Ankle osteoarthritis: an online survey of current treatment practices of UK-based podiatrists and physiotherapists.

BACKGROUND: Patients with painful ankle osteoarthritis (OA) have a mixed experience of non-surgical management which they may attribute to a lack of guidance for clinicians on usual care treatment. Therefore, the purpose of this study was to survey the current clinical practices of UK-based physiotherapists and podiatrists for the treatment of painful ankle osteoarthritis (OA). METHODS: UK-based physiotherapists and podiatrists who treat patients with ankle OA completed a self-administered online questionnaire about their professional and clinical service characteristics, diagnostic criteria, treatment aims, preferred treatment options, and treatment outcome measures. Data were collected anonymously and stored on JISC online survey. 'Usual care' was defined as a combination of 'Always', and 'Frequently', and 'Not usual care' was defined as 'Sometimes' 'Rarely,' 'Never', and 'not applicable' combined. Statistically significant differences in responses between the physiotherapists and podiatrists were analysed using X2 tests for each treatment modality. Statistical significance was set at p < 0.05. RESULTS: Between 1st June 2021 and 31st August 2021, 100 responses were received; 2 were invalid. Of the 98 valid responses, 63 were from physiotherapists and 35 from podiatrists. The most common treatment aims in both professions were to reduce pain (n = 87, 89%) and improve quality of life (n = 82, 84%). 50 respondents (51%) offered 3 or 4 treatment sessions and 53 respondents (54%) saw patients for 30-40 min at the first treatment session. The five most common modalities used by physiotherapists were patient education (n = 63, 100%), teaching self-management (n = 58, 92%), lifestyle modification (n = 54, 86%), ankle strengthening (n = 55, 87%), and proprioception exercises (n = 54, 86%). For podiatrists, these were patient education (n = 35, 100%), ankle strengthening (n = 31, 89%), activity pacing (n = 28, 80%), lifestyle modification (n = 27, 77%), and gait training (n = 27, 77%). CONCLUSIONS: This first-ever survey revealed physiotherapists' and podiatrists' current practices to treat painful ankle OA. This study provides a better understanding of how ankle OA is treated in UK current clinical practice and can inform future clinical trials to compare current practice with new treatment modalities.

Patient and healthcare provider experience and perceptions of a preoperative rehabilitation class for lumbar discectomy: A qualitative study.

BACKGROUND: Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients. OBJECTIVES: To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend. DESIGN: A qualitative interpretive approach using focus groups and individual interviews. METHODS: Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis. RESULTS/FINDINGS: Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance. CONCLUSIONS: For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively.

Prognostic factors associated with changes in knee pain outcomes, identified from initial primary care consultation data. A systematic literature review.

BACKGROUND: Data collected during initial primary care consultations could be a source of baseline prognostic factors associated with changes in outcome measures for patients with knee pain. OBJECTIVES: To identify, appraise and synthesize studies investigating prognostic factors associated with changes in outcome for people presenting with knee pain in primary care. METHODS: EMBASE, CINAHL, AMED, MEDLINE and MedRxiv electronic databases were searched from inception to March 2021 and repeated in August 2022. Prospective cohort studies of adult participants with musculoskeletal knee pain assessing the association between putative prognostic factors and outcomes in primary care were included. The Quality in Prognostic Studies (QUIPS) tool and The Modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, specific to prognostic reviews were used to appraise and synthesize the evidence respectively. RESULTS: Eight studies were included. Eight knee pain outcomes were identified. Methodological and statistical heterogeneity resulted in qualitative analysis. All evidence was judged to be of low to very low quality. Bilateral knee pain (multivariable odds ratio (OR) range 2.60-2.74; 95%CI range 0.90-8.10, p value = 0.09) and a lower educational level (multivariable (OR) range 1.74-5.6; 95%CI range 1.16-16.20, p value = <0.001) were synonymously associated with persisting knee pain at 12-month follow up. A total of 37 univariable and 63 multivariable prognostic factors were statistically associated with outcomes (p ≤ 0.05) in single studies. CONCLUSIONS: There was consensus from two independent studies that bilateral knee pain and lower educational level were associated with persistent knee pain. Many baseline factors were associated with outcome in individual studies but not consistently between studies. The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited. This review will provide an essential guide for candidate variable selection in future primary care prognostic confirmatory studies.Key messagesBilateral knee pain and lower educational level were associated with persistent knee pain.Many baseline factors were associated with outcome in individual studies but not consistently between studies.The current understanding, accuracy and reliability of the prognostic value of initial primary care consultation data for knee pain outcomes are limited.

Can prognostic factors for indirect muscle injuries in elite football (soccer) players be identified using data from preseason screening? An exploratory analysis using routinely collected periodic health examination records.

BACKGROUND: In elite football, periodic health examination (PHE) may be useful for injury risk prediction. OBJECTIVE: To explore whether PHE-derived variables are prognostic factors for indirect muscle injuries (IMIs) in elite players. DESIGN: Retrospective cohort study. SETTING: An English Premier League football club. PARTICIPANTS: 134 outfield elite male players, over 5 seasons (1 July 2013-19 May 2018). OUTCOME AND ANALYSIS: The outcome was any time-loss, lower extremity index IMI (I-IMI). Prognostic associations were estimated using odds ratios (ORs) and corresponding statistical significance for 36 variables, derived from univariable and multivariable logistic regression models. Missing data were handled using multiple imputation. Non-linear associations were explored using fractional polynomials. RESULTS: During 317 participant-seasons, 138 I-IMIs were recorded. Univariable associations were determined for previous calf IMI frequency (OR 1.80, 95% CI 1.09 to 2.97), hamstring IMI frequency (OR 1.56, 95% CI 1.17 to 2.09), if the most recent hamstring IMI occurred >12 months but <3 years prior to PHE (OR 2.95, 95% CI 1.51 to 5.73) and age (OR 1.12 per 1-year increase, 95% CI 1.06 to 1.18). Multivariable analyses showed that if a player's most recent previous hamstring IMI was >12 months but <3 years prior to PHE (OR 2.24, 95% CI 1.11 to 4.53), this was the only variable with added prognostic value over and above age, which was a confirmed prognostic factor (OR 1.12 per 1-year increase, 95% CI 1.05 to 1.18). Allowing non-linear associations conferred no advantage over linear associations. CONCLUSION: PHE has limited use for injury risk prediction. Most variables did not add prognostic value over and above age, other than if a player experienced a hamstring IMI >12 months but <3 years prior to PHE. However, the precision of this prognostic association should be confirmed in future. TRIAL REGISTRATION NUMBER: NCT03782389.

The Effect of Dietary Nitrate on the Contractile Properties of Human Skeletal Muscle: A Systematic Review and Meta-Analysis.

The propose of this study was to systematically review the current literature and meta-analyse the effects of dietary nitrate (NO3-) supplementation on the contractile properties of skeletal muscle. A literature search of three databases was conducted in June 2021, with 19 studies meeting the inclusion criteria. Studies were included if a placebo versus dietary NO3--only supplementation protocol was used in healthy human, assessed muscle contraction or activities that was < 3 minutes in duration and focused on the lower-body. For the meta-analysis, a pooled standardised mean difference (SMD) was determined for maximum voluntary contraction (MVC) (n = 11), cycling, running and inertial load squad peak power output (PPO) (n = 8), mean power output (MPO) (n = 6) and time to PPO (n = 4). NO3- supplementation demonstrated a small improvement in PPO (SMD = 0.25, P = 0.030) and MPO (SMD = 0.28, P = 0.030) when compared to the placebo. NO3- also resulted in an enhanced time to PPO (SMD = -0.78, P < 0.001). There was no clear effect of NO3- on isometric MVC (SMD = 0.03, P = 0.758). This review reports that NO3- supplementation may have potential to enhance PPO, MPO and time to PPO during dynamic exercise, which may transfer to brief explosive actions commonly observed in sporting activities. Due to the variability in studies, we encourage researchers to use this work to explore areas where evidence in lacking and standardize the study design and procedures.Key teaching pointsFindings from this meta-analysis highlight the potential positive ergogenic effect of dietary NO3-supplementation on PPO, MPO and time to PPO during short duration (<10 s) dynamic exercise.NO3- supplementation might be considered as an ergogenic aid when executing power-based actions (e.g., 100 m sprinter or weightlifter).This review highlights that further research is required to address some of the contrasting findings presented here using a standardised procedure to allow for improved synthesis.

Do the General Public and Health Care Professionals Think That Running Is Bad for the Knees? A Cross-sectional International Multilanguage Online Survey.

Background: Running is a popular sport with widely recognized health benefits. Given the high rates of knee injury in runners and the growing prevalence of knee osteoarthritis (KOA), it may be useful to assess perceptions about running and knee joint health. Purpose: The objectives of this study were to (1) explore and compare the perceptions of the general public (PUB) and health care professionals (HCPs) on the topic of running and knee health and (2) explore recommendations about running and knee health provided by HCPs. Study Design: Cross-sectional study. Methods: We conducted an online survey between June 18 and October 1, 2020. The questionnaire included questions on running and knee health, and HCPs were asked about their typical recommendations and level of confidence in providing recommendations on the topic. Perceptions (proportions) were compared between the PUB and HCPs using the chi-square test. Results: In total, 4521 responses (PUB, n = 2514; HCPs, n = 2007) were analyzed. A greater proportion of HCPs perceived regular running as healthy for knees (86% vs 68%; P < .001). More of the PUB than HCPs (P < .001) believed that running frequently (29% vs 13%), long distances (54% vs 45%), and on hard surfaces (60% vs 36%) increased the risk of developing KOA. Running for those with KOA was perceived by the PUB as posing an increased risk of getting more knee pain (48%) and needing joint replacement surgery (38%), more so than by HCPs (26% and 17%, respectively). The majority of HCPs reported being relatively confident in providing evidence-based recommendations about running and knee health and mostly recommended that runners with KOA modify training parameters instead of quit. Conclusion: More HCPs perceived running as healthy for knees when compared with the PUB. Most HCPs felt confident in providing evidence-based recommendations about running and knee health.

Physical therapy of patients undergoing first-time lumbar discectomy: a survey of current UK practice.

BACKGROUND: The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers. METHOD: Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy. RESULTS: Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription. CONCLUSIONS: Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.

Effect of nitrate supplementation on skeletal muscle motor unit activity during isometric blood flow restriction exercise.

BACKGROUND: Nitrate (NO3-) supplementation has been reported to lower motor unit (MU) firing rate (MUFR) during dynamic resistance exercise; however, its impact on MU activity during isometric and ischemic exercise is unknown. PURPOSE: To assess the effect of NO3- supplementation on knee extensor MU activities during brief isometric contractions and a 3 min sustained contraction with blood flow restriction (BFR). METHODS: Sixteen healthy active young adults (six females) completed two trials in a randomized, double-blind, crossover design. Trials were preceded by 5 days of either NO3- (NIT) or placebo (PLA) supplementation. Intramuscular electromyography was used to determine the M. vastus lateralis MU potential (MUP) size, MUFR and near fibre (NF) jiggle (a measure of neuromuscular stability) during brief (20 s) isometric contractions at 25% maximal strength and throughout a 3 min sustained BFR isometric contraction. RESULTS: Plasma nitrite (NO2-) concentration was elevated after NIT compared to PLA (475 ± 93 vs. 198 ± 46 nmol L-1, p < 0.001). While changes in MUP area, NF jiggle and MUFR were similar between NIT and PLA trials (all p > 0.05), MUP duration was shorter with NIT compared to PLA during brief isometric contractions and the sustained ischemic contraction (p < 0.01). In addition, mean MUP duration, MUP area and NF jiggle increased, and MUFR decreased over the 3 min sustained BFR isometric contraction for both conditions (all p < 0.05). CONCLUSIONS: These findings provide insight into the effect of NO3- supplementation on MUP properties and reveal faster MUP duration after short-term NO3- supplementation which may have positive implications for skeletal muscle contractile performance.

The prevalence of patellofemoral pain in the Rugby League World Cup (RLWC) 2021 spectators: A protocol of a cross-sectional study.

Patellofemoral pain (PFP) can cause significant pain leading to limitations in societal participation and physical activity. PFP is usually associated with athletes undergoing intensive physical training, or military recruits; but recent evidence shows that PFP is common in the general population. The relationship of PFP with physical activity is not entirely clear. Our aim is to provide a better estimate of the general population prevalence of PFP and to relate this to the level of physical activity, and demographic characteristics. The Survey instrument for Natural history, Aetiology and Prevalence of Patellofemoral pain Studies (SNAPPS) was developed as a PFP screening tool to be used in the community. The electronic version of the SNAPPS (eSNAPPS) has recently been validated and was used to survey attendees at mass-participation running events. We will use an electronic survey to collect data from a sample of 1100 Rugby League World Cup spectators. The survey will have four sections: i) general and demographic; ii) knee pain (eSNAPPS); iii) level of physical activity; and iv) quality of life in relation to knee pain. The primary analytic approach will be descriptive of PFP prevalence. Secondary analyses will explore the relationships of the presence of PFP and the other variables. We will disseminate this work by publication of peer-reviewed papers in scientific journals, presentations at scientific conferences, and on the dedicated SNAPPS website https://www.snappspfp.com/.

Clinical Prediction Models in Sports Medicine: A Guide for Clinicians and Researchers.

SYNOPSIS: Participating in sport carries inherent risk of injury. Clinicians execute high-level clinical reasoning and decision making to support athletes to achieve the best outcomes. Accurately diagnosing a problem, estimating prognosis, or selecting the most suitable intervention for each athlete is challenging. Clinical prediction models are tools to assist clinicians in estimating the risk or probability of a health outcome for an individual by using data from multiple predictors. Although common in general medical literature, clinical prediction models are rare in sports medicine. The purpose of this article was to (1) describe the steps required to develop and validate (ie, evaluate) a clinical prediction model for clinical researchers, and (2) help sports medicine clinicians understand and interpret clinical prediction model studies. Using a case study to illustrate how to implement clinical prediction models in practice, we address the following issues in developing and validating a clinical prediction model: study design and data, sample size, missing data, selecting predictors, handling continuous predictors, model fitting, internal and external validation, performance measures, reporting, and model presentation. Our work builds on initiatives to improve diagnostic and prognostic clinical research, including the PROGnosis RESearch Strategy (PROGRESS) series of papers and textbook and the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement. J Orthop Sports Phys Ther 2021;51(10):517-525. doi:10.2519/jospt.2021.10697.

Assessment of bone marrow oedema-like lesions using MRI in patellofemoral knee osteoarthritis: comparison of different MRI pulse sequences.

OBJECTIVE: To compare bone marrow oedema-like lesion (BML) volume in subjects with symptomatic patellofemoral (PF) knee osteoarthritis (OA) using four different MRI sequences and to determine reliability of BML volume assessment using these sequences and their correlation with pain. METHODS: 76 males and females (mean age 55.8 years) with symptomatic patellofemoral knee OA had 1.5 T MRI scans. PD fat suppressed (FS), STIR, contrast-enhanced (CE) T1W FS, and 3D T1W fast field echo (FFE) sequences were obtained. All sequences were assessed by one reader, including repeat assessment of 15 knees using manual segmentation and the measurements were compared. We used random-effects panel linear regression to look for differences in the log-transformed BML volume (due to positive skew in the BML volume distribution) between sequences and to determine associations between BML volumes and knee pain. RESULTS: 58 subjects had PF BMLs present on at least one sequence. Median BML volume measured using T1W FFE sequence was significantly smaller (224.7 mm3, interquartile range [IQR] 82.50-607.95) than the other three sequences. BML volume was greatest on the CE sequence (1129.8 mm3, IQR 467.28-3166.02). Compared to CE sequence, BML volumes were slightly lower when assessed using PDFS (proportional difference = 0.79; 95% confidence interval [CI] 0.62, 1.01) and STIR sequences (proportional difference = 0.85; 95% CI 0.67, 1.08). There were strong correlations between BML volume on PDFS, STIR, and CE T1W FS sequences (ρs = 0.98). Correlations were lower between these three sequences and T1W FFE (ρs = 0.80-0.81). Intraclass correlation coefficients were excellent for proton density fat-suppressed, short-tau inversion recovery, and CE T1W FS sequences (0.991-0.995), while the ICC for T1W FFE was good at 0.88. We found no significant association between BML volumes assessed using any of the sequences and knee pain. CONCLUSION: T1W FFE sequences were less reliable and measured considerably smaller BML volume compared to other sequences. BML volume was larger when assessed using the contrast enhanced T1W FS though not statistically significantly different from BMLs when assessed using PDFS and STIR sequences. ADVANCES IN KNOWLEDGE: This is the first study to assess BMLs by four different MRI pulse sequences on the same data set, including different fluid sensitive sequences and gradient echo type sequence.

Management of patellofemoral joint osteoarthritis using biomechanical device therapy: a systematic review with meta-analysis.

BACKGROUND: Current clinical guidelines recommend conservative management including non-pharmacologic therapy prior to considering surgery for knee OA. There is a paucity of clinical trials investigating the use of biomechanical device therapies on those with patellofemoral joint osteoarthritis (PFJOA). The aim was to systematically review the effectiveness of biomechanical devices (bracing, taping, and footwear) in the management of symptomatic PFJOA. METHOD: The Cochrane, PEDro, MEDLINE, CINAHL, AMED and EMBASE electronic databases were search from inception to October 31, 2020. Included studies were randomised controlled or clinical trials studying any form of biomechanical device therapy in the management of PFJOA in the English language. Studies included in the search were quality-appraised using the PEDro scoring system. RESULT: Eleven studies were identified which included assessment of either patellar taping, or foot orthotics, knee bracing or combined physiotherapy treatments. Trial quality ranged from 'poor' through 'fair' to 'good'. For patellar bracing, pooled analysis of two good quality randomised controlled trials showed no overall significant improvement on a visual analogue scale (VAS) (random effects (RE) standardised mean difference (SMD) = -0.42 (95%CI -1.12 to +0.29). Pooled data from the same two studies showed a non-significant improvement in favour of bracing assessed by the KOOS/WOMAC (RE SMD = -0.18 (95%CI -0.66 to +0.31). Two studies of 'fair' and 'good' quality applying patellar tape showed a significant reduction in pain immediately after application and after 4 days. A randomised trial of a foot orthotic showed a non-significant improvement in pain after 6 weeks with a between groups adjusted mean difference for maximum VAS of 21.9 mm (95% CI - 2.1 to 46.0) and 8.1 (95% CI- 6.9 to 23.1) for KOOS pain. A multimodal physiotherapy intervention (which included taping in two studies) showed a pooled significant improvement in VAS (SMD = -0.4; (95% CI -0.71 to -0.09) at 3 months compared to controls. CONCLUSION: There is some good quality evidence that a combined physiotherapy approach significantly reduces short-term pain in those with PFJOA. Long-term effects of all interventions are still unknown, which indicates the need for further research to determine the longer term impact of all biomechanical devices on outcomes in symptomatic PFJOA.

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies.

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.

Effect of a cervical collar on head and neck acceleration profiles during emergency spinal immobilisation and extrication procedures in elite football (soccer) players: protocol for a randomised, controlled cross-over trial.

When immobilisation after a cervical spine or head injury is required, the role of the rigid cervical collar is unclear and controversial. There is a need for further studies investigating the use of a rigid cervical collar when head and neck trauma occurs in sport. This study will compare present practice (immobilisation with a cervical collar) to the same procedure without a collar during a simulated spinal immobilisation and extraction scenario from the field of play to the side-line in football (soccer). It will use a prospective cohort within-subjects cross over randomised, controlled trial design. Healthy participants will assume the role of players with a head or neck injury. Clinical practitioners will perform the immobilisation and extrication procedure according to current clinical guidelines. Three dimensional linear and angular acceleration profiles of the head and torso will be measured and the time taken to complete the procedure. The interventions will be a 'cervical collar' or 'no collar' in random order. Data from the IMUs will be transferred wirelessly to a computer for analysis. Accordingly, within-subject differences between each condition (collar vs no collar) will be assessed with parametric or non-parametric inferential statistics. Statistical significance will be set at p<0.05. Trial registration number: ISRCTN16515969.

An exploration of the experiences of people living with painful ankle osteoarthritis and the non-surgical management of this condition.

OBJECTIVES: Osteoarthritis (OA) of the ankle joint is associated with life-long joint pain and disability if not appropriately managed. There is a dearth of research concerning ankle OA and the impact on those living with the condition. AIM: To explore the experiences of people living with painful OA ankle and their views about the non-surgical management of this condition. DESIGN: Qualitative design, using semi-structured interviews. PARTICIPANTS: Nine participants, recruited from an orthopaedic clinic at a UK hospital and the general population. All had a clinical and radiographic diagnosis of OA ankle. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was undertaken to identify emerging themes. Ethical approval was obtained. RESULTS: Nine semi-structured interviews were undertaken. Eight participants were male, median age=55 years (IQR=42.5-64.5). Mechanism of onset was due to trauma (falls, repeated inversion injuries or road traffic collisions) (n=7), or the effects of haemophilia (n=2). The median duration of symptoms was 2 years (IQR=1.5-10). Data saturation was achieved. Four themes were identified: CONCLUSIONS: This is the first study to explore the experiences of people with symptomatic OA ankle. Our findings suggest that those with OA ankle suffer with severe pain, which has a substantial negative impact on a person's physical and mental wellbeing. The findings of this study may be used to inform future research.

The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review.

INTRODUCTION: An increasing number of patients are attending the Emergency Department (ED) with back pain with or without sciatica. There is evidence to suggest that medical management is varied and inconsistent. OBJECTIVE: The purpose of this study was to review the literature to determine the evidence base for the therapeutic management of adults presenting with back pain with or without sciatica in the ED. METHODS: A systematic review of the literature included the therapeutic management of patients presenting in the ED. Articles published in peer review journals in English language up to August 2018 were searched for in the following data-bases: MEDLINE, EMBASE, SCOPUS, CINAHL, ZETOC, PubMed, The Cochrane Library (Cochrane Database of Systematic Reviews), Web of Science, Open Grey and ETHOS. A narrative synthesis approach was followed. RESULTS: Twenty two studies, including 17 randomised control trials, one randomised control pilot study, two cohort studies, one cohort pilot study and one retrospective audit were included. The Downs and Black methodological quality scores ranged from 16 to 31 with a mean score of 24 out of a possible 32. CONCLUSION: Evidence suggests that Naproxen alone should be considered as first line management in cases of back pain without sciatica. Intra-venous corticosteroids should be considered in the management of cases of severe sciatica. More high quality trials are needed to determine an evidence-based management protocol for the treatment of acute low back pain in the ED, specifically focusing on non-pharmacological management and the first line management of patients presenting with LBP with sciatica. Systematic Review Registration Number PROSPERO CRD42016042087.

The Value of Preseason Screening for Injury Prediction: The Development and Internal Validation of a Multivariable Prognostic Model to Predict Indirect Muscle Injury Risk in Elite Football (Soccer) Players.

BACKGROUND: In elite football (soccer), periodic health examination (PHE) could provide prognostic factors to predict injury risk. OBJECTIVE: To develop and internally validate a prognostic model to predict individualised indirect (non-contact) muscle injury (IMI) risk during a season in elite footballers, only using PHE-derived candidate prognostic factors. METHODS: Routinely collected preseason PHE and injury data were used from 152 players over 5 seasons (1st July 2013 to 19th May 2018). Ten candidate prognostic factors (12 parameters) were included in model development. Multiple imputation was used to handle missing values. The outcome was any time-loss, index indirect muscle injury (I-IMI) affecting the lower extremity. A full logistic regression model was fitted, and a parsimonious model developed using backward-selection to remove factors that exceeded a threshold that was equivalent to Akaike's Information Criterion (alpha 0.157). Predictive performance was assessed through calibration, discrimination and decision-curve analysis, averaged across all imputed datasets. The model was internally validated using bootstrapping and adjusted for overfitting. RESULTS: During 317 participant-seasons, 138 I-IMIs were recorded. The parsimonious model included only age and frequency of previous IMIs; apparent calibration was perfect, but discrimination was modest (C-index = 0.641, 95% confidence interval (CI) = 0.580 to 0.703), with clinical utility evident between risk thresholds of 37-71%. After validation and overfitting adjustment, performance deteriorated (C-index = 0.589 (95% CI = 0.528 to 0.651); calibration-in-the-large = - 0.009 (95% CI = - 0.239 to 0.239); calibration slope = 0.718 (95% CI = 0.275 to 1.161)). CONCLUSION: The selected PHE data were insufficient prognostic factors from which to develop a useful model for predicting IMI risk in elite footballers. Further research should prioritise identifying novel prognostic factors to improve future risk prediction models in this field. TRIAL REGISTRATION: NCT03782389.

Change in pain and its relation to change in activity in osteoarthritis.

Objective: Trials testing promising interventions in knee osteoarthritis (OA) often fail to show pain reductions. This may be due to change in activity whereby a person's pain decreases, leading them to increase their activity levels, in turn increasing pain back to baseline levels. Using data from a trial of a beneficial treatment for knee pain, we explored whether activity changes might mask a treatment's effect on pain, by looking at whether activity levels increased with effective treatment and whether change in activity level related to change in pain. Design: During the InRespond trial (ISRCTN55059760) participants wore an accelerometer for 7 days before and during treatments. We assessed change in pain on treatment using scores for overall knee pain and pain in a nominated pain-aggravating activity both in the last week and evaluated change in different types of activity using accelerometer data. Principal components analysis tested whether change in activity and pain outcomes were correlated and created composites combining them. We then tested whether activity, pain or the composites showed a treatment effect, and examined their responsiveness. Results: In the 61 participants (mean age 64.5 years, 38% women, mean overall knee pain score 5.08 (0-10)), activity levels mostly decreased during the trial. Principal component analyses suggested that pain and activity did not correlate highly, loading on different components. Treatment that showed significant effects on pain did not show similar effects on either activity (e.g. the active treatment had a slightly greater reduction in total steps taken than the control treatment (difference 1942.6 steps/week, p = 0.42) nor on composites combining activity and pain. Pain outcomes were the most responsive; static loading (standing) outcomes were the most responsive activity outcome. Conclusion: We found no evidence to support the hypothesis that activity levels increase during effective OA treatment and might account for the negligible pain effects of OA treatments.

Do Clinical Correlates of Knee Osteoarthritis Predict Outcome of Intraarticular Steroid Injections?

OBJECTIVE: To determine whether clinical correlates of knee osteoarthritis (OA) affect the outcome of intraarticular steroid injections (IASI) in symptomatic knee OA. METHODS: Men and women aged ≥ 40 years with painful knee OA who participated in an open-label trial of IASI completed questionnaires and clinical examination. The Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess response to therapy in the short term (within 2 weeks). Among those who initially responded, those whose pain had not returned to within 20% of the baseline Knee Injury and Osteoarthritis Outcome Score pain score at 6 months were characterized as longer-term responders. Log-binomial regression was used to examine factors associated with outcome. RESULTS: One hundred ninety-nine participants were included, of whom 146 (73.4%) were short-term and 40 (20.1%) longer-term responders. Compared to short-term nonresponders, participants with these characteristics were more likely to be short-term responders: medial joint line tenderness [relative risk (RR) 1.42, 95% CI 1.10-1.82], medial and lateral joint line tenderness (RR 1.38, 95% CI 1.03-1.84), patellofemoral tenderness (RR 1.27, 95% CI 1.04-1.55), anserine tenderness (RR 1.27, 95% CI 1.06-1.52), and a belief that treatment would be effective [RR/unit increase (range 0-10) = 1.05 (1.01-1.09)]. Aspiration of joint fluid (RR 0.79, 95% CI 0.66-0.95) and previous ligament/meniscus injury (RR 0.63, 95% CI 0.44-0.91) were associated with a reduced risk of being a short-term responder. Compared to initial nonresponders and those whose pain recurred within 6 months, participants with a higher number of pain sites [RR/unit increase (range 0-10) = 0.83, 95% CI 0.72-0.97], chronic widespread pain (RR 0.32, 95% CI 0.10-0.98), perceived chronicity of disease [RR/unit increase (range 0-10) = 0.86, 95% CI 0.78-0.94], and a higher depression score [RR/unit increase (range 0-21) = 0.89, 95% CI 0.81-0.99] were less likely to be longer-term responders. CONCLUSION: Among patients with symptomatic knee OA, tenderness around the knee was associated with better short-term outcome of IASI. However, clinical-related factors did not predict longer-term response, while those with chronic widespread pain and depressive symptoms were less likely to obtain longer-term benefits.