Publications by authors named "Dylan Morrissey"

91 Publications

Embedding supervised exercise training for men on androgen deprivation therapy into standard prostate cancer care: a feasibility and acceptability study (the STAMINA trial).

Sci Rep 2021 06 14;11(1):12470. Epub 2021 Jun 14.

Allied Health Professionals, Radiotherapy and Oncology, Sheffield Hallam University, Sheffield, UK.

Lifestyle interventions involving exercise training offset the adverse effects of androgen deprivation therapy in men with prostate cancer. Yet provision of integrated exercise pathways in cancer care is sparse. This study assessed the feasibility and acceptability of an embedded supervised exercise training intervention into standard prostate cancer care in a single-arm, multicentre prospective cohort study. Feasibility included recruitment, retention, adherence, fidelity and safety. Acceptability of behaviourally informed healthcare and exercise professional training was assessed qualitatively. Despite the imposition of lockdown for the COVID-19 pandemic, referral rates into and adherence to, the intervention was high. Of the 45 men eligible for participation, 79% (n = 36) received the intervention and 47% (n = 21) completed the intervention before a government mandated national lockdown was enforced in the United Kingdom. Patients completed a mean of 27 min of aerobic exercise per session (SD = 3.48), at 77% heart rate maximum (92% of target dose), and 3 sets of 10 reps of 3 resistance exercises twice weekly for 12 weeks, without serious adverse event. The intervention was delivered by 26 healthcare professionals and 16 exercise trainers with moderate to high fidelity, and the intervention was deemed highly acceptable to patients. The impact of societal changes due to the pandemic on the delivery of this face-to-face intervention remain uncertain but positive impacts of embedding exercise provision into prostate cancer care warrant long-term investigation.
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http://dx.doi.org/10.1038/s41598-021-91876-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203669PMC
June 2021

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies.

Br J Sports Med 2021 Jun 14. Epub 2021 Jun 14.

Sports and Exercise Medicine, Queen Mary University of London, London, UK.

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.
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http://dx.doi.org/10.1136/bjsports-2020-103700DOI Listing
June 2021

Usability Testing of a Digital Assessment Routing Tool: Protocol for an Iterative Convergent Mixed Methods Study.

JMIR Res Protoc 2021 May 18;10(5):e27205. Epub 2021 May 18.

Centre for Sports & Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.

Background: Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing burden on health care utilization. Digital technologies that improve health care outcomes and efficiency are considered a priority; however, innovations are often inadequately developed and poorly adopted. Further, they are rarely tested with sufficient rigor in clinical trials-the gold standard for clinical proof of efficacy. We have developed a new musculoskeletal Digital Assessment Routing Tool (DART) that allows users to self-assess and be directed to the right care. DART requires usability testing in preparation for clinical trials.

Objective: This study will use the iterative convergent mixed methods design to assess and mitigate all serious usability issues to optimize user experience and adoption. Using this methodology, we will provide justifiable confidence to progress to full-scale randomized controlled trials when DART is integrated into clinical management pathways. This study protocol will provide a blueprint for future usability studies of mobile health solutions.

Methods: We will collect qualitative and quantitative data from 20-30 participants aged 18 years and older for 4 months. The exact number of participants recruited will be dependent on the number of iterative cycles required to reach the study end points. Building on previous internal testing and stakeholder involvement, quantitative data collection is defined by the constructs within the ISO 9241-210-2019 standard and the system usability scale, providing a usability score for DART. Guided by the participant responses to quantitative questioning, the researcher will focus the qualitative data collection on specific usability problems. These will then be graded to provide the rationale for further DART system improvements throughout the iterative cycles.

Results: This study received approval from the Queen Mary University of London Ethics of Research Committee (QMREC2018/48/048) on June 4, 2020. At manuscript submission, study recruitment was on-going, with data collection to be completed and results published in 2021.

Conclusions: This study will provide evidence concerning mobile health DART system usability and acceptance determining system improvements required to support user adoption and minimize suboptimal system usability as a potential confounder within subsequent noninferiority clinical trials. Success should produce a safe effective system with excellent usability, facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This deliberately rigorous approach to mobile health innovation could be used as a guide for other developers of similar apps.

International Registered Report Identifier (irrid): DERR1-10.2196/27205.
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http://dx.doi.org/10.2196/27205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170557PMC
May 2021

Online questionnaire, clinical and biomechanical measurements for outcome prediction of plantar heel pain: feasibility for a cohort study.

J Foot Ankle Res 2021 Apr 26;14(1):34. Epub 2021 Apr 26.

Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft road, London, E1 4DG, UK.

Background: Plantar heel pain (PHP) accounts for 11-15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study.

Methods: Thirty-six people (19 females & 17 males; 20-63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures.

Results: There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = - 0.31-0.25). Questionnaire reliability was good or excellent (ICC)(ICC 0.86-0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces.

Conclusion: Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible.

Level Of Evidence: IV.
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http://dx.doi.org/10.1186/s13047-021-00472-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077700PMC
April 2021

The effectiveness of PROLOTHERAPY for recalcitrant Medial TIBIAL Stress Syndrome: a prospective consecutive CASE series.

J Foot Ankle Res 2021 Apr 16;14(1):32. Epub 2021 Apr 16.

Centre for Sports and Exercise Medicine, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.

Background: Medial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.

Objective: To evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.

Method: The study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.

Intervention: An ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.

Main Outcome Measures: Pain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman's non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.

Results: Patients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as 'much improved' at medium-term follow-up and the median return to sports score was 'returned to desired but not pre-injury level' at medium-term and long-term follow-up. No adverse events were reported.

Conclusions: Ultrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.

Clinical Relevance: Clinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.
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http://dx.doi.org/10.1186/s13047-021-00453-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052809PMC
April 2021

Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values.

Br J Sports Med 2021 Mar 30. Epub 2021 Mar 30.

Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia.

Objective: To develop a best practice guide for managing people with plantar heel pain (PHP).

Methods: Mixed-methods design including systematic review, expert interviews and patient survey.

Data Sources: Medline, Embase, CINAHL, SPORTDiscus, Cochrane Central Register of Controlled Trials, trial registries, reference lists and citation tracking. Semi-structured interviews with world experts and a patient survey.

Eligibility Criteria: Randomised controlled trials (RCTs) evaluating any intervention for people with PHP in any language were included subject to strict quality criteria. Trials with a sample size greater than n=38 were considered for proof of efficacy. International experts were interviewed using a semi-structured approach and people with PHP were surveyed online.

Results: Fifty-one eligible trials enrolled 4351 participants, with 9 RCTs suitable to determine proof of efficacy for 10 interventions. Forty people with PHP completed the online survey and 14 experts were interviewed resulting in 7 themes and 38 subthemes. There was good agreement between the systematic review findings and interview data about taping (SMD: 0.47, 95% CI 0.05 to 0.88) and plantar fascia stretching (SMD: 1.21, 95% CI 0.78 to 1.63) for first step pain in the short term. Clinical reasoning advocated combining these interventions with education and footwear advice as the core self-management approach. There was good expert agreement with systematic review findings recommending stepped care management with focused shockwave for first step pain in the short-term (OR: 1.89, 95% CI 1.18 to 3.04), medium-term (SMD 1.31, 95% CI 0.61 to 2.01) and long-term (SMD 1.67, 95% CI 0.88 to 2.45) and radial shockwave for first step pain in the short term (OR: 1.66, 95% CI 1.00 to 2.76) and long term (OR: 1.78, 95% CI 1.07 to 2.96). We found good agreement to 'step care' using custom foot orthoses for general pain in the short term (SMD: 0.41, 95% CI 0.07 to 0.74) and medium term (SMD: 0.55, 95% CI 0.09 to 1.02).

Conclusion: Best practice from a mixed-methods study synthesising systematic review with expert opinion and patient feedback suggests core treatment for people with PHP should include taping, stretching and individualised education. Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.
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http://dx.doi.org/10.1136/bjsports-2019-101970DOI Listing
March 2021

The development of a theory and evidence-based intervention to aid implementation of exercise into the prostate cancer care pathway with a focus on healthcare professional behaviour, the STAMINA trial.

BMC Health Serv Res 2021 Mar 25;21(1):273. Epub 2021 Mar 25.

Institute for Population Health Sciences, Queen Mary, University of London, London, UK.

Background: Twice-weekly supervised aerobic and resistance exercise for 12 weeks reduces fatigue and improves quality of life in men on Androgen Deprivation Therapy for prostate cancer. Despite the National Institute for Health and Care Excellence (NICE) proposing this as standard of care, it does not routinely take place in practice. Healthcare professionals are in a prime position to deliver and integrate these recommendations. A change in the behaviour of clinical teams is therefore required. In this paper, we describe the development of a training package for healthcare professionals using theory and evidence to promote delivery of such recommendations as standard care.

Methods: The intervention development process was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. Target behaviours were identified from the literature and thirty-five prostate cancer care healthcare professionals (including oncologists, consultant urologists, clinical nurse specialists, physiotherapists, general practitioners and commissioners) were interviewed to understand influences on these behaviours. The Theoretical Domains Framework was used to identify theoretical constructs for change. Behaviour change techniques were selected based on theory and evidence and were translated into intervention content. The intervention was refined with the input of stakeholders including healthcare professionals, patients, and exercise professionals in the form of rehearsal deliveries, focus groups and a workshop.

Results: Seven modifiable healthcare professional target behaviours were identified to support the delivery of the NICE recommendations including identifying eligible patients suitable for exercise, recommending exercise, providing information, exercise referral, providing support and interpret and feedback on progress. Ten domains from the Theoretical Domain's Framework were identified as necessary for change, including improving knowledge and skills, addressing beliefs about consequences, and targeting social influences. These were targeted through twenty-two behaviour change techniques delivered in a half-day, interactive training package. Based on initial feedback from stakeholders, the intervention was refined in preparation for evaluation.

Conclusions: We designed an intervention based on theory, evidence, and stakeholder feedback to promote and support the delivery of NICE recommendations. Future work will aim to test this training package in a multi-centre randomised trial. If proven effective, the development and training package will provide a template for replication in other clinical populations, where exercise has proven efficacy but is insufficiently implemented.
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http://dx.doi.org/10.1186/s12913-021-06266-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992804PMC
March 2021

Towards implementing exercise into the prostate cancer care pathway: development of a theory and evidence-based intervention to train community-based exercise professionals to support change in patient exercise behaviour (The STAMINA trial).

BMC Health Serv Res 2021 Mar 22;21(1):264. Epub 2021 Mar 22.

Institute for Population Health Sciences, Queen Mary University of London, London, UK.

Background: The National Institute for Health and Care Excellence (NICE) recommend that men on androgen deprivation therapy (ADT) for prostate cancer should receive supervised exercise to manage the side-effects of treatment. However, these recommendations are rarely implemented into practice. Community-based exercise professionals (CBEPs) represent an important target group to deliver the recommendations nationally, yet their standard training does not address the core competencies required to work with clinical populations, highlighting a need for further professional training. This paper describes the development of a training package to support CBEPs to deliver NICE recommendations.

Methods: Development of the intervention was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. In step one, target behaviours, together with their barriers and facilitators were identified from a literature review and focus groups with CBEPs (n = 22) and men on androgen deprivation therapy (n = 26). Focus group outputs were mapped onto the Theoretical Domains Framework (TDF) to identify theoretical constructs for change. In step two, behaviour change techniques and their mode of delivery were selected based on psychological theories and evidence to inform intervention content. In step three, the intervention was refined following delivery and subsequent feedback from intervention recipients and stakeholders.

Results: Six modifiable CBEPs target behaviours were identified to support the delivery of the NICE recommendations. Nine domains of the TDF were identified as key determinants of change, including: improving knowledge and skills and changing beliefs about consequences. To target the domains, we included 20 BCTs across 8 training modules and took a blended learning approach to accommodate different learning styles and preferences. Following test delivery to 11 CBEPs and feedback from 28 stakeholders, the training package was refined.

Conclusion: Established intervention development approaches provided a structured and transparent guide to intervention development. A training package for CBEPs was developed and should increase trust amongst patients and health care professionals when implementing exercise into prostate cancer care. Furthermore, if proven effective, the development and approach taken may provide a blueprint for replication in other clinical populations where exercise has proven efficacy but is insufficiently implemented.
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http://dx.doi.org/10.1186/s12913-021-06275-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982309PMC
March 2021

Exercise therapy for the treatment of tendinopathies: a scoping review protocol.

JBI Evid Synth 2021 Mar 17. Epub 2021 Mar 17.

School of Health Sciences, Robert Gordon University, Aberdeen, UK The Scottish Centre for Evidence-based, Multi-professional Practice: A JBI Centre of Excellence Centre for Sports & Exercise Medicine, Barts and the London School of Medicine and Dentistry, London, UK Library Services, Robert Gordon University, Aberdeen, UK.

Objective: The aim of the review is to provide a map of exercise interventions and outcomes that have been reported for the treatment of any tendinopathy.

Introduction: Tendinopathy is a common condition that affects athletic and non-athletic populations. Exercise is the mainstay of conservative management of tendinopathy, and a range of different exercise types are recommended. There is a significant body of literature on exercise for tendinopathy, but to date no scoping review has provided a clear map of interventions used and outcomes reported in the literature.

Inclusion Criteria: We will include people of any age or gender with a diagnosis of tendinopathy of any severity or duration at any anatomical location. We will exclude full-thickness/massive tears and plantar fasciitis. The exercise therapy may take place at any location, including hospital, community, or people's homes, and may be supervised or unsupervised. We will include systematic reviews, quantitative, qualitative, and mixed-methods studies conducted in any developed nation.

Methods: We will search MEDLINE, CINAHL, AMED, Embase, SPORTDiscus, Cochrane (controlled trials; systematic reviews), JBI Evidence Synthesis, Epistemonikos, four trial registries, and six gray literature databases. We will use Scopus to search for cited/citing articles from included studies and will perform hand searching where relevant. We will include literature from 1998 to 2020 in any language for which we can access translation. Studies will be screened by two independent reviewers at title/abstract and full-text screening stages; a third reviewer will resolve conflicts. Data will be extracted into a bespoke charting form and will be presented as figure/tables with accompanying narrative.
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http://dx.doi.org/10.11124/JBIES-20-00175DOI Listing
March 2021

A Bayesian Network Decision Support Tool for Low Back Pain Using a RAND Appropriateness Procedure: Proposal and Internal Pilot Study.

JMIR Res Protoc 2021 Jan 15;10(1):e21804. Epub 2021 Jan 15.

Sport and Exercise Medicine, Queen Mary University of London, London, United Kingdom.

Background: Low back pain (LBP) is an increasingly burdensome condition for patients and health professionals alike, with consistent demonstration of increasing persistent pain and disability. Previous decision support tools for LBP management have focused on a subset of factors owing to time constraints and ease of use for the clinician. With the explosion of interest in machine learning tools and the commitment from Western governments to introduce this technology, there are opportunities to develop intelligent decision support tools. We will do this for LBP using a Bayesian network, which will entail constructing a clinical reasoning model elicited from experts.

Objective: This paper proposes a method for conducting a modified RAND appropriateness procedure to elicit the knowledge required to construct a Bayesian network from a group of domain experts in LBP, and reports the lessons learned from the internal pilot of the procedure.

Methods: We propose to recruit expert clinicians with a special interest in LBP from across a range of medical specialties, such as orthopedics, rheumatology, and sports medicine. The procedure will consist of four stages. Stage 1 is an online elicitation of variables to be considered by the model, followed by a face-to-face workshop. Stage 2 is an online elicitation of the structure of the model, followed by a face-to-face workshop. Stage 3 consists of an online phase to elicit probabilities to populate the Bayesian network. Stage 4 is a rudimentary validation of the Bayesian network.

Results: Ethical approval has been obtained from the Research Ethics Committee at Queen Mary University of London. An internal pilot of the procedure has been run with clinical colleagues from the research team. This showed that an alternating process of three remote activities and two in-person meetings was required to complete the elicitation without overburdening participants. Lessons learned have included the need for a bespoke online elicitation tool to run between face-to-face meetings and for careful operational definition of descriptive terms, even if widely clinically used. Further, tools are required to remotely deliver training about self-identification of various forms of cognitive bias and explain the underlying principles of a Bayesian network. The use of the internal pilot was recognized as being a methodological necessity.

Conclusions: We have proposed a method to construct Bayesian networks that are representative of expert clinical reasoning for a musculoskeletal condition in this case. We have tested the method with an internal pilot to refine the process prior to deployment, which indicates the process can be successful. The internal pilot has also revealed the software support requirements for the elicitation process to model clinical reasoning for a range of conditions.

International Registered Report Identifier (irrid): DERR1-10.2196/21804.
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http://dx.doi.org/10.2196/21804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846442PMC
January 2021

Factors associated with outcome following exercise interventions for Achilles tendinopathy: A systematic review.

Physiother Res Int 2021 Apr 22;26(2):e1889. Epub 2020 Dec 22.

Sports and Exercise Medicine, Queen Mary, University of London, London, UK.

Objective: This systematic review aimed to synthesize current evidence on contributing factors influencing outcome following exercise management for Achilles tendinopathy (AT).

Data Sources: Databases (PubMed, Embase, and Cochrane Library) were searched from inception to February 2020.

Study Selection: Studies investigating factors (e.g., age, BMI) associated with outcome (e.g., pain and function questionnaires) following exercise interventions for AT were included.

Data Extraction: Data were extracted into a standardized form, including patient demographics, population sample, study type, factors associated with outcome, and outcome measures.

Data Synthesis: Meta-analysis was planned to be performed, where appropriate. Where data could not be pooled, we summarized the findings descriptively.

Results: Six studies investigating 11 different factors were included; overall the quality of evidence was poor. There was conflicting evidence that imaging measures had an association with a change in VISA-A outcome. These included signal intensity and tendon size determined by MRI, and Ultrasound Tissue Characterization echopattern. Three studies found that duration of symptoms was not associated with a change in VISA-A. Also, three studies found that age, and one study found that prior sporting activity level, were not associated with outcome. Baseline pain with activity, baseline VISA-A, sex, and BMI were inconsistently associated with specific outcomes.

Conclusion: Due to the poor quality of evidence overall, no firm conclusions can be drawn. At best, there was inconsistent evidence that imaging factors, baseline pain and function, BMI, and sex showed some associations with outcomes, but these findings need to be confirmed in more extensive studies.
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http://dx.doi.org/10.1002/pri.1889DOI Listing
April 2021

Neuromuscular Function of the Knee Joint Following Knee Injuries: Does It Ever Get Back to Normal? A Systematic Review with Meta-Analyses.

Sports Med 2021 Feb;51(2):321-338

Sports and Exercise Medicine, Queen Mary University of London, London, UK.

Background: Neuromuscular deficits are common following knee injuries and may contribute to early-onset post-traumatic osteoarthritis, likely mediated through quadriceps dysfunction.

Objective: To identify how peri-articular neuromuscular function changes over time after knee injury and surgery.

Design: Systematic review with meta-analyses.

Data Sources: PubMed, Web of Science, Embase, Scopus, CENTRAL (Trials).

Eligibility Criteria For Selecting Studies: Moderate and high-quality studies comparing neuromuscular function of muscles crossing the knee joint between a knee-injured population (ligamentous, meniscal, osteochondral lesions) and healthy controls. Outcomes included normalized isokinetic strength, muscle size, voluntary activation, cortical and spinal-reflex excitability, and other torque related outcomes.

Results: A total of 46 studies of anterior cruciate ligament (ACL) and five of meniscal injury were included. For ACL injury, strength and voluntary activation deficits were evident (moderate to strong evidence). Cortical excitability was not affected at < 6 months (moderate evidence) but decreased at 24+ months (moderate evidence). Spinal-reflex excitability did not change at < 6 months (moderate evidence) but increased at 24+ months (strong evidence). We also found deficits in torque variability, rate of torque development, and electromechanical delay (very limited to moderate evidence). For meniscus injury, strength deficits were evident only in the short-term. No studies reported gastrocnemius, soleus or popliteus muscle outcomes for either injury. No studies were found for other ligamentous or chondral injuries.

Conclusions: Neuromuscular deficits persist for years post-injury/surgery, though the majority of evidence is from ACL injured populations. Muscle strength deficits are accompanied by neural alterations and changes in control and timing of muscle force, but more studies are needed to fill the evidence gaps we have identified. Better characterisation and therapeutic strategies addressing these deficits could improve rehabilitation outcomes, and potentially prevent PTOA.

Trial Registration Number: PROSPERO CRD42019141850.
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http://dx.doi.org/10.1007/s40279-020-01386-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846527PMC
February 2021

CD28 Costimulatory Domain-Targeted Mutations Enhance Chimeric Antigen Receptor T-cell Function.

Cancer Immunol Res 2021 01 13;9(1):62-74. Epub 2020 Nov 13.

Department of Blood and Marrow Transplant and Cellular Immunotherapy, Division of Clinical Science, H. Lee Moffitt Cancer Center, Tampa, Florida.

An obstacle to the development of chimeric antigen receptor (CAR) T cells is the limited understanding of CAR T-cell biology and the mechanisms behind their antitumor activity. We and others have shown that CARs with a CD28 costimulatory domain drive high T-cell activation, which leads to exhaustion and shortened persistence. This work led us to hypothesize that by incorporating null mutations of CD28 subdomains (YMNM, PRRP, or PYAP), we could optimize CAR T-cell costimulation and enhance function. , we found that mice given CAR T cells with only a PYAP CD28 endodomain had a significant survival advantage, with 100% of mice alive after 62 days compared with 50% for mice with an unmutated endodomain. We observed that mutant CAR T cells remained more sensitive to antigen after antigen and PD-L1 stimulation, as demonstrated by increased cytokine production. The mutant CAR T cells also had a reduction of exhaustion-related transcription factors and genes such as , and Our results demonstrated that CAR T cells with a mutant CD28 endodomain have better survival and function. This work allows for the development of enhanced CAR T-cell therapies by optimizing CAR T-cell costimulation.
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http://dx.doi.org/10.1158/2326-6066.CIR-20-0253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864379PMC
January 2021

Lived experience and attitudes of people with plantar heel pain: a qualitative exploration.

J Foot Ankle Res 2020 Mar 6;13(1):12. Epub 2020 Mar 6.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia.

Background: Plantar heel pain is a common source of pain and disability. Evidence-based treatment decisions for people with plantar heel pain should be guided by the best available evidence, expert clinical reasoning, and consider the needs of the patient. Education is a key component of care for any patient and needs to be tailored to the patient and their condition. However, no previous work has identified, far less evaluated, the approaches and content required for optimal education for people with plantar heel pain. The aim of this study was to gather the patients' perspective regarding their lived experience, attitudes and educational needs in order to inform the content and provision of meaningful education delivery approaches.

Methods: Using a qualitative descriptive design, semi-structured interviews were conducted with participants with a clinical diagnosis of plantar heel pain. A topic guide was utilised that focused on the experience of living with plantar heel pain and attitudes regarding treatment and educational needs. Interviews were audio recorded, transcribed verbatim and analysed using the Framework approach. Each transcription, and the initial findings, were reported back to participants to invite respondent validation.

Results: Eighteen people with plantar heel pain were interviewed. Descriptive analysis revealed eight themes including perceptions of plantar heel pain, impact on self, dealing with plantar heel pain, source of information, patient needs, patient unmet needs, advice to others and interest in online education. Participants revealed doubt about the cause, treatment and prognosis of plantar heel pain. They also expressed a desire to have their pain eliminated and education individually tailored to their condition and needs. Respondent validation revealed that the transcripts were accurate, and participants were able to recognise their own experiences in the synthesised themes.

Conclusion: Plantar heel pain has a negative impact on health-related quality of life. Participants wanted their pain eliminated and reported that their expectations and needs were frequently unmet. Health professionals have an important role to be responsive to the needs of the patient to improve their knowledge and influence pain and behaviour. Our study informs the content needed to help educate people with plantar heel pain.
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http://dx.doi.org/10.1186/s13047-020-0377-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059663PMC
March 2020

Is markerless, smart phone recorded two-dimensional video a clinically useful measure of relevant lower limb kinematics in runners with patellofemoral pain? A validity and reliability study.

Phys Ther Sport 2020 May 10;43:36-42. Epub 2020 Feb 10.

Sports & Exercise Medicine, Queen Mary University of London, United Kingdom; Physiotherapy Department, Barts Health NHS Trust, London, UK.

Objectives: Investigate the validity and reliability of markerless, smart phone collected, two-dimensional (2D) video, analysed using the 'Hudl technique' application, compared to three-dimensional (3D) kinematics during running, in participants with patellofemoral pain (PFP).

Design: Validity/reliability study.

Setting: Biomechanics laboratory.

Participants: Males/females with PFP (n = 21, 10 males, 11 females, age 32.1 months [±12.9]).

Main Outcome Measures: Manually synchronised 2D and 3D measurement of peak hip adduction (HADD) and peak knee flexion (KFLEX) during running.

Results: 2D and 3D measures of peak KFLEX (p = 0.02, d = 1.13), but not peak HADD (p = 0.25, d = -0.27), differed significantly. Poor validity was identified for 2D measurement of peak HADD (ICC 0.06, 95% CI -0.35, 0.47) and peak KFLEX ICC 0.42, 95% CI (-0.10, 0.75). Moderate intra-rater reliability was identified for both variables (ICC 0.61-65), alongside moderate inter-rater reliability for peak KFLEX (ICC 0.71) and poor inter-rater reliability for peak HADD (ICC 0.31).

Conclusions: Measurement of peak HADD and KFLEX in runners with PFP using markerless, smart phone collected 2D video, analysed using the Hudl technique Application is invalid, with poor to moderate reliability. Investigation of alternate 2D video approaches to increase precision is warranted. At present, 2D video analysis of running using Hudl Technique cannot be advocated.
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http://dx.doi.org/10.1016/j.ptsp.2020.02.004DOI Listing
May 2020

'There is a very distinct need for education' among people with rotator cuff tendinopathy: An exploration of health professionals' attitudes.

Musculoskelet Sci Pract 2020 02 12;45:102103. Epub 2019 Dec 12.

Department of Physiotherapy, School of Primary and Allied Health, Monash University, Australia.

Background: Clinical practice guidelines recommend non-surgical care in the management of rotator cuff tendinopathy prior to considering imaging or surgery. However, this requires effective education to promote adherence to treatment.

Objectives: To explore expert shoulder clinician's experiences with managing rotator cuff tendinopathy including practice beliefs towards providing education.

Design: An in-depth qualitative study.

Method: We conducted interviews (n = 8) with an international sample of expert shoulder clinician-researchers. Data were analysed using an inductive thematic approach with constant comparison.

Results: Three key themes emerged: (1) The need for early, focused education: "Some beliefs can be detrimental to rehabilitation options", (2) Developing therapeutic alliance: "If a patients trust you then you are generally going to get much better results" and (3) What is required moving forward in current day RT management: "Maybe we can get better."

Conclusions: Our findings highlight the importance of education to alleviate potential barriers to effective conservative care (including exercise) and self-management for rotator cuff tendinopathy. We also identified actionable ways to promote a collaborative therapeutic alliance however, this hinges on sufficient clinical time to educate patients adequately, which may be a barrier in busy clinical settings. Further, there is need for targeted education to facilitate development of clinical skills required to implement effective patient education strategies.
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http://dx.doi.org/10.1016/j.msksp.2019.102103DOI Listing
February 2020

Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: A single cohort feasibility study.

Phys Ther Sport 2019 Nov 14;40:107-116. Epub 2019 Aug 14.

Sports and Exercise Medicine. Queen Mary University of London, London, UK; Department of Physiotherapy, Monash University, Australia. Electronic address:

Objectives: To examine the feasibility of recommended education and exercise supplemented by a hopping intervention implemented based on self-reported pain over 12 weeks for recreational runners with Achilles tendinopathy.

Design: Single cohort feasibility study.

Setting: One private physiotherapy clinic in Melbourne, Australia.

Participants: Fifteen male recreational runners with midportion Achilles tendinopathy.

Main Outcome Measures: Recruitment and adherence measures, adverse events, intervention acceptability and treatment effect trends were measured at baseline, 4 and 12 weeks.

Results: Recruitment (100%), retention (87%) and follow-up (93%) rates were high. Exercise adherence was 70% (SD = 12.7) but fidelity was 50% (SD = 13.9). Three participants suffered adverse events (undertaking activities contrary to advice). Participants reported the education package, perceived benefit, and feedback frequency as intervention enablers; while the onerous time commitment was regarded a barrier. At 12 weeks, five participants were satisfied and eight very satisfied, while VISA-A had improved 24 ± 20.65 points (μ2 = 0.740).

Conclusions: A randomised control trial including recommended education and exercise with a pain-guided hopping intervention as treatment for recreational runners with midportion Achilles tendinopathy may be warranted, once strategies to improve adherence and reduce adverse events are addressed.
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http://dx.doi.org/10.1016/j.ptsp.2019.08.007DOI Listing
November 2019

Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis.

Gait Posture 2019 09 12;73:189-201. Epub 2019 Jul 12.

Sports and Exercise Medicine. Queen Mary University of London, United Kingdom; Physiotherapy Department, Barts Health NHS Trust, London, United Kingdom. Electronic address:

Introduction: Biomechanical alterations during running and hopping in people with Achilles tendinopathy (AT) may provide treatment and prevention targets. This review identifies and synthesises research evaluating biomechanical alterations among people with AT during running, jumping and hopping.

Method: MEDLINE, EMBASE, CiNAHL and SPORTDiscus were searched in July 2018 for case control, cross-sectional and prospective studies investigating kinematics, kinetics, plantar pressures and neuromuscular activity in AT participants during running or hopping. Study quality was assessed with a modified version of the Downs and Black quality checklist, and evidence grading applied.

Results: 16 studies reported 249 outcomes, of which 17% differed between groups. Reduced peroneus longus (standardized mean difference [95%CI]; -0.53 [-0.98, -0.09]) and medial gastrocnemius (-0.60 [-1.05, -0.15]) amplitude in AT runners versus control was found (limited evidence). Increased hip adduction impulse 1.62 [0.69, 2.54], hip peak external rotation moment (1.55 [0.63, 2.46] and hip external rotation impulse (1.45 [0.55, 2.35]) was found in AT runners versus control (limited evidence). Reduced anterior (-0.94 [-1.64, -0.24] and greater lateral (-0.92 [-1.61, -0.22]) displacement of plantar pressure preceded AT in runners (limited evidence). Delayed onsets of gluteus medius (1.95 [1.07, 2.83] and gluteus maximus (1.26 [0.48, 2.05] and shorter duration of gluteus maximus activation (-1.41 [-2.22, -0.61] was found during shod running in the AT group versus control (limited evidence). Earlier offset time of gluteus maximus (-1.03 [-1.79, -0.27] and shorter duration of activation of gluteus medius (-0.18 [-0.24, -0.12] during running in AT runners versus control was found (limited evidence). Reduced leg stiffness was found in the affected side during submaximal hopping (-0.39 [-0.79, -0.00]) (limited evidence).

Conclusion: This review identified potential biomechanical treatment targets in people with AT. The efficacy of treatments targeting these biomechanics should be assessed.

Systematic Review Registry: PROSPERO registration number: CRD42016048636.
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http://dx.doi.org/10.1016/j.gaitpost.2019.07.121DOI Listing
September 2019

Increased hip adduction during running is associated with patellofemoral pain and differs between males and females: A case-control study.

J Biomech 2019 Jun 21;91:133-139. Epub 2019 May 21.

Sports & Exercise Medicine, Queen Mary University of London, United Kingdom; Physiotherapy Department, Barts Health NHS Trust, London, UK.

Patellofemoral pain is common amongst recreational runners and associated with altered running kinematics. However, it is currently unclear how sex may influence kinematic differences previously reported in runners with patellofemoral pain. This case-control study aimed to evaluate lower limb kinematics in males and females with and without patellofemoral pain during running. Lower limb 3D kinematics were assessed in 20 runners with patellofemoral pain (11 females, 9 males) and 20 asymptomatic runners (11 females, 9 males) during a 3 km treadmill run. Variables of interest included peak hip adduction, internal rotation and flexion angles; and peak knee flexion angle, given their previously reported association with patellofemoral pain. Age, height, mass, weekly run distance and step rate were not significantly different between groups. Mixed-sex runners with patellofemoral pain were found to run with a significantly greater peak hip adduction angle (mean difference = 4.9°, d = 0.91, 95% CI 1.4-8.2, p = 0.01) when compared to matched controls, but analyses for all other kinematic variables were non-significant. Females with patellofemoral pain ran with a significantly greater peak hip adduction angle compared to female controls (mean difference = 6.6°, p = 0.02, F = 3.41, 95% CI 0.4-12.8). Analyses for all other kinematic variables between groups (males and females with/without PFP) were non-significant. Differences in peak hip adduction between those with and without patellofemoral pain during running appear to be driven by females. This potentially highlights different kinematic treatment targets between males and females. Future research is encouraged to report lower limb kinematic variables in runners with patellofemoral pain separately for males and females.
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http://dx.doi.org/10.1016/j.jbiomech.2019.05.014DOI Listing
June 2019

An in vitro investigation into the effects of 10 Hz cyclic loading on tenocyte metabolism.

Scand J Med Sci Sports 2019 Oct 2;29(10):1511-1520. Epub 2019 Jun 2.

School of Engineering and Material Science, Queen Mary University of London, London, UK.

Tendinopathy is a prevalent, highly debilitating condition, with poorly defined etiology. A wide range of clinical treatments has been proposed, with systematic reviews largely supporting shock wave therapy or eccentric exercise. Characterizing these treatments have demonstrated both generate perturbations within tendon at a frequency of approximately 8-12 Hz. Consequently, it is hypothesized that loading in this frequency range initiates increased anabolic tenocyte behavior, promoting tendon repair. The primary aim of this study was to investigate the effects of 10 Hz perturbations on tenocyte metabolism, comparing gene expression in response to a 10 Hz and 1 Hz loading profile. Tenocytes from healthy and tendinopathic human tendons were seeded into 3D collagen gels and subjected to 15 minutes cyclic strain at 10 Hz or 1 Hz. Tenocytes from healthy tendon showed increased expression of all analyzed genes in response to loading, with significantly increased expression of inflammatory and degradative genes with 10 Hz, relative to 1 Hz loading. By contrast, whilst the response of tenocytes from tendinopathy tendon also increased with 10 Hz loading, the overall response profile was more varied and less intense, possibly indicative of an altered healing response. Through inhibition of the pathway, IL1 was shown to be involved in the degradative and catabolic response of cells to high-frequency loading, abrogating the loading response. This study has demonstrated for the first time that loading at a frequency of 10 Hz may enhance the metabolic response of tenocytes by initiating an immediate degradatory and inflammatory cell response through the IL1 pathway, perhaps as an initial stage of tendon healing.
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http://dx.doi.org/10.1111/sms.13465DOI Listing
October 2019

Improving the management of musculoskeletal conditions: can an alternative approach to referral management underpinned by quality improvement and behavioural change theories offer a solution and a better patient experience? A mixed-methods study.

BMJ Open 2019 02 19;9(2):e024710. Epub 2019 Feb 19.

Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.

Objectives: To assess whether a quality improvement-based approach to referral management can result in better musculoskeletal care within general practice.

Design: Prospective cohort study using mixed methodology including random-effects meta-analysis and interrupted time series.

Setting And Participants: 36 general practices in East London.

Intervention: Informed by the results of a Cochrane review on educational interventions to improve general practitioners' (GPs) musculoskeletal care, we developed a multifaceted intervention, underpinned by quality improvement and behavioural change theories. It combined locally agreed clinical pathways, feedback on referral rates, clinical audit and peer review.

Main Outcome Measures: Referral letter content, pathway adherence, referral rates, inter-practice variability and patient experience were evaluated before and after the intervention.

Results: Referral letter content on suspected diagnosis and prior management improved from a pooled preintervention proportion of 59% (95% CI 53% to 65%) and 67% (95% CI 61% to 73%), respectively, to 77% (95% CI 70% to 84%) and 81% (95% CI 74% to 88%). Pathway adherence improved from a pooled preintervention percentage of 42% (95% CI 35% to 48%) to 66% (95% CI 57% to 76%). The effect was greater across all quality outcomes for practices with baseline performance below or equal to the pooled baseline performance. There were reductions in the variability and rates of orthopaedic referrals at 6, 12 and 18 months (referral rate relative effect 32% (95% CI 14% to 48%), 30% (95% CI 7% to 53%) and 30% (95% CI 0% to 59%), respectively). Patient rating of how well GPs explained the musculoskeletal condition improved by 29% (95% CI 14% to 43%) and patient perception on the usefulness of the GP appointment improved by 24% (95% CI 9% to 38%).

Conclusions: A quality improvement-based approach to referral management which values GPs' professionalism can result in improvements across a range of outcomes including referral quality, patient experience, referral rates and variability.
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http://dx.doi.org/10.1136/bmjopen-2018-024710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398779PMC
February 2019

Factors associated with physical activity engagement among adults with rheumatoid arthritis: A cross-sectional study.

Musculoskeletal Care 2019 06 6;17(2):163-173. Epub 2019 Feb 6.

Centre for Sports and Exercise Medicine, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, UK.

Objectives: Physical activity (PA) has a number of benefits for rheumatoid arthritis (RA) patients. However, these patients are more physically inactive than the general population. The primary aim of this study was to investigate factors associated with PA engagement among RA patients. The secondary aim was to identify their preference for PA support.

Methods: There were 96 participants, 76 of whom were female, with a mean age of 56.9 years (range = 34-72 years) and a median RA disease duration of 5 years (interquartile range = 2-12). All patients completed questionnaires assessing demographic status, health status (including cardiovascular disease [CVD] risk and RA disease profile), PA levels and preferences, alongside the perceived benefits of-and barriers to-PA. Hierarchical regressions were carried out to assess the relationship between reported PA levels and both engagement determinants and disease features.

Results: Forty-five per cent (n = 44) had low levels (<600 metabolic equivalent-min/week) of PA. Low level of PA was significantly associated with: CVD risk profile (η  = 0.118, p < 0.002); functional disability (η  = 0.206, p < 0.032); pain (η  = 0.154, p < 0.028); general personal (η  = 0.190, p < 0.001) and arthritis-specific personal (η  = 0.170, p < 0.001) barriers to PA; age (η  = 0.076, p < 0.026); and sedentary behaviour (η  = 0.275, p < 0.001). Participants displayed a preference for unsupervised (n = 37, 38.5%), low-intensity (n = 45, 46.9%), indoor home (n = 50, 52.1%) exercises, with no preferences for the diversity of the exercise prescribed (n = 39, 40.6%) or for who provided the exercise counselling (n = 34, 35.4%).

Conclusions: These results suggest that CVD profile, disability, pain, and general and arthritis-specific personal barriers are associated with PA levels among RA patients. Intervention development should address these factors to facilitate an increase in PA uptake.
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http://dx.doi.org/10.1002/msc.1385DOI Listing
June 2019

Bilateral scapular kinematics, asymmetries and shoulder pain in wheelchair athletes.

Gait Posture 2018 09 20;65:151-156. Epub 2018 Jul 20.

Peter Harrison Centre for Disability Sport, School of Sport, Exercise & Health Sciences, Loughborough University, UK(1).

Background: Shoulder pain is the most common complaint for wheelchair athletes. Scapular orientation and dyskinesia are thought to be associated with shoulder pathology, yet no previous studies have examined the bilateral scapula kinematics of wheelchair athletes during propulsion.

Research Question: To examine bilateral scapular kinematics of highly trained wheelchair rugby (WR) players and any associations with self-reported shoulder pain during everyday wheelchair propulsion.

Methods: Ten WR players (5 with shoulder pain, 5 without) performed 2 × 3-minute bouts of exercise in their everyday wheelchair on a wheelchair ergometer at two sub-maximal speeds (3 and 6 km h). During the final minute, 3D kinematic data were collected at 100 Hz to describe scapulothoracic motion relative to each propulsion cycle. Instantaneous asymmetries in scapular orientation between dominant and non-dominant sides were also reported. Differences in scapular kinematics and propulsion asymmetries were compared across shoulders symptomatic and asymptomatic of pain.

Results: An internally rotated, upwardly rotated and anteriorly tilted scapula was common during wheelchair propulsion and asymmetries ≤14° did exist, yet minimal changes were observed across speeds. Participants with bilateral shoulder pain displayed a less upwardly rotated scapula during propulsion, however large inter-individual variability in scapular kinematics was noted.

Significance: Scapular asymmetries are exhibited by wheelchair athletes during wheelchair propulsion, yet these were not exacerbated by increased speed and had limited associations to shoulder pain. This suggests that propulsion kinematics of highly trained athletes may not be the primary cause of pain experienced by this population.
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http://dx.doi.org/10.1016/j.gaitpost.2018.07.170DOI Listing
September 2018

Towards an Evidence-Based Decision Support Tool for Management of Musculoskeletal Conditions.

Stud Health Technol Inform 2018 ;255:175-179

Sports and Exercise Medicine, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.

Musculoskeletal (MSK) problems present an increasing burden for the healthcare sector, particularly in ageing populations. Advances in evidence are often slow to influence clinical decisions, suggesting decision support would be beneficial. We propose a Bayesian network (BN) for providing evidence-based decision support as it can explicitly represent domain knowledge as causal relations and allows both domain knowledge and clinical data to be combined to create a usable decision model. We make a preliminary evaluation of the model's performance.
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August 2019

Medial and Lateral Patellofemoral Joint Retinaculum Thickness in People With Patellofemoral Pain: A Case-Control Study.

J Ultrasound Med 2019 Jun 24;38(6):1483-1490. Epub 2018 Sep 24.

Physiotherapy Department, Barts Health National Health Service Trust, London, England.

Objectives: To measure the medial and lateral retinaculum thickness in individuals with and without patellofemoral pain using ultrasound and to assess associations with the symptom duration and function.

Methods: Medial and lateral patellofemoral joint retinaculum thicknesses of 32 knees (16 with patellofemoral pain and 16 asymptomatic) were measured with B-mode ultrasound at 0.5, 1, and 1.5 cm from the patella border. Participants with patellofemoral pain completed a Kujala questionnaire, and both groups underwent a single-leg squat performance assessment. Two-way analyses of variance (site × group) determined the overall effect, and Cohen d values were calculated to describe the magnitude of the difference for each measurement.

Results: The groups were matched for age, height, and weight. Compared to controls, participants with patellofemoral pain had thicker lateral (overall effect, P = .03) and medial (overall effect, P < 0.01) retinacula. No correlations between retinaculum thickness and Kujala scores (lateral retinaculum, r = 0.106 [0.5 cm], -0.093 [1 cm], and -0.207 [1.5 cm]; and medial retinaculum, r = 0.059, 0.109, and -0.219), symptom duration (lateral retinaculum, r = 0.001, -0.041, and 0.302; and medial retinaculum, r = -0.027, -0.358, and -0.346), or single-leg squat performance scores (lateral retinaculum, r = 0.051, 0.114, and 0.046; and medial retinaculum, r = -0.119, -0.292, and 0.011) were observed.

Conclusions: Increased lateral and medial retinaculum thickness in individuals with patellofemoral pain compared to controls identifies structural changes that may be associated with the pathogenesis of patellofemoral pain. The absence of a significant correlation between retinaculum thickness and the symptom duration or function further shows a lack of an association between structure and function in individuals with patellofemoral pain.
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http://dx.doi.org/10.1002/jum.14828DOI Listing
June 2019

Risk factors for patellofemoral pain: a systematic review and meta-analysis.

Br J Sports Med 2019 Mar 21;53(5):270-281. Epub 2018 Sep 21.

Department of General Practice, Erasmus MC, Rotterdam, The Netherlands.

Background: Patellofemoral pain (PFP) is a prevalent condition commencing at various points throughout life. We aimed to provide an evidence synthesis concerning predictive variables for PFP, to aid development of preventative interventions.

Methods: We searched Medline, Web of Science and SCOPUS until February 2017 for prospective studies investigating at least one potential risk factor for future PFP. Two independent reviewers appraised methodological quality using the Newcastle-Ottawa Scale. We conducted meta-analysis where appropriate, with standardised mean differences (SMD) and risk ratios calculated for continuous and nominal scaled data.

Results: This review included 18 studies involving 4818 participants, of whom 483 developed PFP (heterogeneous incidence 10%). Three distinct subgroups (military recruits, adolescents and recreational runners) were identified. Strong to moderate evidence indicated that age, height, weight, body mass index (BMI), body fat and Q angle were not risk factors for future PFP. Moderate evidence indicated that quadriceps weakness was a risk factor for future PFP in the military, especially when normalised by BMI (SMD -0.69, CI -1.02, -0.35). Moderate evidence indicated that hip weakness was not a risk factor for future PFP (multiple pooled SMDs, range -0.09 to -0.20), but in adolescents, moderate evidence indicated that increased hip abduction strength was a risk factor for future PFP (SMD 0.71, CI 0.39, 1.04).

Conclusions: This review identified multiple variables that did not predict future PFP, but quadriceps weakness in military recruits and higher hip strength in adolescents were risk factors for PFP. Identifying modifiable risk factors is an urgent priority to improve prevention and treatment outcomes.
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http://dx.doi.org/10.1136/bjsports-2017-098890DOI Listing
March 2019

Immediate and Short-Term Effects of Short- and Long-Duration Isometric Contractions in Patellar Tendinopathy.

Clin J Sport Med 2020 07;30(4):335-340

Department of Physiotherapy, School of Primary & Allied Health Care, Faculty of Medicine, Nursing & Health Science, Monash University, Frankston, Australia.

Objectives: Isometric muscle contractions are used in the management of patellar tendinopathy to manage pain and improve function. Little is known about whether long- or short-duration contractions are optimal to improve pain. This study examined the immediate and short-term (4 weeks) effects of long- and short-duration isometric contraction on patellar tendon pain, and tendon adaptation.

Design: Repeated measures within groups.

Setting: Clinical primary care.

Patients: Participants (n = 16, males) with patellar tendinopathy.

Intervention: Short-duration (24 sets of 10 seconds) or long-duration (6 sets of 40 seconds) isometric knee extension loading (85% maximal voluntary contraction), for 4 weeks.

Main Outcome Measure: Immediate change in pain with single-leg decline squat (SLDS) and hop, as well as change in pain and tendon adaptation [within-session anterior-posterior (AP) strain] were assessed over 4 weeks.

Results: Pain was significantly reduced after isometric loading on both SLDS (P < 0.01) and hop tests (P < 0.01). Pain and quadriceps function improved over the 4 weeks (P < 0.05). There was significant AP strain at each measurement occasion (P < 0.01). Although transverse strain increased across the training period from ∼14% to 22%, this was not significant (P = 0.08).

Conclusions: This is the first study to show that short-duration isometric contractions are as effective as longer duration contractions for relieving patellar tendon pain when total time under tension is equalized. This finding provides clinicians with greater options in prescription of isometric loading and may be particularly useful among patients who do not tolerate longer duration contractions. The trend for tendon adaptation over the short 4-week study period warrants further investigation.
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http://dx.doi.org/10.1097/JSM.0000000000000625DOI Listing
July 2020

Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC).

Trials 2018 Jul 31;19(1):408. Epub 2018 Jul 31.

School of Healthcare Sciences, Bangor University, Bangor, UK.

Background: Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early.

Methods: A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase.

Results: The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants.

Conclusions: Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica.

Trial Registration: Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.
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http://dx.doi.org/10.1186/s13063-018-2801-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069989PMC
July 2018

Fc receptor-like 3 (-169T>C) polymorphism increases the risk of tendinopathy in volleyball athletes: a case control study.

BMC Med Genet 2018 07 18;19(1):119. Epub 2018 Jul 18.

Research Division, National Institute of Traumatology and Orthopaedics, Avenida Brasil, 500, Rio de Janeiro, RJ, 20940-070, Brazil.

Background: Tendinopathy pathogenesis is associated with inflammation. Regulatory T (Treg) cells contribute to early tissue repair through an anti-inflammatory action, with the forkhead box P3 (FOXP3) transcription factor being essential for Treg function, and the FC-receptor-like 3 (FCRL3) possibly negatively regulating Treg function. FCRL3 -169T>C and FOXP3 -2383C>T polymorphisms are located near elements that regulate respective genes expression, thus it was deemed relevant to evaluate these polymorphisms as risk factors for tendinopathy development in athletes.

Methods: This case-control study included 271 volleyball athletes (146 tendinopathy cases and 125 controls) recruited from the Brazilian Volleyball Federation. Genotyping analyses were performed using TaqMan assays, and the association of the polymorphisms with tendinopathy evaluated by multivariate logistic regression.

Results: Tendinopathy frequency was 63% patellar, 22% rotator cuff and 15% Achilles tendons respectively. Tendinopathy was more common in men (OR = 2.87; 95% CI = 1.67-4.93). Higher age (OR = 8.75; 95% CI = 4.33-17.69) and more years of volleyball practice (OR = 8.38; 95% CI = 3.56-19.73) were risk factors for tendinopathy. The FCRL3 -169T>C frequency was significantly different between cases and controls. After adjustment for potential confounding factors, the FCRL3 -169C polymorphism was associated with increased tendinopathy risk (OR = 1.44; 95% CI = 1.02-2.04), either considering athletes playing with tendon pain (OR = 1.98; 95% CI = 1.30-3.01) or unable to train due to pain (OR = 1.89; 95% CI = 1.01-3.53). The combined variant genotypes, FCRL3 -169TC or -169CC and FOXP3 -2383CT or -2383TT, were associated with an increased risk of tendinopathy among athletes with tendon pain (OR = 2.24; 95% CI: 1.14-4.40 and OR = 2.60; 95% CI: 1.11-6.10). The combined analysis of FCRL3 -169T>C and FOXP3 -2383C>T suggests a gene-gene interaction in the susceptibility to tendinopathy.

Conclusions: FCRL3 -169C allele may increase the risk of developing tendinopathy, and together with knowledge of potential risk factors (age, gender and years playing) could be used to personalize elite athletes' training or treatment in combination with other approaches, with the aim of minimizing pathology development risk.
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http://dx.doi.org/10.1186/s12881-018-0633-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052601PMC
July 2018

The effects & mechanisms of increasing running step rate: A feasibility study in a mixed-sex group of runners with patellofemoral pain.

Phys Ther Sport 2018 Jul 31;32:244-251. Epub 2018 May 31.

Sports & Exercise Medicine, Queen Mary University of London, United Kingdom; Physiotherapy Department, Bart's Health NHS Trust, London, United Kingdom. Electronic address:

Objectives: To explore feasibility of recruitment and retention of runners with patellofemoral pain (PFP), before delivering a step rate intervention.

Design: Feasibility study.

Setting: Human performance laboratory.

Participants: A mixed-sex sample of runners with PFP (n = 11).

Main Outcome Measures: Average/worst pain and the Kujala Scale were recorded pre/post intervention, alongside lower limb kinematics and surface electromyography (sEMG), sampled during a 3 KM treadmill run.

Results: Recruitment and retention of a mixed-sex cohort was successful, losing one participant to public healthcare and with kinematic and sEMG data lost from single participants only. Clinically meaningful reductions in average (MD = 2.1, d = 1.7) and worst pain (MD = 3.9, d = 2.0) were observed. Reductions in both peak knee flexion (MD = 3.7°, d = 0.78) and peak hip internal rotation (MD = 5.1°, d = 0.96) were observed, which may provide some mechanistic explanation for the identified effects. An increase in both mean amplitude (d = 0.53) and integral (d = 0.58) were observed for the Vastus Medialis Obliqus (VMO) muscle only, of questionable clinical relevance.

Conclusions: Recruitment and retention of a mixed sex PFP cohort to a step rate intervention involving detailed biomechanical measures is feasible. There are indications of both likely efficacy and associated mechanisms. Future studies comparing the efficacy of different running retraining approaches are warranted.
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July 2018