The effects of a two-week neuromuscular intervention on biopsychosocial variables in people with patellofemoral pain: an observational study.

Introduction: Patellofemoral pain (PFP) is common and predominately affects active populations. Altered biomechanics and psychosocial variables have been reported in people with PFP, but the effects of neuromuscular exercise on these variables is unknown. We aimed to investigate changes in biopsychosocial measures following a two-week neuromuscular intervention in people with PFP. Materials and Methods: We measured pain (visual analogue scale), function (Kujala), activity level (Tegner), psychological well-being (Orebro), lower-limb isometric strength (handheld dynamometry), three-dimensional (3D) lower limb kinematics, and surface electromyography (sEMG), in people with PFP. 3D lower-limb kinematics and sEMG were synchronously sampled during step-up, step-down, and overground running. All measures were repeated after participants had completed a two-week neuromuscular intervention consisting of three exercises completed once per day, five days per week. Results: 18 participants completed pre/post testing (60% females, mean age 30.6 years ±7.0, height 173.4cm ±10.4, mass 70.2kg ±12.4, symptom duration 39.0 months ±58.8), with three of 21 participants lost to follow-up. Across all clinical measures (muscle onsets, muscle activation and kinematics), the 95% bootstrapped confidence intervals (CI) of the mean difference contained the null hypothesis following the two-week neuromuscular intervention, indicating no significant differences. Conclusion: A two-week neuromuscular intervention did not change biomechanical or psychosocial measures in people with PFP. Interventions with a longer duration or greater load magnitude are required to fully evaluate the biopsychosocial mechanisms of effect for exercise in people with PFP.

Variables associated with successful outcome after anterior cruciate ligament reconstruction in recreational athletes: A prospective cohort study.

BACKGROUND: Anterior cruciate ligament (ACL) injury and subsequent reconstruction is common and has a profound effect on health-related quality of life. There is currently limited understanding as to which variables are associated with a successful outcome post-ACL reconstruction (ACLR) in recreational athletes. PURPOSE: Explore the association between both patient-reported and performance-based measures, and successful outcome, post-ACLR in recreational athletes. PROCEDURES: We sought to recruit recreational athletes within one month of a primary-ACLR for a prospective cohort study. A dichotomised patient specific functional scale of ≥9 points determined a successful outcome at nine-months post-operative. Secondary patient-reported and performance-based data were collected at baseline, three-, six-, and nine-months post-operative. The association between secondary data and the primary outcome was determined using binomial logistic regression, expressed using odds ratio (OR) and 95% confidence intervals (CI). MAIN RESULTS: 90 participants were recruited (males: 58, females: 32, mean age 32.8 years [±7.9], mean height 173.5 [±10.0], mean body mass 74.0 kg [±15.8]), 87 consented to baseline measures. 47 participants completed full data collection and 21 (45%) reported a successful outcome. Higher knee osteoarthritis outcome score (OR range 1.07-1.12) and anterior cruciate ligament quality of life (ACL-QoL) scores (OR range 1.06-1.10) were associated with a successful outcome post-ACLR at various timepoints. CONCLUSIONS: Patient-reported, rather than performance-based, measures were associated with successful outcome nine-months post-ACLR in recreational athletes. Both patient-reported and performance-based characteristics are advocated to guide optimal return to function in clinical practice.

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.

The feasibility, safety, and efficacy of upper limb garment-integrated blood flow restriction training in healthy adults.

BACKGROUND: Blood flow restriction training (BFR) has been demonstrated to increase muscle hypertrophy and strength, but has logistical and cost barriers. Garment-integrated BFR has the potential to reduce these barriers by lowering equipment demands and cost. The primary aim of the study was to explore the feasibility of garment-integrated BFR in the upper limb of healthy adults, with a secondary aim of exploring safety and efficacy. METHODS: Physically active and otherwise healthy participants with no previous experience with BFR were sought. Eligible participants completed a five-week garment-integrated BFR programme that involved completing two sessions per week. Feasibility was determined by a priori defined thresholds for recruitment, adherence to the garment-integrated BFR programme, and data collection. Safety was determined by recording adverse events and by monitoring for total arterial occlusion pressure using a fingertip pulse oximeter. Efficacy was determined by measuring push-ups to volitional failure, arm girth, and number of prescribed repetitions completed. Feasibility and safety outcomes were reported descriptively or as a proportion with associated 95% confidence intervals (95% CI). Mean change, 95% CIs, and associated effect sizes were calculated for efficacy outcomes. RESULTS: Twenty-eight participants were included (15 men, 13 women; mean age 31.6 years [±9.1]) and 27 successfully completed the study. Participants were successfully recruited within three months and 278/280 sessions were successfully completed (adherence=99.3%, 95% CI 97.4%, 99.9%). Minimal adverse events were reported; one incident of localised bruising (0.36%, 95% CI 0.06%, 2.0%) and three incidences of excessive pain during or post-exercise from two separate participants (1.07%, 95% CI 0.03%, 3.1%). 82/2240 pulse oximeter readings were not recorded (3.7%, 95% CI 2.9%, 4.5%). Mean push-ups to volitional failure increased by 40% (mean change=8.0, 95% CI 6, 10, d=1.40). Mean arm girth and number of prescribed repetitions completed were unchanged. CONCLUSIONS: Garment-integrated BFR is feasible and has no signal of important harm in the upper limb of healthy adults, and could proceed to a future trial with stop/go criteria for randomisation. Further work is required to investigate the efficacy of garment-integrated BFR and determine its equivalence or superiority compared to existing BFR methods.

Clinicians' experience of the diagnosis and management of patellofemoral pain: A qualitative exploration.

BACKGROUND: Patellofemoral pain (PFP) is common and has a poor long-term prognosis. There is a lack of clarity about the clinical reasoning of recognised inter-disciplinary experts in the published literature. OBJECTIVES: To help identify best practice by exploring the clinical reasoning of a range of inter-disciplinary experts that regularly diagnose and treat PFP. DESIGN: Qualitative study with semi-structured interviews. METHOD: Recruitment resulted in a convenience sample for semi-structured interview, which were recorded and transcribed verbatim. Data were analysed until theoretical saturation, as determined by multiple investigators. FINDINGS: Interviews with 19 clinical experts (15 men, 4 women; mean experience 18.6 years ± 8.6) from four broad professions yielded four themes. Firstly, the assessment and diagnosis process should include a thorough history and examination to rule in PFP. Secondly, information provision should aim to increase patients' understanding, aid in controlling symptoms, and facilitate behaviour change. Thirdly, active rehabilitation, which was a salient theme and included advocacy of combined hip and knee exercise that is adapted to the individual. Finally, treatment adjuncts, which can be used selectively to modify symptoms, may include running retraining, taping, or foot orthoses. CONCLUSIONS: PFP should be diagnosed clinically, and tailored treatment programmes should be prescribed for people with PFP. Exercise was considered the most effective treatment and underlying psychological factors should be addressed to improve prognosis.

Patient experience of the diagnosis and management of patellofemoral pain: A qualitative exploration.

BACKGROUND: Patellofemoral pain (PFP) is common and long-term treatment outcomes are unsatisfactory. Qualitative exploration of diagnosis and management from the perspective of people with PFP is lacking. OBJECTIVES: To inform care and improve intervention delivery by exploring the experience of people with PFP regarding diagnosis and management. DESIGN: Qualitative study with semi-structured interviews. METHOD: Online recruiting yielded a convenience sample of participants with PFP for semi-structured interview. Interviews were recorded, transcribed verbatim, and analysed using thematic analysis until theoretical saturation by multiple investigators to determine themes and sub-themes. RESULTS: 12 participants were interviewed, with three themes identified; the value of diagnosis, the need for tailored (individualised) care, and the role of education. Participants viewed receiving a diagnosis as essential to guide management, yet one was rarely provided, causing uncertainty about pain mechanisms; "it's nice to be told what it is that's wrong". Interventions needed to be tailored to the individual as not all participants responded in the same way to treatment(s) or had the same needs; "everyone copes and reacts differently". Finally, participants viewed education as essential to empower them to understand and manage the condition; "if I'd have been given more information, I think I'd know how to deal with it more". CONCLUSIONS: The overarching narrative from three themes was a desire for clearly communicated personalised care that meets individual needs. People with PFP desire a diagnosis to explain their pain, tailored interventions, and appropriate education to optimise their experience and outcomes.

Achilles Scraping and Plantaris Tendon Removal Improves Pain and Tendon Structure in Patients with Mid-Portion Achilles Tendinopathy-A 24 Month Follow-Up Case Series.

BACKGROUND: Studies have demonstrated that a sub-group of patients with medial Achilles pain exhibit Achilles tendinopathy with plantaris tendon involvement. This clinical condition is characterised by structural relationships and functional interference between the two tendons, resulting in compressive or shearing forces. Surgical plantaris tendon removal together with an Achilles scraping procedure has demonstrated positive short-term clinical results. The aim of this case series was to determine the long-term outcomes on pain and Achilles tendon structure. METHODS: 18 consecutive patients (13 males; 5 females; mean age 39 years; mean symptom duration 28 months), of which three were elites, were included. Clinical examination, b-mode ultrasound (US) and Ultrasound Tissue Characterisation (UTC) confirmed medial Achilles tendon pain and tenderness, medial Achilles tendinopathy plus a plantaris tendon located close to the medial side of the Achilles tendon. Patients underwent US-guided local Achilles scraping and plantaris tendon removal followed by a structured rehabilitation program. Outcomes were VISA-A score for pain and function and UTC for Achilles structure. RESULTS: 16 of 18 patients completed the 24 months follow-up. Mean VISA-A scores increased from 58.2 (±15.9) to 92.0 (±9.2) (mean difference = 33.8, 95% CI 25.2, 42.8, p < 0.01). There was an improvement in Achilles structure with mean organised echo pixels (UTC type I+II, in %) increasing from 79.9 (±11.5) to 86.4 (±10.0) (mean difference = 6.5%, 95% CI 0.80, 13.80, p =0.01), exceeding the 3.4% minimum detectable change. All 16 patients reported satisfaction with the procedure and 14 returned to pre-injury activity levels. There were no reported complications. CONCLUSIONS: Improved pain, function and tendon structure were observed 24 months after treatment with Achilles scraping and plantaris excision. The improvement in structure on the medial side of the Achilles after plantaris removal indicates that compression from the plantaris tendon might be an important presenting factor in this sub-group.

Is there a role for acupuncture in the treatment of tendinopathy?

Tendinopathy is a debilitating condition in athletic and sedentary populations for which a gold standard treatment strategy does not yet exist. While the pathophysiology of tendinopathy is well understood, a debate remains as to the nature of the pain mechanism in tendinopathy which makes treatment selection challenging. This clinical discussion presents evidence to suggest that acupuncture may have a role in the treatment of tendinopathy, through the facilitation of tendon blood flow and fibroblastic activity, making recommendations for further research.