Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: a cross-sectional study

Gluteal tendinopathy is the most common lower limb tendinopathy presenting to general practice. It has a high prevalence amongst middle-aged women and impacts on daily activities, work participation and quality of life. The aim was to compare physical and psychological characteristics between subgroups of severity of pain and disability.A multicentre cross-sectional cohort of 204 participants (mean age 55\ua0years, 82% female) who had a clinical diagnosis of gluteal tendinopathy with magnetic resonance imaging confirmation were assessed. A range of physical and psychosocial characteristics were recorded. Pain and disability were measured with the VISA-G questionnaire. A cluster analysis was used to identify mild, moderate and severe subgroups based on total VISA-G scores. Between-group differences were then evaluated with a MANCOVA, including sex and study site as covariates, followed by a Bonferroni post hoc test. Significance was set at 0.05.There were significantly higher pain catastrophizing and depression scores in the more severe subgroups. Lower pain self-efficacy scores were found in the severe group compared to the moderate and mild groups. Greater waist girth and body mass index (BMI), lower activity levels and poorer quality of life were reported in the severe group compared to the mild group. Hip abductor muscle strength and hip circumference did not differ between subgroups of severity.Individuals with severe gluteal tendinopathy present with psychological distress, poorer quality of life, greater BMI and waist girth. Given these features, the consideration of psychological factors in more severe patients may be important to optimize patient outcomes and reduce healthcare utilization.Patients with severe gluteal tendinopathy exhibit greater psychological distress, poorer quality of life and greater waist girth and BMI when compared to less severe cases. This implies that clinicians ought to consider psychological factors in the management of more severe gluteal tendinopathy

The foot posture index, ankle lunge test, Beighton scale and the lower limb assessment score in healthy children: a reliability study

<p>Abstract</p> <p>Background</p> <p>Outcome measures are important when evaluating treatments and physiological progress in paediatric populations. Reliable, relevant measures of foot posture are important for such assessments to be accurate over time. The aim of the study was to assess the intra- and inter-rater reliability of common outcome measures for paediatric foot conditions.</p> <p>Methods</p> <p>A repeated measures, same-subject design assessed the intra- and inter-rater reliability of measures of foot posture, joint hypermobility and ankle range: the Foot Posture Index (FPI-6), the ankle lunge test, the Beighton scale and the lower limb assessment scale (LLAS), used by two examiners in 30 healthy children (aged 7 to 15 years). The Oxford Ankle Foot Questionnaire (OxAFQ-C) was completed by participants and a parent, to assess the extent of foot and ankle problems.</p> <p>Results</p> <p>The OxAFQ-C demonstrated a mean (SD) score of 6 (6) in adults and 7(5) for children, showing good agreement between parents and children, and which indicates mid-range (transient) disability. Intra-rater reliability was good for the FPI-6 (ICC = 0.93 - 0.94), ankle lunge test (ICC = 0.85-0.95), Beighton scale (ICC = 0.96-0.98) and LLAS (ICC = 0.90-0.98). Inter-rater reliability was largely good for each of the: FPI-6 (ICC = 0.79), ankle lunge test (ICC = 0.83), Beighton scale (ICC = 0.73) and LLAS (ICC = 0.78).</p> <p>Conclusion</p> <p>The four measures investigated demonstrated adequate intra-rater and inter-rater reliability in this paediatric sample, which further justifies their use in clinical practice.</p

A Randomized Trial of Patellofemoral Bracing for Treatment of Patellofemoral Osteoarthritis

Purpose The number of effective knee osteoarthritis (OA) interventions, especially those tailored to specific compartmental involvement, are small. The objective of this study was to determine the efficacy of a realigning patellofemoral (PF) brace in improving pain and function among persons with symptomatic lateral PF OA. Method We conducted a double blind, randomized crossover trial of a realigning PF brace for persons with lateral PF OA. Participants had lateral PF OA with anterior knee symptoms on most days of the month, lateral PF joint space narrowing, and radiographic evidence of a definite osteophyte in the PF joint. We compared two treatments: (1) Control treatment consisting of a BioSkin Q Brace with patellar realigning strap removed; and (2) Active treatment consisting of a realigning BioSkin Q Brace with the strap applied. For each participant, the trial lasted 18 weeks, including 6 weeks each of active and control treatment period separated by a 6-week washout period. The order of treatments was randomized. The primary outcome was change in knee pain on the visual analog scale (VAS). Secondary outcomes included WOMAC pain, function, and stiffness. An unstructured correlation matrix for observations within participants was used in generalized estimating equation fitting to derive a linear regression model that expressed the relation between the intervention and change in VAS pain. Results 80 participants (63 F) with a mean age and body mass index of 61 years and 28 kg/m2, respectively, were randomized by order of treatment. A model examining the main effects for change in VAS knee pain (0–100) demonstrated no significant treatment effect (−0.68 VAS units, 95% CI: −6.2, 4.8 units, P = 0.81) and no differential carryover effect. There was also no significant difference between active and control treatments for WOMAC pain, function, or stiffness outcomes. Conclusion The effects of a specific realigning PF brace are not of clinical or statistical significance

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: Protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)

Introduction Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people's risk of poor outcome. Methods and analysis Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-Adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-To-Treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. Ethics and dissemination Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. Trial registration number ACTRN12619000871145

Patient-Facing Mobile Apps to Support Physiotherapy Care: Protocol for a Systematic Review of Apps Within App Stores

BACKGROUND: Care delivered by physiotherapists aims to facilitate engagement in positive health behaviors by patients (eg, adherence to exercise). However, research suggests that behavioral interventions are frequently omitted from care. Hence, better understanding of strategies that can be used by physiotherapists to support patients to engage in positive behaviors is important and likely to optimize outcomes. Digital health interventions delivered via mobile apps are garnering attention for their ability to support behavior change. They have potential to incorporate numerous behavior change techniques (BCTs) to support goals of physiotherapy care, including but not limited to self-monitoring, goal setting, and prompts/alerts. Despite their potential to support physiotherapy care, much is still unknown about what apps are available to consumers, the BCTs they use, their quality, and their potential to change behaviors. OBJECTIVE: The primary aim of this study is to systematically review the mobile apps available in app stores that are intended for use by patients to support physiotherapy care, including the BCTs within these apps. The secondary aims are to evaluate the quality and behavior change potential of these apps. METHODS: A systematic review of mobile apps in app stores will be undertaken. This will be guided by recommendations for systematic reviews in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement but adapted to suit our app store search, consistent with similar systematic reviews of apps published in the Journal of Medical Internet Research. Apple Store and Google Play will be searched with a two-step search strategy, using terms relevant to physiotherapy, physiotherapists, and common physiotherapy care. Key eligibility criteria will include apps that are intended for use by patients and are self-contained or stand-alone without the need of additional wearable devices or other add-ons. Included apps will be coded for BCTs and rated for quality using the Mobile Application Rating Scale (MARS) and for potential to change behavior using the App Behavior Change Scale (ABACUS). RESULTS: App store search and screening are expected to be completed in 2021. Data extraction and quality appraisal are expected to commence by November 2021. The study results are expected to be published in a subsequent paper in 2022. CONCLUSIONS: Knowledge gained from this review will support clinical practice and inform research by providing a greater understanding of the quality of currently available mobile apps and their potential to support patient behavior change goals of physiotherapy care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/29047

Tibiofemoral Contact Forces in the Anterior Cruciate Ligament-Reconstructed Knee.

PURPOSE: To investigate differences in ACL reconstructed (ACLR) and healthy individuals in terms of the magnitude of the tibiofemoral contact forces, as well as the relative muscle and external load contributions to those contact forces, during walking, running and sidestepping gait tasks. METHODS: A computational electromyography-driven neuromusculoskeletal model was used to estimate the muscle and tibiofemoral contact forces in those with combined semitendinosus and gracilis tendon autograft ACLR (n=104, 29.7±6.5 years, 78.1±14.4 kg) and healthy controls (n=60, 27.5±5.4 years, 67.8±14.0 kg) during walking (1.4±0.2 ms), running (4.5±0.5 ms) and sidestepping (3.7±0.6 ms). Within the computational model, the semitendinosus of ACLR participants was adjusted to account for literature reported strength deficits and morphological changes subsequent to autograft harvesting. RESULTS: ACLRs had smaller maximum total and medial tibiofemoral contact forces (~80% of control values, scaled to bodyweight) during the different gait tasks. Compared to controls, ACLRs were found to have a smaller maximum knee flexion moment, which explained the smaller tibiofemoral contact forces. Similarly, compared to controls, ACLRs had both a smaller maximum knee flexion angle and knee flexion excursion during running and sidestepping, which may have concentrated the articular contact forces to smaller areas within the tibiofemoral joint. Mean relative muscle and external load contributions to the tibiofemoral contact forces were not significantly different between ACLRs and controls. CONCLUSION: ACLRs had lower bodyweight-scaled tibiofemoral contact forces during walking, running and sidestepping, likely due to lower knee flexion moments and straighter knee during the different gait tasks. The relative contributions of muscles and external loads to the contact forces were equivalent between groups

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study. Their primary role was to provide remotely delivered weight-loss services (via the Healthy Weight for Life program) to eligible participants in the intervention group. These services were partly provided as in-kind and partly funded through the study. We have received ethical approval from the University of Sydney to replace the Healthy Weight for Life program with the Commonwealth Scientific and Industrial Research Organisation's (CSIRO) Total Wellbeing Diet. The amended weight loss advice and support paragraph of the manuscript is outlined below. All changes to the protocol were made and approved before starting the trial and were prospectively changed on our trial registration (ACT RN12617001595303). Amended weight loss advice and support paragraph: If the patient has a BMI =27 kg/m2, the patient will be offered the option of participating in the remotelydelivered weight loss program. The Australian Commonwealth Scientific and Industrial Research Organisation's (CSIRO) "Total Wellbeing Diet" is based on an evidence-based weight management strategy that utilises a structured, nutritionally balanced eating plan designed to be incorporated into a balanced lifestyle program [2, 3]. The program is a 12- week, low glycaemic index, high protein, healthy eating program with online support and tracking tools, meal plans and educational resources on a healthy diet. It is delivered by SP Health (http://www.sphealth.com/) on behalf of the CSIRO. After completion of the 12-week program, patients may elect to continue the basic program for an additional 12-weeks. Patients who elect to undertake the online weight-loss program will continue to be supported by the PARTNER Care Support Team throughout their time on the weight-loss program. This program will be undertaken in conjunction with the PARTNER exercise program and educational resources on healthy lifestyle change.

Tibiofemoral contact forces during walking, running and sidestepping

We explored the tibiofemoral contact forces and the relative contributions of muscles and external loads to those contact forces during various gait tasks. Second, we assessed the relationships between external gait measures and contact forces. A calibrated electromyography-driven neuromusculoskeletal model estimated the tibiofemoral contact forces during walking (1.44 ± 0.22 m s−1), running (4.38 ± 0.42 m s−1) and sidestepping (3.58 ± 0.50 m s−1) in healthy adults (n = 60, 27.3 ± 5.4 years, 1.75 ± 0.11 m, and 69.8 ± 14.0 kg). Contact forces increased from walking (∼1–2.8 BW) to running (∼3–8 BW), sidestepping had largest maximum total (8.47 ± 1.57 BW) and lateral contact forces (4.3 ± 1.05 BW), while running had largest maximum medial contact forces (5.1 ± 0.95 BW). Relative muscle contributions increased across gait tasks (up to 80–90% of medial contact forces), and peaked during running for lateral contact forces (∼90%). Knee adduction moment (KAM) had weak relationships with tibiofemoral contact forces (all R2 < 0.36) and the relationships were gait task-specific. Step-wise regression of multiple external gait measures strengthened relationships (0.20 < Radj2 < 0.78), but were variable across gait tasks. Step-wise regression equations from a particular gait task (e.g. walking) produced large errors when applied to a different gait task (e.g. running or sidestepping). Muscles well stabilized the knee, increasing their role in stabilization from walking to running to sidestepping. KAM was a poor predictor of medial contact force and load distributions. Step-wise regression models results suggest the relationships between external gait measures and contact forces cannot be generalized across tasks. Neuromusculoskeletal modelling may be required to examine tibiofemoral contact forces and role of muscle in knee stabilization across gait tasks

Feasibility of neuromuscular training in patients with severe hip or knee OA: The individualized goal-based NEMEX-TJR training program

<p>Abstract</p> <p>Background</p> <p>Although improvements are achieved by general exercise, training to improve sensorimotor control may be needed for people with osteoarthritis (OA). The aim was to apply the principles of neuromuscular training, which have been successfully used in younger and middle-aged patients with knee injuries, to older patients with severe hip or knee OA. We hypothesized that the training program was feasible, determined as: 1) at most acceptable self-reported pain following training; 2) decreased or unchanged pain during the training period; 3) few joint specific adverse events related to training, and 4) achieved progression of training level during the training period.</p> <p>Methods</p> <p>Seventy-six patients, between 60 and 77 years, with severe hip (n = 38, 55% women) or knee OA (n = 38, 61% women) underwent an individualized, goal-based neuromuscular training program (NEMEX-TJR) in groups for a median of 11 weeks (quartiles 7 to 15) prior to total joint replacement (TJR). Pain was self-reported immediately after each training session on a 0 to 10 cm, no pain to pain as bad as it could be, scale, where 0-2 indicates safe, > 2 to 5 acceptable and > 5 high risk pain. Joint specific adverse events were: not attending or ceasing training because of increased pain/problems in the index joint related to training, and self-reported pain > 5 after training. The level of difficulty of training was registered.</p> <p>Results</p> <p>Patients with severe OA of the hip or knee reported safe pain (median 2 cm) after training. Self-reported pain was lower at training sessions 10 and 20 (p = 0.04) and unchanged at training sessions 5 and 15 (p = 0.170, p = 0.161) compared with training session 1. There were no joint specific adverse events in terms of not attending or ceasing training. Few patients (n = 17, 22%) reported adverse events in terms of self-reported pain > 5 after one or more training sessions. Progression of training level was achieved over time (p < 0.001).</p> <p>Conclusions</p> <p>The NEMEX-TJR training program is feasible in patients with severe hip or knee OA, in terms of safe self-reported pain following training, decreased or unchanged pain during the training period, few joint specific adverse events, and achieved progression of training level during the training period.</p

Ownership and control in a competitive industry

We study a differentiated product market in which an investor initially owns a controlling stake in one of two competing firms and may acquire a non-controlling or a controlling stake in a competitor, either directly using her own assets, or indirectly via the controlled firm. While industry profits are maximized within a symmetric two product monopoly, the investor attains this only in exceptional cases. Instead, she sometimes acquires a noncontrolling stake. Or she invests asymmetrically rather than pursuing a full takeover if she acquires a controlling one. Generally, she invests indirectly if she only wants to affect the product market outcome, and directly if acquiring shares is profitable per se. --differentiated products,separation of ownership and control,private benefits of control