Associations Between Physical Activity and Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate the associations between adolescent idiopathic scoliosis (AIS) and physical activity (PA). DATA SOURCES: MEDLINE, EMBASE, AMED, SPORTDiscus, Cochrane Library, and CINAHL electronic databases were searched from inception to August 2022/plus citation tracking. STUDY SELECTION: Observational studies of participants with radiographically confirmed AIS with ≥10° lateral spinal curvature (Cobb method) and comparator groups without AIS that measured PA were selected by 2 reviewers. DATA EXTRACTION: Data were extracted independently and cross-checked by 2 reviewers. Risk of bias was evaluated using Newcastle Ottawa Scales and overall confidence in the evidence using the GRADE approach. DATA SYNTHESIS: Sixteen studies with 9627 participants (9162, 95% women) were included. A history of vigorous PA significantly reduced the odds of being newly diagnosed with AIS by 24% (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.65-0.89) (high certainty). Moderate PA reduced odds by 13% (moderate certainty) and light PA increased odds by 9% (low certainty), but neither analysis was statistically significant. Ballet or gymnastics (OR 1.47, 95% CI 3.08 (1.90, 5.00) were the only individual sports significantly associated with AIS diagnosis (moderate certainty). Case-control studies of people with and without AIS provided greater evidence that having AIS reduces vigorous PA and sports participation, and less evidence light PA and walking are affected. CONCLUSION: Adolescents who participate in more vigorous PA are less likely to be diagnosed with AIS. Ballet and gymnastics are associated with AIS diagnosis, but the direction of this association is uncertain. People with AIS are likely to do less vigorous physical and sporting activity compared with those without AIS, which could negatively affect health and quality of life. Further research is warranted into the inter-relations between PA and AIS, studies need to be of sufficient size, include men, and evaluate vigorous including higher-impact PA compared with moderate or light PA.

The experience of living with adolescent idiopathic scoliosis: a qualitative evidence synthesis using meta-ethnography.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity with physical and psychosocial implications for adolescents. The aim of this qualitative evidence synthesis (QES) was to systematically search for, identify, and synthesise qualitative research in order to improve our understanding of what it is like to live with AIS and to facilitate empathetic and effective healthcare. METHODS: We systematically searched 4 databases (Medline, EMBASE, PsycINFO and CINAHL) and used the 7 phases of meta-ethnography to synthesise qualitative evidence including studies with children and adolescents, and additional viewpoints from parents about the experience of AIS. RESULTS: We distilled 7 themes. (1) Diagnosis turned time on its head revolves around the AIS diagnosis and the uncertainty of the future that accompanied it. (2) Usual activities no longer the same explores how activities and participation in everyday life are impacted by AIS. (3) Hiding my body describes the pervasive struggle with self-image and appearance. (4) I want to feel normal again explores adolescents' desire to return to 'normality' and challenges of feeling different. (5) Balancing isolation and support considers the relationships in the adolescents' lives alongside their feelings of isolation. (6) Trying to keep control of treatment decisions explores how adolescents and their parents strive to feel in control. (7) Fearing surgery yet feeling hopeful focused on the apprehension and fear around spinal surgery and the beacon of hope it represented. CONCLUSIONS: Our QES contributes to the understanding of the adolescent experience of living with AIS. From our findings, clinicians can better understand the physical and psychosocial obstacles and the challenges faced throughout the journey of AIS to inform their clinical interactions with these patients.

Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial.

BACKGROUND: Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. METHODS: In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28. FINDINGS: Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported. INTERPRETATION: Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders. FUNDING: UK National Institute for Health Research Technology Assessment Programme.

Experiences of urinary tract infection: A systematic review and meta-ethnography.

AIM: To understand the experience of urinary tract infection (UTI) by synthesizing primary qualitative research findings and developing a conceptual model that illustrates this experience. METHOD: A systematic search of Medline, PsychInfo, Embase, and CINAHL from inception to August 2020 to find qualitative research exploring the experience of UTI. Qualitative evidence synthesis in the form of meta-ethnography was undertaken. Findings are reported in keeping with eMERGe guidance. RESULTS: We included 16 qualitative studies in the synthesis of evidence, providing data from over 1038 participants aged 13-97 years. We developed nine themes: the impact of UTI on my whole body; impact on quality of life, activities, and the associated psychological toll; I know my body and my experience has taught me when I need to seek care; worry and the transition to medicalization; antibiotics are a valuable treatment approach; antibiotics are a last resort; being heard, seen, and cared for with dignity; self-judgment; and the end of the road, a need for information and cure. These themes supported a conceptual model to illustrate the patient experience of UTI. CONCLUSIONS: The conceptual model communicates the wide and varied symptoms of patients' UTI experiences and how they process this and make care decision based on past health experiences. For some, there appears to be a sense of hopelessness and frustration. This model may be used to highlight the need for improvements in diagnostic and treatment pathways. Future research to further understand the nuances of acute, recurrent, and persistent UTI is needed.

The challenges and gains of delivering a home-exercise intervention: a qualitative study of physiotherapists and physiotherapy assistants.

OBJECTIVES: The paper presents insights from the Community based Rehabilitation after Knee Arthroplasty (CORKA) trial. We aimed to explore physiotherapists and physiotherapy assistants' experiences of delivering a home-base exercise intervention following knee replacement surgery. We were particularly interested in the feasibility, potential benefits and barriers of a community-based exercise programme from the perspective of physiotherapists and physiotherapy assistants and to understand any constraints or training needs that arose.  DESIGN: Qualitative thematic analysis of semi-structured interviews.  SETTING: The Community based Rehabilitation after Knee Arthroplasty (CORKA) trial. PARTICIPANTS: Five physiotherapists and six physiotherapy assistants with a range of clinical experience. METHODS: Interviews were digitally recorded and transcribed verbatim. We used the stages of reflexive thematic analysis suggested by Braun and Clarke. One researcher conducted the interviewers whilst three researchers with experience in qualitative research methods contributed to the coding and analysis of data. RESULTS: We developed seven themes that help to understand the benefits and challenges of delivering treatment interventions in a person's home: seeing the person in their own world; thinking outside the cubicle;developing people skills; enjoying the above and beyond; treading a fine line between patient and friend; feeling outside my comfort zone; needing a support network. CONCLUSIONS: Treating people in their own homes facilitates a holistic approach. Our findings highlight areas for clinical education: (1) how do we help clinicians to tread the fine line between friend and professional (2) how do we balance the need to provide support and structure with the freedom to work creatively and independently?

Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis.

Exercise and physical activity can improve bone strength and the risk of falls, which may offer benefits in the prevention and management of osteoporosis. However, uncertainty about the types of exercise that are safe and effective instigates lack of confidence in people with osteoporosis and health professionals. Existing guidelines leave some questions unresolved. This consensus statement aimed to determine the physical activity and exercise needed to optimise bone strength, reduce fall and fracture risk, improve posture and manage vertebral fracture symptoms, while minimising potential risks in people with osteoporosis. The scope of this statement was developed following stakeholder consultation. Meta-analyses were reviewed and where evidence was lacking, individual studies or expert opinion were used to develop recommendations. A multidisciplinary expert group reviewed evidence to make recommendations, by consensus when evidence was not available. Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. For safety, we recommend avoiding postures involving a high degree of spinal flexion during exercise or daily life. People with vertebral fracture or multiple low trauma fractures should usually exercise only up to an impact equivalent to brisk walking. Those at risk of falls should start with targeted strength and balance training. Vertebral fracture symptoms may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with specialist advice to encourage return to normal activities. Everyone with osteoporosis may benefit from guidance on adapting postures and movements. There is little evidence that physical activity is associated with significant harm, and the benefits, in general, outweigh the risks.

A meta-ethnography to understand the experience of living with urinary incontinence: 'is it just part and parcel of life?'

BACKGROUND: Urinary incontinence (UI) is highly prevalent and affects the lives of many men and women. We aimed to conduct a qualitative evidence synthesis (QES) to explore the experience of living with UI and to develop a conceptual model that can help us to understand this experience, and the potential barriers to appropriate healthcare. METHODS: We used the methods of meta-ethnography developed by Noblit and Hare and recently refined for larger studies. Meta-ethnography involves identifying concepts from the studies and abstracting these concepts into a line of argument. We searched for studies that explored the experience of adults with UI. We used the GRADE-CERQual framework to assess confidence in review findings. RESULTS: We screened 2307 titles, 429 abstracts, 107 full texts and included 41 studies (36 unique samples) in the synthesis. We organised the concepts into 26 conceptual categories, which we further abstracted into 6 themes: (1) Am I ill or is this normal? (2) It effects who I am and how I feel; (3) I feel stigmatised, ashamed and guilty; (4) talking can be difficult but it can help; (5) keeping incontinence under control; (6) have I got to the point that I need help? Our model conceptualises living with UI as navigating antagonists: Is UI normal or am I ill? Do I need help or am I managing? Do I keep UI to myself (and manage alone) or do I tell other people (and get the support that I need)? Do I use control strategies that focus on concealing (avoid risky situations, wear pads) versus, I use strategies that focus on improving the bodily function to improve continence. Our model highlights the experience of stigma, shame and guilt which exert a pull towards concealment. CONCLUSIONS: The culture of secrecy and profound sense of shame is barrier to seeking help. An environment which reduces the shame and stigma of UI may help people to switch the focus to strategies that will improve continence, rather than conceal incontinence.

The Experience of Living to an Extreme Age: A Meta-Ethnography.

Advances in health care mean that we can now treat diseases that once cut lives short. However, the increase in life expectancy has not been matched by improvements in quality of life. The World Health Organization warns us that all countries should prepare to meet the challenges of an aging population and this is integral to the United Nations 2030 Agenda for Sustainable Development. This may require a shift in attitude toward aging. We aimed to use meta-ethnography to explore the experience of adults living beyond the age of 80. Our conceptual model illuminates the phenomenon of connection in older age and reflects on the paradox of time: ephemeral, yet interminable. Our findings encourage us to reflect on the influence of enlightenment philosophies that underpin the desire for autonomy at all costs. Our study challenges the stereotypes of old age and has the potential to influence people's perspectives toward aging.

Knee Arthroplasty Patients Predicted Versus Actual Recovery: What Are Their Expectations About Time of Recovery After Surgery and How Long Before They Can Do the Tasks They Want to Do?

OBJECTIVES: (1) To determine evidence-based guidance for the length of time to return to specific valued functional and leisure activities after knee arthroplasty (KA). (2) To determine what patients feel are the most important functional or leisure activities to recover after KA. (3) To collect information about patients' expectations and compare them to the actual time it takes to return. DESIGN: Prospective longitudinal cohort observational survey. SETTING: Specialist orthopedic hospital. PARTICIPANTS: Patients (N=99) with osteoarthritis or rheumatoid arthritis (mean=69.9y [range 44-88]) listed for total knee arthroplasty (TKA) or unicompartmental knee arthroplasty. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Valued activities list (VAL) used to select activities patients expect to return to and report the actual time taken to return. RESULTS: Participants in unicompartmental knee arthroplasty group returned to the 6 most popular valued activities (walking >1km, stair climbing, housework, driving, gardening, and kneeling) 8%-33% more quickly than TKA group, and they were satisfied with performing these activities sooner on average (4%-18%) than the TKA group. The percentage of participants satisfied at 12 months postsurgery ranged from 96% returning to housework to 36% returning to kneeling. The Wilcoxon signed-rank test was used to compare the expected time and the actual time to return: Housework (Z=-5.631, P<.05, effect size=0.64) and swimming (Z=-3.209, P<.05, effect size=0.59) were quicker than expected, and walking >1 km (Z=-2.324, P<.05, effect size=0.27) was slower than expected. CONCLUSIONS: A more tailored and personalized approach with consideration of prior level of activity and comorbidities must be taken into account and adequately discussed to help bridge the gap between the expected and actual recovery time.

Neuropathic pain is a feature in patients with symptomatic femoral acetabular impingement.

Femoral acetabular impingement syndrome (FAIS) is a cause of hip pain thought to be nociceptive, although pain phenotypes e.g., burning, pain attacks, prickling, numbness etc., are reported, mimicking neuropathic pain. Although no lesion to the somatosensory system is identified, neuropathic pain (NeP) may explain why nociceptive-focussed treatments are not always successful. OBJECTIVE: To identify NeP in patients with FAIS and investigate if related to poorer outcomes. DESIGN: A secondary analysis of the Femoral Acetabular Impingement Trial (FAIT). Outcome of interest: PainDETECT questionnaire; secondary outcomes of interest; International Hip Outcome Tool (iHOT33), Hospital Anxiety and Depression Scale (HADS) and VAS 'average pain over a month', at baseline and 8 months follow-up. Intervention (surgery or physiotherapy) were pooled. RESULTS: 173 data sets at baseline; 123 at 8 months follow-up. Baseline painDETECT identified three groups: 69% nociceptive, 19% unclear and 12% neuropathic pain phenotypes. Baseline, median scores were higher for the neuropathic group compared to the nociceptive group demonstrating borderline anxiety (9.5(5.3 to 14.2), 5(3 to 8), higher normal values for depression (7.5(2.3 to 11.8), (4(2 to 9), higher average pain (7 (6 to 8), 5(4 to 6) and lower iHOT33 14.2(9 to 21.1), 38.4(26.2 to 55.7). Post treatment, there was a median change in the neuropathic score in both iHOT33 (40.8 (25 to 76.5) with a median difference of 24.13 (CI 95% 10.46 to 45.92) and average pain 4.5(1.5 to 7) with a median difference of 2 (CI 95% 1 to 5) but to a lesser amount than the nociceptive group, iHOT33 (64(38.2 to 86.6) with a median difference of 15.50 (CI 95% 6.41 to 21.82) and average pain 3(1 to 5.7) with a median difference of 1 (CI 95% 0.5 to 1). CONCLUSION: NeP exists in symptomatic FAIS patients and is associated with increased average pain, and functional limitations. Nociceptive-targeted treatment improves hip function and pain but with less improvement in the NeP group when compared to the nociceptive group. Pain phenotyping before intervention may improve outcomes. CONTRIBUTION OF PAPER.

Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT.

Background: Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. Objective(s): To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). Design: A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Setting: Twenty-nine NHS orthopaedic units in the United Kingdom. Participants: Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Interventions: Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. Main outcome measures: The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Results: Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Limitations: Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Conclusions: Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Future work: Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. Trial registration: This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

The study aimed to find out whether it is better to offer surgical reconstruction or rehabilitation first to patients with a more long-standing injury of their anterior cruciate ligament in their knee. This injury causes physical giving way of the knee and/or sensations of it being wobbly (instability). The instability can affect daily activities, work, sport and can lead to arthritis. There are two main treatment options for this problem: non-surgical rehabilitation (prescribed exercises and advice from physiotherapists) or an operation by a surgeon to replace the damaged ligament (anterior cruciate ligament reconstruction). Although studies have highlighted the best option for a recently injured knee, the best management was not known for patients with a long-standing injury, perhaps occurring several months previously. Because the surgery is expensive to the NHS (around £100 million per year), it was also important to look at the costs involved. We carried out a study recruiting 316 non-acute anterior cruciate ligament-injured patients from 29 different hospitals and allocated each patient to either surgery or rehabilitation as their treatment option. We measured how well they did with special function and activity scores, patient satisfaction and costs of treatment. Patients in both groups improved substantially. It was expected that some patients in the rehabilitation group would want surgery if non-surgical management was unsuccessful. Forty-one per cent of patients who initially underwent rehabilitation subsequently elected to have reconstructive surgery. Overall, the patients allocated to the surgical reconstruction group had better results in terms of knee function and stability, activity level and satisfaction with treatment than patients allocated to the non-operative rehabilitation group. There were few problems or complications with either treatment option. Although the surgery was a more expensive treatment option, it was found to be cost-effective in the UK setting. The evidence can be discussed in shared decision-making with anterior cruciate ligament-injured patients. Both strategies of management led to improvement. Although a rehabilitation strategy can be beneficial, especially for recently injured patients, it is advised that later-presenting non-acute and more long-standing anterior cruciate ligament-injured patients undergo surgical reconstruction without necessarily delaying for a period of rehabilitation.

Recovery of function following hip resurfacing arthroplasty: a randomized controlled trial comparing an accelerated versus standard physiotherapy rehabilitation programme.

OBJECTIVE: To identify if a tailored rehabilitation programme is more effective than standard practice at improving function in patients undergoing metal-on-metal hip resurfacing arthroplasty. DESIGN: Randomized controlled trial. SETTING: Specialist orthopaedic hospital. SUBJECTS: 80 men with a median age of 56 years. INTERVENTIONS: Tailored post-operative physiotherapy programme compared with standard physiotherapy. MAIN OUTCOMES: Primary outcome - Oxford Hip Score (OHS), Secondary outcomes: Hip disability and Osteoarthritis Outcome Score (HOOS), EuroQol (EQ-5D-3L) and UCLA activity score. Hip range of motion, hip muscle strength and patient selected goals were also assessed. RESULTS: At one year the mean (SD) Oxford Hip Score of the intervention group was higher, 45.1 (5.3), than the control group, 39.6 (8.8). This was supported by a linear regression model, which detected a 5.8 unit change in Oxford Hip Score (p < 0.001), effect size 0.76. There was a statistically significant increase in Hip disability and Osteoarthritis Outcome Score of 12.4% (p < 0.0005), effect size 0.76; UCLA activity score differed by 0.66 points (p < 0.019), effect size 0.43; EQ 5D showed an improvement of 0.85 (p < 0.0005), effect size 0.76. A total of 80% (32 of 40) of the intervention group fully met their self-selected goal compared with 55% (22 of 40) of the control group. Hip range of motion increased significantly; hip flexion by a mean difference 17.9 degrees (p < 0.0005), hip extension by 5.7 degrees (p < 0.004) and abduction by 4 degrees (p < 0.05). Muscle strength improved more in the intervention group but was not statistically significant. CONCLUSIONS: A tailored physiotherapy programme improved self-reported functional outcomes and hip range of motion in patients undergoing hip resurfacing.

Early post-operative physiotherapy rehabilitation after primary unilateral unicompartmental knee replacement: a systematic review.

BACKGROUND: Unicompartmental Knee Replacement (UKR) is an established treatment for end stage arthritis affecting one compartment of the knee. UKR lends itself to rapid recovery and early discharge. The content, type, timing and dose of early post-operative physiotherapy treatment has yet to be reviewed. OBJECTIVE: To review the content of early physiotherapy in the first eight weeks following unilateral UKR. DATA SOURCES: A literature search of Medline, CINAHL, AMED and PubMed and the Physiotherapy Evidence Database (PEDRo) plus citation searching. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and observational studies reporting a physiotherapy intervention for UKR involving a form of post-operative exercise/education/advice delivered within the first eight weeks of surgery and commencing as an in-patient. Two reviewers independently performed screening, data extraction and risk of bias assessment. DATA SYNTHESIS: Narrative syntheses were undertaken due to the heterogeneity of the primary outcomes. RESULTS: Eleven studies were included (n = 1293 participants), three RCTs and eight observational studies. The dose and content of post-operative physiotherapy was highly variable with a move in recent years to rapid recovery and same day discharge with more self-directed rehabilitation. No studies had a low risk of bias. LIMITATIONS: Small sample sizes and high heterogeneity limit our findings CONCLUSIONS: This review highlights the range of post-operative physiotherapy provision following UKR with a recent move to minimal physiotherapy input. Further research is required to identify those patients who may need additional physiotherapy above that now routinely provided, along with the most effective timing, type, and dosage of the intervention. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021243238. CONTRIBUTION OF THE PAPER.

The experience of women reporting damage from vaginal mesh: a reflexive thematic analysis.

Background: The UK's 'First do no harm' report highlighted missed opportunities to prevent harm and emphasised the need to incorporate patient voices into healthcare. Due to concerns about, and the subsequent suspension, of vaginal mesh for urinary incontinence thousands of women face the decision about mesh removal surgery. The aim of this study was to explore and understand the experience of living with complications attributed to vaginal mesh surgery so that this knowledge can contribute to improvements in care for those considering mesh, or mesh removal, surgery. Methods: This study was embedded in the 'PURSUE' study which explored the experiences of 74 people with urogynaecological conditions in the UK (30th April 2021-17th December 2021). Of these 74 people, fifteen women reported complications that they attributed to vaginal mesh surgery. We used the six stages of reflexive thematic analysis to conceptualise these fifteen accounts. Findings: Our conceptual model anchors eight themes around two dualities: (1) body parts versus body whole, (2) dominant discourse versus marginal discourse. Our themes indicate that trust can be established through: (1) embodied healthcare that focuses on connecting with patients' lived experience, (2) dialectic communication that recognises patient experiences and remains open to alternative perspectives. Interpretation: This study raises some important issues for education and practice. Our findings can translate to other health settings where treatments aimed to provide care have caused harm. Funding: NIHR Policy Research Programme (NIHR202450).

Comparison of postdischarge physiotherapy versus usual care following primary total knee arthroplasty for osteoarthritis: an exploratory pilot randomized clinical trial.

OBJECTIVE: To evaluate a pilot trial of a postdischarge physiotherapy intervention to improve patient function versus usual physiotherapy in patients undergoing total knee arthroplasty aiming to assess: recruitment rate, feasibility and acceptability of the intervention and control, suitability of outcomes, retention and adverse events and to inform sample size calculation for a definitive trial. DESIGN: Exploratory pilot randomized controlled trial using independent assessment. SETTING: Mixed urban and rural, UK. PARTICIPANTS: Patients undergoing primary, elective unilateral knee arthroplasty for osteoarthritis. INTERVENTION: Two additional home physiotherapy visits of functional weight-bearing exercises, functional task-specific training versus treatment as usual. MAIN OUTCOME: Oxford Knee Score at 12 months. SECONDARY OUTCOMES: completion rates, adverse events, Knee Injury and Osteoarthritis Outcome Score, leg extensor power, timed 10-m walk, timed sit-to-stand, resource use diaries. Assessments completed at baseline (pre-operatively), 3, 6 and 12 months. RESULTS: Of 181 eligible participants 107 (59.1%) were randomized over 13 months, one participant withdrew, no adverse events. Intervention group n = 56 (mean age 67.8), control group n = 51 (mean age 70.8). The difference in mean change of Oxford Knee Scores between groups (intervention--control) at 12 months was 0.2 (95% confidence interval (CI) -3.8, 4.2), P = 0.94. Patient diaries revealed non-trial additional physiotherapy requires improved measurement. CONCLUSIONS: Successful recruitment and retention rates were achieved. The intervention appeared feasible and acceptable but may be suboptimal in intensity given recent research. A sample size of 1271 participants would be required for a fully powered randomized controlled trial using the main outcome. However new outcomes, potentially of greater validity and responsiveness, require consideration.

Does thoracic kyphosis severity predict response to physiotherapy rehabilitation in patients with osteoporotic vertebral fracture? A secondary analysis of the PROVE RCT.

OBJECTIVES: To describe participant characteristics based on kyphosis severity, examine the relationship between kyphosis and physical function, and investigate whether kyphosis severity predicts improvement after physiotherapy intervention. DESIGN AND SETTING: Secondary longitudinal analysis of the PROVE trial, a multicentre RCT. Data from all three trial arms were pooled and divided into quartile groups according to baseline kyphosis severity for linear mixed model analysis. PARTICIPANTS: 604 men and women with osteoporotic vertebral fracture. MAIN OUTCOME MEASURES: Estimated marginal means reported from adjusted mixed models for thoracic kyphosis, Six-minute Walk Test (6MWT), functional reach and Short Performance Physical Battery (SPPB). RESULTS: Thoracic kyphosis improved at 4-months and 12-months in participants with moderate hyperkyphosis (-2.4 ° and -3.0 °) and severe hyperkyphosis (-5.7 ° and -8.0 °). Functional reach scores were lower in the severe hyperkyphosis group compared to normal and hypokyphosis groups by at least 2.3 cm. 6MWT scores were worse in the severe hyperkyphosis group compared to the normal kyphosis group by 39.6 m. SPPB scores were worse in severe hyperkyphosis group compared to the normal kyphosis group by 0.72 points, but all participants, regardless of kyphosis severity, improved SPPB at 4 months by 0.42 points and at 12 months by 0.25 points. CONCLUSIONS: Results suggest that presenting with hyperkyphosis and osteoporotic vertebral fracture does not prevent improvement in thoracic curvature and physical performance after physiotherapy compared with baseline values. While higher kyphosis correlated with poorer physical function scores, baseline kyphosis severity could not predict change in physical function measures. REGISTRY: ISRCTN 49117867.

Validity of sagittal thoracolumbar curvature measurement using a non-radiographic surface topography method.

PURPOSE: To estimate the criterion validity of sagittal thoracolumbar spine measurement using a surface topography method in a clinical population against the gold standard and to estimate concurrent validity against two non-radiographic clinical tools. METHODS: In this cross-sectional validity study, thoracolumbar curvature was measured in adults with spinal conditions recruited from a specialist orthopaedic hospital. A surface topography method using a Kinect sensor was compared to three other measurement methods: spinal radiograph (gold standard), flexicurve and digital inclinometer. Correlation coefficients and agreement between the measurement tools were analysed. RESULTS: Twenty-nine participants (79% female) were included in criterion validity analyses and 38 (76% female) in concurrent validity analyses. The surface topography method was moderately correlated with the radiograph (r = .70, p < .001) in the thoracic spine, yet there was no significant correlation with the radiograph in the lumbar spine (r = .32, p = .89). The surface topography method was highly correlated with the flexicurve (rs = .91, p < .001) and digital inclinometer (r = .82, p < .001) in the thoracic spine, and highly correlated with the flexicurve (r = .74, p < .001) and digital inclinometer (r = .74, p < .001) in the lumbar spine. CONCLUSIONS: The surface topography method showed moderate correlation and agreement in thoracic spine with the radiograph (criterion validity) and high correlation with the flexicurve and digital inclinometer (concurrent validity). Compared with other non-radiographic tools, this surface topography method displayed similar criterion validity for kyphosis curvature measurement.

Physiotherapy exercise rehabilitation with tailored exercise adherence support for people with osteoporosis and vertebral fractures: protocol for a randomised controlled trial - the OsteoPorosis Tailored exercise adherence INtervention (OPTIN) study.

INTRODUCTION: Vertebral fragility fractures affect at least 20% of the older population in the UK. Best practice guidelines recommend the use of exercise to slow the rate of bone loss, to maintain muscle strength and physical function, and to prevent falls and further fractures. However, treatment effects are often small and difficult to sustain and adherence, or the extent to which patients engage in treatment, has been identified as an important issue by many studies. Our hypothesis is that integrating adherence intervention strategies with an exercise intervention will be beneficial. We will compare physiotherapy exercise rehabilitation with adherence support versus physiotherapy exercise rehabilitation alone in terms of effects on (A) physical function, quality of life and fear of falling and (B) exercise self-efficacy and adherence. METHODS AND ANALYSIS: A multicentre, two-arm, parallel group, superiority randomised controlled trial with blinded assessments at baseline (0) and 4, 8 and 12 months, with a nested qualitative study and health economic analysis. 116 participants will be allocated to either (1) outpatient physiotherapy which will include a musculoskeletal assessment and treatment including balance, posture, strength training and low impact weight-bearing exercises over 16 weeks or (2) OsteoPorosis Tailored exercise adherence INtervention intervention. This includes standard physiotherapy as above plus an additional, integrated assessment interview (30 min) and 60 min of adherence support spread over the subsequent 16 weeks. ETHICS AND DISSEMINATION: The study protocol was approved by West of Scotland Research Ethics Committee 4 (21/WS/0071). Trial registration number ISRCTN 14465704. The paper is based on Protocol V.4. TRIAL REGISTRATION NUMBER: ISRCTN 14465704.

The Clinical Effectiveness of a Physiotherapy Delivered Physical and Psychological Group Intervention for Older Adults With Neurogenic Claudication: The BOOST Randomized Controlled Trial.

BACKGROUND: Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults' mobility and quality of life. METHODS: A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat. RESULTS: The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: -1.4 [95% confidence intervals (CI) -4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: -3.7 [95% CI -6.27, -1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: -0.2 [95% CI -0.45, -0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment. CONCLUSIONS: The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability. Clinical Trials Registration Number: ISRCTN12698674.

Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement: A Randomized Clinical Trial.

Importance: More than half of patients who undergo knee replacement surgery report substantial acute postoperative pain. Objective: To evaluate the efficacy and cost-effectiveness of periarticular liposomal bupivacaine for recovery and pain management after knee replacement. Design, Setting, and Participants: This multicenter, patient-blinded, pragmatic, randomized clinical superiority trial involved 533 participants at 11 institutions within the National Health Service in England. Adults undergoing primary unilateral knee replacement for symptomatic end-stage osteoarthritis were enrolled between March 29, 2018, and February 29, 2020, and followed up for 1 year after surgery. Follow-up was completed March 1, 2021. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis. Interventions: Two hundred sixty-six milligrams of liposomal bupivacaine admixed with 100 mg of bupivacaine hydrochloride compared with 100 mg of bupivacaine hydrochloride alone (control) administered by periarticular injection at the time of surgery. Main Outcome and Measures: The coprimary outcomes were Quality of Recovery 40 (QoR-40) score at 72 hours and pain visual analog scale (VAS) score area under the curve (AUC) from 6 to 72 hours. Secondary outcomes included QoR-40 and mean pain VAS at days 0 (evening of surgery), 1, 2, and 3; cumulative opioid consumption for 72 hours; functional outcomes and quality of life at 6 weeks, 6 months, and 1 year; and cost-effectiveness for 1 year. Adverse events and serious adverse events up to 12 months after randomization were also assessed. Results: Among the 533 participants included in the analysis, the mean (SD) age was 69.0 (9.7) years; 287 patients were women (53.8%) and 246 were men (46.2%). Baseline characteristics were balanced between study groups. There was no difference between the liposomal bupivacaine and control groups in QoR-40 score at 72 hours (adjusted mean difference, 0.54 [97.5% CI, -2.05 to 3.13]; P = .64) or the pain VAS score AUC at 6 to 72 hours (-21.5 [97.5% CI, -46.8 to 3.8]; P = .06). Analyses of pain VAS and QoR-40 scores demonstrated only 1 statistically significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (adjusted difference -0.54 [97.5% CI, -1.07 to -0.02]; P = .02). No difference in cumulative opioid consumption and functional outcomes was detected. Liposomal bupivacaine was not cost-effective compared with the control treatment. No difference in adverse or serious adverse events was found between the liposomal bupivacaine and control groups. Conclusions and Relevance: This study found no difference in postoperative recovery or pain associated with the use of periarticular liposomal bupivacaine compared with bupivacaine hydrochloride alone in patients who underwent knee replacement surgery. Trial Registration: isrctn.com Identifier: ISRCTN54191675.