1000 Norms Project: Protocol of a cross-sectional study cataloging human variation

Background Clinical decision-making regarding diagnosis and management largely depends on comparison with healthy or ‘normal’ values. Physiotherapists and researchers therefore need access to robust patient-centred outcome measures and appropriate reference values. However there is a lack of high-quality reference data for many clinical measures. The aim of the 1000 Norms Project is to generate a freely accessible database of musculoskeletal and neurological reference values representative of the healthy population across the lifespan. Methods/design In 2012 the 1000 Norms Project Consortium defined the concept of ‘normal’, established a sampling strategy and selected measures based on clinical significance, psychometric properties and the need for reference data. Musculoskeletal and neurological items tapping the constructs of dexterity, balance, ambulation, joint range of motion, strength and power, endurance and motor planning will be collected in this cross-sectional study. Standardised questionnaires will evaluate quality of life, physical activity, and musculoskeletal health. Saliva DNA will be analysed for the ACTN3 genotype (‘gene for speed’). A volunteer cohort of 1000 participants aged 3 to 100 years will be recruited according to a set of self-reported health criteria. Descriptive statistics will be generated, creating tables of mean values and standard deviations stratified for age and gender. Quantile regression equations will be used to generate age charts and age-specific centile values. Discussion This project will be a powerful resource to assist physiotherapists and clinicians across all areas of healthcare to diagnose pathology, track disease progression and evaluate treatment response. This reference dataset will also contribute to the development of robust patient-centred clinical trial outcome measures

Why Do Ankle Sprains Recur?

The first objective of this thesis was to determine the predictors of recurrent sprain after an index ankle sprain. Findings of our comprehensive systematic review of the literature demonstrated a scientific gap with regards to predictors of chronic ankle instability (CAI) after an index sprain. The second and third studies therefore, were designed to investigate what impairments after an index sprain predispose participants to recurrent sprains. Participants with a recent index sprain (n=30) and controls (n=70) were recruited. Ankle joint range of motion (ROM), balance, proprioception, motor planning, inversion/eversion peak power, and timed stair tests were measured and compared between two groups. Participants were then followed up for 12 months and occurrence of ankle sprains was recorded. Younger participants with an index sprain found to be at significantly higher risk of incurring recurrent sprains. Although impaired balance was evident after an index sprain, balance deficits did not independently predict the likelihood of ankle sprain. The second aim of this thesis was to investigate the physical, physiological, functional and central differences among participants with CAI (n=42), copers (participants who recovered from a sprain, n=19) and controls (n=21). Ankle joint laxity and ROM, balance, proprioception, motor planning, timed stair test, peak power, and cortical representation of the foot and ankle measured by limb laterality recognition task, were compared among the three groups. The groups did not demonstrate any significant differences across ranges variables measured. However, deficits in inversion/eversion, balance, and performance in limb laterality recognition task were associated with pain at the ankle joint. Further, proprioceptive deficits were present in participants regardless of a history of ankle sprain and were associated with centrally mediated changes shown by bilateral impairments in performance of limb laterality recognition task

Difference in knee joint position sense in athletes with and without patellofemoral pain syndrome

Purpose: The purpose of this study was to evaluate knee joint position sense (JPS) in athletes with patellofemoral pain syndrome (PFPS) and compare it with healthy participants under non-weight bearing (sitting) and weight bearing (standing) conditions. Methods: Twenty patients and 20 healthy athletes participated in this study. JPS was evaluated by active replication of knee angles with visual cues eliminated. Two target angles in sitting and one in standing were tested. Each test and replication was repeated three times. By subtracting the test angle from the replicated angle, the absolute error was calculated as a dependent variable. Results: No significant difference in knee JPS was found between groups either in the sitting or in the standing tests. Conclusion: It seems that PFPS does not affect the knee JPS in athletes. The lack of deficiency in patients could possibly be attributed to their severity of knee pathology, pain intensity and their physical activity level. Level of evidence: Case-control study, Level III

Systematic review of timed stair tests

Functional testing is particularly useful in the clinic and for making research translatable; however, finding measures relevant across ages and different conditions can be difficult. A systematic review was conducted to investigate timed stair tests as an objective measure of functional abilities and musculoskeletal integrity. Data were analyzed for their ability to differentiate between controls and patient groups and between different patient groups. Literature was reviewed using the Medline, CINAHL, and PubMed databases until February 2012. Data were grouped according to methodology, ages, and medical conditions. Time per step was calculated to allow comparison between studies. Eighty-eight studies were included in this review. Methodologies varied considerably with stair ascent, stair descent, or a combination of the two being used across a wide range of ages and medical conditions. Times increased with age for ascent, descent, and combined and for a variety of medical problems. Timed stair tests appear to be sensitive to medical conditions but further data are required to obtain normative values for this test. We suggest that timed stair tests should follow a more standardized methodology using a combination of ascent and descent and asking participants to complete the stairs as quickly and safely as possible

Multiple emergency department encounters for acute musculoskeletal presentation with an existing mental health diagnosis

Key Clinical Message Reconceptualising acute Musculoskeletal (MSK) injuries with both stress‐ and tissue‐ based factors is required to consider prior influences of mental health disorders on acute persistent MSK pain presentations. This report describes repeated emergency presentations of an individual with acute persistent MSK pain in their twenties living with mental health. Their mental health diagnoses included depression, mood disorders, and anorexia nervosa. This person also had mental health related inpatient admissions that were not captured under the retrospective record review for a large district hospital emergency department using the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) classification system. This case report attempts to demonstrate that improving the understanding of preexisting vulnerabilities and mental health diagnoses may assist with informing healthcare design to develop specialised care pathways for acute injury presentations within triage settings

(Reliability of a system consists of skin markers, digital photography, and AutoCAD software for measuring the knee angles)

Background and aim: In physical evaluations, measuring the joint angle is one of the most important outcomes to assess the patient’s progress, the effectiveness of various treatment techniques and to delineate the need for future treatments. The aim of this study is to study the reliability of a system consists of skin markers, digital photography, and AutoCAD software for measuring the knee joint angles. Materials and methods: In first section, reliability of markers placement was evaluated within three different intervals (five minutes, two days, and twenty days). At second section, reliability of digital photography was evaluated while position of the skin markers and subjects was the same. At the end, in third section, reliability of angle measurement by means of AutoCAD software was assessed. Results: In first section, the ICC for test-retest reliability of markers placement between first and second sessions, first and third sessions, and also first and forth sessions were 0.97, 0.94, and 0.73, respectively. In second section, the ICC for test-retest reliability of digital photography was 0.99 and in third section, the ICC for intra-rater reliability of angle measurement by means of AutoCAD software was 0.99 (p=0.05). Conclusion: It was noted that the introduced system was highly reliable, so it could be utilized to measure the knee joint angles

(The effect of chronic ankle instability on knee joint position sense)

Background and Aim: The rapid growth of the athletic training profession has been accompanied by an equally rapid increase in focus on basic and clinical research. Lateral ankle sprain (LAS) is an extremely common athletic injury. Despite extensive clinical and basic science research, the recurrence rate remains high. Chronic ankle instability (CAI) following LAS is hypothesized to predispose individuals to re-injury because of neuromuscular control deficits which result following injury. No investigation has been carried out on the existence of joint position deficits in the knee joint of patients with CAI. In this study, joint position sense (JPS) was evaluated in patients with CAI. Materials and Methods: Ten female patients with CAI and ten healthy control subjects participated in this study. JPS was evaluated by reproduction of the angles in two standing and sitting positions, and in each position two target angles were tested. The knee joints in both lower limbs of patients and the dominant knee-limb of healthy subjects were evaluated. The knee angles were measured by using a system comprised of skin markers, digital photography, and Auto CAD software. Absolute error was considered as a dependant variable. Result: There were no significant differences between the knee JPS of dominant leg in healthy subjects and both knee joints of patients. There were also no significant differences between knee JPS in two standing and sitting positions and in two different target angles (p>0/05). Conclusion: The result of this study suggests that subjects who have CAI do not have deficit in knee JPS when tested in sitting position and also under functional weight bearing conditions

Menstrual cycle and knee joint position sense in healthy female athletes

Purpose. The aim of this study was to investigate the effect of menstrual cycle on knee joint position sense (JPS) in healthy female athletes. Methods. Sixteen healthy female athletes participated in this study. Serum estrogen and progesterone levels were collected during the three phases of menstrual cycle. The knee JPS was also measured during the same phases using a system comprise of skin markers, digital photography, and AutoCAD software. Absolute angular errors were calculated as well as changes in hormone levels between the three phases. Results. Serum estrogen concentration was significantly higher during the mid-luteal (179.5 Pg/ml) and mid-follicular (125.6 Pg/ml) phases as compared with the early follicular (menses) (22.8 Pg/ml) phase (P = 0.0001). Also serum progesterone concentration was significantly higher during the mid-luteal phase (7.35 Ng/ml) as compared with the menses (0.58 Ng/ml) and mid-follicular (0.5 Ng/ml) phases (P = 0.0001). The greatest amount of mean (SD) value of absolute error was at menses (4. 2°), and the least amount of it was at mid-luteal (2. 5°) phase. Also, a significant difference was observed within three phases of menstrual cycle (P = 0.025). Conclusion. The result of this study suggests that healthy female athletes have different levels of knee JPS across a menstrual cycle. JPS accuracy decreases in menses, when circulating sex-hormones levels are low. Therefore, female athletes are at higher risk of injury at menses and improving their awareness regarding the knee injury risk factors can be a fundamental step toward preventing injuries