'There are things I have learned the hard way' Patient experiences on lasting challenges 4 months after Transient Ischemic Attack: A qualitative study.

BACKGROUND: Fatigue, depression, anxiety and cognitive difficulties are reported by 1/3 of patients following transient ischemic attack (TIA). AIMS: To explore the timeline and how the diagnosis impacts individuals experiencing lasting challenges after TIA. Furthermore, to identify what they believed facilitated return to everyday life. DESIGN: Qualitative exploratory study with a phenomenological-hermeneutic approach. METHODS: Individual semi-structured interviews and thematic analysis. RESULTS: Fifteen patients were included. Four themes were identified; (1) 'They say it is transient - no, not for me' where all participants described lasting challenges emphasizing invalidating fatigue and impaired social participation, (2) 'I am a changed person; how does this impact my future?' which reflects altered identity and elevated alertness to symptoms, (3) 'Time has been my ally and new perspectives have evolved' where most participants described improvement over time and a few considered the diagnosis a wake-up call to change lifestyle. Lastly (4) 'What would have helped me recover?' which unfolds that close, trustful relations influence positively. In addition, the system often failed to support. Participants described pressure to return to work and lack of trust and negative experiences when involving their general practitioner. CONCLUSIONS: During the 4 months since diagnosis, participants experienced limitations impacting physical, psychological and social domains. They felt uninformed that lasting challenges could affect them. Different coping strategies were activated, and participants with close, supportive relations managed better. A pressure to return to work and a lack of trust in the general practitioner affected their recovery negatively. Overall, return to everyday life after TIA was considered stressful and appropriate support lacking. RELEVANCE TO CLINICAL PRACTICE: To be able to support patients with challenges following TIA, we as healthcare professionals need to understand the identified impact and life changing circumstances. Currently the system seemingly is not able to provide timely, sufficient and competent support. IMPACT (ADDRESSING): WHAT PROBLEM DID THE STUDY ADDRESS?: We know from the literature that up to 1/3 of patients following transient ischemic attack experience lasting challenges measured on a variety of questionnaires. This is paradoxical to a diagnosis defined by focal neurological symptoms that resolve within 24 h. It is unknown how patients with lasting challenges experience the timeline from diagnosis and until 4 months after, how the diagnosis impacts the lives of these individuals, and what they believe as beneficial in returning to their everyday life. WHAT WERE THE MAIN FINDINGS?: These participants with self-reported lasting challenges experienced substantial impacts on physical, psychological and social domains. Further, they felt alone with their struggles and when in need of support from the healthcare system, it failed to provide this. A pressure to return to work and a lack of trust in the general practitioner affected return to everyday life negatively, whereas close and supportive relations facilitated positively. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: This study will have an impact on the healthcare professionals that provide support and the (limited) follow-up services to patients after TIA. These healthcare professionals are often specialized nurses who need to know what these patients experience and need in order to act upon their struggles and provide timely support. REPORTING METHOD: The Standards of Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: Patients with TIA was involved in planning this study. They participated in a panel to plan a prospective observational cohort study and emphasized the importance of exploring the subjective perspectives of impact and prognosis for those patients struggling in a longer term (through qualitative interviews).

Item generation for a new patient-reported outcome measure: The non-traumatic anterior knee pain (AKP)-YOUTH scale.

BACKGROUND: Non-traumatic anterior knee pain affects one in every five adolescents. Despite the commonality of the condition, there are no patient-reported outcome measures developed specifically for this population. The aim of this study was to identify domains and develop a preliminary item bank for adolescents with non-traumatic anterior knee pain. PARTICIPANTS: Twenty-one adolescents with anterior knee pain participated in semi-structured interviews which explored their experience of living with knee pain. Following thematic analysis, we generated an item bank based on the domains which emerged from the impact their knee pain had on their daily life. Ten clinical experts provided input on the preliminary item bank via an online survey. Cognitive interviews were conducted using the think-aloud approach with ten adolescents to evaluate the comprehensibility and face validity of the items. RESULTS: From the interviews we identified four overarching domains where adolescents were impacted by their knee pain: knee symptoms, limitations in physical activity/sport, limitations in social activities, and emotional impact of pain. Eighteen items were initially developed and expanded to 23 following clinical expert input. The cognitive interviews with adolescents demonstrated that the items were comprehensive, understandable, and relevant for adolescents. CONCLUSION: This study developed an item bank of 23 items. These spanned four domains of impact for adolescents with anterior knee pain. The items had good face validity and were deemed relevant and understandable for adolescents with knee pain. Further steps are needed to validate and reduce the items for the non-traumatic anterior knee pain (AKP)-YOUTH scale.

Physical Therapists' Prognosis of Outcomes After a Hip or Quadriceps Exercise Intervention in Patients With Patellofemoral Pain: A Secondary Analysis of a Randomized Trial.

OBJECTIVE: Can physical therapists who are treating patients with patellofemoral pain (PFP) predict the outcome of a 12-week exercise intervention based on initial assessment, and what are the physical therapists' reasons for prediction? DESIGN: Secondary analysis of a randomized trial. METHODS: After the initial assessment, physical therapists were asked to predict the prognosis of 200 patients with PFP who were allocated to 12 weeks of quadriceps exercises (QEs) or hip exercises (HEs) on a 1-to-10 Likert scale, and to describe their reasoning for the prediction score. OUTCOMES: measures were changes from baseline to weeks 12 and 26 on the Anterior Knee Pain Scale (range 0-100) and a transition questionnaire (TransQ). Linear mixed-effects models were used to assess the prediction. Secondly, we used a qualitative approach to summarize the physical therapists' reasoning (written notes) when predicting the outcome. RESULTS: There was no association between physical therapists' prognosis and changes in Anterior Knee Pain Scale for QE or HE at weeks 12 and 26 (slopes: -0.14 to -0.51 with wide 95% confidence intervals). There was no association between physical therapists' assessment of prognosis using TransQ for QE or HE at weeks 12 and 26 (odds ratio: 0.99 to 1.17 with wide 95% confidence intervals). CONCLUSION: Physical therapists' prognosis based on initial assessment was not associated with outcomes after 12 weeks of either quadriceps or hip exercise therapy among patients with PFP. Physical therapists' prognoses were not useful as a source of information and to identify PFP patients with poor or good projected outcomes. J Orthop Sports Phys Ther 2024;54(8):541-550. Epub 6 June 2024. doi:10.2519/jospt.2024.12258.

Self-management including exercise, education and activity modification compared to usual care for adolescents with Osgood-Schlatter (the SOGOOD trial): protocol of a randomized controlled superiority trial.

BACKGROUND: Osgood-Schlatter is the most frequent growth-related injury affecting about 10% of physically active adolescents. It can cause long-term pain and limitations in sports and physical activity, with potential sequela well into adulthood. The management of Osgood-Schlatter is very heterogeneous. Recent systematic reviews have found low level evidence for surgical intervention and injection therapies, and an absence of studies on conservative management. Recently, a novel self-management approach with exercise, education, and activity modification, demonstrated favorable outcomes for adolescents with patellofemoral pain and Osgood-Schlatter in prospective cohort studies. AIM: The aim of this trial is to assess the effectiveness of the novel self-management approach compared to usual care in improving self-reported knee-related function in sport (measured using the KOOS-child 'Sport/play' subscale) after a 5-month period. METHODS: This trial is a pragmatic, assessor-blinded, randomized controlled trial with a two-group parallel arm design, including participants aged 10-16 years diagnosed with Osgood-Schlatter. Participants will receive 3 months of treatment, consisting of either usual care or the self-management approach including exercise, education, and activity modification, followed by 2 months of self-management. Primary endpoint is the KOOS-child 'Sport/play' score at 5 months. This protocol details the planned methods and procedures. DISCUSSION: The novel approach has already shown promise in previous cohort studies. This trial will potentially provide much-needed level 1 evidence for the effectiveness of the self-management approach, representing a crucial step towards addressing the long-term pain and limitations associated with Osgood-Schlatter. TRIAL REGISTRATION: Clinicaltrials.gov: NCT05174182. Prospectively registered December 30th 2021. Date of first recruitment: January 3rd 2022. Target sample size: 130 participants.

Feasibility of an early progressive resistance exercise program for acute Achilles tendon rupture.

BACKGROUND: Long-term strength deficits are common after Achilles tendon ruptures. Early use of progressive resistance exercises may help reduce strength deficits, but the feasibility of this approach is unknown. The aim was to investigate the feasibility of early progressive resistance exercises regarding patient acceptability and compliance with the intervention. METHODS: We recruited patients with an acute Achilles tendon rupture treated non-surgically. During 9 weeks of immobilisation with a walking boot, participants attended weekly supervised physiotherapy sessions of progressive resistance exercises and performed home exercises, consisting of isometric ankle plantarflexion, seated heel-rise, and elastic band exercises. Acceptability was evaluated using a 7-point Likert scale (1 = very unacceptable and 7 = very acceptable) with feasibility threshold at 80% of the participants rating ≥ 4. Adherence to the exercises was defined as 80% of the participants performing at least 50% of the home exercises. During the intervention, tendon healing and adverse events were monitored. RESULTS: Sixteen participants (mean age 46 (range 28-61), male/female = 13/3) completed the intervention. Pre-injury Achilles tendon total rupture score was 98 (SD 8). All participants rated the acceptability of the exercises ≥ 5 (moderate acceptable to very acceptable) at 9- and 13-week follow-up and 9/16 rated 7 points (very acceptable). Participants performed 74% (range 4-117) of the total prescribed home exercises and 15/16 performed > 50%. One participant was not compliant with the home exercises due to feeling uncomfortable performing these independently. There were no re-ruptures, but one case of deep venous thrombosis. CONCLUSIONS: The early progressive resistance exercise program for treatment of non-surgically treated Achilles tendon rupture was feasible. Future studies should investigate the efficacy of the progressive intervention. TRIAL REGISTRATION: The study was registered at Clinical Trials (NCT04121377) on 29 September 2019. CLINICALTRIALS: NCT04121377 .

"I Feel Like I Have Lost Part Of My Identity" - A Qualitative Study Exploring The Impact Of Chronic Ankle Instability.

Introduction: Lateral ankle sprain is the most common ankle injury and up to 40% of those who sustain a lateral ankle sprain will develop chronic ankle instability (CAI). The aim of this study was to explore the thoughts and expectations of CAI-patients concerning their condition and expectations of care in an orthopedic setting. . Study Design: Qualitative study. Methods: Nine semi-structured one-to-one interviews were conducted with CAI-patients who were referred to an orthopedic setting. Interviews were recorded, transcribed, and analyzed using systematic text condensation with an inductive goal free approach. . Results: Seven themes emerged. The themes were Injury history and symptoms (Lateral ankle sprain during sport, pain and instability), Information from health professional (conflicting information about management and prognosis), Management (mental and physical challenges), Expectation and hope (explanation of symptoms, prognosis and imaging to provide clarification of condition), Activity and participation (restriction in sport and daily life and feelings of uncertainty), Support (support from family/friends) and Identity (low ability to participate in sport and social life result in loss of identity). . Conclusion: The impact of CAI exceeds an experience of pain and instability. Patients experienced loss of identity, having to manage uncertainty regarding their diagnosis and prognosis and had hopes of being able to explain their condition. . Level of Evidence: Not applicable.

Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns.

OBJECTIVES: Management of patients with chronic musculoskeletal pain (CMP) remains a challenge in general practice. The general practitioner (GP) often experiences diagnostic uncertainty despite frequently referring patients with CMP to specialized departments. Therefore, it remains imperative to gain insights on how to optimize and reframe the current setup for the management of patients with CMP. The objective was to explore GP's perspectives on the challenges, needs, and visions for improving the management of patients with CMP. METHODS: A qualitative study with co-design using the future workshop approach. Eight GPs participated in the future workshop (five females). Insights and visions emerged from the GP's discussions and sharing of their experiences in managing patients with CMP. The audio-recorded data were subjected to thematic text analysis. RESULTS: The thematic analysis revealed four main themes, including (1) challenges with current pain management, (2) barriers to pain management, (3) the need for a biopsychosocial perspective, and (4) solutions and visions. All challenges are related to the complexity and diagnostic uncertainty for this patient population. GPs experienced that the patients' biomedical understanding of their pain was a barrier for management and underlined the need for a biopsychosocial approach when managing the patients. The GPs described taking on the role of coordinators for their patients with CMP but could feel ill-equipped to handle diagnostic uncertainty. An interdisciplinary unit was recommended as a possible solution to introduce a biopsychosocial approach for the examination, diagnosis, and management of the patient's CMP. CONCLUSIONS: The complexity and diagnostic uncertainty of patients with CMP warrants a revision of the current setup. Establishing an interdisciplinary unit using a biopsychosocial approach was recommended as an option to improve the current management for patients with CMP.

Translation, contextual adaptation, and reliability of the Danish Concept of Pain Inventory (COPI-Adult (DK)) - A self-reported outcome measure.

OBJECTIVES: Pain is a growing concern globally, and an individual and societal burden. Pain science education (PSE) is a promising avenue for managing chronic pain, but targeted PSE is needed. The Concept of Pain Inventory for Adults (COPI-Adult) is a newly developed self-reported outcome measure aimed at targeting PSE. It is currently unavailable in Danish and has unknown reliability. The aims of this study were (1) to translate and contextually adapt to Danish and (2) to determine reliability in terms of test-retest reliability, internal consistency, and measurement error. METHODS: Step (1) was as follows: a dual panel approach was used to translate, contextually adapt into a Danish version. Step (2) was follows: a heterogenic sample of Danish adults >18 years (n = 150) was included in the test-retest analysis, test interval between 7 and 14 days, both answered via REDCap-link. Based on COSMIN recommendations, the following reliabilities were estimated: the test-retest using intraclass correlation coefficient (ICC2.1) and internal consistency using Cronbach's alpha level. Measurement error in terms of standard error of measurement (SEM) and smallest detectable change (SDC) were calculated. RESULTS: Step (1) was as follows: the first panel reached 100% consensus on the wording of the COPI-Adult (DK), with no alterations by the second panel. Step (2) was as follows: good to excellent test-retest reliability was found with ICC2.1 value (95% confidence interval) 0.88 (0.84-0.91), excellent internal consistency for the 13-item COPI-Adult (DK) with α = 0.939, SEM of 2.53, and SDC of 7.02. DISCUSSION: The COPI-Adult (DK) was successfully translated and contextually adapted. It is a reliable questionnaire with excellent internal consistency. The COPI-Adult (DK) shows promise in research and clinical practice.

There is a Lack of Clinical Homogeneity in Lower-Limb Tendinopathy Trials: A Scoping Review.

OBJECTIVE: It is unclear if clinical trials of treatments for lower-limb tendinopathies include clinically homogeneous participant populations (an assumption for pooling in meta-analyses). We assessed the recruitment setting and participant characteristics used in randomized controlled trials (RCTs) that were investigating any treatment for lower-limb tendinopathies. DESIGN: Scoping review. METHODS: We conducted a systematic literature search in the PubMed, Embase, Cochrane CENTRAL, and Web of Science databases. All RCTs that were investigating treatments for lower-limb tendinopathies in an adult population (≥18 years) were eligible for inclusion. At least 2 authors conducted independent screening and selection of full-text papers, and extracted data from included studies. RESULTS: Of 18 341 records, 342 RCTs (21 897 participants) were eligible for inclusion and data extraction. The most common diagnoses were plantar fasciopathy (n = 195, 57%), Achilles tendinopathy (n = 82, 24%), and patellar tendinopathy (n = 41, 12%). Secondary care (n = 144, 42%) was the most reported recruitment setting, followed by an open setting (n = 44, 13%). In 93 (27%) RCTs, the recruitment setting was not described. We found high heterogeneity in participant characteristics (eg, symptom duration, age, body mass index, and the Victorian Institute of Sport Assessment [VISA] questionnaire score) within and between recruitment settings. CONCLUSION: Our results question whether clinical homogeneity can be adequately assumed in clinical trials of lower-limb tendinopathies due to the lack of clear reporting of the recruitment setting and the variability within and between recruitment settings of key participant characteristics. These findings threaten assumptions for meta-analyses in lower-limb tendinopathies. J Orthop Sports Phys Ther 2024;54(1):1-10. Epub 5 December 2023. doi:10.2519/jospt.2023.11722.

Competences to self-manage low back pain among care-seeking adolescents from general practice - a qualitative study.

BACKGROUND: There is limited knowledge about when and how adolescents with low back pain (LBP) interact with health care providers. This limits our understanding of how to best help these young patients. This study aimed to understand when and how care-seeking adolescents with LBP interact with health care providers and which health literacy competencies and strategies do they use to self-managing their LBP. METHOD: Ten semi-structured interviews (duration 20-40 min) were conducted online among adolescents aged 15-18 with current or recent LBP (pain duration range; 9 months - 5 years). The interview guide was informed by literature on health literacy and self-management in patients. We conducted a semantic and latent thematic data analyses. RESULTS: Three major themes emerged from the analysis: (1) Self-management, (2) Pain and Function, and (3) Communication. All adolescents were functionally limited by their pain but the main reason to consult a health care provider was an increase in pain intensity. Many were able to navigate the healthcare system, but experienced difficulties in communicating with health care providers, and many felt that they were not being taken seriously. Their first line self-management option was often over-the-counter pain medicine with limited effects. Most adolescents expressed a desire to self-manage their LBP but needed more guidance from health care providers. CONCLUSION: Adolescents with LBP seek care when pain intensifies, but they lack self-management strategies. Many adolescents want to self-manage their LBP with guidance from health care providers, but insufficient communication is a barrier for collaboration on self-management.

Exploring the barriers and facilitators for supporting adolescents with knee pains adherence to mobile health apps: A think-aloud study.

Background: Mobile health (mHealth) applications have the potential to support adolescents' self-management of knee pain. However, ensuring adherence remains a barrier when designing mHealth concepts for adolescents. Objective: This study aimed to explore barriers and facilitators for adhering to mHealth interventions to inform design principles. Methods: Think-aloud tests were conducted with 12 adolescents (aged 12.5 years median) with knee pain, using a low-fidelity prototype. The prototype was informed by the authors previous work, rapid prototyping sessions with seven health professionals, and synthesis via the Behavioral Intervention Technology Model. The think-aloud tests were video recorded and analyzed thematically to identify design principles. Results: The analysis based on user testing with adolescents with knee pain identified three themes: "user experience and feedback," "contextual challenges," and "new features" and nine subthemes. Adolescents were able to use mHealth behavioral features such as self-tracking, goal setting, education, and data visualization to capture and reflect on their knee pain developments, which facilitated use. However, adolescents struggle with timing interventions, breaking down management behaviors, and biases towards interventions were identified as internal threats to adherence. Competing activities, parental meddling, and privacy concerns were external adherence barriers. Twelve design principles were identified for integrating these insights into mHealth designs. Conclusion: Participants' motivations for adherence were influenced by internal and external factors. While adolescents were able to use mHealth behavioral features to capture and reflect on knee pain developments, understanding how to accommodate adolescents' cognitive abilities, competing activities, and need for independence is quintessential to enhance adherence in everyday contexts.

Exploring the pain and disability continuum in adolescents with non-traumatic anterior knee pain: a mediation analysis using individual participant data of prospective studies.

OBJECTIVE: To use individual patient data (IPD) to investigate if the effect of pain on sports-related disability is mediated through physical (lower extremity isometric strength) or psychological (depression/anxiety and knee confidence) factors in adolescents with non-traumatic anterior knee pain. METHODS: This study included four datasets from a previously harmonised IPD dataset. Prior to analysis, the protocol and analysis approach were predefined and published on Open Science Framework. Potential mediators were pre-sepcified as isometric knee and hip strengths, self-reported anxiety/depression and confidence in the knee, allmeasured at 12 weeks after baseline evaluation. Mediation analyses were undertaken using the CMAVerse package in RStudio using the regression-based approach to decompose the total effect of the exposure (pain at baseline evaluation) on the outcome (sports-related disability at 6 months) into the 'indirect effect' (the portion of the total effect acting through the mediators) and the 'direct effect'. RESULTS: Two-hundred and seventy-nine adolescents with non-traumatic knee pain were included in the analysis. Median age was 13 (range 10-19), and 72% were women. Baseline pain was associated with sports-related disability at 6 months. There was no evidence of the association being mediated by any of the proposed mediators (total natural indirect effect for strength 0.01 (-1.14 to 1.80) and psychological factors 0.00 (-0.66 to 2.02)). CONCLUSION: We found an effect of pain on sports-related disability at 6 months which appears to be independent of lower extremity muscle strength, or depression/anxiety and knee confidence in adolescents with non-traumatic anterior knee pain.

What matters to people with chronic musculoskeletal pain consulting general practice? Comparing research priorities across different sectors.

OBJECTIVES: Chronic musculoskeletal pain (CMP) is a common condition, often consulted in general practice. Our previous study identified research priorities among people with CMP using a broad recruitment strategy. It is unclear whether these research priorities reflect specific settings, including the population in general practice. Potential dissimilarities may have important implications for future research. Therefore, the study aims to explore potential differences between the previously established research priorities compared to priorities of people with CMP consulting general practice. METHODS: Eighty-eight people living with CMP (51 females/37 males) from four regions of Denmark were recruited when they consulted their general practitioner. Participants were presented to an online survey and asked to prioritise predefined research themes (n=14) and research questions (n=38). The prioritisations were summarised into a Top-10 research priorities and compared the Top-10 from our previous study. RESULTS: Treatment (n=57), diagnosis (n=46), cross-sectoral management (n=39) and influence on daily life (n=39) were the most selected research themes. The most prioritised research questions regarded the effectiveness of treatments and cross-sectoral management, improving diagnostic approaches and how pain affects the individuals' mental state. Four out of ten research questions aligned with our previous Top-10. CONCLUSIONS: Our study identified several differences in research priorities between people living with CMP from the general population and from general practice. These findings highlight the needs for investigating how different settings influence research prioritisation. This adds important knowledge for researchers and policymakers focusing on future research within the management of CMP.

The potential effect of walking on quantitative sensory testing, pain catastrophizing, and perceived stress: an exploratory study.

OBJECTIVES: Studies suggest that a range of pain mechanisms, such as poor quality of sleep, perceived stress, pain catastrophizing or pain sensitivity, are likely to enhance clinical pain. Animal studies suggest that these pain mechanisms can be modulated by increasing physical activity, but human data are needed to support this hypothesis. This exploratory study aimed to investigate the changes in pain mechanisms after a simple self-directed walking program of 8-weeks. Additionally, this exploratory study investigated the interaction between changes over time in assessments of poor quality of sleep, perceived stress, pain catastrophizing or pain sensitivity and how these changes interacted with each other. METHODS: This prospective cohort study included 30 healthy subjects who were assessed at baseline and 4- and 8-weeks after initiating the walking program (30 min walking/day for 8 weeks). Self-report outcomes included: Pain Catastrophizing Scale (PCS), the Perceived Stress Scale (PSS) and Pittsburgh Sleep Quality Index. Pressure pain thresholds, temporal summation of pain and conditioned pain modulation (CPM) were assessed using cuff algometry. RESULTS: Twenty-four subjects completed all the visits (age: 42.2, SD: 14.9, 16 females). PCS and PSS significantly decreased at the 8-week's visit compared to baseline (p<0.05). No significant differences were seen for an improvement in quality of sleep (p=0.071) and pain sensitivity (p>0.075) when comparing the 8-week's visit to the baseline visit. Changes in pain mechanisms comparing baseline and 8-weeks data were calculated and regression analyses found that an improvement in PCS was associated with an improvement in CPM (R2=0.197, p=0.017) and that a higher adherence to the walking program was associated with a larger improvement in PCS (R2=0.216, p=0.013). CONCLUSIONS: The current exploratory study indicates that a simple self-directed walking program of 8-weeks can improve pain catastrophizing thoughts, perceived stress. Higher adherence to the walking program were associated with an improvement in pain catastrophizing and an improvement in pain catastrophizing was associated with an increase in conditioned pain modulation.

The development of an informative leaflet for children and adolescents suffering from Osgood-Schlatter disease.

The mainstay in the treatment of Osgood-Schlatter Disease (OSD) is guidance on activity modification alongside exercises. The purpose of this study was to create an informative leaflet for patients with OSD, based on evidence and stakeholders perspectives. A synthesis of the literature, including national reference work, clinical research, and systematic reviews informed the initial leaflet. Twelve children with OSD and four clinical experts provided feedback through semi-structured interviews. After incorporating stakeholder input, the leaflet 'Osgood-Schlatter-Information and guidance' was developed. This provides a resource to assist the provision of information and translation of the current evidence.

Does a corticosteroid injection plus exercise or exercise alone add to the effect of patient advice and a heel cup for patients with plantar fasciopathy? A randomised clinical trial.

OBJECTIVE: To compare the effectiveness of patient advice plus heel cup alone (PA) versus PA and lower limb exercise (PAX) versus PAX plus corticosteroid injection (PAXI) to improve self-reported pain in patients with plantar fasciopathy. METHODS: We recruited 180 adults with plantar fasciopathy confirmed by ultrasonography for this prospectively registered three-armed, randomised, single-blinded superiority trial. Patients were randomly allocated to PA (n=62), PA plus self-dosed lower limb heavy-slow resistance training consisting of heel raises (PAX) (n=59), or PAX plus an ultrasound-guided injection of 1 mL triamcinolone 20 mg/mL (PAXI) (n=59). The primary outcome was changed in the pain domain of the Foot Health Status Questionnaire (ranging from 0 'worst' to 100 'best') from baseline to the 12-week follow-up. The minimal important difference in the pain domain is 14.1 points. The outcome was collected at baseline and at 4, 12, 26, and 52 weeks. RESULTS: The primary analysis found a statistically significant difference between PA and PAXI after 12 weeks favouring PAXI (adjusted mean difference: -9.1 (95% CI -16.8 to -1.3; p=0.023)) and over 52 weeks (adjusted mean difference: -5.2 (95% CI -10.4 to -0.1; p=0.045)). At no follow-up did the mean difference between groups exceed the pre-specified minimal important difference. No statistically significant difference was found between PAX and PAXI or between PA and PAX at any time. CONCLUSION: No clinically relevant between-group differences were found after 12 weeks. The results indicate that combining a corticosteroid injection with exercise is not superior to exercise or no exercise. TRIAL REGISTRATION NUMBER: NCT03804008.

Do adolescents with Osgood-Schlatter display nociplastic pain manifestations compared to controls: A cross-sectional study.

OBJECTIVES: Osgood-Schlatter disease is an overuse musculoskeletal pain condition. The pain mechanism is considered nociceptive, but no studies have investigated nociplastic manifestations. This study investigated pain sensitivity and inhibition evaluated through exercise-induced hypoalgesia in adolescents with and without Osgood-Schlatter. DESIGN: Cross-sectional study. METHODS: Adolescents underwent a baseline assessment comprising clinical history, demographics, sports participation, and pain severity rated (0-10) during a 45-second anterior knee pain provocation test, consisting of an isometric single leg squat. Pressure pain thresholds were assessed bilaterally at the quadriceps, tibialis anterior muscle, and the patella tendon before and after a three-minute wall squat. RESULTS: Forty-nine adolescents (27 Osgood-Schlatter, 22 controls) were included. There were no differences in the exercise-induced hypoalgesia effect between Osgood-Schlatter and controls. Overall, an exercise-induced hypoalgesia effect was detected at the tendon only in both groups with a 48 kPa (95 % confidence interval 14 to 82) increase in pressure pain thresholds from before to after exercise. Controls had higher pressure pain thresholds at the patellar tendon (mean difference 184 kPa 95 % confidence interval 55 to 313), tibialis anterior (mean difference 139 kPa 95 % confidence interval 24 to 254), and rectus femoris (mean difference 149 kPa 95 % confidence interval 33 to 265). Higher anterior knee pain provocation severity was associated with lower exercise-induced hypoalgesia at the tendon (Pearson correlation = 0.48; p = 0.011) in participants with Osgood-Schlatter. CONCLUSIONS: Adolescents with Osgood-Schlatter display increased pain sensitivity locally, proximally, and distally but similar endogenous pain modulation compared to healthy controls. Greater Osgood-Schlatter severity appears to be associated with less efficient pain inhibition during the exercise-induced hypoalgesia paradigm.

Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial.

OBJECTIVE: To assess effectiveness equivalence between two commonly prescribed 12-week exercise programmes targeting either the quadriceps or the hip muscles in patients with patellofemoral pain (PFP). METHODS: This randomised controlled equivalence trial included patients with a clinical diagnosis of PFP. Participants were randomly assigned to either a 12-week quadriceps-focused exercise (QE) or a hip-focused exercise (HE) programme. The primary outcome was the change in Anterior Knee Pain Scale (AKPS) (0-100) from baseline to 12-week follow-up. Prespecified equivalence margins of ±8 points on the AKPS were chosen to demonstrate comparable effectiveness. Key secondary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire pain, physical function and knee-related quality of life subscales. RESULTS: 200 participants underwent randomisation; 100 assigned to QE and 100 to HE (mean age 27.2 years (SD 6.4); 69% women). The least squares mean changes in AKPS (primary outcome) were 7.6 for QE and 7.0 for HE (difference 0.6 points, 95% CI -2.0 to 3.2; test for equivalence p<0.0001), although neither programme surpassed the minimal clinically important change threshold. None of the group differences in key secondary outcomes exceeded predefined equivalence margins. CONCLUSION: The 12-week QE and HE protocols provided equivalent improvements in symptoms and function for patients with PFP. TRIAL REGISTRATION NUMBER: NCT03069547.

Quality of life in adolescents with longstanding non-traumatic knee pain: An analysis of 316 adolescents with Patellofemoral Pain and Osgood-Schlatter Disease.

OBJECTIVES: To describe the Quality of Life (QoL) among adolescents with Patellofemoral Pain (PFP) and Osgood-Schlatter Disease (OSD) and investigate characteristics associated with QoL. STUDY DESIGN: Cross-sectional. PARTICIPANTS: 316 adolescents with PFP or OSD. MAIN OUTCOME MEASURES: QoL subscale of The Knee injury and Osteoarthritis Outcome Score (KOOS) and the EuroQol 5-dimensions (EQ-5D). RESULTS: The KOOS-QoL was 51 ± 18, and the total index score for the EQ5D was 0.67 ± 0.21. KOOS-QoL subscale showed that 60% reported being aware of their knee problems daily or constantly, 38% reported severe to extreme lack of confidence in their knees, 28% reported severe to extreme difficulty with their knees, and 20% reported severely or totally modifying their lifestyle to avoid potentially damaging activities to their knee. EQ-5D showed that 79% experienced problems with everyday activities, 48% reported mobility problems, 17% felt worried, sad, or unhappy, and 7% reported problems looking after themselves. CONCLUSIONS: Many adolescents with longstanding non-traumatic knee pain experience low QoL. More than half were aware of their knee problems at least daily, one in three reported a severe lack of confidence in their knee, and one in six felt worried, sad, or unhappy.

Development of a tool to support general practitioners to help adolescents with knee pain: an analysis using the Theoretical Domains Framework.

AIM: Using the Theoretical Domains Framework (TDF) and COM-B model, this study aimed to determine the facilitators to a support tool for adolescent non-traumatic knee pain in general practice. BACKGROUND: Many children and adolescents with non-traumatic knee pain consult their general practice. Currently, there are no tools to support general practitioners in the diagnosis and management of this group. There is a need to identify behavioural targets that would facilitate further development and implementation of such a tool. METHODS: This study was designed as a qualitative study using focus group interviews with 12 medical doctors working in general practice. The semi-structured focus group interviews conducted online and followed an interview guide based on the TDF and COM-B model. Data were analysed via thematic text analysis. FINDINGS: One of the biggest challenges from the general practitioner's perspective was how to manage and guide adolescents with non-traumatic knee pain. The doctors had doubts in their capability to diagnose knee pain and saw opportunity to help structure the consultation. The doctors felt motivated to use a tool but considered access a potential barrier. Increasing opportunity and motivation by creating access in the community among general practitioners was considered important. We identified several barriers and facilitators for a support tool for the management of adolescent non-traumatic knee pain in general practice. To align with user needs, future tools should support diagnostic workup, structure the consultation and be easily available among doctors working in general practice.