Wireless pressure insoles may enable the assessment of movement biomechanics in a real-world setting, and thus play an important role in the recommendation of clinical management, but they are not yet a gold standard due to the unknown accuracy and reliability with respect to different functional activities. Here, we compare novel wireless pressure insoles with force plates and examine the test-retest reliability of the insoles for measuring vertical ground reaction forces (vGRFs) and trajectories of the center of pressure (COP). In this observational study, healthy adults underwent two data collection sessions during one day. The Bland-Altman analysis was used to compare the outcomes measured with the two instruments during squats, jumps, and the sit-to-stand test. Test-retest reliability was assessed by the interclass correlation coefficient and the standard error of measurement for the outcomes during squats, jumps, walking, and stair ambulation. Trajectories of the COP in the anterior-posterior direction were comparable between the two systems during all activities. The insoles consistently measured shorter trajectories of the COP in the medial-lateral direction (except jumps) and lower vGRFs than the force plates. Test-retest reliability of the insoles was fair to high or excellent for all outcomes during all activities. In conclusion, the insoles provide reliable measures of vGRFs and trajectories of the COP during multiple functional activities in healthy adults. Although the insoles do not produce identical results to the force plate, the qualitative similarity and consistency between the two systems confirm the insoles can be used to measure these outcomes, based on the purpose and accuracy required.

Keywords: Digital health; Anterior cruciate ligament; Behaviour change Purpose: To evaluate the feasibility of TRAK-ACL, a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following anterior cruciate ligament (ACL) reconstruction. Methods: The study design was a two-arm parallel randomised control trial (RCT). Eligible participants were adults, English speakers, had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at 3 sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention, completeness of outcome measures at follow-up, fidelity of intervention delivery, and engagement with the TRAK-ACL website. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures. Results: Fifty-nine people were assessed for eligibility and 51 were randomised, 26 were allocated to TRAK-ACL and 25 to TAU. Retention was 44 and 40 at 3 and 6 months. All eligible participants were identified at two of the participating sites. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (Inter Quartile Range 3-13), over 18 weeks (Standard Deviation 12.2). Conclusion(s): The feasibility of TRAK-ACL has been demonstrated and would be suitable for evaluation of effectiveness in a fully powered RCT. Further investment in the intervention would be required. Impact: This research provides an evidence-based digital health intervention that reflects the expertise of physiotherapy led ACL rehabilitation. TRAK ACL, could go some way to overcoming the variations in care at a national level and improving access to the information, exercises and benchmarks that are needed at all stages of ACL rehabilitation. TRAK ACL has the potential to improve access to optimal care across the NHS. Technical work to increase its functionality will be a part of its ongoing impact. Funding acknowledgements: NIHR Clinical Doctoral Research Fellowship.

Purpose: TRAK is a blended intervention for the physiotherapy rehabilitation of knee conditions, designed around self-efficacy principles, that combines online or face to face consultations, alongside access to the TRAK website from home. TRAK has been designed to support remote self-management by providing the user with health information, a personalised exercise plan, exercise monitoring and remote clinical support (see figure 1). Previous feasibility studies in the United Kingdom with people with knee conditions have found that TRAK in combination with treatment as usual was easy to use, accessible, and acceptable to a wide range of users.

◼ The identification and assessment by physiotherapists of movement adaptations during functional tasks in people following a knee injury are subjective, relying on observational skills to detect potential risk factors.◼ It is challenging to identify movement patterns in both lower limbs at three joints, each with six planes of movement whilst performing tasks.Technology exists to improve the objective identification of compensation strategies through using wearable biomechanical sensors in the clinic.◼ An intervention is being developed that provides the treating physiotherapist and patient with a movement feedback report 1 , based on the assessment using sensors.In providing objectivity, there is potential to provide reassurance in understanding biomechanics related to sub-optimal recovery and re-injury presented in a format that the physiotherapist and patient can understand.◼ Personalised and tailored treatment approaches can be developed to target the movement adaptations associated with the ACLR patient population.◼ Physiotherapist acceptability and usability have been explored as part of the development of a new biomechanically informed movement feedback intervention. 2◼ This study aimed to evaluate patient experience and acceptance of the sensor-based movement feedback during rehabilitation.

Researchers have begun to investigate the role of forgiveness in disrupting intergroup conflict and promoting peace.This thesis has refined our understanding of the ingroup identity and forgiveness relationship by determining which ingroup identity dimension (i.e., Leach et al., 2008) is most consequential for group members' forgiveness.First, we demonstrated that previous research conflated both identity dimensions into one empirical estimate (Study 1, k = 39).In the Brexit conflict, cross-sectional (Study 2a, N = 911) and longitudinal studies (Study 2b, N = 519) provided strong evidence that self-investment (vs.self-definition) identity dimension suppressed forgiveness.Next, we integrated our refined understanding of ingroup identity with collective suffering (Study 3, N = 860).The self-investment dimension was a facilitating mechanism, and the self-definition dimension was an inhibiting mechanism, of the competitive victimhood and forgiveness relationship.Conflict type (direct vs. structural) moderated the relationships between competitive victimhood and both identity dimensions and the former and forgiveness, being stronger in direct conflicts.Next, we integrated our refined understanding of ingroup identity with the role of justice concerns (restorative, retributive, distributive, and procedural) and negative forms of ingroup attachment (ingroup glorification and collective narcissism).In a three-wave longitudinal study in post-Apartheid South Africa (Study 4, N = 491), whereas retributive and distributive justice suppressed forgiveness, restorative and procedural justice increased forgiveness.Further, the self-investment dimension increased forgiveness and collective narcissism suppressed forgiveness.Finally, we tested the causal effect of structural violence on women's forgiveness (Study 5, N = 309).There was no causal effect of structural violence on forgiveness; the selfinvestment dimension attenuated the effect of structural violence on forgiveness.Our refined findings demonstrate that both the self-investment and self-definition dimensions There are many people I would like to thank because without them this thesis would not have been possible.I would like to thank

Keywords: Movement analysis; Sensors; Gait Purpose: Movement analysis is a key physiotherapy skill, but being subjective lacks standardization. Technology is now available for the clinical setting to change this, using 3-dimensional, portable Inertial Measurement Units (IMUs). However, there is still the potential for variation in how physiotherapists report any "observed differences" in movement patterns between limbs. To address this a framework for standardising the reporting of the waveform data has been developed. The aim of the current study was to identify kinematic movement alterations of Gait using IMUs in people with knee pain compared to healthy people using observational movement analysis and the standardised reporting template. Methods: In this between-subject design, Gait data were collected for 21 people with knee pain, and 31 healthy individuals, using 3-D IMUs. Evaluation of movement analysis reports of kinematic waveforms of hip, knee and ankle joints in the sagittal and frontal planes were undertaken using the standardised reporting template. For the knee pain group the painful limb (KPPL) was compared to the non-painful limb and for the healthy group the dominant leg was compared to the non-dominant limb (HDL). A description of the gait deviations for each group and the frequency of each deviation was reported and compared between groups. Results: Overall, there were 102 deviations in lower limb movement patterns (54 for the HDL and 48 for KPPL) across both planes of movement. In the sagittal plane, there were 38 deviations (21HDL and 17 KPPL). There was no consistency in the nature of the deviation so each individual was using a different strategy. For both groups, deviation of movement patterns was most common at the ankle (8/21 for HDL and 8/17 for KPPL). For HDL this was altered plantar-flexion range of motion (ROM) (increased or decreased) during swing and/or stance phase. For KPPL at the ankle this was altered plantarflexion ROM (increased or decreased) during swing or, decreased or increased dorsiflexion ROM during stance. For the frontal plane, there were a total of 64 lower-limb deviations in movement among the 3 joints for both groups (33 for the HDL and 31 for KPPL). However, these were not consistent at the hip and ankle. As for the knee joint, HDK and KPPL demonstrated increased peak adduction or decreased peak abduction at swing-phase but this occurred earlier for the KPPL. Conclusion(s): A high number of deviations in movement patterns were identified between dominant and non-dominant limbs in healthy individuals and between painful and non-painful limbs in people with knee pain. In addition, there was a lack of consistency in the type of deviation used between limbs and groups, highlighting the various ways people could potentially compensate. Impact: The high number of between limb deviations found in the healthy group means that clinicians need to interpret movement analysis reports with caution as not all movement deviations in a pain population will be caused by the pathology. The lack of consistency in the movement deviations highlights the need for personalized gait assessment to individualize treatment plans. Funding acknowledgements: The Ministry of Higher Education, Saudi Arabia. Biomechanics and Bioengineering Research Centre Versus Arthritis, Cardiff University.

OBJECTIVE:To develop evidence-informed recommendations to support the delivery of best practice therapeutic exercise for people with knee and/or hip osteoarthritis (OA). DESIGN:A multi-stage, evidence-informed, international multi-disciplinary consensus process that included: 1) a narrative literature review to synthesise existing evidence; 2) generation of evidence-informed proposition statements about delivery of exercise for people with knee and/or hip OA by an international multi-disciplinary expert panel, with statements refined and analysed thematically; 3) an e-Delphi survey with the expert panel to gain consensus on the most important statements; 4) a final round of statement refinement and thematic analysis to group remaining statements into domains. RESULTS:The expert panel included 318 members (academics, health care professionals and exercise providers, patient representatives) from 43 countries. Final recommendations comprised 54 specific proposition statements across 11 broad domains: 1) use an evidence-based approach; 2) consider exercise in the context of living with OA and pain; 3) undertake a comprehensive baseline assessment with follow-up; 4) set goals; 5) consider the type of exercise; 6) consider the dose of exercise; 7) modify and progress exercise; 8) individualise exercise; 9) optimise the delivery of exercise; 10) focus on exercise adherence; and 11) provide education about OA and the role of exercise. CONCLUSION:The breadth of issues identified as important by the international diverse expert panel highlights that delivering therapeutic exercise for OA is multi-dimensional and complex.

A common measure of rehabilitation effectiveness post-stroke is self-selected walking speed, yet individuals may achieve the same speed using different coordination strategies. Asymmetry in the propulsion generated by each leg can provide insight into paretic leg coordination due to its relatively strong correlation with hemiparetic severity. Subjects walking at the same speed can exhibit different propulsion asymmetries, with some subjects relying more on the paretic leg and others on the nonparetic leg. The goal of this study was to assess whether analyzing propulsion asymmetry can help distinguish between improved paretic leg coordination versus nonparetic leg compensation.Three-dimensional forward dynamics simulations were developed for two post-stroke hemiparetic subjects walking at identical speeds before/after rehabilitation with opposite changes in propulsion asymmetry. Changes in the individual muscle contributions to forward propulsion were examined.The major source of increased forward propulsion in both subjects was from the ankle plantarflexors. How they were utilized differed and appears related to changes in propulsion asymmetry. Subject A increased propulsion generated from the paretic plantarflexors, while Subject B increased propulsion generated from the nonparetic plantarflexors. Each subject's strategy to increase speed also included differences in other muscle groups (e.g., hamstrings) that did not appear to be related to propulsion asymmetry.The results of this study highlight how speed cannot be used to elucidate underlying muscle coordination changes following rehabilitation. In contrast, propulsion asymmetry appears to provide insight into changes in plantarflexor output affecting propulsion generation and may be useful in monitoring rehabilitation outcomes.

Clinical neural transplantation in Huntington's disease has moved forward as a series of small studies, which have provided some preliminary proof of principle that neural transplantation can provide benefit. However, to date, such benefits have not been robust, and there are a number of important issues that need to be addressed. These include defining the optimum donor tissue conditions and host characteristics in order to produce reliable benefit in transplant recipients, and whether, and for how long, immunosuppression is needed. Further clinical studies will be required to address these, and other issues, in order to better understand the processes leading to a properly functioning neural graft. Such studies will pave the way for future clinical trials of renewable donor sources, in particular, stem cell-derived neuronal progenitor grafts.

In this paper we investigate traveling wave solutions of a non-linear differential equation describing the behaviour of one-dimensional viscoelastic medium with implicit constitutive relations. We focus on a subclass of such models known as the strain-limiting models introduced by Rajagopal. To describe the response of viscoelastic solids we assume a non-linear relationship among the linearized strain, the strain rate and the Cauchy stress. We then concentrate on traveling wave solutions that correspond to the heteroclinic connections between the two constant states. We establish conditions for the existence of such solutions, and find those solutions, explicitly, implicitly or numerically, for various forms of the non-linear constitutive relation.

•Standardised terminology for the interpretation of movement analysis waveforms is provided, to describe the amount, nature and timing of a compensation strategy.•A stand-alone application have been created for users to generate a movement analysis report for lower limb joint kinematics.•A digital, interactive version of the movement analysis report is now being created in the next iteration of the sensor based portable movement analysis toolkit.

Purpose: Movement analysis is an essential component in assessing patient joint kinematics within physiotherapy clinical settings. Video-based 2-dimensional (2D) movement analysis is the most widely available tool in physiotherapy settings. Portable inertial sensors technology has been introduced as a validated 3-Dimensional (3D) movement analysis tool. However, the similarity of kinematic measurements made by 2D video analysis compared to 3D analysis in sagittal and frontal planes is questionable, for high-speed complex tasks, such as hopping. The aim of this study was to compare joint angular kinematics provided by inertial sensors (Xsens MVN Analyze system) against joint kinematics provided by digital video cameras and Kinovea video player goniometer software in sagittal and frontal planes during a single leg distance hop (SLDH) task.

Purpose: Analysing human movement is a core component of physiotherapy practice and is used to make judgements about how an individual is moving, what compensations they are using and what treatment techniques need to be applied to improve performance, recovery and/or prevent injury. However, human movement is complex and in clinical practice this assessment is often restricted to observation methods. Wearable technology (body worn sensors) have the potential to transform physiotherapy movement feedback interventions for individuals following anterior cruciate ligament surgery. Sensors can provide large volumes of objective kinematic data in real-time about 3D joint motion during clinic based functional tasks. For ease of use in the clinical setting, we designed a movement analysis report that displays hip, knee and ankle joint angle waveforms in the sagittal and frontal planes, along with a stick figure representing the movement performed and a summary of performance measures. However, the accuracy of reporting the interpretation of this data is unknown and inaccuracy could result in variation in clinical decision making. Therefore, the aim of this study was to develop a standardised template to support physiotherapist reporting of kinematic waveform data by: 1. Evaluating between and within user agreement in the identification of movement compensation strategies. 2. Analysing user free text interpretations of movement compensations. Methods: A mixed research design using between- and within-user agreement and thematic analysis of the free text was used. All data was collected within physiotherapy clinics within one University Health Board. Fourteen individuals with anterior cruciate ligament reconstruction performed overground gait, double-leg squat, and stair ascent while wearing seven body-worn sensors (Xsens Technologies B.V., Enschede, The Netherlands). Five users viewed 252 kinematic waveforms from 14 movement analysis reports, that showed hip, knee and ankle joint angle waveforms in the sagittal and frontal planes. Reports were generated using custom written code in Matlab. The users were four physiotherapists with varying experience of movement analysis and one movement scientist. For each waveform users indicated 'YES' or 'NO' if they thought a movement compensation strategy was present (between-user agreement) and three physiotherapy users repeated this after one week (within-user agreement). Between and within-user agreement were quantified using observed agreement, Gwet's agreement coefficient with first-order chance correction (AC1), and weighted Cohen's kappa. For chance-corrected agreement a value less that 0.2 was considered as poor agreement, 0.21-0.4 as fair, 0.41-0.6 as moderate, 0.61-0.8 as strong and greater than 0.80 as near-complete agreement. When users identified a movement compensation strategy they were required to write a free text description of it. The free text in the reports was analysed using thematic analysis to identify categories and themes. One researcher coded all of the manuscripts and this was checked by a second researcher. Findings from data sets were integrated to answer the research aim. Results: Between-user (n=5) observed agreement for presence of a movement compensation was 0.57-0.84 for the sagittal plane and 0.73-1.0 for the frontal plane. The number of times (n) a compensation strategy was identified as present and between-user agreement for the presence of a compensation strategy is displayed in Table 1.Tabled 1Table 1: between-user agreement for compensation strategiesGaitDouble leg squatStairsnGwet's AC1KappaObserved AgreementnGwet's AC1KappaObserved AgreementnGwet's AC1KappaObserved AgreementHipsagittal plane240.220.150.57290.50.480.74400.190.20.59frontal plane580.620.120.73670.910.010.91680.940.010.94Kneesagittal plane540.620.340.76350.690.690.84540.230.270.73frontal plane620.770.140.81670.910.010.91701.0Nan1.0Anklesagittal460.270.170.60280.370.350.67520.420.1450.64frontal plane610.710.060.77590.690.20.77660.87Nan0.89 Open table in a new tab Within-user observed agreement (n=3) was 0.57-1.00 for the sagittal plane and 0.71-1.00 for the frontal plane. Kappa has the paradox of giving smaller values when there is high agreement in one category. Three themes and seven categories around movement compensations were identified from the waveform interpretations. The definitions of the themes are: 1. Amount: Description relating to the size or magnitude of a compensation strategy. 2. Nature: Description relating to the type of compensation strategy. 3. Timing: Description relating to when the compensation strategy occurred in the movement cycle. The definitions of the categories and example codes are displayed in Table 2.Tabled 1Table 2. Definitions of categories and codesThemeCategoryDefinitionExample codesAmountQualitative descriptionA description in words of the size or magnitude of the compensation strategy.Decreased, reduced, too little, lack of, less slight, minimal, subtle, increased, greater, too much, early, rapid, late, delay inquantitative descriptionThe size or amplitude of the compensation described in numbersDegrees e.g. 10 degreesNaturePeak (maximum)An alteration in the peak (maximum) on the waveformPeak, maximumRange of motion (ROM)An alteration in the range of motion of the waveform.Range of motion, ROM, rangeTimingAn alteration in the timing of the waveform.Timing, asynchronous, rapid, delayedTimingCycleA compensation strategy that is identified as happening throughout the entire movement cycleThroughout cycle, during squat, across full movement cycle, throughout the whole taskPhaseA compensation strategy that is identified as happening during a specific phase of the movement cycleStance phase, initial descent phase, step up phase, through decent, swing phaseDiscrete time pointA compensation strategy that is identified as happening at a discrete time point within the movement cycleInitial contact, mid stance, toe off, at full squat depth, at foot contact with step Open table in a new tab Conclusions: Between-user agreement ranged from moderate to near-complete agreement and was higher for movement compensation strategies in the frontal than in the sagittal plane and for analysis of knee than hip or ankle joint motion. Within-user agreement was near-complete agreement across all activities, planes of motion and joints. This suggests that there would be better consistency in decision making if the same user interpreted a report over time. However, there was variation in how movement compensations were described using free text. This could lead to differences in clinical decision making and treatment planning. Based on our findings, user training is recommended to standardise terminology used in interpretation based on the amount, nature and timing of the movement compensation strategies. A standardised template for interpretation of kinematic waveforms is proposed and is displayed in Figure 1. Work is in progress to develop a digital, interactive version of the report that will be included in the next iteration of the toolkit to assist users in providing a consistent description of movement compensation strategies.

Key-Words: Validity, Sensor, Avatar

Purpose: In our prior research in Saudi Arabia, we have found that individuals with Knee Osteoarthritis (OA) and healthy controls were physically inactive with high body composition. This finding was not expected since there are recommendations on physical activity levels for adults. However, the utilisation of such recommendation and organisation of care by the healthcare providers in this setting, as well as the attitude and awareness of members of society to physical activity has not been addressed yet. Therefore, this study aimed to explore: 1. Stakeholder perspectives on the opportunities and barriers to physical activity in Saudi Arabia for individuals with knee osteoarthritis.2. Stakeholder perspectives on healthcare delivery for individuals with knee osteoarthritis in Saudi Arabia. Methods: A qualitative design using semi-structured telephone interviews. Recruitment of a purposive sample was carried out by social media posts and advertisements at local hospitals in the three main regions in Saudi Arabia (Western, Central and Eastern). The interview schedule was guided by the literature around knee OA management and healthcare system in Saudi Arabia, physical activity studies and the findings of a prior study. Interviews were digital audio recorded and were transcribed verbatim and translated from Arabic to English. Data were analysed using thematic analysis. After familiarisation with data, two researchers coded 40% of the interviews independently and agreed on the coding in discussion with a 3rd reviewer. All of the manuscripts were coded by the lead researcher. Codes were grouped into categories and themes inductively by the lead applicant and discussed and agreed upon with the rest of the team. Data were managed using NVIVO software. Ethical approval was obtained from the School of Healthcare Sciences at Cardiff University. Results: 26 interviews were carried out with stakeholders; 6 physiotherapists, five physicians, eight people with knee OA, five healthy members of the society without knee pain, one personal trainer and one teacher. Data analysis revealed four themes, which are displayed in Figure 1. Theme 1) Organisation of care for individuals with knee OA. This theme detailes the perspective of people with knee OA and stakeholders on the journey within the healthcare system in Saudi Arabia for the management of knee OA, from the time of the first contact with a healthcare professional to discharge. Key findings from this theme are an uncoordinated multidisciplinary team or organised system for the management of knee OA. The journey pathways and treatments choices were mainly dependant on the available resources, the choices of the individual with knee OA and the decisions of their physician. Theme 2) Physiotherapy service and International guidelines practice for knee OA. This theme focuses on the different issues related to the physiotherapy service such as the number and organisation of clinics, treatments protocols and adherence to treatment guidelines for knee osteoarthritis. Key findings are lack of physiotherapy clinics, delayed referrals, limited autonomy and limited use of treatment guidelines by physiotherapists. Theme 3) The Culture of Physical Inactivity. This explores the stakeholder perception of physical activity while identifying barriers to physical activity and suggestions to increase it. Key findings were several barriers that led to the state physical inactivity, especially with females. Theme 4) Stakeholders views of the healthcare system for individuals with knee OA. This theme describes the experience of individuals with knee OA with the healthcare service. The key findings were the limitations in healthcare service that led to the individuals with knee OA reporting a negative experience such as the delayed care and the repetition of care by physicians. Moreover, it revealed an issue of lack of awareness of the role physiotherapy in knee OA management. Conclusions: The findings provide insight into the healthcare provision from the perspective of stakeholders and individuals with knee OA. There was a consensus amongst all stakeholders that there was poor engagement with physical activity as part of the care for people with knee OA. Limitations and challenges were identified that could be addressed to improve the service and organisation of care. A coordinated approach to care amongst members of the multi-disciplinary team is required, with all members recognising the role that the different professions have to play. Better links with facilities within the community that can support the individuals to become more physically active and the need to promote physical activity in children's education are recommended.

ObjectiveThere are few guidelines for clinical trials of interventions for prevention of post-traumatic osteoarthritis (PTOA), reflecting challenges in this area. An international multi-disciplinary expert group including patients was convened to generate points to consider for the design and conduct of interventional studies following acute knee injury.DesignAn evidence review on acute knee injury interventional studies to prevent PTOA was presented to the group, alongside overviews of challenges in this area, including potential targets, biomarkers and imaging. Working groups considered pre-identified key areas: eligibility criteria and outcomes, biomarkers, injury definition and intervention timing including multi-modality interventions. Consensus agreement within the group on points to consider was generated and is reported here after iterative review by all contributors.ResultsThe evidence review identified 37 …

Purpose: The identification, targeting and assessment of modifiable risk factors such as movement compensation strategies by Physiotherapists following knee injury is subjective, relying on observational skills to detect potential risk factors. It is a challenge to identify lower limb movement patterns across three joints, each with six planes of movement whilst performing dynamic tasks. Technology now exists to improve objective identification of movement disorders through using wearable inertial measurement units (sensors). Objective data can be used to provide the treating physiotherapist and patient with a personalised movement feedback report that is based on the assessment of a range of functional tasks using the sensors in the clinic. The aim of this study was to evaluate physiotherapist experience and acceptance of the sensor based movement feedback approach. Methods: A qualitative semi-structured interview study design used nineteen patients following anterior cruciate ligament reconstruction (6 to 52 weeks following surgery) who underwent sensor-based movement analysis in the clinic. Patients performed up to five functional tasks (typical of their usual care, stage of recovery and physical capabilities) whilst wearing seven MTw2 sensors (Xsens technologies BV, Enschede, The Netherlands). Tasks included; gait, double leg squat, single leg squat, stairs and vertical jump. Biomechanical data were extracted using Xsens MVN Biomech and MATLAB (Mathworks) software packages and used to generate the feedback report. The report contained; temporo-spatial and kinematic lower limb waveform data (average and consistency graphs) and avatars in the sagittal and frontal planes. The twelve treating physiotherapists were provided with these data in the clinic and were interviewed after an interval of at least one week. Semi-structured interview questions explored the acceptability and usability of the feedback, framed around the Technology Acceptance Model 2. Interviews were transcribed verbatim and 75% of the transcripts were dual-coded achieving a high level of agreement. An inductive process using framework analysis method (familiarisation, open coding, indexing, mapping and interpretation) was used for data analysis to develop codes, categories and key themes. Results: Four key themes were identified. The themes, codes and code descriptions are detailed in Table 1. Theme 1, ‘Usability’ described the extent to which the report was used by physiotherapists to achieve high levels of satisfaction, effectiveness and efficiency in their normal job role. Physiotherapists identified positive and negative features of the report design. Recommendations were also made towards the future design of the report. Theme 2, ‘Clinical Integration and Decision Making’ described strategies of how physiotherapists made sense of the feedback report drawing on their clinical experience and knowledge to understand, interpret and apply the feedback report. Although physiotherapists did draw upon the feedback to inform treatment decision making, they also discussed hypothetical case examples. Theme 3 focused on ‘Behaviour Change’ strategies employed by physiotherapists in the usability, interpretation and application of the sensor-based feedback report that influenced their approach to standard care. Theme 4 ‘Previous, Current and Future use’ describes previous physiotherapist experience of how biomechanics and technology have been used in clinical practice. Recommendations towards the future implementation of this sensor-based feedback were identified. Conclusions: The sensor based biomechanical feedback report was usable and acceptable by physiotherapists. The report was used as a feedback tool to educate, inform and incentivise the patient through quantifiable data that was presented in a visual format. There were no large barriers identified to usability in the clinic. Physiotherapists were able to identify biomechanical movement compensations in patients that would lead to a more individualised targeted approach to treatment. However, there was variability in the descriptions of the feedback report and the terminology used which may highlight a training need to upskill physiotherapists in understanding biomechanical data and its integration to clinical practice. The acceptability of the sensor based movement feedback approach is currently being explored amongst patients. This will inform the development of a personalised sensor-based movement feedback intervention for testing in a future randomised control trial.

Purpose: The current recommended pathway for adults with musculoskeletal pain is management in primary care with core treatments of self-management, information, weight loss and exercise. If a specialist opinion is required, then the patient is referred to a multi-professional assessment and treatment clinic, at the interface between primary and secondary care. With an aging population and rising treatment expectations the burden on healthcare resources is increasing. Therefore triage methods that maximise efficiency and ensure patients receive optimal care for their needs are required. Therefore the aim of this study was to evaluate the content of the referral letters to identify variables that independently predict an optimised care pathway. Methods: This study used a prospective longitudinal design. A convenience sample of patients with hip or knee pain were recruited from orthopaedic (ORTHO), specialist GP (GP) and advanced physiotherapy practitioner (APP) clinics, in one University Health Board, after referral for specialist opinion. At the initial appointment consented individuals completed a knee or hip osteoarthritis outcome score (KOOS or HOOS), these were completed again after 6 months. From the referral letter participant demographics, body mass index (BMI), medication and co-morbidity data were extracted. Data mining techniques were used to code the free text of the referral letters to identify concept variables. Treatment outcome was extracted from the consultation letter as the definitive treatment (or imaging) that resulted from the consultation. Each of the treatment outcomes was classified as being an optimal or sub-optimal pathway per clinic type. An optimal pathway was defined as avoiding repetition, unnecessary referral or delayed treatment for the patient. This definition was based on the literature and consensus amongst the research steering committee. Logistic regression was used to identify variables that were independently associated with an optimal pathway. Results: A total of 643 participants were recruited, referral letters were available for 586/643 participants. Complete data sets including demographics, BMI, medications and co-morbidities were available from 386/643 participant referrals. Per clinic type the total number of participants, age and mean baseline KOOS/HOOS pain and function subscale scores are listed in Table 1. A total of 53 different treatment outcome combinations were identified. Half of the participants had one treatment outcome, 306 (48.3%) had two or more treatment outcomes. This resulted in 419/653 (66.7%) of participants being classified as having an optimal pathway. Variables independently associated with having an optimal care pathway were lower BMI (CI 0.929 to 0.986 mean 29.5 P = 0.004), use of non-steroidal anti-inflammatory medication (NSAID's) (CI 0.319 to 0.872 P = 0.013), higher number of diagnostic procedures (CI 0.733 to 3.191 P<0.001), disease or syndrome (CI 1.101 to 2.818 P = 0.018) and pharmacologic substance (CI 1.110 to 3.608 P = 0.021). KOOS and HOOS sub-scale scores at 6 months were not associated with an optimal pathway. Conclusions: The complexities of the care pathway for hip and knee pain are reflected in the high number of treatment outcome combinations participants received. Not all patients received a treatment outcome that resulted in an optimal care pathway, and in this cohort of patients this could be improved for over 30% of cases. This represents potential inefficiency and wasted healthcare resource use. Variables associated with optimal care should be routinely included on referral letters as part of a minimum dataset. Furthermore, despite BMI being a strong predictor it was frequently missing, so addressing this in future referrals from primary care is essential. Based on the patient rated outcomes, participants with less pain and higher function were seen in the APP clinic. This would seem appropriate for individuals considering conservative treatment. The amount of pain and functional level of participants at 6 months wasn't associated with optimised care.Table 1Number of participants and KOOS and HOOS pain sub-scale scores per clinic typeType of clinicGPAPPCONSNumber of participants seen in each clinic194190259Baseline KOOS/HOOS pain sub scale mean (SD)48.1 (20.11)58 (22.41)45.7 (22.44)Baseline KOOS/HOOS function sub scale mean (SD)43 (23.40)63.8 (24.32)49.3 (25.06)Age mean (SD)59.2 (13.94)41.8 (13.64)57.8 (16.85)Gender male: female96:9892:98123:136 Open table in a new tab