Biomechanical Effects of Prophylactic Knee Bracing on Anterior Cruciate Ligament Injury Risk: A Systematic Review.

OBJECTIVE: Prophylactic knee braces (PKBs) are widely used by athletes in pivoting and landing sports and have the potential to influence knee movement and alignment, thus modulating anterior cruciate ligament (ACL) injury risk. This systematic review analyses current evidence on the biomechanical effects that PKBs have in the prevention of ACL injuries. DATA SOURCES: The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were conducted on PubMed, Web of Science, Scopus, Ovid MEDLINE, EMBASE, Cochrane, and CINAHL for studies published from inception until May 31, 2021. Included studies assessed the effects of PKBs on biomechanical variables associated with ACL injuries in landing or pivoting tasks, comparing between braced and unbraced conditions. MAIN RESULTS: A total of 234 articles were identified; from which, 14 controlled, laboratory, biomechanical studies were included in this review. The effects of PKBs on knee biomechanics could be divided into kinematic variables in the coronal, sagittal, and transverse planes; and common kinetic variables, such as ground reaction force (GRF) and ACL load/strain. Also, PKBs were found to have protective effects in coronal and transverse plane kinematics, but results in the sagittal plane were inconclusive. Assessing knee kinetics, PKBs were advantageous in decreasing ACL load/strain but had no significant effect on GRF. CONCLUSIONS: Prophylactic knee braces may serve to reduce ACL injury risk by modulating knee coronal and transverse plane movements and ACL load/strain during high-risk maneuvres. Precise recommendations are limited by study heterogeneity. More prospective studies are needed to assess ACL injury risk during high-risk sports using specific PKBs.

A Systematic Review and Qualitative Analysis of Concussion Knowledge amongst Sports Coaches and Match Officials.

Sport-related concussion (SRC) is a public health issue of increasing concern. Sports coaches and match officials are important stakeholders in facilitating early recognition, immediate management and appropriate return-to-play following SRC. This systematic review analyses the current evidence on SRC knowledge amongst sports coaches and match officials. The review was conducted in accordance to PRISMA guideline. A qualitative analysis of knowledge on identification, management, prevention and consequences of SRC as well as return-to-play principles was performed. The Appraisal Tool for Cross-sectional Studies was employed to assess the quality and reliability of each study. Searches were conducted on PubMed, Medline Ovid, Web of Science, CINAHL, SPORTDiscus and Psycinfo. Studies included were primary studies in English published in peer-reviewed journals assessing the level of concussion knowledge or education level amongst coaches, officials or both, regardless of sports or competitive level. A total of 20880 studies were identified, from which 27 were included in this review. There were 26 cross-sectional studies and one randomized controlled trial; 20 assessed SRC knowledge amongst coaches, one considered only officials and six studies assessed both groups. Concussion knowledge amongst coaches and match officials was deemed moderate in most studies, although significant knowledge gaps were identified. There is considerable room for further education on SRC amongst coaches and officials, particularly with the less commonly recognized symptoms of SRC and misconceptions about SRC management and prevention. Beyond knowledge assessment, further investigation should explore the translation of concussion knowledge to on-field management of players with SRC.

Clinical assessment of antero-medial rotational knee laxity: a systematic review.

PURPOSE: To inventory the examination methods available to assess antero-medial rotational laxity (AMRL) of the knee following medial collateral ligament injury. METHODS: Searches were conducted in accordance with the PRISMA guidelines and using four online databases: WEB OF SCIENCE, MEDLINE, EMBASE, and AMED. The Critical Appraisal Skills Programme guidelines for Diagnostic Test Studies were used for the quality assessment of the articles. RESULTS: A total of 2241 articles were identified from the database searches. From this, four articles were included in the final review. All were case-control studies, considered a combined ACL/MCL injury and had small study populations. Specialised equipment was required in all studies, and one needed additional imaging support before measurements could be taken. Two employed commercially available measuring equipment as part of the assessment process. CONCLUSION: Clinical assessment of AMRL in relation to a MCL injury remains challenging. Although methods have been developed to support clinical examination, they are limited by a number of factors, including the need for additional time in the clinical environment when setting up equipment, the need for specific equipment to produce and measure rotational movement and imaging support. In addition, there are patient safety concerns from the repeated imaging. A reliable and valid clinical examination remains to be found to truly assess antero-medial rotational laxity of the knee. LEVEL OF EVIDENCE: IV.

Consensus statement on Singapore integrated 24-hour activity guide for early childhood.

Introduction: Early childhood is a critical period for growth and development. Adopting healthy lifestyle behaviours during this period forms the foundation for future well-being and offers the best protection against non-communicable diseases. Singapore studies have shown that many young children are not achieving the recommendations on physical activity, sedentary behaviour and sleep. A workgroup was set up to develop recommendations for caregivers of infants, toddlers and preschoolers (aged <7 years) on how to integrate beneficial activities within a daily 24-hour period for optimal development and metabolic health. Method: The Grading of Recommendations Assessment, Development and Evaluation (GRADE)- ADOLOPMENT approach was employed for adoption, adaption or de novo development of recommendations. International and national guidelines were used as references, and an update of the literature reviews up to September 2021 was conducted through an electronic search of PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Results: Four consensus statements were developed for each age group: infants, toddlers and preschoolers. The statements focus on achieving good metabolic health through regular physical activity, limiting sedentary behaviour, achieving adequate sleep and positive eating habits. The 13th consensus statement recognises that integration of these activities within a 24-hour period can help obtain the best results. Conclusion: This set of recommendations guides and encourages caregivers of Singapore infants, toddlers and preschoolers to adopt beneficial lifestyle activities within each 24-hour period.

Can the Boston Carpal Tunnel Syndrome Questionnaire Be Used as a Screening Tool Among a Potentially High-Risk Population in Singapore?

Introduction Carpal tunnel syndrome (CTS) causes significant morbidity with delayed diagnosis or management. The Boston Carpal Tunnel Questionnaire (BCTQ) is validated for monitoring CTS following diagnosis; however, it has not been trialed in a screening capacity. The study aimed to determine whether it can be utilized when screening a focused population in Singapore. Materials and Methods A single-center survey-based study was undertaken prospectively to identify whether positive symptoms could be identified among nursing and administrative staff. Results A total of 605 staff responded. Positive symptoms were identified in 317 (52.4%) of participants and 23 (3.8%) reported them to be severe. Functional limitations were detected in 157 (26.0%) of participants with 5 (0.8%) reporting these as severe. Positive symptoms (84.9%) and functional limitations (81.5%) were more prevalent among nursing staff. Cronbach's α scores (0.896 for symptoms and 0.84 for functional limitations) suggested good reliability in matching symptoms and functional limitations. Conclusion The BCTQ can potentially be implemented as a screening tool for CTS among those without a prior diagnosis. It has a greater depth of questioning with symptomatic and functional limitations considered, and in situations where a formal diagnosis is subsequently made, the same tool can be subsequently used for progression tracking pre- and post-treatment. Level of Evidence This is a Level II study.

Consensus statement on Singapore integrated 24-hour activity guide for children and adolescents.

INTRODUCTION: Lifestyle activities, such as regular physical activity, are important for good metabolic health and the prevention of non-communicable diseases. Epidemiological studies highlight an increase in the proportion of overweight children in Singapore. A workgroup was formed to develop recommendations to encourage children and adolescents (aged 7-17 years) to adopt a holistic approach towards integrating beneficial activities within a daily 24-hour period for good metabolic and general health. METHODS: The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision framework was employed to formulate the public health question, assess the evidence and draw conclusions for the guide. The evidence for international 24-hour movement guidelines, and guidelines for physical activity, sedentary behaviour, and sleep and eating habits were reviewed. An update of the literature review from August 2018 to end of September 2020 was conducted through an electronic search of Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. RESULTS: Ten consensus statements were developed. The statements focused on the overall aim of achieving good metabolic health through integration of these activities and initiatives: light and moderate- to vigorous-intensity physical activity on a regular basis; muscle- and bone-strengthening activities; limiting sedentary behaviour; regular and adequate sleep; good eating habits and choosing nutritionally balanced foods and drinks; practise safety in exercise; and aiming to achieve more or all aforementioned recommendations for the best results. CONCLUSION: This set of recommendations provides guidance to encourage Singapore children and adolescents to adopt health-beneficial activities within a 24-hour period.

Median and ulnar nerve injuries in cyclists: A narrative review.

Cycling is popular internationally as a mode of transport and sport. Cyclists often report sensory and motor changes in the hands during rides. In the past, assessment of these symptoms was based on clinical history, physical examination and neurophysiology. The aim of this narrative review was to evaluate existing publications and determine if there are areas for further improvement in the clinical setting. METHODS: Searches were undertaken in accordance with the PRISMA guidelines using four online databases: PUBMED, OVID, CINAHL and WEB OF SCIENCE. Articles were evaluated using adapted versions of guidelines for case and cohort studies. RESULTS: 2630 articles were found and 13 were included in the review. 2 considered median, 9 considered ulnar and 2 assessed both nerves. 11 were case and 2 were cohort studies. 7 discussed neurophysiology and 1 mentioned ultrasound as a modality of investigation. Interventions were described in 3 articles. CONCLUSION: The quality of evidence is generally low when considering this problem. Clinical assessment and neurophysiology are commonly regarded as the method for assessing nerve symptoms amongst cyclists. Advances in musculoskeletal ultrasound add to our early investigative repertoire and may help expedite management and limit future disability. In addition, further research is required into screening and preventative measures amongst cyclists.

Ultrasound-Guided Lumbar Spine Injection for Axial and Radicular Pain: A Single Institution Early Experience.

STUDY DESIGN: Clinical audit via retrospective review of a database. PURPOSE: To report an early experience using ultrasound-guided lumbar spinal injection for axial and radicular pain in an Asian multiethnic cohort. OVERVIEW OF LITERATURE: Ultrasound-guided spine injection therapy is a comparatively new technique in the management of axial and radicular pain from degenerative lumbar spinal conditions, which may be a reasonable alternative to conventional fluoroscopic or computed tomography-guided injection. METHODS: A retrospective review was conducted, involving all patients who underwent ultrasound-guided lumbar spine injection therapy at a single institution over 1 year. Patients were evaluated by two interventionists, who then performed standardized ultrasound-guided lumbar facet joint and pararadicular spinal injections. RESULTS: There were 42 patients treated at our Sports Medicine Centre; with 27 patients (64.3%) receiving facet joint injections and 18 patients (42.9%) receiving nerve root injections. The majority (90.5%) of patients experienced an improvement of >30% in pain intensity at 3 months post-injection, using the Numerical Rating Scale pain score (p<0.001); with 40 patients (95.2%) reporting a reduction in Oswestry Disability Index score (p<0.001). No complications were reported. CONCLUSIONS: Our initial experience confirms the safety, feasibility, and effectiveness of ultrasound-guided lumbar spinal injection for the treatment of axial and radicular pain in an Asian multiethnic cohort.

Scoping review and international multi-centre cohort study investigating teaching, knowledge and beliefs regarding physical activity as a health intervention among medical students: a comparison between Singapore and the UK.

INTRODUCTION: Physical inactivity is a global challenge and physicians must promote physical activity (PA) among their patients. Nevertheless, PA counselling remains inadequate due to limitations in knowledge, education and information availability. This study evaluates the understanding of PA as a health intervention and knowledge of World Health Organization (WHO) guidelines among Singapore and United Kingdom (UK) medical students, the next generation of physicians. METHODS: Students from Singapore (Yong Loo Lin School of Medicine and Lee Kong Chian School of Medicine) and the UK (Universities of Cardiff, Leicester, Oxford and Birmingham) were invited to complete a 12-item online survey. Questions assessed knowledge of WHO guidelines, understanding of PA in health and illness, personal PA levels and exposure to PA counselling in clinical practice. RESULTS: Among 633 Singapore and UK students who completed the questionnaire, 94.8% believed that PA was important in preventing disease, but only 70.9% recognised its importance in treating disease. The majority (85.3%) indicated participation in PA and exercise. General understanding of WHO guidelines for adults was poor, with less than half (46.8%) correctly answering this section. 3 (0.5%) students identified that PA in adults could be accumulated in multiple ways. Understanding of PA in health and familiarity with guidelines did not differ significantly between Singapore and UK students. CONCLUSION: There is considerable room for improvement in the knowledge of WHO guidelines and the role of PA in health. Education should begin during the undergraduate phase so that future doctors are better equipped to counsel their patients.

Pilot single-centre cross-sectional study to determine emergency physicians' knowledge and management of sports concussion: an experience from Singapore.

INTRODUCTION: Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore. METHODS: An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition. RESULTS: Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion. CONCLUSION: Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.

Musculoskeletal examination--an ignored aspect. Why are we still failing the patients?

Over the past two decades, rheumatologists from around the world have not only championed the musculoskeletal system examination but also modified the undergraduate teaching curriculum. This has led to the development and adoption of the gait, arms, legs and spine (GALS) screening along with regional examination techniques. The purpose of this study is to review current practice, determining the frequency of patient exposure to appropriate examination and confidence of junior doctors when dealing with MSK conditions. Two district-general hospitals (non-teaching) and one teaching hospital in North-East London were chosen. At each site, 50 patient notes were reviewed from the acute admission wards for medicine and surgery and the medical assessment unit. Factors considered included whether GALS screenings had taken place, documentation of MSK examinations and assessment of confidence of junior doctors in assessing MSK conditions. GALS screenings were performed for 4% of patients on the medical assessment unit, 7% of acute medical and 0% of acute surgical patients on admission. Examination of the MSK system yielded better results with 16%, 22% and 10% on each of the respective wards. Interviews with junior doctors found 10% routinely screening for MSK conditions, despite 87% feeling confident in taking MSK histories. This prospective audit of clinical practice highlights that patients failed to have a minimal assessment of the MSK system through GALS screenings. When examining the MSK system, results were somewhat better, although still fewer than expected. It is curious that the majority of junior doctors in training felt confident in dealing with MSK disease but few did it in practice. This begs the question of whether current teaching curricula and strategies are adequate. At a time where there is ever-increasing national momentum to address issues on obesity and cardiovascular health, our patients are still deprived of a standard MSK examination by the medical faculty.