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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

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).)

Background: Lumbar Disc Degeneration (LDD) is associated with recurrent low back pain (LBP) (symptomatic). However, in some instances of LDD, people do not experience LBP (asymptomatic)., Research Question: As a step towards understanding why some people with LDD experience LBP and others do not, the primary aim of this study was to examine differences in anticipatory (APA) and compensatory postural adjustments (CPA), between symptomatic LDD patients (LDD pain) and asymptomatic LDD controls (LDD no pain) during postural perturbation. The secondary aim was to determine simultaneous differences in mental health, disability and quality of life status., Methods: 3 T MRI was used to acquire T2 weighted images (L1-S1) from LDD no pain (n = 34) and LDD pain groups (n = 34). In this observational study, responses to predicted and unpredicted forward perturbations were examined using three dimensional motion capture. A Mann Whitney U test was conducted to examine group differences in sagittal spine and lower limb kinematics (integrated angular displacements during four established APA and CPA time intervals), anxiety, depression, disability and quality of life., Results: The LDD pain group exhibited lower hip and knee displacements (p = 0.049-0.040) than the LDD no pain group during predicted and unpredicted perturbation. The LDD pain group also exhibited higher compensatory lumbar displacement than the LDD no pain group (p = 0.040-0.005) in the predicted condition but there was no difference observed in the unpredicted condition. The LDD pain group experienced higher levels of depression, anxiety and disability (p < 0.0001) and lower quality of life (p = 0.0001) than LDD controls., Significance: Symptomatic LDD patients are different from LDD controls; they exhibit different kinematic strategies, levels of disability, anxiety, depression and quality of life. Effective care may benefit from evaluating and targeting these differences., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity., Objective: The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy., Methods: An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL)., Results: Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien-Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores., Conclusion: This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit., (© 2021. The Author(s).)

Objective: The aim of this study was to elicit the views of relevant stakeholders on the design of a device using simulated affective touch to reduce procedural anxiety surrounding radiotherapy and imaging., Design: This qualitative study collected data from focus groups which were then analysed using inductive thematic analysis in line with Braun and Clarke's methods., Participants and Setting: Twenty patients and carers were recruited, as well as 10 healthcare practitioners involved in either delivering radiotherapy or imaging procedures., Results: Patients, carers and healthcare practitioners agreed on some aspects of the device design, such as ensuring the device is warm and flexible in where it can be used on the body. However, patient and healthcare practitioner cohorts had at times differing viewpoints. For example, healthcare practitioners provided professional perspectives and required easy cleaning of the device. Meanwhile patients focused on anxiety-relieving factors, such as the tactile sensation of the device being either a vibration or pulsation. There was no consensus on who should control the device., Conclusions: The desired features of a simulated affective touch device have been investigated. Different priorities of patients and their carers and healthcare practitioners were evident. Any design must incorporate such features as to appease both groups. Areas where no consensus was reached could be further explored, alongside including further patient and public involvement in the form of a project advisory group., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

The majority of limb prostheses are socket mounted. For these devices, the socket is essential for adequate prosthetic suspension, comfort, and control. The socket is unique among prosthetic components as it is not usually mass-produced and must instead be custom-made for individual residual limbs by a prosthetist. The knowledge of what constitutes "good" socket fit is gained by expert prosthetists and technicians over years of experience, and rarely documented. The reliance on tacit knowledge makes it difficult to standardize the criteria for a well-fitting socket, leading to difficulties understanding the impact of socket fit. Despite its importance, the workflow for socket fitting is often overlooked in literature. Due to the customized nature of sockets, if information is provided in literature, generally only the type of socket and suspension mechanism is noted, with information regarding the fitting and manufacturing processes omitted. In this article, the concerns, issues and consequences arising from lack of upper and lower limb socket documentation are discussed from a researcher perspective, supported by healthcare professionals and socket fabrication specialists. Key changes are proposed to the way socket manufacturing and evaluation are documented to assist future research., 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 © 2022 Olsen, Turner, Chadwell, Dickinson, Ostler, Armitage, McGregor, Dupan and Day.)

Background: Successful rehabilitation is essential to improve the physical and mental outcomes of people with lower limb amputation(s). Individuals have different goals and expectations of successful rehabilitation and experience issues that affect their quality of life., Objectives: To determine factors affecting lower limb prosthetic rehabilitation from people with amputation(s), important for studies focusing on prosthetic and socket design and fitting because they provide context of need and user issues., Study Design: Thematic analysis of semistructured interviews., Methods: Ten people with amputation(s) were self-selected from a survey identifying factors affecting lower limb prosthetic rehabilitation. The telephone interviews were semistructured exploring the biggest impactors on and frustrations with rehabilitation and the socket. A thematic analysis was completed by following the undermentioned steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and reporting., Results: Five distinct but interrelated themes were identified: External to Prosthesis, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Work and Social Impact. Those living with amputation(s) mentioned prosthetic-related issues affecting their work and social life, including difficulties wearing their prosthesis all day, the socket's rigidity, and the ability to participate in hobbies., Conclusions: The study provides new insights into the issues experienced during prosthetic rehabilitation, highlighting impacts beyond just physical health consequences. The study provides an evidence base for areas of the rehabilitation journey which could be improved to improve the quality of life of people with amputation(s)., (Copyright © 2021 The Authors.)

Successful prosthetic rehabilitation is essential to improve the physical and mental outcomes of people with lower-limb amputation. Evaluation of prosthetic services from a prosthesis user perspective have been published and commissioned by the national bodies, however, the perspectives of clinicians working with service users during rehabilitation have not to date been sought. We sought to determine factors impacting lower-limb prosthetic rehabilitation from a clinician's perspective to inform studies focusing on prosthetic and socket design and fitting. Six clinician (2 prosthetists, 4 physiotherapists) interviewees were self-selected from a survey exploring issues and frustrations during lower-limb prosthetic rehabilitation. Semi-structured interviews explored the impactors on and frustrations with rehabilitation and the prosthetic socket. A thematic analysis was subsequently conducted to identify themes in the responses. Five themes were identified: Service Disparity, Body Impactors, Consequences of Ill-Fit, Prosthesis Irritants, and Limitations of Practice. Each theme, though distinct, relates to the others either as a cause or consequence and should be viewed as such. Addressing the themes will have benefits beyond the issues addressed but also expand into the other themes. This study provides an insight into the clinician perspectives on lower-limb prosthetic rehabilitation, which has not been formally documented to date., 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 © 2022 Turner, Belsi and McGregor.)

Electromagnetic (EM) tracking has been used to quantify biomechanical parameters of the lower limb and lumbar spine during ergometer rowing to improve performance and reduce injury. Optical motion capture (OMC) is potentially better suited to measure comprehensive whole-body dynamics in rowing. This study compared accuracy and precision of EM and OMC displacements by simultaneously recording kinematics during rowing trials at low, middle, and high rates on an instrumented ergometer (n=12). Trajectories calculated from OMC and EM sensors attached to the pelvis, lumbar spine, and right leg were highly correlated, but EM tracking lagged behind ergometer and OMC tracking by approximately 6%, yielding large RMS errors. When this phase-lag was corrected by least squares minimization, agreement between systems improved. Both systems demonstrated an ability to adequately track large dynamic compound movements in the sagittal plane but struggled at times to precisely track small displacements and narrow angular ranges in medial/lateral and superior/inferior directions. An OMC based tracking methodology can obtain equivalence with a previously validated EM system, for spine and lower limb metrics. Improvements in speed and consistency of data acquisition with OMC are beneficial for dynamic motion studies. Compatibility ensures continuity by maintaining the ability to compare to prior work.

Background: Joint Hypermobility Syndrome (JHS) is a rare Heritable Disorder of Connective tissue characterised by generalised joint laxity and chronic widespread pain. Joint Hypermobility Syndrome has a large impact on patients' day to day activities, and many complain of symptoms when standing for prolonged periods. This study investigates whether people with JHS exhibit the same behaviours to deal with the effects of prolonged standing as people with equal hypermobility and no pain, and people with normal flexibility and no pain., Methods: Twenty three people with JHS, 22 people with Generalised Joint Hypermobility (GJH), and 22 people with normal flexibility (NF) were asked to stand for a maximum of 15 min across two force-plates. Fidgets were counted and quantified using a cumulative sum algorithm and sway parameters of the quiet standing periods between fidgets were calculated., Results: Average standing time for participants with JHS was 7.35 min and none stood for the full 15 min. All participants with GJH and NF completed 15 min of standing. There were no differences in fidgeting behaviour between any groups. There was a difference in anteroposterior sway (p = .029) during the quiet standing periods., Conclusion: There is no evidence to suggest people with JHS exhibit different fidgeting behaviour. Increased anteroposterior-sway may suggest a muscle weakness and strengthening muscles around the ankle may reduce postural sway and potentially improve the ability to stand for prolonged periods., (© 2021. The Author(s).)

Background: Several studies have assessed the impact of COVID-19-related lockdowns on sleep quality across global populations. However, no study to date has specifically assessed at-risk populations, particularly those at highest risk of complications from coronavirus infection deemed "clinically-extremely-vulnerable-(COVID-19CEV)" (as defined by Public Health England). Methods: In this cross-sectional study, we surveyed 5,558 adults aged ≥50 years (of whom 523 met criteria for COVID-19CEV) during the first pandemic wave that resulted in a nationwide-lockdown (April-June 2020) with assessments of sleep quality (an adapted sleep scale that captured multiple sleep indices before and during the lockdown), health/medical, lifestyle, psychosocial and socio-demographic factors. We examined associations between these variables and sleep quality; and explored interactions of COVID-19CEV status with significant predictors of poor sleep, to identify potential moderating factors. Results: Thirty-seven percent of participants reported poor sleep quality which was associated with younger age, female sex and multimorbidity. Significant associations with poor sleep included health/medical factors: COVID-19CEV status, higher BMI, arthritis, pulmonary disease, and mental health disorders; and the following lifestyle and psychosocial factors: living alone, higher alcohol consumption, an unhealthy diet and higher depressive and anxiety symptoms. Moderators of the negative relationship between COVID-19CEV status and good sleep quality were marital status, loneliness, anxiety and diet. Within this subgroup, less anxious and less lonely males, as well as females with healthier diets, reported better sleep. Conclusions: Sleep quality in older adults was compromised during the sudden unprecedented nation-wide lockdown due to distinct modifiable factors. An important contribution of our study is the assessment of a "clinically-extremely-vulnerable" population and the sex differences identified within this group. Male and female older adults deemed COVID-19CEV may benefit from targeted mental health and dietary interventions, respectively. This work extends the available evidence on the notable impact of lack of social interactions during the COVID-19 pandemic on sleep, and provides recommendations toward areas for future work, including research into vulnerability factors impacting sleep disruption and COVID-19-related complications. Study results may inform tailored interventions targeted at modifiable risk factors to promote optimal sleep; additionally, providing empirical data to support health policy development in this area., Competing Interests: LM reports clinical trial grants from Janssen R&D, Novartis and Takeda outside the submitted work. The remaining 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 © 2021 Udeh-Momoh, Watermeyer, Sindi, Giannakopoulou, Robb, Ahmadi-Abhari, Zheng, Waheed, McKeand, Salman, Beaney, de Jager Loots, Price, Atchison, Car, Majeed, McGregor, Kivipelto, Ward and Middleton.)

Objective: To evaluate adherence to and effect of postnatal physical activity (PA) interventions., Design: Systematic review of PA intervention randomised controlled trials in postnatal women. The initial search was carried out in September 2018, and updated in January 2021., Data Sources: Embase, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) databases, hand-searching references of included studies. The 25 identified studies included 1466 postnatal women in community and secondary care settings., Eligibility Criteria: Studies were included if the PA interventions were commenced and assessed in the postnatal year., Data Extraction and Synthesis: Data were extracted using a prespecified extraction template and assessed independently by two reviewers using Cochrane ROB 1 tool., Results: 1413 records were screened for potential study inclusion, full-text review was performed on 146 articles, 25 studies were included. The primary outcome was adherence to PA intervention. The secondary outcomes were the effect of the PA interventions on the studies' specified primary outcome. We compared effect on primary outcome for supervised and unsupervised exercise interventions. Studies were small, median n=66 (20-130). PA interventions were highly variable, targets for PA per week ranged from 60 to 275 min per week. Loss to follow-up (LTFU) was higher (14.5% vs 10%) and adherence to intervention was lower (73.6% vs 86%) for unsupervised versus supervised studies., Conclusions: Studies of PA interventions inconsistently reported adherence and LTFU. Where multiple studies evaluated PA as an outcome, they had inconsistent effects, with generally low study quality and high risk of bias. Agreement for effect between studies was evident for PA improving physical fitness and reducing fatigue. Three studies showed no adverse effect of PA on breast feeding. High-quality research reporting adherence and LTFU is needed into how and when to deliver postnatal PA interventions to benefit postnatal physical and mental health., Prospero Registration Number: CRD42019114836., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to explore the perceptions of orthopaedic clinicians about consultations for people with persistent musculoskeletal low back pain (PMLBP) in which surgery is not recommended. Surgery is not recommended for the majority of PMLBP consulting in secondary care settings., Setting: Secondary care sector in the UK., Participants: Semi-structured qualitative interviews were conducted with 24 orthopaedic team clinicians from 17 different hospitals in the UK and Ireland. Interviews explored clinicians' perceptions of the challenges in consultations where surgery is not indicated. Interviews were transcribed verbatim and analysed using thematic analysis., Results: Two meta-themes, Difficulties and Enablers, each consisting of several subthemes were identified. Difficulties included challenges around the choice of appropriate terminology and labels for PMLBP, managing patients' expectations, working with mentally vulnerable patients and explaining imaging findings. Enablers included early management of expectations, use of routine imaging, triaging, access to direct referral elsewhere, including other non-surgical practitioners in the team, training to improve communication skills and understanding of psychological issues., Conclusion: The findings highlight clinicians' perceived need for concordance in messages delivered across the care pathway and training of orthopaedic clinicians to deliver effective reassurance and address patients' needs in circumstances where surgery is not indicated., Competing Interests: Competing interests: TP has held consultancy roles teaching Psychologically Informed Practice through her University position. The other authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Musculoskeletal models of the lumbar spine have been developed with varying levels of detail for a wide range of clinical applications. Providing consistency is ensured throughout the modelling approach, these models can be combined with other computational models and be used in predictive modelling studies to investigate bone health deterioration and the associated fracture risk. To provide precise physiological loading conditions for such predictive modelling studies, a new full-body musculoskeletal model including a detailed and consistent representation of the lower limbs and the lumbar spine was developed. The model was assessed against in vivo measurements from the literature for a range of spine movements representative of daily living activities. Comparison between model estimations and electromyography recordings was also made for a range of lifting tasks. This new musculoskeletal model will provide a comprehensive physiological mechanical environment for future predictive finite element modelling studies on bone structural adaptation. It is freely available on https://simtk.org/projects/llsm/.

Amputation of a major limb, and the subsequent return to movement with a prosthesis, requires the development of compensatory strategies to account for the loss. Such strategies, over time, lead to regional muscle atrophy and hypertrophy through chronic under or overuse of muscles compared to uninjured individuals. The aim of this study was to quantify the lower limb muscle parameters of persons with transtibial and transfemoral amputations using high resolution MRI to ascertain muscle volume and to determine regression equations for predicting muscle volume using femur- and tibia-length, pelvic-width, height, and mass. Twelve persons with limb loss participated in this study and their data were compared to six matched control subjects. Subjects with unilateral transtibial amputation showed whole-limb muscle volume loss in the residual-limb, whereas minor volume changes in the intact limb were found, providing evidence for a compensation strategy that is dominated by the intact-limb. Subjects with bilateral-transfemoral amputations showed significant muscle volume increases in the short adductor muscles with an insertion not affected by the amputation, the hip flexors, and the gluteus medius, and significant volume decreases in the longer adductor muscles, rectus femoris, and hamstrings. This study presents a benchmark measure of muscle volume discrepancies in persons with limb-loss, and can be used to understand the compensation strategies of persons with limb-loss and the impact on muscle volume, thus enabling the development of optimised intervention protocols, conditioning therapies, surgical techniques, and prosthetic devices that promote and enhance functional capability within the population of persons with limb loss., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Physical inactivity is more common in older adults, is associated with social isolation and loneliness and contributes to increased morbidity and mortality. We examined the effect of social restrictions to reduce COVID-19 transmission in the UK (lockdown), on physical activity (PA) levels of older adults and the social predictors of any change., Design: Baseline analysis of a survey-based prospective cohort study., Setting: Adults enrolled in the Cognitive Health in Ageing Register for Investigational and Observational Trials cohort from general practitioner practices in North West London were invited to participate from April to July 2020., Participants: 6219 cognitively healthy adults aged 50-92 years completed the survey., Main Outcome Measures: Self-reported PA before and after the introduction of lockdown, as measured by metabolic equivalent of task (MET) minutes. Associations of PA with demographic, lifestyle and social factors, mood and frailty., Results: Mean PA was significantly lower following the introduction of lockdown from 3519 to 3185 MET min/week (p<0.001). After adjustment for confounders and prelockdown PA, lower levels of PA after the introduction of lockdown were found in those who were over 85 years old (640 (95% CI 246 to 1034) MET min/week less); were divorced or single (240 (95% CI 120 to 360) MET min/week less); living alone (277 (95% CI 152 to 402) MET min/week less); reported feeling lonely often (306 (95% CI 60 to 552) MET min/week less); and showed symptoms of depression (1007 (95% CI 612 to 1401) MET min/week less) compared with those aged 50-64 years, married, cohabiting and not reporting loneliness or depression, respectively., Conclusions and Implications: Markers of social isolation, loneliness and depression were associated with lower PA following the introduction of lockdown in the UK. Targeted interventions to increase PA in these groups should be considered., Competing Interests: Competing interests: LTM reports research funding from Janssen, Novartis, Merck and Takeda, outside the submitted work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Joint Hypermobility Syndrome (JHS) presents with a range of symptoms including widespread joint hypermobility and chronic arthralgia. The study objective was to investigate whether impairments in JHS are due to hypermobility or another factor of JHS by identifying impairments in gait and stair-climbing tasks; an activity that is demanding and so may better show differences between the cohorts., Methods: Sixty-eight adults participated; 23 JHS, 23 Generalised Joint Hypermobility (GJH), and 22 Normal Flexibility (NF). Inclusion criteria for JHS participants were a positive classification using the Brighton Criteria, for GJH a Beighton Score ≥ 4, and for NF a Beighton Score < 4 with no hypermobile knees. Participants were recorded with a 10-camera Vicon system whilst they performed gait and stair-climbing. Temporal-spatial, and sagittal plane kinematic and kinetic outcome measures were calculated and input to statistical analyses by statistical parametric mapping (SPM)., Results: During the gait activity JHS had significantly greater stride time and significantly lower velocity than NF, and significantly greater stride time, lower velocity, and lower stride length than GJH. SPM analysis showed no significant differences between groups in gait kinematics. There were significant differences between groups for gait moments and powers; people with JHS tended to have lower moments and generate less power at the ankle, and favour power generation at the knee. A similar strategy was present in stair ascent. During stair descent people with JHS showed significantly more hip flexion than people with NF., Conclusions: As there was only one significant difference between GJH and NF we conclude that impairments cannot be attributed to hypermobility alone, but rather other factor(s) of JHS. The results show that both gait and stair-climbing is impaired in JHS. Stair-climbing results indicate that JHS are using a knee-strategy and avoiding use of the ankle, which may be a factor for clinicians to consider during treatment., (© 2021. The Author(s).)

Public health organisations typically recommend a minimum amount of moderate intensity activities such as walking or cycling for two and a half hours a week, combined with some more demanding physical activity on at least 2 days a week to maintain a healthy musculoskeletal condition. For populations at risk of bone loss in the lumbar spine, these guidelines are particularly relevant. However, an understanding of how these different activities are influential in maintaining vertebral bone health is lacking. A predictive structural finite element modelling approach using a strain-driven algorithm was developed to study mechanical stimulus and bone adaptation in the lumbar spine under various physiological loading conditions. These loading conditions were obtained with a previously developed full-body musculoskeletal model for a range of daily living activities representative of a healthy lifestyle. Activities of interest for the simulations include moderate intensity activities involving limited spine movements in all directions such as, walking, stair ascent and descent, sitting down and standing up, and more demanding activities with large spine movements during reaching and lifting tasks. For a combination of moderate and more demanding activities, the finite element model predicted a trabecular and cortical bone architecture representative of a healthy vertebra. When more demanding activities were removed from the simulations, areas at risk of bone degradation were observed at all lumbar levels in the anterior part of the vertebral body, the transverse processes and the spinous process. Moderate intensity activities alone were found to be insufficient in providing a mechanical stimulus to prevent bone degradation. More demanding physical activities are essential to maintain bone health in the lumbar spine., 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 © 2021 Favier, McGregor and Phillips.)

People with chronic low back pain (LBP) exhibit changes in postural control. Stereotypical muscle activations resulting from external perturbations include anticipatory (APAs) and compensatory (CPAs) postural adjustments. The aim and objective of this study was to determine differences in postural control strategies (peak amplitude, APAs and CPAs) between symptomatic and asymptomatic adults with and without Lumbar Disc Degeneration (LDD) using surface electromyography during forward postural perturbation. Ninety-seven subjects participated in the study (mean age 50 years (SD 12)). 3T MRI was used to acquire T2 weighted images (L1-S1). LDD was determined using Pfirrmann grading. A bespoke translational platform was designed to deliver horizontal perturbations in sagittal and frontal planes. Electromyographic activity was analysed bilaterally from 8 trunk and lower limb muscles during four established APA and CPA epochs. A Kruskal-Wallis H test with Bonferroni correction for multiple comparisons was conducted. Four groups were identified: no LDD no pain (n = 19), LDD no pain (n = 38), LDD pain (n = 35) and no LDD pain (n = 5). There were no significant differences in age or gender between groups. The most significant difference between groups was observed during forward perturbation. In the APA and CPA phases of predictable forward perturbation there were significant differences ankle strategy between groups (p = 0.007-0.008); lateral gastrocnemius and tibialis anterior activity was higher in the LDD pain than the LDD no pain group. There were no significant differences in the unpredictable condition (p>0.05). These findings were different from the remaining groups, where significant differences in hip strategy were observed during both perturbation conditions (p = 0.004-0.006). Symptomatic LDD patients exhibit different electromyographic strategies to asymptomatic LDD controls. Future LBP electromyographic research should benefit from considering assessment of both lower limbs in addition to the spine. This approach could prevent underestimation of postural control deficits and guide targeted rehabilitation., Competing Interests: Authors have declared that no competing interests exist.

Competing Interests: Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Objectives: This study aims to investigate the feasibility and acceptability of using an app-based technology to train balance in the older population., Design: Prospective feasibility study., Setting: The study was conducted in a university setting and participants' homes., Participants: Thirty-five volunteers ≥55 years old were recruited., Intervention: Participants were asked to follow a balance exercise programme 7 days a week for 3 weeks using a phone application. Seventeen participants trained for a further 3 weeks., Outcome Measures: Postural sway measures during quiet standing with feet at shoulder width apart and feet together, one leg standing and tandem stance were measured at baseline, and at the end of the 3 and 6 training weeks; the International Physical Activity Questionnaire (IPAQ) assessed participants' physical activity level before training; and app acceptability was recorded using a user experience questionnaire., Results: Participants on the 3 and 6-week programme on average completed 20 (±5) and 38 (±11) days of training, respectively, and all scored moderate to high on the IPAQ. Between baseline and the 3-week assessments, statistically significant improvements were observed for anteroposterior sway, mediolateral sway, sway area during tandem stance, for anteroposterior sway during one leg standing and for sway area during feet together stance. Improvements were observed at 6 week compared with baseline but those between 3 and 6 weeks were not significant. Based on the questionnaire, participants reported that the app is an appropriate tool for balance training (77%), they reported benefits from the training (50%) and found it easy to fit it into daily routine (88%)., Conclusion: The high level of adherence and improvements observed in the analysed measures demonstrate the feasibility of using an app to train balance in moderately to highly physically active older participants. This demonstrates that given appropriate tools the older population is positive towards and receptive of digital interventions aimed to improve balance., Competing Interests: Competing interests: The authors report grants from Nymbl (Nymbl Science, Denver, USA) during the conduct of the study., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: A systematic review., Objective: To identify published studies that assess the prevalence and incidence of Low Back Pain (LBP) in the Saudi Arabian population., Methods: Six electronic databases were searched for articles published between January 1995 and December 2018. Crosssectional or cohort studies were included if they were conducted in the KSA and focused on the prevalence or incidence of LBP in adults. Case-control and retrospective studies were excluded. Studies were also excluded if they did not meet the quality criteria set out by the Joanna Briggs Institute (JBI) assessment or had a high or medium risk of bias according to the criteria proposed by Hoy et al. One independent reviewer (MAA) verified that the studies met the inclusion criteria, and three independent reviewers (MAA, AHM, CMA) assessed the quality of the studies and extracted their relevant characteristics. All the studies were assessed for quality using the JBI assessment and were assessed for risk of bias according to the Hoy et al. approach., Results: The initial search identified 158 papers; five studies met the inclusion criteria. The nature of the findings meant no meta-analysis could be performed; therefore, a narrative summary was generated to discuss the findings. The prevalence of LBP in different professional groups within a working-age group ranged between 64% and 89%., Discussion: The prevalence of LBP in the KSA has only been examined within specific professional groups, which limits the ability to generalize the finding. The review clarifies the need for further quality epidemiological studies to identify the prevalence of LBP in the general population. Many of the issues identified are problems related to occupational risk of LBP. The implication therefore is that these occupational factors need to be assessed so that risk factors for LBP among employees in KSA can be modified., Key Points: ., 1: The prevalence of LBP in the KSA has only been examined within specific professional groups., 2: The included studies link the prevalence of LBP to numbers of occupational-risk factors such as; participants' specialities, years of experience and working load., 3: The prevalence of LBP is more common in female employee., 4: This review outlines the need for further epidemiology studies of the general population in the KSA., Competing Interests: The authors declare they have no conflicts of interest., (© 2020 The Authors. Published by Atlantis Press International B.V.)

Objectives: As a step towards the comprehensive evaluation of movement in patients with low back pain, the aim of this study is to design a marker set (three rigid segment spine, pelvic and lower limb model) and evaluate the reliability and minimal detectable change (MDC) of this marker set in healthy adults during gait and sit to stand (STS) tasks using three dimensional motion capture., Results: The 'Imperial Spine' marker set was used to assess relative peak angles during gait and STS tasks using the minimum recommended sample size (n = 10) for reliability studies with minimum Intraclass Correlation Coefficient (ICC) of 0.70, optimum ICC 0.90 and 9 trials replicated per subject per task. Intra- and inter-tester reliability between an experienced and inexperienced user was examined. ICC, mean, standard error (SEM), Bland Altman 95% limits of agreement (LOA) and MDC were computed. ICC values demonstrated excellent intra- and inter-tester reliability in both tasks, particularly in the sagittal plane (majority ICCs > 0.80). SEM measurements were lower in gait (0.8-5.5°) than STS tasks (1°-12.6°) as were MDC values. LOA demonstrated good agreement. The 'Imperial Spine' marker set is reliable for use in healthy adults during functional tasks. Future evaluation in patients is required.

Background: Lumbar disc degeneration (LDD) is a condition associated with recurrent low back pain (LBP). Knowledge regarding effective management is limited. As a step towards the identification of risk, prognostic or potentially modifiable factors in LDD patients, the aim of this study was to explore the hypothesis that intrinsic lumbar spine shape is associated with LDD and clinical outcomes in symptomatic adults., Methods: 3 T MRI was used to acquire T2-weighted sagittal images (L1-S1) from 70 healthy controls and LDD patients (mean age 49 years, SD 11, range 31-71 years). Statistical Shape Modelling (SSM) was used to describe lumbar spine shape. SSM identified variations in lumbar shape as 'modes' of variation and quantified deviation from the mean. Intrinsic shape differences were determined between LDD groups using analysis of variance with post-hoc comparisons. The relationship between intrinsic shape and self-reported function, mental health and quality of life were also examined., Results: The first 7 modes of variation explained 91% of variance in lumbar shape. Higher LDD sum scores correlated with a larger lumbar lordosis (Mode 1 (55% variance), P = 0.02), even lumbar curve distribution (Mode 2 (12% variance), P = 0.05), larger anterior-posterior (A-P) vertebral diameter (Mode 3 (10% variance), P = 0.007) and smaller L4-S1 disc spaces (Mode 7 (2% variance), P ≤ 0.001). In the presence of recurrent LBP, LDD was associated with a larger A-P vertebral diameter (Mode 3) and a more even lumbar curvature with smaller L5/S1 disc spaces (Mode 4), which was significantly associated with patient quality of life (P = 0.002-0.04, r p  = 0.43-0.61))., Conclusions: This exploratory study provides new evidence that intrinsic shape phenotypes are associated with LDD and quality of life in patients. Longitudinal studies are required to establish the potential role of these risk or prognostic shape phenotypes.

Objectives: To determine the perspectives of amputees and rehabilitation clinicians on the effect of socket fit and issues caused by ill-fitting sockets throughout lower limb prosthetic rehabilitation., Design: A survey was developed to identify rehabilitation factors and issues for prosthesis wearers and rehabilitation clinicians. Participants opted to participate in a further telephone interview., Setting: Online and across the United Kingdom., Participants: Lower limb prosthetic wearers and clinicians who are part of a lower limb prosthetic rehabilitation team (N=94)., Interventions: Not applicable., Main Outcome Measures: A survey and an interview to measure the perceived effect of socket fit on lower limb rehabilitation., Results: Issues related to socket fit were identified as the biggest factor affecting rehabilitation by 48.0% of amputees and 65.7% of clinicians. Amputee interviewees focused on the effect of fit on quality of life and the ability to complete daily tasks, whereas clinicians focused on the lack of widespread ability to adjust the socket and gait re-education., Conclusions: Socket fit has a large effect on and is a large source of frustration to amputees and their clinical teams throughout rehabilitation. From the interviews, it became clear that the interpretation of socket fit is different for each person; thus, "socket fit" does not mean the same for all patients., (© 2020 The Authors.)

Thoracotomy is a major cause of respiratory impairment, increasing the risk of postoperative pulmonary complications (PPC). Systems assessing ribcage kinematics may detect changes in chest expansion following thoracotomy and may thus aid in the development of patient-tailored chest physiotherapy. Hence, we aimed to identify studies assessing changes in chest wall movement following thoracotomy using objective measures. The Cochrane library, MEDLINE, EMBASE, Scopus and Web of Science databases were searched to find relevant articles providing an objective assessment of chest wall movement following thoracotomy. Methodological quality of included studies concerning chest wall movement following thoracotomy was assessed by use of QUADAS-2 tool. A total of 12 articles were included for the assessment of chest wall changes following thoracotomy using objective measures. Four studies measured changes in the cross-sectional area of the ribcage and abdomen using the respiratory inductive plethysmography (RIP), 1 study computed the chest wall compliance by monitoring the intra-pleural pressure, 3 studies measured changes in chest circumference with a simple tape measure and 4 articles performed a compartmental analysis of the chest wall volume by means of an optoelectronic plethysmography (OEP). There was no delay in the collection of data of the index test and reference standard, resulting in a low risk of bias for the flow and timing domain. Across all studies, participants underwent the same reference standard, resulting in a low risk of verification bias. Several objective measures were able to detect changes in chest wall displacement following thoracotomy and differed in the practical use and invasive nature. OEP allows a compartmental analysis of the chest wall volume. Hence, this system allows to assess chest wall movement changes following thoracotomy and the impact of different types of surgical approach. Furthermore, it could aid in the development of tailored physiotherapy., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Changes in movement pattern in low back pain (LBP) groups have been analysed by reporting predefined discrete variables. However, this approach does not consider the full kinematic data waveform and its dynamic information, potentially exposing the analysis to bias. Statistical Parametric Mapping (SPM) has been introduced and applied to 1 dimensional (D) kinematic variables allowing the assessment of data over time. The aims of this study were to assess differences in 3D kinematics patterns in people with and without LBP during functional tasks by using SPM and to investigate if SPM analysis was consistent with standard 3D range of motion (RoM) assessments. 3D joints kinematics of the spine and lower limbs were compared between 20 healthy controls and 20 participants with non-specific LBP during walking, sit-to-stand and lifting. SPM analysis showed significant differences in the 3Dkinematics of the lower thoracic segment, upper and lower lumbar segment and knee joint during walking and lifting mostly observed at the beginning and/or towards the end of the tasks. ROMs differed between groups in the lower thoracic segment (walking/sit-to-stand), upper and lower lumbar segments (walking/sit-to-stand/lifting), hip and knee (sit-to-stand/lifting). Based on these results, the two approaches can yield different data interpretations. SPM analysis allows the identification of differences in movement that occur over time. This adds value to LBP movement analysis as it allows an understanding of the LBP strategies adopted during motion that may not be conveyed by simple discrete parameters such as ROMs., 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 © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)