Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

BACKGROUND

Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.

AIMS

The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.

RESULTS AND DISCUSSION

Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.

CONCLUSION

We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Can resistance training improve throwing performance in handball players? A Systematic review and meta-analysis

BACKGROUND

Throwing is one of the most important movement in handball. Throwing performance is crucial for success in handball.

OBJECTIVE

Τo investigate the level of evidence for the effect of resistance training (RT) on throwing performance in handball players.

METHODS

Systematic searches of Pubmed, Medline complete, Cinahl, Sport Discus and Scopus were undertaken for peer reviewed articles published between 18 March 1995 to 18 March 2023. Randomized, controlled, clinical studies, written in English, aiming to investigate the effect at least one modality of RT on throwing performance (velocity or/and accuracy) in handball players were considered for inclusion in the study. The eligible studies were assessed for methodological quality using the Physical Therapy Evidence Database (PEDRO) scale. The Best Evidence Synthesis (BES) approach was used for synthesizing and reporting the results. Furthermore, the random-effects model was used for the meta-analysis and the Q-statistic was used to test the null hypothesis that all studies in the analysis share a common effect size.

RESULTS

One hundred ninety-eight studies were identified, of which 30 were included. A total of 727 handball players (males = 388, females = 292) were included. 28 of the 30 studies were rated as high methodological quality studies (PEDRO score > 70%) while the rest of the studies were rated as moderate methodological quality studies (PEDRO score ≤ 60%). The mean effect size for the effectiveness of resistance training (RT) in improving jumping throw, running throw, and standing throw velocity were 1.128 (95% CI 0.457 - 1.798), 1.756 (95% CI 1.111 - 2.400), and 1.098 (95% CI 0.689 - 1.507) correspondingly. Traditional weight training using barbells in mostly compound lifts yielded the most significant and robust results. Other RT modalities such as elastic bands, medicine balls, core training and ballistic training showed no significant results or positive effects due to the limited number of the studies.

CONCLUSION

Strong evidence exists only for the effectiveness of RT using barbells in increasing throwing velocity. In contrast, the remaining RT modalities, while yielding positive results, have limited support due to limited number of studies and the high heterogeneity between studies. Furthermore, there is insufficient evidence to support various forms of RT in increasing throw distance. Finally, medicine ball training and elastic band training demonstrated no benefits in improving throwing accuracy.

TRIAL REGISTRATION

PROSPERO ID: CRD42023393574.

Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis

INTRODUCTION

The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy.

OBJECTIVES

This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review.

DESIGN

The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach.

RESULTS

Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains.

CONCLUSION

The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Effectiveness of non-surgical management in rotator cuff calcific tendinopathy (the effect trial): protocol for a randomised clinical trial

INTRODUCTION

Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT.

METHODS AND ANALYSIS

A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis.

ETHICS AND DISSEMINATION

Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05478902.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain

OBJECTIVE

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.

METHODS

This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.

RESULTS

Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.

CONCLUSION

Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.

IMPACT

Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Diet, cellular, and systemic homeostasis control the cycling of potassium stable isotopes in endothermic vertebrates

The naturally occurring stable isotopes of potassium (41K/39K, expressed as δ41K) have the potential to make significant contributions to vertebrate and human biology. The utility of K stable isotopes is, however, conditioned by the understanding of the dietary and biological factors controlling natural variability of δ41K. This paper reports a systematic study of K isotopes in extant terrestrial endothermic vertebrates. δ41K has been measured in 158 samples of tissues, biofluids, and excreta from 40 individuals of four vertebrate species (rat, guinea pig, pig and quail) reared in two controlled feeding experiments. We show that biological processing of K by endothermic vertebrates produces remarkable intra-organism δ41K variations of ca. 1.6‰. Dietary δ41K is the primary control of interindividual variability and δ41K of bodily K is +0.5-0.6‰ higher than diet. Such a trophic isotope effect is expected to propagate throughout trophic chains, opening promising use for reconstructing dietary behaviors in vertebrate ecosystems. In individuals, cellular δ41K is related to the intensity of K cycling and effectors of K homeostasis, including plasma membrane permeability and electrical potential. Renal and intestinal transepithelial transports also control fractionation of K isotopes. Using a box-modeling approach, we establish a first model of K isotope homeostasis. We predict a strong sensitivity of δ41K to variations of intracellular and renal K cycling in normal and pathological contexts. Thus, K isotopes constitute a promising tool for the study of K dyshomeostasis.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Prospective Clinical Adoption of Artificial Intelligence for Organ Contouring in Head and Neck Radiation Treatment Planning

PURPOSE/OBJECTIVE(S)

Patients that undergo head and neck (H&N) radiation therapy (RT) require laborious delineation of organs-at-risk (OARs) on computed tomography (CT) scans in a treatment planning system (TPS) to minimize radiation to normal tissue. This task can be completed rapidly and accurately with recently developed artificial intelligence-based semantic segmentation models. The current study aims to deploy and evaluate a strategy for improving clinical practice with this technology.

MATERIALS/METHODS

Deep learning models were trained and tested with CT scans and OAR contours from previous H&N RT cases at our clinic. Two medical physicists vetted the models and selected a 2.5D U-Net for further implementation. The model was embedded in a dedicated server at the hospital, programmed to read H&N CT scans staged for import into the TPS, generate auto-contours, and write them into a TPS-compatible format made available alongside the scan. In the pilot implementation, the auto-contouring service was utilized for more than 60 cases, prospectively. The auto-contours were quantitatively evaluated against the treatment-approved contours to determine how much modification was performed by the clinical team.

RESULTS

The 2.5D U-Net selected for clinical integration segments 21 OARs in less than 3 minutes per scan. Across all the prospective cases, the mean Dice score and mean 95th percentile Hausdorff distance (mm) between the auto-contour and treatment-approved contour for each of the 21 OARs were as follows, respectively: brainstem (0.93, 1.94), optic chiasm (0.70, 2.96), left cochlea (0.69, 2.37), right cochlea (0.68, 2.44), esophagus (0.88, 2.46), left globe (0.93, 1.50), right globe (0.93, 1.63), glottis (0.91, 2.13), larynx (0.93, 2.76), mandible (0.90, 4.86), left optic nerve (0.78, 1.64), right optic nerve (0.82, 1.65), oral cavity (0.86, 8.46), left parotid gland (0.91, 2.78), right parotid gland (0.91, 2.39), pharynx (0.85, 2.39), spinal cord (0.87, 2.27), left submandibular gland (0.85, 3.46), right submandibular gland (0.83, 3.69), left temporal lobe (0.94, 2.20), and right temporal lobe (0.95, 2.09). The auto-contours for the optic chiasm, optic nerves, cochleas, and submandibular glands differed substantially from the final contours, a finding corroborated by the clinical team; the rest were clinically acceptable with minor or no edits necessary.

CONCLUSION

The proposed strategy provides a sophisticated starting point for treatment planning that has garnered overall favorable feedback from the participating radiation oncologists and dosimetrists. Consequently, the technique is being extended to other treatment sites.

Mitigation of IMRT/SBRT Treatment Planning Errors on the First Biology-Guided Radiotherapy System Using FMEA within Six Sigma Framework

PURPOSE/OBJECTIVE(S)

Utilize the Six Sigma methodology and Failure Mode and Effect Analysis (FMEA) to prevent and mitigate errors in IMRT/SBRT treatment planning with the first clinical installation of biology-guided radiotherapy (BgRT) system.

MATERIALS/METHODS

The Six Sigma approach consisted of five phases: Define-Measure-Analyze-Improve-Control. The Define-Measure-Analyze phases consisted of process mapping and an FMEA of the IMRT/SBRT treatment planning process on the BgRT system. The multidisciplinary team outlined the workflow process and identified the failure modes associated with the plan check items using AAPM TG-100 recommendations. Items with the highest average risk priority numbers (RPN) and Severity ≥7 were prioritized for automation using the treatment planning system scripting API (ESAPI). The Improve phase consisted of developing ESAPI scripts prior to the launch of the BgRT system to improve efficiency and safety. In the Control phase, the FMEA ranking was re-evaluated 1-year post-clinical launch.

RESULTS

Overall, 100 plan check items were identified where the RPN values ranged from 10.2 to 429.0. Fifty of these items (50%) were suitable for automation within ESAPI. Of the 10 highest-risk items (Table 1), 8 were suitable for automation. Based on the results of the FMEA, two scripts were developed: Planning Assistant used by the planner during preparation for planning and the Automated Plan Check used by the planner and the plan checker during plan preparation for treatment. At 1-year post-clinical launch, the scripts were used for 80 patients successfully treated in 1747 fractions. During this period only 3 errors were reported: omitted bolus during treatment, nomenclature error in the BgRT system plan prescription, and dose tracking plan not approved following physics plan check. The average RPN pre-scripts was 138.0 compared to the average post-scripts RPN of 47.8 (p < 0.05) signifying a safer process.

CONCLUSION

Implementing new technology into the clinic can be an error-prone process where the likelihood of errors increases with increasing pressure to implement the technology quickly. To limit errors in the clinical implementation of the first BgRT system, the Six Sigma methodology was utilized to identify failure modes, establish quality control checks, and re-evaluate these checks 1-year post-clinical launch.

mTOR-dependent loss of PON1 secretion and antiphospholipid autoantibody production underlie autoimmunity-mediated cirrhosis in transaldolase deficiency

Transaldolase deficiency predisposes to chronic liver disease progressing from cirrhosis to hepatocellular carcinoma (HCC). Transition from cirrhosis to hepatocarcinogenesis depends on mitochondrial oxidative stress, as controlled by cytosolic aldose metabolism through the pentose phosphate pathway (PPP). Progression to HCC is critically dependent on NADPH depletion and polyol buildup by aldose reductase (AR), while this enzyme protects from carbon trapping in the PPP and growth restriction in TAL deficiency. Although AR inactivation blocked susceptibility to hepatocarcinogenesis, it enhanced growth restriction, carbon trapping in the non-oxidative branch of the PPP and failed to reverse the depletion of glucose 6-phosphate (G6P) and liver cirrhosis. Here, we show that inactivation of the TAL-AR axis results in metabolic stress characterized by reduced mitophagy, enhanced overall autophagy, activation of the mechanistic target of rapamycin (mTOR), diminished glycosylation and secretion of paraoxonase 1 (PON1), production of antiphospholipid autoantibodies (aPL), loss of CD161+ NK cells, and expansion of CD38+ Ito cells, which are responsive to treatment with rapamycin in vivo. The present study thus identifies glycosylation and secretion of PON1 and aPL production as mTOR-dependent regulatory checkpoints of autoimmunity underlying liver cirrhosis in TAL deficiency.

The concurrent validity and reliability of virtual reality to measure shoulder flexion and scaption range of motion

BACKGROUND

Shoulder pain commonly has a detrimental impact on patient's work and social activities. Although pain is the most common reason for seeking care, a reduction in shoulder range of motion (ROM) is another common impairment. ROM assessment is used as an evaluation tool and multiple methods are available to measure shoulder ROM. Virtual reality (VR) has been introduced into shoulder rehabilitation, mostly when exercise and ROM measurement is indicated. This study evaluated the concurrent validity and system reliability of active ROM measurements of VR for people with and without shoulder pain.

METHODS

Forty volunteers participated in this study. Virtual goniometry was used to assess active shoulder ROM. Participants performed flexion and scaption to six predetermined angles. Measurements from the VR goniometer and smartphone inclinometers were recorded simultaneously. To assess reliability, two identical test sequences were performed.

RESULTS

The concurrent validity ICCs were 0.93 for shoulder flexion and 0.94 for shoulder scaption. The VR goniometer application on average systematically overestimated the ROM compared to the smartphone inclinometer. The mean difference between goniometer values was -11.3 degrees for flexion and -10.9 for scaption. The system reliability was excellent with an overall ICC of 0.99 for the flexion movements and 0.99 for the scaption movements.

CONCLUSION

Although the VR system demonstrated excellent reliability, and high ICC's for concurrent validity, the large range between the lower and upper 95% CI limits suggests it lacks measurement precision. This suggests VR, as used in this study, should not be used interchangeably with other measurement tools. CONTRIBUTION OF THE PAPER.

Are clinical outcomes associated with baseline sensory profiles in people with musculoskeletal shoulder pain? Protocol for a prospective longitudinal observational study

BACKGROUND

Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis.

METHODS

This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale.

ANALYSIS

Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models.

DISCUSSION

Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Discriminating Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Using Latent Neuroimaging and Neuropsychological Profiles in Active-Duty Military Service Members

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.

METHODS

Active-Duty US Service Members ( n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.

RESULTS

For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.

CONCLUSIONS

The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Virtual reality in the management of stress and anxiety disorders: A retrospective analysis of 61 people treated in the metaverse

Mental health is the second largest group of health disorders associated with prolonged disability. Treating conditions such as stress and anxiety are a global health challenge due to inadequate funding and resources. Therefore, providing virtual treatment in the metaverse may provide a novel method of treatment for these conditions. We conducted a retrospective analysis of health records of people experiencing stress and anxiety who were treated principally in the metaverse using virtual reality. The main objective was to determine if virtual mental health treatment was achievable and safe, with measurable outcomes repeated at multiple time points. Here, 61 participants health records were evaluated (50% were female, 19% male, 31% identified as other). The cohort was 45.7 ± 15.7 years of age and reported no adverse effects with outcomes measured. Specifically, anxiety (via Generalized Anxiety Disorder Scale) decreased by 34% (p = 0.002) and stress (via Perceived Stress Scale) decreased by 32% (p < 0.001) after virtual intervention. The data suggests that this method of treatment was feasible, safe, and outcomes were obtainable over a range of time points. This early data suggest that management in the metaverse for these conditions may be beneficial, however, further prospective studies are necessary to better understand these clinical findings.

The relevance of false positive acid phosphatase reactions indicative of the presence of seminal fluid from oral and vaginal samples

The Body Fluid Forum of the Association of Forensic Science Providers recognised concerns raised by forensic practitioners regarding the lack of data to inform on the incidence of significant AP (Acid Phosphatase) reactions from vaginal and oral samples, i.e. those which might be misinterpreted as indicating the presence of semen. This is particularly relevant in the light of appeal court rulings regarding the need for data to support evaluations. This paper presents collaborative data on the nature and incidence of AP reactions from vaginal and oral swabs provided by donors. The results demonstrate that caution is required with mid to strong purple AP reactions from direct testing of oral swabs and with mid purple reactions from vaginal swabs. The use of a Bayesian approach to assist with the provision of opinions regarding the presence of seminal fluid is highlighted.

Virtual reality in the management of patients with low back and neck pain: a retrospective analysis of 82 people treated solely in the metaverse

BACKGROUND

Clinically, neck pain disorders (NPD) and non-specific low back pain (NS-LBP) are respectively the fourth and first most common conditions associated with the greatest number of years lived with disability. Remote delivery of care may benefit healthcare sustainability, reduce environmental pollution, and free up space for those requiring care non-virtual care.

METHODS

A retrospective analysis was performed on 82 participants with NS-LBP and/or NPD who received exercise therapy delivered solely in the metaverse using virtually reality. The study was to determine if this was achievable, safe, had appropriate outcome measures that could be collected, and if there was any early evidence of beneficial effects.

RESULTS

The study demonstrated that virtual reality treatment delivered via the metaverse appears to be safe (no adverse events or side effects). Data for more than 40 outcome measures were collected. Disability from NS-LBP was significantly reduced (Modified Oswestry Low Back Pain Disability Index) by 17.8% (p < 0.001) and from NPD (Neck Disability Index) by 23.2% (p = 0.02).

CONCLUSIONS

The data suggest that this method of providing exercise therapy was feasible, and safe (no adverse events reported), that complete reports were obtained from a large selection of patients, and that software acquired outcomes were obtainable over a range of time points. Further prospective research is necessary to better understand our clinical findings.

Living with frozen shoulder. 'Here are the risks. I want the injection'. An interpretative phenomenological analysis

BACKGROUND

Frozen shoulder is a disabling condition characterised by severe pain and loss of shoulder movement and may affect up to 5% of the population. Qualitative research documents debilitating pain and how treatment to reduce pain is a priority for people diagnosed with frozen shoulder. Corticosteroid injections are a principal treatment to reduce the pain of frozen shoulder, however little is known about the patient experience.

OBJECTIVES

This study aims to address this gap in the knowledge by exploring the lived experience of people with frozen shoulder who have undergone an injection and to highlight other novel findings.

DESIGN

This is a qualitative study using interpretative phenomenological analysis. One-to-one, semi-structured interviews were conducted with seven people diagnosed with frozen shoulder who had received a corticosteroid injection as part of their management.

METHODOLOGY

A purposive sample of participants were interviewed via MSTeams™ due to Covid-19 restrictions. Data was collected through semi-structured interviews and analysed in accordance with interpretive phenomenological analysis methods.

RESULTS

Three group experiential themes were identified: the dilemma surrounding injections; the challenges of understanding the causes of frozen shoulder; the impact on self and others.

CONCLUSION

Participants conveyed a strong desire in seeking a corticosteroid injection whilst seemingly dismissing the risks. A novel concept was illuminated as frozen shoulder seemed inextricably linked with the ageing process, which negatively impacted body-image. The impact on others is driven by a sense of the unfamiliar nature of illness and it is incumbent on healthcare professionals to seek opportunities to explore the individual's beliefs.

Physiotherapists nearly always prescribe exercise for rotator cuff-related shoulder pain; but why? A cross-sectional international survey of physiotherapists

BACKGROUND AND AIMS

This cross-sectional international survey explored the beliefs of physiotherapists regarding the possible mechanisms of benefit of exercise for rotator cuff-related shoulder pain (RCRSP). Clinical practice guidelines recommend physiotherapists use exercise as a primary treatment to help people with RCRSP, but the explanations provided to patients by physiotherapists regarding its mechanism of effect is unknown.

MATERIALS AND METHODS

Registered physiotherapists were surveyed about 'how and why' they believe exercise provides a clinical benefit for people with RCRSP. Information was also gathered about commonly used exercise types and preferred diagnostic labels. The survey was designed and reported in concordance with Consensus-Based Checklist for Reporting of Survey Studies guidelines.

RESULTS

Four hundred and eighty physiotherapists from forty-nine countries completed the survey. Psychosocial and biomedical mechanisms of exercise were evenly selected by participants. Improving muscle strength, muscle endurance, pain self-efficacy and reducing kinesiophobia, and fear avoidance beliefs were the most common individual mechanisms thought to underpin exercise therapy for RCRSP. Rotator cuff-related shoulder pain was the most commonly used diagnostic label.

DISCUSSION AND CONCLUSION

Physiotherapists hold beliefs regarding exercise mechanisms that is largely concordant with the current evidence base, which is commendable. Future research should consider the patients perspective and consider testing commonly selected mechanisms of exercise, such as shoulder muscle strength, pain self-efficacy and kinesiophobia as possible mediators of recovery.

Complementary and alternative medicine for children with sickle cell disease: A systematic review

BACKGROUND

Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population.

METHODS

The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science.

RESULTS

Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores.

CONCLUSIONS

CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study

INTRODUCTION

There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists.

OBJECTIVES

The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework.

DESIGN

Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke.

RESULTS

Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs).

CONCLUSION

This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Physiotherapist beliefs and perspectives on virtual reality supported rehabilitation for the management of musculoskeletal shoulder pain: A focus group study

BACKGROUND

Virtual Reality (VR) is an immersive computer-generated environment that provides a multi-sensory experience for the user. Modern technology allows the user to explore and interact with the virtual environment, offering opportunities for rehabilitation. The use of immersive VR in the management of musculoskeletal shoulder pain is relatively new and research is required to demonstrate its feasibility and effectiveness in this field.

AIM

The aims of this study were, firstly, to explore physiotherapists' beliefs and perspectives of immersive VR as a platform for rehabilitation in patients with musculoskeletal shoulder pain, secondly, to identify potential barriers and facilitators to using VR in a musculoskeletal setting and thirdly, to gain insight from clinicians that would inform the development of a VR intervention for the rehabilitation of musculoskeletal shoulder pain.

METHODS

This study used qualitative descriptive design methodology. A series of three focus group interviews were carried out, via Microsoft Teams. Physiotherapists received an Oculus Quest™ headset to use at home prior to the focus group interviews. A six-phase process of reflexive thematic analysis was carried out to identify themes within the data. Atlas Ti Qualitative Data Analysis software was used to facilitate thematic analysis.

RESULTS

Five themes were identified within the data. They reflected physiotherapists beliefs that VR provides novel opportunities for shoulder rehabilitation and may offer new avenues for managing movement-related fear and improving concordance with rehabilitation. However, barriers related to safety and practical considerations associated with using VR were also identified in the final themes.

CONCLUSION

These findings provide valuable insight into clinician acceptability of immersive VR as a platform for rehabilitation and the need for further research to answer the questions posed by physiotherapists in the current study. This research will contribute to human-centered design of VR-supported interventions for managing musculoskeletal shoulder pain.

Cytosolic aldose metabolism contributes to progression from cirrhosis to hepatocarcinogenesis

Oxidative stress modulates carcinogenesis in the liver; however, direct evidence for metabolic control of oxidative stress during pathogenesis, particularly, of progression from cirrhosis to hepatocellular carcinoma (HCC), has been lacking. Deficiency of transaldolase (TAL), a rate-limiting enzyme of the non-oxidative branch of the pentose phosphate pathway (PPP), restricts growth and predisposes to cirrhosis and HCC in mice and humans. Here, we show that mitochondrial oxidative stress and progression from cirrhosis to HCC and acetaminophen-induced liver necrosis are critically dependent on NADPH depletion and polyol buildup by aldose reductase (AR), while this enzyme protects from carbon trapping in the PPP and growth restriction in TAL deficiency. Both TAL and AR are confined to the cytosol; however, their inactivation distorts mitochondrial redox homeostasis in opposite directions. The results suggest that AR acts as a rheostat of carbon recycling and NADPH output of the PPP with broad implications for disease progression from cirrhosis to HCC.

A systematic review of the global prevalence and incidence of shoulder pain

BACKGROUND AND OBJECTIVES

Studies reporting on the population burden of people living with shoulder pain show wide heterogeneity in terms of case definition, study samples, and occurrence. This systematic review aims to summarize evidence pertaining to the prevalence and incidence of shoulder pain, including variability based on sex and geography. We also explored the potential influence of methodological limitations and important sources of heterogeneity (case definition and reference period) on reported estimates of shoulder pain prevalence.

DATABASES AND DATA TREATMENT

The study protocol was registered on Prospero under CRD42021243140. We searched EMBASE, CINAHL, Web of Science and Medline from inception to March 2021. Study selection, data extraction and risk of bias assessment was conducted by a team of three researchers. We performed a narrative synthesis of the data, using forest plots to summarize study findings, and stratified data presentation to explore the potential association of risk of bias, case definition, and reference period with estimates of prevalence and incidence of shoulder pain.

RESULTS

We obtained data from 61 studies reporting data from high-, middle- and low-income countries. The overall risk of bias was low, with most rated as "low-risk" and no studies rated as "high-risk". The community prevalence of shoulder pain varied widely across the countries included in our review, with a median of 16% (range 0.67 to 55.2%). Longer reference periods were typically associated with higher prevalence estimates. Primary care prevalence ranged from 1.01 to 4.84% (median 2.36%). Estimates were generally higher for women than men and were higher in high-income nations. The incidence of shoulder pain ranged from 7.7 to 62 per 1000 persons per year (median 37.8 per 1000 persons per year). Risk of bias did not clearly explain variability in study findings, but there was considerable variation in study samples, methods used, and a relative absence of data from low-income countries.

CONCLUSIONS

Our review demonstrates that a significant proportion of the population across the world will experience shoulder pain daily, yearly, and throughout a lifetime. Regional gaps in evidence and methodological inconsistencies must be addressed in order to establish a more definitive global burden.

"You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise." A scoping review of the possible mechanisms underpinning exercise therapy

BACKGROUND

Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.

OBJECTIVE

To synthesise the range of mechanisms proposed for exercise in people with RCRSP.

DESIGN

Scoping review METHODS: A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were "fitness training", "strength training", "stretching, mobilisation, manipulation, massage", "upper arm, shoulder, or shoulder girdle", "pain", and "musculoskeletal". Data were analysed using quantitative and qualitative approaches.

RESULTS

626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.

CONCLUSIONS

The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.

Changes in IPCC Scenario Assessment Emulators Between SR1.5 and AR6 Unraveled

The IPCC's scientific assessment of the timing of net-zero emissions and 2030 emission reduction targets consistent with limiting warming to 1.5°C or 2°C rests on large scenario databases. Updates to this assessment, such as between the IPCC's Special Report on Global Warming of 1.5°C (SR1.5) of warming and the Sixth Assessment Report (AR6), are the result of intertwined, sometimes opaque, factors. Here we isolate one factor: the Earth System Model emulators used to estimate the global warming implications of scenarios. We show that warming projections using AR6-calibrated emulators are consistent, to within around 0.1°C, with projections made by the emulators used in SR1.5. The consistency is due to two almost compensating changes: the increase in assessed historical warming between SR1.5 (based on AR5) and AR6, and a reduction in projected warming due to improved agreement between the emulators' response to emissions and the assessment to which it is calibrated.

Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis

QUESTIONS

To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).

DESIGN

Systematic review with meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.

INTERVENTION

Exercise as an intervention for L-MRCTTs.

OUTCOME MEASURES

Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes.

CONCLUSION

A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

A Systematic Review of COVID-19 and Pericarditis

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China in December 2019. Since then, the disease has spread globally, leading to the ongoing pandemic. It can cause severe respiratory illness; however, many cases of pericarditis have also been reported. This systematic review aims to recognize the clinical features of pericarditis and myopericarditis in COVID-19 patients.

Google Scholar, Medline/PubMed, CINAHL, Cochrane Central, and Web of Science databases were searched for studies reporting “Coronavirus” or “COVID” and “Peri-myocarditis,” “heart,” or “retrospective.” Case reports and retrospective studies published from May 2020 to February 2021 were reviewed.

In total, 33 studies on pericarditis, myopericarditis, and pericardial infusion were included in this review. COVID-19 pericarditis affected adult patients at any age. The incidence is more common in males, with a male-to-female ratio of 2:1. Chest pain (60%), fever (51%), and shortness of breath (51%) were the most reported symptoms, followed by cough (39%), fatigue (15%), myalgia (12%), and diarrhea (12%). Laboratory tests revealed leukocytosis with neutrophil predominance, elevated D-dimer, erythrocyte rate, and C-reactive protein. Cardiac markers including troponin-1, troponin-T, and brain natriuretic peptide were elevated in most cases. Radiographic imaging of the chest were mostly normal, and only 31% of chest X-rays showed cardiomegaly and or bilateral infiltration. Electrocardiography (ECG) demonstrated normal sinus rhythm with around 59% ST elevation and rarely PR depression or T wave inversion, while the predominant echocardiographic feature was pericardial effusion. Management with colchicine was favored in most cases, followed by non-steroidal anti-inflammatory drugs (NSAIDs), and interventional therapy was only needed when patient developed cardiac tamponade. The majority of the reviewed studies reported either recovery or no continued clinical deterioration.

The prevalence of COVID-19-related cardiac diseases is high, and pericarditis is a known extrapulmonary manifestation. However, pericardial effusion and cardiac tamponade are less prevalent and may require urgent intervention to prevent mortality. Pericarditis should be considered in patients with chest pain, ST elevation on ECG, a normal coronary angiogram, and COVID-19. We emphasize the importance of clinical examination, ECG, and echocardiogram for decision-making, and NSAIDs, colchicine, and corticosteroids are considered to be safe in the treatment of pericarditis/myopericarditis associated with COVID-19.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

An Open Letter to You, a Unique Individual Living with Shoulder Pain

Dear unique individual: Really very sorry to hear that you are living with shoulder pain. I'm writing this open letter to you to support decisions you will need to make about how best to manage your symptoms. Shoulder pain never comes at the right time, it always interferes with important work, sports, or social events, and like any pain, we want it gone the moment it starts. In this letter I present to you information that I hope may support you with decisions you will need to make about how best to find an answer for your symptoms. I would like to share with you information about shoulder pain and information about imaging investigations, injections, surgical, and nonsurgical management. I would also like to share with you important lifestyle factors that you need to be aware of, that may also help make sense of the symptoms you are experiencing. This letter focuses on the 90% of people who experience non-traumatic shoulder pain. This letter includes important questions you should ask when you see a clinician. Remember, it is you, not the health professional, who is the most important person in healthcare. No decision should be made without you being fully and truthfully informed of the anticipated benefits, timeframes, and commitments you will need to address and the possible harm of any intervention. I hope you find this letter helpful.

Successful outcomes using Long Acting Buprenorphine (LAB - Buvidal) to treat Codeine, Tramadol and other Opioid Analgesia Dependencies (OAD) in Wales during the Pandemic

Introduction

Long Acting Buprenorphine (LAB) – Buvidal (CAM2038) – is a prolonged release treatment for opioid dependence in adults. Its extensive use was funded by Welsh Government during the pandemic in Wales and it has been found to be a significantly better than oral medications in improving quality of life, possibly through providing allostatic craving and anxiety reduction

Objectives

This is a case series of 10 patients who were referred to Community Addiction Services in North and South West Wales with OAD.

Methods

Patients were mainly using Codeine or Tramadol and were referred due to either ongoing illicit use or via primary care services requesting support. As part of the pandemic initiative, they were initiated on Buvidal and followed up.

Results

All ten patients successfully started on Buvidal without significant issues. As a group, if transferred straight to Buvidal, they tended to have fewer significant withdrawal symptoms prior to starting on the Buvidal compared to those on Methadone or Heroin. They were treated on the usual range of Buvidal doses (1 on 64mg, the others on 96-128mg monthly). They have all stabilised and successfully moved on with their lives on Buvidal. One has used the time on Buvidal to have psychological input around past traumas and successfully detoxified in the community using Buvidal.

Conclusions

Recommendations for services considering OAD - it is a surprisingly effective treatment which is easy to start. It has the scope for being both an effective OAD recovery medication and a potentially simple detoxification strategy for this patient group.

Disclosure

Professor Melichar has provided consultancy work, presentations, training and chaired panel discussions for all the companies in this area in the UK and some outside the UK. Recent work includes Althea (UK), Britannia (UK), Camurus (UK and Global), Martin

Missed opportunities for diagnosis and treatment in patients with TB symptoms: a systematic review

BACKGROUND

The identification of patients with symptoms is the foundation of facility-based TB screening and diagnosis, but underdiagnosis is common. We conducted this systematic review with the hypothesis that underdiagnosis is largely secondary to patient drop out along the diagnostic and care pathway.

METHODS

We searched (up to 22 January 2019) MEDLINE, Embase, and Cinahl for studies investigating patient pathway to TB diagnosis and care at health facilities. We used Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) to assess risk of bias. We reported proportions of patients with symptoms at each stage of the pathway from symptom screening to treatment initiation.

RESULTS

After screening 3,558 abstracts, we identified 16 eligible studies. None provided data addressing the full cascade of care from clinical presentation to treatment initiation in the same patient population. Symptom screening, the critical entry point for diagnosis of TB, was not done for 33-96% of participants with symptoms in the three studies that reported this outcome. The proportion of attendees with symptoms offered a diagnostic investigation (data available for 15 studies) was very low with a study level median of 38% (IQR 14-44, range 4-84).

CONCLUSIONS

Inefficiencies of the TB symptom screen-based patient pathway are a major contributor to underdiagnosis of TB, reflecting inconsistent implementation of guidelines to ask all patients attending health facilities about respiratory symptoms and to offer diagnostic tests to all patients promptly once TB symptoms are identified. Better screening tools and interventions to improve the efficiency of TB screening and diagnosis pathways in health facilities are urgently needed.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.