP, 2) apportioning responsibility, 3) self-management is important, 4) understanding self-management. CONCLUSION: Novel findings from this research demonstrate examples of attitudes and beliefs that determine when and how self-management for people with LBP is implemented. Due to these attitudes and beliefs, physiotherapists may not consistently provide supported self-management for people with LBP. Participants had good understanding of LBP but lacked a contemporary knowledge of the natural history and tended to apportion responsibility for persistent or recurrent episodes to the person with LBP. Physiotherapists should be encouraged to assimilate more contemporary research evidence into their expectations of recovery for LBP. Further education about the role of physiotherapists in supporting self-management, the core components of self-management, including engagement, and reflection upon individual unconscious bias should be encouraged.

Test-Retest Reliability of a Passive Joint Position Sense Test After ACL Reconstruction: Influence of Direction, Target Angle, Limb, and Outcome Measures.

Background: The joint position sense (JPS) is an element of proprioception and defined as an individual's ability to recognize joint position in space. The JPS is assessed by measuring the acuity of reproducing a predetermined target angle. The quality of psychometric properties of knee JPS tests after anterior cruciate ligament reconstruction (ACLR) is uncertain. Purpose/Hypothesis: The purpose of this study was to evaluate the test-retest reliability of a passive knee JPS test in patients who underwent ACLR. We hypothesized that the passive JPS test would produce reliable absolute error, constant error, and variable error estimates after ACLR. Study Design: Descriptive laboratory study. Methods: Nineteen male participants (mean age, 26.3 ± 4.4 years) who had undergone unilateral ACLR within the previous 12 months completed 2 sessions of bilateral passive knee JPS evaluation. JPS testing was conducted in both the flexion (starting angle, 0°) and the extension (starting angle, 90°) directions in the sitting position. The absolute error, constant error, and variable error of the JPS test in both directions were calculated at 2 target angles (30° and 60° of flexion) by using the angle reproduction method for the ipsilateral knee. The standard error of measurement (SEM), smallest real difference (SRD), and intraclass correlation coefficients (ICCs) with 95% Cis were calculated. Results: ICCs were higher for the JPS constant error (operated and nonoperated knee, 0.43-0.86 and 0.32-0.91, respectively) compared with the absolute error (0.18-0.59 and 0.09-0.86, respectively) and the variable error (0.07-0.63 and 0.09-0.73, respectively). The constant error of the 90°-60° extension test showed moderate to excellent reliability for the operated knee (ICC, 0.86 [95% CI, 0.64-0.94]; SEM, 1.63°; SRD, 4.53°), and good to excellent reliability for the nonoperated knee (ICC, 0.91 [95% CI, 0.76-0.96]; SEM, 1.53°; SRD, 4.24°). Conclusion: The test-retest reliability of the passive knee JPS tests after ACLR varied depending on the test angle, direction, and outcome measure (absolute error, constant error, or variable error). The constant error appeared to be a more reliable outcome measure than the absolute error and the variable error, mainly during the 90°-60° extension test. Clinical Relevance: As constant errors have been found reliable during the 90°-60° extension test, investigating these errors-in addition to absolute and variable errors-to reflect bias in passive JPS scores after ACLR is warranted.

'Thinking about pain in a different way': Patient perspectives of a neuroscience-informed physiotherapy programme for rotator cuff-related shoulder pain.

BACKGROUND: Rotator cuff-related shoulder pain (RCRSP) is a common musculoskeletal problem. The multi-factorial contributors to persistent pain are often overlooked during treatment. Pain neuroscience education (PNE) contributes to a holistic approach for patients with persistent pain but has not yet been researched for patients with RCRSP. OBJECTIVE: To explore the perspectives and experiences of participants with RCRSP who had completed a programme of PNE-informed pragmatic physiotherapy. DESIGN: A qualitative study using semi-structured interviews. METHODS: We included a sub-group of five males and five females, aged 46-75 years, with persistent RCRSP of at least three months. They had undertaken a three-month pragmatic physiotherapy integrated with PNE. Individual semi-structured interviews were recorded, transcribed verbatim, and analysed using the General Inductive Approach. RESULTS: Four themes emanated from the interviews. The first two themes were named 'Patient Beliefs' and overall 'Rapport and Relationship'. Another theme, 'Perspective and Understanding of the Resources', indicated diverse uptake of the resource information. The participants reported developing self-management skills, active coping strategies and a reduction in fear of pain described by the theme: 'Empowerment: My Shoulder into the Future'. CONCLUSIONS: Participants experienced a change in their beliefs, which were enhanced by an individualised delivery and a strong therapeutic relationship through the course of the physiotherapy care. The participants appeared to value when the physiotherapist listened to and understood their beliefs. This required a shift in the patient-therapist relationship from the physiotherapist being the 'expert' to facilitating the patient's ability to take control of their shoulder health.

The balancing act - Physiotherapists' experiences of managing rugby-related concussion in the community.

BACKGROUND: New Zealand Rugby (NZR) implemented a concussion management pathway (CMP) to improve management at the community level. Physiotherapists play an important role in the CMP. OBJECTIVE: This study explored physiotherapists' experiences in the management of community rugby-related concussion as part of the CMP. METHODS: We adopted a pragmatic, descriptive qualitative approach to explore perceptions of twenty-four physiotherapists involved in the CMP. Thematic analysis was used to analyze data. RESULTS: Four themes represented participants' experiences: 1) 'walking the tight rope between player welfare and performance' described the balancing act between different attitudes and priorities of the various rugby stakeholders; 2) empowering physiotherapists' authority and responsibilities, described the influence of physiotherapists' authority within the team and concussion management responsibilities; 3) multi-directional communication, described the role of communication between multiple stakeholders; and 4) the influence of context, which included the complexity of concussion, concussion knowledge of the physiotherapists and team, resource support for the physiotherapist, and access to a medical doctor. CONCLUSION: Physiotherapists had positive attitudes toward the CMP and are well-positioned to play an active role in the pathway. Priorities of other stakeholders, authority of the physiotherapist and the communication flow influences physiotherapists' ability to optimally manage players with concussion.

Clinicians' perspectives on planned interventions tested in the Otago MASTER feasibility trial: an implementation-based process evaluation study.

OBJECTIVES: This study reports a process evaluation of the Otago MASTER (MAnagement of Subacromial disorders of The shouldER) feasibility trial. This mixed-methods, process evaluation study was conducted parallel to the Otago MASTER feasibility trial. Our aims were to investigate: (1) supervised treatment fidelity of the interventions and (2) clinicians' perceptions of the trial interventions through a focus group. DESIGN: Nested process evaluation study using a mixed-methods approach. SETTING: Outpatient clinic. PARTICIPANTS: Five clinicians (two men, three women) aged 47-67 years, with clinical experience of 18-43 years and a minimum of postgraduate certificate training, were involved with the delivery of interventions within the feasibility trial. We assessed treatment fidelity for supervised exercises through audit of clinicians' records and compared those with the planned protocol. Clinicians took part in a focus group that lasted for approximately 1 hour. The focus group was transcribed verbatim and focus group discussion was analysed thematically using an iterative approach. RESULTS: The fidelity score for the tailored exercise and manual therapy intervention was 80.3% (SD: 7.7%) and for the standardised exercise intervention, 82.9% (SD: 5.9%). Clinicians' perspectives about the trial and planned intervention were summarised by one main theme 'conflict experienced between individual clinical practice and the intervention protocol', which was supported by three subthemes: (1) programme strengths and weaknesses; (2) design-related and administrative barriers; and (3) training-related barriers. CONCLUSION: This mixed-methods study assessed supervised treatment fidelity of interventions and clinicians' perceptions on planned interventions tested in the Otago MASTER feasibility trial. Overall, treatment fidelity was acceptable for both intervention arms; however, we observed low fidelity for certain domains within the tailored exercise and manual therapy intervention. Our focus group identified several barriers clinicians faced while delivering the planned interventions. Those findings are of relevance for planning the definite trial and for researchers conducting feasibility trials. TRIAL REGISTRATION NUMBER: ANZCTR: 12617001405303.

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System.

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders.