‘Spring Theory’ - The Role of the Ankle during Sub-Maximal Hopping and its Modulation by Pathology, Fatigue and Training

This thesis explores how various modulatory factors (pathology, fatigue, and therapeutic training) influenced ankle behaviour during a sub-maximal hopping task. In addition, it presents a novel theoretical model, referred to as ‘Spring Theory’ that describes a model by which clinicians, researchers and educators can explore lower limb overuse injury

The association of working alliance, outcome expectation, adherence and self-efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study)

Introduction: This study evaluated the feasibility of a large longitudinal cohort study utilizing an online platform to investigate the association and predictive relationship of working alliance, outcome expectations, adherence and self-efficacy with outcome in Achilles tendinopathy. The objectives were: (1) to determine the recruitment and retention rate and (2) to carry out preliminary data analysis of the selected variables and clinical outcomes. Methods: A multi-centred, longitudinal feasibility cohort study was used. Eligible participants were directed to a bespoke online platform hosting study information and the outcome measures in the form of an online questionnaire. Responses from the online questionnaire were collected on three occasions: at baseline, at 6 and at 12 weeks following completion of the first questionnaire. Feasibility outcomes (recruitment and retention rates) were described using descriptive statistics. Results: The website recorded a total 55 views. These 55 views resulted in 24 participants consenting to join the study. The questionnaire at baseline was started 63 times and completed on 60 separate occasions resulting in a 95% conversion rate. Retainment for completion of the questionnaire for a second time was 83.3% and for the third time was 66.6%. All questionnaires were completed fully yielding a missing data indicator of 0%. Conclusions: Feasibility studies ask the question ‘can this be done’? Based on the data from recruitment and rates and exploratory correlation analysis a future study can be done; this previously untested online platform appears feasible, but changes could be useful before proceeding to a much larger study

Eccentric loading increases peak torque angle of the ankle plantar flexors in healthy volunteers

Eccentric loading of the ankle plantar Flexor’s (PF) has demonstrated clinical efficacy in the conservative treatment of Achilles tendinopathy, however, its mechanism of therapeutic benefit remains unclear. The purpose of this study was to examine the effects of PF eccentric loading on PF angle to peak torque (AtPT), peak torque (PT) and lower limb vertical stiffness. Thirty healthy volunteers were randomised to an eccentric (n=15) or concentric (n=13) exercise group. A 10-week loading programme of the ankle plantar flexors was completed. AtPT, PT and vertical stiffness were compared within and between groups before and after the interventions. AtPT increased in the eccentric group by 3.2° dorsiflexion (p=0.001) and decreased by 0.7° dorsiflexion (p=0.528) for the concentric group with significant post-intervention group differences (p\u3c0.001). PT levels were unchanged following the interventions for both groups (p\u3e0.2); however, post-intervention the eccentric group showed a greater PT than the concentric group (p\u3e0.05). Between group comparison showed no significant difference in vertical stiffness (p\u3e0.5). However, the concentric group demonstrated a vertical stiffness increase of 765kNm-¹ (p ≥ 0.05). This study demonstrates that a clinically derived eccentric loading programme can produce an adaptive shift in AtPT of the ankle plantar flexors in a healthy population. These results support the theory that in part, eccentric loading derives its therapeutic benefit from mechanisms that influence plantar flexor motor performance

Eccentric fatigue modulates stretch-shortening cycle effectiveness - a possible role in lower limb overuse injuries

The role of fatigue in injury development is an important consideration for clinicians. In particular, the role of eccentric fatigue in stretch shortening cycle (SSC) activities may be linked to lower limb overuse conditions. The purpose of this study was to explore the influence of ankle plantarflexor eccentric fatigue on SSC effectiveness during a hopping task in healthy volunteers. 11 healthy volunteers (23.2 ± 6.7 years) performed a sub-maximal hopping task on a custom- built sledge system. 3D motion capture and surface EMG were utilised to measure lower limb stiffness, temporal kinematic measures and muscle timing measures at baseline and immediately following an eccentric fatigue protocol. A linear mixed model was used to test whether measures differed between conditions. Compared to baseline, eccentric fatigue induced increased stiffness during the hopping task (+ 15.3 %; P \u3c 0.001). Furthermore, ankle stretch amplitude decreased (– 9.1 %; P \u3c 0.001), whilst all other ankle kinematic measures remained unchanged. These changes were accompanied by a temporal shift in onset of activity in soleus and tibialis anterior muscles (– 4.6 to – 8.5 %; p \u3c 0.001). These findings indicate that eccentric fatigue alters SSC effectiveness in healthy volunteers. These findings may be applied to inform pathogenetic models of overuse injury development

Achilles tendinopathy alters stretch shortening cycle behaviour during a sub-maximal hopping task

Objectives To describe stretch shortening cycle behaviour of the ankle and lower limb in patients with Achilles tendinopathy (AT) and establish differences with healthy volunteers. Design Between-subjects case-controlled. Methods Fifteen patients with AT (mean age 41.2 ± 12.7 years) and 11 healthy volunteers (CON) (mean age 23.2 ± 6.7 years) performed sub-maximal single-limb hopping on a custom built sledge-jump system. Using 3D motion analysis and surface EMG, temporal kinematic (lower limb stiffness, ankle angle at 80 ms pre-contact, ankle angle at contact, peak ankle angle, ankle stretch amplitude) and EMG measures (onset, offset and peak times relative to contact) were captured. Data between AT and CON were compared statistically using a linear mixed model. Results Patients with AT exhibited significantly increased lower limb stiffness when compared to healthy volunteers (p \u3c 0.001) and their hopping range was shifted towards a more dorsiflexed position (p \u3c 0.001). Furthermore, ankle stretch amplitude was greater in AT compared with healthy volunteers (p \u3c 0.001). A delay in muscle activity was also observed; soleus onset (p \u3c 0.001), tibialis anterior peak (p = 0.026) and tibialis anterior offset (p \u3c 0.001) were all delayed in AT compared with CON. Conclusions These findings indicate that patients with AT exhibit altered stretch-shortening cycle behaviour during sub-maximal hopping when compared with healthy volunteers. Patients with AT hop with greater lower limb stiffness, in a greater degree of ankle dorsiflexion and have a greater stretch amplitude. Likewise, delayed muscle activity is evident. These findings have implications in terms of informing the understanding of the pathoaetiology and management of AT

Prevalence of Salmonella serovars isolated from reptiles in Norwegian zoos

Background Reptiles are known to be asymptomatic carriers of Salmonella spp. in their gastrointestinal mucosa and a variety of Salmonella serovars including exotic serovars mainly associated with reptiles as well as human pathogenic serovars have been isolated. There are many case reports of reptile-associated Salmonella infections worldwide, including one case in Norway in 2000. In August 2017, there was a legislative change in Norway that allowed more permissive reptile ownership and legalized the keeping of 19 different reptile species by private persons. There has been a concern that this new legislation will lead to an increase in reptile-associated salmonellosis in Norway, however knowledge is lacking on the occurrence of Salmonella spp. in Norwegian reptiles. The aim of this study was therefore to investigate the prevalence of Salmonella spp. in captive reptile species in Norway, identify the serovars and evaluate their zoonotic potential. Thus, cloacal swabs were taken from 53 snakes, 15 lizards and 35 chelonians from three Norwegian zoos, and assessed for the presence of Salmonella spp. by culture, biochemical testing and serotyping. Results In total, 43% of the reptiles were shedding Salmonella spp., with a prevalence of 62%, 67% and 3% in snakes, lizards and chelonians, respectively. A total of 26 different serovars were found, including Salmonella enterica spp. enterica (40%) and S. enterica spp. arizonae (4%), both of which are considered to have a high zoonotic potential. S. enterica spp. diarizonae, salamae and houtenae were also identified, however these serovars are considered to have a lower zoonotic potential. Conclusions The current study demonstrates that captive Norwegian reptiles are carriers of potentially zoonotic Salmonella spp. Given the increasing popularity of reptiles as pets and the legislative change, reptile-associated salmonellosis could become an increasingly important public health concern in Norway. Adequate public information about the risk of Salmonella infection as well as preventive measures to avoid Salmonella transmission from reptiles to humans is needed. The risk of Salmonella infection is considered low when recommended precautions are taken and good hygiene exhibited.publishedVersio

Assessment and monitoring of Achilles tendinopathy in clinical practice: A qualitative descriptive exploration of the barriers clinicians face

Our primary objective was to explore the barriers preventing clinicians from implementing what they think is ideal practice as it relates to using tools to aid diagnosis and monitor progress in mid-portion Achilles tendinopathy. Our secondary objectives were to describe the assessments employed by clinicians in their own practice to aid with (a) diagnosis and (b) monitoring progress in Achilles tendinopathy and explore the outcome measure domains clinicians believe to be the most and least important when managing patients with Achilles tendinopathy. We employed a qualitative descriptive study design. Thirteen participants (eight female, five male) from across Australia, consisting of two junior physiotherapists, five senior physiotherapists working in private practice, four senior physiotherapists working within elite sports organisations and two sport and exercise medicine doctors, were included and one-on-one interviews were performed. Audio was transcribed then entered into NVivo for coding and analysis. Four main themes were perceived as barriers to implementing ideal practice of assessment and monitoring in people with Achilles tendinopathy: financial constraints, time constraints, access to equipment and patient symptom severity. Assessments related to function, pain on loading, pain over a specified time frame and palpation are commonly used to assist diagnosis. Assessments related to disability, pain on loading, pain over a specified time frame and physical function capacity are used to monitor progress over time. Furthermore, pain on loading and pain over a specified time frame were considered the most important outcome measure domains for assisting diagnosis whereas pain on loading, patient rating of the condition and physical function capacity were the most important outcome measure domains for monitoring progress. A number of barriers exist that prevent clinicians from implementing what they view as ideal assessment and monitoring for Achilles tendinopathy. These barriers should be considered when developing new assessments and in clinical practice recommendations

Conservative management of acute lower limb tendinopathies: A systematic review

Background Most knowledge regarding conservative management for lower limb tendinopathy (LLT) is for persistent symptoms, with less known about conservative management of acute LLT. Sub‐optimal management of acute LLT is detrimental in many regards, not least the likely conversion to persistent symptoms. Objectives To synthesise existing literature on conservative management of acute LLTs. Design Systematic review of relevant literature (PROSPERO [ID: CRD42018117882]). Method A search was made of multiple databases (MEDLINE, CINAHL and EMBASE) using relevant search terms. Titles, abstracts and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction and quality assessment, using the Grading of Recommendations Assessment, Development and Evaluation, were done independently by two authors. To understand how the interventions impacted the duration of reported symptoms, results were split into three time points: short‐term (12 weeks). Results Thirteen studies (n = 534) met the criteria for inclusion. There was very low level of certainty for the effectiveness of interventions at short‐term, medium‐term and long-term follow ups. However, there were large effects seen across a number of different treatments on pain intensity and disability in LLTs. Conclusions This review demonstrates that limited evidence currently exists to guide the management of acute LLT, and the quality of the existing evidence is collectively low. These findings inform the discussion of different treatment options with patients in a shared decision-making process to empower and enable the patient

Can we really say getting stronger makes your tendon feel better? No current evidence of a relationship between change in Achilles tendinopathy pain or disability and changes in Triceps Surae structure or function when completing rehabilitation: A systematic review

Objectives: Determine if improvements in pain and disability in patients with mid-portion Achilles tendinopathy relate to changes in muscle structure and function whilst completing exercise rehabilitation. Design: A systematic review exploring the relationship between changes in pain/disability and muscle structure/function over time, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methods: Six online databases and the grey literature were searched from database inception to 16th December 2022 whereas clinical trial registries were searched from database inception to 11th February 2020. We included clinical studies where participants received exercise rehabilitation (± placebo interventions) for mid-portion Achilles tendinopathy if pain/disability and Triceps Surae structure/function were measured. We calculated Cohen\u27s d (95 % confidence intervals) for changes in muscle structure/function over time for individual studies. Data were not pooled due to heterogeneity. Study quality was assessed using a modified Newcastle–Ottawa Scale. Results: Seventeen studies were included for synthesis. No studies reported the relationship between muscle structure/function and pain/disability changes. Twelve studies reported muscle structure/function outcome measures at baseline and at least one follow-up time-point. Three studies reported improvements in force output after treatment; eight studies demonstrated no change in structure or function; one study did not provide a variation measure, precluding within group change over time calculation. All studies were low quality. Conclusions: No studies explored the relationship between changes in tendon pain and disability and changes in muscle structure and function. It is unclear whether current exercise-based rehabilitation protocols for mid-portion Achilles tendinopathy improve muscle structure or function. Systematic review registration: PROSPERO (registration number: CRD42020149970)

Breath analysis of COVID-19 patients in a tertiary UK hospital by optical spectrometry : the E-Nose CoVal Study

Throughout the SARS-CoV-2 pandemic, diagnostic technology played a crucial role in managing outbreaks on a national and global level. One diagnostic modality that has shown promise is breath analysis, due to its non-invasive nature and ability to give a rapid result. In this study, a portable FTIR (Fourier Transform Infra-Red) spectrometer was used to detect chemical components in the breath from Covid positive symptomatic and asymptomatic patients versus a control cohort of Covid negative patients. Eighty-five patients who had a nasopharyngeal polymerase chain reaction (PCR) test for the detection of SARS-CoV-2 within the last 5 days were recruited to the study (36 symptomatic PCR positive, 23 asymptomatic PCR positive and 26 asymptomatic PCR negative). Data analysis indicated significant difference between the groups, with SARS-CoV-2 present on PCR versus the negative PCR control group producing an area under the curve (AUC) of 0.87. Similar results were obtained comparing symptomatic versus control and asymptomatic versus control. The asymptomatic results were higher than the symptomatic (0.88 vs. 0.80 AUC). When analysing individual chemicals, we found ethanol, methanol and acetaldehyde were the most important, with higher concentrations in the COVID-19 group, with symptomatic patients being higher than asymptomatic patients. This study has shown that breath analysis can provide significant results that distinguish patients with or without COVID-19 disease/carriage