Footwear and Falls in Long-Term Residential Aged Care Facilities: An Analysis of Video Capture Data.

INTRODUCTION: Several footwear characteristics have been shown to affect balance and gait patterns and may therefore influence the risk of falling in older adults. However, attributing a link between footwear and falls is inherently difficult as it often relies on self-report which may be inaccurate. METHODS: Archival video recordings of falls that occurred in two long-term residential aged care facilities were initially screened to determine whether the footwear worn at the time (barefoot, socks, slippers/sandals, or shoes) could be documented. These falls were then independently evaluated by three additional assessors and a meeting was held to obtain consensus in relation to whether the footwear could have potentially contributed to the fall, and what mechanism may have been responsible. Cross-tabulations were performed in relation to footwear type and fall characteristics (proposed mechanism and fall direction). RESULTS: There were 300 falls experienced by 118 older adults aged 58 years-98 years (mean age 82.8 years, SD 7.6). Of these falls, footwear could be ascertained in 224 (75%). After the consensus meeting, the proportion of falls considered to be potentially related to footwear was 40 (18%). The likelihood of footwear contributing to the fall was highest when participants were wearing socks (14/19 falls; 74% of all footwear-related falls), followed by being barefoot (2/6 falls; 33%), wearing slippers/sandals (17/100 falls; 17%), and wearing shoes (7/99 falls, 7%). CONCLUSION: Footwear could be a potential contributor to a substantial number of falls in residential aged care. Wearing socks would appear to place an older person at risk of future falls and should therefore be avoided in this population.

Anterior Knee Pain Following Primary Unilateral Total Knee Arthroplasty With Posterior-Stabilized Prosthesis and Patellar Resurfacing: Prevalence and Clinical Implications.

BACKGROUND: Anterior knee pain following total knee arthroplasty (TKA) is associated with patient dissatisfaction. Factors related to postoperative anterior knee pain and its impact on patient outcomes are poorly understood. The following are the aims of this study: (1) to report the prevalence of anterior knee pain before and after TKA using a posterior-stabilized prosthesis with routine patellar resurfacing; (2) to investigate the association of preoperative clinical factors with the presence of anterior knee pain after TKA; and (3) to explore the association of postoperative anterior knee pain with postoperative self-reported function and quality of life. METHODS: This retrospective study included 506 patients who had undergone elective primary unilateral TKA with a posterior-stabilized prosthesis and patellar resurfacing. Outcome measures prior to and 12 months after TKA included self-reported anterior knee pain, knee function, and quality of life. RESULTS: Prevalence of anterior knee pain was 72% prior to and 15% following TKA. Patients who had preoperative anterior knee pain had twice the risk of experiencing anterior knee pain after TKA than patients who did not have preoperative anterior knee pain (risk ratio: 2.37, 95% CI 1.73-2.96). Greater severity of preoperative anterior knee pain and worse self-reported function were associated with the presence of postoperative anterior knee pain (rho = 0.15, P < .01; rho = 0.13, P < .01, respectively). Preoperative age, gender, and quality of life were not associated with postoperative anterior knee pain. Greater severity of postoperative anterior knee pain was associated with worse knee function at 12 months postoperative (rho = 0.49, P < .01). CONCLUSION: One in 7 patients reported anterior knee pain 12 months following posterior-stabilized and patella-resurfaced TKA. The presence of preoperative anterior knee pain and worse self-reported function are associated with postoperative anterior knee pain.

Pelvic floor muscle function in the standing position in women with pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: Clinical assessment of the pelvic floor muscles (PFMs) in a standing position may provide a more valid representation of PFM function experienced by patients in daily life than assessment in the lying position. The primary aim of this study was to examine PFM function in a standing versus a lying position in parous women with any type of urinary incontinence and/or pelvic organ prolapse. METHODS: In this exploratory cross-sectional study, participant symptom status was determined using the Australian Pelvic Floor Questionnaire. Pelvic floor muscle function was assessed in standing and lying positions with a randomised order of testing. The primary outcome measure was vaginal squeeze pressure (VSP) using intra-vaginal manometry. Secondary outcomes included vaginal resting pressure, total PFM work and digital muscle testing. The difference between PFM function in a standing position compared with a lying position was analysed using paired t test or Wilcoxon's signed rank test. RESULTS: Vaginal squeeze pressure assessed with manometry was higher in a standing than in a lying position (p = 0.001): standing (mean [SD]) 24.90 [12.67], lying 21.15 [14.65]. In contrast, PFM strength on digital muscle testing was lower in a standing position than in a lying position. CONCLUSIONS: This study has demonstrated that PFM function in a standing position is different from that in a lying position in women with pelvic floor dysfunction. Whether the higher VSP observed in a standing position reflects a true difference in strength between positions, or a higher pressure reading due to incorrect PFM contraction technique in a standing position is uncertain. Further research with larger cohorts and a measurement tool that can accurately distinguish a rise in intra-vaginal pressure from PFM contraction rather than increasing intra-abdominal pressure is required to confirm this difference, and the clinical significance of any difference.

Differences in accuracy and consistency in elite lawn bowlers.

The aim of this study was to determine whether there are differences in the accuracy and consistency of repeated lawn bowl deliveries between different bowling conditions and to describe the bias of bowls that missed the target (jack). Twenty-seven elite lawn bowl athletes were recruited to partake in the study. Participants delivered 16 bowls in four conditions: (i) forehand and (ii) backhand towards a target 23 metres away and (iii) forehand and (iv) backhand towards a target 27 metres away. The resting position of each bowl relative to the jack was described in terms of absolute displacement, width displacement and length displacement. For each participant and each condition, the average absolute displacement of deliveries was calculated as a measure of accuracy; the average width and length displacement was used to describe the bias of deliveries; and the bivariate variable error of absolute displacement was calculated as a measure of consistency. The forehand towards a target 23 metres away was significantly less accurate and consistent when compared with other conditions. There was a bias for greater width displacement of both forehand deliveries (p < 0.001). Analysing lawn bowls in this detail provides specific areas for coaching to improve lawn bowling performance.

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts.

PURPOSE: To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. METHODS: Thirty-five QT patients (age 20; range 15-34 years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32 years) patients. The following assessments were performed at 6 and 12 months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12 months) and between-subject (Graft; QT and HT) factors. RESULTS: Patient reported outcome measures and hop performance improved between 6 and 12 months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12 months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.001) and 180 deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.01) and 180 deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group. CONCLUSION: Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12 months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12 months. This may have implications for decisions regarding return to sport. LEVEL OF EVIDENCE: III.

The Effectiveness of Aquatic Plyometric Training in Improving Strength, Jumping, and Sprinting: A Systematic Review.

CONTEXT: Aquatic plyometric training may provide benefits due to reduced joint loading compared with land plyometric training; however, the reduced loading may also limit performance gains. OBJECTIVE: To systematically review the effect of aquatic plyometric training on strength, performance outcomes, soreness, and adverse events in healthy individuals. EVIDENCE ACQUISITION: Five databases were searched from inception to June 2020. Quality assessment and data extraction were independently completed by 2 investigators. When similar outcome measures were used, standardized mean differences were calculated. EVIDENCE SYNTHESIS: A total of 19 randomized controlled trials with 633 participants (mean age, range 14-30 y) were included. Aquatic plyometric training was most commonly performed in waist to chest deep water (12/19 studies), 2 to 3 times per week for 6 to 12 weeks (18/19 studies), with final program foot contacts ranging from 120 to 550. Meta-analyses were not completed due to the clinical and statistical heterogeneity between studies. Compared with land plyometric training, aquatic plyometric training exercises and dosage were replicated (15/16 studies) and showed typically similar performance gains (3/4 knee extensor strength measures, 2/4 leg extensor strength measures, 3/4 knee flexor strength measures, 7/10 vertical jump measures, 3/3 sprint measures). In total, 2 of 3 studies monitoring muscle soreness reported significantly less soreness following training in water compared with on land. Compared with no active training (no exercise control group or passive stretching), most effect sizes demonstrated a mean improvement favoring aquatic plyometric training (23/32 measures). However, these were not significant for the majority of studies measuring isokinetic knee strength, vertical jump, and sprinting. The effect sizes for both studies assessing leg press strength indicated that aquatic plyometric training is significantly more effective than no training. CONCLUSION: Aquatic plyometric training appears similarly effective to land plyometric exercise for improving strength, jumping, and sprinting and may be indicated when joint impact loading needs to be minimized. However, the low quality of studies limits the strength of the conclusions.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial.

OBJECTIVES: To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy. METHODS: This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance. RESULTS: There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points. CONCLUSION: In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions. TRIAL REGISTRATION NUMBER: ACTRN12617001225303.

Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis.

PURPOSE: Restoration of knee muscle strength is associated with better outcomes following anterior cruciate ligament (ACL) reconstruction, but little is known about the outcome of strength following quadriceps tendon autograft (QT) ACL reconstruction in relation to other graft types. The aim of this review was to evaluate strength outcomes of the knee extensors and knee flexors following QT ACL reconstruction compared to (1) the non-reconstructed contralateral limb and (2) alternative ACL graft types. METHODS: Four electronic databases were searched up until 21st February 2020. Summary meta-analyses were performed comparing knee strength outcomes following QT ACL reconstruction to the contralateral limb by way of limb symmetry index (LSI). Comparative meta-analyses were performed comparing QT ACL reconstruction to alternative ACL grafts for the two most frequently reported strength outcome measures which were peak knee extensor torque LSI, and peak knee flexor torque LSI at the following post-operative periods: 3, 5-8, 9-15, 24, 36-60 months. RESULTS: In total, 18 studies met the inclusion criteria. Knee strength outcomes of 952 QT ACL reconstructions were included and compared to either the contralateral limb or 1 of 4 alternative ACL graft types; 245 hamstring tendon autograft (HT), 143 patellar tendon autograft (PT), 45 quadriceps tendon allograft, and 21 tibialis anterior allograft. Knee extensor strength LSI following QT ACL reconstruction did not reach 90% even at 24 months post-operatively. Conversely, knee flexor strength LSI following QT ACL reconstruction exceeded 90% at the 9-15 months post-operative period. Knee extensor strength at 5-8 months following QT ACL reconstruction appears similar to PT but weaker than HT ACL reconstruction. In addition, peak knee flexor LSI was significantly greater at 5-8 months in QT ACL reconstruction patients compared to HT patients. CONCLUSION: The decision to utilize a QT graft for ACL reconstruction should include consideration of strength outcomes. Knee extensor strength recovery following QT ACL reconstruction appears not to be restored before 24 months. LEVEL OF EVIDENCE: Level IV.

Can target effects or discomfort ratings discriminate between small-arms weapon configurations?

Defence acquisitions use accuracy measures as a discriminating factor in weapon purchases, but assessments are generally completed in static, supported postures at static targets with few differences being seen between configurations. The aim of this study was to investigate whether an assessment requiring repositioning between shots could reveal differences. Participants shot at a static target under four conditions: an unweighted rifle and the addition of a mass fixed at three different positions. Accuracy and timing as well as discomfort measures were captured and compared. Hit percentage, consistency and timing varied over time, and timing increased with the addition of mass in two out of the three conditions. There was an increase in discomfort with the addition of mass further from the participant. The results showed that relying on accuracy and consistency measures alone to make acquisition decisions could have the consequence of purchasing equipment not fit for the human. Practitioner Summary: This research shows that relying on accuracy and consistency measures alone to make weapon-system acquisition decisions could have the consequence of purchasing equipment not fit for the user. Further research should focus on 'upstream' issues such as muscle fatigue and aim point stability in order to better understand human-weapon-system interactions.

Calf muscle strain injuries in elite Australian Football players: A descriptive epidemiological evaluation.

BACKGROUND: Calf muscle strain injuries (CMSI) show consistent rates of prevalence and re-injury in elite Australian Football players. An epidemiological evaluation is warranted to better understand the clinical presentation and recovery of CMSI. PURPOSE: First, to describe the epidemiology of CMSI in elite Australian Football players. Second, to determine if recovery following injury is different according to: (a) injury type (index vs re-injury); (b) muscle injured (soleus vs gastrocnemius); and (c) mechanism of injury (running-related activity vs non running-related activity). STUDY DESIGN: Descriptive epidemiological. METHODS: Data retrieved from the Soft Tissue injury Registry of the Australian Football League were analyzed. Sixteen clubs submitted data on CMSI from 2014 to 2017. Data included: player characteristics, training and match history at the time of injury, MRI, and the time to reach recovery milestones. RESULTS: One hundred and eighty-four CMSI were included (149 index injuries; 35 re-injuries). Soleus injuries were most prevalent (84.6%). Soleus injuries took 25.4 ± 16.2 days to return to play, whereas gastrocnemius injuries took 19.1 ± 14.1 days (P = .097). CMSI sustained during running-related activities took approximately 12 days longer to recover than injuries sustained during non running-related activities (P = .001). Compared to index injuries, re-injuries involved older players (P = .03) and significantly more time was taken to run at >90% of maximum speed, return to full training, and return to play (P ≤ .001). Almost all of the observed re-injuries involved soleus (91.4%). CONCLUSION: Soleus injuries are more prevalent than gastrocnemius injuries in elite Australian Football players. Prognosis appears to be influenced by clinical factors, with CMSI sustained during running-related activities and re-injuries needing more time to recover.

The impact of pelvic organ prolapse and/or continence surgery on pelvic floor muscle function in women: A systematic review.

AIMS: To systematically review the evidence for the effect of pelvic organ prolapse (POP) and/or continence surgery on pelvic floor muscle (PFM) morphometry and function in women, and to investigate whether a relationship exists between PFM measures and clinician-reported objective pelvic floor outcomes postoperatively. METHODS: Six electronic databases were searched until March 2018. Studies were included if they examined the effect of POP and/or continence surgery on the PFM in women, and reported pre- and postoperative data. Methodological quality was assessed using a modified Downs and Black checklist. Three meta-analyses were planned based on postoperative follow-up time. RESULTS: Twenty-one studies met the inclusion criteria. Varied surgical interventions and 33 different PFM measures were represented. The methodological quality of included studies varied considerably. The 0 to 6 weeks postoperative meta-analysis showed no statistically significant change in PFM function (SMD = 0.04; 95% confidence interval [CI] = -0.26 to 0.33). This was consistent at 3 and 6 or more months (SMD = 1.13; 0.35 95% CI = -0.34 to 2.60, - 0.42 to 1.12 respectively). None of the included studies investigated the relationship between PFM measures and clinician-reported objective outcomes postoperatively. CONCLUSIONS: This review did not show a clear effect of POP and/or continence surgery on PFM morphometry or function in women and was unable to show a relationship with outcomes such as objective prolapse score and urodynamic findings. This could be because surgery does not measurably impact on the PFM or due to the poor quality and heterogeneity of studies. Future well-designed research is needed to specifically investigate change in the PFM following surgery.

Predictors of substantial improvement in physical function six months after lumbar surgery: is early post-operative walking important? A prospective cohort study.

BACKGROUND: Resuming walking after lumbar surgery is a common focus of early post-operative rehabilitation, however there is no knowledge about whether increased walking is associated with better functional outcomes. This study aimed to determine whether time spent walking in the week after lumbar surgery, along with co-morbidities, pre-operative pain duration, pre-operative physical activity or function, or surgical variables predict substantial improvement in physical function six months after lumbar surgery. METHODS: A prospective cohort study design was utilized. Participants undergoing lumbar surgery (discectomy, decompression, fusion) were recruited between April and November 2016. Predictor variables were collected pre-operatively (age, sex, smoking status, obesity, diabetes, depression, anxiety, pre-operative pain duration, neurological deficit, physical activity levels, mobility restriction, function) and early post-operatively (post-operative walking time, surgical procedure, single/multi-level surgery). Outcome variables (physical function, back pain and leg pain severity) were measured pre-operatively and six-months post-operatively. Logistic regression analysis was used to establish prediction of substantial improvement in outcome at six months. RESULTS: Participants (N = 233; 50% female; age 61 (SD = 14) years) who walked more in the first post-operative week were more likely to have substantially improved function on the Oswestry Disability Questionnaire at six months (OR 1.18, 95%CI 1.02-1.37), as were participants with < 12 months pre-operative pain (OR 2.71, 95%CI 1.28-5.74), and those with lower pre-operative function (OR 4.02, 95%CI 2.33-6.93). Age < 65 years (OR 2.36, 95%CI 1.14-4.85), and < 12 months pre-operative pain (OR 3.52 95%CI 1.69-7.33) predicted substantial improvement on the SF-36 Physical Component Summary. There were no significant predictors for substantial improvement in either leg or back pain. CONCLUSIONS: Walking time in the week after lumbar surgery is one of several predictors of substantial improvement in function at six months. Further research is required to determine whether intervention designed to increase walking early after lumbar surgery results in improved longer-term recovery of function. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), registration number 12616000747426 . Retrospectively registered on the 7th of June 2016.

Rehabilitation Exercises for the Gluteus Minimus Muscle Segments: An Electromyography Study.

CONTEXT: The gluteus minimus (GMin) muscle consists of 2 uniquely oriented segments that have potential for independent function and have different responses to pathology and aging. For healthy young adults, it is unknown that which rehabilitation exercises specifically target the individual segments. OBJECTIVE: To quantify segmental GMin activity for 6 common lower-limb rehabilitation exercises in healthy young adults and determine if significant differences exist in segmental activity levels between the exercises. METHOD: Six common lower-limb rehabilitation exercises were performed by 10 healthy young adults with fine-wire electromyography (EMG) electrodes inserted into the anterior and posterior segments of the GMin muscle. MAIN OUTCOME MEASURES: Electromyography signals were recorded, and median normalized exercise activity levels were reported and compared for each GMin segment across the 6 exercises. RESULTS: High activity levels were generated in the anterior segment by the resisted hip abduction-extension exercise (51% maximum voluntary isometric contraction [MVIC]), whereas for the posterior segment, high activity levels were produced by the single-leg bridge (49% MVIC), the side-lie hip abduction (43% MVIC), the resisted hip abduction-extension exercise (43% MVIC), and the single-leg squat (40% MVIC). There were significant differences (P < .05) in the median electromyography activity levels for the anterior GMin segment but not for the posterior GMin segment across some of the exercises with large effect sizes. CONCLUSION: Targeted rehabilitation exercises graded by exercise intensity can be prescribed specifically for the anterior and posterior GMin segments to aid in restoration of hip function following injury or aging.

Rehabilitation Exercises for the Gluteus Medius Muscle Segments: An Electromyography Study.

CONTEXT: Many different rehabilitation exercises have been recommended in the literature to target the gluteus medius (GMed) muscle based mainly on single-electrode, surface electromyography (EMG) measures. With the GMed consisting of 3 structurally and functionally independent segments, there is uncertainty on whether these exercises will target the individual segments effectively. OBJECTIVE: To measure individual GMed segmental activity during 6 common, lower-limb rehabilitation exercises in healthy young adults, and determine if there are significant differences between the exercises for each segment. METHOD: With fine-wire EMG electrodes inserted into the anterior, middle, and posterior segments of the GMed muscle, 10 healthy young adults performed 6 common, lower-limb rehabilitation exercises. MAIN OUTCOME MEASURES: Recorded EMG activity was normalized, then reported and compared with median activity for each of the GMed segments across the 6 exercises. RESULTS: For the anterior GMed segment, high activity was recorded for the single-leg squat (48% maximum voluntary isometric contraction [MVIC]), the single-leg bridge (44% MVIC), and the resisted hip abduction-extension exercise (41% MVIC). No exercises recorded high activity for the middle GMed segment, but for the posterior GMed segment very high activity was recorded by the resisted hip abduction-extension exercise (69% MVIC), and high activity was generated by the single-leg squat (48% MVIC) and side-lie hip abduction (43% MVIC). For each of the GMed segments, there were significant differences (P < .05) in the median EMG activity levels between some of the exercises and the side-lie clam with large effect sizes favoring these exercises over the side-lie clam. CONCLUSIONS: Open-chain hip abduction and single-limb support exercises appear to be effective options for recruiting the individual GMed segments with selection dependent on individual requirements. However, the side-lie clam does not appear to be effective at recruiting the GMed segments, particularly the anterior and middle segments.

Sex Differences in Gait After Total Knee Arthroplasty.

BACKGROUND: Before total knee arthroplasty (TKA), males walk with biomechanics that are distinct from females. It is not known whether these sex-specific profiles are maintained after TKA and whether any differences reflect those typical of unimpaired males and females. The aim of this study was to compare knee biomechanics of males and females with TKA with unimpaired controls during walking. METHODS: Eighty-five participants (44 females and 41 males) who were at least 12 months after unilateral TKA and 39 matched control participants (21 females and 18 males) were included in this observational cohort study. All participants were assessed with 3-dimensional motion analysis during comfortable speed walking. RESULTS: All key biomechanics parameters during walking were significantly different between males with TKA and male controls (P < .01). There were no differences in the same parameters between females with TKA and female controls. CONCLUSION: Sex-specific biomechanics profiles are maintained after TKA. Biomechanics of females with TKA were closer to normal than males, suggesting that previous studies that investigate a mixed-sex cohort may have underestimated biomechanics outcome from TKA for females. Future studies should consider evaluating outcome from TKA independently for males and females.

Effectiveness of Aquatic Exercise in Improving Lower Limb Strength in Musculoskeletal Conditions: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the effectiveness of aquatic exercise in improving lower limb strength in people with musculoskeletal conditions. DATA SOURCES: A systematic search used 5 databases, including MEDLINE, CINAHL, Embase, SPORTDiscus, and The Cochrane Library. STUDY SELECTION: Randomized controlled trials evaluating aquatic exercise with a resistance training component for adults with musculoskeletal conditions compared with no intervention or land-based exercise were identified. Fifteen studies from the initial yield of 1214 met these criteria. DATA EXTRACTION: Data related to participant demographics, study design, and methods, interventions, and outcomes, including numerical means and SDs, were extracted independently by 2 reviewers. DATA SYNTHESIS: Nine of the 15 studies were of high quality, scoring at least 6 on the Physiotherapy Evidence Database Scale. Limited consideration of the prescription of resistance in the aquatic exercise and application of resistance training principles existed. Low- or very low-quality evidence indicates there was no difference in average effect between aquatic exercise and no exercise in improving hip abductor strength (standardized mean difference [SMD], .28; 95% confidence interval [CI], -.04 to .59), knee extensor strength (SMD, .18; 95% CI, -.03 to .40), knee flexor strength (SMD, .13; 95% CI, -.20 to .45), or lower limb endurance (SMD, .35; 95% CI, -.06 to .77). Low-quality evidence indicates no difference in average effect between aquatic and land exercise for knee extensor (SMD, -.24; 95% CI, -.49 to .02) or flexor strength (SMD, -.15; 95% CI, -.53 to .22). CONCLUSIONS: It is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions. Future research is needed to quantify resistance with aquatic exercises and to determine if using opportunities for greater resistance in aquatic rehabilitation and appropriate resistance training principles can be more effective in improving muscle strength.

Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial.

BACKGROUND: Quadriceps strengthening exercises are part of the treatment of patellofemoral pain (PFP), but the heavy resistance exercises may aggravate knee pain. Blood flow restriction (BFR) training may provide a low-load quadriceps strengthening method to treat PFP. METHODS: Seventy-nine participants were randomly allocated to a standardised quadriceps strengthening (standard) or low-load BFR. Both groups performed 8 weeks of leg press and leg extension, the standard group at 70% of 1 repetition maximum (1RM) and the BFR group at 30% of 1RM. Interventions were compared using repeated-measures analysis of variance for Kujala Patellofemoral Score, Visual Analogue Scale for 'worst pain' and 'pain with daily activity', isometric knee extensor torque (Newton metre) and quadriceps muscle thickness (cm). Subgroup analyses were performed on those participants with painful resisted knee extension at 60°. RESULTS: Sixty-nine participants (87%) completed the study (standard, n=34; BFR, n=35). The BFR group had a 93% greater reduction in pain with activities of daily living (p=0.02) than the standard group. Participants with painful resisted knee extension (n=39) had greater increases in knee extensor torque with BFR than standard (p<0.01). No between-group differences were found for change in Kujala Patellofemoral Score (p=0.31), worst pain (p=0.24), knee extensor torque (p=0.07) or quadriceps thickness (p=0.2). No difference was found between interventions at 6 months. CONCLUSION: Compared with standard quadriceps strengthening, low load with BFR produced greater reduction in pain with daily living at 8 weeks in people with PFP. Improvements were similar between groups in worst pain and Kujala score. The subgroup with painful resisted knee extension had larger improvements in quadriceps strength from BFR. TRIAL REGISTRATION NUMBER: 12614001164684.

Does the addition of hip strengthening exercises improve outcomes following total knee arthroplasty? A study protocol for a randomized trial.

BACKGROUND: Total knee arthroplasty (TKA) is effective in reducing pain and improving function for end-stage knee osteoarthritis. However, muscle weakness and functional limitations persist despite assistance from post-operative rehabilitation programs that traditionally focus on quadriceps strengthening and range of movement exercises. Hip abductor muscle weakness is evident in knee osteoarthritis and hip muscle strengthening reduces knee pain in this group. Following TKA, people with weak hip abductor strength perform more poorly on measures of physical function. However, very little is known of the effectiveness of including hip abductor strengthening exercises in post-operative rehabilitation. The aim of this trial is to compare the effects of targeted hip abductor strengthening to those of traditional care in a TKA rehabilitation program on muscle strength, patient reported outcomes and functional performance measures. METHODS/DESIGN: This protocol describes a single-blinded randomized controlled trial, where 104 participants referred for inpatient rehabilitation following TKA will be recruited. Participants will be randomized using computer-generated numbers to one of two groups: usual care or usual care with additional hip strengthening exercises. Participants will attend physiotherapy daily during their inpatient length of stay, and will then attend between six and eight physiotherapy sessions as an outpatient. Primary outcomes are isometric hip abductor strength and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes are stair climb test, 6 min walk test, timed up and go, 40 m fast-paced walk test, 30 second chair stand test, isometric quadriceps strength, Lower Extremity Functional Scale (LEFS) and SF-12. Outcome measures will be recorded at baseline (admission to inpatient rehabilitation), and then 3 weeks, 6 weeks and 6 months post admission to rehabilitation. DISCUSSION: The findings of this study will determine whether the addition of targeted hip strengthening to usual care rehabilitation improves physical performance and patient reported outcomes following TKA when compared to usual care rehabilitation. This will then determine whether targeted hip strengthening exercises should be included in traditional rehabilitation programs to improve the outcomes following total knee arthroplasty. TRIAL REGISTRATION: The trial protocol was registered with the Australian Clinical Trial Registry ( ACTRN12615000863538 ) on 18 August 2015.

Does walking after lumbar spinal surgery predict recovery of function at six months? Protocol for a prospective cohort study.

BACKGROUND: Physiotherapists are commonly involved in the management of patients immediately following lumbar spinal surgery. There is however, very little research to guide physiotherapy intervention in the acute post-operative period, and the advice provided to patients regarding post-operative walking and physical activity has been shown to be highly variable. The primary aim of this research is to establish whether the amount of walking patients perform in the week following lumbar spinal surgery predicts improvement in function at 6 months. METHODS: This study will be a prospective cohort study design, with a projected sample size of 250 participants. Patients undergoing surgery for the management of a disc prolapse, degenerative disc disease, lumbar spinal stenosis and/or degenerative spondylolysthesis will be invited to participate in this study. Outcome measurement will take place pre-operatively and at six months post-operatively. The primary outcome variable will be self-reported function, measured using the Modified Oswestry Disability Questionnaire and the physical component summary of the SF-36. Each participant will be fitted with an activPAL3 accelerometer to be worn for the first seven post-operative days. This accelerometer will record time spent in active versus sedentary postures, step count and time spent walking. Multivariable logistic regression analysis will be used to investigate the relationship between the total time spent walking over the first seven post-operative days, and outcome at six months. DISCUSSION: The results from this research will help to guide patient management during the inpatient phase, by identifying patients who are at risk of poorer outcome due to limited walking time. These patients may benefit from ongoing rehabilitation and outpatient physiotherapy services. This information will also provide a foundation for further research into interventions designed to optimise post-operative activity. TRIAL REGISTRATION: ACTRN12616000747426 , retrospectively registered 7th June 2016.

Symmetry of squatting and the effect of fatigue following anterior cruciate ligament reconstruction.

PURPOSE: To evaluate weight-bearing and joint symmetry during the double-leg squat exercise at baseline and after fatigue in patients who have undergone anterior cruciate ligament reconstruction (ACLR) compared to uninjured controls. METHODS: Ten males who had returned to sport after primary ACLR participated along with ten uninjured male controls. Lower limb kinematic, kinetic and ground reaction force (GRF) data were collected during double-leg squats at baseline and after a generalised fatigue protocol. Symmetry indices were calculated for hip and knee external flexion moments and the vertical GRF (weight-bearing symmetry) at maximum squat depth. These were compared between ACLR and control groups before and after fatigue using ANOVA models. RESULTS: The ACL group preferentially unloaded the reconstructed limb at baseline, but changed to a more symmetrical load distribution to perform the squat exercise in the fatigue condition. This same loading pattern was seen at both the knee and hip joints. The control group did not show any effect of fatigue. For both groups, symmetry indices were closer to zero (which indicated perfect symmetry) in the fatigue condition. CONCLUSIONS: When prescribing squat exercises, it should be recognised that initially, patients with ACLR tend to unload the affected knee. More symmetrical loading patterns may be achieved by inducing bilateral fatigue. When fatigued, loading symmetry was similar between this patient group and controls. This is relevant information for those who implement rehabilitation training programmes. LEVEL OF EVIDENCE: III.