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

Objective

To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT.

Methods

Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT).

Results

341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT.

Conclusions

Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.

Do posted foot orthoses alter hip biomechanics and pain during walking in women with greater trochanteric pain syndrome?

BACKGROUND

Greater trochanteric pain syndrome (GTPS), including gluteal tendinopathy and bursitis, is a common, painful and debilitating condition. It is thought to involve overload of the gluteal tendons, which may be amplified through increased hip adduction moment (HAM) seen during gait in these individuals. Reducing the aberrant HAM may improve pain and function in this population. We aimed to determine if medially-posted foot orthoses immediately reduce HAM and pain in females with GTPS during walking gait.

METHODS

A double-blind, repeated-measures trial with randomised intervention order compared three conditions in 53 women with GTPS. Participants acted as their own control during baseline (everyday-shoe insole), medially-posted (active) orthosis, or flat insert (sham orthosis) walking. Data were collected via three-dimensional gait analysis for HAM, hip, pelvic, and thorax kinematics; as well as ground reaction force; and pain via the numerical rating scale. Subgroup analysis was performed based on a pronated foot-posture defined by the Foot Posture Index.

RESULTS

A small pain reduction was found between the active orthosis and flat insert (mean difference = -0.444, p = 0.017). No difference was detected for pain between other condition comparisons. Thoracic lateral flexion increased at second-peak HAM between the baseline and active conditions (mean difference = -0.917, p = 0.040). No differences were detected for HAM, remaining kinematic or kinetic variables, or ground reaction force data across the three conditions. No significant differences were detected between any of the three conditions for biomechanical or pain data in the pronated-foot subgroup.

SIGNIFICANCE

A medially-posted foot orthosis did not immediately alter gait biomechanics or provide a clinically meaningful pain reduction in women with GTPS. There is uncertainty regarding the clinical benefit of orthoses in the management of GTPS. Longer-term follow-up or the use of customised orthoses may produce different outcomes and should be explored in future research.

The natural history of greater trochanteric pain syndrome: an 11-year follow-up study

Background

Greater trochanteric pain syndrome (GTPS) is a musculoskeletal condition which can cause disability and reduce quality of life. However, limited evidence is available on the long-term outcomes of people with GTPS. Our aims were to determine the long-term prevalence of GTPS; to calculate the proportion of people with GTPS who had developed hip osteoarthritis (OA); and to determine the level of function and quality of life, 11-years after initial GTPS diagnosis.

Methods

A prospective 11-year natural history study. Two groups [GTPS group (n = 24), asymptomatic control (ASC) group (n = 20)] were evaluated at baseline, 12-months and 11-years. At 11-years all participants completed the modified Harris Hip Score (mHHS), Oswestry Disability Index (ODI) and Assessment of Quality-of-Life questionnaire. At 11-year follow-up 20/24 GTPS and 19/20 ASC participants were clinically assessed for GTPS and hip OA, completed the 10 metre-walk-test, timed up and go, and hip abduction and external rotation strength testing.

Results

At 11-year follow-up 45.0% of GTPS participants had GTPS compared to 5.3% of ASC participants (p = 0.008), OR [95% CI]: 10.19 [1.95, 104.3], and 35.0% of GTPS participants were clinically diagnosed with hip OA compared to none of the ASC participants (p = 0.002), OR [95% CI]: 21.6, [2.3, 2898.0]. GTPS participants reported more pain and disability than ASC participants via the ODI, mean difference [95% CI]: 6.1 [0.7, 11.6] but not the modified Harris Hip Score, mean difference [95% CI]: -3.3 [-10.3, 3.7]. Both groups had similar levels of quality of life and measures of function.

Conclusions

GTPS is a chronic condition: people with GTPS at baseline had twice the odds of being clinically diagnosed with GTPS or hip OA than the control group at 11-years. Further, there appears to be a temporal relationship between GTPS and the development of hip OA. This finding highlights the need to identify effective treatments that address the underlying impairments associated with GTPS. Pain and function results varied depending on the assessment tools used. Between group differences in quality of life seen at baseline are not found at the 11-year follow-up. The small sample size means the results must be considered with caution.

Level of Evidence

Level II Natural history Study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04935-w.

Nutrition and Healthy Ageing Trajectories in Retirement Living in the Australian Capital Territory: Study Protocol

Objectives

There are a growing number of people aged over 55 years living in retirement communities in Australia. These communities typically consist of accommodation, services and community facilities which cater to older people and the desire to maintain independence. The Nutrition and Healthy Ageing Trajectories in Retirement Living (NutriHAT-RL) study aims to investigate the nutrition and lifestyle-based behaviours which contribute to healthy ageing and the maintenance of social and physical functioning among older people living in retirement communities.

Methods

This study will recruit a total of 2,770 people aged 55 years or over living in retirement communities in the Australian Capital Territory and southern New South Wales regions of Australia for a four-year prospective longitudinal study commencing in March 2021. A range of measures, including nutritional intake, health and lifestyle behaviours, cognitive and psychological function, and physical health, will be completed on three occasions over a total of four years. Participants will complete a face-to-face comprehensive, validated food frequency questionnaire at each time point. Risk of malnutrition and nutritional behaviour (emotional appetite and intuitive eating) will also be evaluated. Multiple mental, social, and physical health domains will be assessed at each time point. This will include cognitive and mental health (depression, anxiety, and loneliness) screening, social and occupational functioning questionnaires, self-reported and observed physical function assessments, and sleep quality. Bitter taste endophenotype, salivary C-reactive protein, telomere length, and blood biomarkers associated with healthy ageing will also be evaluated.

Results

Ethics approval has been obtained through the University of Canberra Human Ethics Research Committee (UCHREC-2306). To reduce risk of COVID-19 transmissions, a risk mitigation plan has been developed.

Conclusions

The NutriHAT-RL study will be the first Australian longitudinal study with a focus on nutrition and healthy ageing in people living in retirement communities. Findings from this study will contribute to understanding of nutrition and healthy ageing in this growing population and will inform policy and practice related to nutrition and ageing in place.

Funding Sources

N/A.

Effects of a virtual group cycling experience on people living with dementia: A mixed method pilot study

Social isolation and sedentary behaviour are common in residential aged care facilities (also known as nursing homes or long-term care). Use of new technologies such as virtual and augmented reality are currently under investigation for their potential to provide exciting and engaging activities for older people in residential aged care facilities. However, there is limited evidence on whether these technologies can promote physical activity in a small group setting for people with cognitive impairment. Using mixed methods, we examined the use of a virtual cycling experience in a sample of 10 participants with cognitive impairment living in residential aged care facilities. In a randomised crossover design, participants engaged in a 25-minute, self-paced, facilitated seated virtual cycling experience and a time-matched seated physical activity session in groups of five. All participants completed a brief pre- and post-intervention mood questionnaire. Video analysis was used for both conditions to compare levels of environmental stimulation, apathy and engagement using both the Person–Environment Apathy Rating Scale and the Engagement of a Person with Dementia Scale. A thematic analysis of semi-structured interviews following the virtual cycling experience was also performed. No differences were observed between conditions for all outcomes except for environmental stimulation, where there was a lower response in the intervention than the control condition ( p = 0.032). This was primarily driven by lower scores for the virtual cycling experience than control in physical accessibility ( p = 0.012). Participants reported the virtual cycling experience to be immersive and challenging and reminisced about cycling earlier in life. The activity manager observed that the virtual cycling experience was an overall positive experience and emphasised benefits of safety screening and preparation prior to the activities. The findings of this study support the use of the virtual cycling experience as an immersive and engaging alternative to usual activities, which might encourage higher levels of physical activity in residential aged care facilities.

An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS)

PURPOSE

To evaluate how physiotherapists across three countries (Australia, New Zealand (NZ) and Ireland) diagnose greater trochanteric pain syndrome (GTPS) using clinical tests and imaging findings, and how physiotherapists update their knowledge regarding GTPS.

DESIGN

Cross-sectional observational study of physiotherapists.

METHODS

An online survey was distributed to registered physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; medians and interquartile ranges were calculated for numerical data. Comparisons between the three countries were made using Chi-squared analyses for nominal/ordinal data and Kruskal Wallis tests for numerical data. Statistical significance was set at p < 0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists; 61% were female and 79.8% worked in private practice. Most respondents were very confident in diagnosing GTPS (67.9%) and incorporated a range of symptoms and tests, including validated tests, in their diagnosis. However, many physiotherapists were not commonly using some available validated diagnostic tests (e.g. FABER and FADER-R). Approximately 30% of physiotherapists used imaging to inform assessment, with ultrasound being most preferred. Physiotherapists rated hands-on experience as most valuable for updating their knowledge of GTPS, followed by courses.

CONCLUSION

While most clinicians appear to be using current evidence in their assessment of patients with GTPS, a proportion use suboptimal methods and/or a limited range of diagnostic tests, suggesting that despite their confidence in diagnosis, further knowledge translation may be required. Future research should determine the best methods of facilitating knowledge acquisition and translation of research into practice.

Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice

OBJECTIVES

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

DESIGN

Cross-sectional observational survey of physiotherapists.

METHODS

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons were made using Chi-squared analyses for nominal/ordinal data and Kruskal-Wallis tests for numerical data. Statistical significance was set at P<0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists, 61% were female and 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

CONCLUSION

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

Tyrosine hydroxylase-containing fibres extend from the rat corpus striatum into grafts of muscularis externa and myenteric plexus

Intrastriatal grafts of myenteric plexus produce a vigorous sprouting response in the surrounding rat brain. Since the striatum receives profuse dopaminergic innervation from the substantia nigra, we have investigated whether central catecholaminergic neurons participated in the sprouting response and grew into grafts of adult myenteric plexus (surrounded by smooth muscle) implanted in the adult corpus striatum. Three weeks after implantation, tyrosine hydroxylase-containing fibres were observed to have grown into, and ramified within, the grafts. The extent of innervation was increased 6 weeks after implantation, and was not diminished if the superior cervical ganglia were removed (to destroy any fibres of sympathetic origin).