Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence - a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C-40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

Challenges in co-designing an intervention to increase mobility in older patients: a qualitative study.

PURPOSE: The aim of this study is to explore and discuss key challenges associated with having stakeholders take part in co-designing a health care intervention to increase mobility in older medical patients admitted to two medical departments at two hospitals in Denmark. DESIGN/METHODOLOGY/APPROACH: The study used a qualitative design to investigate the challenges of co-designing an intervention in five workshops involving health professionals, patients and relatives. "Challenges" are understood as "situations of being faced with something that needs great mental or physical effort in order to be done successfully and therefore tests a person's ability" (Cambridge Dictionary). Thematic content analysis was conducted with a background in the analytical question: "What key challenges arise in the material in relation to the co-design process?". FINDINGS: Two key challenges were identified: engagement and facilitation. These consisted of five sub-themes: recruiting patients and relatives, involving physicians, adjusting to a new researcher role, utilizing contextual knowledge and handling ethical dilemmas. RESEARCH LIMITATIONS/IMPLICATIONS: The population of patients and relatives participating in the workshops was small, which likely affected the co-design process. PRACTICAL IMPLICATIONS: Researchers who want to use co-design must be prepared for the extra time required and the need for skills concerning engagement, communication, facilitation, negotiation and resolution of conflict. Time is also required for ethical discussions and considerations concerning different types of knowledge creation. ORIGINALITY/VALUE: Engaging stakeholders in co-design processes is increasingly encouraged. This study documents the key challenges in such processes and reports practical implications.

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial.

AIM: Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise. METHODS: This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis. RESULTS: From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care. CONCLUSION: We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02931058.

Diagnosis, prevention and treatment of common lower extremity muscle injuries in sport - grading the evidence: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement summarises and appraises the evidence on diagnosis, prevention and treatment of the most common lower extremity muscle injuries in sport. We systematically searched electronic databases, and included studies based on the highest available evidence. Subsequently, we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, grading the quality of evidence from high to very low. Most clinical tests showed very low to low diagnostic effectiveness. For hamstring injury prevention, programmes that included the Nordic hamstring exercise resulted in a hamstring injury risk reduction when compared with usual care (medium to large effect size; moderate to high quality of evidence). For prevention of groin injuries, both the FIFA 11+programme and the Copenhagen adductor strengthening programme resulted in a groin injury risk reduction compared with usual care (medium effect size; low to moderate quality of evidence). For the treatment of hamstring injuries, lengthening hamstring exercises showed the fastest return to play with a lower reinjury rate compared with conventional hamstring exercises (large effect size; very low to low quality of evidence). Platelet-rich plasma had no effect on time to return-to-play and reinjury risk (trivial effect size; moderate quality of evidence) after a hamstring injury compared with placebo or rehabilitation. At this point, most outcomes for diagnosis, prevention and treatment were graded as very low to moderate quality of evidence, indicating that further high-quality research is likely to have an important impact on the confidence in the effect estimates.

Disentangling the complexity of mobility of older medical patients in routine practice: An ethnographic study in Denmark.

AIM: Many older medical patients experience persistent functional limitations after hospitalization, such as dependency in activities of daily living, recurring fall incidents and increased mortality. Therefore, increased activity and mobilization during hospitalization are essential to prevent functional decline in older medical patients. No previous studies have explored how the social context influences how health professionals decide whether or not to mobilize patients. This qualitative study aimed to explore how social contextual circumstances affect the mobility of older medical patients in medical departments. METHODS: An ethnographic field study was conducted in six medical departments in three public hospitals in the capital region of Copenhagen, Denmark. Participant observations were carried out from January to June 2017. The researchers were present for up to 14 days (range, 8-14 days) in the six departments. A total of 210 pages of field notes were produced. The participants were health professionals involved in the care of older medical patients: physiotherapists, registered nurses, nursing assistants and physicians. A content analysis was conducted. FINDINGS: Five themes concerning mobility of patients emerged: (1) materialities; (2) professional roles; (3) encouraging moments; (4) patients and relatives; and (5) organization and management. Of these, professional roles seem to be the most important because it pervaded all themes. Different health professionals in the medical departments recognized, spoke and acted based on different cultural models. CONCLUSION: It was found that mobility of older medical patients is entangled in a complex network of social contextual circumstances. Mobility of older medical patients is based on health professionals' different cultural models, which shape distinct professional identities and lead to contradictions and blurring of the priorities and responsibilities among the health professionals involved in mobilization. The consequence is that no profession "owns" the responsibility for mobilization, thus restricting mobilization of the patients during hospitalization.

[Diagnosis, prevention and treatment of acute lateral ankle sprains].

Acute lateral ankle sprain is a frequent musculoskeletal injury, especially in sports. Most people recover within weeks, however, some have persistent symptoms for years. The Ottawa Ankle Rules can be used for initial investigation of a fracture in the ankle. Five days after the injury, a clinical examination should be completed. Both proprioceptive exercise and mechanical support can prevent ankle injuries and are also effective treatment modalities. Only few require surgery.

A tailored strategy for designing the Walk-Copenhagen (WALK-Cph) intervention to increase mobility in hospitalised older medical patients: a protocol for the qualitative part of the WALK-Cph project.

INTRODUCTION: Older medical patients (>65 years) represent 54% of the admissions to Danish medical and emergency departments. Acute admissions and bed-rest during hospitalisation are independent risk factors for death and dependency in older patients. Even short hospitalisations are associated with increased dependency in activities of daily living after discharge. Interventions that increase mobility during hospitalisation are therefore important. The purpose of this protocol is to describe the intervention design of the WALK-Copenhagen project, aimed at increasing 24 hours mobility in older medical patients during acute hospitalisations and following discharge. METHODS AND ANALYSIS: This study is based on ethnographic fieldwork and interviews. Workshops are used to develop and co-design the intervention in collaboration with key stakeholders (patients, relatives, health professionals and researchers). The theory of cultural learning processes, and the cultural historical activity theory will be used to help us understand the interaction between health professionals, structures and objects in relation to mobility in the medical departments. ETHICS AND DISSEMINATION: The project will adhere to the directives of the Helsinki Declaration. Ethical approval was not required for the study since formal ethical approval is not mandatory for studies that do not involve biomedical issues (I-Suite no: 05078) according to Danish law. Informed consent was obtained for all participants. The results will be disseminated to health professionals, managers, patients and relatives, who will be invited to afternoon meetings where the project will be discussed. The results will be published in peer-reviewed scientific journals and presented at scientific conferences.

Efficacy of pre-operative quadriceps strength training on knee-extensor strength before and shortly following total knee arthroplasty: protocol for a randomized, dose-response trial (The QUADX-1 trial).

BACKGROUND: Patients with knee osteoarthritis (OA) report knee pain, limitation in physical activities and low quality of life. The two primary treatments for knee OA are non-surgical treatment (e.g., exercise) and surgery (total knee arthroplasty (TKA)); however, national guidelines recommend non-surgical treatment to be tried prior to surgical procedures. Patients with knee OA are characterized by decreased muscle strength, particularly in the knee-extensor muscles. Correspondingly, decreased knee-extensor strength is found to be associated with an increased risk of development, progression and severity of knee OA symptoms. Recent trials suggest a positive effect of pre-operative exercise on pre- and post-operative outcome; however, the most effective pre-operative knee-extensor strength exercise dosage is not known. The purpose of the present trial is to investigate the efficacy of three different exercise dosages of pre-operative, home-based, knee-extensor strength exercise on knee-extensor strength before and shortly after surgery in patients eligible for TKA due to end-stage knee OA. METHODS: In this randomized dose-response trial with a three-arm parallel design, 140 patients with end-stage knee OA (candidates for TKA) are randomized to one of three exercise dosages (two, four or six session/week) of knee-extensor strength exercise (three sets, 12 repetitions at 12 RM, per exercise session) for 12 weeks. The knee-extensor strength exercise is home-based (unsupervised) and performed with an elastic exercise band following an initial exercise instruction. Adherence is objectively quantified using a sensor attached to the exercise band. The primary outcome will be the change in knee-extensor strength. Following the 12-week exercise period, the need for TKA surgery is re-assessed by an orthopedic surgeon. DISCUSSION: Decreased knee-extensor strength is a major challenge in patients with knee OA. Exercise programs focusing on knee-extensor strength are found to be more effective in relieving knee OA pain and symptoms compared to more general exercise programs. However, the optimal exercise dosage for knee-extensor strength deficits in patients with knee OA is inconclusive. Knowledge on the dose-response relationship for knee-extensor strength exercise in patients with knee OA will help guide future non-surgical treatment in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02931058 . Pre-registered on 10 October 2016.

RAPID KNEE-EXTENSIONS TO INCREASE QUADRICEPS MUSCLE ACTIVITY IN PATIENTS WITH TOTAL KNEE ARTHROPLASTY: A RANDOMIZED CROSS-OVER STUDY.

BACKGROUND: Inhibition of the quadriceps muscle and reduced knee-extension strength is common shortly following total knee arthroplasty (weeks to months), due to reduced voluntary activation of the quadriceps muscle. In healthy subjects, strength training with heavy loads is known to increase agonist muscle activity, especially if the exercise is conducted using rapid muscle contractions. PURPOSE: The purpose of this study was to examine if patients with total knee arthroplasty could perform rapid knee-extensions using a 10 RM load four to eight weeks after surgery, and the degree to which rapid knee-extensions were associated with greater voluntary quadriceps muscle activity during an experimental strength training session, compared to that elicited using slow knee-extensions. STUDY DESIGN: A randomized cross-over study. METHODS: Twenty-four patients (age 66.5) 4-8 weeks post total knee arthroplasty randomly performed one set of five rapid, and one set of five slow knee-extensions with the operated leg, using a load of their 10 repetition maximum, while surface electromyography recordings were obtained from the vastus medialis and lateralis of the quadriceps muscle. RESULTS: Data from 23 of the 24 included patients were analyzed. Muscle activity was significantly higher during rapid knee-extensions (120.2% [10th-90th percentile: 98.3-149.1]) compared to slow knee-extensions (106.0% [88.8-140.8]) for the vastus lateralis (p<0.01), but not for the vastus medialis (120.8% [90.4-134.0]) and (121.8% [93.0-133.0]) (p = 0.17), respectively. Slow and rapid knee-extensions were performed at a median angular velocity of 19.7 degrees/sec (13.7-24.4) and 51.4 degrees/sec (28.9-63.1), respectively. CONCLUSION: Four to eight weeks after their total knee arthroplasty, the patients in the present study were able to conduct rapid knee-extensions according to the experimental protocol with an approximately doubled angular velocity compared to slow knee-extensions. This was associated with increased muscle activity in the vastus lateralis when compared to slow knee-extensions, but not in the vastus medialis. Whether this significant, although relatively small, difference in vastus lateralis muscle activity has any clinical relevance needs further study. LEVEL OF EVIDENCE: 3.