Perceived factors and barriers affecting physiotherapists' decision to use spinal manipulation and mobilisation among infants, children, and adolescents: an international survey.

OBJECTIVE: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. RESULTS: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist's knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. CONCLUSION: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists.

INTRODUCTION: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions. METHOD: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes). RESULTS: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined. CONCLUSION: Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists.

OBJECTIVE: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. RESULTS: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. CONCLUSION: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Relationships between physical fitness characteristics, technical skill attributes, and sports injury in female Australian football players.

OBJECTIVES: To explore the relationships between physical fitness and i) technical skills and ii) time-loss from Australian football injury in female players across the talent and participation pathways. METHODS: This study uses a subset of data from two cross-sectional and one prospective cohort studies. A total of 223 female Australian football players across five competition levels (elite/non-elite senior, high-level junior, and non-elite junior (14-17 years)/(10-13 years)) were included in this study. Comprehensive physical fitness assessments and modified Australian football kicking and handballing tests were conducted in the 2018/19 pre-seasons. During the respective competitive in-season, time-loss injuries were recorded by team personnel. Stepwise multiple linear regressions were performed to determine the relationship between physical fitness and kicking and handballing scores. Cox proportional regressions were conducted to identify physical fitness factors associated with injury. RESULTS: Increased running vertical jump height, greater hip abduction strength, and faster timed 6 m hop speed demonstrated a relationship with kicking accuracy when adjusted for years of Australian football playing experience (adjusted R2 = 0.522, p < 0.001). Faster agility time and increased lean mass were associated with better handballing accuracy (adjusted R2 = 0.221, p < 0.001). Multivariate Cox regression revealed an increased risk for sustaining a time-loss injury in less agile players (adjusted HR 2.41, 95% CI 1.23, 4.73, p = 0.010). However, this relationship no longer remained when adjusted for age and years of Australian football experience (adjusted HR 1.68, 95% CI 0.81, 3.50, p = 0.166). CONCLUSIONS: Physical fitness may be a significant factor contributing to development of Australian football technical skills in female players. However, its role is unclear in protecting against injury risk in this athlete population. Further research is needed to explore the multifactorial and complex phenomenon of talent development and injury risk reduction in female Australian football players.

Psychometric measurement properties of patient-reported and observer-reported outcome measures for spinal mobilisations and manipulation on paediatric subjects with diverse medical conditions: A systematic review.

INTRODUCTION: Reliable, valid, and responsive outcomes is foundational to address concerns about the risks and benefits of performing spinal manipulation and mobilization in pediatric populations. The aim of this systematic review was to synthesize evidence on measurement properties from cohort/case-control/cross-sectional/randomized studies on patient-reported (SQLI - Scoliosis Quality of Life Index; VAS-Visual Analog Scale; PAQLQ - Pediatric Asthma Quality of Life Questionnaire), observer-reported (Crying Diaries; ATEC - Autism Treatment Evaluation Checklist) and mixed (PedsQL - Pediatric Quality of Life Inventory) outcome measurements identified through a scoping review on manipulation and mobilization for pediatric populations with diverse medical conditions. METHOD AND ANALYSIS: Electronic databases, clinicaltrial.gov and Ebsco Open Dissertations were searched up to 21 October 202221 October 2022. Two independent reviewers selected studies, extracted data, and assessed risk of bias. Qualitative synthesis was performed using COSMIN and Cochrane GRADE methodology to establish the certainty of evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), indeterminate (?). RESULTS: Eighteen studies (2 SQLI for scoliosis; 1 VAS - perceived influence of exertion or movement/position on low back problems; 1 PAQLQ for asthma; 1 Crying Diaries for infantile colic; 8 ATEC for autism; 5 PedsQL for cerebral palsy/scoliosis/healthy) with 9653 participants were selected. ATEC and PedsQL had overall sufficient (+) measurement properties with moderate certainty evidence. PAQLQ had indeterminate measurement properties with moderate certainty evidence. Very low certainty of evidence identified measurement properties to be indeterminate (?) for SQLI, Crying Diaries, and VAS- perceived influence of exertion or movement/position on low back problems. CONCLUSION: ATEC for autism and PedsQL for asthma may be a suitable clinical outcome assessment (COA); additional validation studies on responsiveness and the minimal important difference are needed. Other COA require further validation.

Psychometric properties of clinician-reported and performance-based outcomes cited in a scoping review on spinal manipulation and mobilization for pediatric populations with diverse medical conditions: a systematic review.

INTRODUCTION: Risks and benefits of spinal manipulations and mobilization in pediatric populations are a concern to the public, policymakers, and international physiotherapy governing organizations. Clinical Outcome Assessments (COA) used in the literature on these topics are contentious. The aim of this systematic review was to establish the quality of clinician-reported and performance-based COAs identified by a scoping review on spinal manipulation and mobilization for pediatric populations across diverse medical conditions. METHOD AND ANALYSIS: Electronic databases, clinicaltrials.gov and Ebsco Open Dissertations were searched up to 21 October 2022. Qualitative synthesis was performed using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to select studies, perform data extraction, and assess risk of bias. Data synthesis used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to determine the certainty of the evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), or indeterminate (?). RESULTS: Four of 17 identified COAs (77 studies, 9653 participants) with supporting psychometric research were classified as:Performance-based outcome measures: AIMS - Alberta Infant Motor Scale (n = 51); or:Clinician-reported outcome measures: LATCH - Latch, Audible swallowing, Type of nipple, Comfort, Hold (n = 10),Cobb Angle (n = 15),Postural Assessment (n = 1).AIMS had an overall sufficient (+) rating with high certainty evidence, and LATCH had an overall sufficient (+) rating with moderate certainty of evidence. For the Cobb Angle and Postural Assessment, the overall rating was indeterminate (?) with low or very low certainty of evidence, respectively. CONCLUSION: The AIMS and LATCH had sufficient evidence to evaluate the efficacy of spinal manipulation and mobilization for certain pediatric medical conditions. Further validation studies are needed for other COAs.

Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review.

PURPOSE: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use. DESIGN: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021. PARTICIPANTS: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition. INTERVENTION: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored. METHOD: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach. RESULTS: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for 'no significant effect' of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition. CONCLUSION: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

Profiling the kicking and handballing accuracy of female Australian football players across five competition levels.

OBJECTIVES: To profile the kicking and handballing accuracy of female Australian football (AF) players and investigate potential differences across five competition levels. METHODS: Female AF players were classified into five competition levels: elite senior (≥18 years) (n=35), non-elite senior (≥18 years) (n=58), high-level junior (<18 years) (n=32), non-elite junior (14-17 years) (n=38), and non-elite junior (10-13 years) (n=42). Modified AF kicking and handballing tests examined accuracy outcomes. Competition level differences in accuracy were modelled using multivariate analysis of variance. RESULTS: A large, significant difference between the competition levels was noted (F=11.508, p<0.001, Wilk's Λ=0.462, η2p=0.227), with significant differences (p<0.001) observed in the modified AF kicking (ω2=0.514) and handballing (η2p=0.150-0.250) tests. Elite seniors and high-level juniors performed the modified AF kicking test more accurately than all non-elite competition levels (p≤0.001). Elite seniors were also more accurate in the modified AF handballing test (dominant hand) compared to all non-elite competition levels (p≤0.001). CONCLUSIONS: This study is the first to report technical skill characteristics in female AF across a broader participation pathway. These exploratory findings could be used as reference data for player development and inform training designs, namely by incorporating non-dominant handballing competitive play situations to develop this skill in female AF players.

Physical fitness profiles of female Australian football players across five competition levels.

OBJECTIVES: To examine physical fitness profiles of female Australian football players and investigate differences according to competition level. METHODS: A testing battery of 28 physical fitness assessments was undertaken with 240 players across five competition levels: elite senior (≥18 years), non-elite senior (≥18 years), high-level junior (<18 years), non-elite junior (14-17 years), and non-elite junior (10-13 years). Physical fitness profiles were examined and competition level differences were investigated using multivariate analyses of variance. RESULTS: Significant differences (p<0.001) were observed between competition levels in body composition (η2p=0.225), flexibility (η2p=0.071), muscular strength and endurance (η2p=0.238), balance (η2p=0.093), reaction time (η2p=0.103), and whole-body locomotor performance (η2p=0.200). Elite seniors and high-level juniors were stronger (p<0.001-0.043), faster (p=0.001-0.022), more responsive (p<0.001-0.048), and had better cardiorespiratory fitness (p<0.001) compared to the non-elite groups. Additionally, body composition and muscular strength and endurance differences were common between the senior and non-elite junior groups. CONCLUSIONS: This is the first study to comprehensively profile physical characteristics of female Australian footballers across a broader development pathway. These preliminary findings may assist sport practitioners to better understand athlete development, provide insight on talent identification and development programs, and injury management in this population.

Injury profiles of Australian football players across five, women's and girls' competition levels.

OBJECTIVES: To describe injury profiles of Australian football players and explore trends across five, women's and girls' competition levels. DESIGN: Prospective cohort study. METHODS: Injuries were prospectively recorded by team personnel across one or two seasons of Australian football (2017-18 and/or 2018-19) including five, women's and girls' competition levels (elite senior, non-elite senior, high-level junior, non-elite junior (14-17 years), and non-elite junior (10-13 years)). Injury incidence rates were calculated per 1000 h and injury prevalence calculated for pre-season, early-season, mid-season, and late-season. Descriptive statistics present injury profiles according to activity, body region, pathology, mechanism, and severity. RESULTS: From the 392 included players, 760 injuries were recorded. Overall injury incidence was 20.9 injuries per 1000 h. Injury prevalence was highest during pre-season (64.1%). Most injuries were to the lower extremity (n = 440; 58.0%). Ligament/joint sprain injuries were common (n = 147, 19.3%). Several injuries resulted from contact mechanisms (n = 314, 61.4%), with many due to contact with another player (n = 131, 52.8%). Injuries resulting in time lost from participation were common (n = 444, 58.9%). Competition level injury trends were observed, with elite senior (125.1 injuries per 1000 h) and high-level junior (116.9 injuries per 1000 h) players having greater match injury incidence compared to their non-elite counterparts (15.5-41.4 injuries per 1000 h). CONCLUSIONS: This study provides preliminary insight into injury profiles of Australian football players in women's and girls' competitions. These findings can drive future injury risk reduction research specific to this population across the developmental pathway.

The utility of physiotherapy assessments delivered by telehealth: A systematic review.

BACKGROUND: Telehealth use is increasing due to its ability to overcome service access barriers and provide continued care when disease transmission is of concern. However, little is known of the validity, reliability and utility of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. The aim of this systematic review was to determine the current clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all areas of physiotherapy practice. METHODS: A comprehensive search of databases (PubMed/MEDLINE, The Cochrane Library, Embase and EBSCO) was undertaken to identify studies investigating the clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. Following selection, a quality appraisal was conducted using the Brink and Louw or Mixed Methods Appraisal Tool. Evidence regarding validity, reliability and utility of synchronous telehealth physiotherapy assessments was extracted and synthesised using a critical narrative approach. RESULTS: Thirty-nine studies conducted in a variety of simulated (n = 15) or real-world telehealth environments (n = 24), were included. The quality of the validity, reliability and utility studies varied. Assessments including range of movement, muscle strength, endurance, pain, special orthopaedic tests (shoulder/elbow), Berg Balance Scale, timed up and go, timed stance test, six-minute walk test, steps in 360-degree turn, Movement Assessment Battery for Children (2nd Edition), step test, ABILHAND assessment, active straight leg raise, and circumferential measures of the upper limb were reported as valid/reliable in limited populations and settings (many with small sample sizes). Participants appeared to embrace telehealth technology use, with most studies reporting high levels of participant satisfaction. If given a choice, many reported a preference for in-person physiotherapy assessments. Some inconsistencies in visual/auditory quality and challenges with verbal/non-verbal communication methods were reported. Telehealth was considered relatively cost-effective once services were established. CONCLUSIONS: Performing physiotherapy assessments using synchronous forms of telehealth appears valid and reliable for specific assessment types in limited populations. Further research is needed in all areas of physiotherapy practice, to strengthen the evidence surrounding its clinometric value. Clinicians contemplating using this assessment mode should consider the client/family preferences, assessment requirements, cultural needs, environment, cost considerations, access and confidence using technology. PROTOCOL REGISTRATION: PROSPERO: CRD42018108166.

Physiotherapy and related management for childhood obesity: A systematic scoping review.

INTRODUCTION: Despite targeted efforts globally to address childhood overweight/obesity, it remains poorly understood and challenging to manage. Physiotherapists have the potential to manage children with obesity as they are experts in movement and physical activity. However, their role remains unclear due to a lack of physiotherapy-specific guidelines. This scoping review aims to explore existing literature, critically appraising and synthesising findings to guide physiotherapists in the evidence-based management of childhood overweight/obesity. METHOD: A scoping review was conducted, including literature up to May 2020. A review protocol exists on Open Science Framework at https://osf.io/fap8g/. Four databases were accessed including PubMed, Embase, CINAHL, Medline via OVID, with grey literature searched through google via "file:pdf". A descriptive synthesis was undertaken to explore the impact of existing interventions and their efficacy. RESULTS: From the initial capture of 1871 articles, 263 intervention-based articles were included. Interventions included qualitative focused physical activity, quantitative focused physical activity and multicomponent interventions. Various outcome measures were utilised including health-, performance- and behaviour-related outcomes. The general trend for physiotherapy involvement with children who are obese appears to favour: 1) multicomponent interventions, implementing more than one component with environmental modification and parental involvement and 2) quantitative physical activity interventions, focusing on the quantity of bodily movement. These approaches most consistently demonstrated desirable changes across behavioural and health-related outcome measures for multicomponent and quantitative physical activity interventions respectively. CONCLUSION: When managing children with obesity, physiotherapists should consider multicomponent approaches and increasing the quantity of physical activity, given consistent improvements in various obesity-related outcomes. Such approaches are well suited to the scope of physiotherapists and their expertise in physical activity prescription for the management of childhood obesity. Future research should examine the effect of motor skill interventions and consider the role of environmental modification/parental involvement as factors contributing to intervention success.

Directly Observed Physical Activity of Year 1 Children during School Class Time: A Cross-Sectional Study.

Providing physical activity opportunities to children throughout the school day may be beneficial for children's health and learning. Existing practices regarding the frequency, type and context of physical activity opportunities being provided to children in the early years of primary school remains largely unknown. The aim of this study was to observe Year 1 children's physical activity and its contexts during school class time and identify opportunities to incorporate additional activity. A cross-sectional study was conducted with 34 Year 1 children (20 boys, 14 girls; mean age = 6.36 ± 0.34 years) from one primary school in Queensland, Australia. A modified version of the Observational System for Recording Physical Activity in Children-Elementary School was used to assess children's physical activity and its contexts during class time. Observational data were collected over a four-week period. The frequencies (and percentages) of intervals of children's activity observed in sedentary, light and moderate-to-vigorous intensities during different instructional and social contexts and physical settings were recorded and calculated. Pearson's chi-square test of association was conducted to evaluate whether social context (group composition) was related to incidental physical activity. A total of 5305 observation intervals (i.e., 5 s observation interval followed by a 25 s recording interval) were available for analysis (~44 h of observation). Year 1 children were sedentary for the majority (86%) of observed intervals during school class time. Children spent limited time performing light (12% of intervals) and moderate-to-vigorous physical activity (2% of intervals). Organised physical activity observed during class time included physical education/school sport (5.9% of intervals) and classroom-based physical activity (2.8% of intervals). When children completed activities in small groups, they were significantly more likely to engage in incidental physical activity than when they completed activities as a whole class (χ2 = 94.73 p < 0.001). Incorporating movement into academic lessons or during transitions between lessons and classrooms may encourage children to be more active. Incidental physical activity may also be promoted through small group activities. Schools should ideally be encouraged and supported to employ a whole-of-school approach to physical activity promotion, which includes identifying and implementing opportunities for children to be active during class time.

The relationship between physical fitness attributes and sports injury in female, team ball sport players: a systematic review.

BACKGROUND: Understanding the relationships between physical fitness characteristics and sports injury may assist with the development of injury minimisation programs. The purpose of this systematic review was to investigate the association between physical fitness attributes and sports injury in female, team ball sport players. METHODS: Four scientific databases (MEDLINE, EMBASE, SPORTDiscus, Scopus) and reference lists of relevant research were searched for eligible studies up to September 2, 2019. Full-text articles examining the relationship between physical fitness and sports injury in female, team ball sport players were included. A modified Downs and Black checklist was used to assess methodological quality. Data synthesis determined summary conclusions based on the number of significant relationships divided by the total relationships investigated and reported as a percentage. Level of certainty was identified for summary conclusions based on level of evidence. Sub-analyses regarding competition level, age, and single injury types were also conducted. RESULTS: A total of 44 studies were included. Data synthesis revealed no associations (low to moderate certainty) between body composition (1/9; 11%), flexibility (18-20%), and balance (2/8; 25%) and 'any injury' classification. No associations (mostly of moderate certainty) were found between flexibility (0-27%), muscular strength (0-27%), and body composition (14-33%) and various body region injury classifications, whereas mixed summary conclusions were shown for balance (0-48%). Many associations between physical fitness and sports injury were deemed 'unknown' or with an insufficient level of certainty. Sub-analyses revealed no association between strength and noncontact ACL injuries (0/5; 0%) or ankle sprains (0/12; 0%), and between flexibility and ankle sprains (1/5; 20%); however, insufficient certainty of these results exists. Clear associations were concluded between balance and lower body injuries in female, non-elite (10/16; 63%) and junior (9/12; 75%) team ball sport players, with moderate and insufficient certainty of these results, respectively. CONCLUSION: Limited evidence is available to demonstrate relationships between physical fitness and sports injury in female, team ball sport players. High-quality evidence investigating the multifactorial nature of sports injury, including the interactions physical fitness qualities have with other injury determinants, is needed to better understand the role of physical fitness in minimising sports injuries in female, team ball sport players. TRIAL REGISTRATION: CRD42017077374 (PROSPERO on September 14, 2017).

The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis.

BACKGROUND: Lower limb serial casting is commonly used therapeutically in paediatric clinical practice with some evidence to support its efficacy. This systematic review aimed to determine the effects of serial casting in isolation or combination with other therapies for the management of lower limb dysfunction in children with Cerebral Palsy (CP). METHODS: A systematic literature search was conducted in February 2019 across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using key terms 'Cerebral Palsy' and 'serial casting' and associated synonyms. A meta-synthesis and meta-analysis were undertaken when sufficient results were available showing the effect of serial casting on functional outcomes including: Ankle range of motion; neurological measures of hypertonicity and spasticity, functional gait measures and; gross motor function. RESULTS: Twenty-five articles from 3219 possible citations were included. Serial casting was found to be effective for: Improving ankle dorsiflexion (DF) passive range of motion (PROM) in the immediate to short-term, decreasing hypertonicity measured by Modified Ashworth Scale (MAS) in the short-term and, enhancing functional gait outcomes in the mid-term. Serial casting with or without botulinum toxin type-A (BTX-A) did not significantly affect gross motor capacity measured by Gross Motor Function Measure (GMFM). Serial casting with pharmacological intervention achieved significantly more DF PROM than serial casting alone (MD - 3.19 degrees; 95% CI - 5.76 to - 0.62; P = 0.01; I2 = 0%), however the clinical importance of improving ankle DF PROM by an additional three degrees remains unclear. CONCLUSIONS: Lower limb serial casting, improves several outcomes relevant to lower limb function supporting its clinical use for improving DF PROM, reducing hypertonicity and improving gait in children with CP. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes such as gross motor function in children with CP. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.