Extracorporeal shock wave therapy plus rehabilitation for insertional and noninsertional achilles tendinopathy shows good results across a range of domains of function

Achilles tendinopathy, both insertional and noninsertional, is a common cause of posterior ankle pain. Although the condition of most patients improves with simple conservative measures, a proportion will go on develop chronic symptoms. This study examines the outcomes of patients following extracorporeal shock wave therapy plus a home exercise program. This prospective case series study involves a total of 39 patients, with a mean follow-up duration of 163 (range 65 to 385) days. This has demonstrated significant benefits in pain, stiffness, and a range of measures of local and global function. Median (interquartile range [IQR]) values for average self-reported pain improved from 6.5 of 10 (IQR 5.0 to 7.8) at baseline to 3.5 of 10 (IQR 2.0 to 5.1) at 3 months and to 2.0 of 10 (IQR 0.6 to 4.8) at 6 months for patients with insertional Achilles tendinopathy. This compares to improvements from 7.0 of 10 (IQR 7.0 to 8.0) at baseline to 6.0 of 10 (IQR 5.6 to 6.8) at 3 months and to 6.0 of 10 (IQR 3.0 to 7.0) at 6 months for patients with noninsertional Achilles tendinopathy. Statistically significant improvements were seen in insertional tendinopathy across a range of outcome measures; however, these were less apparent for patients with noninsertional tendinopathy. Despite these figures, no significant differences were seen in the outcomes for patients with insertional and noninsertional tendinopathy. Despite the improvements seen in the aspects of pain and function, physical activity levels had not increased following the treatment

The provision of simple written material does not significantly improve physical activity rates in a population with musculoskeletal problems, a double-blinded randomised controlled trial

BACKGROUND: Physical activity has been shown to have significant health benefits to individuals, being effective in the treatment and prevention of multiple different conditions. However, despite these benefits, rates of physical activity remain low in the western world and less than 40% of people in the UK meet physical activity recommendations. Musculoskeletal pain can be a barrier to activity, and patients with pain can stop all activity out of fear of harm. This project seeks to see if simple written advice can influence activity rates and behaviours. METHODS: A double-blinded randomised controlled trial was conducted to assess any impact of simple written material on physical activity rates in patients attending a single UK National Health Service (NHS) Sports Medicine Department. 546 consecutive patients with a range of musculoskeletal problems were randomised to either an “intervention group” (n=235) or “control group” (n=311). Patients in the intervention group received simple written material encouraging of the benefits of physical activity for general aspects of health, including practical steps to increase regular activity in daily life such as commuting, and work. RESULTS: No significant difference in activity rates were seen between the members of the two groups in any of the outcome measures used. These measures included the short-form/7-day recall version of the International Physical Activity Questionnaire (IPAQ), the General Practitioner Physical Activity Questionnaire (GPPAQ), and the “Vital Signs” questions. There were no differences seen in transport choices. Overall physical activity levels were low among both groups, with only one-third reaching national targets of 150minutes of moderate-level physical activity per week, and one in five patients undertaking no regular physical activity. CONCLUSIONS: The provision of simple written material does not significantly improve physical activity rates in patients referred to this NHS Sports Medicine Clinic in the UK. Consideration must be given to more tailored and individualised approached to physical activity promotion

The addition of a tension night splint to a structured home rehabilitation programme in patients with chronic plantar fasciitis does not lead to significant additional benefits in either pain, function or flexibility: a single-blinded randomised controlled trial

Objective To identify any improvements in pain or function in patients with chronic plantar fasciitis following the use of a tension night splint (TNS). Methods Single-blinded randomised controlled trial, with participants split evenly between intervention group (TNS + home exercise programme/HEP) and control group (HEP only). Follow-up at 3 months, with interim data at 6 weeks. Results 40 patients recruited. Mean age 52.1 years, 33% male, mean body mass index 30.8 kg/m2, mean duration of symptoms of 25 months. Improvement in self-reported ‘average pain’ in the intervention group from 6.8/10 at baseline to 5.6/10 at 6 weeks, and 5.3/10 at 3 months (both clinically and statistically significant at both time points), compared with control group of 7.1/10 at baseline to 6.2/10 at 6 weeks and 5.6/10 at 3 months (significant only at 3 months). Improvements in self-reported ‘worst pain’, ‘pain walking’ and ‘pain first thing in the morning’ in both groups at all time periods. Improvements were seen in revised Foot Function Index at all time points in both groups, but limited changes seen in flexibility and no significant changes in anxiety or depression Hospital Anxiety and Depression Scale domains or sleep quality in either group. However, no differences were seen between the outcomes seen in the two groups for the majority of the measures studied. Conclusions Improvements in pain and some functional measures seen in both groups, with few, if any, differences seen in outcomes between the intervention group compared with the control group. However, ongoing pain symptoms were reported in both groups, suggesting that ‘help’ rather than ‘cure’ was obtained for the majority. There is a possibility of earlier benefit seen in the intervention group compared with the control group, but data are unclear and further work may be needed

Up to a quarter of patients with certain chronic recalcitrant tendinopathies may have central sensitisation: a prospective cohort of more than 300 patients

Introduction: To identify the possible prevalence of ‘central sensitisation’, in patients with chronic recalcitrant lower limb tendinopathy conditions, with the Central Sensitisation Inventory (CSI) questionnaire. Methods: Patients with chronic lower limb tendinopathy conditions treated within a single hospital outpatient clinic specialising in tendinopathy were identified from clinical records. As part of routine care, self-reported numerical markers of pain, global function (using the EuroQol-5D (EQ-5D) questionnaire) and the CSI score to investigate the possibility of central sensitisation were completed. Results: A total of 312 suitable patients with chronic lower limb tendinopathy and similar conditions were identified, who had completed a CSI questionnaire. Of these, 108 presented with greater trochanteric pain syndrome, 12 with patella tendinopathy, 33 with non-insertional Achilles tendinopathy, 48 with insertional Achilles tendinopathy and 110 with plantar fasciitis. A total of 66% of the patients were female, the median age was 54.9 years and the median duration of symptoms was 24 months. There was a median CSI score of 25%, with statistically significant differences noted between the different conditions studied. Overall, 20% of patients scored above a threshold of 40% on CSI questionnaire, indicating that central sensitisation was possible. Greater trochanteric pain syndrome and plantar fasciitis had the highest proportions in the conditions studied. Weak correlations were found between CSI and other pain scores studied. Conclusion: The CSI questionnaire may identify up to a quarter of patients with some chronic lower limb tendinopathy and associated conditions as being more likely to have central sensitisation, and these proportions differed between conditions. The clinical significance of this is unclear, but worth further study to see if/how this may relate to treatment outcomes. These are results from a single hospital clinic dealing with patients with chronic tendinopathy, and comparison with a control group is currently lacking. However, on the information presented here, the concept of central sensitisation should be considered in patients being treated for chronic tendinopathy

The role of extra-corporeal shockwave therapy (ESWT) plus rehabilitation for patients with chronic greater trochanteric pain syndrome (GTPS): A case series assessing effects on pain, sleep quality, activity and functioning

Background: Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain, most commonly affecting female patients aged 40–60, and which can have a significant impact on patients’ quality of life. Extra-corporeal shockwave therapy (ESWT) alongside a structured rehabilitation programme has been shown in previous research studies to have a significant improvement in patient's levels of pain, although it is unclear if this then leads to improved level of global functioning or activity. This case series examines the change in a range of patient reported outcome measures following shockwave therapy as well as the frequency of self-reported side-effects. Methods: Patients undergoing ESWT for GTPS were identified from case logs from a single NHS clinic. Patients completed a range of validated patient-rated outcome measures at baseline and at subsequent follow-up appointments. These include measures of pain, and measures of local hip functioning (Oxford Hip Score – OHS, Non-Arthritic Hip Score – NAHS), global functioning (EQ-5D-5L), sleep quality (Pittsburgh Sleep Quality Index – PSQI), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale – HADS), and activity levels (International Physical Activity Questionnaire – IPAQ). Results: Forty-five patients who completed ESWT for GTPS were identified; with a median follow-up duration of 189 days. Side-effect incidence was low, with <10% reporting bruising, and no patients withdrew due to side-effects. ‘Average’ and ‘worst’ self-reported pain values improved significantly from baseline at all time-periods studied; 6.3/10 and 8.2/10 to 3.8/10 and 5.4/10 at 3 months, respectively, correlating to an improvement of about a third. At 3 months 63% of patients were either satisfied or very satisfied, and 70% would recommend the procedure, these figures increased at 6 months. Sleep quality, measures of local hip functioning, and depressive symptoms all improved consistently across different time-points; however, activity levels and global health markers showed less evidence of improvement. Conclusions: ESWT is known to be effective in patients with greater trochanteric pain alongside a structured rehabilitation programme, and this case series is in keeping with the available evidence. This series demonstrates benefits across different areas of functioning. In this series, even though pain decreased, physical activity levels did not increase. As staying active has numerous health benefits further targeted intervention to address this alongside the reduction of pain may be required for optimal health outcomes

How effective is the integration of sport and exercise medicine in the English national health service for sport related injury treatment and health management?

Background: Regular participation in sport, exercise and physical activity is associated with positive health outcomes and form a mainstay of British public health policies. However, regular participation in sport and exercise can result in sport related injury (SRI) which, in turn, is a key cause of exercise cessation. The integration of Sport and Exercise Medicine (SEM) in the English National Health Service (NHS) aims to provide a specialist service for public populations and thus reduce the impact of SRI on exercise cessation and associated negative health outcomes. More broadly it aims to both support physical activity health promotion policies and improve healthcare organisations efficiencies through providing the most condition-appropriate treatment. Methods: This qualitative interview study examines patients’ (n=19) experiences of accessing and receiving SEM treatment within the English NHS. Results: The research demonstrates that referral pathways into SEM were often prolonged, characterised by multiple General Practitioner (GP) visits and referrals into other musculoskeletal services, demonstrating an inefficient use of healthcare resources. Prolonged pathways fostered only limited recovery back to previous physical activity levels and other negative health behaviours, yet on accessing the SEM clinic, patients experienced progressive rehabilitation back into sport and exercise participation. Conclusion: This study highlights the importance of more fully integrating SEM services into public healthcare as a way of improving the organisational capacity of healthcare in treating SRI and ensuring that citizens comply with state interventions which orchestrate health management through raising physical activity levels across the population

Primary care knowledge and beliefs about physical activity and health: a survey of primary healthcare team members

Background: Physical activity has numerous health benefits and the primary healthcare team are ideally suited to promote activity. The Royal College of General Practitioners (RCGP) has announced physical activity to be a clinical priority in the next few years. However little attention is given to this in medical training, with unclear levels of knowledge and confidence. Aim: To explore the primary healthcare team knowledge of the benefits of physical activity in preventing and treating ill health. Design & setting: Questionnaire-based study, from six East Midlands sites in the UK. Method: Self-completed anonymised questionnaire. Results: Three hundred and two results were obtained in total, from 166 GPs, 65 GP registrars, and 71 practice nurses. There was a mean age of 44.8 years (range 22–71), with 62% female responders. Fifty-five per cent of responders underestimated UK recommended activity guidance. Responders considered activity promotion as part of their professional role, but this was discussed about one-third as often as other health promotion behaviours, such as weight or smoking. Barriers reported were lack of time (91.2%) and resources (36.8%). Conclusion: This study has shown reasonable knowledge of recommended levels of activity and accrued health, but most underestimated UK guidance, suggest inadequate levels of activity for optimal health may be being recommended. Confidence in this area is lower in GP registrars than GPs which may mirror other health problems. There was a poor recognition of simple tools to assess the level of physical activity, and low levels of onward signposting or recommendations. If physical activity is to be a clinical priority area of the RCGP, then further opportunities for professional development may be required

What do patients really know? An evaluation of patients’ physical activity guideline knowledge within general practice

Background: Physical inactivity is well recognised as one of the leading causes of preventable death. However, little is known about the general public’s knowledge surrounding national physical activity guidelines, particularly within general practice (GP). Setting: Two GPs (York and Maidenhead, UK). Question: Are GP patients aware of the national physical guidelines? Also, are health care professionals routinely raising the issue of physical inactivity and would patients welcome support from health care professionals regarding inactivity? Methodology: A questionnaire was distributed in two GPs over a one-week period to evaluate patients knowledge of the national physical activity guidelines. Results: Ninety-four participants completed the questionnaire over one week (60 female; 34 male), with an average age of 54.2 (standard deviation: 19.9 years). 14% (95% Confidence Interval (CI): 8–22%) of the total participants correctly knew the recommended national guidelines for physical activity. 52% (95% CI: 42–63%) recalled being asked by a health care professional about their activity levels. 46% (95% CI: 35–56%) would welcome support from a health care professional around improving their activity levels. Discussion/Conclusion: Only 14% of responders correctly knew the current national minimum activity guidelines. Encouragingly 46% of participants in our study were interested in physical activity advice from a health care professional. Health care professionals need to be aware that many patients do not know the current physical activity guidelines and recognise that primary care may be an underutilised opportunity to educate and promote physical activity

The functional significance of hamstrings composition: is it really a ‘fast’ muscle group?

Hamstrings muscle fibre composition may be predominantly fast-twitch and could explain the high incidence of hamstrings strain injuries. However, hamstrings muscle composition in vivo, and its influence on knee flexor muscle function, remains unknown. We investigated biceps femoris long head (BFlh) myosin-heavy chain (MHC) composition from biopsy samples, and the association of hamstrings composition and hamstrings muscle volume (using MRI) with knee flexor maximal and explosive strength. Thirty-one young men performed maximal (concentric, eccentric, isometric) and explosive (isometric) contractions. BFlh exhibited a balanced MHC distribution (mean±SD (min-max); 47.1±9.1% (32.6-71.0%) MHC-I, 35.5±8.5% (21.5-60.0%) MHC-IIA, 17.4±9.1% (0.0-30.9%) MHC-IIX). Muscle volume was correlated with knee flexor maximal strength at all velocities and contraction modes (r= 0.62–0.76, P< 0.01), but only associated with late phase explosive strength (time to 90 Nm; r= -0.53, P< 0.05). In contrast, BFlh muscle composition was not related to any maximal or explosive strength measure. BFlh MHC composition was not found to be ‘fast’, and therefore composition does not appear to explain the high incidence of hamstrings strain injury. Hamstrings muscle volume explained 38-58% of the inter-individual differences in knee flexor maximum strength at a range of velocities and contraction modes, while BFlh muscle composition was not associated with maximal or explosive strength

Kinematic and kinetic differences between military patients with patellar tendinopathy and asymptomatic controls during single leg squats

© 2019 Background: Knee valgus alignment has been associated with lower-limb musculoskeletal injury. This case-control study aims to: assess biomechanical differences between patients with patellar tendinopathy and healthy controls. Methods: 43 military participants (21 cases, 22 controls) were recorded using 3D-motion capture performing progressively demanding, small knee bend, single leg and single leg decline squats. Planned a priori analysis of peak: hip adduction, knee flexion, pelvic tilt, pelvic obliquity and trunk flexion was conducted using MANOVA. Kinematic and kinetic data were graphed with bootstrapped t-tests and 95% CI's normalised to the squat cycle. ANOVA and correlations in SPSS were used for exploratory analysis. Findings: On their symptomatic side cases squatted to less depth (−6.62° p 0.05). Cases experienced more pain on testing on decline board (ES = 0.69, p 0.05), correlated with extensor knee moment. Interpretation: Knee valgus alignment is a plausible risk factor for patellar tendinopathy. Conclusions relating to causation are limited by the cross-sectional study design. Increasing squat depth, use of a declined surface and isolating the eccentric phase enable progression of loading prescription guided by pain