Experiences of Boosting Inpatient Exercise After HipFracture Surgery Using An Alternative Workforce - A Qualitative Study.

BACKGROUND: Thrice-daily physiotherapy immediately following surgical repair of hip fracture has been shown to be safe and to reduce total hospital length of stay. However, implementing this is challenging with respect to health service funding and staffing. A novel approach may be to utilize an alternative workforce (allied health staff and student physiotherapists) to deliver two of the three daily treatments. However, how patients and staff may view such an approach is unknown. Thus, the aim of this qualitative study was to explore the views of inpatients with surgical repair of a hip fracture, their carers, health care professionals, and physiotherapy students about the implementation and acceptability of thrice-daily physiotherapy, with two sessions delivered by the alternative workforce (the BOOST study). METHODS: Semi-structured interviews and focus groups with patients, carers, health professionals and physiotherapy students. All interviews were digitally recorded and transcribed via verbatim. The transcripts were coded, and the data analysed via inductive thematic analysis. RESULTS: A total of 37 interviews (32 one-to-one interviews and five focus group interviews) were analysed. Five main themes were identified: (1) individual perceptions of the intervention: inpatients/carer/staff/student, (2) implementation within the service and organisational context, (3) implementation strategies that were effective, (4) improvements to implementation strategies/barriers to implementation/unsuccessful strategies and (5) future directions of BOOST. CONCLUSIONS: The qualitative data revealed that higher frequency physiotherapy was well-received by inpatients and that staff/students involved in providing care perceived it as a safe, acceptable and valuable practice. Implementation of higher daily frequency of physiotherapy using an alternative workforce may feasibly be adopted for inpatients following hip fracture surgery. TRIAL REGISTRATION: This study was approved by the Human Research Ethics Committee (HREC) of the Western Sydney Local Health District (2020/ETH02718). Mutual recognition of approval was subsequently obtained from Northern Sydney Local Health District HREC.

Boosting inpatient exercise after hip fracture using an alternative workforce: a mixed methods implementation evaluation.

BACKGROUND: Hip fracture has a devastating impact on individuals and is an increasing burden for health systems and society. Compared to usual care, increased physiotherapy provision has demonstrated efficacy in improving patient and health service outcomes in this population. However, physiotherapy workforce challenges prevent sustained implementation. METHODS: Our aim was to evaluate the safety, feasibility, acceptability, effectiveness and implementation cost of thrice daily physiotherapy for patients in the acute care setting after hip fracture at two public hospitals. We added twice-daily exercise implemented by an alternative workforce, to usual care consisting of daily mobility practice by a physiotherapist. Sites identified their preferred alternative workforce, with pre-registration physiotherapy students and allied health assistants chosen. We used a mixed methods approach, using the Consolidated Framework for Implementation Research (CFIR) as a determinant framework to guide implementation planning and data collection. We compared hospital length of stay data to a reference cohort. RESULTS: We recruited 25 patients during the study period. Acute care hospital length of stay decreased from 11 days in the reference cohort to 8 days in the BOOST cohort (mean difference - 3.3 days, 95%CI -5.4 to -1.2 days, p = 0.003). Intervention fidelity was 72% indicating feasibility, no safety concerns were attributed to the intervention, and uptake was 96% of all eligible patients. The intervention was acceptable to patients, carers and healthcare providers. This intervention was cost-effective from the acute orthopaedic service perspective. CONCLUSION: Higher daily frequency of physiotherapy can be safely, feasibly and effectively implemented by an alternative workforce for patients in the acute care setting following hip fracture surgery.

Prevalence and determinants of physical activity, sedentary behaviour and fatigue five years after total knee replacement.

OBJECTIVE: To determine the prevalence and predictors of physical activity, sedentary behaviour and fatigue five years after total knee replacement surgery. DESIGN: A longitudinal cohort study. SETTING: Community-dwelling adults who had previously undergone total knee replacement. METHODS: Five-year follow-up questionnaire data were obtained from participants previously enrolled in a randomised controlled trial examining rehabilitation after total knee replacement. Main study outcomes at one year did not differ between randomisation groups, hence data were pooled for the present longitudinal analysis. Before and one and five years after surgery, participants completed questionnaires (Active Australia Survey, WOMAC, SF12 v2, demographics and fatigue). RESULTS: 272/422 community-dwelling adults (45-74 years) completed the questionnaires at five years. Excessive sedentary behaviour was evident in 91% of the cohort, predicted by excessive sedentary behaviour and lack of energy at one year. Inadequate physical activity at five years was evident for 59% of the cohort, predicted by higher fatigue and comorbidity scores pre-surgery and inadequate physical activity at one year. Just under half (47%) of the cohort experienced clinically-important fatigue at five years, predicted by clinically-important fatigue before and one year after surgery, lack of sleep before surgery and physical activity one year after surgery. CONCLUSION: Documenting physical activity, sedentary behaviour and fatigue before and one year after knee replacement is important to identify those at risk of longer-term inadequate physical activity, excessive sedentary behaviour and clinically-important fatigue. Interventions to maintain activity and reduce sedentary behaviour are needed to reap the potential health benefits of total knee replacement surgery.

An update on potential links between type 2 diabetes mellitus and Alzheimer's disease.

Alzheimer's disease (AD) and type 2 diabetes (T2D) major feature is insulin resistance. Brain and peripheral insulin resistance lead to hyperglycemia, which contributes to the development of T2D-linked comorbidities, such as obesity and dyslipidemia. Individuals with hyperglycemia in AD present with neuronal loss, formation of plaques and tangles and reduced neurogenesis. Inflammation seems to play an essential role in the development of insulin resistance in AD and T2D. We conducted a literature review about the links between AD and T2D. Alterations in glucose metabolism result from changes in the expression of the insulin receptor substrates 1 and 2 (IRS-1 and IRS-2), and seem to be mediated by several inflammatory pathways being present in both pathologies. Although there are some similarities in the insulin resistance of AD and T2D, brain and peripheral insulin resistance also have their discrete features. Failure to activate IRS-1 is the hallmark of AD, while inhibition of IRS-2 is the main feature in T2D. Inflammation mediates the alterations in glucose metabolism in AD and T2D. Targeting inflammation and insulin receptors may be a successful strategy to prevent and ameliorate T2D and AD symptoms.

Increased Cardiovascular Response to a 6-Minute Walk Test in People With Type 2 Diabetes.

BACKGROUND AND OBJECTIVE: Exercise is a cornerstone of management for type 2 diabetes; however, little is known about the cardiovascular (CV) response to submaximal functional exercise in people with type 2 diabetes. The aim of this study was to compare performance and CV response during a 6-minute walk test (6MWT) between people with type 2 diabetes and matched control subjects. METHODS: CV response and distance walked during the 6MWT were assessed in 30 people with type 2 diabetes, matched for age, body composition, physical activity, and estimated aerobic capacity with 34 control subjects (type 2 diabetes group: 16 men, 59.8 ± 8.8 years of age, 33.3 ± 10.9% body fat, physical activity of 7,968 ± 3,236 steps·day-1, estimated aerobic capacity 31.9 ± 11.1 mLO2·kg-1·min-1; control group: 19 men, 59.3 ± 8.8 years of age, 32.7 ± 8.5% body fat, physical activity 8,228 ± 2,941 steps·day-1, estimated aerobic capacity 34.9 ± 15.4 mLO2·kg-1·min-1). RESULTS: People with type 2 diabetes walked a similar distance (590 ± 75 vs. 605 ± 69 m; P = 0.458) compared with control subjects during the 6MWT and had similar ratings of perceived exertion (RPE) after the 6MWT (4.19 ± 1.56 vs. 3.65 ± 1.54, P = 0.147). However, at the end of the 6MWT, people with type 2 diabetes had a higher heart rate (108 ± 23 vs. 95 ± 18 beats·min-1; P = 0.048), systolic blood pressure (169 ± 26 vs. 147 ± 22 mmHg, P = 0.003), and rate-pressure product (18,762 ± 5,936 vs. 14,252 ± 4,330, P = 0.009) than control subjects. CONCLUSION: Although people with type 2 diabetes had similar performance and RPE during the 6MWT compared with control subjects, the CV response was greater for people with type 2 diabetes, indicating greater cardiac effort for similar perceived effort and performance of 6MWT. These data suggest that observation and prescription of exercise intensity should include both perceived effort and CV response.

Aerobic exercise training may improve nerve function in type 2 diabetes and pre-diabetes: A systematic review.

Diabetic neuropathy is a major complication of type 2 diabetes. Emerging evidence also suggests that people with pre-diabetes may develop similar symptoms related to nerve dysfunction. While regular exercise provides many benefits to patients with diabetes, whether exercise influences nerve function has not been established. As such, the aim of this systematic review was to evaluate current evidence regarding the effect of exercise training on the progression and development of diabetic neuropathy. A systematic search of MEDLINE (Ovid), CINAHL, AMED, PEDro, the Cochrane Library, Embase, and Scopus databases identified a total of 12 studies that were eligible for inclusion in this systematic review. Quality rating and data extraction were performed by two independent reviewers. The 12 included studies examined people with pre-diabetes (n = 1) and with type 2 diabetes (n = 11). There was heterogeneity of study quality and exercise type and dosage among these studies. Eleven studies reported that exercise training had a positive influence on nerve function or neuropathy-related symptoms; and only one study reported mild adverse events. Evidence from this systematic review suggests aerobic exercise training may positively influence nerve function among people with type 2 diabetes, with minimal risk of adverse events. Further research will be required to determine the optimal dosage of exercise training and the effect on nerve function in pre-diabetes and in women with previous gestational diabetes. This review is registered on PROSPERO (CRD42018088182).

Contributions of birthweight, annualised weight gain and BMI to back pain in adults: a population-based co-twin control study of 2754 Australian twins.

PURPOSE: To investigate associations between anthropometric measures (birthweight, weight gain and current BMI) and back pain; and to determine whether these associations differ between those born with low or full birthweight. METHODS: The cross-sectional associations between the lifetime prevalence of back pain and anthropometric measures (birthweight, weight gain and current BMI) among 2754 adult twins were investigated in three stages: total sample; within-pair case-control for monozygotic and dizygotic twins together; and within-pair case-control analysis separated by dizygotic and monozygotic. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Birthweight was not associated with back pain (OR 0.99; 95% CI 0.99-1.00), but a weak association was found between weight gain (OR 1.01; CI 1.00-1.01) or current BMI (OR 1.02; 95% CI 1.00-1.05) and back pain in the total sample analysis. These associations did not remain significant after adjusting for genetics. The associations did not differ between those whose were born with low or full birthweight. CONCLUSION: Birthweight was not associated with prevalence of back pain in adulthood. Weight gain and current BMI were weakly associated with back pain prevalence in the total sample analysis but did not differ between those born with low or full birthweight. However, the small-magnitude association only just achieved significance and appeared to be confounded by genetics and the early shared environment. Our results suggest that a direct link between these predictors and back pain in adults is unlikely. These slides can be retrieved under Electronic Supplementary Material.

Does Psychological Health Influence Hospital Length of Stay Following Total Knee Arthroplasty? A Systematic Review.

OBJECTIVE: To systematically review the literature to determine if preoperative psychological health affected hospital length of stay among adults following primary unilateral total knee arthroplasty. DATA SOURCES: Systematic review. We searched 6 online databases for original research published before December 31, 2016, that investigated adults undergoing primary unilateral total knee arthroplasty. STUDY SELECTION: We included studies that used any measure of preoperative psychological health and reported length of stay, irrespective of study design. We excluded studies that considered participants with cognitive impairment or substance abuse; studies that considered participants who experienced revision, bilateral or hip surgery; and studies that did not have full text available in English. DATA EXTRACTION: One review author screened 438 titles and abstracts for inclusion. Another author reviewed a 10% sample of excluded studies for adherence to the review protocol, with no violations observed. For all included studies, 2 authors independently extracted data from each study using a form designed a priori and independently assessed study quality according to the Joanna Briggs Checklist for Cohort Studies. DATA SYNTHESIS: In view of the heterogeneity of the included studies, we present a narrative synthesis . Of the 7 included studies, 5 reported statistically significant increases in hospital length of stay among those with worse preoperative psychological health. These differences were often <1 calendar day, and, therefore, the clinical significance of these results remains unknown, but the potential to reduce health care costs may still be significant. CONCLUSIONS: Adults experiencing worse preoperative psychological health before total knee arthroplasty may have a longer hospital stay compared to those with unremarkable psychological health.

Prevalence and determinants of physical activity and sedentary behaviour before and up to 12 months after total knee replacement: a longitudinal cohort study.

OBJECTIVE: This study aims to evaluate the prevalence and determinants of inadequate physical activity and excessive sedentary behaviour before and after total knee replacement. DESIGN, SETTING AND SUBJECTS: Secondary analysis was performed on data from a cohort of 422 adults (45-74 years), drawn from 12 public or private hospitals, undergoing primary unilateral or bilateral total knee replacement surgery. MAIN MEASURES: Questionnaires were used to determine the presence of inadequate physical activity and excessive sedentary behaviour before and 6 and 12 months after total knee replacement surgery. Knee pain, activity limitations, comorbidities, muscle strength, psychological well-being, fatigue, sleep and body mass index were measured/assessed as possible determinants of physical activity or sedentary behaviour. RESULTS: Before surgery, 77% ( n = 326) of the cohort participated in inadequate physical activity according to World Health Organization guidelines, and 60% ( n = 253) engaged in excessive sedentary behaviour. Twelve months after surgery, 53% ( n = 185) of the cohort engaged in inadequate physical activity and 45% ( n = 157) in excessive sedentary behaviour. Inadequate physical activity before surgery ( P = 0.02), obesity ( P = 0.07) and comorbidity score >6 ( P = 0.04) predicted inadequate physical activity 12 months after surgery. Excessive sedentary behaviour and activity limitations before surgery predicted excessive sedentary behaviour 12 months after surgery. CONCLUSION: Although there were improvements after total knee replacement, 12 months after surgery about half the cohort did not meet World Health Organization recommendations for activity. Pre-surgery assessment of physical activity, activity limitations, sedentary behaviour and body mass index is essential to identify patients at risk for long-term inactivity.

Fitness training for cardiorespiratory conditioning after traumatic brain injury.

BACKGROUND: Reduced cardiorespiratory fitness (cardiorespiratory deconditioning) is a common consequence of traumatic brain injury (TBI). Fitness training may be implemented to address this impairment. OBJECTIVES: The primary objective of this updated review was to evaluate whether fitness training improves cardiorespiratory fitness in people who have sustained a TBI. The secondary objectives were to evaluate whether fitness training improves body function and structure (physical and cognitive impairments, psychological responses resulting from the injury), activity limitations and participation restrictions in people who have sustained a TBI as well as to evaluate its safety, acceptance, feasibility and suitability. SEARCH METHODS: We searched 10 electronic databases (the Cochrane Injuries Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Embase; PubMed (MEDLINE); CINAHL; AMED; SPORTDiscus; PsycINFO; PEDro and PsycBITE) and the International Clinical Trials Registry Platform for relevant trials. In addition we screened reference lists from systematic reviews related to the topic that we identified from our search, and from the included studies, and contacted trialists to identify further studies. The search was run in August 2017. SELECTION CRITERIA: Randomised controlled studies with TBI participants were eligible if they compared an exercise programme incorporating cardiorespiratory fitness training to usual care, a non-exercise intervention, or no intervention. DATA COLLECTION AND ANALYSIS: Two authors independently screened the search results, extracted data and assessed bias. We contacted all trialists for additional information. We calculated mean difference (MD) or standardised mean difference (SMD) and 95% confidence intervals (CI) for continuous data, and odds ratio with 95% CI for dichotomous data. We pooled data when there were sufficient studies with homogeneity. MAIN RESULTS: Two new studies incorporating 96 participants were identified in this update and were added to the six previously included studies. A total of eight studies incorporating 399 participants are included in the updated review. The participants were primarily men aged in their mid-thirties who had sustained a severe TBI. No studies included children. The studies were clinically diverse with regard to the interventions, time postinjury and the outcome measures used. At the end of intervention, the mean difference in peak power output was 35.47 watts (W) in favour of fitness training (MD 35.47 W, 95% CI 2.53 to 68.41 W; 3 studies, 67 participants; low-quality evidence). The CIs include both a possible clinically important effect and a possible negligible effect, and there was moderate heterogeneity among the studies.Five of the secondary outcomes had sufficient data at the end of intervention to enable meta-analysis: body composition (SMD 0.29 standard deviations (favouring control), 95% CI -0.22 to 0.79; 2 studies, 61 participants; low-quality evidence), strength (SMD -0.02 (favouring control), 95% CI -0.86 to 0.83; 2 studies, 23 participants; very low-quality evidence), fatigue (SMD -0.32 (favouring fitness training), 95% CI -0.90 to 0.26; 3 studies, 130 participants; very low-quality evidence), depression (SMD -0.43 (favouring fitness training), 95% CI -0.92 to 0.06; 4 studies, 220 participants; very low-quality evidence), and neuromotor function (MD 0.01 m (favouring fitness training), 95% CI -0.25 to 0.27; 2 studies, 109 participants; moderate-quality evidence). It was uncertain whether fitness training was more or less effective at improving these secondary outcomes compared to the control interventions. Quality of life was assessed in three trials, but we did not pool the data because of substantial heterogeneity. Five of the eight included studies had no dropouts from their intervention group and no adverse events were reported in any study. AUTHORS' CONCLUSIONS: There is low-quality evidence that fitness training is effective at improving cardiorespiratory deconditioning after TBI; there is insufficient evidence to draw any definitive conclusions about the other outcomes. Whilst the intervention appears to be accepted by people with TBI, and there is no evidence of harm, more adequately powered and well-designed studies are required to determine a more precise estimate of the effect on cardiorespiratory fitness, as well as the effects across a range of important outcome measures and in people with different characteristics (e.g. children). In the absence of high quality evidence, clinicians may be guided by pre-exercise screening checklists to ensure the person with traumatic brain injury is safe to exercise, and set training parameters using guidelines established by the American College of Sports Medicine for people who have suffered a brain injury.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs.

OBJECTIVE: To identify effective mind-body exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning non-traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with mind-body exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement). RESULTS: The four high-quality studies identified demonstrated that various mind-body exercise programs are promising for improving the management of knee osteoarthritis. Hatha Yoga demonstrated significant improvement for pain relief (Grade B) and physical function (Grade C+). Tai Chi Qigong demonstrated significant improvement for quality of life (Grade B), pain relief (Grade C+) and physical function (Grade C+). Sun style Tai Chi gave significant improvement for pain relief (Grade B) and physical function (Grade B). CONCLUSION: Mind-body exercises are promising approaches to reduce pain, as well as to improve physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs.

OBJECTIVES: To identify effective aerobic exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement). RESULTS: The five high-quality studies included demonstrated that various aerobic training exercises are generally effective for improving knee osteoarthritis within a 12-week period. An aerobic exercise program demonstrated significant improvement for pain relief (Grade B), physical function (Grade B) and quality of life (Grade C+). Aerobic exercise in combination with strengthening exercises showed significant improvement for pain relief (3 Grade A) and physical function (2 Grade A, 2 Grade B). CONCLUSION: A short-term aerobic exercise program with/without muscle strengthening exercises is promising for reducing pain, improving physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs.

OBJECTIVE: To identify effective strengthening exercise programs and provide rehabilitation teams and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+ or D-) was based on statistical significance ( p < 0.5) and clinical importance (⩾15% improvement). RESULTS: The 26 high-quality studies identified demonstrated that various strengthening exercise programs with/without other types of therapeutic exercises are generally effective for improving knee osteoarthritis management within a six-month period. Strengthening exercise programs demonstrated a significant improvement for pain relief (four Grade A, ten Grade B, two Grade C+), physical function (four Grade A, eight Grade B) and quality of life (three Grade B). Strengthening in combination with other types of exercises (coordination, balance, functional) showed a significant improvement in pain relief (three Grade A, 11 Grade B, eight Grade C+), physical function (two Grade A, four Grade B, three Grade C+) and quality of life (one Grade A, one Grade C+). CONCLUSION: There are a variety of choices for strengthening exercise programs with positive recommendations for healthcare professionals and knee osteoarthritis patients. There is a need to develop combined behavioral and muscle-strengthening strategies to improve long-term maintenance of regular strengthening exercise programs.

Exercise for osteoarthritis of the knee.

BACKGROUND: Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines. OBJECTIVES: To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life. SEARCH METHODS: Five electronic databases were searched, up until May 2013. SELECTION CRITERIA: All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group. DATA COLLECTION AND ANALYSIS: Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months). MAIN RESULTS: In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup. AUTHORS' CONCLUSIONS: High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.

The reliability, validity, and feasibility of physical activity measurement in adults with traumatic brain injury: an observational study.

OBJECTIVE: To determine the reliability and validity of the Physical Activity Scale for Individuals with a Physical Disability (PASIPD) in adults with severe traumatic brain injury (TBI) and estimate the proportion of the sample participants who fail to meet the World Health Organization guidelines for physical activity. DESIGN AND PARTICIPANTS: A single-center observational study recruited a convenience sample of 30 community-based ambulant adults with severe TBI. PROTOCOL: Participants completed the PASIPD on 2 occasions, 1 week apart, and wore an accelerometer (ActiGraph GT3X; ActiGraph LLC, Pensacola, Florida) for the 7 days between these 2 assessments. RESULTS: The PASIPD test-retest reliability was substantial (intraclass correlation coefficient = 0.85; 95% confidence interval, 0.70-0.92), and the correlation with the accelerometer ranged from too low to be meaningful (R = 0.09) to moderate (R = 0.57). From device-based measurement of physical activity, 56% of participants failed to meet the World Health Organization physical activity guidelines. CONCLUSION: The PASIPD is a reliable measure of the type of physical activity people with severe TBI participate in, but it is not a valid measure of the amount of moderate to vigorous physical activity in which they engage. Accelerometers should be used to quantify moderate to vigorous physical activity in people with TBI.

Exercise for osteoarthritis of the knee: a Cochrane systematic review.

OBJECTIVE: To determine whether land-based therapeutic exercise is beneficial for people with knee osteoarthritis (OA) in terms of reduced joint pain or improved physical function and quality of life. METHODS: Five electronic databases were searched, up until May 2013. Randomised clinical trials comparing some form of land-based therapeutic exercise with a non-exercise control were selected. Three teams of two review authors independently extracted data and assessed risk of bias for each study. Standardised mean differences immediately after treatment and 2-6 months after cessation of formal treatment were separately pooled using a random effects model. RESULTS: In total, 54 studies were identified. Overall, 19 (35%) studies reported adequate random sequence generation, allocation concealment and adequately accounted for incomplete outcome data. However, research results may be vulnerable to selection, attrition and detection bias. Pooled results from 44 trials indicated that exercise significantly reduced pain (12 points/100; 95% CI 10 to 15) and improved physical function (10 points/100; 95% CI 8 to 13) to a moderate degree immediately after treatment, while evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect (4 points/100; 95% CI 2 to 5). In addition, 12 studies provided 2-month to 6-month post-treatment sustainability data which showed significantly reduced knee pain (6 points/100; 95% CI 3 to 9) and 10 studies which showed improved physical function (3 points/100; 95% CI 1 to 5). CONCLUSIONS: Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2-6 months after cessation of formal treatment.

Moderate concentrations of supplemental oxygen worsen hypercapnia in obesity hypoventilation syndrome: a randomised crossover study.

INTRODUCTION: In people with obesity hypoventilation syndrome (OHS), breathing 100% oxygen increases carbon dioxide (PCO2), but its effect on pH is unknown. This study investigated the effects of moderate concentrations of supplemental oxygen on PCO2, pH, minute ventilation (VE) and physiological dead space to tidal volume ratio (VD/VT) among people with stable untreated OHS, with comparison to healthy controls. METHODS: In a double-blind randomised crossover study, participants breathed oxygen concentrations (FiO2) 0.28 and 0.50, each for 20 min, separated by a 45 min washout period. Arterialised-venous PCO2 (PavCO2) and pH, VE and VD/VT were measured at baseline, then every 5 min. Data were analysed using general linear model analysis. RESULTS: 28 participants were recruited (14 OHS, 14 controls). Among OHS participants (mean ± SD arterial PCO2 6.7 ± 0.5 kPa; arterial oxygen 8.9 ± 1.4 kPa) FiO2 0.28 and 0.50 maintained oxygen saturation 98-100%. After 20 min of FiO2 0.28, PavCO2 change (ΔPavCO2) was 0.3 ± 0.2 kPa (p = 0.013), with minimal change in VE and rises in VD/VT of 1 ± 5% (p = 0.012). FiO2 0.50 increased PavCO2 by 0.5 ± 0.4 kPa (p = 0.012), induced acidaemia and increased VD/VT by 3 ± 3% (p = 0.012). VE fell by 1.2 ± 2.1 L/min within 5 min then recovered individually to varying degrees. A negative correlation between ΔVE and ΔPavCO2 (r = -0.60, p = 0.024) suggested that ventilatory responses were the key determinant of PavCO2 rises. Among controls, FiO2 0.28 and 0.50 did not change PavCO2 or pH, but FiO2 0.50 significantly increased VE and VD/VT. CONCLUSION: Commonly used oxygen concentrations caused hypoventilation, PavCO2 rises and acidaemia among people with stable OHS. This highlights the potential dangers of this common intervention in this group.

A longitudinal study of knee pain in older men: Concord Health and Ageing in Men Project.

BACKGROUND: chronic knee pain is still considered a fairly benign disease by many, an 'unavoidable' consequence of ageing. This passive acceptance may be unnecessarily exposing older people to disability and serious co-morbidity. The aim of this study was to determine the disease burden associated with chronic knee pain and the role of knee extensor strength as a modifiable risk factor. METHODS: a longitudinal cohort study with 2-year follow-up conducted among 1,587 community-dwelling men aged 70 years and over, 637 (40%) reported chronic knee pain. Of the 950 (60%) men without knee pain at baseline, 768 (81%) returned for the follow-up assessment with 150 (20%) reporting incident chronic knee pain. RESULTS: knee pain was significantly associated with marked mobility disability [odds ratio (OR) 2.38; 95% confidence interval (CI) 1.74-3.29], falls (OR: 1.31; 95% CI: 1.01-1.70) and having four or more co-morbidity (OR: 1.63; 95% CI: 1.16-2.30) as well as reduced knee extensor strength and mass (dual X-ray absorptiometry). Men with incident knee pain at the 2-year follow-up assessment demonstrated greater increases in these measures of disease burden and greater decreases in muscle strength and mass, compared with those without incident chronic knee pain. Obesity, high co-morbidity burden, back pain, higher levels of physical activity or low knee extensor strength were all significant risk factors for incident knee pain. CONCLUSION: prevention of chronic knee pain may reduce a considerable burden of mobility disability and increased risk of serious co-morbidity among older men.

Improving musculoskeletal physiotherapists' confidence in patient-centred care informed by acceptance and commitment therapy: A descriptive study.

BACKGROUND: Patient-centred care is essential for high quality musculoskeletal care, however, few evidence-based opportunities exist that address the barriers to implementation for clinicians. OBJECTIVE: To develop and evaluate a simulation-based educational strategy for musculoskeletal physiotherapists to increase knowledge and confidence in patient-centred care. METHODS: Repeated-measures, single-group educational interventional descriptive study. Primary outcome was participant-reported knowledge and confidence in patient-centred care. Customized survey data was collected at baseline (T1) (N = 22), immediately after a face-to-face workshop (T2) (N = 22), and six weeks after the workshop (T3) (N = 17). Secondary outcomes included sustained implementation using the Normalization Measure Development (NoMAD) tool. Repeated-measures ANOVA was used to analyse primary outcomes. RESULTS: Our participants were typically female (72%), early career (mean 3.3 years post-graduate) and culturally diverse (67%). Significant increases in participant confidence were noted at all time points on all five learning outcomes (repeated measures ANOVA, p < 0.001 to p = 0.009). Participants had very high baseline knowledge and no further increases were found following the intervention (p > 0.05). Normalization Measure Development data indicated high coherence, high cognitive participation, and high reflexive monitoring, with neutral results for collective action. CONCLUSION: A novel, psychologically-informed, simulation-based educational strategy is effective in improving musculoskeletal physiotherapist confidence in patient-centred care. Participants reported implementation of skills learnt in the workshop into subsequent clinical practice.

The modifier effect of physical activity, body mass index, and age on the association of metformin and chronic back pain: A cross-sectional analysis of 21,899 participants from the UK Biobank.

BACKGROUND: There is growing evidence of the anti-inflammatory effect of the anti-diabetic drug metformin and its use to reduce pain. However, we currently lack studies investigating whether metformin is associated with a reduction in chronic back pain prevalence when considering physical activity levels, body mass index (BMI), and age. OBJECTIVE: To investigate whether use of metformin is associated with lower levels of reporting of chronic back pain in a large cohort with type 2 diabetes when stratified for physical activity, BMI, and age. METHODS: This is a cross-sectional study of 21,889 participants with type 2 diabetes who were drawn from the UK Biobank database. We investigated whether people using metformin reported a higher prevalence of chronic low back pain than those who did not. Type 2 diabetes, chronic back pain, and metformin were self-reported. Participants were stratified according to their physical activity level (low, moderate and high), BMI (normal, overweight, and obese), and age (40 to <50; 50 to < 60; and ≥60 years). Logistic regression models were built for each physical activity level, BMI and age category to investigate the prevalence of chronic back pain amongst those using and not using metformin. RESULTS: Participants who were using metformin and who had low levels of physical activity [OR 0.87, 95%CI 0.78 to 0.96] or who were obese [OR 0.90, 95%CI 0.86 to 0.98] or older [OR 0.85, 95%CI 0.78 to 0.93] had lower odds of reporting chronic back pain than their counterparts. CONCLUSION: The anti-diabetic drug metformin might reduce prevalence of chronic low back pain in people who are older, overweight, or less active. These findings should be confirmed in studies using a longitudinal design.