Experiences of training and delivery of Physical therapy informed by Acceptance and Commitment Therapy (PACT): a longitudinal qualitative study.

OBJECTIVES: Physiotherapy informed by Acceptance and Commitment Therapy (PACT) is a novel intervention that is related to improved disability and functioning in people with chronic lowback pain. This study explored physiotherapists experiences over time of the PACT training programme and intervention delivery. DESIGN: A longitudinal qualitative study using semi-structured, in-depth, individual interviews at three time points was conducted. METHODS: A phenomenological approach underpinned the methods. Interviews followed topic-guides developed a priori. Transcribed interviews were coded inductively to generate themes. Data were member checked by participants and validated by two researchers. PARTICIPANTS: Eight clinical physiotherapists from three secondary care centres in the United Kingdom (n = 5 female; age, 24 to 44 years; duration of practice, 3 to 14 years) were included. RESULTS: Five themes emerged from the data. Experiential learning techniques were challenging but valued because they bridged theoretical principles and concepts with practice. Ongoing individual and group supervision was beneficial, but required tailoring and tapering. PACT delivery extended physiotherapy skills and practice, including techniques that acknowledged and addressed patient treatment expectations. With experience, participants desired greater flexibility and autonomy to tailor PACT delivery. CONCLUSIONS: PACT training and delivery were acceptable to physiotherapists. Existing skills were developed and additional, applicable approaches were provided that addressed psychosocial and behavioural aspects of chronic low back pain.

Does delayed onset muscle soreness affect the biomechanical variables of the drop vertical jump that have been associated with increased ACL injury risk? A randomised control trial.

INTRODUCTION: Delayed onset muscle soreness (DOMS) and Anterior Cruciate Ligament (ACL) injuries are both prevalent in sport. It is currently unknown whether DOMS increases ACL injury risk. AIM: This study aimed to provide preliminary insight on whether DOMS affects ACL injury risk by investigating whether DOMS affects the biomechanical variables of the DVJ that have been identified as risk factors for future ACL injury. METHODS: This was a randomised control trial involving 32 active individuals aged 18-35 years, with no history of ACL injury. Participants underwent two sessions of force-plate testing and 3D motion analysis of the drop vertical jump (DVJ). The DVJ was chosen as it has been investigated prospectively for association with future ACL injury. Initial testing was followed by randomisation to DOMS or control group. The DOMS group underwent a DOMS-inducing exercise protocol, the control group did not. Both groups were re-tested 48 h after initial testing. Five variables of the DVJ that have been associated with future ACL injury were chosen for analysis - peak knee flexion angle, peak vertical ground reaction force, ground contact time, peak knee abduction angle & peak knee abduction moment. Between-group differences were compared using a two-way mixed analysis of variance; alpha level set to 0.05. RESULTS: DOMS was successfully induced in all participants of the DOMS group however no statistically significant group x time interactions were found for any of the five variables analysed. CONCLUSIONS: DOMS did not affect the biomechanical variables of the DVJ that have been associated with future ACL injury. By extension, this may suggest that DOMS might not affect ACL injury risk. However, it is also possible that certain attributes of the DVJ meant that any effect of DOMS was simply unable to be quantified, even if an effect existed. All considered, our position is that conclusion cannot be drawn from this study alone on whether DOMS affects ACL injury risk. Further research is required.

Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial.

Chronic low back pain (CLBP) is a major cause of global disability and improving management is essential. Acceptance and commitment therapy (ACT) is a promising treatment for chronic pain but has not been modified for physical therapy. This randomized controlled trial (RCT) compared physical therapy informed by ACT (PACT) against standard care physical therapy for patients with CLBP. Patients with CLBP (duration ≥12 weeks, mean 3 years) were recruited from physical therapy clinics in 4 UK public hospitals. The Roland-Morris Disability Questionnaire (RMDQ) at 3 months' post-randomization was the primary outcome. Two hundred forty-eight participants (59% female, mean age = 48) were recruited and 219 (88.3%) completed measures at 3 and/or 12 months' follow-up. At 3 months, PACT participants reported better outcomes for disability (RMDQ mean difference = 1.07, p = .037, 95% CI = -2.08 to -.07, d = .2), Patient Specific Functioning (p = .008), SF12 physical health (p = .032), and treatment credibility (p < .001). At 12 months' follow-up, there were no significant differences between groups. PACT was acceptable to patients and clinicians and feasible to deliver. Physical therapists incorporated psychological principles successfully and treatment was delivered with high (≥80%) fidelity. Our results may inform the management of CLBP, with potential benefits for patients, health care providers, and society. PERSPECTIVE: Psychologically informed physical therapy has great potential but there are challenges in implementation. The training and support included in the PACT trial enabled the intervention to be delivered as planned. This successfully reduced disability in the short but not long term. Findings could inform physical therapists' treatment of CLBP.

The effect of minimalist footwear and instruction on running: an observational study.

BACKGROUND: It is not known whether the effects on altered running style which are attributed to minimalist footwear can be achieved by verbal instructions in standard running shoes (SRS). AIM: To explore the effect of Vibram FiveFingers (VFF) versus SRS plus running instruction on lower extremity spatiotemporal parameters and lower limb joint kinematics. METHODS: 35 healthy subjects (mean=30 years, 18 females) were assessed on two occasions with 3D motion analysis. At each session subjects ran on a treadmill (3.58 m/s) for 2 min in either VFF or SRS (randomised order); with and without running instruction. Differences between spatiotemporal parameters and lower limb joint kinematics between conditions were assessed using a 2x2 repeated-measures ANOVA. RESULTS: Wearing VFF significantly increased cadence (p<0.001) and reduced stride length (p<0.01). Prior to initial contact, both instruction and VFF significantly increased foot (p<0.001 and p=0.02, respectively) and ankle (p<0.001 and p=0.02, respectively) plantarflexion, while wearing VFF significantly increased knee extension (p=0.04). At initial contact, instruction significantly increased knee flexion (p=0.04), and foot (p=0.001) and ankle (p=0.03) plantarflexion. At mid-stance and toe-off, instruction significantly increased knee flexion (p=0.048 and p<0.001, respectively) and foot plantarflexion (p<0.001 and p=0.01, respectively). Instruction had a greater effect on increasing knee flexion (p=0.007) and plantarflexion angle (p<0.001) when subjects wore SRS and VFF, respectively. CONCLUSION: Alterations in spatiotemporal parameters observed when running in VFF are likely to be attributable to the minimalist footwear. However, the kinematic adaptations observed following instruction suggests that changes in joint angles previously attributed to minimalist footwear alone may be similarly achieved with instruction.

Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain.

INTRODUCTION: Chronic low back pain (CLBP) is a common condition and source of significant suffering, disability and healthcare costs. Current physiotherapy treatment is moderately effective. Combining theory-based psychological methods with physiotherapy could improve outcomes for people with CLBP. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of Physiotherapy informed by Acceptance and Commitment Therapy (PACT) on functioning in patients with CLBP. METHODS AND ANALYSIS: The PACT trial is a two-armed, parallel-group, multicentre RCT to assess the efficacy of PACT in comparison with usual physiotherapy care (UC). 240 patients referred to physiotherapy with CLBP will be recruited from three National Health Service (NHS) hospitals trusts. Inclusion criteria are: age ≥18 years, CLBP ≥12-week duration, scoring ≥3 points on the Roland-Morris Disability Questionnaire (RMDQ) and adequate understanding of spoken and written English to participate. Patients will be randomised to PACT or UC (120 per arm stratified by centre) by an independent randomisation service and followed up at 3 and 12 months post randomisation. The sample size of 240 will provide adequate power to detect a standardised mean difference of 0.40 in the primary outcome (RMDQ; 5% significance, 80% power) assuming attrition of 20%. Analysis will be by intention to treat conducted by the trial statistician, blind to treatment group, following a prespecified analysis plan. Estimates of treatment effect at the follow-up assessments will use an intention-to-treat framework, implemented using a linear mixed-effects model. ETHICS AND DISSEMINATION: This trial has full ethical approval (14/SC/0277). It will be disseminated via peer-reviewed publications and conference presentations. The results will enable clinicians, patients and health service managers to make informed decisions regarding the efficacy of PACT for patients with CLBP. TRIAL REGISTRATION NUMBER: ISRCTN95392287; Pre-results.

The effect of open kinetic chain knee extensor resistance training at different training loads on anterior knee laxity in the uninjured.

BACKGROUND: The commonly used open kinetic chain knee extensor (OKCKE) exercise loads the sagittal restraints to knee anterior tibial translation. OBJECTIVE: To investigate the effect of different loads of OKCKE resistance training on anterior knee laxity (AKL) in the uninjured knee. STUDY DESIGN: non-clinical trial. METHODS: Randomization into one of three supervised training groups occurred with training 3 times per week for 12 weeks. Subjects in the LOW and HIGH groups performed OKCKE resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Subjects in the isokinetic training group (ISOK) performed isokinetic OKCKE resistance training using 2 sets of 20 maximal efforts. AKL was measured using the KT2000 arthrometer with concurrent measurement of lateral hamstrings muscle activity at baseline, 6 weeks and 12 weeks. RESULTS: Twenty six subjects participated (LOW n = 9, HIGH n = 10, ISOK n = 7). The main finding from this study is that a 12-week OKCKE resistance training programme at loads of 20 sets of 2RM, leads to an increase in manual maximal AKL. CONCLUSIONS: OKCKE resistance training at high loads (20 sets of 2RM) increases AKL while low load OKCKE resistance training (2 sets of 20RM) and isokinetic OKCKE resistance training at 2 sets of 20RM does not.

Effect of repeated passive anterior loading on human knee anterior laxity.

BACKGROUND: Increased knee anterior laxity results when the anterior cruciate ligament is injured. This increased laxity can cause knee dysfunction. Until recently this laxity was believed to be only diminished through surgery. But recent findings indicate that knee anterior laxity may be decreased with repeated loading of the knee. OBJECTIVE: The purpose of this study was to test the hypothesis that regular passive anterior loading of the uninjured human knee would enhance its stiffness. STUDY DESIGN: Randomized controlled trial. METHODS: Knee anterior laxity was tested using an arthrometer in 22 young, uninjured females before, during and after a 3 month period during which passive anterior loading was applied by a trained physiotherapist over 5 sessions per week to a randomly assigned knee. RESULTS: Knee anterior laxity was not affected by the passive anterior loading of the knee. CONCLUSIONS: Given that in this study repeated passive loading of the knee did not change knee anterior laxity, it would be easy to conclude that this training is ineffective and no further research is required. We caution against this given the relatively short duration and possibly insufficient intensity of the training and the population studied; individuals with normal joint laxity. We recommend that future research be performed that consists of individuals with lax joints who receive training for prolonged periods.

The effect of knee extensor open kinetic chain resistance training in the ACL-injured knee.

PURPOSE: To investigate the effect of different loads of knee extensor open kinetic chain resistance training on anterior knee laxity and function in the ACL-injured (ACLI) knee. METHODS: Fifty-eight ACLI subjects were randomised to one of three (12-week duration) training groups. The STAND group trained according to a standardised rehabilitation protocol. Subjects in the LOW and HIGH group trained as did the STAND group but with the addition of seated knee extensor open kinetic chain resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Anterior knee laxity and measurements of physical and subjective function were performed at baseline, 6 and 12 weeks. Thirty-six subjects were tested at both baseline and 12 weeks (STAND n = 13, LOW n = 11, HIGH n = 12). RESULTS: The LOW group demonstrated a reduction in 133 N anterior knee laxity between baseline and 12 weeks testing when compared to the HIGH and the STAND groups (p = 0.009). Specifically, the trained-untrained knee laxity decreased an average of approximately 5 mm in the LOW group while remaining the same in the other two groups. CONCLUSION: Twelve weeks of knee extensor open kinetic chain resistance training at loads of 2 sets of 20RM led to a reduction in anterior knee laxity in the ACLI knee. This reduction in laxity does not appear to offer any significant short-term functional advantages when compared to a standard rehabilitation protocol. These results indicate that knee laxity can be decreased with resistance training of the thigh muscles. LEVEL OF EVIDENCE: Randomised controlled trial, Level II.

The effect of thigh muscle activity on anterior knee laxity in the uninjured and anterior cruciate ligament-injured knee.

PURPOSE: The main purpose of this study was to describe the nature of the relationship between hamstring muscle activity and anterior knee laxity. METHODS: This was a cross-sectional study. Anterior knee laxity was measured at 133N and manual maximal forces using the KT2000 knee arthrometer, in 8 ACL-injured and 13 uninjured individuals. Electromyographic activity of the lateral hamstrings was measured during laxity testing. Subjects contracted the hamstrings during anterior knee laxity testing at eight predetermined levels of maximal voluntary isometric contraction. RESULTS: Volitional contraction of the lateral hamstrings reduced anterior knee laxity logarithmically for both the 133N and manual maximal tests in both the ACL-injured and uninjured knees. A simple linear regression model, with the log of percentage of maximum lateral hamstrings activity as the sole predictor, explained approximately 70-80% of the variation in anterior knee laxity. Both ACL-injured and uninjured subjects reduced anterior knee laxity at the same rate with increases in muscle activity. However, initial lateral hamstrings muscle activity had a greater effect on percentage anterior knee laxity scores in the ACL-injured as compared to the uninjured knee. CONCLUSIONS: Lateral hamstrings activity reduces anterior knee laxity in a nonlinear manner, whereby the initial lower level of activation produces the greatest change in anterior knee laxity. Therefore, hamstrings muscle activity must be monitored during anterior knee laxity testing.

Bench testing of a knee joint arthrometer.

The KT1000 and KT2000 knee joint arthrometers (MEDmetric Corp, San Diego, California) have been shown to overestimate the measurement of knee joint sagittal laxity. The purpose of this study was to investigate the accuracy of the KT arthrometers as measures of anterior and posterior linear displacement. The anterior and posterior linear displacements of 3 KT arthrometers (2 KT1000 arthrometers and 1 KT2000 arthrometer) were compared with the simultaneous displacement measured by a precision linear Vernier Dial Test Indicator (Davenport Ltd, London, United Kingdom). The displacement calculated using the analog output of the KT2000 was also compared with the values on the KT2000 displacement dial. Compared with the Vernier Dial Test Indicator, the KT arthrometers overestimated anterior linear displacement by between 22% and 24%. True anterior displacement for all 3 arthrometers, as recorded by the Vernier Dial Test Indicator, was found by multiplying the KT value by 0.79. When compared with the Vernier Dial Test Indicator, the KT arthrometers underestimated posterior linear displacement by between 18% and 19%. True posterior displacement, as recorded by the Vernier Dial Test Indicator, was found by multiplying the KT1000 value by 1.17 and the KT2000 value by 1.16. The internal apparatus of the KT2000 and KT1000 knee joint arthrometers overestimates anterior displacement and underestimates posterior displacement with a predictable relative systematic error. Future validation studies should use these correction equations to assess the accuracy of the KT arthrometers. Sagittal plane knee laxity measured with the KT devices requires systematic correction for optimal accuracy.

Robotic knee laxity testing: reliability and normative data.

PURPOSE: To evaluate the reliability of the GeNouRoB knee arthrometer and present normative values of knee anterior laxity using this device on young females. METHODS: Anterior laxity in both knees was tested in two groups of young, uninjured females using the hamstrings electromyography biofeedback feature of the device. There were 13 participants in the group tested for reliability and 23 for the normative study. Laxity (mm of movement of the proximal tibia in the anterior direction relative to the femur) was calculated at test forces of 134 N and 250 N with values presented for the unstandardised and standardised (relative to stabilisation force) conditions. RESULTS: The relative reliability (95% limits of agreement) of the device for laxity at a test force of 134 N was 2 to 3mm. Left knee anterior laxity was almost 1mm greater than the right. CONCLUSIONS: The relative reliability of the GeNouRoB arthrometer is comparable to the KT device. In agreement with previous work on the nonrobotic KT arthrometer, the knee anterior laxity values found with the GeNouRoB are greater in the left as compared to the right knee.

The immediate effects of open kinetic chain knee extensor exercise at different loads on knee anterior laxity in the uninjured.

BACKGROUND: There is evidence that anterior laxity may be affected by knee extensor open kinetic chain (OKC) exercise with responses being load-dependent. The aim of this study is to evaluate the immediate and short-term changes in passive knee anterior laxity following a single session of OKC knee extensor exercise. METHODS: Thirty two participants were randomly allocated to perform either high load (20 sets of 2 repetitions) or low load (2 sets of 20 repetitions) knee extensor OKC exercise with knee anterior laxity assessed before exercise, immediately after exercise and 45 and 90min after exercise with a KT-2000 arthrometer using a 133N force. RESULTS: A significant effect of time was observed on knee laxity (p<0.001). However, a significant interaction of time and group was not found (p=0.54) and so the results presented here are for the combined (low and high load) group mean±standard deviation knee anterior laxity (mm) in the exercised leg: 7.2±2.2 (baseline), 8.2±2.3 (immediate post exercise, 14% change from baseline), 8.1±2.3 (45min post exercise, 12% change from baseline), and 7.7±2.2/0.29 (6.9) (90min post exercise, 7% change from baseline). CONCLUSION: OKC knee extensor exercise at high loads and low loads causes an immediate increase in knee laxity that begins to decrease within 90min.