Can on-line gait training improve clinical practice? Study protocol for feasibility randomised controlled trial of an on-line educational intervention to improve clinician's gait-related decision-making in ambulant children and young people with cerebral palsy.

BACKGROUND: Instrumented gait analysis (IGA) is an assessment and research tool with proven impacts on clinical decision-making for the management of ambulant children and young people with cerebral palsy (CYPwCP) but is underused and variably understood by relevant clinicians. Clinicians' difficulties in gaining expertise and confidence in using IGA are multifactorial and related to access for clinical decision-making, limited training opportunities and inability to translate this training into clinical practice. METHODS: The primary aim of this study is to test the feasibility of an educational intervention to advance clinicians' application of gait analysis in CYPwCP, to inform a definitive trial. The secondary aim is to measure the effect that appropriate IGA training has on physiotherapists' knowledge, skills, confidence and behaviours. This will be a two-arm feasibility randomised controlled trial with an experimental and control group. The 6-week on-line intervention uses a multicomponent approach grounded in behavioural change techniques. A repeated measures design will be adopted, whereby participants will complete outcome measures at baseline, immediately after the intervention and at 4 months. The primary outcome measures (trial feasibility-related outcomes) are recruitment and engagement. The secondary outcome measures (trial research-related outcomes) are knowledge, skills, confidence and practice change. Outcome measures will be collected via online questionnaires and during observed skill assessments. Analysis of data will use descriptive statistics, two-way mixed ANOVA model and qualitative content analysis. DISCUSSION: This study will determine feasibility of the definitive randomised control trial of educational intervention delivered to advance clinicians' application of gait analysis in CYPwCP. This study offers the shift in emphasis from regarding IGA as a tool to a focus on clinicians' requirements for access, training and a well-defined role to optimise utilisation of IGA. The impact of this should be better engagement with IGA and clinical practice change. This study will contribute to a body of educational research into clinical education of healthcare professionals and IGA training offering insight into high levels of evaluation evidence including clinical behaviour change. TRIAL REGISTRATION: Protocol has been registered with the Open Science Framework (osf.io/nweq6) in June 2023.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review.

PURPOSE: This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes. METHODS: Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B). RESULTS: Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities). CONCLUSIONS: Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

Education, instruction and use of an exercise diary (Psychological Capability), demonstration and monitoring of rehabilitation behaviour (Social Opportunity), and a time-efficient program with access to equipment and a health professional (Physical Opportunity) are common behaviour change strategies to improve rehabilitation adherence.A barrier to adherence we identified was negative beliefs about capabilities and consequences, and fear of pain and causing further damage (Reflective Motivation), which may be addressed by appropriate education.Positive reinforcement and teaching habit formation (Automatic Motivation) is not present in reports and should be considered in the future.Physical Capability of tendinopathy patients to perform the rehabilitation program should not be assumed by rehabilitation professionals when prescribing and delivering rehabilitation.

Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy.

Objective: To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT. Methods: Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT). Results: 341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT. Conclusions: Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness.

Background: Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions: (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods: A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results: Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations: Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion: The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work: There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration: This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Tendons are cords of strong, flexible tissue that attach muscles to bones, allowing joints to move. Tendinopathy is a common condition that can affect any tendon in the body, causing pain and limiting function. Exercise is often used to treat tendinopathy. We examined over 500 research papers on exercise for tendinopathy. The most common tendons to be studied were the calf (Achilles), knee (patellar), elbow and shoulder. Strengthening exercise was studied most often, especially in lower-limb tendinopathy. Other types of exercise such as stretching, balance and aerobic activity were less common, but were used to some extent in the upper and lower limbs. We found that exercise therapy is safe and beneficial for the tendinopathies that have been studied to date. Exercise may be most beneficial when combined with another intervention such as injection or electro-therapy. Strengthening exercise may be most beneficial for lower-limb tendinopathies. However, more research is needed on the type of strengthening and the dosage, such as how many exercises and how much resistance to use. Shoulder tendinopathies may benefit from exercise that targets joint flexibility and position more than strengthening. We also found that people who receive exercise therapy for tendinopathy are generally satisfied with the effect it has on their symptoms. Finally, we found that an individualised, person-centred approach to delivering exercise therapy is valued by people with tendinopathy. They also believe that the patient-healthcare provider relationship is important for promoting the confidence and motivation people need to continue with exercise programmes, especially when they complete them independently. Although we examined a lot of papers, many of the studies were low quality. This means there is still a need for high-quality studies to tell us how effective specific types of exercise are for specific tendinopathies. There is also a need for more studies on patients' and professionals' experiences of receiving or providing exercise for tendinopathy.

Developing a diagnostic framework for patients presenting with Exercise Induced Leg Pain (EILP): a scoping review.

BACKGROUND: Numerous conditions are grouped under the generic term exercise-induced leg pain (EILP), yet clear diagnostic guidelines are lacking. This scoping review was conducted to clarify the definition and diagnostic criteria of nine commonly occurring EILP conditions. METHODS: Three online databases were searched from inception to April 2022 for any English language original manuscripts identifying, describing, or assessing the clinical presentation and diagnostic criteria of the nine most common conditions that cause EILP. We included manuscripts considering all adults with any reported diagnostic criteria for EILP in any setting. Methodological quality was assessed using the Mixed Method Appraisal tool. Condition definitions were identified and categorised during data charting. Twenty-five potential elements of the history, 24 symptoms, 41 physical signs, 21 investigative tools, and 26 overarching diagnostic criteria, were identified and coded as counts of recommendation per condition, alongside qualitative analysis of the clinical reasoning. Condition definitions were constructed with 11 standardised elements based on recent consensus exercises for other conditions. RESULTS: One hundred nineteen retained manuscripts, of which 18 studied multiple conditions, had a median quality of 2/5. A combination of the history, pain location, symptoms, physical findings, and investigative modalities were fundamental to identify each sub-diagnosis alongside excluding differentials. The details differed markedly for each sub-diagnosis. Fifty-nine manuscripts included data on chronic exertional compartment syndrome (CECS) revealing exertional pain (83% history), dull aching pain (76% symptoms), absence of physical signs (78% physical findings) and elevated intercompartment pressure (93% investigative modality). Twenty-one manuscripts included data on medial tibial stress syndrome (MTSS), revealing persistent pain upon discontinuation of activity (81% history), diffuse medial tibial pain (100% pain location), dull ache (86% symptoms), diffuse tenderness (95% physical findings) and MRI for exclusion of differentials (62% investigative modality). Similar analyses were performed for stress fractures (SF, n = 31), popliteal artery entrapment syndrome (PAES, n = 22), superficial peroneal nerve entrapment syndrome (SPNES, n = 15), lumbar radiculopathy (n = 7), accessory/low-lying soleus muscle syndrome (ALLSMS, n = 5), myofascial tears (n = 3), and McArdle's syndrome (n = 2). CONCLUSION: Initial diagnostic frameworks and definitions have been developed for each condition of the nine most common conditions that cause EILP, suitable for clinical consideration and consensus confirmation.

Assessing Serious Spinal Pathology Using Bayesian Network Decision Support: Development and Validation Study.

BACKGROUND: Identifying and managing serious spinal pathology (SSP) such as cauda equina syndrome or spinal infection in patients presenting with low back pain is challenging. Traditional red flag questioning is increasingly criticized, and previous studies show that many clinicians lack confidence in managing patients presenting with red flags. Improving decision-making and reducing the variability of care for these patients is a key priority for clinicians and researchers. OBJECTIVE: We aimed to improve SSP identification by constructing and validating a decision support tool using a Bayesian network (BN), which is an artificial intelligence technique that combines current evidence and expert knowledge. METHODS: A modified RAND appropriateness procedure was undertaken with 16 experts over 3 rounds, designed to elicit the variables, structure, and conditional probabilities necessary to build a causal BN. The BN predicts the likelihood of a patient with a particular presentation having an SSP. The second part of this study used an established framework to direct a 4-part validation that included comparison of the BN with consensus statements, practice guidelines, and recent research. Clinical cases were entered into the model and the results were compared with clinical judgment from spinal experts who were not involved in the elicitation. Receiver operating characteristic curves were plotted and area under the curve were calculated for accuracy statistics. RESULTS: The RAND appropriateness procedure elicited a model including 38 variables in 3 domains: risk factors (10 variables), signs and symptoms (17 variables), and judgment factors (11 variables). Clear consensus was found in the risk factors and signs and symptoms for SSP conditions. The 4-part BN validation demonstrated good performance overall and identified areas for further development. Comparison with available clinical literature showed good overall agreement but suggested certain improvements required to, for example, 2 of the 11 judgment factors. Case analysis showed that cauda equina syndrome, space-occupying lesion/cancer, and inflammatory condition identification performed well across the validation domains. Fracture identification performed less well, but the reasons for the erroneous results are well understood. A review of the content by independent spinal experts backed up the issues with the fracture node, but the BN was otherwise deemed acceptable. CONCLUSIONS: The RAND appropriateness procedure and validation framework were successfully implemented to develop the BN for SSP. In comparison with other expert-elicited BN studies, this work goes a step further in validating the output before attempting implementation. Using a framework for model validation, the BN showed encouraging validity and has provided avenues for further developing the outputs that demonstrated poor accuracy. This study provides the vital first step of improving our ability to predict outcomes in low back pain by first considering the problem of SSP. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21804.

Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis.

OBJECTIVE: To investigate potential moderating effects of resistance exercise dose components including intensity, volume and frequency, for the management of common tendinopathies. DESIGN: Systematic review with meta-analysis and meta-regressions. DATA SOURCES: Including but not limited to: MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and ISRCTN Registry. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding ≥2 components of exercise dose. RESULTS: A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared with body mass only (large effect size domains: ß BodyMass: External = 0.50 (95% credible interval (CrI): 0.15 to 0.84; p=0.998); small effect size domains (ß BodyMass: External = 0.04 (95% CrI: -0.21 to 0.31; p=0.619)) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains when combined or analysed separately (p≥0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent. SUMMARY/CONCLUSION: Resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery.

Predicting the outcome of plantar heel pain in adults: a systematic review of prognostic factors.

BACKGROUND: Plantar Heel Pain (PHP) is a common disorder with many treatment pathways and is not self-limiting, hence prognostic information concerning recovery or recalcitrance is needed to guide practice. In this systematic review, we investigate which prognostic factors are associated with favourable or unfavourable PHP outcomes. METHODS: MEDLINE, Web of Science, EMBASE, Scopus and PubMed electronic bibliographic databases were searched for studies evaluating baseline patient characteristics associated with outcomes in prospective longitudinal cohorts or after specific interventions. Cohort, clinical prediction rule derivation and single arms of randomised controlled trials were included. Risk of bias was evaluated with method-specific tools and evidence certainty with GRADE. RESULTS: The review included five studies which evaluated 98 variables in 811 participants. Prognostic factors could be categorised as demographics, pain, physical and activity-related. Three factors including sex and bilateral symptoms (HR: 0.49[0.30-0.80], 0.33[0.15-0.72], respectively) were associated with a poor outcome in a single cohort study. The remaining four studies reported twenty factors associated with a favourable outcome following shockwave therapy, anti-pronation taping and orthoses. Heel spur (AUC = 0.88[0.82-0.93]), ankle plantar-flexor strength (Likelihood ratio (LR): 2.17[1.20-3.95]) and response to taping (LR = 2.17[1.19-3.90]) were the strongest factors predicting medium-term improvement. Overall, the study quality was low. A gap map analysis revealed an absence of research that included psychosocial factors. CONCLUSIONS: A limited number of biomedical factors predict favourable or unfavourable PHP outcomes. High quality, adequately powered, prospective studies are required to better understand PHP recovery and should evaluate the prognostic value of a wide range of variables, including psychosocial factors.

Ultrasound Measurement of Local Deformation in the Human Free Achilles Tendon Produced by Dynamic Muscle-Induced Loading: A Systematic Review.

Achilles tendinopathy is the most prevalent lower limb tendinopathy, yet it remains poorly understood, with mismatches between observed structure and reported function. Recent studies have hypothesised that Achilles tendon (AT) healthy function is associated with variable deformation across the tendon width during use, focusing on quantifying sub-tendon deformation. Here, the aim of this work was to synthesise recent advances exploring human free AT tissue-level deformation during use. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Embase, Scopus and Web of Science were systematically searched. Study quality and risk of bias were assessed. Thirteen articles were retained, yielding data on free AT deformation patterns. Seven were categorised as high-quality and six as medium-quality studies. Evidence consistently reports that healthy and young tendons deform non-uniformly, with the deeper layer displacing 18%-80% more than the superficial layer. Non-uniformity decreased by 12%-85% with increasing age and by 42%-91% in the presence of injury. There is limited evidence of large effect that AT deformation patterns during dynamic loading are non-uniform and may act as a biomarker of tendon health, risk of injury and rehabilitation impact. Better considered participant recruitment and improved measurement procedures would particularly improve study quality, to explore links between tendon structure, function, aging and disease in distinct populations.

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis.

Objective: To quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains to inform future research and clinical practice through conducting a systematic review with meta-analysis. Design: Systematic review with meta-analysis exploring moderating effects and context-specific small, medium and large thresholds. Eligibility criteria: Randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration. Methods: Common databases, six trial registries and six grey literature databases were searched on 18 January 2021 (PROSPERO: CRD42020168187). Standardised mean difference (SMDpre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25 (small), 0.5 (medium) and 0.75 quantiles (large) and compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool. Results: Data were obtained from 114 studies comprising 171 treatment arms 4104 participants. SMDpre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small=0.5, medium=0.9 and large=1.4), disability (small=0.6, medium=1.0 and large=1.5) and function (small=0.6, medium=1.1 and large=1.8) and lower threshold values obtained for quality of life (small=-0.2, medium=0.3 and large=0.7) and objective measures of physical function (small=0.2, medium=0.4 and large=0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations. Conclusion: The effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change.

Self-reported bio-psycho-social factors partially distinguish patellar tendinopathy from other knee problems and explain patellar tendinopathy severity in jumping athletes: A case-control study.

OBJECTIVE: To determine what combinations of self-reported factors distinguish patellar tendinopathy (PT) from other knee problems, and explain PT severity variance. DESIGN: Case-control study. SETTING: Social media, private practice and National Health Service. PARTICIPANTS: An international sample of jumping athletes diagnosed with either PT (n = 132; 30.7 ± 8.9 years; 80 males; VISA-P = 61.6 ± 16.0) or another musculoskeletal knee condition (n = 89; 31.8 ± 9.9 years; 47 males; VISA-P = 62.9 ± 21.2) by a clinician in the last 6 months. MAIN OUTCOME MEASURES: We considered clinical diagnosis (case = having PT vs control = having other knee problems) as the dependent variable. Severity and sporting impact were defined by VISA-P and availability, respectively. RESULTS: A model comprising seven factors distinguished PT from other knee problems; training duration (OR = 1.10), sport type (OR = 2.31), injured side (OR = 2.28), pain onset (OR = 1.97), morning pain (OR = 1.89), condition acceptability (OR = 0.39) and swelling (OR = 0.37). Sports-specific function (OR = 1.02) and player level (OR = 4.11) explained sporting availability. 44% of PT severity variance was explained by quality of life (ß = 0.32), sports-specific function (ß = 0.38) and age (ß = -0.17). CONCLUSION: Sports-specific, biomedical and psychological factors partially distinguish PT from other knee problems. Availability is mainly explained by sports-specific factors, while psychosocial factors impact on severity. Adding sports-specific and bio-psycho-social factors into assessments could help better identification and management of jumping athletes with PT.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study.

OBJECTIVES: To estimate Achilles tendon forces and their relationship with self-reported pain in runners with Achilles tendinopathy (AT) during common rehabilitation exercises. DESIGN: Cross-sectional. SETTING: Laboratory. PARTICIPANTS: 24 recreational male runners (45.92 (8.24) years old; 78.20 (8.01) kg; 177.17 (6.69) cm) with symptomatic AT. MAIN OUTCOME MEASURES: Kinematic and kinetic data were collected to estimate Achilles tendon forces during 12 commonly prescribed exercises. Achilles tendon forces were estimated from biomechanical data and normalised to the participant's bodyweight. The secondary aim was to investigate the relationship between Achilles tendon forces and pain during these exercises. RESULTS: Two exercise clusters were identified based on Achilles tendon forces. Cluster1 included various exercises including double heel raises, single heel raises, and walking (range: 1.10-2.76 BWs). Cluster2 included running, jumping and hopping exercises (range: 5.13-6.35 BWs). Correlation between tendon forces and pain was at best low for each exercise (range: -0.43 - 0.20). Higher force exercises lead to more tendon load for a given amount of pain (R2 = 0.7505; y = 0.2367x + 0.6191). CONCLUSION: This study proposes a hierarchical exercise progression based on Achilles tendon forces to guide treatment of runners with AT. Achilles tendon forces and pain are not correlated in runners with AT.

Neuromuscular joint function in knee osteoarthritis: A systematic review and meta-analysis.

BACKGROUND: Neuromuscular alterations are common in people with knee osteoarthritis (KOA). A comprehensive understanding of these alterations is important to enable targeted rehabilitation strategies. OBJECTIVES: This systematic review and meta-analysis aimed to comprehensively understand the neuromuscular alterations around the knee joint in people with KOA. METHODS: Moderate- and high-quality studies based on a modified version of the Downs and Black checklist, comparing neuromuscular function of peri­articular muscles between people with KOA and controls were retrieved from five databases from inception to October 2020. Outcomes included normalized isokinetic strength, muscle size, voluntary activation, cortical and spinal-reflex excitability, and torque-related outcomes. Data were pooled according to structural KOA severity with sensitivity analysis based on sex. Evidence levels are presented in evidence gap maps. RESULTS: A total of 7 high-quality and 22 moderate-quality studies were retained (1146 people with KOA and 1353 age- and sex-matched controls). Studies demonstrated quadriceps and hamstring strength deficits and increased hamstring-to-quadriceps strength ratios across KOA severities. Women presented lower quadriceps strength at early KOA (very limited evidence) and lower voluntary activation at end stage KOA (very limited evidence) as compared with controls, whereas men did not (moderate evidence). People with KOA also demonstrated lower quadriceps force control ability with no change in rapid force production (very limited evidence). Voluntary activation deficits for quadriceps were evident (moderate evidence), with no change in quadriceps cortical excitability (very limited evidence) or soleus spinal reflexes (very limited evidence). No muscle size change was demonstrated except for the vastus medialis (limited evidence). Evidence gaps were found for neural and torque-related measures and differences in hamstring, gastrocnemius, soleus, and popliteus. CONCLUSIONS: Neuromuscular deficits are evident across different structural KOA severities and are seen in muscle strength, voluntary activation, muscle size, and force control ability. Women may exhibit these alterations to a greater extent than men. PROSPERO REGISTRATION NUMBER: CRD42019160845.

The impact of instrumented gait analysis on decision-making in the interprofessional management of cerebral palsy: A scoping review.

BACKGROUND: Management of gait-related problems in children and young people with Cerebral Palsy (CYPwCP) is complex and requires an interprofessional approach. Irrespective of underlying mechanisms, instrumented gait analysis (IGA) can provide quantification of gait to support clinical decision-making for CYPwCP when planning treatment interventions. AIM: This scoping review aimed to determine the impact of instrumented gait analysis (IGA) on treatment decision-making for CYPwCP, paying particular attention to interprofessional decision-making. METHOD: PubMed, EMBASE, Web of Science and Scopus databases were searched from inception to October 2019 for studies including CYPwCP age<25 years. The PRISMA ScR protocol was followed, and Quality was assessed with the Downs and Black (D&B) scale. Influences on decision-making were coded according to the International Classification of Functioning, Disability and Health for Children and Youth framework (ICF-CY). RESULTS: Seventeen studies (1144 patients, 2.8-23 years) of varying quality (mean D&B = 17.2, range = 11-26) were included. Studies considered IGA influence at three decision-making stages 'Clinical Planning', 'Treatment Performed' and 'Follow up'. Child and Family, and Clinician and Service-centred factors had a high impact on engagement with IGA recommendations. INTERPRETATION: IGA guided recommendations can differ from initial clinical plans, and often lead to modification of the treatment ultimately performed. The effect on individual patients' outcomes when treatment recommendations based on instrumented gait analysis are followed is not yet clear and warrants further research. The differences in clinicians' engagement with IGA recommendations occur due to an array of Child and Family, and Clinician and Service-centred factors. Overall, IGA leads to less surgical recommendations, and has the potential to influence conservative gait-related management in CYPwCP.

Self-reported bio-psycho-social factors partially distinguish rotator cuff tendinopathy from other shoulder problems and explain shoulder severity: A case-control study.

OBJECTIVE: Examine how rotator cuff (RC) tendinopathy differed from other shoulder problems (OSP) by measuring a variety of self-reported bio-psycho-social factors, and establish which explain severity. METHODS: A validated online survey battery was used to collect self-reported biopsychosocial variables in an international population. Diagnostic group and severity were the dependent variables. Multiple logistic and linear regression analyses were utilised to generate explanatory models for group differences and severity after group comparison and univariate regression analysis. RESULTS: 82 people with RC tendinopathy (50 female, 42.8 ± 13.9 years) and 54 with OSP (33 female, 40.2 ± 14.1 years) were recruited. Both groups had comparable severity results (Shoulder Pain and Disability Index = 37.3 ± 24.5 vs. 33.7 ± 22.5). Seven factors individually differentiated RC tendinopathy from OSP. The multivariable model included 4 factors: activity effect on pain (OR(95%CI) = 2.24(1.02-4.90)), previous injury in the shoulder (OR(95% CI) = 0.30(0.13-0.69)), activity level (moderate OR(95% CI) = 3.97(1.29-12.18), high OR(95% CI) = 3.66(1.41-9.48)) and self-efficacy (OR(95%CI) = 1.12(1.02-1.22)) demonstrating acceptable accuracy. The second multivariable model for RC tendinopathy severity included one demographic, three psychological and two biomedical variables (ß(range) = 0.19-0.38) and explained 68% of the variance. CONCLUSION: Self-reported bio-psycho-social variables may be beneficial for further detailed clinical assessment as they partially distinguish RC tendinopathy from OSP, even when the groups have comparable overall pain and functional problems. Moreover, these variables were shown to be substantially associated with RC tendinopathy severity variance, implying that the clinical evaluation might be improved, perhaps by pre-consultation online data collection. The models should be validated in the future and considered alongside data from physical and imaging examinations.

Achilles tendon thickness reduces immediately after a marathon.

BACKGROUND: The purpose of the present investigation was to evaluate the immediate effect of running a marathon on Achilles tendon anteroposterior thickness. METHODS: In 25 runners who took part in the London marathon, ultrasonography was used to measure the Achilles tendon thickness pre- and immediately post-marathon and to identify any structural abnormalities indicating tendinopathy. Pain was recorded using a numerical rating scale at baseline and post-marathon. Twenty-one participants were included in the final analysis. RESULTS: Running a marathon resulted in a significant decrease (- 13%, p < 0.01) in anteroposterior diameter of the Achilles tendon immediately following the marathon. There was no change in the proportion of Achilles tendons with structural abnormalities (34%) or pain (12%) following the marathon (p > 0.05). CONCLUSION: Running a marathon resulted in an immediate reduction in anteroposterior diameter of the Achilles tendon. This finding may have implications for injury prevention and recovery following a marathon.

Reducing the question burden of patient reported outcome measures using Bayesian networks.

Patient Reported Outcome Measures (PROMs) are questionnaires completed by patients about aspects of their health status. They are a vital part of learning health systems as they are the primary source of information about important outcomes that are best assessed by patients such as pain, disability, anxiety and depression. The volume of questions can easily become burdensome. Previous techniques reduced this burden by dynamically selecting questions from question item banks which are specifically built for different latent constructs being measured. These techniques analyzed the information function between each question in the item bank and the measured construct based on item response theory then used this information function to dynamically select questions by computerized adaptive testing. Here we extend those ideas by using Bayesian Networks (BNs) to enable Computerized Adaptive Testing (CAT) for efficient and accurate question selection on widely-used existing PROMs. BNs offer more comprehensive probabilistic models of the connections between different PROM questions, allowing the use of information theoretic techniques to select the most informative questions. We tested our methods using five clinical PROM datasets, demonstrating that answering a small subset of questions selected with CAT has similar predictions and error to answering all questions in the PROM BN. Our results show that answering 30% - 75% questions selected with CAT had an average area under the receiver operating characteristic curve (AUC) of 0.92 (min: 0.8 - max: 0.98) for predicting the measured constructs. BNs outperformed alternative CAT approaches with a 5% (min: 0.01% - max: 9%) average increase in the accuracy of predicting the responses to unanswered question items.

Anxiety, insomnia, and depression during COVID-19 lockdown in elite individual and team sport athletes.

PURPOSE: Pandemic-induced lockdowns disrupted sport training and competition. We aimed to identify the impact on the mental health of high-level athletes and clarify whether the effects differ for team-based and individual athletes. METHODS: This cross-sectional survey, stratified by sex and sport type, collected demographic data and mental health measurements from 274 Brazilian high-performance athletes (142 from team sports and 132 from individual sports) involved with the Brazilian Olympic Committee program for the Tokyo Olympics 2021. Depression, disturbed sleep, and anxiety were assessed by the 9-Item Patient Health Questionnaire, 7-Item Insomnia Severity Index, and 7-Item Generalized Anxiety Disorder scale respectively. Responses were analyzed dichotomously according to published threshold values, characterizing the relative frequency distribution of prevalence (PCRS) or non-prevalence of clinically relevant symptoms (NPCRS). RESULTS: Out of all participants, 47 [17.1%], Z(274) = 15.38, p = .001, 32 [11.7%], Z(274) = 17.94, p = .001, and 49 [17.9%], Z(274) = 15.04, p = .001 had PCRS of anxiety, insomnia, and depression, respectively. There were no significant differences in the PCRS among genders. Compared with individual sport athletes, team sport athletes were more likely to report PCRS of insomnia (12 [37.5%] vs 20 [62.5%], Z(274) = -2.00, p = .046), and depression (18 [36.7%] vs 31 [63.3%], Z(274) = -2.63, p = .009) but not for anxiety. CONCLUSION: Athletes reported high levels of mental health problems during the lockdown. Team sport athletes reported worse symptoms of insomnia and depression than individual sport athletes, possibly due to the impact of unaccustomed social isolation and lack of social team activity. Therefore, it becomes relevant to consider psychological support to team sport athletes who for some reason, such as a pandemic, enduring crisis even injury rehabilitation needs to be isolated.

Pseudo-Thrombotic Microangiopathy Secondary to Vitamin B12 Deficiency.

Background: Clinical B12 deficiency with hematological or neurological manifestations is rare. An unusual manifestation of B12 deficiency is pseudo-thrombotic microangiopathy (TMA), which is characterized by hemolytic anemia, thrombocytopenia, and schistocytosis and only occurs in 2.5% of those with B12 deficiency. Pseudo-TMA is misdiagnosed as thrombotic thrombocytopenic purpura (TTP) in 40% of cases, resulting in misguided treatment including plasmapheresis. Case: A 44-year-old Hispanic presented with 3 weeks of progressively worsening non-radiating chest pain, fatigue, and shortness of breath (SOB). Laboratory findings revealed severe pancytopenia and macrocytosis with a hemoglobin of 5.4 g/dL, mean corpuscular volume of 116.3 fL, and vitamin B12 low at 149 pg/mL. She was diagnosed with pseudo-TMA and after starting 1000 micrograms of parenteral vitamin B12 injections daily and discontinuing plasmapheresis and steroid administration, she improved. Conclusion: Failure to recognize pseudo-TMA often results in unnecessary treatment with plasmapheresis and delays appropriate treatment with vitamin B12 supplementation. It is therefore extremely important to consider pseudo-TMA as a differential diagnosis in patients that present with hemolytic anemia, thrombocytopenia, and schistocytosis.

Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: To determine the effects of nonsurgical treatments on pain and function in people with patellofemoral pain (PFP). DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched MEDLINE, Web of Science, and Scopus databases from their inception until May 2022 for interventional randomized controlled trials (RCTs) in people with PFP. STUDY SELECTION CRITERIA: We included RCTs that were scored ≥7 on the PEDro scale. DATA SYNTHESIS: We extracted homogenous pain and function data at short- (≤3 months), medium- (>3 to ≤12 months) and long-term (>12 months) follow-up. Interventions demonstrated primary efficacy if outcomes were superior to sham, placebo, or wait-and-see control. Interventions demonstrated secondary efficacy if outcomes were superior to an intervention with primary efficacy. RESULTS: We included 65 RCTs. Four interventions demonstrated short-term primary efficacy: knee-targeted exercise therapy for pain (standardized mean difference [SMD], 1.16; 95% CI: 0.66, 1.66) and function (SMD, 1.19; 95% CI: 0.51, 1.88), combined interventions for pain (SMD, 0.79; 95% CI: 0.26, 1.29) and function (SMD, 0.98; 95% CI: 0.47, 1.49), foot orthoses for global rating of change (OR = 4.31; 95% CI: 1.48, 12.56), and lower-quadrant manual therapy for function (SMD, 2.30; 95% CI: 1.60, 3.00). Two interventions demonstrated short-term secondary efficacy compared to knee-targeted exercise therapy: hip-and-knee-targeted exercise therapy for pain (SMD, 1.02; 95% CI: 0.58, 1.46) and function (SMD, 1.03; 95% CI: 0.61, 1.45), and knee-targeted exercise therapy and perineural dextrose injection for pain (SMD, 1.34; 95% CI: 0.72, 1.95) and function (SMD, 1.21; 95% CI: 0.60, 1.82). CONCLUSIONS: Six interventions had positive effects at 3 months for people with PFP, with no intervention adequately tested beyond this time point. J Orthop Sports Phys Ther 2022;52(11):750-768. Epub: 8 September 2022. doi:10.2519/jospt.2022.11359.