Prehabilitation for total knee arthroplasty: A patient-centred approach to maximizing surgical outcomes

The purpose of this dissertation was to investigate the role of prehabilitation in post-operative recovery for patients undergoing total knee arthroplasty (TKA) for osteoarthritis. Study one was a meta-analysis that aimed to consolidate the body of knowledge regarding prehabilitation for TKA patients. Study two compared the Lower Limb Tasks Questionnaire (LLTQ) to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in terms of agreement and responsiveness. Study three investigated the effect of a six-week pre-surgical strength training program on post-operative outcomes (quadriceps strength, mobility, pain, self-reported function, health-related quality of life, arthritis self efficacy) for TKA patients. Finally, study four provided a preliminary insight into the implementation context of prehabilitation for TKA. Study one demonstrated that prehabilitation had no effect on post-operative pain or self-reported function, but had a large effect on length of hospital stay (ES = -0.819; 95% CI: -0.985 - -0.653). Pre-operative exercise had no significant effect on quadriceps strength in the early post-operative phase (hospital discharge to 12 weeks after surgery), but did have a small effect on strength beyond 12 weeks (ES = 0.279; 95% CI: 0.018 – 0.540). Study two found that the LLTQ activities of daily living (ADL) subscale had good agreement with the WOMAC global score [bias = -1.40 (SD = 10.00); 95% limits of agreement = -22.00% to +19.00%.] Conversely, the LLTQ sport/recreation subscale had very poor agreement with WOMAC [bias = -31.00 (SD = 17.00); 95% limits of agreement = -65.00% to +2.40%]. The statistical responsiveness of the WOMAC was superior to that of the LLTQ ADL and sport/recreation subscales (1.17, -0.63, and -0.01, respectively). Study three showed that pre-surgical strength training had a large effect on quadriceps strength, F(3,18) = 0.89, p = 0.47, η2 = 0.13, and walking speed, F(3,18) = 1.47, p = 0.26, η2 = 0.20 before TKA. After TKA, there were no significant differences in any outcome measures between the prehabilitation and control groups. Furthermore, there were no significant correlations between self-reported and objective measures of function. Finally, study four indicated that TKA patients are likely to participate in prehabilitation, particularly exercise-based programs

Implementation of the Activate injury prevention exercise programme in English schoolboy rugby union

Objectives: The implementation of the Activate injury prevention exercise programme has not been assessed in an applied context. This study aimed to (1) describe the knowledge and perceptions of school rugby coaches and players towards injury risk, prevention and Activate and (2) evaluate Activate implementation in schoolboy rugby using the reach, effectiveness, adoption, implementation and maintenance framework. Methods: Bespoke electronic surveys were administered to coaches (including support staff) and players at participating English schools (2018–2020). Most questions and statements were answered using a 7-point Likert scale. At baseline, participants detailed their Activate awareness and perceptions of injury risk and prevention in schoolboy rugby. At postseason, participants reported Activate use throughout the study and their perceptions towards the programme. Results: At baseline, significant differences existed between coaches (n=106) and players (n=571) in Activate awareness (75% and 13% respectively; χ2=173.5, p<0.001). Coaches perceived rugby had a significantly greater injury risk than players, while holding more positive perceptions towards injury prevention. At postseason, coaches reported greater Activate adoption compared with players (76% and 18% respectively; χ2=41.8, p<0.001); 45% of players were unaware if they used the programme. Median session adherence was twice weekly, with a median duration of 10–15 min. This suggests Activate was not implemented as intended, with recommendations of three 20 min sessions per week. Both groups identified common barriers to implementation, such as lack of time and inclusion of a ball. Conclusion: Coaches are instrumental in the decision to implement Activate. Targeting behavioural change in these individuals is likely to have the greatest impact on intervention uptake

Employing standardised methods to compare injury risk across seven youth team sports

Injury surveillance systems seek to describe injury risk for a given sport, in order to inform preventative strategies. This often leads to comparisons between studies, although these inferences may be inappropriate, considering the range of methods adopted. This study aimed to describe the injury epidemiology of seven youth sports, enabling valid comparisons of injury risk. Consistent methods were employed across seven sports [male American football, basketball, soccer, rugby league, rugby union; female soccer and rugby union] at a high school in England. A 24-hour time-loss injury definition was adopted. Descriptive statistics and injury incidence (/1000 match-hours) are reported. In total, 322 injuries were sustained by 240 athletes (mean age=17.7±1.0) in 10 273 player-match hours. American football had a significantly greater injury incidence (86/1000 h; 95% CI 61–120) than all sports except female rugby union (54/1000 h; 95% CI 37–76). Concussion was the most common injury (incidence range 0.0–26.7/1000 h), while 59% of injuries occurred via player contact. This study employed standardized data collection methods, allowing valid and reliable comparisons of injury risk between youth sports. This is the first known study to provide epidemiological data for female rugby union, male basketball and American football in an English youth population, enabling the development of preventative strategies

Strategies used by professional rugby union clubs to manage players for artificial turf exposure

Background: The use of artificial turf on rugby pitches is increasingly commonplace but there is limited evidence around its effects on injury, recovery, and performance. It is unclear whether this uncertainty influences player management strategies in professional clubs. Objectives: To understand how professional rugby union clubs in England approach player management for artificial turf, to explore how the beliefs of medical and strength/conditioning staff influence these decisions, and to determine whether differences exist between clubs with different levels of exposure to artificial surfaces. Methods: The study was a cross-sectional mixed methods study. Twenty-three medical and strength/conditioning staff members from 12 English Premiership Rugby Union clubs completed two bespoke questionnaires and participated in a semi-structured interview. Results: Two-thirds of the participants described formal club-level approaches to artificial turf. All participants from low- exposure clubs (&lt;50% training and match time on artificial pitches) reported adjusting player recovery strategies following games on artificial turf to mitigate elevated muscle soreness and fatigue. Clubs with artificial surfaces at their home venues were less likely to adapt recovery than clubs with natural turf pitches. Regardless of exposure participants believed switching between surface types was a risk factor for injury. Medics reported that acute injuries associated with artificial turf exposure typically occurred at the foot or ankle, whereas abrasions and overuse injuries were more common and often affected the knees, hips and lower back. Players with compromised joints were less likely to be selected for matches on artificial surfaces. Conclusion: Player management around artificial turf is a focus for staff at professional rugby union clubs. Club practices vary by exposure and may consequently influence injury risk estimates

‘Do we know if we need to reduce head impact exposure?’: A mixed-methods study highlighting the varied understanding of the longterm risk and consequence of head impact exposure across all stakeholders at the highest level of rugby union

Background: One strategy to prevent and manage concussion is to reduce head impacts, both those resulting in concussion and those that do not. Because objective data on the frequency and intensity of head impacts in rugby union (rugby) are sparse, stakeholders resort to individual perceptions to guide contact training. It is unknown whether there is a level of contact training that is protective in preparing elite players for contact during matches.  Objectives: This study aimed to describe how contact training is managed in elite male rugby, and how staff and players perceive contact training load and head impact load. Methods: This was a sequential explanatory mixed-methods study. Forty-four directors of rugby, defence coaches, medical and strength/conditioning staff and 23 players across all 13 English Premiership Rugby Union clubs and the National senior team participated in semi-structured focus groups and completed two bespoke questionnaires. Results: The study identified the varied understanding of what constitutes head impact exposure across all stakeholder groups, resulting in different interpretations and a range of management strategies. The findings suggest that elite clubsconduct low levels of contact training; however, participants believe that some exposure is required to prepare players andthat efforts to reduce head impact exposure must allow for individualised contact training prescription. Conclusion: There is a need for objective data, possibly from instrumented mouthguards to identify activities with a high risk for head impact and possible unintended consequences of reduced exposure to these activities. As data on head impact exposure develop, this must be accompanied with knowledge exchange within the rugby community.