OBJECTIVE:To determine whether adding compartment specific knee bracing with an adherence intervention to advice, written information, and exercise instruction (AIE+B) is superior to advice, written information, and exercise instruction (AIE) only in improving patient reported outcomes in people with knee osteoarthritis. DESIGN:Multicentre, parallel group, superiority, statistician blinded, randomised (1:1; block; stratified; centralised web based) controlled trial. SETTING:Recruitment through general practices and the community in Cheshire, Manchester, North Tyneside, and Staffordshire, England; enrolment 25 November 2019 to 16 September 2022. PARTICIPANTS:466 adults aged ≥45 years with symptoms of knee osteoarthritis. INTERVENTIONS:AIE was delivered in one in-person consultation by a trained physiotherapist. Individuals randomised to the AIE+B group were also fitted with a patellofemoral, tibiofemoral unloading, or neutral stabilising knee brace, according to their predominant compartmental distribution of knee osteoarthritis, and were offered a two week follow-up consultation. Brief motivational interviewing with targeted text reminders supported brace adherence. MAIN OUTCOME MEASURES:The primary outcome was a composite patient reported Knee Osteoarthritis Outcomes Score (KOOS)-5 (0-100) at six months after randomisation. Key secondary outcomes were KOOS-5 at three and 12 months, KOOS-5 subscale scores, and pain on weight bearing activity at three, six, and 12 months. RESULTS:466 participants (mean age 64 (standard deviation 9) years; 46% female participants) were randomised, with 401 (86%), 394 (85%), and 370 (79%) participants followed up with analysable data at three, six, and 12 months, respectively. At six months, greater improvement in KOOS-5 was seen in the AIE+B group than in the AIE group (adjusted mean difference 3.39, 95% confidence interval (CI) 0.96 to 5.82; effect size 0.24). Secondary outcomes showed the benefits of AIE+B over AIE that diminished over time. The largest effects observed were for pain reduction (KOOS pain (0-100) adjusted mean difference at six months 6.13, 95% CI 3.36 to 8.91; effect size 0.39). Adverse events were minor and expected. CONCLUSIONS:Adding compartment specific knee bracing and an adherence intervention to advice, written information, and exercise instruction resulted in small improvements in patient reported outcomes among individuals with knee osteoarthritis. This safe intervention offers a potential treatment option for this common condition. TRIAL REGISTRATION:ISRCTN28555470.

OBJECTIVE:To explore agreement between self-report and objectively measured adherence to brace wearing by patients with knee osteoarthritis. METHOD:A single-arm observational analysis nested within the PROP OA randomised controlled trial (ISRCTN28555470). Of 237 adults with symptomatic knee osteoarthritis randomised to brace treatment, 60 were included in this sub-study investigating three different methods of assessing knee brace wear time over 26 weeks: 1. Self-report questionnaires (SRQ) at 12 weeks and 26 weeks; 2. Short message service (SMS) questions (days worn in past week, typical hours per day when worn) administered from week 1 to week 24; 3. A skin temperature sensor embedded in the brace, sampling every 10 min for 26 weeks. The presence and reason for the sensor were concealed from participants. The estimated proportion of participants meeting "minimum brace use", defined a priori as ≥1 h on ≥2 days in past week, was described for each measurement method, overall and by brace type (unloader, neutral). For temperature sensor measurements, time spent above 24°C and time spent above 25°C were used. Agreement between the measures was summarised by percentage agreement and kappa (ĸ). RESULTS:The estimated proportions of participants meeting "minimum brace use" at 12 weeks were 83% (SRQ), 83% (SMS), 60% and 58% (temperature sensor, 24°C and 25°C thresholds, respectively). At 26 weeks, the corresponding estimates reduced to 72%, 71% (SMS at 24 weeks), 43% and 37%. Sensor data suggested the sharpest decline in brace use occurred within the first 12 weeks. Agreement between self-report measures was higher than between self-report measures and sensor (SRQ vs SMS at 12 weeks: 92% agreement, ĸ=0.67 (95%CI: 0.34, 1.00); SRQ vs Sensor at 12 weeks: 74%, 0.35 (0.10, 0.60); SMS vs Sens at 12 weeks: 76%, 0.36 (0.05, 0.66). Agreement between all measurement methods reduced at 26 weeks. CONCLUSIONS:This novel use of a temperature sensor to monitor brace adherence in knee osteoarthritis indicates that self-report adherence substantially overestimates knee brace wearing time, with implications for clinical trials and practice.

With growing support for more active healthier lifestyles, focus on injury prevention and treatment solutions is rising. One debated topic is the use of knee braces for knee injuries. Evidence and clinical recommendations in preventing and treating knee injuries have changed with the development and refinement of knee braces. Given the various knee braces available, this paper explores potential opportunities and recommendations for future research. The ten questions paper examines the use of braces and the relationship between user experience, design and performance. It further explores challenges and issues associated with knee braces. It offers a fresh perspective into redesigning braces with the latest innovations in materials and sensors. Through these questions, we hope to offer a fresh perspective on knee bracing and advance understanding of future opportunities to improve knee brace design.

INTRODUCTION:Measuring rate of torque development (RTD) and peak torque (PT) for hip muscle performance presents challenges in clinical practice. This study investigated the construct validity of a handheld dynamometer (HHD) versus an isokinetic dynamometer (IKD), and intra-rater repeated reliability for RTD and PT and their relationship in hip joint movements. METHODS:Thirty healthy individuals (mean age = 30 ± 8 years, 13 males) underwent two test sessions in a single day. RTD (0-50, 0-100, 0-150, 0-200ms) and PT normalised to body mass in maximal voluntary isometric contractions were measured using a HHD and an IKD in hip flexion, extension, abduction, adduction, internal and external rotation. RESULTS:For validity between the devices, RTD0-50 exhibited the largest significant systematic bias in all hip movements (3.41-11.99 Nm·s-1 kg-1) and widest limits-of-agreement, while RTD0-200 had the lowest bias (-1.33-3.99 Nm·s-1 kg-1) and narrowest limits-of-agreement. For PT, agreement between dynamometers was observed for hip flexion (0.08 Nm·kg-1), abduction (-0.09 Nm·kg-1), internal (-0.01 Nm·kg-1), and external rotation (0.05 Nm·kg-1). For reliability, intra-rater intraclass correlation coefficient (ICC2,1) ranged from moderate to good in RTD0-50 and RTD0-100 (0.5-0.88), and good to excellent in RTD0-150 and RTD0-200 (0.87-0.95) in all movements. The HHD displayed excellent intra-rater, relative reliability values (ICC2,1) in all movements (0.85-0.95). Pearson's correlation revealed good linear correlation between PT and RTD0-150 and RTD0-200 in all movements (r = .7 to .87, p = < .001). CONCLUSION:Validity analysis demonstrated significant systematic bias and lack of agreement in RTD measures between the HHD and IKD. However, the HHD displays excellent to moderate intra-rater, relative reliability for RTD and PT measures in hip movements. Clinicians may use the HHD for hip muscle PT assessment but note, late phase RTD measures are more reliable, valid, and relate to PT than early phase RTD. Additionally, the correlation between RTD and PT at various time epochs was examined to better understand the relationship between these measures.

Purpose (the aim of the study): We performed a systematic review with individual participant data (IPD) meta-analysis (MA) of randomized controlled trials (RCTs) investigating mechanical devices to treat knee OA. We aimed to identify subgroup characteristics that moderate treatment effects.

Background: The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients.Methods: 30 patellofemoral joint osteoarthritis patients (40-70 years) ascended and descended an instrumented staircase with force plates under two conditions - wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded.Findings: During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.70, P = 0.002), maximal adduction angle (2.00, P = 0.044), total sagittal range of motion (2.00, P = 0.008), total frontal range of motion (1.70, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.80, P = 0.039) and total sagittal range of motion (1.50, P = 0.045) compared to control. Interpretation: The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.

Purpose: Approximately 16,000 individuals die every year as a result of trauma in England and Wales. Thousands survive, but have physical disabilities which can cause emotional distress, impacting on their recovery. The responsibility to identify patients that would benefit from mental health (MH) support, or to whom the patient speaks about their MH, often lies with ward-based professionals without specialist MH training. The fundamental skills that healthcare professionals possess make a good grounding to have these conversations, however they can be reluctant to do this. This may be due to a lack of knowledge, skills, time, or an absence of interest. The psychological care of MT patients has been highlighted as a research priority by the James Lind Alliance.

ObjectivesTo explore physiotherapists' experiences and perceived acceptability of delivering a bracing intervention for knee osteoarthritis (OA) in the 'PROvision of braces for Patients with knee OA' (PROP OA) randomised controlled trial.MethodSemi-structured telephone interviews with consenting physiotherapists who received the PROP OA training programme and delivered the knee bracing intervention (advice, information and exercise instruction plus knee brace matched to patients' clinical and radiographic presentation and with adherence support). Interviews were recorded and transcribed verbatim. Two-stage analytic framework: inductive thematic analysis preceded mapping to constructs of the Theoretical Framework of Acceptability.ResultsEight physiotherapists were interviewed and six key themes were developed. Perceptions of the training programme were generally positive, but additional formal training and experiential learning consolidated confidence and skills in novel intervention components. Advice, information, and exercise instruction reflected usual physiotherapy care for knee OA. Physiotherapists were confident in delivering the knee brace, but determining the pattern of knee OA to inform brace type selection was challenging. Physiotherapists valued brace adherence enhancing strategies and the follow-up appointment to facilitate adherence. Perceived impact of the bracing intervention for people with OA was positive. The bracing intervention was perceived as acceptable, although improving self-efficacy to deliver novel intervention components (e.g., reading x-rays) would enhance acceptability.ConclusionThe complex knee bracing intervention was broadly perceived as acceptable by physiotherapists. If implemented within clinical practice beyond the trial, physiotherapists might benefit from not only initial training in brace selection but also ongoing support and mentoring to increase self-efficacy in delivery.

Objective To identify and synthesise the content of knee bracing interventions in randomised controlled trials (RCTs) of knee osteoarthritis (OA). Design In this scoping review, three electronic databases (PubMed, Web of Science, Cochrane) were searched up to 10th June 2024. Nineteen previous systematic reviews of knee bracing for knee OA and four recent international clinical practice guidelines were also hand searched. Identified studies were screened for eligibility by two independent reviewers. Information on bracing interventions was extracted from included RCT reports, informed by Template for Intervention Description and Replication (TIDieR) guidelines. Data were synthesised narratively. Results Thirty-one RCTs testing 47 different bracing interventions were included. Braces were broadly grouped as valgus/varus, patellofemoral, sleeve, neutral hinged, or control/placebo knee braces. Brace manufacturer and models varied, as did amount of recommended brace use. Only three interventions specifically targeted brace adherence. Information on brace providers, setting, number of treatment sessions, and intervention modification over time was poorly reported. Adherence to brace use was described for 32 (68%) interventions, most commonly via self-report. Several mechanisms of action for knee braces were proposed, broadly grouped as biomechanical, neuromuscular, and psychological. Conclusions Many different knee brace interventions have been tested for knee OA, with several proposed mechanisms of action, a lack of focus on adherence, and a lack of full reporting. These issues may be contributing to the heterogeneous findings and inconsistent guideline recommendations about the clinical effectiveness of knee bracing for knee OA to date.

Purpose To describe and compare the movement patterns, anthropometric and physical characteristics of male and female Touch players; and examine the relationships between Functional Movement Screening (FMS ™ ) scores and the anthropometric and physical characteristics. Methods This was a cross-sectional study with 35 elite Touch players (18 males, age = 24.7 ± 4.9 years; 17 females, age = 26.7 ± 5.2 years). Anthropometric (stature, body mass) and physical characteristics (sprint times, glycolytic change-of-direction test, and countermovement jump (CMJ) flight time and peak power) were assessed alongside movement patterns using the FMS ™ battery. Data were analysed for between-sex differences (independent t -test, Mann–Whitney U) and relationships (Spearman’s correlation coefficient). Results Between-sex differences in body mass ( t = 6.082, P < 0.001), stature ( t = 9.247, P < 0.001), CMJ flight time ( t = 3.576, P = 0.001), relative CMJ peak power ( t = 6.578, P < 0.001), 10 m sprint time ( t = 15.861, P < 0.001), glycolytic change of direction test time ( t = − 11.831, P < 0.001) and Yo–Yo IR1 ( t = 6.842, P < 0.001) were observed. There were minimal differences for deep squat ( Z = − 1.036, P = 0.443), in-line lunge ( Z = − 1.284, P = 0.303), shoulder mobility ( Z = − 0.173, P = 0.883), trunk stability push-up ( Z = − 0.896, P = 0.483) and rotary stability ( Z = − 1.537, P = 0.273). The correlation between total and individual FMS ™ scores with anthropometric and physical characteristics ranged from trivial-to-moderate ( r = − 0.502 to 0.488). Conclusion The lack of difference for the FMS ™ composite score and small-to-trivial differences in individual scores allows a comparison between mixed populations within Touch. Whilst many of the correlations were trivial-to-small, there were differences between sexes in the associations and evidence that improvements in functional deficiencies could translate into improved physical performance.

OBJECTIVES: To (1) create and evaluate the usefulness of an online evidence-based education resource about running and knee health (eg, knee osteoarthritis) for the public and health care professionals, and (2) assess the online resource’s effects on perceptions about running and knee health. DESIGN: Cross-sectional survey. METHODS: We created an online education resource (series of infographics) in 7 languages with community input. Then, we conducted a single-round online survey in which participants rated its usefulness and answered questions on perceptions about running and knee health before and after reading the infographics. RESULTS: Two thousand six hundred ninety-four participants (1291 members of the general public and 1403 health care professionals; 45.7% with knee osteoarthritis and 67.6% runners) from 60 countries viewed the infographics and responded to the postinfographics questions. The online resource was considered very useful, with a median rating of 9 out of 10. 23.2% of participants reported no change in their perceptions about running and knee health, 46.2% changed a little bit, 19.3% changed a moderate amount, and 11.3% changed a lot. Perceptions of running were more favorable after reading the infographics, especially about the effects of regular and frequent running on knee health, and running in individuals with knee osteoarthritis. Perceptions about running long distances were less favorable after the infographics. CONCLUSION: Our free online education resource was considered useful by both the public and health care professionals. Overall, the online resource led to more positive perceptions about recreational running and knee health. However, its effects on behavior change and running participation remain unknown. JOSPT Open 2024;2(3):246-255. Epub 9 May 2024. doi:10.2519/josptopen.2024.0149

Purpose: To determine if patients following an unrestricted pathway after THR with no precautions, report a difference in outcomes, compared with patients following a restricted pathway with precautions.

Idiopathic Normal Pressure Hydrocephalus (iNPH) is a progressive neurologic disorder (fluid build-up in the brain) that affects 0.2%-5% of the UK population aged over 65. Mobility problems, dementia and urinary incontinence are symptoms of iNPH but often these are not properly evaluated, and patients receive the wrong diagnosis. Here, we describe the development and testing of firmware embedded in a wearable device in conjunction with a user-based software system that records and analyses a patient's gait. The movement patterns, expressed as quantitative data, allow clinicians to improve the non-invasive assessment of iNPH as well as monitor the management of patients undergoing treatment. The wearable sensor system comprises a miniature electronic unit that attaches to one ankle of the patient via a simple Velcro strap which was designed for this application. The unit monitors acceleration along three axes with a sample rate of 60 Hz and transmits the data via a Bluetooth communication link to a tablet or smart phone running the Android and the iOS operating systems. The software package extracts statistics based on stride length, stride height, distance walked and speed. Analysis confirmed that the system achieved an average accuracy of at least 98% for gait tests conducted over distances 9 m. This device has been developed to assist in the management and treatment of older adults diagnosed with iNPH.

Aim: To determine the efficacy of transdermal anti-inflammatory patches in the treatment of acute and chronic musculoskeletal pain.Methods: A comprehensive search of: Cochrane Central register of controlled trials, EMBASE, MEDLINE, CINAHL and PubMed, for studies using transdermal anti-inflammatory patches vs placebo for management of musculoskeletal pain, e.g. soft tissue injuries or tendonitis (last search January 2024). Cochrane Risk of Bias Tools v1 was used for quality assessment and GRADE determined certainty of evidence. Meta-analysis was performed.Results: Twenty-three randomized placebo-controlled trials (n = 4729) were included. There was low-certainty evidence that transdermal patches provided statistically and clinically significant pain relief on movement at long-term follow-up for chronic musculoskeletal pain (effect size -2-69 (95% CI: -4.14, -1.24) and at short-term follow-up which was non-clinically significant, (-1.24: 95% CI: -1.78, -0.69).Conclusion: Several types of transdermal anti-inflammatory patches may offer short-term and long-term pain relief for acute and chronic musculoskeletal conditions. However, the clinical significance of this effect for the long-term pain relief was based on low-certainty evidence of transdermal anti-inflammatory patches versus placebo; for short-term pain there was an overall non-clinically significant improvement. Performing a meta-analysis for all outcomes was not possible due to insufficiency in the evidence-base.Protocol registration: www.crd.york.ac.uk/prospero identifier is CRD42020185944.

Background In elite football, periodic health examination (PHE) may be useful for injury risk prediction.Objective To explore whether PHE-derived variables are prognostic factors for indirect muscle injuries (IMIs) in elite players.Design Retrospective cohort study.Setting An English Premier League football club.Participants 134 outfield elite male players, over 5 seasons (1 July 2013–19 May 2018).Outcome and analysis The outcome was any time-loss, lower extremity index IMI (I-IMI). Prognostic associations were estimated using odds ratios (ORs) and corresponding statistical significance for 36 variables, derived from univariable and multivariable logistic regression models. Missing data were handled using multiple imputation. Non-linear associations were explored using fractional polynomials.Results During 317 participant-seasons, 138 I-IMIs were recorded. Univariable associations were determined for previous calf IMI frequency (OR 1.80, 95% CI 1.09 to 2.97), hamstring IMI frequency (OR 1.56, 95% CI 1.17 to 2.09), if the most recent hamstring IMI occurred >12 months but <3 years prior to PHE (OR 2.95, 95% CI 1.51 to 5.73) and age (OR 1.12 per 1-year increase, 95% CI 1.06 to 1.18). Multivariable analyses showed that if a player’s most recent previous hamstring IMI was >12 months but <3 years prior to PHE (OR 2.24, 95% CI 1.11 to 4.53), this was the only variable with added prognostic value over and above age, which was a confirmed prognostic factor (OR 1.12 per 1-year increase, 95% CI 1.05 to 1.18). Allowing non-linear associations conferred no advantage over linear associations.Conclusion PHE has limited use for injury risk prediction. Most variables did not add prognostic value over and above age, other than if a player experienced a hamstring IMI >12 months but <3 years prior to PHE. However, the precision of this prognostic association should be confirmed in future.Trial registration number NCT03782389.

BACKGROUND:Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients.OBJECTIVES:To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend.DESIGN:A qualitative interpretive approach using focus groups and individual interviews.METHODS:Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis.RESULTS/FINDINGS:Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance.CONCLUSIONS:For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively.

Summary High‐flow nasal oxygen can be administered at induction of anaesthesia for the purposes of pre‐oxygenation and apnoeic oxygenation. This intervention is claimed to enhance carbon dioxide elimination during apnoea, but the extent to which this occurs remains poorly quantified. The optimal nasal oxygen flow rate for gas exchange is also unknown. In this study, 114 patients received pre‐oxygenation with high‐flow nasal oxygen at 50 l.min ‐1 . At the onset of apnoea, patients were allocated randomly to receive one of three nasal oxygen flow rates: 0 l.min ‐1 ; 70 l.min ‐1 ; or 120 l.min ‐1 . After 4 minutes of apnoea, all oxygen delivery was ceased, tracheal intubation was performed, and oxygen delivery was recommenced when SpO 2 was 92%. Mean (SD) PaCO 2 rise during the first minute of apnoea was 1.39 (0.39) kPa, 1.41 (0.29) kPa, and 1.26 (0.38) kPa in the 0 l.min ‐1 , 70 l.min ‐1 and 120 l.min ‐1 groups, respectively; p = 0.16. During the second, third and fourth minutes of apnoea, mean (SD) rates of rise in PaCO 2 were 0.34 (0.08) kPa.min ‐1 , 0.36 (0.06) kPa.min ‐1 and 0.37 (0.07) kPa.min ‐1 in the 0 l.min ‐1 , 70 l.min ‐1 and 120 l.min ‐1 groups, respectively; p = 0.17. After 4 minutes of apnoea, median (IQR [range]) arterial oxygen partial pressures in the 0 l.min ‐1 , 70 l.min ‐1 and 120 l.min ‐1 groups were 24.5 (18.6–31.4 [12.3–48.3]) kPa; 36.6 (28.1–43.8 [9.8–56.9]) kPa; and 37.6 (26.5–45.4 [11.0–56.6]) kPa, respectively; p < 0.001. Median (IQR [range]) times to desaturate to 92% after the onset of apnoea in the 0 l.min ‐1 , 70 l.min ‐1 and 120 l.min ‐1 groups, were 412 (347–509 [190–796]) s; 533 (467–641 [192–958]) s; and 531 (462–681 [326–1007]) s, respectively; p < 0.001. In conclusion, the rate of carbon dioxide accumulation in arterial blood did not differ significantly between apnoeic patients who received high‐flow nasal oxygen and those who did not.

Background: A new recombinant activated factor VII, eptacog beta (SEVENFACT®, rFVIIa-jncw) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of bleeding events (BEs) in individuals >12 years of age with hemophilia A or B (HAB) with inhibitors. In the eptacog beta phase III trial (Wang, Haemophilia, 2017), 87% of BEs were successfully treated using two different dosing regimens within 12 hours of bleeding onset. In two studies looking at the safety of eptacog beta Ducore, Haemophilia, 2017), a total of 11 treatment-emergent adverse events (TEAEs) were reported in 42 participants, all mild and transitory. To date, no studies designed to assess safety of treatment of breakthrough BEs in people on emicizumab with eptacog beta have been performed.