Advances in Hand Therapy: Best Practice in Conservative Management of Proximal Phalangeal Fractures in Children

BACKGROUND

Proximal phalangeal fractures are one of the most commonly treated hand injuries in children. Conservative management of these fractures is often to splint for 5 weeks post injury, despite children presenting as clinically healed at 3 weeks post injury. Therefore, we investigated the effect of splinting for only 3 weeks in children who present with clinically healed proximal phalangeal fractures at 3 weeks compared with usual care.

METHODS

Participants (n=80, aged 10.3 ±2.5 years) presenting to the Hand Clinic of a tertiary Children's Hospital in Sydney, Australia, were randomly allocated into a Current Protocol and a New Protocol group. Following were the inclusion criteria: aged between 5 and 16 years; present with an non-displaced or minimally displaced and stable fracture; no surgical intervention; assessed as clinically healed at 3-week visit. The primary outcome measure was total active motion (TAM) of the injured digit compared with the contralateral digit (deg), at 5 weeks post injury. Secondary outcome measures were grip strength, and a parent-reported questionnaire. Statistical analysis used χ 2 test and the absolute difference described by a 90% CI. The New Protocol was considered noninferior if the 90% CI overlap was > 20% of the Current Protocol. Analysis was by intention to treat.

RESULTS

There was a 10% loss to follow up at 5 weeks (Current Protocol =4, New Protocol =4). All CIs between groups overlapped by >10%. TAM 90% CI for Current Protocol was 17.7 to 5.4 degrees and for the New Protocol was 4.7 to 1.6 degrees.

CONCLUSIONS

A change in practice is warranted to cease immobilization for children with conservatively managed proximal phalangeal fractures who present as clinically healed at 3 weeks. Therapist assessment of fracture healing is an appropriate indicator for intervention and can be utilized in a therapist-led model of care.

LEVEL OF EVIDENCE

Level 1-noninferiority randomized control trial with 2 parallel arms.

Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AIM

To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.

DESIGN

Mixed-methods study describing the development of a patient decision aid.

SETTING

A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids.

PARTICIPANTS

People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group.

PRIMARY AND SECONDARY OUTCOMES

Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis.

RESULTS

We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.

Effects of sport or physical recreation for adults with physical or intellectual disabilities: a systematic review with meta-analysis

OBJECTIVES

To evaluate the effects of sport or physical recreation on participation, mobility and quality of life for adults living with disabilities.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Six databases searched from inception to May 2022.

ELIGIBILITY CRITERIA

Randomised controlled trials including adults living with a physical or intellectual disability, comparing sport or physical recreation to non-active control.

RESULTS

Seventy-four trials (n=2954; mean age 55 years) were included. Most (70) trials included people with physical disabilities, none evaluated sport and the most common physical recreation activities tested were traditional Chinese exercise (35%), yoga (27%) and dance (18%). Mean frequency and duration was 65 min/session, two times per week for 13 weeks. Most (86%) interventions were led by people with experience and/or training in the recreation activity, and only 37% reported leader experience and/or training working with people with disabilities. Participation was measured as attendance (mean 81%, 30 intervention groups). Physical recreation improved mobility (standardised mean difference (SMD) 0.38, 95% CI 0.07 to 0.69, n=469) and walking endurance (mean difference (MD) 40.3 m, 95% CI 19.5 to 61.1, n=801) with low certainty evidence and balance (Berg Balance Scale, range 0-56 points; MD 3.4 points, 95% CI 2.3 to 4.4, n=906) and quality of life (physical health; SMD 0.37, 95% CI 0.02 to 0.72, n=468) with very low certainty evidence, but not walking speed (MD 0.03 m/s, 95% CI -0.05 to 0.11, n=486).

CONCLUSION

Physical recreation may confer multiple benefits for people living with disabilities regardless of the activity chosen, thus offering a potentially enjoyable and scalable strategy to increase physical activity.

PROSPERO REGISTRATION NUMBER

CRD42018104379.

Development of a functional outcome measure for riboflavin transporter deficiency

BACKGROUND AND AIMS

Riboflavin transporter deficiency (RTD) is a progressive inherited neuropathy of childhood onset, characterised clinically by pontobulbar palsy, sensory ataxia, sensorineural deafness, muscle weakness, optic atrophy and respiratory failure. A robust and responsive functional outcome measure is essential for future clinical trials of disease-modifying therapies including genetic therapies. The Charcot-Marie-Tooth disease Pediatric Scale (CMTPedS) is a well-validated outcome measure for CMT and related neuropathies, and might have utility for measuring disease progression in individuals with RTD. However, the CMTPedS requires modifications to account for phenotypic differences between children with CMT and RTD. The aim of this study was to develop a functional outcome measure based on the CMTPedS for specific use in individuals with RTD.

METHODS

The CMTPedS data collected over the last 10 years in individuals with RTD attending the Peripheral Neuropathy Management Clinic at the Children's Hospital at Westmead (Sydney, Australia) were reviewed to evaluate each item within the CMTPedS. A literature review of articles published until September 2021 for functional outcome measures generated an item pool for pilot testing. The results of this pilot testing, alongside analysis of existing CMTPedS item scores in the RTD cohort, informed the modification of the CMTPedS.

RESULTS

CMTPedS data were reviewed for eight individuals over the past 10 years. Two items were identified as requiring modification or removal and additional items of proximal strength and function needed to be considered. Six studies were identified in the literature review, and five items were selected for pilot testing. 'Shoulder internal rotation' and the '30-s sit to stand test' were added as proximal measures of strength and function. The composite balance item comprising nine tasks in the CMTPedS showed a ceiling effect and was replaced with the single 'Feet apart on a line eyes open' balance item. 'Pinprick sensation' was removed due to a floor effect.

INTERPRETATION

This study provides preliminary evidence that the Riboflavin Transporter Deficiency Pediatric Scale (RTDPedS) is a functional outcome measure covering strength, upper and lower limb function, balance and mobility for individuals with RTD to assess disease severity and progression in clinical trials and cohort studies.

The association between musculoskeletal pain during pregnancy and pregnancy outcomes: A systematic review and meta-analyses

OBJECTIVE

To systematically investigate the association between musculoskeletal pain during pregnancy and birth outcomes including caesarean section, newborn birthweight, newborn birth length, and gestational age at birth.

METHODS

Medline, Embase, Web of Science, Cinahl and Scopus were systematically searched to identify eligible studies. Odds ratios, mean differences, and confidence intervals were used to describe results. Risk of Bias was assessed using the Newcastle-Ottawa Scale for observational studies. GRADE (The Grading of Recommendation Assessment, Development, and Evaluation) was used to assess the quality of each outcome.

RESULTS

Seven studies were included with a total population of 85,991 participants. There is low- quality evidence that pregnant women with musculoskeletal pain had 1.59 greater odds to experience delivery by caesarean section compared to those without musculoskeletal pain ([OR] 1.59, 95 % confidence interval [CI] 1.09 to 2.31). Both newborn birth weight (Mean Difference [MD] 77.79 g, 95 % [CI] -23.09 to 178.67) and newborn birth length ([MD] 0.55 cm, 95 % [CI] -0.47 to 1.56) were not affected by musculoskeletal pain, with very low-quality and low-quality evidence, respectively. There was moderate evidence that pregnant women with musculoskeletal pain had shorter gestational age (weeks), although the effect was small and possibly not clinically relevant ([MD] -0.41, 95 % [CI] -0.41 to -0.07).

CONCLUSION

Pregnant women experiencing musculoskeletal pain are at greater odds of delivering their babies via caesarean than those without musculoskeletal pain, however, musculoskeletal pain during pregnancy does not appear to affect newborn birth weight, length, or gestational age at birth.

Multicenter Validation of the Charcot-Marie-Tooth Functional Outcome Measure

BACKGROUND AND OBJECTIVES

Charcot-Marie-Tooth disease type 1A (CMT1A), caused by a duplication of PMP22, is the most common hereditary peripheral neuropathy. For participants with CMT1A, few clinical trials have been performed; however, multiple therapies have reached an advanced stage of preclinical development. In preparation for imminent clinical trials in participants with CMT1A, we have produced a Clinical Outcome Assessment (COA), known as the CMT-Functional Outcome Measure (CMT-FOM), in accordance with the FDA Roadmap to Patient-Focused Outcome Measurement to capture the key clinical end point of function.

METHODS

Participants were recruited through CMT clinics in the United States (n = 130), the United Kingdom (n = 52), and Italy (n = 32). To derive the most accurate signal with the fewest items to identify a therapeutic response, a series of validation studies were conducted including item and factor analysis, Rasch model analysis and testing of interrater reliability, discriminative ability, and convergent validity.

RESULTS

A total of 214 participants aged 18-75 years with CMT1A (58% female) were included in this study. Item, factor, and Rasch analysis supported the viability of the 12-item CMT-FOM as a unidimensional interval scale of function in adults with CMT1A. The CMT-FOM covers strength, upper and lower limb function, balance, and mobility. The 0-100 point scoring system showed good overall model fit, no evidence of misfitting items, and no person misfit, and it was well targeted for adults with CMT1A exhibiting high inter-rater reliability across a range of clinical settings and evaluators. The CMT-FOM was significantly correlated with the CMT Examination Score (r = 0.643; p < 0.001) and the Overall Neuropathy Limitation Scale (r = 0.516; p < 0.001). Significantly higher CMT-FOM total scores were observed in participants self-reporting daily trips and falls, unsteady ankles, hand tremor, and hand weakness (p < 0.05).

DISCUSSION

The CMT-FOM is a psychometrically robust multi-item, unidimensional, disease-specific COA covering strength, upper and lower limb function, balance, and mobility to capture how participants with CMT1A function to identify therapeutic efficacy.

'Benched' the effect of the COVID-19 lockdown on injury incidence in sub-elite football in Australia: a retrospective population study using injury insurance records

OBJECTIVES

The primary aim of this study was to compare injury rates pre- and post-COVID-19 lockdown in sub-elite football (soccer) players by analysing the full season and the first month of each season between 2018 and 2020. Secondary aims were to describe the incidence, location and type of injuries and to compare injuries by age group and sex.

DESIGN

Descriptive epidemiological study.

METHODS

A de-identified insurance database was retrospectively coded using the Orchard Sports Injury Classification System. Injury incidence per 1000 hours as well as incidence rate ratios (IRR) with confidence intervals were calculated.

RESULTS

No significant difference was found in the overall incidence rate in 2020 compared with the 2018 and 2019 seasons (IRR, 1.04 [95% CI, 0.96-1.13]; p = 0.294). However, overall injuries increased by 26% (IRR: 1.26 [95% CI 1.07-1.47]; p < 0.005) and joint sprains increased by 45% (IRR: 1.45 [95% CI 1.14-1.84]; p < 0.005) in the first month of 2020 compared with 2018-2019. Between 2018 and 2020, there were 4149 injury insurance claims, with anterior cruciate ligament (ACL) ruptures accounting for 19% of all injuries. When comparing sex, female players had significantly more ankle sprains whilst male players suffered more dental injuries.

CONCLUSIONS

This study adds to a growing body of evidence investigating injury rates post-COVID-19 lockdowns in sport. Sub-elite players appear to be at higher risk of joint injuries within the first month of training following a period of lockdown. Overall, stakeholders involved in sub-elite football should prioritise knee and ankle joint injury prevention.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

OBJECTIVE

To develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures.

DESIGN

Mixed methods.

SETTING

A draft decision aid was developed using guidance from a multidisciplinary steering group and existing patient decision aids. Participants were recruited through social media.

PARTICIPANTS

People who have previously sustained an Achilles tendon rupture and health professionals who manage these patients.

PRIMARY AND SECONDARY OUTCOMES

Semi-structured interviews and questionnaires were used to gather feedback on the decision aid from health professionals and patients who had previously suffered an Achilles tendon rupture. The feedback was used to redraft the decision aid and assess acceptability. An iterative cycle of interviews, redrafting according to feedback and further interviews was used. Interviews were analysed using reflexive thematic analysis. Questionnaire data were analysed descriptively.

RESULTS

We interviewed 18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 chiropractor, 1 sports medicine physician) and 15 patients who had suffered an Achilles tendon rupture (median time since rupture was 12 months). Most health professionals and patients rated the aid's acceptability as good-excellent. Interviews showcased agreement among health professionals and patients on most aspects of the decision aid: introduction, treatment options, comparing benefits and harms, questions to ask health professionals and formatting. However, health professionals had differing views on details about Achilles tendon retraction distance, factors that modify the risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to both patients and health professionals, and our study highlights the views of key stakeholders on important information to consider when developing a patient decision aid for Achilles tendon rupture management. A randomised controlled trial evaluating the impact of this tool on the decision-making of people considering Achilles tendon surgery is warranted.

Insurance cost and injury characteristics of anterior cruciate ligament injuries in sub-elite football: A population analysis involving 3 years of Australian insurance data

OBJECTIVES

To investigate the injury characteristics and insurance cost of anterior cruciate ligament injuries in sub-elite football players in New South Wales, Australia.

DESIGN

Descriptive epidemiological study.

METHODS

Three years of insurance records (2018-2020) was used to describe anterior cruciate ligament injury costs and characteristics. Concomitant injuries and the mechanism of injury were determined by analysing the injury descriptions. Claim characteristics and costs are presented by age group (junior = 7-17 years, senior = 18-34 years, and veteran = 35 + years) and sex. Categorical data (including age-groups and sex) are presented as counts and percentages and analysed using a Chi squared or Fisher's exact test. Cost data are reported as means ± standard deviation with 95 % confidence intervals.

RESULTS

Over the course of three football seasons (2018-2020), 786 anterior cruciate ligament injuries were reported to the injury insurance company. The total insurance cost was AU$3,614,742 with direct injury insurance costs accounting for 36.3 % of the total costs. The mean indirect insurance costs were six-fold higher than direct insurance costs (AU$11,458 vs AU$1914). Isolated injuries had an average cost of $4466 whilst concomitant injuries had an average cost of $4951. Surgical costs are excluded from direct cost calculations. The peak injury count occurred in the first month of all three football seasons, immediately after the pre-season.

CONCLUSIONS

Anterior cruciate ligament injuries represent a substantial economic burden to the insurer and individual. The cost data provided can be used for future economic and modelling studies.

Heading in Football: Insights from stakeholders in amateur football

Despite emerging research questioning the long-term effect of purposeful heading on players' brain health, heading-related perspectives and behaviours of stakeholders in amateur football in Australia (a country without heading guidelines) remain unknown. This study aimed to explore current heading-related perspectives and behaviours of football stakeholders. In total, 290 players (aged over 11 years), 54 coaches, 34 non-coaching staff and 14 medical staff completed the survey. Of the 290 players, 56.5% reported being formally trained in heading, with female players less likely to be trained than male players (p < 0.05). Players were the least concerned about the long-term effects of heading, while medical staff were the most concerned (33.1% and 57.1%, respectively). From proposed strategies to reduce heading burden, a heading ban for all ages was least popular (2.3%), while teaching heading technique was most popular (67.3%). Our study provides insights into football stakeholders' heading-related perspectives, which could be used, along with scientific evidence, to inform pragmatic future heading guidelines.

Do Cutting Kinematics Change as Boys Mature? A Longitudinal Cohort Study of High-School Athletes

OBJECTIVE

Examine longitudinal changes in trunk, hip, and knee kinematics in maturing boys during an unanticipated cutting task.

DESIGN

Prospective cohort study.

SETTING

Biomechanical laboratory.

PARTICIPANTS

Forty-two high-school male basketball, volleyball, and soccer athletes.

ASSESSMENT OF RISK FACTORS

Trunk, hip, and knee range-of-motion (RoM), peak angles, and angles at initial contact during an unanticipated 45 degrees sidestep cutting task were estimated using laboratory-based three-dimensional optoelectronic motion capture. Maturation was classified using a modified Pubertal Maturational Observational Scale (PMOS) into prepubertal, midpubertal, or postpubertal stages.

MAIN OUTCOME MEASURES

Trunk total RoM in frontal, sagittal, and transverse planes; peak trunk flexion, right lateral flexion and right rotation angles; hip total RoM in frontal, sagittal, and transverse planes; hip flexion angle at initial contact; peak hip flexion and adduction angles; knee total RoM in frontal, sagittal, and transverse planes; knee flexion angle at initial contact; peak knee flexion and abduction angles.

RESULTS

As boys matured, there was a decrease in hip sagittal-plane RoM (49.02 degrees to 43.45 degrees, Benjamini-Hochberg adjusted P = 0.027), hip flexion at initial contact (29.33 degrees to 23.08 degrees, P = 0.018), and peak hip flexion (38.66 degrees to 32.71 degrees, P = 0.046), and an increase in trunk contralateral rotation (17.47 degrees to 25.05 degrees, P = 0.027).

CONCLUSIONS

Maturing male athletes adopted a more erect cutting strategy that is associated with greater knee joint loading. Knee kinematic changes that increase knee joint loading were not observed in this cohort.

Children with idiopathic toe walking display differences in lower limb joint ranges and strength compared to peers: a case control study

Background

Idiopathic toe walking (ITW) is an exclusionary diagnosis. There has been limited exploration of lower limb active range of motion and strength measures in children with ITW. This researched aimed to determine any differences in lower limb muscle active range of motion and strength in children who have ITW, compared to normative data collected from children who displayed typical gait.

Methods

Children were recruited with had a diagnosis of ITW, aged between 4 and 10 years, and no recent treatment. Data collected included parent reported data such as time spent toe walking, percentage of time spent toe walking, and clinician collected data such as age, height and weight. Joint ranges of motion and strength measures were collected by an experience clinician. Active and weight bearing joint ranges of motion were evaluated with a goniometer or digital inclinometer. Lower limb muscle strength measures were evaluated with a hand-held dynamometer. Published normative data sets were used for comparison. Measures were analysed with regression analyses to determine differences between groups in different measures, considering measures known to impact range and strength. Odds ratios (OR), 95% confidence intervals (CI) and p values were reported.

Results

Twenty-six children with ITW participated. Reduced weight bearing ankle range of motion, when measured with the knee bent, was associated with being in the ITW group (p = 0.009), being older (p < 0.001) and weighing less (p < 0.001). Reduced ankle plantar flexion range was only associated with being in the ITW group (p = 0.015). For all lower limb strength measures, excluding hip external rotation, children who displayed greater strength, did not toe walk (p < 0.002), were older (p < 0.001) and weighed more (p < 0.014). with ITW.

Conclusion

Children with ITW displayed reduced overall plantar and dorsiflexion at the ankle, compared to non-toe walking children. Reduced plantarflexion is children with ITW has not been described before, however reduced dorsiflexion is commonly reported. Children with ITW were weaker in many lower limb measures, even when age and weight were considered. This should lead clinicians and researchers to pay greater attention to lower limb strength measures in this population.

Online information about the management of anterior cruciate ligament ruptures in Australia: A content analysis

BACKGROUND

Most people who suffer an anterior cruciate ligament (ACL) injury search for information online.

OBJECTIVES

Summarise the proportion of webpages on ACL rupture management that present evidence-based information.

DESIGN

Content analysis.

METHODS

We examined webpage information on ACL ruptures identified through (1) Google searches using terms synonymous with 'anterior cruciate ligament rupture' and searching 'knee surgeon' linked to each Australian capital city, and (2) websites of professional associations. The primary outcome was the proportion of webpages that suggest people can return to at least some form of sport with non-surgical management. Secondary outcomes included webpage information on return to sport with ACL reconstruction (ACLR) and non-surgical management, benefits, harms, and risk of osteoarthritis related to these options, and activity modification.

RESULTS

Out of 115 webpages analysed, 48% suggested people can return to at least some form of sport with non-surgical management. Almost half of webpages suggested most people will return to some form of sport following ACLR (41%) and mentioned benefits of ACLR (43%). Fewer webpages mentioned benefits of non-surgical management (14%), approximately two in three people return to pre-injury level of sport following ACLR (4%), risk of re-injury following ACLR (23%), most people return to sport within 9 months of ACLR (27%), activity modification as a management approach (20%), and ACLR will reduce the risk of osteoarthritis (23%).

CONCLUSION

Most online information on ACL rupture management isn't aligned with the best available evidence. Inaccurate information could mislead patients' treatment choices and create unrealistic expectations for return to sport.

Non-contact Anterior Cruciate Ligament Injury Epidemiology in Team-Ball Sports: A Systematic Review with Meta-analysis by Sex, Age, Sport, Participation Level, and Exposure Type

Background

Not all anterior cruciate ligament (ACL) injuries are preventable. While some ACL injuries are unavoidable such as those resulting from a tackle, others that occur in non-contact situations like twisting and turning in the absence of external contact might be more preventable. Because ACL injuries commonly occur in team ball-sports that involve jumping, landing and cutting manoeuvres, accurate information about the epidemiology of non-contact ACL injuries in these sports is needed to quantify their extent and burden to guide resource allocation for risk-reduction efforts.

Objective

To synthesize the evidence on the incidence and proportion of non-contact to total ACL injuries by sex, age, sport, participation level and exposure type in team ball-sports.

Methods

Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, Scopus and SPORTDiscus) were searched from inception to July 2021. Cohort studies of team ball-sports reporting number of knee injuries as a function of exposure and injury mechanism were included.

Results

Forty-five studies covering 13 team ball-sports were included. The overall proportion of non-contact to total ACL injuries was 55% (95% CI 48–62, I² = 82%; females: 63%, 95% CI 53–71, I² = 84%; males: 50%, 95% CI 42–58, I² = 86%). The overall incidence of non-contact ACL injuries was 0.07 per 1000 player-hours (95% CI 0.05–0.10, I² = 77%), and 0.05 per 1000 player-exposures (95% CI 0.03–0.07, I² = 97%). Injury incidence was higher in female athletes (0.14 per 1000 player-hours, 95% CI 0.10–0.19, I² = 40%) than male athletes (0.05 per 1000 player-hours, 95% CI 0.03–0.07, I² = 48%), and this difference was significant. Injury incidence during competition was higher (0.48 per 1000 player-hours, 95% CI 0.32–0.72, I² = 77%; 0.32 per 1000 player-exposures, 95% CI 0.15–0.70, I² = 96%) than during training (0.04 per 1000 player-hours, 95% CI 0.02–0.07, I² = 63%; 0.02 per 1000 player-exposures, 95% CI 0.01–0.05, I² = 86%) and these differences were significant. Heterogeneity across studies was generally high.

Conclusion

This study quantifies several key epidemiological findings for ACL injuries in team ball-sports. Non-contact ACL injuries represented over half of all ACL injuries sustained. The proportion of non-contact to total ACL injuries and injury incidence were higher in female than in male athletes. Injuries mostly occurred in competition settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-022-01697-w.

Normative Reference Values for Knee Extensor Muscle Rate of Torque Development and Torque Steadiness in Adolescents and Adults

OBJECTIVE

The aim of this study was to establish reference values for rate of torque development (RTD) and muscle torque steadiness (MTS) of knee extensors across the lifespan, and evaluate if these measures are independently associated with Osteoarthritis Research Society International (OARSI)-recommended performance-based measures (6-minute walk test, 30-second chair stand test, stair climb test) and other clinical variables.

METHODS

In this cross-sectional observational study, knee extensor strength of 764 participants (12-89 years) from the 1000 Norms Project was assessed via fixed dynamometry. Age- and sex-stratified normative RTD (Nms-1 kg-1) and MTS (Nm kg-1) values were presented as means and 95% confidence intervals. Correlations and multiple regression analyses were calculated to identify factors (age, sex, height, weight, OARSI-recommended performance-based measures, Knee Injury and Osteoarthritis Outcome Score, vertical jump, long jump, grip strength, basic gait-related knee biomechanics) independently associated with RTD or MTS.

RESULTS

Age- and sex-stratified normative RTD and MTS reference values were generated. Male subjects exhibited higher RTD but poorer MTS (less steady) than female subjects across all age groups. Better performance in OARSI-recommended performance-based measures, vertical jump, long jump, and grip strength were associated with greater RTD but poorer MTS. Thirty-second chair stand test, stair climb test, vertical jump, long jump, and grip strength were independent determinants of RTD and MTS.

CONCLUSIONS

The RTD and MTS demonstrated associations with clinical variables relevant to knee osteoarthritis. The normative reference values generated may help identify the presence and extent of impairments in RTD and MTS associated with knee osteoarthritis and assist in developing responsive outcome measures for therapeutic trials.

The Effect of the FIFA 11 + with Added Neck Exercises on Maximal Isometric Neck Strength and Peak Head Impact Magnitude During Heading: A Pilot Study

BACKGROUND

Higher neck strength has been postulated to reduce head impact magnitude during purposeful heading in football.

OBJECTIVES

This pilot trial explored the effect of a neck exercise programme on (1) neck strength and (2) head impact magnitude during heading in male and female adolescent football players.

METHODS

Boys and girls (aged 12-17 years) were randomised by team to the intervention (5 weeks of supervised neuromuscular neck exercises integrated into part 2 of the FIFA 11 + , completed three times per week) or the control group (usual part 2 of the FIFA 11 + , no neck exercises). Outcomes included isometric neck strength and head impact magnitude (peak linear acceleration and peak angular velocity) during standardised heading from a throw-in (at baseline and 6 weeks) plus completion of an evaluation survey by intervention players and coaches.

RESULTS

In total, 52 players (n = 31 intervention; n = 21 control) completed the study. Mixed-model analysis of variance (ANOVA) revealed significant differences in neck strength variables (p < 0.001), peak linear acceleration (p = 0.04) and peak angular velocity (p = 0.04) between the intervention and control groups over time. Intervention players demonstrated increases in mean composite neck strength (53.8% intervention vs 15.6% control) as well as decreases in mean peak linear head acceleration during heading (- 11.8% vs - 5.0%) from baseline to follow-up. Reduction in peak angular velocity was more pronounced in girls (- 27.7%) than boys (- 11.5%) in the intervention group. The addition of neck exercises into part 2 of the FIFA 11 + was feasible and accepted by players and coaches.

CONCLUSION

On average, players who completed neck exercises demonstrated an increase in isometric neck strength and a decrease in head impact magnitude during heading. These exercises were easily incorporated into usual training. Australian New Zealand Clinical Trials Registry (no: ACTRN12619001375145).

Association Between Body Mass Index and Disability in Children With Charcot-Marie-Tooth Disease

BACKGROUND AND OBJECTIVES

This study examined the association between body mass index (BMI) and disability in children with Charcot-Marie-Tooth disease (CMT).

METHODS

We conducted a cross-sectional analysis of 477 patients with CMT who were 3 to 20 years of age from the Inherited Neuropathy Consortium and 316 age- and sex-matched healthy children from the 1,000 Norms Project. BMI was categorized according to the International Obesity Task Force (IOTF) criteria, and BMI categorization was compared with healthy children. IOTF categories (adult equivalent BMI cut points) were severely underweight (BMI <17 kg/m2), underweight (BMI ≥17-<18.5 kg/m2), healthy weight (BMI ≥18.5-<25 kg/m2), overweight (BMI ≥25-<30 kg/m2), and obese (BMI ≥30 kg/m2). Scores on the 0 to 44-point CMT Pediatric Scale (CMTPedS), a well-validated measure of disability, were examined in relation to BMI.

RESULTS

There was a higher proportion of children with CMT categorized as severely underweight (5.7% vs 0.3%), underweight (10.3% vs 5.1%), and obese (7.3% vs 3.8%) (p < 0.05). Fewer children with CMT were categorized as healthy weight (61.8% vs 74.4%) (p < 0.05), and the proportion of overweight (14.9% vs 16.5%) between groups was similar. CMTPedS scores (mean ± SD) for weight categories were as follows: severely underweight 27 ± 9, underweight 20 ± 8, healthy weight 17 ± 9, overweight 17 ± 9, and obese 22 ± 10. Compared to children with a healthy weight with CMT, being severely underweight was associated with being more disabled (p < 0.001), as was being obese (p = 0.015).

DISCUSSION

The proportion of children with CMT who are underweight or obese is higher compared to age- and sex-matched healthy children. In children with CMT, being underweight or obese is associated with greater disability, when compared to children with CMT of healthy weight.

Evaluating the validity and reliability of inertial measurement units for determining knee and trunk kinematics during athletic landing and cutting movements

Inertial Measurement Units (IMUs) are promising alternatives to laboratory-based motion capture methods in biomechanical assessment of athletic movements. The aim of this study was to investigate the validity of an IMU system for determining knee and trunk kinematics during landing and cutting tasks for clinical and research applications in sporting populations. Twenty-seven participants performed five cutting and landing tasks while being recorded using a gold-standard optoelectronic motion capture system and an IMU system. Intra-class coefficients, Pearson's r, root-mean-square error (RMSE), bias, and Bland-Altman limits of agreements between the motion capture and IMU systems were quantified for knee and trunk sagittal- and frontal-plane range-of-motion (ROM) and peak angles. Our results indicate that IMU validity was task-, joint-, and plane-dependent. Based on good-to-excellent (ICC) correlation, reasonable accuracy (RMSE < 5°), bias within 2°, and limits of agreements within 10°, we recommend the use of this IMU system for knee sagittal-plane ROM estimations during cutting, trunk sagittal-plane peak angle estimation during the double-leg landing task, trunk sagittal-plane ROM estimation for almost all tasks, and trunk frontal-plane peak angle estimation for the right single-leg landing task. Due to poor comparisons with the optoelectronic system, we do not recommend this IMU system for knee frontal-plane kinematic estimations.

When puberty strikes: Longitudinal changes in cutting kinematics in 172 high-school female athletes

OBJECTIVES

Young female athletes involved in high-speed cutting and change-of-direction sports are particularly susceptible to anterior cruciate ligament (ACL) injuries. Little is known if maturational changes in cutting technique contribute to the increased injury risk. Our objective was to examine longitudinal changes in cutting kinematics in female athletes as they matured through puberty.

DESIGN

Longitudinal cohort study METHODS: High school female athletes (n=172) performed an unanticipated 45° cutting task in the biomechanics laboratory across two or more pubertal stages. Pubertal stages were classified using a modified Pubertal Maturational Observational Scale (pre-, mid-, or post-pubertal stages). Generalized linear mixed models were used to compare kinematics across pubertal stages.

RESULTS

As girls matured through puberty, they displayed a decrease in sagittal-plane hip (1.8-2.6°, p<0.03) and knee range-of-motion (ROM) (2.7-2.9°, p≤0.01), and decreased peak hip (2.9-3.2°, p≤0.02) and knee flexion angles (2.7-2.9°, p≤0.01), which is indicative of greater quadriceps dominance. Peak knee abduction angles also increased as girls progressed through puberty (0.9-1.4°, p≤0.02), suggesting greater ligament dominance. In terms of trunk dominance, there were mixed findings with a decrease in trunk frontal- (2.5-5.7°, p≤0.03) and sagittal-plane ROM (2.0°, p≤0.01), but an increase in trunk transverse-plane ROM (2.8-3.6°, p≤0.02) observed as girls mature. Other significant changes in cutting technique were decreased peak trunk flexion (3.8-7.8°, p≤0.01), and decreased hip flexion (2.9-3.3°, p≤0.02) and knee flexion angles (2.0-3.0°, p≤0.03) at initial contact, suggesting a more upright and stiffer cutting posture.

CONCLUSIONS

As girls mature through puberty, there is a change in cutting strategy characterized by greater quadriceps and ligament dominance.

Correlates of night-time and exercise-associated lower limb cramps in healthy adults

INTRODUCTION/AIMS

We explored correlates of night-time and exercise-associated lower limb cramps in participants of the 1000 Norms Project.

METHODS

A volunteer community sample of healthy people aged ≥18 y underwent assessment of motor function and physical performance, and were questioned about muscle cramps in the previous 3 mo.

RESULTS

Of 491 (221 female) participants age 18-101 y (mean: 59.12; SD: 18.03), about 1 in 3 experienced night-time lower limb cramps, and about 1 in 4 experienced exercise-associated lower limb cramps. For night-cramps, a one unit increase in Beighton score (greater whole-body flexibility) was associated with a 31% reduced odds of cramps (odds ratio [OR] = 0.69, 95% confidence interval [CI]:0.45, 0.99) and passing all three lesser-toe strength tests was associated with 50% reduced odds of cramps (OR = 0.50, 95% CI: 0.32, 0.78). For exercise-associated cramps, participants in the fourth (lowest arch) quartile of Foot Posture Index were 2.1 times (95% CI: 1.11, 3.95) more likely to experience cramps than participants in the first (highest arch) quartile. Odds of experiencing both types of cramps versus no cramps were lower with passing all three lesser-toe strength tests (OR = 0.40, 95% CI: 0.19, 0.85) and better performance in the six-minute walk test (OR = 0.997, 95% CI: 0.996, 0.998).

DISCUSSION

People who experienced both exercise-associated and night-time cramps were less functional. The association between night-time cramps with less whole-body flexibility and reduced lesser-toe flexor strength should be explored to determine causation. Planovalgus (low-arched) foot type was independently associated with exercise-associated cramps. The effectiveness of foot orthoses for secondary prevention of exercise-associated cramps in people with low-arched feet should be explored.

L-carnitine supplementation for muscle weakness and fatigue in children with neurofibromatosis type 1: A Phase 2a clinical trial

Reduced muscle tone, muscle weakness, and physical fatigue can impact considerably on quality of life for children with neurofibromatosis type 1 (NF1). Human muscle biopsies and mouse models of NF1 deficiency in muscle show intramyocellular lipid accumulation, and preclinical data have indicated that L-carnitine supplementation can ameliorate this phenotype. The aim of this study is to examine whether daily L-carnitine supplementation is safe and feasible, and will improve muscle strength and reduce fatigue in children with NF1. A 12-week Phase 2a trial was conducted using 1000 mg daily oral levocarnitine tartrate supplementation. Recruited children were between 8 and 12 years old with a clinical diagnosis of NF1, history of muscle weakness and fatigue, and naïve to L-carnitine. Primary outcomes were safety (self-reporting, biochemical testing) and compliance. Secondary outcomes included plasma acylcarnitine profiles, functional measures (muscle strength, long jump, handwriting speed, 6-minute-walk test [6MWT]), and parent-reported questionnaires (PedsQL™, CBCL/6-18). Six children completed the trial with no self-reported adverse events. Biochemical tests for kidney and liver function were normal, and the average compliance was 95%. Plasma acylcarnitine levels were low, but within a range not clinically linked to carnitine deficiency. For strength measures, there was a mean 53% increase in dorsiflexion strength (95% confidence interval [CI] 8.89-60.75; p = 0.02) and mean 66% increase in plantarflexion strength (95% CI 12.99-134.1; p = 0.03). In terms of muscle performance, there was a mean 10% increase in long jump distance (95% CI 2.97-16.03; p = 0.01) and 6MWT distance (95% CI 5.88-75.45; p = 0.03). Comparison with the 1000 Norms Project data showed a significant improvement in Z-score for all of these measures. Parent reports showed no negative impact on quality of life, and the perceived benefits led to the majority of individuals remaining on L-carnitine after the study. Twelve weeks of L-carnitine supplementation is safe and feasible in children with NF1, and a Phase 3 trial should confirm the efficacy of treatment.

Joint hypermobility and its association with self-reported knee health: A cross-sectional study of healthy Australian adults

AIM

The primary aim of this study was to determine the association between generalized joint hypermobility (GJH), knee-specific hypermobility (KSH) and self-reported knee health in an Australian population. Secondary aims included elucidating ethnic/gender differences in GJH/KSH prevalence and knee health, and identifying KSH using a novel knee extension range of motion cut-off method.

METHOD

Knee extension range, Beighton score, and 5 domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected from adults aged 18-101 years self-identifying as healthy, and were grouped by ethnicity and gender. Two established Beighton score criteria and 1 novel knee extension range cut-off method were used to determine GJH and KSH respectively. Point-biserial correlation tested the associations between GJH/KSH and KOOS. Differences in GJH/KSH prevalence and knee health between ethnic/gender groups were determined with the Chi-squared test.

RESULTS

Of 732 participants (50% male), 80.3% were Caucasian. No correlations were found between GJH and KOOS while a very weak correlation was found between KSH and 1 KOOS domain (r > -.30; P = .04). Prevalence of GJH was higher in non-Caucasians (17.4% vs 5.6%, P < .001) and females (4.4% vs 1.1%, P = .007). Prevalence of KSH between ethnic and gender groups was not significantly different (P = .50 and P = .69 respectively). Non-Caucasians scored higher (better) in all KOOS domains than Caucasians (all P < .05).

CONCLUSION

Those who met the age- and gender-specific criteria for GJH/KSH did not report worse knee health than their non-hypermobile counterparts. Clinicians can assure individuals who exhibit GJH/KSH that these are not associated with lower knee health and function.

12-Month progression of motor and functional outcomes in congenital myotonic dystrophy

BACKGROUND

We aim to describe 12-mo functional and motor outcome performance in a cohort of participants with congenital myotonic dystrophy (CDM).

METHODS

CDM participants performed the 6 Minute Walk Test (6MWT), 10 Meter Run, 4 Stair Climb, Grip Strength, and Lip Force at baseline and 12-mo visits. Parents completed the Vineland Adaptive Behavior Scale.

RESULTS

Forty-seven participants, aged 0 to 13 y old, with CDM were enrolled. 6MWT, 10 Meter Run, and 4 Stair Climb were completed in >85% of eligible participants. The only significant difference between mean baseline and 12-mo performance was an improvement in 6MWT in children 3-6 y old (P = .008). This age group also had the largest mean % improvement in performance in all other timed functional testing. In children >7 y, the slope of change on timed functional tests decreased or plateaued, with further reductions in performance in children ≥10 y. Participants with CTG repeat lengths <500 did not perform differently than those with repeat lengths >1000.

CONCLUSIONS

The 6MWT, 10 Meter Run, and 4 Stair Climb were the most feasible measures. Our findings are consistent with the clinical profile and prior cross-sectional data, helping to establish reasonable expectations of functional trajectories in this population as well as identifying points in which therapeutic interventions may be best studied. Further study of outcomes in children >10 y old and <3 y is warranted, but this new information will assist planning of clinical trials in the CDM population.

Is there a relationship between sagittal cervical spine mobility and generalised joint hypermobility? A cross-sectional study of 1000 healthy Australians

OBJECTIVES

The primary aim was to determine the association between sagittal cervical mobility and the presence and extent of GJH across the lifespan. Secondary aims were to determine which features explain variability in cervical range of motion (CROM) and to establish the sagittal cervical hypermobile range in both genders across the lifespan.

DESIGN

Cross-sectional observational study. Spearman's rho determined the relationship between presence and extent of GJH and CROM, age, gender and ethnicity. Multiple regression identified the factors explaining variability in CROM. The hypermobile CROM was identified as the upper 5% of flexion, extension and combined ranges for age and gender.

SETTING

University laboratory in Sydney Australia.

PARTICIPANTS

One thousand healthy individuals, aged 3-101 years.

OUTCOME MEASURES

Cervical active range of motion was assessed using an inclinometer, extent of and presence of generalised joint hypermobility were assessed using the Beighton scoring system and age- and gender-specific criteria respectively.

RESULTS

CROM correlated positively with GJH (Beighton score as a continuous or dichotomous age and gender specific variable) (rho=0.12-0.50; p < 0.001) and negatively with age (rho=0.54; p < 0.001). Age, gender and extent of GJH (Beighton as a continuous score) accounted for 19 to 51% of variability in CROM. Cut-offs for cervical hypermobility were calculated across the lifespan.

CONCLUSIONS

Increased sagittal CROM was observed in individuals identified with GJH. Extension CROM decreased with age more than flexion; the greatest loss in the second and third decades. CROM screening is warranted for patients identified with GJH and for rehabilitation goal-setting.

Physical performance of children with longitudinal fibular deficiency (fibular hemimelia)

PURPOSE

Longitudinal fibular deficiency (LFD) is the most common congenital long bone deficiency. This study aimed to objectively assess the physical performance of children and adolescents with LFD compared with unaffected peers, and to examine trends over age for subgroups of the LFD population.

METHODS

Differences between children with LFD and unaffected peers were examined with hand-held dynamometry for lower-limb muscle strength, Six-Minute Walk Test, Timed up and down stairs test, Star Excursion Balance Test, and Standing long jump.

RESULTS

Thirty-nine children with LFD and 284 unaffected peers participated. Children with LFD performed at a lower level than their unaffected peers, on all measures of physical performance (mean 2.1 z-scores lower, all p < 0.01), except in long jump (p = 0.27). When comparing the performance of children with LFD to their unaffected peers across four age groups, there was a significant between-groups difference on all strength measures, and on the Six-Minute Walk distance, between children with and without LFD. These differences were smallest in young children (3-6 years) and largest in the older children (15-18 years) (all p < 0.01). Children with no lengthening surgery performed better on the Six-Minute Walk Test, covering a greater distance during the test, than those who had surgery (mean difference 83 metres, p < 0.01). There were no significant differences between children who had or had not undergone an amputation.

CONCLUSIONS

Children with LFD performed at a significantly lower level than unaffected peers on all measures of physical performance other than jumping. The largest differences were in older children. This paper provides baseline functional data for future interventions in LFD.

LEVEL OF EVIDENCE

Cross-sectional study.Implications for RehabilitationThis paper provides the first baseline functional data using validated objective measures on a consecutive cohort of children and adolescents with longitudinal fibular deficiency.Children with LFD performed significantly worse than their unaffected peers on all measures of physical performance other than jumping, with children falling further behind their peers as they age.Children who undergo an amputation typically have the most severe anatomical presentation and yet perform at an equivalent functional level.This paper identifies multiple modifiable impairments that represent potential opportunities for rehabilitation professionals to target with conservative treatment options to improve functional performance.

Feasibility of the Archercise biofeedback device to strengthen foot musculature

Background

Foot muscle weakness can produce foot deformity, pain and disability. Toe flexor and foot arch exercises focused on intrinsic foot muscle strength and functional control may mitigate the progression of foot deformity and disability. Ensuring correct exercise technique is challenging due to the specificity of muscle activation required to complete some foot exercises. Biofeedback has been used to improve adherence, muscle activity and movement patterns. We investigated the feasibility of using a novel medical device, known as “Archercise”, to provide real-time biofeedback of correct arch movement via pressure change in an inflatable bladder, and foot location adherence via sensors embedded in a footplate during four-foot exercises.

Methods

Thirty adults (63% female, aged 23–68 years) performed four-foot exercises twice on the Archercise sensor footplate alone and then with biofeedback. One-way repeated measures ANOVA with pairwise comparisons were computed to assess the consistency of the exercise protocol between trial 1 and trial 2 (prior to biofeedback), and the effectiveness of the Archercise biofeedback device between trial 2 and trial 3 (with biofeedback). Outcome measures were: Arch movement exercises of arch elevation and lowering speed, controlled arch elevation, controlled arch lowering, endurance of arch elevation; Foot location adherence was determined by percentage of time the great toe, fifth toe and heel contacted footplate sensors during testing and were analysed with paired sample t-tests. Participant survey comments on the use of Archercise with biofeedback were reported thematically.

Results

Seventeen (89%) arch movement and foot location variables were collected consistently with Archercise during the foot exercises. Archercise with biofeedback improved foot location adherence for all exercises (p = 0.003–0.008), coefficient of determination for controlled arch elevation (p < 0.0001) and endurance area ratio (p = 0.001). Twenty-nine (97%) participants reported Archercise with biofeedback, helped correct exercise performance.

Conclusions

Archercise is a feasible biofeedback device to assist healthy participants without foot pathologies perform foot doming exercises.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): 12616001559404. Registered 11 November 2016, http://www.ANZCTR.org.au/ACTRN12616001559404p.aspx

Limitations of 6-minute walk test reference values for spinal muscular atrophy

INTRODUCTION

The 6-minute walk test (6MWT) is a well-established clinical assessment of functional endurance, validated as a measure of walking ability in spinal muscular atrophy (SMA). The current availability of disease-modifying therapies for SMA indicates a growing need for normative reference data to compare SMA patients with healthy controls.

METHODS

The literature was searched in two scientific databases. Studies were evaluated and selected based on adherence to American Thoracic Society guidelines for administering the 6MWT. Reference equations from the selected studies were applied to 6MWT data collected from SMA patients to calculate and compare % predicted values.

RESULTS

Three pediatric and six adult studies were selected for comparison. The % predicted values using the pediatric and adult equations ranged from 47.7 ± 18.2% to 67.6 ± 26.2% and 43.0 ± 17.9% to 59.5 ± 26.2%, respectively, and were significantly different (P < 0.001).

DISCUSSION

Results suggest significant variability between % predicted values derived from published reference equations in children and adults, despite adherence to 6MWT standardization.

Can pedobarography predict the occurrence of heel rocker in children with lower limb spasticity?

BACKGROUND

Pedobarography software calculates the centre-of-pressure trajectory in relation to the foot to quantify foot contact patterns. This study presents two new pedobarography measures using the centre-of-pressure trajectory to assess heel rocker.

METHODS

To validate these pedobarography measures against 3D gait analysis, emed_®-x and Vicon Nexus gait analysis data were captured from 25 children aged 8-16 years (11 male) with unilateral (n = 18) and bilateral (n = 7) cerebral palsy or acquired brain injury. 3D gait analysis identified whether heel rocker was intact (n = 22 feet) or absent (n = 28 feet) based on centre-of-pressure at initial contact and the ankle kinematic curve between 0 and 2% of the gait cycle. Pedobarography measures calculated from the initial centre-of-pressure point were the distance to the heel (point of initial contact) and to the most posterior point of the trajectory (rollback), reported as a percentage of foot length.

FINDINGS

The median point of initial contact in limbs with an intact heel rocker was 9% (range 7-12%) and median rollback was 0% (range 0-0.2%), whereas the median point of initial contact in limbs with an absent heel rocker was 58% (range 8-78%) and rollback was 18% (range 0-40%). Point of initial contact is the more accurate method for predicting heel rocker, with a threshold of 14% of foot length identifying the correct heel rocker status in 94% of cases.

INTERPRETATION

Point of initial contact can assess heel rocker with high accuracy. Both point of initial contact and rollback provide sensitive information on foot strike pattern, enhancing the utility of pedobarography.

Knee thrust prevalence and normative hip-knee-ankle angle deviation values among healthy individuals across the lifespan

OBJECTIVE

To report the prevalence of varus thrust and normative values for hip-knee-ankle (HKA) angle deviation across the lifespan, and to explore associations between HKA angle deviation and selected clinical factors.

DESIGN

This was a cross-sectional observational study of 572 participants from the 1000 Norms Project, aged 3-101 years and who self-reported as being healthy. Video recordings (2D) of frontal plane gait were reviewed by physiotherapists for presence of knee thrust and quantification of HKA angle deviation (the difference between HKA angle at initial contact and mid-stance). Age and sex-stratified normative HKA angle deviation values were presented as means and 95% confidence intervals (CIs). Correlations were calculated between HKA angle and clinical measures (age, sex, body mass index (BMI), alignment, knee and hip strength, Knee Injury and Osteoarthritis Outcomes Scores (KOOS), foot posture index, temporo-spatial gait, and hypermobility).

RESULTS

Overall, 31% of the cohort had varus thrust, most prevalent among adults older than 60 years (42%) and children aged 3-9 (41%). Varus thrust was common in adolescents (25%) and adults aged 20-59 (23%). Mean HKA angle deviation for the entire cohort was 1.2° (95%CI: 1.07, 1.36) towards varus, and 2.1° (95%CI: 1.84, 2.36) among people with clinical varus thrust. Weak associations were identified between HKA angle deviation and BMI, stride width, and KOOS-Sports among adolescents, and in adults weakly associated with height.

CONCLUSIONS

Prevalence of varus thrust is common across the lifespan. Normative values established here can be readily used by clinicians and researchers in monitoring this gait deviation.

What are the similarities and differences between healthy people with and without pain?

BACKGROUND AND AIMS

Knowledge of pain characteristics among the healthy population or among people with minimal pain-related disability could hold important insights to inform clinical practice and research. This study investigated pain prevalence among healthy individuals and compared psychosocial and physical characteristics between adults with and without pain.

METHODS

Data were from 1,000 self-reported healthy participants aged 3-101 years (1,000 Norms Project). Single-item questions assessed recent bodily pain ("none" to "very severe") and chronic pain (pain every day for 3 months in the previous 6 months). Assessment of Quality of Life (AQoL) instrument, New Generalised Self-Efficacy Scale, International Physical Activity Questionnaire, 6-min walk test, 30-s chair stand and timed up-and-down stairs tests were compared between adults with and without pain.

RESULTS

Seventy-two percent of adults and 49% of children had experienced recent pain, although most rated their pain as mild (80% and 87%, respectively). Adults with recent pain were more likely to be overweight/obese and report sleep difficulties, and had lower self-efficacy, AQoL mental super dimension scores and sit-to-stand performance, compared to adults with no pain (p<0.05). Effect sizes were modest (Cohen's d=0.16-0.39), therefore unlikely clinically significant. Chronic pain was reported by 15% of adults and 3% of children. Adults with chronic pain were older, more likely to be overweight/obese, and had lower AQoL mental super dimension scores, 6-min walk, sit-to-stand and stair-climbing performance (p<0.05). Again, effect sizes were modest (Cohen's d=0.25-0.40).

CONCLUSIONS

Mild pain is common among healthy individuals. Adults who consider themselves healthy but experience pain (recent/chronic) display slightly lower mental health and physical performance, although these differences are unlikely clinically significant.

IMPLICATIONS

These findings emphasise the importance of assessing pain-related disability in addition to prevalence when considering the disease burden of pain. Early assessment of broader health and lifestyle risk factors in clinical practice is emphasised. Avenues for future research include examination of whether lower mental health and physical performance represent risk factors for future pain and whether physical activity levels, sleep and self-efficacy are protective against chronic pain-related disability.

Spatiotemporal and plantar pressure patterns of 1000 healthy individuals aged 3-101 years

OBJECTIVE

The purpose of this study was to establish normative reference values for spatiotemporal and plantar pressure parameters, and to investigate the influence of demographic, anthropometric and physical characteristics.

METHODS

In 1000 healthy males and females aged 3-101 years, spatiotemporal and plantar pressure data were collected barefoot with the Zeno™ walkway and Emed^® platform. Correlograms were developed to visualise the relationships between widely reported spatiotemporal and pressure variables with demographic (age, gender), anthropometric (height, mass, waist circumference) and physical characteristics (ankle strength, ankle range of motion, vibration perception) in children aged 3-9 years, adolescents aged 10-19 years, adults aged 20-59 years and older adults aged over 60 years.

RESULTS

A comprehensive catalogue of 31 spatiotemporal and pressure variables were generated from 1000 healthy individuals. The key findings were that gait velocity was stable during adolescence and adulthood, while children and older adults walked at a comparable slower speed. Peak pressures increased during childhood to older adulthood. Children demonstrated highest peak pressures beneath the rearfoot whilst adolescents, adults and older adults demonstrated highest pressures at the forefoot. Main factors influencing spatiotemporal and pressure parameters were: increased age, height, body mass and waist circumference, as well as ankle dorsiflexion and plantarflexion strength.

CONCLUSION

This study has established whole of life normative reference values of widely used spatiotemporal and plantar pressure parameters, and revealed changes to be expected across the lifespan.

Self-reported knee pain and disability among healthy individuals: reference data and factors associated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child

OBJECTIVE

To develop normative reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child, as well as investigate socio-demographic, psychological and physical factors associated with knee pain and disability among healthy adults.

METHOD

The KOOS or KOOS-Child (each containing five subscales) was administered to participants aged 8-101 years within the 1000 Norms Project, an observational study of 1000 self-reported healthy individuals. Self-efficacy, physical activity, body mass index (BMI), lower limb alignment, knee frontal plane projection angle (FPPA), knee range of motion (ROM), knee and hip strength, six-minute walk, 30-second chair stand and timed up and down stairs tests were collected. KOOS data were dichotomised using established cut-off scores and logistic regression analyses were conducted for each subscale.

RESULTS

Socio-demographic characteristics were similar to the Australian population. Normative reference data were generated for children (8-17 years) and adults (18-101 years). Female adults were up to twice as likely to report knee pain, symptoms and sport/recreation (Sport/Rec) limitations compared to males (P < .05). Older age, lower self-efficacy, greater BMI, varus lower limb alignment, lower knee flexion ROM and lower hip external rotation (ER) strength were independently associated with knee pain and disability among adults.

CONCLUSIONS

Age- and gender-stratified reference data for the KOOS and KOOS-Child have been developed to guide interpretation of results in practice and research for individuals with knee disorders. Psychological and physical factors are linked with self-reported knee pain/disability among adults, and longitudinal studies to investigate causation are required.

Relationship between physical performance and self-reported function in healthy individuals across the lifespan

BACKGROUND

Functional outcome measures in clinical trials of musculoskeletal conditions need to be meaningful to individuals.

OBJECTIVES

To investigate the relationship between physical performance and self/proxy-reported function in 1000 healthy children and adults.

DESIGN

Cross-sectional observational study (1000 Norms Project).

METHODS

One thousand males and females aged 3-101 years, healthy by self-report and without major physical disability, were recruited. Twelve performance-based tests were analysed: vertical and long jump, two hand dexterity tests, four balance tests, stepping reaction time, 30-second chair stand, timed up-and-down stairs, and six-minute walk. Self/proxy-reported function was assessed using the Infant-Toddler Quality of Life questionnaire, Child Health Questionnaire, Assessment of Quality of Life (AQoL)-6D Adolescent, AQoL-8D, International Physical Activity Questionnaire and work ability question. Bivariate and multivariate correlational analyses were constructed for infants (3-4y), children (5-10y), adolescents (11-17y), adults (18-59y) and older adults (60+).

RESULTS/FINDINGS

Socio-demographic characteristics were similar to the Australian population. Among infants/children, greater jump and sit-to-stand performance correlated with higher proxy-reported function (p < 0.05). There were no significant relationships observed for adolescents (p > 0.05). Greater jump, dexterity, balance, reaction time, sit-to-stand, stair-climbing and six-minute walk performance correlated with higher self-reported function in adults (r = -0.097 to.231; p < 0.05) and older adults (r = -0.135 to 0.625; p < 0.05). Multivariate regression modelling revealed a collection of independent performance measures explaining up to 46% of the variance in self/proxy-reported function.

CONCLUSIONS

Many performance-based tests were significantly associated with self/proxy-reported function. We have identified a set of physical measures which could form the basis of age-appropriate functional scales for clinical trials of musculoskeletal conditions.

Reference values and factors associated with musculoskeletal symptoms in healthy adolescents and adults

BACKGROUND

Insufficient attention has been given to individuals who report musculoskeletal symptoms yet experience minimal disability.

OBJECTIVES

To examine musculoskeletal symptoms among healthy individuals, and compare demographic, psychological and physical factors between individuals with and without symptoms.

DESIGN

Cross-sectional observational study.

METHOD

Data were from the 1000 Norms Project which recruited 1000 individuals aged 3-101 years. Participants were healthy by self-report and had no major physical disability. Musculoskeletal symptoms (ache/pain/discomfort, including single-site and multi-site symptoms) were assessed in adolescents (11-17y) and adults (18-101y) using the Extended Nordic Musculoskeletal Questionnaire (NMQ-E). To compare individuals with single-site, multi-site and no symptoms, body mass index, grip strength, 6-min walk, 30-s chair stand and timed up-and-down stairs (all participants), and mental health, sleep difficulties, self-efficacy and physical activity (adults), were collected.

RESULTS

/findings: Socio-demographic characteristics were similar to the Australian population. Twelve-month period prevalence of all symptoms was 69-82%; point prevalence was 23-39%. Adults with single-site symptoms were more likely to be overweight/obese and had lower sit-to-stand and stair-climbing performance (p < 0.05). Adults with multi-site symptoms were more likely to be female and overweight/obese, had lower mental health, greater sleep difficulties and lower grip strength, 6-min walk and sit-to-stand performance (p < 0.05). Differences were only observed among 50-59, 60-69, 70-79 and 80-101 year-olds.

CONCLUSIONS

Normative reference data for the NMQ-E have been generated. Musculoskeletal symptoms are common among healthy individuals. In older adults, musculoskeletal symptoms are linked with overweight/obesity, lower mental health, sleep difficulties and lower physical performance, emphasising the importance of multi-dimensional assessments in musculoskeletal disorders.

Repeatability, consistency, and accuracy of hand-held dynamometry with and without fixation for measuring ankle plantarflexion strength in healthy adolescents and adults

INTRODUCTION

Hand-held dynamometry (HHD) is commonly used to measure ankle plantarflexion strength but has variable reliability measuring higher forces. Fixed HHD is suggested to improve reliability. We, therefore, compared the reliability, consistency, and accuracy of measuring plantarflexion strength.

METHODS

Plantarflexion strength was measured in 25 healthy individuals with fixed HHD and HHD alone. Intraclass correlation coefficients (ICC_2,2 ), SEM, minimal detectable change, and Spearman correlation coefficients were calculated to assess inter-trial repeatability, consistency, agreement, and accuracy.

RESULTS

Both methods were repeatable (ICC_2,2 0.96 to 0.98) and highly correlated (Spearman rho = 0.815; P < 0.01). Fixed HHD produced significantly higher force outputs. HHD alone provided more consistent force values.

CONCLUSIONS

Both methods of measuring ankle plantarflexion force were reliable. Force measured with fixed HHD will likely be more accurate for adults and individuals with greater strength, while HHD alone will be more consistent for individuals with lower strength. Muscle Nerve 56: 896-900, 2017.

Reference values for developing responsive functional outcome measures across the lifespan

Objective:

To generate a reference dataset of commonly performed functional outcome measures in 1,000 children and adults and investigate the influence of demographic, anthropometric, strength, and flexibility characteristics.

Methods:

Twelve functional outcome measures were collected from 1,000 healthy individuals aged 3–101 years: 6-minute walk test, 30-second chair stand test, timed stairs test, long jump, vertical jump, choice stepping reaction time, balance (Star Excursion Balance Test, tandem stance eyes open and closed, single-leg stance eyes closed), and dexterity (9-hole peg test, Functional Dexterity Test). Correlation and multiple regression analyses were performed to identify factors independently associated with each measure.

Results:

Age- and sex-stratified reference values for functional outcome measures were generated. Functional performance increased through childhood and adolescence, plateaued during adulthood, and declined in older adulthood. While balance did not differ between the sexes, male participants generally performed better at gross motor tasks while female participants performed better at dexterous tasks. Height was the most consistent correlate of functional performance in children, while lower limb muscle strength was a major determinant in adolescents and adults. In older adults, age, lower limb strength, and joint flexibility explained up to 63% of the variance in functional measures.

Conclusions:

These normative reference values provide a framework to accurately track functional decline associated with neuromuscular disorders and assist development and validation of responsive outcome measures for therapeutic trials.

Normative reference values for strength and flexibility of 1,000 children and adults

OBJECTIVE

To establish reference values for isometric strength of 12 muscle groups and flexibility of 13 joint movements in 1,000 children and adults and investigate the influence of demographic and anthropometric factors.

METHODS

A standardized reliable protocol of hand-held and fixed dynamometry for isometric strength of ankle, knee, hip, elbow, and shoulder musculature as well as goniometry for flexibility of the ankle, knee, hip, elbow, shoulder, and cervical spine was performed in an observational study investigating 1,000 healthy male and female participants aged 3-101 years. Correlation and multiple regression analyses were performed to identify factors independently associated with strength and flexibility of children, adolescents, adults, and older adults.

RESULTS

Normative reference values of 25 strength and flexibility measures were generated. Strong linear correlations between age and strength were identified in the first 2 decades of life. Muscle strength significantly decreased with age in older adults. Regression modeling identified increasing height as the most significant predictor of strength in children, higher body mass in adolescents, and male sex in adults and older adults. Joint flexibility gradually decreased with age, with little sex difference. Waist circumference was a significant predictor of variability in joint flexibility in adolescents, adults, and older adults.

CONCLUSIONS

Reference values and associated age- and sex-stratified z scores generated from this study can be used to determine the presence and extent of impairments associated with neuromuscular and other neurologic disorders, monitor disease progression over time in natural history studies, and evaluate the effect of new treatments in clinical trials.

Symptomatic 5-fluorouracil-induced sinus bradycardia

5-Fluorouracil (5-FU) is a commonly used anti-neoplastic agent. 5-FU has been not uncommonly associated with cardiotoxicity, although the many potentially causative mechanisms are yet to be established. Here, we present the case of a 61-year-old gemstone miner who developed symptomatic sinus bradycardia while receiving a continuous 5-FU infusion combined with radiotherapy for locally advanced rectal cancer. This dysrhythmia is an unusual type of 5-FU toxicity, our case being the second described. We review the actions of 5-FU and the various proposed mechanisms of its cardiotoxic effects.

H2AX phosphorylation screen of cells from radiosensitive cancer patients reveals a novel DNA double-strand break repair cellular phenotype

Background:

About 1–5% of cancer patients suffer from significant normal tissue reactions as a result of radiotherapy (RT). It is not possible at this time to predict how most patients’ normal tissues will respond to RT. DNA repair dysfunction is implicated in sensitivity to RT particularly in genes that mediate the repair of DNA double-strand breaks (DSBs). Phosphorylation of histone H2AX (phosphorylated molecules are known as γH2AX) occurs rapidly in response to DNA DSBs, and, among its other roles, contributes to repair protein recruitment to these damaged sites. Mammalian cell lines have also been crucial in facilitating the successful cloning of many DNA DSB repair genes; yet, very few mutant cell lines exist for non-syndromic clinical radiosensitivity (RS).

Methods:

Here, we survey DNA DSB induction and repair in whole cells from RS patients, as revealed by γH2AX foci assays, as potential predictive markers of clinical radiation response.

Results:

With one exception, both DNA focus induction and repair in cell lines from RS patients were comparable with controls. Using γH2AX foci assays, we identified a RS cancer patient cell line with a novel ionising radiation-induced DNA DSB repair defect; these data were confirmed by an independent DNA DSB repair assay.

Conclusion:

γH2AX focus measurement has limited scope as a pre-RT predictive assay in lymphoblast cell lines from RT patients; however, the assay can successfully identify novel DNA DSB repair-defective patient cell lines, thus potentially facilitating the discovery of novel constitutional contributions to clinical RS.