Infusing behavior science into large language models for activity coaching.

Large language models (LLMs) have shown promise for task-oriented dialogue across a range of domains. The use of LLMs in health and fitness coaching is under-explored. Behavior science frameworks such as COM-B, which conceptualizes behavior change in terms of capability (C), Opportunity (O) and Motivation (M), can be used to architect coaching interventions in a way that promotes sustained change. Here we aim to incorporate behavior science principles into an LLM using two knowledge infusion techniques: coach message priming (where exemplar coach responses are provided as context to the LLM), and dialogue re-ranking (where the COM-B category of the LLM output is matched to the inferred user need). Simulated conversations were conducted between the primed or unprimed LLM and a member of the research team, and then evaluated by 8 human raters. Ratings for the primed conversations were significantly higher in terms of empathy and actionability. The same raters also compared a single response generated by the unprimed, primed and re-ranked models, finding a significant uplift in actionability and empathy from the re-ranking technique. This is a proof of concept of how behavior science frameworks can be infused into automated conversational agents for a more principled coaching experience.

Measure by measure: Resting heart rate across the 24-hour cycle.

BACKGROUND: Photoplethysmography (PPG) sensors, typically found in wrist-worn devices, can continuously monitor heart rate (HR) in large populations in real-world settings. Resting heart rate (RHR) is an important biomarker of morbidities and mortality, but no universally accepted definition nor measurement criteria exist. In this study, we provide a working definition of RHR and describe a method for accurate measurement of this biomarker, recorded using PPG derived from wristband measurement across the 24-hour cycle. METHODS: 433 healthy subjects wore a wrist device that measured activity and HR for up to 3 months. HR during inactivity was recorded and the duration of inactivity needed for HR to stabilise was ascertained. We identified the lowest HR during each 24-hour cycle (true RHR) and examined the time of day or night this occurred. The variation of HR during inactivity through the 24-hour cycle was also assessed. The sample was also subdivided according to daily activity levels for subset analysis. FINDINGS: Adequate data was obtained for 19,242 days and 18,520 nights. HR stabilised in most subjects after 4 minutes of inactivity. Mean (SD) RHR for the sample was 54.5 (8.0) bpm (day) and 50.5 (7.6) bpm (night). RHR values were highest in the least active group (lowest MET quartile). A circadian variation of HR during inactivity was confirmed, with the lowest values being between 0300 and 0700 hours for most subjects. INTERPRETATION: RHR measured using a PPG-based wrist-worn device is significantly lower at night than in the day, and a circadian rhythm of HR during inactivity was confirmed. Since RHR is such an important health metric, clarity on the definition and measurement methodology used is important. For most subjects, a minimum rest time of 4 minutes provides a reliable measurement of HR during inactivity and true RHR in a 24-hour cycle is best measured between 0300 and 0700 hours. Funding: This study was funded by Google.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T).

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

ICON 2019-International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients.

BACKGROUND: The absence of any agreed-upon tendon health-related domains hampers advances in clinical tendinopathy research. This void means that researchers report a very wide range of outcome measures inconsistently. As a result, substantial synthesis/meta-analysis of tendon research findings is almost futile despite researchers publishing busily. We aimed to determine options for, and then define, core health-related domains for tendinopathy. METHODS: We conducted a Delphi study of healthcare professionals (HCP) and patients in a three-stage process. In stage 1, we extracted candidate domains from clinical trial reports and developed an online survey. Survey items took the form: 'The 'candidate domain' is important enough to be included as a core health-related domain of tendinopathy'; response options were: agree, disagree, or unsure. In stage 2, we administered the online survey and reported the findings. Stage 3 consisted of discussions of the findings of the survey at the ICON (International Scientific Tendinopathy Symposium Consensus) meeting. We set 70% participant agreement as the level required for a domain to be considered 'core'; similarly, 70% agreement was required for a domain to be relegated to 'not core' (see Results next). RESULTS: Twenty-eight HCP (92% of whom had >10 years of tendinopathy experience, 71% consulted >10 cases per month) and 32 patients completed the online survey. Fifteen HCP and two patients attended the consensus meeting. Of an original set of 24 candidate domains, the ICON group deemed nine domains to be core. These were: (1) patient rating of condition, (2) participation in life activities (day to day, work, sport), (3) pain on activity/loading, (4) function, (5) psychological factors, (6) physical function capacity, (7) disability, (8) quality of life and (9) pain over a specified time. Two of these (2, 6) were an amalgamation of five candidate domains. We agreed that seven other candidate domains were not core domains: range of motion, pain on clinician applied test, clinical examination, palpation, drop out, sensory modality pain and pain without other specification. We were undecided on the other five candidate domains of physical activity, structure, medication use, adverse effects and economic impact. CONCLUSION: Nine core domains for tendon research should guide reporting of outcomes in clinical trials. Further research should determine the best outcome measures for each specific tendinopathy (ie, core outcome sets).

Inflammation in Tendon Disorders.

The role of inflammation in tendon disorders has long been a subject of considerable debate. Developments in our understanding of the basic science of inflammation have provided further insight into its potential role in specific forms of tendon disease, and the circumstances that may potentiate this. Such circumstances include excessive mechanical stresses on tendon and the presence of systemic inflammation associated with chronic diseases. In this chapter a brief review of the basic science of inflammation is provided and the influence that it may play on tendons is discussed.

Tendinopathy: Update on Pathophysiology.

Synopsis Tendinopathy has become the accepted term to describe a spectrum of changes that occur in damaged and/or diseased tendons. Over the past 2 decades, there have been new insights into tendon pathophysiology of relevance to clinicians, including (1) better characterization of the overuse injury process and the resultant structural and functional disruption in chronically painful tendons, (2) improved understanding of the pathomechanics associated with chronic tendon injury, and (3) greater knowledge about the influence of lifestyle factors and drugs on tendon pathology. The implications of these new insights are discussed. J Orthop Sports Phys Ther 2015;45(11):833-841. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5884.

Challenges of pain masking in the management of soft tissue disorders: optimizing patient outcomes with a multi-targeted approach.

Current approaches to managing soft tissue injuries often rely upon the use of non-steroidal anti-inflammatory drugs (NSAIDs). The use of NSAIDs in this manner is contentious, and some believe that the risks of using NSAIDs can outweigh any potential benefit. In this article the issues of toxicity, pain masking and return to full activity are reviewed, and an alternative strategy for the management of inflammation in soft tissue injuries is proposed. We consider that a multi-targeted approach has the potential to improve healing, reduce additional injury from premature return to full activity as a consequence of pain masking, and improve prognosis for many patients with soft tissue injuries.

A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence.

BACKGROUND: 'Shock wave' therapies are now extensively used in the treatment of musculoskeletal injuries. This systematic review summarises the evidence base for the use of these modalities. METHODS: A thorough search of the literature was performed to identify studies of adequate quality to assess the evidence base for shockwave therapies on pain in specific soft tissue injuries. Both focused extracorporeal shockwave therapy (F-ESWT) and radial pulse therapy (RPT) were examined. RESULTS: 23 appropriate studies were identified. There is evidence for the benefit of F-ESWT and of RPT in a number of soft tissue musculoskeletal conditions, and evidence that both treatment modalities are safe. There is evidence that F-ESWT is effective in the treatment of plantar fasciitis, calcific tendinitis, and that RPT is effective in plantar fasciitis. Where benefit is seen in F-ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. There is low level evidence for lack of benefit of low-dose F-ESWT and RPT in non-calcific rotator cuff disease and mixed evidence in lateral epicondylitis.

Validation of clinical examination versus magnetic resonance imaging and arthroscopy for the detection of rotator cuff lesions.

Limited evidence exists regarding the validity of clinical examination for the detection of shoulder pathology. We therefore wished to establish the sensitivity, specificity, positive predictive value and negative predictive value of clinical tests and magnetic resonance imaging (MRI) in the diagnosis of rotator cuff disorders against findings at arthroscopy. Using recognised tests for specific shoulder lesions, 117 patients with shoulder symptoms awaiting surgery were examined in a standard manner. The diagnoses were categorised and compared with abnormalities found on MRI and at surgery. Results were cross-tabulated to determine the above parameters. Ninety-four patients formed the study group with a mean age of 51 years. The median duration of symptoms was 45 weeks. For clinical examination, sensitivity and specificity to detect a tear or rupture of supraspinatus were 30 % (16/54) and 38 % (15/40) and, for the detection of any pathology, were 94 % (67/71) and 22 % (5/23), respectively, compared with arthroscopy. Correspondingly, the sensitivity of MRI compared with arthroscopy to detect a tear or rupture of supraspinatus was 90 % (28/31) with a specificity of 70 % (46/53), whereas for the detection of any abnormality, the sensitivity was 92 % (65/71) with a specificity of 48 % (11/23). The sensitivity of detecting any rotator cuff abnormality is high when examination and MRI is compared with arthroscopy with the specificity being greater with MRI than examination. In patients with shoulder symptoms severe enough to consider surgery, clinical assessment followed by specific imaging may help define the pathology in order to direct appropriate management.

High-performance sports medicine.

High performance sports medicine involves the medical care of athletes, who are extraordinary individuals and who are exposed to intensive physical and psychological stresses during training and competition. The physician has a broad remit and acts as a 'medical guardian' to optimise health while minimising risks. This review describes this interesting field of medicine, its unique challenges and priorities for the physician in delivering best healthcare.

What is sport and exercise medicine?

Sport and exercise medicine involves the provision of preventative and reactive care for all aspects of health in relation to sport and the use of exercise prescription in the management of health and disease. This article gives an overview of the specialty as it develops in the UK.

MR imaging appearances of acromioclavicular joint dislocation.

The key structures involved in dislocation of the acromioclavicular joint (ACJ) are the joint itself and the strong accessory coracoclavicular ligament. ACJ dislocations are classified with the Rockwood system, which comprises six grades of injury. Treatment planning requires accurate grading of the ACJ disruption, but correct classification can be difficult with clinical assessment. Magnetic resonance (MR) imaging has a well-established role in evaluation of ACJ pain. MR imaging performed in the coronal oblique plane parallel to the distal clavicle allows assessment of the acromioclavicular and coracoclavicular ligaments owing to its in-plane orientation in relation to these structures. This technique enables distinction between grade 2 and grade 3 injuries, which can be difficult with conventional clinical and radiographic evaluation. In addition, diagnosis of grade 1 injuries is possible by demonstration of a ruptured superiodorsal acromioclavicular ligament. Resultant thickening of the acromioclavicular or coracoclavicular ligament allows identification of chronic ACJ injuries.

Exercise-related menstrual dysfunction: implications for menopausal health.

Physical activity is a well recognized approach to the enhancement of general health and wellbeing in both healthy and diseased populations. However, excessive activity can result in exercise-related menstrual dysfunction (ERMD), which can adversely affect bone health and increase the risk of infertility and cardiovascular events in later life. Physicians should maintain a high awareness of EMRD in assessing health risks in the menopausal woman.

The assessment and management of chronic hamstring/posterior thigh pain.

Hamstring injuries have a high incidence and recurrence rate. Much is understood with regards to the mechanism of hamstring injury, with eccentric loading at fast rates being important. Little is known about the aetiology of hamstring injury, with age and previous injury being the only causative factors with robust scientific support. Clinically, it can be difficult to differentiate between a lesion occurring in hamstring tissue and pain that is experienced in the hamstrings that is referred from elsewhere. The use of specific examination procedures such as the slump test and the straight leg raise, supplemented with other sensitive and specific tests can help in the differential diagnosis. This chapter will explore the aetiology of chronic hamstring injury/posterior thigh pain, will discuss the differential diagnosis of chronic hamstring/posterior thigh pain, and present a model for the management of these injuries.