Search

Charlotte Goss, Fiona J Culley, Prabha Parthasarathy, Ken MacLeod, Alison H McGregor, Amir H Sam Faculty of Medicine, Imperial College London, London, UKCorrespondence: Amir H Sam, Email a.sam@imperial.ac.ukAbstract: The General Medical Council’s publication ‘Outcomes for Graduates’ places emphasis on doctors being able to integrate biomedical science, research and scholarship with clinical practice. In response, a new paradigm of assessment was introduced for the intercalated Bachelor of Science program at Imperial College School of Medicine in 2019. This innovative approach involves authentic “active learning” assessments analogous to tasks encountered in a research environment and intends to test a wider range of applied scientific skills than traditional examinations. Written assessments include a “Letter to the Editor”, scientific abstract, and production of a lay summary. A clinical case study titled “Science in Context” presents a real or virtual patient, with evaluation of current and emerging evidence within that field. Another assessment emulates the academic publishing process: groups submit a literature review and engage in reciprocal peer review of another group’s work. A rebuttal letter accompanies the final submission, detailing how feedback was addressed. Scientific presentation skills are developed through tasks including a research proposal pitch, discussion of therapies or diagnostics, or review of a paper. A data management assignment develops skills in hypothesis generation, performing analysis, and drawing conclusions. Finally, students conduct an original research project which is assessed via a written report in the format of a research paper and an oral presentation involving critical analysis of their project. We aspire to train clinicians who apply scientific principles to critique the evidence base of medical practice and possess the skillset to conduct high-quality research underpinned by the principles of best clinical and academic practice. Assessment drives learning, and active learning has been demonstrated to enhance academic performance and reduce attainment gaps in science education. We therefore believe this strategy will help to successfully shape our students as future scientists and scholars as well as clinical practitioners and professionals.Keywords: biomedical science, assessment, active learning, professional skills

Abstract Background The life-time incidence of low back pain is high and diagnoses of spinal stenosis and disc prolapse are increasing. Consequently, there is a steady rise in surgical interventions for these conditions. Current evidence suggests that while the success of surgery is incomplete, it is superior to conservative interventions. A recent survey indicates that there are large differences in the type and intensity of rehabilitation, if any, provided after spinal surgery as well as in the restrictions and advice given to patients in the post-operative period. This trial will test the hypothesis that functional outcome following two common spinal operations can be improved by a programme of post-operative rehabilitation that combines professional support and advice with graded active exercise and/or an educational booklet based on evidence-based messages and advice. Methods/Design The study design is a multi-centre, factorial, randomised controlled trial with patients stratified by surgeon and operative procedure. The trial will compare the effectiveness and cost-effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression, each compared with "usual care"using a 2 × 2 factorial design. The trial will create 4 sub-groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The trial aims to recruit 344 patients, which equates to 86 patients in each of the four sub-groups. All patients will be assessed for functional ability (through the Oswestry Disability Index - a disease specific functional questionnaire), pain (using visual analogue scales), and satisfaction pre-operatively and then at 6 weeks, 3, 6 and 9 months and 1 year post-operatively. This will be complemented by a formal analysis of cost-effectiveness. Discussion This trial will determine whether the outcome of spinal surgery can be enhanced by either a post-operative rehabilitation programme or an evidence-based advice booklet or a combination of the two and as such will contribute to our knowledge on how to manage spinal surgery patients in the post-operative period. Trial Registration Current controlled trials ISRCTN46782945 UK CRN ID: 2670

Study Design: This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure.Objective: This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with graded active exercise commencing 6 weeks after surgery and/or an educational booklet based on evidence-based messages and advice received at discharge from hospital, each compared with usual care.Summary Of Background Data: Surgical interventions on the spine are increasing, and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management, functional outcome, and patient satisfaction are not optimal.Methods: The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with "usual care" using a 2 × 2 factorial design, randomizing patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analog scale measures of back and leg pain.Results: Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks, 3, 6, 9 and 12 months postoperatively. Twelve months postoperatively the observed effect of rehabilitation on ODI was -2.7 (95% CI: -6.8 to 1.5) and the effect of booklet was 2.7 (95% CI: -1.5 to 6.9).Conclusion: This study found that neither intervention had a significant impact on long-term outcome. [ABSTRACT FROM AUTHOR]

Background: Fatigue is thought to impact performance and may be a factor in injury mechanism. However, the full impact of a potentially fatiguing task on performance is unclear. Objective: To explore changes in maximum voluntary torque and electromyographic (EMG) activity following a sixty second isometric maximum voluntary contraction (MVC) of the quadriceps muscles and to follow the time course of any changes observed. Method: 21 subjects (14 males and 7 females) were recruited. Torque during brief maximum voluntary isometric contractions of the quadriceps muscle group was recorded in right and left legs using a Cybex Norm Isokinetic Dynamometer before, during and at intervals after a 60 second isometric fatigue task. EMG activity of the vastus medialis, rectus femoris and vastus lateralis was also recorded synchronously. Results: Mean peak torque was significantly (p< 0.05) lower in both legs at the end of the fatigue task. However, 10 minutes following the cessation of the task, it had increased and was significantly higher than the pre-fatigue level. It remained higher until the end of the protocol (30 mins post fatigue). The EMG amplitudes decreased slightly compared to pre-fatigue values during the fatigue task, a few of which were significantly lower than those of the pre-fatigue task. Following the fatigue task, EMG amplitudes increased gradually and were significantly higher than those of the pre-fatigue task in all the muscles at the final time point. Median frequencies decreased significantly during the fatigue task and were similar to pre-fatigue values by 5mins post-fatigue. Conclusion: This study has revealed that both torque and EMG rise following a sustained isometric 60 second hold to higher levels than pre-hold and that this rise is maintained for up to 30 minutes. This rise however, was not associated with increased muscle firing frequency. The mechanisms behind this rise remain to be elucidated. [ABSTRACT FROM AUTHOR]

Background: Trunk flexor-extensor asymmetry has been attributed a role in spinal function. However, left-right asymmetry within muscle groups (extensors or flexors) has received little attention. Objective: To examine left-right symmetry within trunk extensors and flexors and the influence of different sporting tasks on this symmetry. Method: Thirty-five subjects (21 males) were recruited and written informed consent obtained; 12 subjects participated in unilateral (UL) sports e.g. tennis, 13 in bilateral (BL) activities e.g. running and 10 controls (C) who were not involved in sport. Isokinetic and isometric trunk flexions and extensions including a fatiguing isometric hold were performed using a Cybex isokinetic dynamometer synchronised with bilateral electromyographic (EMG) recordings from the erector spinae at L4 and rectus abdominis at T10. A ratio of left-right EMG activity was calculated for each set of muscles, to examine asymmetry. Results: No differences were seen in left:right extensor EMG ratios across any of the test protocols. However, the UL group had higher (P <0.05) left:right flexor EMG ratios than the BL group during pre-fatigue (UL: 1.32 ± 0.15 vs BL: 0.84 ± 0.07) and post-fatigue (UL: 1.30 ± 0.18 vs BL: 0.84 ± 0.07) isometric flexion. Torque data showed that the trunk extensor-flexor ratio was larger (P <0.05) in the BL group compared to the C in the isokinetic exercises at the 30degrees/s (BL: 1.27 ± 0.05; C: 1.00 ± 0.06) and at the 90degrees/s (BL: 1.28 ± 0.05; C: 0.95 ± 0.08), but no differences were seen during isometric testing. Conclusion: This study suggests that participation in different activities such as sports may generate asymmetry in the trunk flexors, the importance of which requires further research. [ABSTRACT FROM AUTHOR]

Assessment of the glenohumeral joint relies upon a detailed, time-dependent history of the presenting complaint and a thorough examination of its subtle signs. As such, the complex is most appropriately approached as a unit, rather than as a discrete number of examinable components. However, understanding the interactions between these components means that a high level of skill is needed to adequately assess the joint, and learning these skills is compounded by the large number of eponymous tests described for examining separate elements.The stabilising mechanisms of the shoulder may crudely be classified as passive (non-contractile) or active (contractile) in function; this artificial distinction neglects the role of contractile tissue in maintaining stability whilst not contracting, but serves to facilitate understanding, and indeed categorise modes and methods of physical examination. Indeed, modes of failure are specific to these groupings. Determining the degree of instability caused by the passive stabilising mechanisms is commonly fraught with both intra- and inter-rater discrepancy, and as such, requires a great deal of experience to implement and interpret. However, an evidence-based approach to a clinical examination sequence can improve its predictive value.A critical review of the literature on examination of passive stabilising mechanisms is presented, followed by a distillation of current concepts resulting in the presentation of an evidence-based approach to examination that is practical, and can be implemented successfully by all involved in the rehabilitation process. [ABSTRACT FROM AUTHOR]

Poor trunk extensor endurance is implicated in low back pain, less is known regarding contributions of different regions of the erector spinae to maximum torque production particularly after fatigue. This study examines torque and electromyographic (EMG) activity following a maximal voluntary contraction (MVC) hold in these muscles.16 students (9 male, 7 female, mean age 21.3 +/- 0.6 years) participated. Testing was performed using a Cybex isokinetic dynamometer with synchronous bilateral EMG recordings (during MVCs of 5 second duration) from the left and right the erector spinae (ES) muscles at vertebral levels T12 and L4, prior to and immediately after the effort and then at 1, 5 and 10 min following a 60 s MVC.A small decrease in maximum torque was observed during 60 s MVC, followed by a non significant step-wise increase. The highest torque value was recorded 10 min post MVC. There was a trend for the ratios of left:right EMG RMS amplitudes to be higher following the fatigue in the lower back and to decrease in the upper back, suggesting the task involved differential use of left and right sides in addition to upper and lower back muscles.This study suggests that 60 s MVC induces differential activation of left and right sides and upper and lower parts of the trunk extensors. The apparent potentiation in force and asymmetry of activation following the 60 s MVC task requires further investigation. [ABSTRACT FROM AUTHOR]

Muscle fatigue has high relevance in human performance and may contribute to the high incidence of back pain amongst athletes. However, the term fatigue is often poorly defined and is used inconsistently, frequently being interchanged with endurance. This study aimed to establish whether the Biering-Sorensen test and a test of fatigue for the abdominal muscles were effective at inducing fatigue using a well established definition. Twenty medical students were subjected to two protocols (A & B). Using a Cybex norm isokinetic dynamometer, the isometric peak torques during extension and flexion were measured before and after each protocol. Protocol A involved a 45 second maximal isometric contraction within the dynamometer while Protocol B entailed a Biering-Sorensen (submaximal) test for extension and a sit up crunch for flexion. Extension testing followed flexion testing. Significant reduction in peak mean torque occurred only in flexion for both protocols. The Biering-Sorensen test did not result in a decrease in peak torque suggesting minimal fatigue (using the definition used in this study). A weak correlation was found between the length of time the Biering-Sorensen test was held and the fatigue index. The Biering-Sorensen test does not appear to reduce maximum voluntary contraction strength and remains a test of endurance. However, a similar test for the abdominal muscles did induce fatigue. Further research is required to develop an effective protocol to assess trunk extensor fatigue. [ABSTRACT FROM AUTHOR]

Background: Measuring isokinetic strength of the shoulder complex is potentially an important clinical tool in both diagnosis and management of injury and pathology. However, a clinically relevant position is yet to be established.Objectives: To establish an appropriate and repeatable protocol to evaluate the functional strength of both internal and external rotators of the glenohumeral joint to enable assessment of clinical injury management and training related developments in upper limb strength.Methods: A population cross-sectional study of shoulder internal and external rotational strengths of 17 normal, healthy volunteers (11 males, 6 females) aged 21 to 45 years were measured both isokinetically and isometrically. Two test positions: seated and supine, were compared by way of reliability and repeatability analyses. Humeral rotation was performed at 45 degrees of abduction in the scapular plane seated, and at 90 degrees of abduction in the supine position.Results: Throughout concentric testing, when the population was considered as a whole the left shoulder data appeared more repeatable than the right shoulder. This however, was not evident when the study population was divided into single sex groupings. Equally, whilst the repeatability trend of sitting vs. supine position was skewed towards the former, more evident in the left shoulder, this was less apparent when sexes were analysed separately. All comparative measures were statistically insignificant.Conclusion: The findings of this study suggest that measurements of isokinetic shoulder rotation strength are highly prone to both joint specific and non-specific errors. [ABSTRACT FROM AUTHOR]

Objective: To investigate the muscle strength profile of the forearm in experienced tennis players and non-tennis players, including establishment of reproducibility data for dynamometer testing of grip strength, forearm and wrist torque.Methods: Grip strength was evaluated using a mechanical handgrip dynamometer. Pronation/supination and wrist extension/flexion performance was tested using an isokinetic dynamometer. Ten subjects (mean age 22.9 +/- 1.8 yrs) took part in reproducibility testing. For the main study, twelve tennis players (mean age 24.6 +/- 9.3) and twelve controls (mean age 22.2 +/- 1.2) were evaluated using the same protocol.Results: Reproducibility values showed variability between testing sessions, highlighting that caution be employed when using this equipment. Average maximum grip strength of tennis players was significantly higher (p < 0.0001) in the dominant arm (51.19 kg) compared to their non-dominant arm (45.03 kg). Pronation in the dominant arm was significantly higher than the non-dominant arm in both subject groups. Wrist extension was stronger in the dominant arm compared to the non-dominant arm in both subject groups.Conclusion: Reproducibility of test protocol needs to be addressed if it is to be used in future comparative studies. This study indicates that prolonged asymmetrical sporting activity produces muscle profile asymmetries between and within limbs. The functional significance of these findings requires further investigation. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Biomechanical measures of movement are being used increasingly to understand injury mechanisms and enhance performance. Frequently, rowing injuries are attributed to poor rowing technique. This suggests a need to understand technique and its influencing factors. This study aimed to quantify rowing technique in terms of lumbopelvic motion, force production, and work done at different work intensities. METHODS: An electromagnetic motion measuring device in conjunction with a load cell was used to determine the ergometer rowing kinematics of 12 elite international oarswomen during a routine step test. This test comprised six steps at a series of different stroke ratings starting at 18 strokes per minute and ending at maximal-output rowing. RESULTS: As work intensity increased, force output increased significantly (P < 0.0001). Stroke length remained relatively consistent throughout the steps, although there was a nonsignificant shortening from 136.5 cm (+/-6.4 SD) at 18 strokes per minute to 130.6 cm (+/-8.1) at maximal testing. Changes in kinematics were also observed, particularly at the catch and finish positions. There was a trend towards less anterior pelvic rotation occurring at the catch with an associated reduction in lumbar rotation and greater extensions occurring in both at the finish at the higher rating. Overall, rowers underutilized pelvic rotation to achieve these positions relying predominantly on lumbar rotation. CONCLUSION: This study quantified the spinal kinematics of elite rowers at different incremental work intensities and noted subtle but important changes to lumbopelvic and spinal kinematics at increasing work levels, particularly at maximal intensity. Such changes particularly are thought to be important with respect to the development of low-back pain. [ABSTRACT FROM AUTHOR]

Manual therapists frequently use posteroanterior mobilisation as both an examination tool and a form of conservative treatment. At present our knowledge of the principles underlying this technique are scant. This study aimed to investigate changes in vertebral kinematics and soft tissue displacement as a result of a sustained posteroanterior (PA) mobilisation applied to the cervical spine of a subject with a history of chronic neck pain.Five subjects were recruited and written informed consent obtained. Subjects were scanned using a General Electric Signa SPI0 Open Interventional MRI scanner. Subjects were scanned in the prone position with their necks in both neutral and flexed positions. In each position a PA mobilisation to the 2nd and 6th cervical vertebrae was performed. Sagittal images of the spine were obtained prior to, during and following the mobilisation, from which measures of vertebral angulation and translation were recorded. Measurements of intervertebral angulation and translation demonstrated little if any motion during the application of a PA mobilisation. Marked and significant changes were seen in terms of soft tissue compression and in some instances overall angulation of the cervical spine.These initial studies suggest that the application of a PA mobilisation to the cervical spine produces minimal if any intervertebral motion. This is in agreement with earlier studies investigating motion in healthy normal spines. [ABSTRACT FROM AUTHOR]

Low back pain is the commonest musculoskeletal complaint in rowers. Research into the relationship between rowing technique, the forces generated during the rowing stroke and the kinematics of spinal motion are increasing, but to date none have investigated the impact of different rowing intensities on this relationship. A technique has been developed using an electromagnetic motion system and strain gauge instrumented load cell to measure spinal and pelvic motion and force generated at the handle during rowing on an exercise rowing ergometer. Using this technique ten collegiate male rowers (mean age 22.1+/-2.8 years) from local rowing clubs were investigated. The test protocol consisted of rowing on an ergometer at three different stroke ratings; 17-20 strokes per minute; 24-28 strokes per minute; and 28-36 strokes per minute. Each rating was held for four minutes, with a five-minute rest between each rating. Marked changes in the force output curve and lumbopelvic kinematics were observed at the different rowing intensities. Although there was no change in the magnitude of peak torque generated during the different rating, there was a marked shift in when this occurred during the stroke. In terms of kinematic changes, these centred around changes in pelvic rotation at the catch and finish stages of the stroke with significantly less anterior rotation occurring at the catch position at higher rowing intensities. To conclude, this study suggests that rowing kinematics and force profiles do change at higher rowing intensities. These changes may be an important factor with respect to injury mechanisms, however, further work is required at an elite level. [ABSTRACT FROM AUTHOR]

This study sought to examine the ability of motion analysis to detect long and short-term changes in performance following lumbar decompression surgery. These changes were compared with changes in more traditional questionnaire based assessments of outcome.Fifty-two patients from an original pool of 84 patients who underwent spinal surgery were assessed pre-operatively using spinal motion analysis and standard questionnaires of pain and function. These assessments were repeated at 6 weeks, and 6 months post-operatively.Significant Improvements in back and leg pain were noted at 6 weeks (p < 0.001) with no further improvements occurring at 6 months. Changes in the Oswestry Disability Score were noted only at the 6-month review, and only certain constructs of the SF-36 reported improvement. Of the motion analysis measures only measures of sagittal posture and anterior-posterior flexion appeared sensitive to change in the patient's condition. However, change in motion was not correlated with change in functional disability scales or pain.Measures of posture and range of motion of flexion may provide useful indices of objective performance in future outcome studies, however, they do not correlate with changes in subjective function or pain, thus their full relevance remains uncertain. [ABSTRACT FROM AUTHOR]

Measurements of trunk flexibility have frequently been used to aid in diagnostic, prognostic and therapeutic processes. However, the speed at which these tests should be performed has not been established. Some authors have performed range of motion studies with subjects moving at their maximum speed, whilst others have asked subjects to move at slow speeds. McIntyre et al. (1991) suggested that tests of human performance should be performed at the subject's preferred speed, since this is a more reliable measure of function. However, the influence of speed on movement characteristics has received limited attention. In addition the impact of speed on repeatability of measures of motion is unclear.The impact of test speed was investigated in a sample of normal control subjects and low back pain subjects with known spinal stenosis. Measurements of lumbar spine motion were obtained using a triaxial potentiometric analysis system (CA 6000 - Spinal Motion Analyser, OSI, USA) during a simple antero-posterior flexion-extension test. Each subject was asked to perform a series of three flexion-extension tests at three different speeds; as fast as they could, slowly and at their preferred/ normal rate of movement.The results demonstrated that in both study populations the speed at which the test was performed had no significant effect on the resultant ROM of flexion. However, in the normal population it did have an influence on ROM extension, with the tests performed at a fast speed producing a significantly greater ROM extension (p < 0.05) than tests performed at the subject's preferred speed or at a slow speed. Not surprisingly the mean velocity characteristics of each test speed showed significant differences in both populations. In terms of test repeatability however, the results indicated that testing at a subject's preferred speed produced more consistent readings of motion characteristics (in terms of both ROM and velocity). In addition all parameters of motion were significantly impaired in the spinal stenosis group with p < 0.01. [ABSTRACT FROM AUTHOR]

Study Design: This study invited patients to evaluate the content and style of a rehabilitation program used as an intervention in a multicenter, factorial, randomized controlled trial of the postoperative management of spinal surgery patients.Objective: To determine the acceptability and content of the rehabilitation program.Summary Of Background Data: The use of rehabilitation after spinal surgery is sporadic, and the evidence for its benefit is mixed. A randomized controlled trial was conducted to determine whether functional outcome of spinal surgery could be improved by a postoperative rehabilitation program and/or an educational booklet provided at hospital discharge, each compared with usual care.Methods: Patients randomized to postoperative rehabilitation began the course 6 weeks after surgery. At the end of the course of 12 classes, patients completed an evaluation of content, style, and length using forced choice and open questions. Patients not attending the final class completed the evaluation at their 3-month review.Results: Compliance with rehabilitation was poor, with 41% of subjects failing to attend any classes and 16% attending less than half. Compliance with the evaluation was 100% for the 105 patients attending 1 or more classes. The length, content, and approach to the classes were rated positively, and patients gave the class a median rating of 9 of 10, range 5 to 10, with 91% rating the classes as 7 or above.Conclusion: Compliance with a postoperative rehabilitation program was disappointing, but the program was assessed positively and of benefit by those who attended. Issues were raised in relation to timing and location of classes. [ABSTRACT FROM AUTHOR]

Purpose: Sixty percent of breast cancer patients develop persistent upper limb pain and dysfunction, but only limited knowledge exists about how these symptoms relate to rehabilitation access., Methods: A postal survey was sent to patients treated at a London University Teaching Hospital (2018-2020). Data were collected on pain (Pain Detect), shoulder function (Disability of Shoulder Arm and Hand (DASH)), quality-of-life (QoL) (EQ-5D-5L), and clinical characteristics, including treatment and access to rehabilitation. The free-text section invited patients' comments on upper limb symptoms and management strategies, which were analysed thematically. Quantitative data were analysed descriptively, and the medians were examined with Mann-Whitley U-Tests or Kruskal-Wallis Test., Results: Of 511 patients surveyed, 162 (32 %) questionnaires were returned and analysed. Respondents' mean age was 62 years (SD 11.3). The majority had Sentinel Node Biopsy 71 % (116/162) and mastectomy 61 % (99/162). 73 % (119/162) reported pain. Mean (SD) Pain Detect and DASH Score were respectively 11.07 (7) and 21.7 (21.5), with 51 % recording significant shoulder dysfunction, and only 28 % reporting access to rehabilitation. Individuals with neuropathic pain had significantly higher median (range) DASH score 60.8 (35.8, 75.0) p = 0.000. Median DASH score for sedentary individuals was significantly higher 22.9 (7.9, 31.8) p = 0.0009. Free-text analysis revealed persistent, progressive symptoms, mixed attitudes towards exercise and variations in access to rehabilitation and support., Conclusion: Two years following surgery many patients reported significant upper limb symptoms which adversely impact on QoL. However, approximately two thirds did not access potentially beneficial rehabilitation treatments. There is a need to improve pathways of care., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: In recent years, radar technology has been extensively utilized in contactless human behavior monitoring systems. The unique capabilities of ultra-wideband (UWB) radars compared to conventional radar technologies, due to time-of-flight measurements, present new untapped opportunities for in-depth monitoring of human movement during overground locomotion. This study aims to investigate the deployability of UWB radars in accurately capturing the gait patterns of healthy individuals with no known walking impairments., Methods: A novel algorithm was developed that can extract ten clinical spatiotemporal gait features using the Doppler information captured from three monostatic UWB radar sensors during a 6-meter walking task. Key gait events are detected from lower-extremity movements based on the joint range-Doppler-time representation of recorded radar data. The estimated gait parameters were validated against a gold-standard optical motion tracking system using 12 healthy volunteers., Results: On average, nine gait parameters can be consistently estimated with 90-98% accuracy, while capturing 94.5% of participants' gait variability and 90.8% of inter-limb symmetry. Correlation and Bland-Altman analysis revealed a strong correlation between radar-based parameters and the ground-truth values, with average discrepancies consistently close to 0., Conclusion: Results prove that radar sensing can provide accurate biomarkers to supplement clinical human gait analysis, with quality similar to gold standard assessment., Significance: Radars can potentially allow a transition from expensive and cumbersome lab-based gait analysis tools toward a completely unobtrusive and affordable solution for in-home deployment, enabling continuous long-term monitoring of individuals for research and healthcare applications.

Background: Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world., Methods: MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument., Results: Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture., Conclusions: Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines., (© 2024. The Author(s).)

Background: Chronic low back pain (CLBP) is a highly prevalent musculoskeletal condition affecting 60-80% of the general population within their lifetime. Given the large numbers of people affected, self-management approaches have been introduced as a way to manage this condition with endorsement by the national institute for health and care excellence. Interventions are often termed self-management without defining either content or goals. Our study sought to determine the content, characteristics, and evidence for self-management of CLBP., Methods: This narrative review was conducted using a systematic approach to search journal articles in English that focused on CLBP self-management. MEDLINE, EMBASE, CINAHL, and PsycINFO databases were used to identify publications with terms relating to back pain and self-management from January 2016 until January 2022., Results: In total, 15 studies were found suitable for inclusion in the review. Core components of self-management strategies include exercise, education, and psychological interventions, but there was a lack of consistency with respect to content. Intervention characteristics were either under-reported or varied. Furthermore, outcome measures used to assess these self-management programmes were diverse, mainly focusing on functional disability and pain intensity., Conclusions: Inconsistencies in the content of self-management interventions, intervention characteristics, and outcome measures used for assessing self-management programmes were found across the literature. Current self-management approaches do not consider the complex biopsychosocial nature of CLBP. A consensus on the key components of self-management interventions, and how they should be evaluated, will pave the way for research to determine whether self-management can effectively manage CLBP., (© 2023. The Author(s).)

Most cases of unilateral knee osteoarthritis (OA) progress to bilateral OA within 10 years. Biomechanical asymmetries have been implicated in contralateral OA development; however, gait analysis alone does not consistently detect asymmetries in OA patient gait. Stair ambulation is a more demanding activity that may be more suited to reveal between-leg asymmetries in OA patients. The objective of this study was to investigate the between-leg biomechanical differences in patients with unilateral mild-to-moderate knee OA. Sixteen unilateral mild-to-moderate medial knee OA patients and 16 healthy individuals underwent kinematic and kinetic analysis of stair ascent and descent. Stair ascent produced higher loading and muscle forces in the unaffected limb compared to the OA limb, and stair descent produced lower loading on the OA limb compared to healthy subjects. These biomechanical differences were apparent in the ankle, knee, and hip joints. The implications of these findings are that OA patients rely more heavily on their unaffected sides than the affected side in stair ascent, a strategy that may be detrimental to the unaffected joint health. The reduction in affected limb loading in stair descent is thought to be related to minimizing pain., (© 2023. The Author(s).)

The association between combat-related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross-sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK-Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency-matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role-in-theatre. BMD was assessed using dual-energy X-ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 versus -0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland., (© 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.)

Background: Aerosol personal protective equipment (PPE) is subjectively reported to negatively impact healthcare workers' performance and well-being, but this has not been assessed objectively., Aims: This randomized controlled crossover study aimed to quantify the heat stress associated with aerosol PPE and to investigate its impact upon mood, cognitive and motor function, and task performance., Methods: Sixteen healthy, young, lean participants (eight males) undertook an exercise protocol, which simulated the metabolic expenditure of hospital work: once wearing aerosol PPE (PPE visit) and once wearing standard surgical attire (control visit). Participants walked on a treadmill for 2 h followed by 30-min rest. Core temperature, heart rate, urine specific gravity, weight, grip strength, mood (Bond-Lader scale) and task performance (Intubation of a Manikin) were recorded. Values are between-visit mean (standard deviation) differences., Results: On the PPE visit core temperature (+0.2 (0.3)°C; P < 0.01), heart rate (+12 (13) bpm; P < 0.001), urine specific gravity (+0.003 (0.005); P < 0.05) and intubation task time (+50 (81) s; P < 0.01) were greater than on the control visit; and alertness (-14 (21) mm; P < 0.001), contentment (-14 (15) mm; P < 0.001) and grip strength (-4 (4) N; P < 0.01) were less., Conclusions: This study demonstrates that wearing aerosol PPE in a simulated hospital environment results in heat exhaustion and has a negative impact upon mood, motor function, and task performance. Whilst wearing PPE is important to prevent disease transmission, strategies should be developed to limit its impact upon healthcare workers' performance and well-being., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Introduction: Due to loss in musculoskeletal capacity, there is an increased burden on the residual limbs of bilateral transfemoral and through-knee persons with limb loss. This reduced capacity is associated with an increased cost of walking that is detrimental to functionality. Compensatory gait strategies are adopted by this population. However, how these strategies relate to specific muscle recruitment is not known. The primary aim of this study is to characterize muscle recruitment during gait of this population. The secondary aim is to assess whether the measured kinematics can be actuated when the endurance of specific muscles is reduced and if this is the case, which alternative muscles facilitate this. Methods: 3D gait data and high-resolution magnetic resonance images were acquired from six bilateral transfemoral and through-knee persons with limb loss. Subject-specific anatomical muscle models were developed for each participant, and a validated musculoskeletal model was used to quantify muscle forces in two conditions: during normal gait (baseline) and when muscles, which were identified as functioning above a "healthy" level at baseline, have a reduced magnitude of maximum force capacity (reduced endurance simulation). To test the hypothesis that there are differences in muscle forces between the baseline trials and the simulations with reduced muscular endurance, a Bonferroni corrected two-way ANOVA with repeated measures was completed between the two states. Results: The baseline analysis showed that the hip flexors experience relatively high muscle activations during gait. The reduced endurance simulation found two scenarios. First, for 5 out of the 12 simulations, the baseline kinematics could not be reproduced with the reduced muscular capacity. Second, for 7 out of 12 cases where the baseline kinematics were achieved, this was possible with compensatory increased activation of some muscles with similar functions ( p ≤ 0.003). Discussion: Evidently, due to the loss of the ankle plantar flexors, gait imposes a high demand on the flexor muscle group of the residual limb. This study highlights how the elevated cost of gait in this population manifests in muscle recruitment. To enhance functionality, it is critical to consider the mechanical demand on the hip flexors and to develop rehabilitation interventions accordingly., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Benton, Amiri, Henson, Sivapuratharasu, Mcgregor and Bull.)

Digital interventions can increase physical activity (PA) levels in adults. However, the COVID-19 pandemic highlighted the complexities faced when guiding people to start or return to PA following illness or inactivity. A digital tool, Movement Foundations, was developed to provide remote guidance on building strength and capacity across functional movement patterns, with graduated progression based on user responses and input. This qualitative study aimed to explore the perceived impacts of using the tool. Nine participants aged over 35 years from the healthcare and academic healthcare sectors were recruited to use it and were subsequently interviewed. Thematic analysis identified three themes falling under the overarching concept of 'Capability, Opportunity and Motivation-Behaviour (COM-B) Plus', encompassing: skills and capacity for movement; opportunities, motivations and barriers for movement; and a personalised, safe space in which to develop. Participants felt that the digital tool increased their capacity and confidence in movement and positively impacted their daily activities. External factors such as illness and stress clouded perceptions of the impacts of PA. Time, work pressures and needing equipment were still considered significant barriers to PA. Still, participants appreciated the flexibility and non-prescriptive nature of the tool and felt that it helped movement to become opportunistic and habitual. Increased capacity for PA and feeling the subsequent physical and mental effects positively influenced motivation. Structure and guidance, with graduated progress, were seen as protective. Guided self-reflection helped participants understand their capacity and limitations with regard to movement and promoted motivation. Although acquiring technical skills to guide movement may be important for those recovering from illness, participants found that a structure promoting individualised guidance, graduated progression and guided self-reflection were important motivational factors for continuing use. Digital interventions should consider these aspects when seeking to promote habitual PA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Amputation imposes significant challenges in locomotion to millions of people with limb loss worldwide. The decline in the use of the residual limb results in muscle atrophy that affects musculoskeletal dynamics in daily activities. The aim of this study was to quantify the lower limb muscle volume discrepancy based on magnetic resonance (MR) imaging and to combine this with motion analysis and musculoskeletal modelling to quantify the effects in the dynamics of key activities of daily living. Eight male participants with traumatic unilateral transtibial amputation were recruited who were at least six months after receiving their definitive prostheses. The muscle volume discrepancies were found to be largest at the knee extensors (35 %, p = 0.008), followed by the hip abductors (17 %, p = 0.008). Daily activities (level walking, standing up from a chair and ascending one step) were measured in a motion analysis laboratory and muscle and joint forces quantified using a detailed musculoskeletal model for people with unilateral transtibial amputation which was calibrated in terms of the muscle volume discrepancies post-amputation at a subject-specific level. Knee extensor muscle forces were lower at the residual limb than the intact limb for all activities (p ≤ 0.008); residual limb muscle forces of the hip abductors (p ≤ 0.031) and adductors (p ≤ 0.031) were lower for standing-up and ascending one step. While the reduced knee extensor force has been reported by other studies, our results suggest a new biomechanically-based mitigation strategy to improve functional mobility, which could be achieved through strengthening of the hip abd/adductor muscles., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Objectives: Through-knee amputation is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a through-knee amputation approach. This article seeks to (1) determine the number of through-knee amputation performed compared with other major lower limb amputations in England over the past decade; (2) identify the theoretical concepts behind through-knee amputation surgical approaches and their potential effect on functional and clinical outcomes and (3) provide a platform for discussion and research on through-knee amputation and surgical outcomes., Methods: National Health Service Hospital Episodes Statistics were used to obtain recent numbers of major lower limb amputations in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on through-knee amputation surgery., Results: In the past decade, 4.6% of major lower limb amputations in England were through-knee amputations. Twenty-six articles presenting through-knee amputation surgical techniques met our criteria. These articles detailed three through-knee amputation surgical techniques: the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur., Conclusions: Through-knee amputation has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional and biomechanical outcomes of through-knee amputation frequently fail to distinguish between the three distinct and differing approaches, making direct comparisons difficult. Future studies that compare through-knee amputation approaches to one another and to other amputation levels are needed.

Deep learning biomechanical models perform optimally when trained with large datasets, however these can be challenging to collect in gait labs, while limited augmentation techniques are available. This study presents a data augmentation approach based on generative adversarial networks which generate synthetic motion capture (mocap) datasets of marker trajectories and ground reaction forces (GRFs). The proposed architecture, called adversarial autoencoder, consists of an encoder compressing mocap data to a latent vector, a decoder reconstructing the mocap data from the latent vector and a discriminator distinguishing random vectors from encoded latent vectors. Direct kinematics (DK) and inverse kinematics (IK) joint angles, GRFs, and inverse dynamics (ID) joint moments calculated for real and synthetic trials were compared using statistical parametric mapping to assure realistic data generation and select optimal architectural hyperparameters based on percentage average differences across the gait cycle length. We observed negligible differences for DK computed joint angles and GRFs, but not for inverse methods (IK: 29.2%, ID: 35.5%). When the same architecture was trained also including the joint angles calculated by IK, we found no significant differences in the kinematics and GRFs, and improvements in joint moments estimation (ID: 25.7%). Finally, we showed that our data augmentation approach improved the accuracy of joint kinematics (up to 23%, 0.8°) and vertical GRFs (11%) predicted by standard neural networks using a single simulated pelvic inertial measurement unit. These findings suggest that predictive deep learning models can benefit from the synthetic datasets produced with the proposed technique., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Medical professionals are increasingly required to use digital technologies as part of care delivery and this may represent a risk for medical error and subsequent malpractice liability. For example, if there is a medical error, should the error be attributed to the clinician or the artificial intelligence-based clinical decision-making system? In this article, we identify and discuss digital health technology-specific risks for malpractice liability and offer practical advice for the mitigation of malpractice risk., (© 2022. The Author(s).)

Wearable technologies are small electronic and mobile devices with wireless communication capabilities that can be worn on the body as a part of devices, accessories or clothes. Sensors incorporated within wearable devices enable the collection of a broad spectrum of data that can be processed and analysed by artificial intelligence (AI) systems. In this narrative review, we performed a literature search of the MEDLINE, Embase and Scopus databases. We included any original studies that used sensors to collect data for a sporting event and subsequently used an AI-based system to process the data with diagnostic, treatment or monitoring intents. The included studies show the use of AI in various sports including basketball, baseball and motor racing to improve athletic performance. We classified the studies according to the stage of an event, including pre-event training to guide performance and predict the possibility of injuries; during events to optimise performance and inform strategies; and in diagnosing injuries after an event. Based on the included studies, AI techniques to process data from sensors can detect patterns in physiological variables as well as positional and kinematic data to inform how athletes can improve their performance. Although AI has promising applications in sports medicine, there are several challenges that can hinder their adoption. We have also identified avenues for future work that can provide solutions to overcome these challenges.

Objective: Obtaining patient geometry is crucial in scoliosis brace design for patients with adolescent idiopathic scoliosis. Advances in 3D scanning technologies provide the opportunity to obtain patient geometries quickly with fewer resources during the design process compared with the plaster-cast method. This study assesses the accuracy and repeatability of such technologies for this application., Methods: The accuracy and repeatability of three different handheld scanners and phone-photogrammetry was assessed using different mesh generation software. Twenty-four scans of a single subject's torso were analyzed for accuracy and repeatability based on anatomical landmark distances and surface deviation maps., Results: Mark II and Structure ST01 scanners showed maximum mean surface deviations of 1.74 ± 3.63 mm and 1.64 ± 3.06 mm, respectively. Deviations were lower for the Peel 1 scanner (maximum of -0.35 ± 2.8 mm) but higher with the use of phone-photogrammetry (maximum of -5.1 ± 4.8 mm). The mean absolute errors of anatomical landmark distance measurements from torso meshes obtained with the Peel 1, Mark II, and ST01 scanners were all within 9.3 mm (3.6%), whereas phone-photogrammetry errors were as high as 18 mm (7%)., Conclusions: Low-cost Mark II and ST01 scanners are recommended for obtaining torso geometries because of their accuracy and repeatability. Subject's breathing/movement affects the resultant geometry around the abdominal and anterolateral regions., (Copyright © 2022 International Society for Prosthetics and Orthotics.)

Background: There is increasing recognition that prehabilitation is important as a means of preparing patients physically and psychologically for cancer treatment. However, little is understood about the role and optimal nature of prehabilitation for gynaecological cancer patients, who usually face extensive and life-changing surgery in addition to other treatments that impact significantly on physiological and psychosexual wellbeing., Review Question: This scoping review was conducted to collate the research evidence on multimodal prehabilitation in gynaecological cancers and the related barriers and facilitators to engagement and delivery that should be considered when designing a prehabilitation intervention for this group of women., Methods: Seven medical databases and four grey literature repositories were searched from database inception to September 2021. All articles, reporting on multimodal prehabilitation in gynaecological cancers were included in the final review, whether qualitative, quantitative or mixed-methods. Qualitative studies on unimodal interventions were also included, as these were thought to be more likely to include information about barriers and facilitators which could also be relevant to multimodal interventions. A realist framework of context, mechanism and outcome was used to assist interpretation of findings., Results: In total, 24 studies were included in the final review. The studies included the following tumour groups: ovarian only (n = 12), endometrial only (n = 1), mixed ovarian, endometrial, vulvar (n = 5) and non-specific gynaecological tumours (n = 6). There was considerable variation across studies in terms of screening for prehabilitation, delivery of prehabilitation and outcome measures. Key mechanisms and contexts influencing engagement with prehabilitation can be summarised as: (1) The role of healthcare professionals and organisations (2) Patients' perceptions of acceptability (3) Factors influencing patient motivation (4) Prehabilitation as a priority (5) Access to prehabilitation., Implications for Practice: A standardised and well evidenced prehabilitation programme for women with gynaecological cancer does not yet exist. Healthcare organisations and researchers should take into account the enablers and barriers to effective engagement by healthcare professionals and by patients, when designing and evaluating prehabilitation for gynaecological cancer patients., (© 2022. The Author(s).)

Objective: This review sought to evaluate the literature on the initial assessment and diagnostic pathway for patients with a suspected Anterior Cruciate Ligament (ACL) tear., Methods: MEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies, PRISMA guidelines were followed. Studies were included if they used at least one assessment method to assess for ACL injury and participants were assessed at an acute trauma centre within 6-weeks of injury. Article quality was evaluated using the QUADAS-2 checklist., Results: A total of 353 studies were assessed for eligibility, 347 were excluded for the following reasons: injuries were not assessed in an acute trauma setting, injuries were not acute, participants had previous ACL injuries or chronic joint deformities affecting the knee, participants were under 18, or participants included animals or cadavers. A total of six studies were included in the review. Common assessment methods included: laxity tests, joint effusion, inability to continue activity, and a history of a 'pop' and 'giving way' at the time of injury. Diagnostic accuracy varied greatly between the assessment method and the assessing clinician. Gold standard diagnostics were MRI and arthroscopy. A weighted meta-mean calculated the time to reach diagnosis to be 68.60 days [CI 23.94, 113.24]. The mean number of appointments to reach diagnosis varied from 2-5. Delay to surgery or surgical consultation ranged from 61 to 328 days., Conclusion: Clinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury. Reliance on specialist assessments or radiological methods inevitably increases the time to reach a diagnosis, which has repercussions on management options. There is an ever-growing demand to improve diagnostic accuracy and efficiency; further exploration into quantitative measures of instability would aid the assessment of peripheral joint assessment., (© 2022. The Author(s).)