Wireless pressure insoles for measuring ground reaction forces and trajectories of the centre of pressure during functional activities

Wireless pressure insoles may enable the assessment of movement biomechanics in a real-world setting, and thus play an important role in the recommendation of clinical management, but they are not yet a gold standard due to the unknown accuracy and reliability with respect to different functional activities. Here, we compare novel wireless pressure insoles with force plates and examine the test-retest reliability of the insoles for measuring vertical ground reaction forces (vGRFs) and trajectories of the center of pressure (COP). In this observational study, healthy adults underwent two data collection sessions during one day. The Bland-Altman analysis was used to compare the outcomes measured with the two instruments during squats, jumps, and the sit-to-stand test. Test-retest reliability was assessed by the interclass correlation coefficient and the standard error of measurement for the outcomes during squats, jumps, walking, and stair ambulation. Trajectories of the COP in the anterior-posterior direction were comparable between the two systems during all activities. The insoles consistently measured shorter trajectories of the COP in the medial-lateral direction (except jumps) and lower vGRFs than the force plates. Test-retest reliability of the insoles was fair to high or excellent for all outcomes during all activities. In conclusion, the insoles provide reliable measures of vGRFs and trajectories of the COP during multiple functional activities in healthy adults. Although the insoles do not produce identical results to the force plate, the qualitative similarity and consistency between the two systems confirm the insoles can be used to measure these outcomes, based on the purpose and accuracy required.

Recommendations for the delivery of therapeutic exercise for people with knee and/or hip osteoarthritis. An international consensus study from the OARSI Rehabilitation Discussion Group

OBJECTIVE

To develop evidence-informed recommendations to support the delivery of best practice therapeutic exercise for people with knee and/or hip osteoarthritis (OA).

DESIGN

A multi-stage, evidence-informed, international multi-disciplinary consensus process that included: 1) a narrative literature review to synthesise existing evidence; 2) generation of evidence-informed proposition statements about delivery of exercise for people with knee and/or hip OA by an international multi-disciplinary expert panel, with statements refined and analysed thematically; 3) an e-Delphi survey with the expert panel to gain consensus on the most important statements; 4) a final round of statement refinement and thematic analysis to group remaining statements into domains.

RESULTS

The expert panel included 318 members (academics, health care professionals and exercise providers, patient representatives) from 43 countries. Final recommendations comprised 54 specific proposition statements across 11 broad domains: 1) use an evidence-based approach; 2) consider exercise in the context of living with OA and pain; 3) undertake a comprehensive baseline assessment with follow-up; 4) set goals; 5) consider the type of exercise; 6) consider the dose of exercise; 7) modify and progress exercise; 8) individualise exercise; 9) optimise the delivery of exercise; 10) focus on exercise adherence; and 11) provide education about OA and the role of exercise.

CONCLUSION

The breadth of issues identified as important by the international diverse expert panel highlights that delivering therapeutic exercise for OA is multi-dimensional and complex.

Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation

AIMS

This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies.

MATERIALS AND METHODS

This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach.

RESULTS

Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK.

CONCLUSIONS

Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.

What should a toolkit to aid the delivery of therapeutic exercise for hip and knee osteoarthritis look like? Qualitative analysis of an international survey of 318 researchers, clinicians, and consumers by the OARSI Rehabilitation Discussion Group

BACKGROUND

We aimed to identify important components of, and practical resources relevant for inclusion in, a toolkit to aid exercise delivery for people with hip/knee osteoarthritis.

METHOD

An online international multi-disciplinary survey was conducted across 43 countries (139 clinicians, 44 people with hip/knee osteoarthritis and 135 osteoarthritis researchers). Participants were presented with the seeding statement 'Practical resources to aid the implementation of exercise for people with hip/knee osteoarthritis should…' and asked to provide up to 10 open text responses. Responses underwent refinement and qualitative content analysis to create domains and categories.

RESULTS

Refinement of 551 open text responses yielded 72 unique statements relevant for analysis. Statements were organised into nine broad domains, suggesting that resources to aid exercise delivery should: (1) be easily accessible; (2) be of high quality; (3) be developed by, and for, stakeholders; (4) include different ways of delivering information; (5) include different types of resources to support exercise and non-exercise components of self-management; (6) include resources on recommended exercises and how to perform/progress them; (7) include tools to support motivation and track progress; (8) include resources to enable tailoring of the programme to the individual and; (9) facilitate access to professional and peer support.

CONCLUSION

Our findings identified important components of, and practical resources to include within, a toolkit to aid delivery of exercise for people with hip/knee osteoarthritis. These findings have implications for exercise providers and lay the foundation for the development of a toolkit to help ensure exercise provision aligns with current international recommendations.

A standardised template for reporting lower limb kinematic waveform movement compensations from a sensor-based portable clinical movement analysis toolkit

•

Standardised terminology for the interpretation of movement analysis waveforms is provided, to describe the amount, nature and timing of a compensation strategy.

•

A stand-alone application have been created for users to generate a movement analysis report for lower limb joint kinematics.

•

A digital, interactive version of the movement analysis report is now being created in the next iteration of the sensor based portable movement analysis toolkit.

Objectives

To develop a standardised template to support physiotherapist reporting of lower limb kinematic waveform data

Design

Within and between user agreement identification of movement compensation strategies.

Setting

University Health Board Physiotherapy Department

Participants

Fourteen individuals with anterior cruciate ligament reconstruction performed overground gait, double-leg squat, and stair ascent wearing body-worn sensors. Six users viewed 252 kinematic waveforms of hip, knee and ankle joint angles in the sagittal and frontal planes.

Main outcome measures

Between and within-user observed agreement and themes from movement analysis reports

Results

Between-user observed agreement for presence of a movement compensation was 0.6–0.9 for the sagittal plane and 0.75–1.0 for the frontal place. Within-user observed agreement was 0.57–1.00 for the sagittal plane and 0.71–1.00 for the frontal plane. Three themes and seven categories were identified from the waveform interpretations: Amount (qualitative and quantitative description), timing (phase, discrete time point, cycle), and nature (peak, range of motion, timing) of the compensation.

Conclusion

There was good agreement between users at identifying the presence of movement compensation from the kinematic waveforms, but there was variation in how movement compensations were described. An interactive report, a standardised template for interpretation of kinematic waveforms, and training to support the clinical application of a movement analysis toolkit are proposed.

A web-based life-style, exercise and activity intervention for people with progressive multiple sclerosis: Results of a single-arm feasibility study

BACKGROUND

People with progressive Multiple Sclerosis often struggle to access appropriate and inclusive support for regular physical activity. The Lifestyle, Exercise and Activity Package (LEAP-MS) intervention, is a co-designed web-based physical activity intervention for people with progressive Multiple Sclerosis (MS). It consists of two key components; (1) web-based physical activity coaching with physiotherapists using self-management support strategies and 2) an interactive web-based platform including a physical activity information suite, an activity selection and planning tool and a participant-physiotherapist messaging system. We aimed to evaluate recruitment, retention and uptake, in a single arm feasibility study.

METHODS

Participants with primary or secondary progressive MS with an Expanded Disability Status Scale score of 6 to 8 were recruited. Assessments included the MS Impact Scale (MSIS-29) and measures of participation at baseline, three and six months. All participants received the intervention which consisted of up to six web-based physiotherapy- led physical activity coaching sessions alongside access to web-based education and activity suites. Recruitment, retention and uptake data were summarised. Pre-defined progression criteria were used to guide feasibility assessment. Clinical outcome data were analysed descriptively.

RESULTS

Fifty-eight percent (21/36) of those submitting expressions of interest were recruited; 76% completed follow-up. Pre-specified progression criteria for retention were met but recruitment did not meet progression criteria. The intervention achieved set fidelity criteria. At three months, 12 participants (75%) reported improvements in routine activities after the intervention. MSIS-29 physical scores improved by an average of eight points (95% CI -12.6 to -3.3). Improvements were also seen in MSIS-29 psychological scores and fatigue. Some improvements were maintained at six months.

CONCLUSIONS

The LEAP-MS intervention is feasible and associated with improvements in MSIS-29 scores. The intervention facilitated partnership working between physiotherapists and people with progressive MS. Users developed valuable skills in supported self-management by focussing on enhancing physical activity to support overall wellbeing. This work has laid the foundations for a large-scale evaluation of a co-designed intervention with potential for far reaching impact on the lives of people with progressive MS.

Applications of Wearable Technology in a Real-Life Setting in People with Knee Osteoarthritis: A Systematic Scoping Review

With the growing number of people affected by osteoarthritis, wearable technology may enable the provision of care outside a traditional clinical setting and thus transform how healthcare is delivered for this patient group. Here, we mapped the available empirical evidence on the utilization of wearable technology in a real-world setting in people with knee osteoarthritis. From an analysis of 68 studies, we found that the use of accelerometers for physical activity assessment is the most prevalent mode of use of wearable technology in this population. We identify low technical complexity and cost, ability to connect with a healthcare professional, and consistency in the analysis of the data as the most critical facilitators for the feasibility of using wearable technology in a real-world setting. To fully realize the clinical potential of wearable technology for people with knee osteoarthritis, this review highlights the need for more research employing wearables for information sharing and treatment, increased inter-study consistency through standardization and improved reporting, and increased representation of vulnerable populations.

Lifestyle, exercise and activity package for people living with progressive multiple sclerosis (LEAP-MS): protocol for a single-arm feasibility study

BACKGROUND

We have co-designed a tailored blended physiotherapy intervention for people with progressive multiple sclerosis (PwPMS) who often struggle to access support for physical activity. Underpinned by self-management principles, the Lifestyle, Exercise and Activity Package for people with Multiple Sclerosis (LEAP-MS) intervention incorporates face-to-face or online physiotherapy coaching sessions with an accompanying online physical activity platform. The LEAP-MS platform is a multi-user system enabling user and physiotherapist to co-create activity plans. The LEAP-MS platform consists of an information and activity suite, interactive components enabling selection of exercises into an activity programme, goal setting and activity logging. The platform also facilitates online remote support from a physiotherapist through an embedded online messaging function. We aim to evaluate the LEAP-MS platform in a feasibility trial.

METHODS

LEAP-MS will be evaluated within a single-arm feasibility study with embedded process evaluation. After registration and initial eligible screening, 21 participants will be required to complete baseline self-completion measures. This will be followed by an initial home-based or online coaching session with a physiotherapist (who has received tailored self-management and digital resource training) and access to the online intervention for an initial 3-month period. During this period, participants are given the option to request up to five further home-based or online physiotherapy coaching sessions. Follow-up questionnaires and semi-structured interviews will be administered 3 months after baseline with participants and intervention physiotherapists. The LEAP-MS platform will be available to participants for a further 3 months. Usage of the LEAP-MS platform will be tracked during the full 6-month period and final follow-up will be conducted 6 months after baseline.

DISCUSSION

Feasibility outcomes (recruitment, retention, intervention uptake and safety) will be reported. The process evaluation will be undertaken to identify possible mechanisms for any observed effects. The data will inform full-scale evaluations of this co-produced, blended physiotherapy intervention.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03951181 . Registered 15 May 2019.

Feasibility randomised controlled trial comparing TRAK-ACL digital rehabilitation intervention plus treatment as usual versus treatment as usual for patients following anterior cruciate ligament reconstruction

Objectives

To evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions—ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction.

Methods

The study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures.

Results

Fifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3–13 logins), over 18 weeks (SD 12.2 weeks).

Conclusion

TRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis (LEAP-MS): adaptions during the COVID-19 pandemic and remote delivery for improved efficiency

The LEAP-MS (Lifestyle, Exercise and Activity Package for People living with Progressive Multiple Sclerosis) study has developed an individualised supported self-management approach for physical activity for people with progressive multiple sclerosis (MS) and severe disability. The intervention has been evaluated in a single-arm feasibility study with embedded process evaluation. The feasibility study was due to open to recruitment during the COVID-19 2020-2021 pandemic, 1 month into the first UK-wide lockdown. We worked rapidly to implement adaptions to the trial procedures and intervention delivery that we believe are applicable to randomised controlled trials. Recruitment became predominantly via self-referral. Electronic consent was employed, with consent discussions occurring over the telephone. Registration, consent, eligibility assessment and data collection as well as the intervention (online physical activity tool) were via a secure, encrypted multi-user web-based platform for participants, physiotherapists and researchers accessible via various hardware. Physiotherapy consultations, as well as the process evaluation, were conducted remotely using video conferencing software or the telephone. A remote training package for physiotherapists and site initiations was also developed and electronic site files employed. Our adaptions are extremely topical given the COVID-19 situation, and whilst not what we had originally planned, have enabled successful delivery of the feasibility study and are relevant to conducting randomised controlled trials and meeting the needs of people with MS who are far more isolated than ever before. TRIAL REGISTRATION: ClinicalTrials.gov NCT03951181 . Registered on 15 May 2019.

Web-based physical activity intervention for people with progressive multiple sclerosis: application of consensus-based intervention development guidance

OBJECTIVES

People with progressive multiple sclerosis (PwPMS) report that they recognise the benefits of activity on their physical and psychological health but need support to achieve their physical activity goals. We aimed to systematically develop a theoretically informed intervention that would enable PwPMS to more readily engage in regular physical activity.

DESIGN

We used an intervention mapping approach to inform intervention development.

SETTING

We conducted semistructured interviews with PwPMS and their families/carers and physiotherapists recruited from secondary care settings.

PARTICIPANTS

Fourteen PwPMS with an Expanded Disability Status Scale score of between 6 and 8 and 7 of their families/carers and 13 physiotherapists and 1 physiotherapy technician participated.

RESULTS

Interview data suggested that the development of supportive coaching relationships with physiotherapists could promote the ability of PwPMS to achieve a desirable and achievable physical activity plan. These interview data informed the prototype 'Lifestyle Exercise and Activity Package for Multiple Sclerosis' (LEAP-MS) consisting of a secure multiuser web-based platform (with an education and activity suite, interactive components enabling selection of exercises, goal setting and activity logging), up to six flexible face-to-face or web-based physiotherapy coaching sessions and remote support via an embedded web-based messaging function that all together draw on specific theory-based methods to achieve physical activity behaviour change, namely active learning, reinforcement, modelling, feedback, facilitation, goal setting and guided practice. Implementation is within a multiuser platform accessible to participants, trained physiotherapists and researchers.

CONCLUSIONS

We have followed an inclusive, systematic and transparent process to develop the LEAP-MS intervention that enables detailed description of components, context and guiding principles to inform ongoing evaluation. Importantly, PwPMS expressed the need for autonomy in developing physical activity plans. This has been achieved through the embedding of self-management principles in the design and delivery of the LEAP-MS intervention.

Patient Triage by Topic Modeling of Referral Letters: Feasibility Study

Background

Musculoskeletal conditions are managed within primary care, but patients can be referred to secondary care if a specialist opinion is required. The ever-increasing demand for health care resources emphasizes the need to streamline care pathways with the ultimate aim of ensuring that patients receive timely and optimal care. Information contained in referral letters underpins the referral decision-making process but is yet to be explored systematically for the purposes of treatment prioritization for musculoskeletal conditions.

Objective

This study aims to explore the feasibility of using natural language processing and machine learning to automate the triage of patients with musculoskeletal conditions by analyzing information from referral letters. Specifically, we aim to determine whether referral letters can be automatically assorted into latent topics that are clinically relevant, that is, considered relevant when prescribing treatments. Here, clinical relevance is assessed by posing 2 research questions. Can latent topics be used to automatically predict treatment? Can clinicians interpret latent topics as cohorts of patients who share common characteristics or experiences such as medical history, demographics, and possible treatments?

Methods

We used latent Dirichlet allocation to model each referral letter as a finite mixture over an underlying set of topics and model each topic as an infinite mixture over an underlying set of topic probabilities. The topic model was evaluated in the context of automating patient triage. Given a set of treatment outcomes, a binary classifier was trained for each outcome using previously extracted topics as the input features of the machine learning algorithm. In addition, a qualitative evaluation was performed to assess the human interpretability of topics.

Results

The prediction accuracy of binary classifiers outperformed the stratified random classifier by a large margin, indicating that topic modeling could be used to predict the treatment, thus effectively supporting patient triage. The qualitative evaluation confirmed the high clinical interpretability of the topic model.

Conclusions

The results established the feasibility of using natural language processing and machine learning to automate triage of patients with knee or hip pain by analyzing information from their referral letters.

Guidance for implementing best practice therapeutic exercise for people with knee and hip osteoarthritis: what does the current evidence base tell us?

OBJECTIVE

Therapeutic exercise is a recommended first-line treatment for people with knee and hip osteoarthritis. However, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim to synthesize current literature informing the implementation of therapeutic exercise for people with knee and hip osteoarthritis.

METHODS

Narrative review focusing on evidence from systematic reviews and randomized controlled trials.

RESULTS

Therapeutic exercise is safe for people with knee and hip osteoarthritis. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind-body exercise) may be utilised at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically-informed strategies to improve adherence to therapeutic exercise, such as patient education, goal setting, monitoring and feedback, may help maintain participation and optimise clinical benefits over the longer-term. Sedentary behaviour is also a risk factor for disability and lower quality of life in people with knee and hip osteoarthritis, although limited evidence exists regarding how best to reduce this behaviour.

CONCLUSION

Current evidence can be used to inform how to implement best practice therapeutic exercise, at a sufficient and appropriate dose, for people with knee and hip osteoarthritis.

A Nonproprietary Movement Analysis System (MoJoXlab) Based on Wearable Inertial Measurement Units Applicable to Healthy Participants and Those With Anterior Cruciate Ligament Reconstruction Across a Range of Complex Tasks: Validation Study

Background

Movement analysis in a clinical setting is frequently restricted to observational methods to inform clinical decision making, which has limited accuracy. Fixed-site, optical, expensive movement analysis laboratories provide gold standard kinematic measurements; however, they are rarely accessed for routine clinical use. Wearable inertial measurement units (IMUs) have been demonstrated as comparable, inexpensive, and portable movement analysis toolkits. MoJoXlab has therefore been developed to work with generic wearable IMUs. However, before using MoJoXlab in clinical practice, there is a need to establish its validity in participants with and without knee conditions across a range of tasks with varying complexity.

Objective

This paper aimed to present the validation of MoJoXlab software for using generic wearable IMUs for calculating hip, knee, and ankle joint angle measurements in the sagittal, frontal, and transverse planes for walking, squatting, and jumping in healthy participants and those with anterior cruciate ligament (ACL) reconstruction.

Methods

Movement data were collected from 27 healthy participants and 20 participants with ACL reconstruction. In each case, the participants wore seven MTw2 IMUs (Xsens Technologies) to monitor their movement in walking, jumping, and squatting tasks. The hip, knee, and ankle joint angles were calculated in the sagittal, frontal, and transverse planes using two different software packages: Xsens’ validated proprietary MVN Analyze and MoJoXlab. The results were validated by comparing the generated waveforms, cross-correlation (CC), and normalized root mean square error (NRMSE) values.

Results

Across all joints and activities, for data of both healthy and ACL reconstruction participants, the CC and NRMSE values for the sagittal plane are 0.99 (SD 0.01) and 0.042 (SD 0.025); 0.88 (SD 0.048) and 0.18 (SD 0.078) for the frontal plane; and 0.85 (SD 0.027) and 0.23 (SD 0.065) for the transverse plane (hip and knee joints only). On comparing the results from the two different software systems, the sagittal plane was very highly correlated, with frontal and transverse planes showing strong correlation.

Conclusions

This study demonstrates that nonproprietary software such as MoJoXlab can accurately calculate joint angles for movement analysis applications comparable with proprietary software for walking, squatting, and jumping in healthy individuals and those following ACL reconstruction. MoJoXlab can be used with generic wearable IMUs that can provide clinicians accurate objective data when assessing patients’ movement, even when changes are too small to be observed visually. The availability of easy-to-setup, nonproprietary software for calibration, data collection, and joint angle calculation has the potential to increase the adoption of wearable IMU sensors in clinical practice, as well as in free living conditions, and may provide wider access to accurate, objective assessment of patients’ progress over time.

Dual-Task Effects on Performance of Gait and Balance in People with Knee Pain: A Systematic Scoping Review

Dual-task paradigms have been increasingly used to assess the interaction between cognitive demands and the control of balance and gait. The interaction between functional and cognitive demands can alter movement patterns and increase knee instability in individuals with knee conditions, such as knee anterior cruciate ligament (ACL) injury or osteoarthritis (OA). However, there is no consensus on the effects of dual-task on gait mechanics and balance in those individuals. This systematic scoping review aims to examine the impact of dual-task gait and standing balance on motor and cognitive performance in individuals with knee OA or ACL injury. A comprehensive search of MEDLINE, PubMed, Web of Science, and EMBASE electronic databases up until December 2019 was carried out. Inclusion criteria was limited to include dual-task studies that combined cognitive tasks performed simultaneously with gait or standing balance in individuals with knee OA or ACL injuries. In total, fifteen studies met the inclusion criteria, nine articles examined dual-task effects on balance, and six articles reported the effects of dual-task on gait. The total number of individuals included was 230 individuals with ACL injuries, and 168 individuals with knee OA. A decline in gait and balance performance during dual-task testing is present among individuals with ACL injury and/or ACL reconstruction and knee OA. Further research is required, but dual taking assessment could potentially be used to identify individuals at risk of falling or further injury and could be used to develop targeted rehabilitation protocols. A variety of outcome measures have been used across the studies included, making comparisons difficult. The authors, therefore, recommend developing a standardized set of biomechanical balance variables.

Using routine referral data for patients with knee and hip pain to improve access to specialist care

Background

Referral letters from primary care contain a large amount of information that could be used to improve the appropriateness of the referral pathway for individuals seeking specialist opinion for knee or hip pain. The primary aim of this study was to evaluate the content of the referral letters to identify information that can independently predict an optimal care pathway.

Methods

Using a prospective longitudinal design, a convenience sample of patients with hip or knee pain were recruited from orthopaedic, specialist general practice and advanced physiotherapy practitioner clinics. Individuals completed a Knee or hip Osteoarthritis Outcome Score at initial consultation and after 6 months. Participant demographics, body mass index, medication and co-morbidity data were extracted from the referral letters. Free text of the referral letters was mapped automatically onto the Unified Medical Language System to identify relevant clinical variables. Treatment outcomes were extracted from the consultation letters. Each outcome was classified as being an optimal or sub-optimal pathway, where an optimal pathway was defined as the one that results in the right treatment at the right time. Logistic regression was used to identify variables that were independently associated with an optimal pathway.

Results

A total of 643 participants were recruited, 419 (66.7%) were classified as having an optimal pathway. Variables independently associated with having an optimal care pathway were lower body mass index (OR 1.0, 95% CI 0.9 to 1.0 p = 0.004), named disease or syndromes (OR 1.8, 95% CI 1.1 to 2.8, p = 0.02) and taking pharmacologic substances (OR 1.8, 95% CI 1.0 to 3.3, p = 0.02). Having a single diagnostic procedure was associated with a suboptimal pathway (OR 0.5, 95% CI 0.3 to 0.9 p < 0.001). Neither Knee nor Hip Osteoarthritis Outcome scores were associated with an optimal pathway. Body mass index was found to be a good predictor of patient rated function (coefficient − 0.8, 95% CI -1.1, − 0.4 p < 0.001).

Conclusion

Over 30% of patients followed sub-optimal care pathway, which represents potential inefficiency and wasted healthcare resource. A core data set including body mass index should be considered as this was a predictor of optimal care and patient rated pain and function.

KLOSURE: Closing in on open-ended patient questionnaires with text mining

Background

Knee injury and Osteoarthritis Outcome Score (KOOS) is an instrument used to quantify patients’ perceptions about their knee condition and associated problems. It is administered as a 42-item closed-ended questionnaire in which patients are asked to self-assess five outcomes: pain, other symptoms, activities of daily living, sport and recreation activities, and quality of life. We developed KLOG as a 10-item open-ended version of the KOOS questionnaire in an attempt to obtain deeper insight into patients’ opinions including their unmet needs. However, the open–ended nature of the questionnaire incurs analytical overhead associated with the interpretation of responses. The goal of this study was to automate such analysis. We implemented KLOSURE as a system for mining free–text responses to the KLOG questionnaire. It consists of two subsystems, one concerned with feature extraction and the other one concerned with classification of feature vectors. Feature extraction is performed by a set of four modules whose main functionalities are linguistic pre-processing, sentiment analysis, named entity recognition and lexicon lookup respectively. Outputs produced by each module are combined into feature vectors. The structure of feature vectors will vary across the KLOG questions. Finally, Weka, a machine learning workbench, was used for classification of feature vectors.

Results

The precision of the system varied between 62.8 and 95.3%, whereas the recall varied from 58.3 to 87.6% across the 10 questions. The overall performance in terms of F–measure varied between 59.0 and 91.3% with an average of 74.4% and a standard deviation of 8.8.

Conclusions

We demonstrated the feasibility of mining open-ended patient questionnaires. By automatically mapping free text answers onto a Likert scale, we can effectively measure the progress of rehabilitation over time. In comparison to traditional closed-ended questionnaires, our approach offers much richer information that can be utilised to support clinical decision making. In conclusion, we demonstrated how text mining can be used to combine the benefits of qualitative and quantitative analysis of patient experiences.

Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review

OBJECTIVE

Musculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults with hip and/or knee pain referred for specialist opinion.

DESIGN

Systematic review.

DATA SOURCES

Electronic database searches were carried out in MEDLINE, MEDLINE In-Process, Cumulative Index of Nursing and Allied Health Literature, Embase, PEDro, PubMed, Web of Science, Cochrane Central and Health Management Information Consortium without language restriction from 1990 onwards. Websites were reviewed for grey literature.

ELIGIBILITY CRITERIA

All study designs and documents that considered care pathways for adults with musculoskeletal hip and/or knee pain referred for specialist opinion were screened by two reviewers. Risk of bias was assessed using The Critical Appraisal Skills Programme checklist for randomised controlled trials and the Joanna Briggs Institute checklists.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were performed by one reviewer and checked by a second. Findings are reported narratively.

RESULTS

The titles and abstracts of 1248 articles were screened and 140 full-text articles retrieved. 19 papers reporting 17 studies met the study inclusion criteria. Quality was low due to study design and methodological flaws. Most of the outcomes relate to organisational process at the 'meso' level of a whole systems approach.

CONCLUSION

It can be concluded that the pathway is not linear, containing variations and activity loops. The available evidence suggests that, from the point of referral for specialist opinion, a model is required that integrates the skills of all the different healthcare professionals and streamlining is required to ensure that individuals are seen by the healthcare professional that best meets their needs. There is very limited evidence of patient experience informing knee and hip care pathways.

PROSPERO REGISTRATION NUMBER

CRD42016035510.

Identifying Priorities for Physiotherapy Research in the UK: the James Lind Alliance Physiotherapy Priority Setting Partnership

OBJECTIVES

To identify unanswered questions for physiotherapy research and help set and prioritise the top 10 generic research priorities for the UK physiotherapy profession; updating previous clinical condition- specific priorities to include patient and carer perspectives, and reflect changes in physiotherapy practice, service provision and new technologies.

DESIGN

The James Lind Alliance (JLA) Priority Setting Partnership (PSP) methodology was adopted, utilising evidence review, survey and consensus methods.

PARTICIPANTS

Anyone with experience and/or an interest in UK physiotherapy: patients, carers, members of the public, physiotherapists, student physiotherapists, other healthcare professionals, researchers, educators, service providers, commissioners and policy makers.

RESULTS

Five hundred and ten respondents (50% patients, carers or members of the public) identified 2152 questions (termed "uncertainties"). Sixty-five indicative questions were developed from the uncertainties using peer reviewed thematic analysis. These were ranked in a second national survey (1,020 responses (62% were complete)). The top 25 questions were reviewed in a final prioritisation workshop using an adapted nominal group technique. The top 10 research priorities focused on optimisation (top priority); access; effectiveness; patient and carer knowledge, experiences, needs and expectations; supporting patient engagement and self-management; diagnosis and prediction.

CONCLUSIONS

This study is currently the UK's most inclusive consultation exercise to identify patients'and healthcare professionals'priorities for physiotherapy research. The exercise deliberately sought to capture generic issues relevant to all specialisms within physiotherapy. The research priorities identified a range of gaps in existing evidence to inform physiotherapy policy and practice. The results will assist research commissioning bodies and inform funding decisions and strategy.

Effect of visual feedback on the performance of the star excursion balance test

INTRODUCTION

Visual feedback is an effective method to enhance postural and balance control in clinical and sports training. The aim of this study was to explore the effect of real-time visual feedback provided by a video camera on the performance of a dynamic balance test, which is the star excursion balance test in healthy subjects.

METHODS

We compared the performance of the star excursion balance test using the maximum reach distance in 20 healthy participants (10 male and 10 female, 26.8 ± 3.7 years) under two conditions: without feedback and whilst they viewed their movements in real-time on a screen in front of them via a video camera.

RESULTS

The results showed that real-time visual feedback had a significant effect on maximum reach distance of the star excursion balance test in the posterolateral direction (P < 0.001). There was a non-significant increase in the maximum reach distance in the anterior and posteromedial directions.

CONCLUSION

The result indicates that the real-time visual feedback appears to be an effective means for improving the performance of the star excursion balance test in the posterolateral direction, and may be a promising tool for clinical rehabilitation and athlete training to enhance dynamic postural control.

Integrating self-management support for knee injuries into routine clinical practice: TRAK intervention design and delivery

BACKGROUND

TRAK is a web-based intervention that provides knee patients with health information, personalised exercise plans and remote clinical support. The aim of this study was to fully define TRAK intervention content, setting and context and develop the training through an implementation study in a physiotherapy out-patient service.

METHODS

A mixed methods study. Phase 1 was a qualitative interview study, whereby fifteen physiotherapists used TRAK for 1 month with a patient of their choice. Interviews explored patient and physiotherapist views of TRAK intervention and training requirements. In Phase 2 seventy-four patients were recruited, all received conventional physiotherapy, a subset of 48 patients used TRAK in addition to conventional Physiotherapy. Aspects of feasibility measured included: uptake and usage of TRAK.

RESULTS

Patients and physiotherapists reported that TRAK was easy to use and highlighted the therapeutic benefit of the exercise videos and personalised exercise plans to remind them of their exercises and the correct technique. Patients reported needing to use TRAK with the guidance of their treating physiotherapist initially. Physiotherapists highlighted appointment time constraints and lack of familiarity with TRAK as factors limiting engagement. In Phase 2, 67% patients accessed TRAK outside of the clinical environment. A total of 91% of patients were given a personalised exercise plan, but these were only updated in 34% of cases.

CONCLUSION

A comprehensive training package for patients and clinicians has been defined. The refined TRAK intervention is reported using the 'Template for Intervention Description and Replication in preparation for a definitive randomised control trial.

Acceptability of a digital health intervention alongside physiotherapy to support patients following anterior cruciate ligament reconstruction

Background

Physiotherapy rehabilitation following surgical reconstruction to the Anterior Cruciate Ligament (ACL) can take up to 12 months to complete. Given the lengthy rehabilitation process, a blended intervention can be used to compliment face-to-face physiotherapy with a digital exercise intervention. In this study, we used TRAK, a web–based tool that has been developed to support knee rehabilitation, which provides individually tailored exercise programs with videos, instructions and progress logs for each exercise, relevant health information and a contact option that allows a patient to email a physiotherapist for additional support. The aim of this study was to evaluate the acceptability of TRAK–based blended intervention in post ACL reconstruction rehabilitation.

Methods

A qualitative research design using semi-structured interviews was used on a convenience sample of participants following an ACL reconstruction, and their treating physiotherapists, in a London NHS hospital. Participants were asked to use TRAK alongside face-to-face physiotherapy for 16 weeks. Interviews were carried out, audio recorded, transcribed verbatim and coded by two researchers independently. Data were analyzed using thematic analysis.

Results

Of the 25 individuals that were approached to be part of the study, 24 consented, comprising 8 females and 16 males, mean age 30 years. 17 individuals used TRAK for 16 weeks and were available for interview. Four physiotherapists were also interviewed. The six main themes identified from patients were: the experience of TRAK rehabilitation, personal characteristics for engagement, strengths and weaknesses of the intervention, TRAK in the future and attitudes to digital healthcare. The main themes from the physiotherapist interviews were: potential benefits, availability of resources and service organization to support use of TRAK.

Conclusions

TRAK was found to be an acceptable method of delivering ACL rehabilitation alongside face-to-face physiotherapy. Patients reported that TRAK, specifically the videos, increased their confidence and motivation with their rehabilitation. They identified ways in which TRAK could be developed in the future to meet technological expectations and further support rehabilitation. For Physiotherapists time and availability of computers affected acceptability. Organization of care to support integration of digital exercise interventions such as TRAK into a blended approach to rehabilitation is required.

Whole Body Coordination and Knee Movement Control During Five Rehabilitation Exercises

Knee rehabilitation exercises to improve motor control, target movement fluency, and displacement variability. Although knee movement in the frontal plane during exercise is routinely assessed in clinical practice, optimal knee control remains poorly understood. In this study, 29 healthy participants (height: 1.73 ± 0.11 m, mass: 73.5 ± 16.4 kg, age: 28.0 ± 6.9 years) performed 4 repetitions of 5 rehabilitation exercises while motion data were collected using the VICON PlugInGait full-body marker set. Fluency and displacement variability were calculated for multiple landmarks, including center of mass (CoM) and knee joint centers. Fluency was calculated as the inverse of the average number of times a landmark velocity in the frontal plane crossed zero. Variability was defined as the standard deviation of the frontal plane movement trajectories. CoM fluency and displacement variability were significantly different between tasks (p < .001). CoM displacement variability was consistently smallest compared to the constituent landmarks (p < .005). This was interpreted as a whole body strategy of compensatory variability constraining CoM frontal plane movement. Ipsilateral knee fluency (p < .01) and displacement variability (p < .001) differed substantially between tasks. The role of the weight-bearing knee seemed dependent on task constraints of the overall movement and balance, as well as constraints specific for knee joint stability.

Taxonomy for the Rehabilitation of Knee Conditions (TRAK), a Digital Intervention to Support the Self-Care Components of Anterior Cruciate Ligament Rehabilitation: Protocol of a Feasibility Study

BACKGROUND

Rupture of the anterior cruciate ligament (ACL) is common, especially in the active population. In defining the problem of ACL rehabilitation, this study draws from the knowledge that improved self-care, strength, and fitness are associated with better outcomes. Traditional rehabilitation involves regular physiotherapy, but it is not clear what the optimal way for delivering rehabilitation is, and it varies widely across the world. Evidence for treatments are discussed in the literature, however standard length of rehabilitation and frequency of appointments are unknown. Additionally, current rehabilitation models in the National Health Service (NHS) struggle with catering to large volumes of patients and the lengthy time span over which rehabilitation is delivered. The use of eHealth (the Internet in health care) has been successful at delivering behavior change to a number of diverse patient groups. In physiotherapy, problems such as exercise compliance, exercise technique, and managing a broad program of rehabilitation and advice can be challenging. An eHealth intervention called Taxonomy for the Rehabilitation of Knee Conditions (TRAK) to support self-management and behavior change has been developed by patients and clinicians, and acceptability studies have yielded positive results. TRAK is not an exercise rehabilitation protocol; it is a tool to support ACL rehabilitation with personalized plans, prompts, and logs to help adherence and videos and instructions to improve quality and address queries. The patients have their own log-ins and can email their physiotherapist through the website. This novel platform is directly in line with current NHS England, National Institute for Health and Care Excellence, and NHS Improvement agendas that call for rehabilitation initiatives using both technology and supported self-management for patients. This study forms part of a research platform to identify a best practice model of ACL care from the literature and opinions of key stakeholders. Patients' exercise programs and duration of treatment are still based on individual needs, but use of the website may offer improved self-management and function and reduced health resource use.

OBJECTIVE

This is a feasibility study to establish recruitment, retention, sample size estimates, and practicality of collecting outcome measures to inform a future trial comparing the TRAK intervention, which has been rigorously designed to address the challenges of ACL rehabilitation, to usual care.

METHODS

This is a feasibility study comparing 2 groups: standard care and standard care plus eHealth. It will use convergent parallel mixed methods where both qualitative and quantitative data are sought for a more thorough understanding of the objectives. Primary outcomes relate to feasibility, including recruitment, retention, and usage. Secondary outcomes relate to health resource use and patient-rated outcome measures.

RESULTS

This research expects to establish the feasibility of a full-scale randomized controlled trial to explore whether patients who use an eHealth intervention to support ACL rehabilitation have better outcomes plus improved self-efficacy and reduced health resource use than a usual care group.

CONCLUSIONS

The study will provide essential information to support the development and powering of a future clinical trial of eHealth and physiotherapy for patients with ACL reconstruction in the NHS.

Three-dimensional kinematic and kinetic gait deviations in individuals with chronic anterior cruciate ligament deficient knee: A systematic review and meta-analysis

BACKGROUND

Altered joint motion that occurs in people with an anterior cruciate ligament deficient knee is proposed to play a role in the initiation of knee osteoarthritis, however, the exact mechanism is poorly understood. Although several studies have investigated gait deviations in individuals with chronic anterior cruciate ligament deficient knee in the frontal and transverse planes, no systematic review has summarized the kinematic and kinetic deviations in these two planes.

METHODS

We searched five electronic databases from inception to 14th October 2013, with key words related to anterior cruciate ligament, biomechanics and gait, and limited to human studies only. Two independent reviewers assessed eligibility based on predetermined inclusion/exclusion criteria and methodological quality was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology statement checklist.

FINDINGS

We identified 16 studies, totaling 183 subjects with anterior cruciate ligament deficient knee and 211 healthy subjects. Due to the variability in reported outcomes, we could only perform meta-analysis for 13 sagittal plane outcomes. The only significant finding from our meta-analysis showed that individuals with anterior cruciate ligament deficient knee demonstrated a significantly greater external hip flexor angular impulse compared to control (P=0.03).

INTERPRETATION

No consensus about what constitutes a typical walking pattern in individuals with anterior cruciate ligament deficient knee can be made, nor can conclusions be derived to explain if gait deviations in the frontal and transverse plane contributed to the development of the knee osteoarthritis among this population.

A novel clinical approach for assessing hop landing strategies: a 2D telescopic inverted pendulum (TIP) model

PURPOSE

Single leg hop for distance is used to inform rehabilitation and return to sport following anterior cruciate ligament reconstruction. However, impairment of landing mechanics may persist after the recommended performance parameter (hop distance) has been met; therefore, alternative methods are required. This study follows the COSMIN guideline to investigate the measurement properties of data from a new instrument (2D TIP). This is a simple motion analysis instrument to assess landing strategy based on more complex biomechanical modelling.

METHODS

Data collected in the clinical setting from 30 subjects with chronic ACL deficiency (mean 15.5, SD 4.3 months following injury) before and 6 months after ACL reconstruction and a healthy control group were analysed. Reliability and measurement error were calculated using two repeated measures from three independent raters. Construct validity was assessed by hypothesis testing, and known groups validity and responsiveness were defined by differences between groups.

RESULTS

The data demonstrate excellent inter-rater (ICC = 0.81-1.00) and intra-rater (ICC = 0.85-1.00) reliability with low measurement error. Of the eight construct validity hypothesis, six were fully and two partially supported. Between-group differences were significant (P < 0.05) supporting the validity and responsiveness hypothesis.

CONCLUSION

2D TIP is a simple and inexpensive instrument for assessing landing strategy that has demonstrated appropriate reliability, validity and responsiveness in the ACL-injured population. The instrument will now be used to identify altered movement strategies and develop novel rehabilitation interventions that target strategy and performance.

LEVEL OF EVIDENCE

Prospective diagnostic study, Level II.

TRAK App Suite: A Web-Based Intervention for Delivering Standard Care for the Rehabilitation of Knee Conditions

Background

Standard care for the rehabilitation of knee conditions involves exercise programs and information provision. Current methods of rehabilitation delivery struggle to keep up with large volumes of patients and the length of treatment required to maximize the recovery. Therefore, the development of novel interventions to support self-management is strongly recommended. Such interventions need to include information provision, goal setting, monitoring, feedback, and support groups, but the most effective methods of their delivery are poorly understood. The Internet provides a medium for intervention delivery with considerable potential for meeting these needs.

Objective

The objective of this study was to demonstrate the feasibility of a Web-based app and to conduct a preliminary review of its practicability as part of a complex medical intervention in the rehabilitation of knee disorders. This paper describes the development, implementation, and usability of such an app.

Methods

An interdisciplinary team of health care professionals and researchers, computer scientists, and app developers developed the TRAK app suite. The key functionality of the app includes information provision, a three-step exercise program based on a standard care for the rehabilitation of knee conditions, self-monitoring with visual feedback, and a virtual support group. There were two types of stakeholders (patients and physiotherapists) that were recruited for the usability study. The usability questionnaire was used to collect both qualitative and quantitative information on computer and Internet usage, task completion, and subjective user preferences.

Results

A total of 16 patients and 15 physiotherapists participated in the usability study. Based on the System Usability Scale, the TRAK app has higher perceived usability than 70% of systems. Both patients and physiotherapists agreed that the given Web-based approach would facilitate communication, provide information, help recall information, improve understanding, enable exercise progression, and support self-management in general. The Web app was found to be easy to use and user satisfaction was very high. The TRAK app suite can be accessed at http://apps.facebook.com/kneetrak/.

Conclusions

The usability study suggests that a Web-based intervention is feasible and acceptable in supporting self-management of knee conditions.

The clinical effectiveness of self-care interventions with an exercise component to manage knee conditions: A systematic review

OBJECTIVE

Treatment of knee conditions should include approaches to support self-care and exercise based interventions. The most effective way to combine self-care and exercise has however not been determined sufficiently. Therefore the aim was to evaluate the clinical effectiveness of self-care programmes with an exercise component for individuals with any type of knee conditions.

METHODS

A keyword search of Medline, CINAHL, Amed, PsycInfo, Web of Science, and Cochrane databases was conducted up until January 2015. Two reviewers independently assessed manuscript eligibility against inclusion/exclusion criteria. Study quality was assessed using the Downs and Black quality assessment tool and the Cochrane Risk of Bias Tool. Data were extracted about self-care and exercise intervention type, control intervention, participants, length of follow-up, outcome measures, and main findings.

RESULTS

From the 7392 studies identified through the keyword search the title and abstract of 5498 were screened. The full text manuscripts of 106 studies were retrieved to evaluate their eligibility. Twenty-one manuscripts met the inclusion/exclusion criteria.

CONCLUSION

The treatment potential of combined self-care and exercise interventions has not been maximised because of limitations in study design and failure to adequately define intervention content. Potentially the most beneficial self-care treatment components are training self-management skills, information delivery, and goal setting. Exercise treatment components could be strengthened by better attention to dose and progression. Modern technology to streamline delivery and support self-care should be considered. More emphasis is required on using self-care and exercise programmes for chronic condition prevention in addition to chronic condition management.

KneeTex: an ontology-driven system for information extraction from MRI reports

BACKGROUND

In the realm of knee pathology, magnetic resonance imaging (MRI) has the advantage of visualising all structures within the knee joint, which makes it a valuable tool for increasing diagnostic accuracy and planning surgical treatments. Therefore, clinical narratives found in MRI reports convey valuable diagnostic information. A range of studies have proven the feasibility of natural language processing for information extraction from clinical narratives. However, no study focused specifically on MRI reports in relation to knee pathology, possibly due to the complexity of knee anatomy and a wide range of conditions that may be associated with different anatomical entities. In this paper we describe KneeTex, an information extraction system that operates in this domain.

METHODS

As an ontology-driven information extraction system, KneeTex makes active use of an ontology to strongly guide and constrain text analysis. We used automatic term recognition to facilitate the development of a domain-specific ontology with sufficient detail and coverage for text mining applications. In combination with the ontology, high regularity of the sublanguage used in knee MRI reports allowed us to model its processing by a set of sophisticated lexico-semantic rules with minimal syntactic analysis. The main processing steps involve named entity recognition combined with coordination, enumeration, ambiguity and co-reference resolution, followed by text segmentation. Ontology-based semantic typing is then used to drive the template filling process.

RESULTS

We adopted an existing ontology, TRAK (Taxonomy for RehAbilitation of Knee conditions), for use within KneeTex. The original TRAK ontology expanded from 1,292 concepts, 1,720 synonyms and 518 relationship instances to 1,621 concepts, 2,550 synonyms and 560 relationship instances. This provided KneeTex with a very fine-grained lexico-semantic knowledge base, which is highly attuned to the given sublanguage. Information extraction results were evaluated on a test set of 100 MRI reports. A gold standard consisted of 1,259 filled template records with the following slots: finding, finding qualifier, negation, certainty, anatomy and anatomy qualifier. KneeTex extracted information with precision of 98.00 %, recall of 97.63 % and F-measure of 97.81 %, the values of which are in line with human-like performance.

CONCLUSIONS

KneeTex is an open-source, stand-alone application for information extraction from narrative reports that describe an MRI scan of the knee. Given an MRI report as input, the system outputs the corresponding clinical findings in the form of JavaScript Object Notation objects. The extracted information is mapped onto TRAK, an ontology that formally models knowledge relevant for the rehabilitation of knee conditions. As a result, formally structured and coded information allows for complex searches to be conducted efficiently over the original MRI reports, thereby effectively supporting epidemiologic studies of knee conditions.

Cognitive styles and future depressed mood in early adulthood: the importance of global attributions

BACKGROUND

Cognitive theories of depression suggest that beliefs of low self-worth and the tendency to attribute negative events to causes that are global (widespread rather than specific) and stable (will persist rather than change in the future) are associated with the development of depressed mood. Such theories are supported by evidence from prospective studies and have guided the development of successful treatment and prevention strategies such as CBT. However, the relative importance of different psychological constructs within cognitive theories is unknown. This is important to refine cognitive theories and develop more efficient prevention strategies.

METHOD

We used prospective data from over 3500 young adults from the Avon Longitudinal Study for Parents and Children (ALSPAC) cohort in the UK to investigate the association between cognitive style, measured by short forms of the Dysfunctional Attitudes Scale (DAS) and Cognitive Styles Questionnaire-Short Form (CSQ-SF) at age 18, and future depressed mood at age 19. Structural equation modelling techniques were used to separate cognitive style constructs.

RESULTS

Cognitive styles were associated with future depressed mood, independently of baseline mood, both as measured by the DAS-SF and the CSQ-SF. Of the different CSQ-SF constructs, only global attributions were associated with both baseline and future mood independently of other constructs.

LIMITATIONS

The study was subject to attrition and the follow-up was relatively short (10 months).

CONCLUSION

The findings suggest that the tendency to attribute negative events specifically to global causes could be particularly important for depression. Reducing global attributions is potentially important in the prevention and treatment of depression.

Motor control strategies during double leg squat following anterior cruciate ligament rupture and reconstruction: an observational study

BACKGROUND

Anterior cruciate ligament (ACL) injured individuals often show asymmetries between the injured and non-injured leg. A better understanding of the underlying motor control could help to improve rehabilitation. Double leg squat exercises allow for compensation strategies. This study therefore investigated motor control strategies during a double leg squat with the aim to investigate if individuals with ACL rupture (ACLD), ACL reconstruction (ACLR) and healthy control subjects (CONT) used different strategies.

METHODS

20 ACLD and 21 ACLR were compared to 21 CONT subjects. Participants performed eight continuous double leg squats to their maximum depth, while kinematic and kinetic data were collected. Outcome measures were calculated to quantify the behavior of the injured and non-injured legs and the asymmetry between these legs.

RESULTS

Squat depth was significantly reduced in ACLR and ACLD compared to CONT (p < 0.05; 106 ± 17°; 105 ± 21°; 113 ± 21°). Peak knee extensor moments (Mkn(mx)) were significantly reduced in ACLR and ACLD compared to CONT in the injured leg only (p < 0.05; 0.045 ± 0.015; 0.046 ± 0.016; 0.059 ± 0.022 body weight.height respectively). There was no significant correlation between symmetry of the support moment (SYM(Msup)) and of the % support moment by the knee (SYM%supkn) in CONT (R(2) = -0.07). Data distribution average indicated good symmetry. ACLR showed a significant correlation between SYM(Msup) and SYM%sup(kn) (R(2) = 0.561) when two participants who did not recover as well were excluded. ACLR controlled knee moment magnitude using two strategies; 1) transfer of support moment to non-injured leg; 2) transfer of support moment from knee to ankle and/or hip of injured leg. These were combined in different proportions, but with the same effect on the knee moment. ACLD showed no significant correlation between SYM(Msup) and SYM%sup(kn) (R(2) = 0.015). Data distribution average indicated reduced symmetry. ACLD therefore used an avoidance strategy: reducing squat depth and subsequently the support moment in the injured leg and the knee contribution.

CONCLUSIONS

ACLD and ACLR individuals used different squatting strategies compared to controls, with ACLR using controlled and ACLD using avoidance behavior regarding knee loading. This has major implications for rehabilitation as these kinetic strategies cannot be observed, but result in the injured leg not being exercised as intended.

Activity progression for anterior cruciate ligament injured individuals

BACKGROUND

Functional exercises are important in the rehabilitation of anterior cruciate ligament deficient and reconstructed individuals but movement compensations and incomplete recovery persist. This study aimed to identify how tasks pose different challenges; and evaluate if different activities challenge patient groups differently compared to controls.

METHODS

Motion and force data were collected during distance hop, squatting and gait for 20 anterior cruciate ligament deficient, 21 reconstructed and 21 controls.

FINDINGS

Knee range of motion was greatest during squatting, intermediate during hopping and smallest during gait (P < 0.01). Peak internal knee extensor moments were greatest during distance hop (P < 0.01). The mean value of peak knee moments was reduced in squatting and gait (P < 0.01) compared to hop. Peak internal extensor moments were significantly larger during squatting than gait and peak external adductor moments during gait compared to squatting (P < 0.01). Fluency was highest during squatting (P < 0.01). All patients demonstrated good recovery of gait but anterior cruciate ligament deficient adopted a strategy of increased fluency (P < 0.01). During squatting knee range of motion and peak internal knee extensor moment were reduced in all patients (P < 0.01). Both anterior cruciate ligament groups hopped a shorter distance (P < 0.01) and had reduced knee range of motion (P < 0.025). Anterior cruciate ligament reconstructed had reduced fluency (P < 0.01).

INTERPRETATION

Distance hop was most challenging; squatting and gait were of similar difficulty but challenged patients in different ways. Despite squatting being an early, less challenging exercise, numerous compensation strategies were identified, indicating that this may be more challenging than gait.

Altered biomechanical strategies and medio-lateral control of the knee represent incomplete recovery of individuals with injury during single leg hop

Anterior cruciate ligament (ACL) injury can result in failure to return to pre-injury activity levels and future osteoarthritis predisposition. Single leg hop is used in late rehabilitation to evaluate recovery and inform treatment but biomechanical understanding of this activity is insufficient.

This study investigated single leg hop for distance aiming to evaluate if ACL patients had recovered: (1) landing strategies and (2) medio-lateral knee control. We hypothesized that patients with reconstructive surgery (ACLR) would have more similar landing strategies and knee control to healthy controls than patients treated conservatively (ACLD).

16 ACLD and 23 ACLR subjects were compared to 20 healthy controls (CONT). Kinematic and ground reaction force data were collected while subjects hopped their maximum distance. The main output parameters were hop distance, peak knee flexor angles and extensor moments and Fluency (a measure introduced to represent medio-lateral knee control). Statistical differences between ACL and control groups were analyzed using a general linear model univariate analysis, with COM velocity prior to landing as covariate.

Hop distance was the smallest for ACLD and largest for CONT (p<0.001; ACLD 57.1±14.1; ACLR 75.1±17.8; CONT 77.7±14.07% height). ACLR used a similar kinematic strategy to CONT, but had a reduced peak knee extensor moment (p<0.001; ACLD 0.32±0.14; ACLR 0.31±0.16; CONT 0.42±0.13 BW.height). Fluency was reduced in both ACLD and ACLR (p=0.006; ACLD 0.13±0.34; ACLR 0.14±0.34; CONT 0.17±0.41 s).

Clinical practice uses hopping distance to evaluate ACL patients' recovery. This study demonstrated that aspects such as movement strategies and knee control need to be evaluated.

Clinical effectiveness of knee rehabilitation techniques and implications for a self-care treatment model

BACKGROUND

Physiotherapy is a complex intervention frequently recommended for knee conditions. The International Classification of Functioning and Disability (ICF) can be used as a framework to evaluate evidence to develop care models and clinical guidelines.

OBJECTIVE

To evaluate the clinical effectiveness of knee rehabilitation modalities categorised according to the ICF domains.

DATA SOURCES

A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from 1996 to 2010 using terms related to the knee joint and physiotherapeutic interventions.

STUDY SELECTION

Reviewer assessment using inclusion/exclusion criteria and a quality assessment tool compiled from the Critical Appraisal Skills Programme Tool, Consort and Cochrane Bone Joint and Muscle Trauma Groups.

DATA EXTRACTION

Information about the research design, intervention and subjects was extracted. Outcome measures and findings were categorised according to ICF domains.

DATA SYNTHESIS

The majority of studies evaluated exercise. Findings were supportive but specific recommendations were limited due to variations in content and application. There was limited quality research to support the theory that manual therapy, electrotherapy or taping in isolation contributes to recovery. Multimodality physiotherapy programmes were found to be beneficial and to reflect clinical practice, but the effectiveness of each component is unknown. Outcome measures from the participation domain of the ICF were used least frequently and were not generally true measures of participation.

CONCLUSION

Development of participation outcome measures is required to evaluate the long-term benefits of interventions. Rehabilitation should be based around delivery of effective exercise programmes incorporating participation outcomes to provide feedback and complement self-care for knee conditions.

Classification of functional recovery of anterior cruciate ligament copers, non-copers, and adapters

OBJECTIVES

(a) To identify whether differences exist in the pattern of recovery with respect to functional outcomes for acutely ruptured anterior cruciate ligament deficient (ACLD) copers, adapters, and non-copers. (b) To identify clinically relevant outcomes that could distinguish between three functional subgroups.

METHODS

A longitudinal study was used to measure gait variables and distance hop at regular intervals after injury using a digital camcorder and computer for quantitative analysis. A sample of 63 ACLD subjects entered the study; 42 subjects were measured at least three times. At 12-36 months after injury, subjects were classified as functional copers, adapters, or non-copers on the basis of which of their preinjury activities they had resumed. To determine the pattern of recovery, repeated measurements were analysed using a least squares fit of the data.

RESULTS

17% of ACLD subjects were classified as functional copers, 45% as adapters, and 38% as non-copers. Only 5% of those who participated in high demand activities before injury returned to them. ACLD copers had recovered above the control mean for all gait variables by 40 days after the injury. Hopping distance did not recover to the control mean. Non-copers struggled to recover to control limits and remained borderline for all the gait variables.

CONCLUSIONS

Distinctive patterns of functional recovery for three subgroups of ACLD subjects have been identified. Gait variables and activity level before injury were the most useful variables for distinguishing between the subgroups. If potential for recovery is identified early after injury, then appropriate treatment can be given.

Measurement of functional recovery in individuals with acute anterior cruciate ligament rupture

OBJECTIVES

To measure functional recovery following acute anterior cruciate ligament (ACL) rupture using a simple and reliable clinical movement analysis system. Clinic based methods that simultaneously quantify different aspects of movement over a range of activities and model functional recovery will help guide rehabilitation.

METHODS

A longitudinal study was used to measure gait variables at initial physiotherapy attendance and then at monthly intervals using a digital camcorder and computer for quantitative analysis. Jogging and distance hopping were added during recovery. A sample of 63 ACL deficient subjects entered the study and 48 subjects were measured at least three times. To determine the pattern of recovery, repeated measurements were analysed using a least square fit of the data.

RESULTS

Gait variables took between 95 and 130 days post injury to reach the control mean and stabilise shortly after this. Hopping distance for the injured leg took 62 days to recover to within normal limits and 5 months post injury to reach the control mean. Jogging was already within the control limits at 30 days post injury and demonstrated little change with recovery.

CONCLUSIONS

Functional recovery of multiple variables has been modelled. In the early phase of post injury, gait velocity seems to be the most useful variable to measure improvement. Recovery of more challenging activities appears to take an average of 5 months. Therefore, patients may need to be monitored in physiotherapy until this time and advised not to return to sport until sufficient recovery is demonstrated on activities such as distance hopping.

Cluster analysis of MMPI scales of patients involuntarily committed for chemical dependency treatment

This study investigated empirical clusters of MMPI scale T scores for 186 men and 112 women involuntarily committed to a chemical dependency unit of a state psychiatric hospital. Ward's method of cluster analysis produced six clusters which were similar to those reported in other cluster-analytic studies of alcoholics but with a prominent increase in Scale 6 elevations. Average profiles for the six clusters were Spike 6, 6-2-8-4, within normal limits (Clusters 3 and 4), and 2-6-8-3-4-1-9. Results are discussed in terms of treatment planning for this population.