If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football.

OBJECTIVES: We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women's elite Australian Football League (AFLW). METHODS: The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items). RESULTS: Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions. CONCLUSION: The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme's deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

Sport and exercise medicine/physiotherapy publishing has a gender/sex equity problem: we need action now!

OBJECTIVES: We aimed to determine (1) the proportion of women authors overall, in first (lead) and last (senior) author positions, (2) the proportion of women research participants and (3) the association between women in first and/or last author positions and the proportion of women research participants in original research articles and editorials/opinion pieces in four sport and exercise medicine/physiotherapy journals. METHODS: The journals evaluated were the British Journal of Sports Medicine, Journal of Orthopaedic and Sports Physical Therapy, Physical Therapy in Sport and International Journal of Sports Physical Therapy.We reviewed all original research articles and editorials/opinion pieces published in 2008, 2009, 2018 and 2019. For each, we aimed to determine the gender/sex of all authors (through gender pronouns, Google Scholar, ResearchGate, institutional profiles, personal websites, photographs and/or social media), and the gender/sex of study participants reported as 'female' or 'male' or 'women' or 'men' or 'girls' or 'boys'. RESULTS: We included 952 original studies and 219 editorials/opinion pieces. There were 5146 authors of original studies and 706 authors of editorials/opinion pieces. Compared with 2008/2009, the proportion of women as first and last authors was 3.6% (33.0% compared with 29.4%) and 4.8% (33.2% compared with 27.4%) higher respectively in 2018/2019. On average, the proportion of women participants in original studies remained largely unchanged over the 10-year period, only 10% of all participants were women in studies. CONCLUSION: Women are strikingly under-represented in first and last author positions, as are women participants in sports and exercise medicine/physiotherapy journals.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes.

OBJECTIVE: Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Seven databases were searched in December 2021. ELIGIBILITY CRITERIA: Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury. RESULTS: We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I2 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26). CONCLUSIONS: Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls. PROSPERO REGISTRATION NUMBER: CRD42021205998.

The patellofemoral pain and osteoarthritis subscale of the KOOS (KOOS-PF): development and validation using the COSMIN checklist.

BACKGROUND: Patellofemoral pain and osteoarthritis are prevalent and associated with substantial pain and functional impairments. Patient-reported outcome measures (PROMs) are recommended for research and clinical use, but no PROMs are specific for patellofemoral osteoarthritis, and existing PROMs for patellofemoral pain have methodological limitations. This study aimed to develop a new subscale of the Knee injury and Osteoarthritis Outcome Score for patellofemoral pain and osteoarthritis (KOOS-PF), and evaluate its measurement properties. METHODS: Items were generated using input from 50 patients with patellofemoral pain and/or osteoarthritis and 14 health and medical clinicians. Item reduction was performed using data from patellofemoral cohorts (n=138). We used the COnsesus-based Standards for the selection of health Measurements INstruments guidelines to evaluate reliability, validity, responsiveness and interpretability of the final version of KOOS-PF and other KOOS subscales. RESULTS: From an initial 80 generated items, the final subscale included 11 items. KOOS-PF items loaded predominantly on one factor, pain during activities that load the patellofemoral joint. KOOS-PF had good internal consistency (Cronbach's α 0.86) and adequate test-retest reliability (intraclass correlation coefficient 0.86). Hypothesis testing supported convergent, divergent and known-groups validity. Responsiveness was confirmed, with KOOS-PF demonstrating a moderate correlation with Global Rating of Change scores (r 0.52) and large effect size (Cohen's d 0.89). Minimal detectable change was 2.3 (groups) and 16 (individuals), while minimal important change was 16.4. There were no floor or ceiling effects. CONCLUSIONS: The 11-item KOOS-PF, developed in consultation with patients and clinicians, demonstrated adequate measurement properties, and is recommended for clinical and research use in patients with patellofemoral pain and osteoarthritis.

Knee kinematics and joint moments during gait following anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

BACKGROUND: Abnormal gait after anterior cruciate ligament reconstruction (ACLR) may contribute to development and/or progression of knee osteoarthritis. OBJECTIVE: To conduct a systematic review and meta-analysis of knee kinematics and joint moments during walking after ACLR. METHODS: We searched seven electronic databases and reference lists of relevant papers, for cross-sectional, human-based observational studies comparing knee joint kinematics and moments during level walking in individuals with ACLR, with the uninjured contralateral knee or healthy individuals as a control. Two independent reviewers appraised methodological quality (modified Downs and Black scale). Where possible, data were pooled by time post-ACLR (RevMan), otherwise narrative synthesis was undertaken. RESULTS: Thirty-four studies were included. Meta-analysis revealed significant sagittal plane deficits in ACLR knees. We found greater knee flexion angles (standardised mean difference: 1.06; 95% CI 0.39 to 1.74) and joint moments (1.61; 0.87 to 2.35) <6 months post-ACLR, compared to healthy controls. However, lower peak knee flexion angles were identified 1-3 years (-2.21; -3.16 to -1.26) and ≥3 years post-ACLR (-1.38, -2.14 to -0.62), and lower knee flexion moment 6-12 months post-ACLR (-0.76; -1.40 to -0.12). Pooled data provided strong evidence of no difference in peak knee adduction moment >3 years after ACLR (vs healthy controls) (0.09; -0.63 to 0.81). No transverse plane conclusions could be drawn. CONCLUSIONS: Sagittal plane biomechanics, rather than the knee adduction moment, appear to be more relevant post-ACLR. Better understanding of sagittal plane biomechanics is necessary for optimal post-operative recovery, and to potentially prevent early onset and progression of knee OA after ACLR. TRIAL REGISTRATION NUMBER: PROSPERO systematic review protocol registration number CRD4201400882 2.

Infrapatellar fat pad volume is greater in individuals with patellofemoral joint osteoarthritis and associated with pain.

There is relatively little research specifically investigating patellofemoral joint osteoarthritis (PFJ OA). In particular, the source of pain in PFJ OA has not been established. One structure that may be an important contributor is the infrapatellar fat pad (IPFP). This cross-sectional study aimed to: (1) compare IPFP volume in individuals with and without PFJ OA and (2) assess the relationship between IPFP volume and pain in individuals with PFJ OA. Thirty-five participants with symptomatic and radiographic PFJ OA and 11 asymptomatic controls with no radiographic signs of OA were recruited. IPFP volume was measured in both groups from magnetic resonance images, and pain in the PFJ OA group was determined using the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-pain). The PFJ OA group had 23.6 % greater IPFP volume than the control group (p = 0.04). After the inclusion of covariates, IPFP volume remained 19.6 % greater in the PFJ OA group (p = 0.03). IPFP volume explained 20.1 % of the variance in KOOS-pain in the PFJ OA group, with a larger IPFP being associated with worse pain (p < 0.01). Individuals with PFJ OA had a larger IPFP than controls, and IPFP volume was directly related to PFJ OA pain. These data suggest a role for the IPFP in PFJ OA and highlight a need for further investigation into the casual relationship between IPFP and PFJ changes.

Injury prevention for women and girls playing Australian Football: programme cocreation, dissemination and early adopter coach feedback.

Background: Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play). Methods: We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women's/girls' teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied. Results: Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1-4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points). Conclusions: Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

No Difference in Hip Muscle Volumes and Fatty Infiltration in Those With Hip-Related Pain Compared to Controls.

Background: Little is known about muscle morphology in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS). Identifying changes in hip muscle volume, fatty infiltrate and establishing relationships between muscle volume and strength, may provide insight into potential early treatment strategies. Purposes: To: (i) compare the volumes and fatty infiltrate of gluteus maximus, gluteus medius, gluteus minimis, tensor fascia latae and quadratus femoris between symptomatic and less-symptomatic sides of participants with hip-related pain; (ii) compare the volumes and fatty infiltrate of hip muscles between healthy controls and symptomatic participants; and (iii) explore relationships of hip muscle volumes to muscle strength and patient-reported outcome measures in people with hip-related pain. Study Design: Cross-sectional study. Methods: Muscle volume and fatty infiltrate (from magnetic resonance imaging), hip muscle strength, patient-reported symptoms, function and quality of life (QOL) were determined for 16 participants with hip-related pain (no clinical signs of FAIS; 37±9 years) and 15 controls (31±9 years). Using One Way Analysis of Co-Variance tests, muscle volume and fatty infiltrate was compared between the symptomatic and less-symptomatic sides in participants with hip-related pain as well as between healthy controls and symptomatic participants. In addition, hip muscle volume was correlated with hip muscle strength, hip-reported symptoms, function and QOL. Results: No differences in all the studied muscle volumes or fatty infiltrate were identified between the symptomatic and less-symptomatic hips of people with hip-related pain; or between people with and without hip-related pain. Greater GMED volume on the symptomatic side was associated with less symptoms and better function and QOL (ρ=0.522-0.617) for those with hip-related pain. Larger GMAX volume was associated with greater hip abduction and internal rotation strength, larger GMED volume was associated with greater hip extension strength, and larger QF volume was associated with greater hip abduction strength (rho=0.507-0.638). Conclusion: People with hip-related pain and no clinical signs of FAIS have hip muscle volumes that are not significantly different than those of matched pain-free controls or their less-symptomatic hip. Larger GMED muscle volume was associated with fewer symptoms and greater strength. Level of evidence: Level 3a.

Evaluation of an injury prevention programme (Prep-to-Play) in women and girls playing Australian Football: design of a pragmatic, type III, hybrid implementation-effectiveness, stepped-wedge, cluster randomised controlled trial.

INTRODUCTION: Due to the increase in participation and risk of anterior cruciate ligament (ACL) injuries and concussion in women's Australian Football, an injury prevention programme (Prep-to-Play) was codesigned with consumers (eg, coaches, players) and stakeholders (eg, the Australian Football League). The impact of supported and unsupported interventions on the use of Prep-to-Play (primary aim) and injury rates (secondary aim) will be evaluated in women and girls playing community Australian Football. METHODS AND ANALYSIS: This stepped-wedge, cluster randomised controlled trial will include ≥140 teams from U16, U18 or senior women's competitions. All 10 geographically separated clusters (each containing ≥14 teams) will start in the control (unsupported) phase and be randomised to one of five dates (or 'wedges') during the 2021 or 2022 season to sequentially transition to the intervention (supported Prep-to-Play), until all teams receive the intervention. Prep-to-Play includes four elements: a neuromuscular training warm-up, contact-focussed football skills (eg, tackling), strength exercises and education (eg, technique cues). When transitioning to supported interventions, study physiotherapists will deliver a workshop to coaches and player leaders on how to use Prep-to-Play, attend team training at least two times and provide ongoing support. In the unsupported phase, team will continue usual routines and may freely access available Prep-to-Play resources online (eg, posters and videos about the four elements), but without additional face-to-face support. Outcomes will be evaluated throughout the 2021 and 2022 seasons (~14 weeks per season). PRIMARY OUTCOME: use of Prep-to-Play will be reported via a team designate (weekly) and an independent observer (five visits over the two seasons) and defined as the team completing 75% of the programme, two-thirds (67%) of the time. SECONDARY OUTCOMES: injuries will be reported by the team sports trainer and/or players. Injury definition: any injury occurring during a football match or training that results in: (1) being unable to return to the field of play for that match or (2) missing ≥ one match. Outcomes in the supported and unsupported phases will be compared using a generalised linear mixed model adjusting for clustering and time. Due to the type III hybrid implementation-effectiveness design, the study is powered to detect a improvement in use of Prep-to-Play and a reduction in ACL injuries. ETHICS AND DISSEMINATION: La Trobe University Ethics Committee (HREC 20488) approved. Coaches provided informed consent to receive the supported intervention and players provided consent to be contacted if they sustained a head or knee injury. Results will be disseminated through partner organisations, peer-reviewed publications and scientific conferences. TRIAL REGISTRATION NUMBER: NCT04856241.

Discriminant validity of the Western Ontario and McMaster Universities Osteoarthritis index physical functioning subscale in community samples with hip osteoarthritis.

UNLABELLED: Pua Y-H, Cowan SM, Wrigley TV, Bennell KL. Discriminant validity of the Western Ontario and McMaster Universities Osteoarthritis Index Physical Functioning Subscale in community samples with hip osteoarthritis. OBJECTIVE: To evaluate, in a community hip osteoarthritis (OA) sample, the discriminant validity of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical functioning (PF) subscale to differentiate between self-report measures of pain and physical function. DESIGN: Cross-sectional. SETTING: Human movement laboratory of a university. PARTICIPANTS: Adults (N=100; 60 women, 40 men; age, 62.3+/-10.1y) with radiographically confirmed symptomatic hip OA. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six self-report measures of pain and physical function-WOMAC-PF and WOMAC-Pain subscales, Lower Extremity Functional Scale, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) bodily pain and PF subscales, and 4-item pain intensity measure-were obtained. Confirmatory factor analysis was applied to a correlated 2-factor measurement model that assumed discriminant validity: self-report measures of pain were conceptualized to load uniquely on 1 factor; self-report measures of physical function were conceptualized to load uniquely on the other factor. RESULTS: Confirmatory factor analysis revealed that the initially proposed model did not achieve an acceptable fit to the data. Allowing a correlation between the error terms of the WOMAC-PF with those of the WOMAC-Pain and the SF-36 bodily pain subscales resulted in a viable model that provided adequate fit to the data (chi(2)=7.5, P=.28). CONCLUSIONS: The findings suggest that the discriminant validity of the WOMAC-PF subscale from self-report pain measures cannot be confirmed in community-dwelling adults with hip OA.

Physiotherapy-led triage clinic for low back pain.

The aims of this study were to evaluate a physiotherapy-led triage clinic (PLTC) and investigate general practitioner satisfaction with the PLTC. A retrospective cohort study was undertaken from January to December 2005 at a Melbourne tertiary teaching hospital. Outcomes assessed included waiting times to first appointment, patient attendance and surgery conversion rates. Outcomes were compared with the hospital 2002 benchmark data. GP satisfaction was evaluated by a survey. One-hundred and five new patients attended the PLTC clinic during the evaluation period. Patients waited 9 weeks for a PLTC appointment compared with 26 weeks for the general orthopaedic clinic and 23 weeks for the spinal orthopaedic clinic. Sixty-seven percent of the patients triaged in the PLTC were discharged from the orthopaedic outpatient department without requiring an orthopaedic surgeon consultation. Referring GPs were at least as satisfied with the management of their patients through the PLTC as with usual management in the general orthopaedic clinic. A PLTC can significantly reduce waiting times for orthopaedic outpatient appointments in a public hospital. Many patients can be managed by these experienced physiotherapists and their GPs, without the need for face-to-face contact with an orthopaedic surgeon. Pilot results indicated that GPs whose patients are managed in this PLTC were satisfied with this model for their patients with low back conditions.

Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in persons with hip osteoarthritis.

OBJECTIVE: To examine the relative and absolute intrarater test-retest reliability of muscle strength and range of motion (ROM) measurements of the hip performed in people with hip osteoarthritis. DESIGN: Repeated measures. SETTING: Human movement laboratory of a university. PARTICIPANTS: Participants (N=22; 10 men, 12 women; age range, 50-84y) with hip osteoarthritis. INTERVENTIONS: On 2 separate occasions, at least 1 week apart, isometric torque measurements were obtained from the hip rotators, flexors, abductors, and extensors. Passive ROMs in hip rotation, flexion, abduction, and extension were also determined. MAIN OUTCOME MEASURES: Relative reliability was estimated using the intraclass correlation coefficient, model 2,2 (ICC(2,2)). Absolute reliability was estimated using the coefficient of variation (CV) and the standard error (SE) of measurement. RESULTS: For measurements of muscle strength, ICC(2,2) ranged from .84 to .97, and the CV ranged from 8% to 15.7%. Hip extensors and internal and external rotators showed high ICC(2,2) (>.96) and low CV (<9.8%); hip abductors showed the lowest ICC(2,2) (.84) and the highest CV (15.7%). For ROM measurements, ICC(2,2) ranged from .86 to .97 and SE ranged from 3.1 degrees to 4.7 degrees . Hip flexion ROM showed the highest ICC(2,2) (.97) and an SE of 3.5 degrees ; hip extension ROM showed the lowest ICC(2,2) (.86) and the highest SE (4.7 degrees ). CONCLUSIONS: Strength and ROM testing of the hip in people with hip osteoarthritis can be performed with good to excellent reliability.

Clinical features of people with hip-related pain, but no clinical signs of femoroacetabular impingement syndrome.

OBJECTIVES: Identifying impairments in hip range of motion (ROM) and muscle strength in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS). STUDY AIMS: to determine if hip strength and ROM i) differs between the symptomatic and less-symptomatic hip of people with hip-related pain; and between people with hip-related pain and healthy controls; and ii) are associated with hip-related Quality of Life and pain. DESIGN: Cross-sectional study. SETTING: University laboratory. PARTICIPANTS: Thirty participants with hip-related pain who were awaiting hip arthroscopy (22 women; age = 37 ±â€¯10yrs), 32 healthy controls (19 women; age = 30 ±â€¯10yrs). MAIN OUTCOME MEASURES: Hip ROM, muscle strength, pain intensity and the Hip disability and Osteoarthritis Outcome Score (HOOS) were assessed. RESULTS: Less hip flexion ROM (p = 0.004), and extension (p = 0.004), abduction (p = 0.001) and internal rotation (IR) (p = 0.048) strength were measured on the symptomatic compared to non-symptomatic side. Hip-related pain participants had lower hip abduction strength (p = 0.045), and less flexion (p < 0.001), IR (p = 0.027) and external rotation (ER) (p = 0.019) ROM compared to controls. Less ER ROM (p = 0.03-0.04), and greater abduction (p = 0.03-0.04) and adduction strength (p = 0.02) were associated with better patient reported outcome measures. CONCLUSIONS: Specific impairments in hip ROM and strength were identified in people with hip-related pain but no FAIS.

A comparison of isometric, isotonic concentric and isotonic eccentric exercises in the physiotherapy management of subacromial pain syndrome/rotator cuff tendinopathy: study protocol for a pilot randomised controlled trial.

BACKGROUND: Subacromial pain syndrome (SPS) involving rotator cuff tendinopathy is a common cause of shoulder pain and disability. Evidence suggests that structured physiotherapy may be as effective as surgery in this condition with significant improvements demonstrated in trials involving scapular retraining, rotator cuff strengthening and flexibility exercises. Most published programs typically utilise isotonic concentric and/or eccentric strengthening modes. Recently, immediate analgesic effects and muscle strength gains following heavy-load isometric exercises in lower limb tendinopathy conditions have been observed. It is pertinent to ascertain whether such outcomes can be replicated in SPS/rotator cuff tendinopathy. The primary aim of this study is to establish the feasibility of undertaking a full-scale randomised controlled trial (RCT) that compares the effects of isometric, isotonic concentric and isotonic eccentric rotator cuff contractions when used as part of a semi-standardised exercise-based physiotherapy program in patients diagnosed with SPS. The secondary aim is to explore potential trends or treatment effects of the exercise intervention. METHODS: Thirty-six participants diagnosed with SPS will be randomised to one of three intervention groups and undergo a one-on-one exercise-based physiotherapy intervention, involving scapular and rotator cuff muscle retraining and strengthening. Each group will utilise a different mode of rotator cuff strengthening-isometric, isotonic concentric or isotonic eccentric. Rotator cuff tendon responses to isometric loading are not yet established in the literature; hence, individualised, progressive loading will be used in this pilot study in accordance with symptoms. The intervention will involve two phases: during Phase 1 (weeks 1-6) participants undertake the active group-specific physiotherapy treatment; in Phase 2 (weeks 6-12), they undertake a progressive, but no longer group-specific exercise program. To determine feasibility, an evaluation of key study parameters including (a) ease of recruitment (rate and number as well as suitability of the assessment algorithm), (b) adherence to all phases of the exercise intervention including home program compliance and logbook completion, (c) participant non-completion (drop out number and rate) and (d) adverse events (nature and number) will be undertaken. Secondary outcomes will measure immediate effects: (i) within-treatment changes in pain perception (verbal rating scale (VRS) and shoulder muscle strength (hand-held dynamometer) as well as longer-term changes: (ii) shoulder-related symptoms and disability (Western Ontario Rotator Cuff Index (WORC) and Shoulder Pain and Disability Index (SPADI)), (iii) perception of pain (11-point numerical rating scale (NRS), (iv) shoulder muscle strength (hand-held dynamometer) and (v) perceived global rating of change score. The immediate within-treatment assessment of pain and muscle strength will be undertaken in treatments 2 and 3, and the longer term measures will be collected at the primary (conclusion of Phase 1 at 6 weeks) and secondary (conclusion of Phase 2 at 12 weeks) end-points of the study. DISCUSSION: The findings of this pilot study will permit evaluation of this study design for a full-scale RCT. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001676404.

Effects of an unloader knee brace on knee-related symptoms and function in people with post-traumatic knee osteoarthritis after anterior cruciate ligament reconstruction.

BACKGROUND AND PURPOSE: This pilot study evaluated the immediate and four-week effects of an unloader knee brace on knee-related symptoms and performance-based function in people with knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR). METHODS: Individuals with knee OA, five to 20years post-ACLR, were recruited for two within-subject randomized studies: immediate effects (n=18) and four-week effects (n=11). Patient-reported knee-related symptoms (knee pain, perceived task difficulty, confidence, stability) were assessed during hop for distance and step-down tests, while performance-based function was assessed with hopping distance under three conditions: i) no brace; ii) unadjusted brace (sagittal plane support); and iii) adjusted brace (sagittal plane support with varus/valgus readjustment). Participants in the four-week brace effect study were randomized to wear the unadjusted or adjusted brace for four weeks after baseline (no brace) testing, and repeated tests in their allocated brace at four-week follow-up. Friedman tests evaluated differences between the three brace conditions for each variable for the immediate brace effect study (p<0.05), and Wilcoxon signed-rank tests evaluated differences between no brace and allocated brace for the four-week study (p<0.05). RESULTS: The adjusted and unadjusted unloader braces produced immediate improvements in knee confidence during hop for distance, and knee pain during step-down. Following the four-week brace intervention, the allocated brace improved knee confidence, perceived task difficulty and stability during hop for distance; and knee pain, perceived task difficulty, confidence, and stability during step-down. CONCLUSIONS: The unloader knee brace, adjusted or unadjusted, has the potential to improve knee-related symptoms associated with knee OA after ACLR.

Immediate Effects of a Brace on Gait Biomechanics for Predominant Lateral Knee Osteoarthritis and Valgus Malalignment After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Lateral knee osteoarthritis is notably common after anterior cruciate ligament reconstruction (ACLR). While valgus bracing has been investigated as an intervention for medial knee osteoarthritis (OA), little is known about the effectiveness of varus bracing for lateral knee OA after ACLR. PURPOSE: To determine the immediate effects of a varus unloader knee brace on gait biomechanics in people with lateral knee OA and valgus malalignment after ACLR. STUDY DESIGN: Controlled laboratory study. METHODS: Nineteen participants who had undergone primary ACLR 5 to 20 years previously and had symptomatic and radiographic lateral knee OA as well as valgus malalignment were included. Three-dimensional gait analyses were conducted during walking under 3 test conditions: (1) no brace, (2) unadjusted brace (sagittal plane support with neutral frontal plane adjustment), and (3) adjusted brace (sagittal plane support with varus adjustment). Knee, pelvis, hip, and ankle kinematics and moments data were statistically analyzed using repeated-measures analysis of variance (α = 0.05). RESULTS: Compared with walking with no brace, the adjusted brace significantly increased peak knee flexion angle (mean difference [95% CI]: 3.2° [1.3° to 5.0°]) and adduction angle (1.7° [0.8° to 2.6°]) and reduced peak internal rotation angle (-3.0° [-4.0° to -2.0°]). Significant increases in peak knee flexion moment (0.14 N·m/kg [0.06 to 0.20 N·m/kg]), adduction moment (0.10 N·m/kg [0.07 to 0.14 N·m/kg]), and external rotation moment (0.01 N·m/kg [0.00 to 0.02 N·m/kg]) were observed with the adjusted brace. The adjusted brace also reduced peak hip adduction angle (-1.29° [-2.12 to -0.47]) and increased peak hip adduction (0.17 N·m/kg [0.04 to 0.31 N·m/kg]) and external rotation moments (0.09 N·m/kg [0.03 to 0.14 N·m/kg]). There were no significant differences between the adjusted and unadjusted brace conditions, except for knee internal rotation angle, where the adjusted brace produced significantly greater reductions relative to the unadjusted brace (-1.46° [-1.98 to -0.95]). CONCLUSION: Irrespective of frontal plane adjustment, the varus unloader brace produced immediate modulations in sagittal, frontal, and transverse plane joint angles and moments in younger individuals with lateral knee OA and valgus malalignment after ACLR. CLINICAL RELEVANCE: The varus unloader brace may have the potential to mitigate abnormal knee joint mechanics associated with the development and progression of lateral knee OA after ACLR.

Age-related changes in electromyographic quadriceps activity during stair descent.

PURPOSE: To determine the effects of age on (i) the onset of vastus medialis obliquus (VMO) activity relative to that of vastus lateralis (VL) and (ii) the onset of quadriceps activity in terminal swing relative to heel-strike, during stair descent. METHODS: Sixty-six healthy men and women with no known knee pathology were recruited from the community and the University of Melbourne. Thirty-three older people aged over 50 (mean (SD) 68 (8) years) and 33 younger people aged under 40 (mean (SD) 25 (4) years) participated. Surface electromyography (EMG) was used to record muscle activity during stair descent. Muscle onset was identified from individual EMG traces with a computer algorithm and validated visually. RESULTS: Both younger and older participants demonstrated a relatively synchronous onset of VMO and VL (i.e. within 10ms of each other) with no differences between the age groups evident (P=0.262). However older participants activated their quadriceps significantly earlier than the younger group (P<0.001) even when differences in body mass and speed of stair descent were accounted for. CONCLUSION: Age-related changes in quadriceps activity are apparent. The clinical implications of such changes are unknown, but increases in joint loading are possible. Earlier quadriceps activation may compensate for balance and strength impairments in older people during challenging activities.

Physical therapy improves knee flexion during stair ambulation in patellofemoral pain.

PURPOSE: This study aimed to examine whether a physical therapy intervention, designed to reduce pain and improve the neuromotor control resulted in greater improvements in stance-phase knee flexion during stair ambulation in individuals with patellofemoral pain. The relationship between changes in stance-phase knee flexion and changes in pain, disability, and onset timing of individual vasti activity was also examined. METHODS: Forty participants aged 40 yr or younger diagnosed with patellofemoral pain were randomly allocated to a physical therapy (N = 21) or placebo (N = 19) treatment group. Stance-phase knee flexion was measured in two dimensions using a PEAK movement analysis system during stair ambulation. Individuals were divided into those with improvements in onset of vastus medialis obliquus (VMO) activity relative to that of the vastus lateralis (VL) of more or less than 10 ms. RESULTS: Groups were similar at baseline. After the 6-wk intervention, individuals in the physical therapy group had significantly greater changes in knee flexion at heel strike (mean difference 4 degrees, 95% CI = 2-7 degrees) and peak stance-phase knee flexion (mean difference 9 degrees, 95% CI = 5-12 degrees) than those in the placebo group. No differences were noted during stair ascent. Individuals with greater change in the onset timing of the vasti had greater improvements in stance-phase knee flexion. Changes in usual pain in the week before testing and change in the vasti onset timing were independent predictors of change in stance-phase knee flexion during stair descent, together accounting for 27-40% of the variability in knee motion. CONCLUSIONS: Physical therapy intervention resulted in significantly greater changes in knee joint motion than a placebo treatment, and these changes in knee motion were partly related to changes in pain and changes in onset timing of the vasti.

Gait Characteristics of People with Lateral Knee Osteoarthritis after ACL Reconstruction.

PURPOSE: Lateral knee osteoarthritis (OA) is common after anterior cruciate ligament reconstruction (ACLR), yet gait characteristics associated with lateral knee OA after ACLR are not well understood. This cross-sectional study aimed to compare knee, trunk, pelvis, hip, and ankle kinematics and moments between people with predominant lateral knee OA after ACLR and healthy controls. METHODS: Nineteen post-ACLR people with lateral knee OA and 25 healthy controls were recruited. Quantitative gait analysis was conducted during walking, and knee pain, confidence, and kinesiophobia were assessed. Between-group differences in peak kinematics and moments were evaluated, and Pearson correlations evaluated relations between biomechanical and patient-reported measures (P < 0.05). RESULTS: Participants with lateral knee OA after ACLR had greater peak knee flexion (mean difference, 3.5°; 95% confidence interval, 0.9-6.1) and lower knee internal rotation angles (-3.3°; -6.2 to -0.5) than the controls. Those with lateral knee OA also had greater peak pelvic anterior tilt (3.1°, 0.4-5.9), hip flexion angles (5.1°, 1.9-8.3), and peak ankle dorsiflexion moment (0.1 N·m·kg(-1), 0.0-0.2). In the lateral knee OA group, worse knee confidence and kinesiophobia were significantly correlated with greater peak trunk flexion angle (r = 0.654 and r = 0.535, respectively) and greater knee pain was significantly correlated with greater peak knee flexion angle (r = 0.535). CONCLUSIONS: Gait characteristics associated with lateral knee OA after ACLR differ from those in healthy individuals, predominantly in the sagittal plane. Increased sagittal plane knee and trunk kinematics seem to be related to worse knee pain, confidence, and kinesiophobia. These findings will assist the development of compartment-specific interventions for individuals with posttraumatic lateral knee OA.