A qualitative study to explore the experiences of first contact physiotherapy practitioners in the NHS and their experiences of their first contact role.

PURPOSE: First Contact Practitioner (FCP) roles have been developed for health professionals with advanced practice skills to take on many of the musculoskeletal responsibilities currently carried out by general practitioners. FCP roles are new and still developing. Currently there is little research that has investigated the experiences of FCPs. This knowledge could help stakeholders and other clinicians gain an understanding into what makes a successful FCP role. The aim of this research was to explore the experiences of FCP working in North West England to gain insight into the first point of contact service, and their experiences of this developing full time FCP role. METHODS: A qualitative design using in-depth semi-structured, face-to-face interviews was undertaken to explore the experiences of FCP providing a first point of contact service. The study took place in an economically deprived and ethnically diverse location in North West England. FINDINGS: Ten FCPs were recruited, four were appointed from Band 6 posts to FCP training posts, 9 were male. The mean years qualified was 12.8. Five themes were identified: 1. 'It's the level of clinical complexity that you're dealing with', 2. FCP role - rewards and challenges, 3. Own wellbeing, 4. Professional development and education, 5. Realities of working in practice governed by business. CONCLUSION: FCP roles are an exciting development for people with MSK conditions, the physiotherapy profession, primary care providers and MSK physiotherapists. Mentorship support, workload and standards of training and practice are important when considering future expansion for the sustainability of these roles.

IGF signalling in germ cells and testicular germ cell tumours: roles and therapeutic approaches.

The insulin-like growth factor (IGF) axis plays key roles in normal tissue growth and development as well as in the progression of several tumour types and their subsequent growth and progression to a metastatic phenotype. This review explores the role of IGF system in normal germ cell development and function in addition to examining the evidence for deregulation of IGF signalling in cancer, with particular relevance to evidence supporting a role in testicular germ cell tumours (TGCTs). Despite the clear preclinical rationale for targeting the IGF axis in cancer, there has been a lack of progress in identifying which patients may benefit from such therapy. Future employment of agents targeting the IGF pathway is expected to concentrate on their use in combination with other treatments to prevent resistance and exploit their potential as chemo- and radiosensitizers.

The effects of three quarter and full length foot orthoses on knee mechanics in healthy subjects and patellofemoral pain patients when walking and descending stairs.

BACKGROUND: An increased load of the patellofemoral joint is often attributed to foot function in patients with patellofemoral pain. Foot orthoses are commonly prescribed for this condition; however the mechanisms by which they work are poorly understood. The aim of this study was to investigate the kinematics and kinetics of the knee between patellofemoral pain patients and a group of healthy subjects when using a standardised foot orthosis prescription during walking and step descent. METHOD: Fifteen healthy subjects and fifteen patients diagnosed with PFP with a foot posture index greater than 6, had foot orthoses moulded to their feet. They were asked to walk at a self-selected pace and complete a 20 cm step descent using customised orthoses with ¾ and full length wedges. Kinematic and Kinetic data were collected and modelled using Calibrated Anatomical System Technique. RESULTS: Significant differences were seen in both the kinematics and kinetics between the healthy group and the PFP patients at the knee. A significant reduction in the knee coronal plane moment was found during the forward continuum phase of step descent when wearing the foot orthoses; this was attributed to a change in the ground reaction force as there were no changes reported in the kinematics of the knee with the orthoses. CONCLUSIONS: This study identified potentially clinically important differences in the knee mechanics between the PFP patients and the healthy group during walking and step descent. The foot orthoses reduced the coronal plane knee moment in the PFP patients to a value similar to that of the healthy subjects with no intervention.

Torque-angle-velocity Relationships and Muscle Performance of Professional and Youth Soccer Players.

Soccer matches consist of a variety of different activities, including repeated sprints. Time to attain velocity (TTAV), load range (LR) and the torque-angle-velocity relationship (TAV3D) represent an important measurement of muscle performance, however there are few related studies. The aim of this study was to compare these outcomes between soccer players of different age category. 17 professional (PRO) and 17 under-17 (U17) soccer players were assessed for concentric knee flexion/extension at 60, 120 and 300°/s. For the extensor muscles, differences were found in favor of the U17 group for TTAV and LR outcomes at 120°/s, however, the PRO group maintained higher torques in both movement directions in comparison to the U17 in TAV3D evaluation. These results suggest that muscle performance of the PRO group is more efficient than the U17 group.

The effect of proprioceptive knee bracing on knee stability during three different sport related movement tasks in healthy subjects and the implications to the management of Anterior Cruciate Ligament (ACL) injuries.

INTRODUCTION: Proprioceptive knee braces have been shown to improve knee mechanics, however much of the work to date has focused on tasks such as slow step down tasks rather than more dynamic sporting tasks. OBJECTIVE: This study aimed to explore if such improvements in stability may be seen during faster sports specific tasks as well as slower tasks. METHOD: Twelve subjects performed a slow step down, single leg drop jump and pivot turn jump with and without a silicone web brace. 3D kinematics of the knee were collected using a ten camera Qualisys motion analysis system. Reflective markers were placed on the foot, shank, thigh and pelvis using the Calibrated Anatomical Systems Technique. A two way ANOVA with repeated measures was performed with post-hoc pairwise comparison to explore the differences between the two conditions and three tasks. RESULTS: Significant differences were seen in the knee joint angles and angular velocities in the sagittal, coronal and transverse planes between the tasks. The brace showed a reduction in knee valgum and internal rotation across all tasks, with the most notable effect during the single leg drop jump and pivot turn jump. The transverse plane also showed a significant reduction in the external rotation knee angular velocity when wearing the brace. DISCUSSION: The brace influenced the knee joint kinematics in coronal and transverse planes which confirms that such braces can have a significant effect on knee control during dynamic tasks. Further studies are required exploring the efficacy of proprioceptive braces in athletic patient cohort.

The Influence of Minimalist Footwear on Knee and Ankle Load during Depth Jumping.

Plyometric training is used by athletes to promote strength and explosive power. However plyometric activities such as depth jumping are associated with a high incidence of injuries. This study examined the influence of minimalist and conventional footwear on the loads experienced by the patellofemoral joint and Achilles tendon. Patellofemoral and Achilles tendon forces were obtained from ten male participants using an eight-camera 3D motion capture system and force platform data as they completed depth jumps in both footwear conditions. Differences between footwear were calculated using paired t-tests. The results show that the minimalist footwear were associated with significantly lower patellofemoral contact force/pressure and also knee abduction moment. It is therefore recommended, based on these observations, that those who are susceptible to knee pain should consider minimalist footwear when performing plyometric training.

Sex differences in knee loading in recreational runners.

Patellofemoral pain is the most common chronic pathology in recreational runners. Female runners are at greater risk of developing patellofemoral pain, although the exact mechanism behind this is not fully understood. This study aimed to determine whether female recreational runners exhibit distinct knee loading compared to males. Fifteen males and 15 females recreational runners underwent 3D running analysis at 4.0 ms(-1)±5%. Sagittal/coronal joint moments, patellofemoral contact forces (PTF) and pressures (PCP) were compared between sexes. The results show that females exhibited significantly greater knee extension (p<0.008, pη(2)=0.27: males=3.04; females=3.47 N m kg(-1)) and abduction (p<0.008, pη(2)=0.28: males=0.54; females=0.82 N m kg(-1)) moments as well as PTF (p<0.008, pη(2)=0.29: males=3.25; females=3.84 B.W.) and PCP (p<0.008, pη(2)=0.26: males=7.96; females=9.27 MPa) compared to males. Given the proposed relationship between knee joint loading and patellofemoral pathology, the current investigation provides insight into the incidence of patellofemoral pain in females.

Exploring aspects of physiotherapy care valued by breast cancer patients.

OBJECTIVE: To explore the reported value of physiotherapy care received by patients who had accessed a Specialist Breast Care Physiotherapy Service. DESIGN: Exploratory qualitative study using in-depth interviews to explore aspects of physiotherapy care valued by breast cancer patients. Thematic network analysis was used to interpret the data and bring together the different experiences of the participants and identify common themes. SETTING: Physiotherapy Department at a NHS Foundation Trust Teaching Hospital. PARTICIPANTS: Nineteen participants were recruited and three were selected to take part in the in-depth interviews. All participants had received physiotherapy care from a Specialist Breast Care Physiotherapy Service and had been discharged within the last six months. RESULTS: Participants valued a patient-centred holistic approach to care and access to a Specialist Service with an experienced clinician. In particular the importance of the therapeutic alliance and the value of psychological, emotional and educational support emerged, with the participants feeling empowered in their recovery. CONCLUSION AND CLINICAL IMPLICATIONS: Participants reported an overall positive experience of their physiotherapy care. This study supports the need for service providers to evaluate their current physiotherapy provision and subsequently develop Specialised Services to meet the physiotherapy needs of breast cancer patients throughout all stages of their treatment pathway from the delivery of pre-operative care through to post-treatment follow-up.

Effects of whole body cryotherapy and cold water immersion on knee skin temperature.

This study sought to (a) compare and contrast the effect of 2 commonly used cryotherapy treatments, 4 min of -110 °C whole body cryotherapy and 8 °C cold water immersion, on knee skin temperature and (b) establish whether either protocol was capable of achieving a skin temperature (<13 °C) believed to be required for analgesic purposes. After ethics committee approval and written informed consent was obtained, 10 healthy males (26.5±4.9 yr, 183.5±6.0 cm, 90.7±19.9 kg, 26.8±5.0 kg/m2, 23.0±9.3% body fat; mean±SD) participated in this randomised controlled crossover study. Skin temperature around the patellar region was assessed in both knees via non-contact, infrared thermal imaging and recorded pre-, immediately post-treatment and every 10 min thereafter for 60 min. Compared to baseline, average, minimum and maximum skin temperatures were significantly reduced (p<0.001) immediately post-treatment and at 10, 20, 30, 40, 50 and 60 min after both cooling modalities. Average and minimum skin temperatures were lower (p<0.05) immediately after whole body cryotherapy (19.0±0.9 °C) compared to cold water immersion (20.5±0.6 °C). However, from 10 to 60 min post, the average, minimum and maximum skin temperatures were lower (p<0.05) following the cold water treatment. Finally, neither protocol achieved a skin temperature believed to be required to elicit an analgesic effect.

Exploratory study of a non-invasive method based on acoustic emission for assessing the dynamic integrity of knee joints.

The paper presents the development of a new measurement system based on acoustic emission (AE) for assessing the dynamic integrity of knee joints, and the evaluation of its efficacy, through an exploratory study using healthy and osteoarthritic knees. For the former, the paper describes the system implemented to acquire joint angle-based AE and the protocol developed to obtain repeatable results. For the latter, the paper reports significant differences between healthy and osteoarthritic knees using statistical analysis of AE occurrence and distribution of AE features in different movement phases. Osteoarthritic knees are found to produce 6-10 times more acoustic emissions than healthy knees, with amplitudes which can be 20 dB higher, and durations which can be 10 times longer. These findings lead to a visual representation method of AE feature profiles based on multidimensional density of AE hits per repeated movement and the use of principal component analysis for objective assessment of the clinical status of knee joints.

Cold legs: a potential indicator of negative outcome in the rehabilitation of patients with patellofemoral pain syndrome.

PURPOSE: The purpose of this paper is to explore the link between a poor outcome in response to an exercise based approach to physiotherapy, in patients with patellofemoral dysfunction and a self-report of legs feeling cold even in warm surroundings. SCOPE: The study was carried out in the physiotherapy outpatients department of Burnley General Hospital, Lancashire, UK with 87 consecutively referred patients with a diagnosis of patellofemoral pain syndrome being assessed for suitability for entry into the study. Of these 77 entered the study with 14 (18%), of these responding 'Yes' to the question 'Do your legs feel cold even in warm surroundings?' All patients were assessed using four outcome measures prior to the commencement of a standardised rehabilitation programme consisting of lower limb biarticular muscle stretching, vastus medialis training and patella taping or biofeedback. The patients were reassessed using the same outcome measures 3 months after completing their course of treatment. CONCLUSIONS: Patients who responded 'Yes' to the question 'Do your legs feel cold even in warm surroundings?' reported higher pain levels and tolerated less physical activity than non-cold sufferers at initial assessment, these differences were statistically significant. The cold sufferers showed less improvement on all of the outcome measures although the differences between the two groups only reached statistical significance for one of the outcome measures. The implications of this in relation to clinical practice are discussed.

Validity and reliability of measurements taken by the Peak 5 motion analysis system.

Many new measurement tools are becoming available for physiotherapists; however, there is often a lack of data to support their validity and reliability. This study attempts to address this issue with respect to the Peak 5 video analysis system. Five experiments were conducted. Experiment A investigated the validity of static angular measurements by filming a universal goniometer. A high level of agreement was recorded with a mean difference between the two instruments of 0.2 degree. Experiment B investigated the validity of angular joint velocity by filming a Biodex isokinetic dynamometer. A high level of agreement was recorded with a mean difference between the two instruments of 0.96 degree s-1. Experiment C investigated the reliability of reflective marker placements on the hip, knee and ankle on 17 healthy volunteers, in weight bearing on three separate days. Reliability was high with the 95% confidence interval (CI) for marker placement being 1.5 cm. Experiment D investigated the normal intrasubject variation of knee joint 'critical angle' and angular velocity measures over time, by filming 17 healthy volunteers performing an eccentric step test on three separate days. For 'critical angle' measures the standard deviation was 5.72 degrees and the 95% CI was +/- 11.44 degrees. For angular velocity measures the standard deviation was 8.51 degrees s-1 and the 95% CI was +/- 17.02 degrees s-1. Experiment E repeated analysis of the reflective marker placement (mean standard deviation 0.6 cm), the 'critical angle' (mean standard deviation 1.32 degrees) and the angular velocity (mean standard deviation 1.29 degrees s-1 showed high consistency, when analysing three pieces of film three times. Data generated in this study suggest that the Peak 5 provides valid angular and angular velocity data when compared to other measuring devices. Reliable data are produced when filming healthy volunteers performing an eccentric step test. These data will be used in the next stage of the project investigating Anterior Knee Pain Patients.