What should a toolkit to aid the delivery of therapeutic exercise for hip and knee osteoarthritis look like? Qualitative analysis of an international survey of 318 researchers, clinicians, and consumers by the OARSI Rehabilitation Discussion Group.

BACKGROUND: We aimed to identify important components of, and practical resources relevant for inclusion in, a toolkit to aid exercise delivery for people with hip/knee osteoarthritis. METHOD: An online international multi-disciplinary survey was conducted across 43 countries (139 clinicians, 44 people with hip/knee osteoarthritis and 135 osteoarthritis researchers). Participants were presented with the seeding statement 'Practical resources to aid the implementation of exercise for people with hip/knee osteoarthritis should…' and asked to provide up to 10 open text responses. Responses underwent refinement and qualitative content analysis to create domains and categories. RESULTS: Refinement of 551 open text responses yielded 72 unique statements relevant for analysis. Statements were organised into nine broad domains, suggesting that resources to aid exercise delivery should: (1) be easily accessible; (2) be of high quality; (3) be developed by, and for, stakeholders; (4) include different ways of delivering information; (5) include different types of resources to support exercise and non-exercise components of self-management; (6) include resources on recommended exercises and how to perform/progress them; (7) include tools to support motivation and track progress; (8) include resources to enable tailoring of the programme to the individual and; (9) facilitate access to professional and peer support. CONCLUSION: Our findings identified important components of, and practical resources to include within, a toolkit to aid delivery of exercise for people with hip/knee osteoarthritis. These findings have implications for exercise providers and lay the foundation for the development of a toolkit to help ensure exercise provision aligns with current international recommendations.

Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation.

AIMS: This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies. MATERIALS AND METHODS: This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach. RESULTS: Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK. CONCLUSIONS: Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

Validity and reliability of accelerations and orientations measured using wearable sensors during functional activities.

Wearable sensors may enable the assessment of movement in a real-world setting, but they are not yet a standard practice in the analysis of movement due to the unknown accuracy and reliability with respect to different functional activities. Here, we established the concurrent validity and test-retest reliability of accelerations and orientations measured using affordable novel sensors during squats, jumps, walking and stair ambulation. In this observational study, participants underwent three data collection sessions during one day. Accelerations and orientations from sacrum, thigh and shank were collected using these sensors and already validated gold-standard sensors as the criterion method. We assessed validity by comparing the similarity of signal waveforms with the Linear Fit Method and by comparing mean differences in range values with the Bland-Altman plots. Reliability was assessed by calculating interclass correlation coefficient and standard error of measurements of the range values. Concurrent validity was from fair to excellent in 91% of the cases for accelerations and in 84.4% for orientations. Test-retest reliability of accelerations was from fair to excellent in 97% of cases when the sensors were attached by a researcher, and in 84.4% of cases when the sensors were attached by participants. Test-retest reliability of orientations was from fair to excellent in 88.9% of cases when the sensors were attached by a researcher, and in 68.9% of cases when the sensors were attached by participants. In conclusion, the new affordable sensors provide accurate measures of accelerations and orientations during multiple functional activities in healthy adults. Reliability of the orientations may depend on the ability to replicate the same position of the sensor under test-retest conditions.

A web-based life-style, exercise and activity intervention for people with progressive multiple sclerosis: Results of a single-arm feasibility study.

BACKGROUND: People with progressive Multiple Sclerosis often struggle to access appropriate and inclusive support for regular physical activity. The Lifestyle, Exercise and Activity Package (LEAP-MS) intervention, is a co-designed web-based physical activity intervention for people with progressive Multiple Sclerosis (MS). It consists of two key components; (1) web-based physical activity coaching with physiotherapists using self-management support strategies and 2) an interactive web-based platform including a physical activity information suite, an activity selection and planning tool and a participant-physiotherapist messaging system. We aimed to evaluate recruitment, retention and uptake, in a single arm feasibility study. METHODS: Participants with primary or secondary progressive MS with an Expanded Disability Status Scale score of 6 to 8 were recruited. Assessments included the MS Impact Scale (MSIS-29) and measures of participation at baseline, three and six months. All participants received the intervention which consisted of up to six web-based physiotherapy- led physical activity coaching sessions alongside access to web-based education and activity suites. Recruitment, retention and uptake data were summarised. Pre-defined progression criteria were used to guide feasibility assessment. Clinical outcome data were analysed descriptively. RESULTS: Fifty-eight percent (21/36) of those submitting expressions of interest were recruited; 76% completed follow-up. Pre-specified progression criteria for retention were met but recruitment did not meet progression criteria. The intervention achieved set fidelity criteria. At three months, 12 participants (75%) reported improvements in routine activities after the intervention. MSIS-29 physical scores improved by an average of eight points (95% CI -12.6 to -3.3). Improvements were also seen in MSIS-29 psychological scores and fatigue. Some improvements were maintained at six months. CONCLUSIONS: The LEAP-MS intervention is feasible and associated with improvements in MSIS-29 scores. The intervention facilitated partnership working between physiotherapists and people with progressive MS. Users developed valuable skills in supported self-management by focussing on enhancing physical activity to support overall wellbeing. This work has laid the foundations for a large-scale evaluation of a co-designed intervention with potential for far reaching impact on the lives of people with progressive MS.

Applications of Wearable Technology in a Real-Life Setting in People with Knee Osteoarthritis: A Systematic Scoping Review.

With the growing number of people affected by osteoarthritis, wearable technology may enable the provision of care outside a traditional clinical setting and thus transform how healthcare is delivered for this patient group. Here, we mapped the available empirical evidence on the utilization of wearable technology in a real-world setting in people with knee osteoarthritis. From an analysis of 68 studies, we found that the use of accelerometers for physical activity assessment is the most prevalent mode of use of wearable technology in this population. We identify low technical complexity and cost, ability to connect with a healthcare professional, and consistency in the analysis of the data as the most critical facilitators for the feasibility of using wearable technology in a real-world setting. To fully realize the clinical potential of wearable technology for people with knee osteoarthritis, this review highlights the need for more research employing wearables for information sharing and treatment, increased inter-study consistency through standardization and improved reporting, and increased representation of vulnerable populations.

Food-related inhibitory control training reduces food liking but not snacking frequency or weight in a large healthy adult sample.

Inhibitory control training has recently been used as an intervention to aid healthy eating and encourage weight loss. The aim of this pre-registered study was to explore the effects of training on food liking, food consumption and weight loss in a large (n = 366), predominantly healthy-weight sample. Participants received four training sessions within a week, in which they had to inhibit their responses to either energy-dense foods (active group) or non-food images (control group). Subjective food ratings, food consumption frequency and weight were measured pre- and post-training. At two-weeks post-training, the active group reported a greater reduction in liking for energy-dense foods, compared to the control group. Active participants also reported a significantly greater increase in healthy food liking, immediately post-training, relative to the control group. There was no statistically significant difference between groups for the change in consumption of trained foods or for weight loss. These findings are partially consistent with previous research conducted in smaller, more overweight samples. Exploratory analyses suggest that some effects of training may be driven by awareness effects. Methodological differences across findings and avenues for future investigation are discussed.

Feasibility randomised controlled trial comparing TRAK-ACL digital rehabilitation intervention plus treatment as usual versus treatment as usual for patients following anterior cruciate ligament reconstruction.

OBJECTIVES: To evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions-ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction. METHODS: The study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures. RESULTS: Fifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3-13 logins), over 18 weeks (SD 12.2 weeks). CONCLUSION: TRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Lifestyle, exercise and activity package for people living with progressive multiple sclerosis (LEAP-MS): protocol for a single-arm feasibility study.

BACKGROUND: We have co-designed a tailored blended physiotherapy intervention for people with progressive multiple sclerosis (PwPMS) who often struggle to access support for physical activity. Underpinned by self-management principles, the Lifestyle, Exercise and Activity Package for people with Multiple Sclerosis (LEAP-MS) intervention incorporates face-to-face or online physiotherapy coaching sessions with an accompanying online physical activity platform. The LEAP-MS platform is a multi-user system enabling user and physiotherapist to co-create activity plans. The LEAP-MS platform consists of an information and activity suite, interactive components enabling selection of exercises into an activity programme, goal setting and activity logging. The platform also facilitates online remote support from a physiotherapist through an embedded online messaging function. We aim to evaluate the LEAP-MS platform in a feasibility trial. METHODS: LEAP-MS will be evaluated within a single-arm feasibility study with embedded process evaluation. After registration and initial eligible screening, 21 participants will be required to complete baseline self-completion measures. This will be followed by an initial home-based or online coaching session with a physiotherapist (who has received tailored self-management and digital resource training) and access to the online intervention for an initial 3-month period. During this period, participants are given the option to request up to five further home-based or online physiotherapy coaching sessions. Follow-up questionnaires and semi-structured interviews will be administered 3 months after baseline with participants and intervention physiotherapists. The LEAP-MS platform will be available to participants for a further 3 months. Usage of the LEAP-MS platform will be tracked during the full 6-month period and final follow-up will be conducted 6 months after baseline. DISCUSSION: Feasibility outcomes (recruitment, retention, intervention uptake and safety) will be reported. The process evaluation will be undertaken to identify possible mechanisms for any observed effects. The data will inform full-scale evaluations of this co-produced, blended physiotherapy intervention. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03951181 . Registered 15 May 2019.

Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis (LEAP-MS): adaptions during the COVID-19 pandemic and remote delivery for improved efficiency.

The LEAP-MS (Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis) study has developed an individualised supported self-management approach for physical activity for people with progressive multiple sclerosis (MS) and severe disability. The intervention has been evaluated in a single-arm feasibility study with embedded process evaluation. The feasibility study was due to open to recruitment during the COVID-19 2020-2021 pandemic, 1 month into the first UK-wide lockdown. We worked rapidly to implement adaptions to the trial procedures and intervention delivery that we believe are applicable to randomised controlled trials. Recruitment became predominantly via self-referral. Electronic consent was employed, with consent discussions occurring over the telephone. Registration, consent, eligibility assessment and data collection as well as the intervention (online physical activity tool) were via a secure, encrypted multi-user web-based platform for participants, physiotherapists and researchers accessible via various hardware. Physiotherapy consultations, as well as the process evaluation, were conducted remotely using video conferencing software or the telephone. A remote training package for physiotherapists and site initiations was also developed and electronic site files employed. Our adaptions are extremely topical given the COVID-19 situation, and whilst not what we had originally planned, have enabled successful delivery of the feasibility study and are relevant to conducting randomised controlled trials and meeting the needs of people with MS who are far more isolated than ever before. TRIAL REGISTRATION: ClinicalTrials.gov NCT03951181 . Registered on 15 May 2019.

Web-based physical activity intervention for people with progressive multiple sclerosis: application of consensus-based intervention development guidance.

OBJECTIVES: People with progressive multiple sclerosis (PwPMS) report that they recognise the benefits of activity on their physical and psychological health but need support to achieve their physical activity goals. We aimed to systematically develop a theoretically informed intervention that would enable PwPMS to more readily engage in regular physical activity. DESIGN: We used an intervention mapping approach to inform intervention development. SETTING: We conducted semistructured interviews with PwPMS and their families/carers and physiotherapists recruited from secondary care settings. PARTICIPANTS: Fourteen PwPMS with an Expanded Disability Status Scale score of between 6 and 8 and 7 of their families/carers and 13 physiotherapists and 1 physiotherapy technician participated. RESULTS: Interview data suggested that the development of supportive coaching relationships with physiotherapists could promote the ability of PwPMS to achieve a desirable and achievable physical activity plan. These interview data informed the prototype 'Lifestyle Exercise and Activity Package for Multiple Sclerosis' (LEAP-MS) consisting of a secure multiuser web-based platform (with an education and activity suite, interactive components enabling selection of exercises, goal setting and activity logging), up to six flexible face-to-face or web-based physiotherapy coaching sessions and remote support via an embedded web-based messaging function that all together draw on specific theory-based methods to achieve physical activity behaviour change, namely active learning, reinforcement, modelling, feedback, facilitation, goal setting and guided practice. Implementation is within a multiuser platform accessible to participants, trained physiotherapists and researchers. CONCLUSIONS: We have followed an inclusive, systematic and transparent process to develop the LEAP-MS intervention that enables detailed description of components, context and guiding principles to inform ongoing evaluation. Importantly, PwPMS expressed the need for autonomy in developing physical activity plans. This has been achieved through the embedding of self-management principles in the design and delivery of the LEAP-MS intervention.

Guidance for Implementing Best Practice Therapeutic Exercise for Patients With Knee and Hip Osteoarthritis: What Does the Current Evidence Base Tell Us?

Therapeutic exercise is a recommended first-line treatment for patients with knee and hip osteoarthritis (OA); however, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim in this narrative review to synthesize current literature informing the implementation of therapeutic exercise for patients with knee and hip OA, focusing on evidence from systematic reviews and randomized controlled trials. Therapeutic exercise is safe for patients with knee and hip OA. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind-body exercise) may be utilized at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically-informed strategies to improve adherence to therapeutic exercise, such as patient education, goal-setting, monitoring, and feedback, may help maintain participation and optimize clinical benefits over the longer term. Sedentary behavior is also a risk factor for disability and lower quality of life in patients with knee and hip OA, although limited evidence exists regarding how best to reduce this behavior. Current evidence can be used to inform how to implement best practice therapeutic exercise at a sufficient and appropriate dose for patients with knee and hip OA.

Patient Triage by Topic Modeling of Referral Letters: Feasibility Study.

BACKGROUND: Musculoskeletal conditions are managed within primary care, but patients can be referred to secondary care if a specialist opinion is required. The ever-increasing demand for health care resources emphasizes the need to streamline care pathways with the ultimate aim of ensuring that patients receive timely and optimal care. Information contained in referral letters underpins the referral decision-making process but is yet to be explored systematically for the purposes of treatment prioritization for musculoskeletal conditions. OBJECTIVE: This study aims to explore the feasibility of using natural language processing and machine learning to automate the triage of patients with musculoskeletal conditions by analyzing information from referral letters. Specifically, we aim to determine whether referral letters can be automatically assorted into latent topics that are clinically relevant, that is, considered relevant when prescribing treatments. Here, clinical relevance is assessed by posing 2 research questions. Can latent topics be used to automatically predict treatment? Can clinicians interpret latent topics as cohorts of patients who share common characteristics or experiences such as medical history, demographics, and possible treatments? METHODS: We used latent Dirichlet allocation to model each referral letter as a finite mixture over an underlying set of topics and model each topic as an infinite mixture over an underlying set of topic probabilities. The topic model was evaluated in the context of automating patient triage. Given a set of treatment outcomes, a binary classifier was trained for each outcome using previously extracted topics as the input features of the machine learning algorithm. In addition, a qualitative evaluation was performed to assess the human interpretability of topics. RESULTS: The prediction accuracy of binary classifiers outperformed the stratified random classifier by a large margin, indicating that topic modeling could be used to predict the treatment, thus effectively supporting patient triage. The qualitative evaluation confirmed the high clinical interpretability of the topic model. CONCLUSIONS: The results established the feasibility of using natural language processing and machine learning to automate triage of patients with knee or hip pain by analyzing information from their referral letters.

A Nonproprietary Movement Analysis System (MoJoXlab) Based on Wearable Inertial Measurement Units Applicable to Healthy Participants and Those With Anterior Cruciate Ligament Reconstruction Across a Range of Complex Tasks: Validation Study.

BACKGROUND: Movement analysis in a clinical setting is frequently restricted to observational methods to inform clinical decision making, which has limited accuracy. Fixed-site, optical, expensive movement analysis laboratories provide gold standard kinematic measurements; however, they are rarely accessed for routine clinical use. Wearable inertial measurement units (IMUs) have been demonstrated as comparable, inexpensive, and portable movement analysis toolkits. MoJoXlab has therefore been developed to work with generic wearable IMUs. However, before using MoJoXlab in clinical practice, there is a need to establish its validity in participants with and without knee conditions across a range of tasks with varying complexity. OBJECTIVE: This paper aimed to present the validation of MoJoXlab software for using generic wearable IMUs for calculating hip, knee, and ankle joint angle measurements in the sagittal, frontal, and transverse planes for walking, squatting, and jumping in healthy participants and those with anterior cruciate ligament (ACL) reconstruction. METHODS: Movement data were collected from 27 healthy participants and 20 participants with ACL reconstruction. In each case, the participants wore seven MTw2 IMUs (Xsens Technologies) to monitor their movement in walking, jumping, and squatting tasks. The hip, knee, and ankle joint angles were calculated in the sagittal, frontal, and transverse planes using two different software packages: Xsens' validated proprietary MVN Analyze and MoJoXlab. The results were validated by comparing the generated waveforms, cross-correlation (CC), and normalized root mean square error (NRMSE) values. RESULTS: Across all joints and activities, for data of both healthy and ACL reconstruction participants, the CC and NRMSE values for the sagittal plane are 0.99 (SD 0.01) and 0.042 (SD 0.025); 0.88 (SD 0.048) and 0.18 (SD 0.078) for the frontal plane; and 0.85 (SD 0.027) and 0.23 (SD 0.065) for the transverse plane (hip and knee joints only). On comparing the results from the two different software systems, the sagittal plane was very highly correlated, with frontal and transverse planes showing strong correlation. CONCLUSIONS: This study demonstrates that nonproprietary software such as MoJoXlab can accurately calculate joint angles for movement analysis applications comparable with proprietary software for walking, squatting, and jumping in healthy individuals and those following ACL reconstruction. MoJoXlab can be used with generic wearable IMUs that can provide clinicians accurate objective data when assessing patients' movement, even when changes are too small to be observed visually. The availability of easy-to-setup, nonproprietary software for calibration, data collection, and joint angle calculation has the potential to increase the adoption of wearable IMU sensors in clinical practice, as well as in free living conditions, and may provide wider access to accurate, objective assessment of patients' progress over time.

Dual-Task Effects on Performance of Gait and Balance in People with Knee Pain: A Systematic Scoping Review.

Dual-task paradigms have been increasingly used to assess the interaction between cognitive demands and the control of balance and gait. The interaction between functional and cognitive demands can alter movement patterns and increase knee instability in individuals with knee conditions, such as knee anterior cruciate ligament (ACL) injury or osteoarthritis (OA). However, there is no consensus on the effects of dual-task on gait mechanics and balance in those individuals. This systematic scoping review aims to examine the impact of dual-task gait and standing balance on motor and cognitive performance in individuals with knee OA or ACL injury. A comprehensive search of MEDLINE, PubMed, Web of Science, and EMBASE electronic databases up until December 2019 was carried out. Inclusion criteria was limited to include dual-task studies that combined cognitive tasks performed simultaneously with gait or standing balance in individuals with knee OA or ACL injuries. In total, fifteen studies met the inclusion criteria, nine articles examined dual-task effects on balance, and six articles reported the effects of dual-task on gait. The total number of individuals included was 230 individuals with ACL injuries, and 168 individuals with knee OA. A decline in gait and balance performance during dual-task testing is present among individuals with ACL injury and/or ACL reconstruction and knee OA. Further research is required, but dual taking assessment could potentially be used to identify individuals at risk of falling or further injury and could be used to develop targeted rehabilitation protocols. A variety of outcome measures have been used across the studies included, making comparisons difficult. The authors, therefore, recommend developing a standardized set of biomechanical balance variables.

Using routine referral data for patients with knee and hip pain to improve access to specialist care.

BACKGROUND: Referral letters from primary care contain a large amount of information that could be used to improve the appropriateness of the referral pathway for individuals seeking specialist opinion for knee or hip pain. The primary aim of this study was to evaluate the content of the referral letters to identify information that can independently predict an optimal care pathway. METHODS: Using a prospective longitudinal design, a convenience sample of patients with hip or knee pain were recruited from orthopaedic, specialist general practice and advanced physiotherapy practitioner clinics. Individuals completed a Knee or hip Osteoarthritis Outcome Score at initial consultation and after 6 months. Participant demographics, body mass index, medication and co-morbidity data were extracted from the referral letters. Free text of the referral letters was mapped automatically onto the Unified Medical Language System to identify relevant clinical variables. Treatment outcomes were extracted from the consultation letters. Each outcome was classified as being an optimal or sub-optimal pathway, where an optimal pathway was defined as the one that results in the right treatment at the right time. Logistic regression was used to identify variables that were independently associated with an optimal pathway. RESULTS: A total of 643 participants were recruited, 419 (66.7%) were classified as having an optimal pathway. Variables independently associated with having an optimal care pathway were lower body mass index (OR 1.0, 95% CI 0.9 to 1.0 p = 0.004), named disease or syndromes (OR 1.8, 95% CI 1.1 to 2.8, p = 0.02) and taking pharmacologic substances (OR 1.8, 95% CI 1.0 to 3.3, p = 0.02). Having a single diagnostic procedure was associated with a suboptimal pathway (OR 0.5, 95% CI 0.3 to 0.9 p < 0.001). Neither Knee nor Hip Osteoarthritis Outcome scores were associated with an optimal pathway. Body mass index was found to be a good predictor of patient rated function (coefficient - 0.8, 95% CI -1.1, - 0.4 p < 0.001). CONCLUSION: Over 30% of patients followed sub-optimal care pathway, which represents potential inefficiency and wasted healthcare resource. A core data set including body mass index should be considered as this was a predictor of optimal care and patient rated pain and function.

Identifying Priorities for Physiotherapy Research in the UK: the James Lind Alliance Physiotherapy Priority Setting Partnership.

OBJECTIVES: To identify unanswered questions for physiotherapy research and help set and prioritise the top 10 generic research priorities for the UK physiotherapy profession; updating previous clinical condition- specific priorities to include patient and carer perspectives, and reflect changes in physiotherapy practice, service provision and new technologies. DESIGN: The James Lind Alliance (JLA) Priority Setting Partnership (PSP) methodology was adopted, utilising evidence review, survey and consensus methods. PARTICIPANTS: Anyone with experience and/or an interest in UK physiotherapy: patients, carers, members of the public, physiotherapists, student physiotherapists, other healthcare professionals, researchers, educators, service providers, commissioners and policy makers. RESULTS: Five hundred and ten respondents (50% patients, carers or members of the public) identified 2152 questions (termed "uncertainties"). Sixty-five indicative questions were developed from the uncertainties using peer reviewed thematic analysis. These were ranked in a second national survey (1,020 responses (62% were complete)). The top 25 questions were reviewed in a final prioritisation workshop using an adapted nominal group technique. The top 10 research priorities focused on optimisation (top priority); access; effectiveness; patient and carer knowledge, experiences, needs and expectations; supporting patient engagement and self-management; diagnosis and prediction. CONCLUSIONS: This study is currently the UK's most inclusive consultation exercise to identify patients'and healthcare professionals'priorities for physiotherapy research. The exercise deliberately sought to capture generic issues relevant to all specialisms within physiotherapy. The research priorities identified a range of gaps in existing evidence to inform physiotherapy policy and practice. The results will assist research commissioning bodies and inform funding decisions and strategy.

KLOSURE: Closing in on open-ended patient questionnaires with text mining.

BACKGROUND: Knee injury and Osteoarthritis Outcome Score (KOOS) is an instrument used to quantify patients' perceptions about their knee condition and associated problems. It is administered as a 42-item closed-ended questionnaire in which patients are asked to self-assess five outcomes: pain, other symptoms, activities of daily living, sport and recreation activities, and quality of life. We developed KLOG as a 10-item open-ended version of the KOOS questionnaire in an attempt to obtain deeper insight into patients' opinions including their unmet needs. However, the open-ended nature of the questionnaire incurs analytical overhead associated with the interpretation of responses. The goal of this study was to automate such analysis. We implemented KLOSURE as a system for mining free-text responses to the KLOG questionnaire. It consists of two subsystems, one concerned with feature extraction and the other one concerned with classification of feature vectors. Feature extraction is performed by a set of four modules whose main functionalities are linguistic pre-processing, sentiment analysis, named entity recognition and lexicon lookup respectively. Outputs produced by each module are combined into feature vectors. The structure of feature vectors will vary across the KLOG questions. Finally, Weka, a machine learning workbench, was used for classification of feature vectors. RESULTS: The precision of the system varied between 62.8 and 95.3%, whereas the recall varied from 58.3 to 87.6% across the 10 questions. The overall performance in terms of F-measure varied between 59.0 and 91.3% with an average of 74.4% and a standard deviation of 8.8. CONCLUSIONS: We demonstrated the feasibility of mining open-ended patient questionnaires. By automatically mapping free text answers onto a Likert scale, we can effectively measure the progress of rehabilitation over time. In comparison to traditional closed-ended questionnaires, our approach offers much richer information that can be utilised to support clinical decision making. In conclusion, we demonstrated how text mining can be used to combine the benefits of qualitative and quantitative analysis of patient experiences.

Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review.

OBJECTIVE: Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion. DESIGN: Systematic review. DATA SOURCES: Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature. ELIGIBILITY CRITERIA: All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists. DATA EXTRACTION AND SYNTHESIS: Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively. RESULTS: The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the 'meso' level of a whole systems approach. CONCLUSION: It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways. PROSPERO REGISTRATION NUMBER: CRD42016035510.

Effect of visual feedback on the performance of the star excursion balance test.

INTRODUCTION: Visual feedback is an effective method to enhance postural and balance control in clinical and sports training. The aim of this study was to explore the effect of real-time visual feedback provided by a video camera on the performance of a dynamic balance test, which is the star excursion balance test in healthy subjects. METHODS: We compared the performance of the star excursion balance test using the maximum reach distance in 20 healthy participants (10 male and 10 female, 26.8 ± 3.7 years) under two conditions: without feedback and whilst they viewed their movements in real-time on a screen in front of them via a video camera. RESULTS: The results showed that real-time visual feedback had a significant effect on maximum reach distance of the star excursion balance test in the posterolateral direction (P < 0.001). There was a non-significant increase in the maximum reach distance in the anterior and posteromedial directions. CONCLUSION: The result indicates that the real-time visual feedback appears to be an effective means for improving the performance of the star excursion balance test in the posterolateral direction, and may be a promising tool for clinical rehabilitation and athlete training to enhance dynamic postural control.

Frontal plane movement of the pelvis and thorax during dynamic activities in individuals with and without anterior cruciate ligament injury.

BACKGROUND: For elite athletes with anterior cruciate ligament (ACL) reconstruction, reducing pelvis and trunk obliquities is a common goal of rehabilitation. It is not known if this is also a suitable goal for the general population. This study aimed to quantify pelvis and thorax obliquities during dynamic activities in individuals from the general population with and without history of ACL injury. METHODS: Retrospective analysis of cross-sectional data from 30 participants with ACL reconstruction, 28 participants with ACL deficiency (ACLD), and 32 controls who performed overground walking and jogging, single-leg squat, and single-leg hop for distance. Pelvis and thorax obliquities were quantified in each activity and compared across groups using one-way ANOVA. Coordination was quantified using cross covariance. RESULTS: In the stance phase of walking and jogging, pelvis and thorax obliquities were within ±10° of neutral and there was a negative correlation between the two segments at close to zero phase lag. In single-leg squat and hop, range of obliquities varied across individuals and there was no consistent pattern of coordination. Eight ACLD participants felt unable to perform the single-leg hop. In the remaining participants, range of pelvis (p = 0.04) and thorax (p = 0.02) obliquities was smaller in ACLD than controls. CONCLUSIONS: In challenging single-leg activities, minimal frontal plane motion was not the typical movement pattern observed in the general population. Coordination between the pelvis and thorax was inconsistent within and across individuals. Care should be taken when considering minimising pelvis and thorax obliquities in patients with ACL injury.