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Objectives To determine the feasibility of a clinical trial that compares a 6-week, physiotherapist-guided gait retraining program with a foot orthoses intervention in runners with patellofemoral pain. Design Pilot randomised controlled trial. Methods Runners aged 18–40 years with clinically diagnosed patellofemoral pain were randomly allocated to either a 6-week gait retraining intervention of increasing cadence and use of a minimalist shoe or prefabricated foot orthoses. Outcomes at baseline and 12-weeks included recruitment, retention, adherence, adverse events, global improvement, anterior knee pain scale, worst and average pain on a 100 mm visual analogue scale. Results Of the 16 randomised participants, two withdrew prior to commencing treatment due to non-trial related matters (n = 1 from each group) and 14 completed the pilot trial. Minor calf muscle soreness was reported by 3 participants in the gait retraining group while no adverse events were reported in the foot orthoses group. There were no deviations from the treatment protocols. There was a large between-group difference favouring gait retraining at 12-weeks in the anterior knee pain scale and the worst pain in the past week, which was reflected in the number needed-to-treat of 2. Conclusions This study supports the feasibility of a trial comparing gait retraining with foot orthoses and provides point estimates of effect that informs the design and planning of a larger clinical trial. It appears that a 6-week gait retraining program has a clinically meaningful effect on runners with patellofemoral pain when compared to an evidence-based treatment of foot orthoses.

Summary Objective To determine if an increase in knee extensor strength mediates the effect of a 12-week knee extensor strength training program on pain and physical function improvement in people with knee osteoarthritis (OA). Design Secondary analysis from a randomised controlled trial comparing the effects of a 12-week knee extensor strengthening exercise program to a control group with no intervention. Methods Data from participants with complete data ( n = 97) enrolled in a previous clinical trial were analysed. Baseline and 12-week follow-up assessments included peak isometric knee extensor strength, pain and physical function. Peak knee extensor strength (Nm/kg) was assessed on an isokinetic dynamometer and subscales of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index were used to assess pain and physical function. Twelve-week change in pain and physical function were regressed separately, on 12-week change in knee extensor strength and group allocation. Covariates included baseline pain or physical function as appropriate, and baseline knee extensor strength, age, sex and knee alignment (stratification variable). Results Improved knee extensor strength mediated the effect of the strengthening program on both pain relief (mediated effect size = 0.69, 95% confidence intervals (CI) 0.05–1.33, P = 0.03), and improved physical function (mediated effect size = 1.86, 95% CI 0.08–3.64, P = 0.04), at 12 weeks. Conclusions Increased knee extensor strength partially mediates the effect of a knee extensor strength training program on pain and physical function improvement in people with knee OA.

To estimate the reliability and measurement error of performance-based tests of physical function recommended by the Osteoarthritis Research Society International (OARSI) in people with hip and/or knee osteoarthritis (OA).Prospective repeated measures between independent raters within a session and within-rater over a week interval. Relative reliability was estimated for 51 people with hip and/or knee OA (mean age 64.5 years, standard deviation (SD) 6.21 years; 47% females; 36 (70%) primary knee OA) on the 30s Chair Stand Test (30sCST), 40m Fast-Paced Walk Test (40mFPWT), 11-Stair Climb Test (11-step SCT), Timed Up and Go (TUG), Six-Minute Walk Test (6MWT), 10m Fast-Paced Walk Test (10mFPWT) and 20s Stair Climb Test (20sSCT) using intra-class correlation coefficients (ICC). Absolute reliability was calculated using standard error of measurement (SEM) and minimal detectable change (MDC).Measurement error was acceptable (SEM 10%) for all tests. Between-rater reliability was: optimal (ICC 0.9, lower 1-sided 95% CI 0.7) for the 40mFPWT, 6MWT and 10mFPWT; sufficient (ICC0.8, lower 1-sided 95% CI 0.7) for 30sCST, 20sSCT; unacceptable (lower 1-side 95% CI 0.7) for 11-step SCT and TUG. Within-rater reliability was optimal for 40mFPWT, and 6MWT; sufficient for 30sCST and 10mFPWT and unacceptable for 11-step SCT, TUG and 20sSCT.The 30sCST, 40mFPWT, 6MWT and 10mFPWT, demonstrated, at minimum, acceptable levels of both between and within-rater reliability and measurement error. All tests demonstrated sufficiently small measurement error indicating they are adequate for measuring change over time in individuals with knee/hip OA.

This article seeks to deepen our understanding of the nature and quality of democratic participation in educational reform by examining the first-year implementation of California’s Local Control Funding Formula (LCFF) mandating civic engagement in district decision-making. Drawing on democratic theory, empirical literature, and data from 10 districts, we find that even when district leaders committed to involving stakeholders in decision-making, achieving this vision was often constrained by power imbalances, deeply engrained institutional habits, and limited capacity. We also find that climates of trust, support from external organizations, and homogeneity appeared to provide the foundation for deeper, broader democratic engagement in a few cases. The article concludes with implications for policy, practice, and future research.

Hip osteoarthritis (OA) is often associated with pain and impaired function. Understanding biomechanical alterations in patients with hip OA during challenging activities such as stair use is important to inform treatments. The aim of this study was to determine whether kinematics and kinetics during stair ambulation differed between people with hip OA and healthy controls. Fifteen participants with symptomatic and radiographic hip OA and 15 asymptomatic healthy controls underwent 3-D motion analysis during stair ascent and descent. Trunk, pelvis, and hip kinematics as well as hip kinetics were evaluated. Analyses were performed unadjusted and adjusted for speed and leg length. In both the unadjusted and adjusted analyses, participants with hip OA ascended stairs with less hip range of motion in all three planes and a lower peak external rotation moment compared to controls. In the unadjusted analysis, hip OA participants descended stairs with greater ipsilateral trunk lean, less sagittal plane range of motion, lower peak extension moment, lower peak external rotation moment, and greater hip adduction moment impulse compared to controls. In the adjusted results, peak internal rotation moment and hip adduction moment impulse were greater in hip OA participants compared to controls. Findings show that individuals with hip OA display limited range of hip joint movement, particularly during stair ascent, and overall indicate the use of strategies (e.g., trunk lean; lower peak external rotation moment; higher adduction moment impulse) that implicate altered hip abductor function. Future research is required to further understand the implications of these findings on hip OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1505-1514, 2017.

Introduction This study aimed to evaluate associations between strength of selected hip and knee muscles and self-reported physical function, and their clinical relevance, in men and women with hip osteoarthritis (OA). Methods Cross-sectional data from 195 participants with symptomatic hip OA were used. Peak isometric torque of hip extensors, flexors, and abductors, and knee extensors were measured, along with physical function using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Separate linear regressions in men and women were used to determine the association between strength and physical function accounting for age, pain, and radiographic disease severity. Subsequently, magnitudes of strength associated with estimates of minimal clinically important improvement (MCII) in physical function were estimated according to severity of difficulty with physical function. Results For men, greater strength of the hip extensors, hip flexors and knee extensors were each associated with better physical function. For women, greater muscle strength of all tested muscles were each associated with better physical function. For men and women, increases in muscle strength between 17–32%, 133–223%, and 151–284% may be associated with estimates of MCII in physical function for those with mild, moderate, and severe physical dysfunction, respectively. Conclusion Greater isometric strength of specific hip and thigh muscle groups may be associated with better self-reported physical function in men and women. In people with mild physical dysfunction, an estimate of MCII in physical function may be associated with attainable increases in strength. However, in patients with more severe dysfunction, greater and perhaps unattainable strength increases may be associated with an estimate of MCII in physical function. Longitudinal studies are required to validate these observations.

Background:Non-pharmacological interventions are recommended as first-line treatment options in the management of fibromyalgia (FM)1. However, whether one intervention is more effective than another for specific patient-centred outcomes in FM is unknown.Objectives:To compare the relative efficacy of non-pharmacological interventions on FM impact questionnaire (FIQ), pain, fatigue, sleep and depression in people with FM.Methods:A Bayesian network meta-analysis was conducted. Randomised controlled trials (RCTs) assessing any non-pharmacological intervention versus usual care, placebo or active controls in patients with FM aged >16 years were searched for in seven databases. A common comparator was identified between interventions to develop a network (Figure 1). Standardised mean difference (SMD) and 95% credible interval (CrI) was estimated between interventions. Direct and indirect evidence were pooled using the random effect model. Modified Cochrane‘s tool was used to assess risk of bias.Figure 1.Network map of different interventions evaluating FIQResults:78 studies (n = 5,639 participants) met the inclusion criteria. There was a high risk of bias on blinding and most trials had small sample size (nWhile multidisciplinary treatment (MDT) was the best for improving pain [-1.28 (-1.84, -0.72)], sleep [-1.14 (-2.38, 0.07)] and depression [-1.20 (-1.99, -0.46)], balneotherapy and exercise were the most effective treatments for FIQ [-1.06 (1.51, -0.61)] and fatigue [-0.75 (-1.35, -0.25)], respectively (Figure 2).Figure 2.Standardised mean difference (SMD) versus usual care in descending order for different outcomesData from 47 exercise trials (n = 3,271 participants) were analysed to examine comparative efficacy of different exercise types. Strengthening showed the greatest benefits for FIQ [-0.76 (-1.39, -0.15)], pain [-0.94 (-1.58, -0.29)] and depression [-0.83 (-1.53, -0.14)], whereas aerobic exercise was the best for fatigue [-0.98 (-2.33, 0.18)] and sleep [-0.96 (-2.08, 0.13)] (Table 1).Table 1.Relative effect size between types of exercisesFIQAerobic-0.58(-1.13, -0.03)-0.09(-0.55, 0.36)0.18(-0.44, 0.80)0.12(-0.36, 0.57)-0.57(-0.95, -0.24)-0.60(-1.36, 0.18)Flexibility0.49(-0.23, 1.20)0.76(-0.07, 1.58)0.70(-0.04, 1.41)0.004(-0.67, 0.64)-0.10(-0.74, 0.53)0.49(-0.50, 1.49)Mind-body0.27(-0.37, 0.91)0.20(-0.24, 0.65)-0.49(-0.85, -0.15)0.05(-0.59, 0.70)0.65(-0.35, 1.63)0.16(-0.53, 0.85)Mixed-0.06(-0.73, 0.59)-0.69(-1.06, -0.34)0.21(-0.42, 0.84)0.80(-0.19, 1.79)0.31(-0.41, 1.02)-0.06(-0.73, 0.59)Strengthening-0.76(-1.39, -0.15)-0.73(-1.16, -0.30)-0.13(-1.02, 0.74)-0.62(-1.15, -0.11)-0.78(-1.31, -0.26)-0.94(-1.58, -0.29)Usual carePainData are standard mean difference (95% credible intervel) between exercises, pairwised from the top left to the bottom right. The negative value indicates that the first exercise is more effective than the second exercise. For example, aerobic is better than flexibility for FIQ -0.58 (-1.13, -0.13), but not pain -0.60 (-1.36, 0.18).Conclusion:Several non-pharmacological interventions are beneficial for FM. However, the effect size varies between interventions and outcomes. All types of exercises are effective for FIQ and pain apart from flexibility exercise. The results of this study may be used to guide the selection of the most effective non-pharmacological interventions according to the predominant symptom in individual patients.References:[1]Macfarlane GJ et al. Ann Rheum Dis 2017;76(2):3-8-28.Disclosure of Interests: :None declared

BACKGROUND: Arthroscopic partial meniscectomy may cause knee osteoarthritis, which may be related to altered joint loading. Previous research has failed to demonstrate that exercise can reduce medial compartment knee loads following meniscectomy but has not considered muscular loading in their estimates. RESEARCH QUESTION: What is the effect of exercise compared to no intervention on peak medial tibiofemoral joint contact force during walking using an electromyogram-driven neuromusculoskeletal model, following medial arthroscopic partial meniscectomy? METHODS: This is a secondary analysis of a randomized controlled trial (RCT). 41 participants aged between 30-50 years with medial arthroscopic partial meniscectomy within the past 3-12 months, were randomly allocated to either a 12-week, home-based, physiotherapist-guided exercise program or to no exercise (control group). Three-dimensional lower-body motion, ground reaction forces, and surface electromyograms from eight lower-limb muscles were acquired during self-selected normal- and fast-paced walking at baseline and follow-up. An electromyogram-driven neuromusculoskeletal model estimated medial compartment contact forces (body weight). Linear regression models evaluated between-group differences (mean difference (95% CI)). RESULTS: There were no significant between-group differences in the change (follow-up minus baseline) in first peak medial contact force during self-selected normal- or fast-paced walking (0.07 (-0.08 to 0.23), P = 0.34 and 0.01 (-0.19 to 0.22), P = 0.89 respectively). No significant between-group difference was found for change in second peak medial contact force during normal- or fast-paced walking (0.09 (-0.09 to 0.28), P = 0.31 and 0.02 (-0.17 to 0.22), P = 0.81 respectively). At the individual level, variability was observed for changes in first (range -26.2% to +31.7%) and second (range -46.5% to +59.9%) peak tibiofemoral contact force. SIGNIFICANCE: This is the first study to apply electromyogram-driven neuromusculoskeletal modelling to an exercise intervention in a RCT. While our results suggest that a 12-week exercise program does not alter peak medial knee loads after meniscectomy, within-participant variability suggests individual-specific muscle activation patterns that warrant further investigation.

Background Dynamic postural control during everyday tasks is poorly understood in people following anterior cruciate ligament reconstruction (ACLR). Understanding dynamic postural control can provide insight into potentially modifiable impairments in people following ACLR who are at increased risk for second ACL injury and/or knee osteoarthritis. Research question Determine whether measures indicative of dynamic postural control differ between individuals with and without ACLR during stair ascent and descent. Methods: Seventeen individuals with ACLR (>1 yr post-surgery) and 16 age and sex-matched healthy controls participated. Centre of pressure (COP) measures included: i) COP excursion, ii) COP velocity, and iii) dynamic time-toboundary (TTB). Mixed linear models were used to compare COP measures for the ACLR leg, non-ACLR leg, and healthy controls during stair ascent and stair descent. Results There were no statistically significant differences observed during stair ascent (all p > 0.05). Several statistical differences were found during stair descent for individual with ACLR, but not between those with ACLR and healthy controls. The ACLR leg had higher medial-lateral COP excursion (mean difference 1.06 cm, [95 %CI 0.08–2.06 cm], p = 0.036; effect size = 0.38) compared to the non-ACLR leg during stair descent. In addition, the ACLR leg had a lower medial-lateral TTB (mean difference −13 ms [95 %CI −38 to 2 ms], p = 0.005; effect size = 0.49) and medial-lateral TTB normalized to stance time (mean difference −5.8 % [95 %CI −10.3 to 1.3 %], p = 0.012; effect size = 0.80) compared to the non-ACLR leg during stair descent. No statistical differences were observed for anterior-posterior measures during stair descent (all p > 0.05). Significance: Taken together, findings indicate that there are small to large differences in medial-lateral postural control in the ACLR leg compared to the non-ACLR leg during stair descent. Further work is required to understand clinical implication of these novel observations.

Objective A systematic review and meta-analysis of controlled trials was carried out to examine the effect of behavioural counselling on determinants of behaviour change in adults with chronic, painful musculoskeletal conditions. Methods Seven databases were searched up to January 2019. Two reviewers independently screened title/abstracts and full texts. Eligible trials included those including participants over 18 years of age with a chronic, painful musculoskeletal condition, a measurement of at least one behavioural determinant and lifestyle behaviour, and where behavioural counselling was the distinguishing intervention. Two reviewers independently extracted data and assessed for risk of bias using the Cochrane Risk of Bias Tool. Meta-analyses were conducted, using standardized mean differences and 95% confidence intervals (CIs) when at least two trials examined the same outcome. The quality of the evidence was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation approach. Results Fourteen unique trials, reported in 16 publications, were included. Low-quality evidence showed that behavioural counselling has a small effect on increasing self-reported physical activity (standardized mean difference 0.26; 95% CI 0.00, 0.53). Very-low-quality evidence showed that behavioural counselling has a moderate effect on self-efficacy related to physical activity (standardized mean difference 0.69; 95% CI 0.19, 1.18). Low-quality evidence suggested that behavioural counselling has no effect on symptoms of depression and anxiety. Conclusions Behavioural counselling may help to increase self-reported physical activity levels in adults with chronic painful musculoskeletal conditions. Self-efficacy may be a behavioural determinant in an underlying causal pathway explaining positive lifestyle change.

The hip joint can often be affected by extra- and intra-articular pathologies including gluteal tendinopathy, femoroacetabular impingement syndrome and hip osteoarthritis. Understanding alterations associated with these pathologies will provide greater insight into developing and optimising patient-specific treatments. A number of biomechanical and neuromuscular impairment are associated with Femoracetabular impingement (FAI), gluteal tendinopathy (GT) and hip osteoarthritis (OA) conditions including but not limited to muscle weakness, altered postural control, restricted range of motion and altered tendon/joint loading. These alterations can present differently in sub-groups of patients and result directly from the pathological process and/or indirectly from pain and its consequences (e.g. reduced activity). These impairments are often targets for conservative interventions but there is currently little clinical trial evidence to show that treatments can modify these impairments. Clinical trial evidence does, however, support conservative treatment options for each of the pathologies reviewed. Clinical outcome tools used to evaluate the effects of treatment and track change over time are recommended.

Our primary objective was to examine external hip joint moments during walking in people with mild radiographic hip osteoarthritis (OA) with and without symptoms and disease-free controls. Three groups were compared (symptomatic with mild radiographic hip OA, n = 12; asymptomatic with mild radiographic hip OA, n = 13; OA-free controls, n = 20). Measures of the external moment (peak and impulse) in the sagittal, frontal and transverse plane during walking were determined. Variables were compared according to group allocation using mixed linear regression models that included individual gait trials, with group allocation as fixed effect and walking speed as a random effect. Participants with evidence of radiographic disease irrespective of symptoms walked 14-16% slower compared to disease-free controls (p = 0.002). Radiographic disease without symptoms was not associated with any altered measures of hip joint moment compared to asymptomatic OA-free controls once speed was taken into account (p ≥ 0.099). People with both mild radiographic disease and symptoms had lower external peak hip adduction moment (p = 0.005) and lower external peak internal rotation moment (p

BACKGROUND: Guidelines recommend exercise as a core treatment for osteoarthritis (OA). However, it is unclear which type of exercise is most effective, leading to inconsistency between different recommendations.OBJECTIVES: The aim of this systematic review and network meta-analysis was to investigate the relative efficacy of different exercises (aerobic, mind-body, strengthening, flexibility/skill, or mixed) for improving pain, function, performance and quality of life (QoL) for knee and hip OA at, or nearest to, 8 weeks.METHODS: We searched nine electronic databases up until December 2017 for randomised controlled trials that compared exercise with usual care or with another exercise type. Bayesian network meta-analysis was used to estimate the relative effect size (ES) and corresponding 95% credibility interval (CrI) (PROSPERO registration: CRD42016033865).FINDINGS: We identified and analysed 103 trials (9134 participants). Aerobic exercise was most beneficial for pain (ES 1.11; 95% CrI 0.69, 1.54) and performance (1.05; 0.63, 1.48). Mind-body exercise, which had pain benefit equivalent to that of aerobic exercise (1.11; 0.63, 1.59), was the best for function (0.81; 0.27, 1.36). Strengthening and flexibility/skill exercises improved multiple outcomes at a moderate level. Mixed exercise was the least effective for all outcomes and had significantly less pain relief than aerobic and mind-body exercises. The trend was significant for pain (p = 0.01), but not for function (p = 0.07), performance (p = 0.06) or QoL (p = 0.65).CONCLUSION: The effect of exercise varies according to the type of exercise and target outcome. Aerobic or mind-body exercise may be the best for pain and function improvements. Strengthening and flexibility/skill exercises may be used for multiple outcomes. Mixed exercise is the least effective and the reason for this merits further investigation.

Summary Objective To establish “normal” ranges for synovial thickness and effusion detected by ultrasound (US) and to determine cut-offs associated with knee pain (KP) and radiographic knee osteoarthritis (RKOA) in the community. Methods 147 women and 152 men ≥40 years old were randomly selected from the Nottingham KP and Related Health in the Community (KPIC) cohort (n = 9506). The “normal” range was established using the percentile method in 163 participants who had no KP and no RKOA. Optimal (maximum sensitivity and specificity) and high specificity (90%) cut-offs were established using receiver operating characteristic (ROC) curve analysis in a comparison between people with both KP and RKOA and normal controls. Results Effusion and synovial hypertrophy differed by gender but not by age or laterality, therefore gender-specific reference limits were estimated. However, the “normal” ranges between men and women were similar for effusion (0–10.3 mm vs 0–9.8 mm), but different for synovial hypertrophy (0–6.8 mm vs 0–5.4 mm). Power Doppler Signal (PDS) in the healthy controls was uncommon (1.2% in men and 0.0% in women). The optimal cut-off was 7.4 mm for men and 5.3 mm for women for effusion, and 3.7 and 1.6 for hypertrophy respectively. The high specificity cut-off was 8.9 for men and 7.8 for women for effusion, and 5.8 and 4.2 for hypertrophy respectively. Conclusions US effusion and synovial hypertrophy but not PDS are common, but differ by gender, in community-derived people without painful knee OA. Currently used cut-offs for abnormality need reappraisal.

Background:Placebo or contextual effect is an integral part of the treatment effect (1). The factors related to this effect are “contextual factors” (CFs) (2). CFs may be categorised into five groups as factors related to practitioner, patient, practitioner-patient interaction, treatment and therapeutic environment (3). Several CFs have demonstrated their therapeutic effect, whereas others not (4). The majority of musculoskeletal pain relief result from CFs (5). Identifying the key CFs may encourage health practitioners to optimize the contextual aspects of care.Objectives:To identify the modifiable CFs that can improve clinical outcomes in published randomised controlled trials (RCTs).Methods:A systematic search was carried out, up until April 18th 2019, on the following databases: MEDLINE via Ovid, EMBASE, AMED, PsycINFO and Cochrane library. RCTs comparing contextual enhanced interventions versus non-enhanced control in adults for any health conditions were searched. The outcomes included both self-reported outcomes and objectively measured outcomes. The effect size and 95%confidence interval were calculated using the standard mean difference. Risk of bias was evaluated using the modified Cochrane tool. The random effects model was used to pool the results.Results:Of 3900 records generated from the systematic search, 15 trials (4615 participants) met the inclusion criteria, and 13 were included in this meta-analysis (Figure 1). Conditions studied included musculoskeletal [4], cardiovascular [2], irritable bowel syndrome [1], diabetes [1], asthma [1], GP or hospital patients [6]. Three CFs have been identified from these trials, including empathy, patient involvement and positive communication. All were found to be effective for patient experience i.e. satisfaction. Positive communication was also effective for symptoms but not objective outcomes (Table 1).Table 1.Summary of results.OutcomeInterventionNumber of studies (Number of participants) SMD (95% CI)I2Patient experience outcomes,e.g. satisfactionEmpathy2 (137)0.45 (0.11, 0.79)42.2 %Patient involvement4 (1596)0.31 (0.21, 0.41)93.0 %Positive communication3 (793)0.38 (0.24, 0.52)93.9 %Symptomatic outcomes,e.g. painEmpathy1 (221)-0.18 (-0.45, 0.08)0.0 %Patient involvement1 (314)-0.05 (-0.27, 0.17)0.0 %Positive communication3 (658)0.20 (0.05, 0.35)64.8 %Objective outcomes,e.g. peak expiratory flowPositive communication2 (266)0.10 (-0.14, 0.34)66.6 %Positive SMD favours intervention group. SMD= Standard mean difference, CI= Confidence interval, I2= heterogeneity.Figure 1.Summary of screening process.Conclusion:This systematic review has identified three CFs (empathy, patient involvement and positive communication) that have therapeutic effects for different conditions in trials, especially for self-reported outcomes. More research is needed to examine the clinical outcomes of CFs and to understand the influence of health practitioners on disease processes.References:[1]Zou K, Wong J, Abdullah N, Chen X, Smith T, Doherty M et al. Examination of overall treatment effect and the proportion attributable to contextual effect in osteoarthritis: meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases. 2016;75(11):1964-1970.[2]Miller F, Kaptchuk T. The power of context: reconceptualizing the placebo effect. Journal of the Royal Society of Medicine. 2008;101(5):222-225.[3]Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. The Lancet. 2001;357(9258):757-762.[4]Howick J, Moscrop A, Mebius A, R Fanshawe T, Lewith G, L Bishop F et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. Journal of the Royal Society of Medicine. 2018;111(7):240–252.[5]Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskeletal Disorders. 2018;19(1).Disclosure of Interests:None declared.

Summary Objective To investigate relationships between external knee adduction moment parameters (KAM) and osteoarthritis (OA) symptoms according to disease severity. Design 164 participants with symptomatic medial knee OA were included. Radiographic severity was graded by (1) Kellgren & Lawrence (KL) scale (Grade 2, n = 49; Grade, n = 52; Grade 4, n = 63) and; (2) medial tibiofemoral joint space narrowing (JSN) (Grade 1, n = 47; Grade 2, n = 50; Grade 3, n = 67). KAM-related parameters (peak KAM, KAM impulse and cumulative load) were determined from three-dimensional gait analysis and pedometry. Cumulative load was determined by multiplying KAM impulse by the average number of steps/day recorded over at least 5 days. Symptoms were assessed via numeric rating scale ((NRS), pain) and Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (pain and physical function). Relationships between KAM parameters (independent variables) and symptoms (dependent variables) were evaluated by radiographic severity using linear models, adjusting for covariates. Results In mild disease (either KL Grade 2 or JSN Grade 1), there were no associations between KAM and symptoms. In moderate disease of KL Grade 3, higher KAM impulse was associated with greater WOMAC pain. In severe disease (KL Grade 4), higher KAM impulse was associated with less WOMAC pain (KL Grade 4), while higher peak KAM was associated with better function (KL Grade 4). Higher cumulative knee adduction load was associated with less pain on both NRS and WOMAC (JSN Grade 3) as well as better function (both JSN Grade 3 and KL Grade 4). Conclusions Relationships between KAM-related parameters and symptoms differ according to underlying radiographic OA severity.

Background:Osteoarthritis (OA) is a leading cause of disability worldwide. Currently, exercise is recognised to be one of the core treatments for OA (NICE, 2014). Convincing evidence shows that exercise can have positive effects on pain and function in people with OA (Fransen et al., 2015). However, a standardised exercise regimen may not suit all patients and adherence to exercise is always an issue. Therefore, several international guidelines recommended individualisation of the exercise regimen according to individual patient characteristics (e.g. pain severity, personal goals and co-morbidities), as this may enhance take up and adherence, hence treatment effect of the intervention (Fernandes et al., 2013).Objectives:The aims of this systematic review were: (1) to evaluate the current evidence for efficacy in randomised controlled trials (RCTs) of individualised exercise (IE) interventions for people with hip or knee OA; and (2) compare this to the efficacy of non-individualised exercise (NIE).Methods:A systematic search was carried out, up until March 6th2018, on the following databases: MEDLINE, CINAHL, AMED, PsycINFO and EMBASE. RCTs of IE interventions, or with subgroup analysis based on specific patient characteristics, were searched. Standardised mean difference and 95% confidence interval (CI) were calculated using random effects model. Risk of bias was evaluated using the modified Cochrane tool. Pain was the primary outcome of interest. Results of IE interventions were then compared to the NIE interventions identified from a previous systematic review (Goh et al., 2019).Results:We reviewed titles of 1,766 records in the systematic search. The screening process (Figure) identified 15 studies (1,826 participants) that met the inclusion criteria, of which 7 were included in a meta-analysis. Most included studies had high risk of bias. Blinding was a consistent problem due to the nature of the intervention. Within the trials exercise was individualised according to factors including severity of symptoms, exercise performance, lower limb muscle strength and presence of co-morbidities (e.g. heart failure, chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) type 2).The analysis showed that IE significantly improved pain, physical function, performance and quality of life outcomes (Table). When compared to NIE interventions, IE showed greater effect size for all outcomes but their 95% CIs were overlapping.Figure showing Summary of screening processTable 1.Summary of resultsOutcomeType of exercise programES95% CINumber of studies (Number of patients)PainIE1.040.32 - 1.777 (991)NIE0.570.44 - 0.6965 (4,723)FunctionIE1.370.50 - 2.247 (991)NIE0.510.38 - 0.6463 (4,829)PerformanceIE2.000.07 - 3.932 (291)NIE0.51038 - 0.6366 (4,889)QoLIE1.30-0.52 - 3.122 (226)NIE0.320.15 - 0.4934 (2,545)ES= Effect size. CI= Confidence Interval. IE= Individualised Exercise. NIE= Non-Individualised Exercise. QoL= Quality of LifeConclusion:The results of this review show that IE may have better outcomes on people with hip or knee OA compared to NIE. However, the small study effect may inflate the estimates of the individualised exercise group, and further head to head comparisons are required.References:[1] FERNANDES L., HAGEN K. B., BIJLSMA J. W., ANDREASSEN O., CHRISTENSEN P., CONAGHAN P. G., DOHERTY M., GEENEN R., HAMMOND A. & KJEKEN I. 2013. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.Annals of the rheumatic diseases,72, 1125-1135.[2] FRANSEN M., MCCONNELL S., HARMER A. R., VAN DER ESCH M., SIMIC M. & BENNELL K. L. 2015. Exercise for osteoarthritis of the knee.The Cochrane Library.[3] GOH S.-L., PERSSON M. S., STOCKS J., HOU Y., WELTON N. J., LIN J., HALL M. C., DOHERTY M. & ZHANG, W. 2019. Relative efficacy of different exercises for pain, function, performance and quality of life in knee and hip osteoarthritis: Systematic review and network meta-analysis.Sports Medicine,49, 743-761.[4] NICE 2014. Osteoarthritis: care and management in adults.https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#non-pharmacological-management-2[Accessed 02/12 2019]Disclosure of Interests:Khalid Yaseen: None declared, Burak Kundakci: None declared, Siew Li Goh: None declared, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Weiya Zhang Consultant of: Grunenthal for advice on gout management, Speakers bureau: Bioiberica as an invited speaker for EULAR 2016 satellite symposium, Abhishek Abhishek Grant/research support from: AstraZeneca and OxfordImmunotech, Speakers bureau: Menarini pharmaceuticals, Michelle Hall: None declared

Background:The role of nurses in managing painful knee OA has been advocated but whether nurses can deliver such interventions as a package of care is unknown.The overall aim of this research is to develop and test a nurse-led complex intervention for knee pain comprising non-pharmacological and pharmacological components. In the first study phase, we report on fidelity and acceptability of a non-pharmacological intervention, to resolve possible challenges to delivery.Objectives:To evaluate fidelity of delivery and acceptability of non-pharmacological components of a complex intervention.Methods:This was a mixed-methods study. Participants with chronic knee pain were recruited from the community to receive the intervention, delivered in 4-sessions over a 5-week period by a trained research nurse. The intervention consisted of holistic assessment, patient education and advice, aerobic and strengthening exercise and weight-loss advice if required. All sessions were video-recorded. Fidelity checklists were completed by the nurse (nurse-rated) and two researchers from the video-recordings (video-rated). Median fidelity scores (%) and interquartile ranges (IQR) were calculated for each component and each session. Semi-structured interviews were conducted with participants. These were audio recorded, transcribed and analysed following the framework approach.Results:18 participants (34% women), with a mean (SD) age and BMI of 68.7 (9.0) years and 31.2 (8.4) kg/m2, took part in the study. Of these, 14 completed all visits. In total, 62 intervention sessions were assessed for fidelity. Overall fidelity was rated high by both nurse-rated scores (97.7%) and video-rated scores (84.2%). The level of agreement between nurse-rated and video-recorded methods was 73.3% (CI 71.3, 75.3) and the inter-rater agreement was 65.5% (CI 60.3, 70.5). Fidelity of delivery was lower for advice on footwear modification and walking aids in all sessions and moderate for education in session 1 and for exercise in session 4 (Table 1).Table 1.Fidelity scores of the components of the intervention for each session,Intervention componentsSession 1*Session 2*Session 3*Session 4*Education78.1 (74.1, 93.7)87.5 (50, 100)87.5 (50, 100)100 (93.7, 100)Exercise94.4 (88.9, 100)88.9 (75, 94)86.1 (72, 100)75 (67.6, 82.8)Adjunctive treatments50 (45.83, 100)0 (0, 50)50 (0, 100)-*median (IQR)17 participants were interviewed. Most found advice supplied straightforward. They were satisfied with the package, which changed their perception of managing knee pain, understanding it can be improved though self-management. However, too much information was provided in a short time-span and it was difficult to fit exercises into their daily routine.Conclusion:Delivery of a non-pharmacological intevention by a nurse is feasible within a research setting. Most components of the intervention were delivered as intended, except for advice about the use of adjunctive treatment.Acknowledgments:This research was funded by the NIHR Nottingham BRC and Pain Centre Versus ArthritisDisclosure of Interests:Polykarpos Angelos Nomikos: None declared, Amy Fuller: None declared, Michelle Hall: None declared, Bonnie Millar: None declared, Reuben Ogollah: None declared, Michael Doherty: None declared, Roshan Nair Speakers bureau: Financial support from pharmaceutical companies (Biogen and Novartis) to present lectures at events related to psychological support for people with multiple sclerosis (Speaker’s bureau)., David Walsh Grant/research support from: 2016: Investigator-led grant from Pfizer Ltd (ICRP) on Pain Phenotypes in RA; non-personal financial disclosure (payment to University)., Consultant of: DAW has undertaken paid consultancy to Pfizer Ltd, Eli Lilly and Company and GSK Consumer Healthcare., Paid instructor for: 2019: Consultancy to Love Productions; consultancy on programme design, contribution to programme content on self-management of chronic pain (payments to University)2019: Consultancy to AbbVie Ltd; 13.06.19; presentation on RA pain at EULAR, Madrid, and webinar (payments to University).2019: Consultancy to Eli Lilly and Company Ltd. 06.06.19 Centre for Collaborative Neuroscience, Windlesham, Surrey, UK (payment to University).2019: Consultancy to Pfizer (payment to University).2018: Consultancy to Pfizer. 07.12.18. USA. 1 day. Tanezumab (payment to University).2018: Consultancy to Pfizer. 23.11.18. Manchester UK. 1 day. Tanezumab (payment to University).2018: Consultancy to Pfizer. 1.11.18. Skype. 4h. Tanezumab (payment to University).2018: Consultancy to GlaxoSmithKline Plc. 1 day. Pain in RA and anti-GM-CSF (payment to University).2018: Consultancy to Pfizer Ltd; Presentation at OARSI; non-personal financial disclosure (payment to University)2018: Consultancy to Pfizer Ltd; Patient preference study; non-personal financial disclosure (payment to University)2017: Consultancy to Pfizer Ltd; personal financial disclosure2017: Consultancy to Pfizer Ltd through Nottingham University; non-personal financial disclosure (payment to University).2015: Consultancy to GSK Consumer Healthcare; personal financial disclosure., Speakers bureau: 2019: Irish Society of Rheumatology: speaker fees (personal pecuniary), Ana Valdes Grant/research support from: Awarded a grant from Pfizer, Abhishek Abhishek: None declared

This study examined whether differences exist in tibial acceleration transients and electromyography (EMG) variables during running across female pubertal development. Sixty-four girls classified as pre- (n = 19), early/mid- (n = 22) and late/post-pubertal development (n = 23) ran in a laboratory whilst EMG data were recorded from quadriceps, hamstring and calf muscle groups, and acceleration transients from a triaxial accelerometer. The late/post-pubertal girls exhibited delayed vastus lateralis onset (mean difference (MD) = 0.02, 95% CI = 0.008, 0.34 ms)) compared to pre-pubertal girls, lower vastus lateralis pre-activation (MD = 7.02, 95% CI = 12.63, 1.42%) compared to early/mid-pubertal girls, and longer time to peak (TTP) anterior/posterior (A/P) tibial acceleration compared to pre-pubertal girls (MD = 0.02, 95% CI = 0.006, 0.03 s). By contrast, late/post-pubertal girls demonstrated earlier semitendinosus onset compared to both early/mid- (MD = 0.02, 95% CI = 0.03, 0.005 ms) and pre-pubertal girls (MD = 0.02, 95% CI = 0.04, 0.007 ms). No other between-group differences were found for peak A/P, vertical and TTP vertical tibial acceleration (p > 0.05). Subsequently, regression analysis revealed that EMG variables accounted for approximately 34% (R2 = 0.34) of the variance in TTP A/P tibial acceleration. These findings highlight that neuromuscular recruitment patterns and kinetics differ across female pubertal development while running and should be further explored in the context of adolescent female musculoskeletal injuries.

iv CHAPTER 1: GENERAL INTRODUCTION INTRODUCTION 1 CHAPTER 2: REVIEW OF LITERATURE 1.1 Incidence and Prevalence of Knee Osteoarthritis following ACL Rupture 5 1.2 Functional Anatomy 1.2.1 The ACL 7 1.2.2 Articular Cartilage 9 1.3 Injury to the ACL 10 1.4 Gait Analysis 12 1.5 Neuromuscular Adaptations following ACL injury leading to Knee Osteoarthritis 1.5.1 Quadriceps Weakness 13 1.5.2 Frontal Plane Mechanics at the Knee 17 1.5.3 Frontal Plane Mechanics at the Hip 19 REFERENCES 21 CHAPTER 3: GAIT ANALYSIS POST ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: KNEE OSTEOARTHRITIS PERSPECTIVE ABSTRACT 26 INTRODUCTION 27 METHODS 29 RESULTS 32 DISCUSSION 33 REFERENCES 40 CHAPTER 4: NEUROMUSCULAR CONTROL DURING GAIT POST ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Walking canes are a self-management strategy recommended for people with knee osteoarthritis (OA) by clinical practice guidelines. Ensuring that an adequate amount of body-weight support (%BWS) is taken through the walking cane is important as this reduces measures of knee joint loading.1) How much body weight support do people with knee OA place through a cane? 2) Do measures of body weight support increase following a brief simple training session?Seventeen individuals with knee pain who had not used a walking cane before were recruited. A standard-grip aluminum cane was then used for 1 week with limited manufacturer instructions. Following this, participants were evaluated using an instrumented force-measuring cane to assess body weight support (% total body weight) through the cane. Force data were recorded during a 430-metre walk undertaken twice; once before 10 min of cane training administered by a physiotherapist, and once immediately after training. Measures of BWS (peak force, average force, impulse equal to the average cane force times duration, and cane-ground contact duration) were extracted. Using bathroom scales, training aimed to take at least 10% body weight support through the cane.Before training, the average peak BWS was 7.2 ± 2.5% of total body weight. Following 10 min of training, there was a significant increase in average peak BWS by 28%, average BWS by 25%, and BWS impulse by 54% (p 0.05). However, individual BWS responses to training were variable. Duration of cane placement increased by 22% after training (p = 0.02). Timing of peak BWS through the cane occurred at 51% of contact phase before training, and at 53% after training (p = 0.05).A short training session can increase the transfer of body weight through a walking cane. However, more sophisticated feedback may be needed to achieve target levels of BWS.

Background Valgus knee braces have been reported to reduce the external knee adduction moment during walking. However, mechanistic investigations into the effects of valgus bracing on medial compartment contact forces using electromyogram-driven neuromusculoskeletal models are limited. Research question What are the immediate effects of valgus bracing on medial tibiofemoral contact forces and muscular loading of the tibiofemoral joint? Methods Sixteen (9 male) healthy adults (27.7 ± 4.4 years) performed 20 over-ground walking trials at self-selected speed both with and without an Ossur Unloader One® brace. Assessment order (i.e., with or without brace) was randomised and counterbalanced to prevent order effects. While walking, three-dimensional lower-body motion, ground reaction forces, and surface electromyograms from eight lower-limb muscles were acquired. These data were used to calibrate an electromyogram-driven neuromusculoskeletal model of muscle and tibiofemoral contact forces (N), from which muscle and external load contributions (%) to those contact forces were determined. Results Although walking with the brace resulted in no significant changes in peak tibiofemoral contact forces at the group-level, individual responses were variable and non-uniform. At the group-level, wearing the brace resulted in a 2.35% (95% CI 0.46-4.24; p = 0.02) greater relative contribution of muscle to lateral compartment contact loading (54.2 ± 11.1%) compared to not wearing the brace (51.8 ± 12.1%) (p

Background All osteoarthritis (OA) guidelines recommend exercise as one of the core treatments for OA.1 However, it is unclear whether one exercise is better than another and for which outcome. Due to the limited evidence that compare different types of exercise, we undertook this network meta-analysis (NMA). Objectives To determine the relative efficacy of different exercises for pain and self-reported function at (or nearest to) eight weeks. Methods Nine electronic databases were searched for eligible randomised controlled trials (RCTs) that compared any types of exercise. The search was first performed in December 2015 and was updated in December 2017. Studies comparing exercise with usual care or with another exercise were included for this NMA. Common comparators such as usual care were used to network different types of exercise. Frequentist NMA was used to estimate the relative effect size (ES), i.e. standard mean difference and its 95% confidence interval (CI).2 Results 217 RCTs (n=20419) met the inclusion criteria. Of these, 89 trials (n=7070; 97 comparisons) were analysed for pain outcome (figure 1), whilst 87 trials (n=7039; 97 comparisons) were analysed for function. Mind-body exercise was the most effective for pain relief, closely followed by aerobic exercise (See the last column, table 1). While mind-body remained the best for improving function, strength and flexibility/skills exercise were better than aerobic exercise (See the last row, table 1). Single exercises were consistently better than mixed exercise. Table 1 Effect size (95% confidence interval) between different exercises Pain outcomes Functional outcomes Note Exercises are in order from the top left to the bottom right. Pain outcomes are at the top and functional outcomes are at the bottom. Numbers in each cell represent effect size (95% confidence interval) between higher comparator versus lower comparator. Aerobic: walking, cycling; FlexSkills: flexibility exercise, neuromotor training, proprioceptive training; Strength: resistance training; Mind-body: Tai-chi, Yoga; Mixed Ex: multi-component exercises Conclusions This exercise hierarchy and their relative efficacy provide a useful basis for patients and clinicians to select the most appropriate exercise whilst taking treatment goals (pain relief or functional improvement) and patient preference into consideration. The reason for the relative poor efficacy of mixed exercise warrants investigation as it contradicts current guidelines. References [1] Fernandes L, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the Rheumatic Diseases2013;72(7):1125–1135. [2] Caldwell DM. An overview of conducting systematic reviews with network meta-analysis. Systematic Reviews2014;3(109):1–4. Disclosure of Interest None declared

Background: Knee pain results from a combination of nociceptive input from the joint, and processing by the central nervous system. Pressure pain detection thresholds (PPTs) are lower and pain is more severe in people with greater central sensitisation. Objective: We hypothesised that lower PPTs predicted worse pain prognosis in people with knee pain. Methods: KPIC participants were people aged >40 years recruited from Nottingham, UK. Participants were mailed questionnaires at baseline and 1 year. This study reports a sample of responders who attended baseline and 1 year clinical assessment, had self-reported knee pain (within the last 4 weeks) and underwent PPT. PPTs were measured at the knee, anterior tibia and the sternum. Radiographic knee OA was classified using an atlas. Questionnaires measured ICOAP (constant and intermittent knee pain), painDETECT (neuropathic-like) and average knee pain severity over 4 weeks (0-10). The presence of pain at baseline and 1 year (persistent pain), or pain severity were predicted from baseline anterior tibia PPT. Additional analyses adjusted for baseline pain score, age, sex, BMI, or for radiographic knee OA. Pain persistence (Yes/No) was analysed using t tests, odds ratios (OR) and logistic regression. Pain severity was analysed using linear regression. Results: The sample for this study contained n=419 people at baseline, and n=182 people reported knee pain persistent over both time points. The mean (SD) values were age 61 (9) years, BMI 30.1 (5.8) kg m-2, 59% female, and 36% fulfilled radiographic OA criteria at the index knee, for those with persistent knee pain at 1 year. In univariate analysis, persistent knee pain was associated with a lower PPT at baseline (461 vs 424 kPa; OR (95% CI) 0.58 (0.34-0.97) p=0.020). Adjustments for age, sex and BMI removed the significance from the association (adjusted OR (95% CI) 0.64 (0.36-1.13) p=0.120). In those with persistent pain, worse 1 year ICOAP-constant, ICOAP-intermittent, painDETECT and knee pain severity were correlated with lower baseline anterior tibia PPT ( r= -0.28 to -0.24; p

BACKGROUND: Hip osteoarthritis (OA) is a significant cause of disability, with hip pain and reduced external hip moments during walking being key features of the condition. The external hip adduction moment is greater in healthy women than men, however these between-sex differences are not evident in those with end-stage hip OA. Whether sex-specific hip kinetics are associated with early-midstage hip OA has not been investigated and may be a potential target for directed treatment. METHODS: Thirty-eight women and twenty-eight men with a diagnosis of symptomatic, unilateral, mild-to-moderate hip OA (Kellegren-Lawrence Grade 2 or 3) underwent three-dimensional gait analysis of normal walking gait using Vicon motion capture. Hip joint, trunk and pelvic angles and hip moments were calculated using the Plug-in-Gait model. The external peak flexion moment, and the first peak, second peak and mid-stance minimum of the hip adduction moment during the stance phase of walking as well as hip, trunk and pelvic kinematics occurring at the three moment time points were compared between groups using an analysis of covariance. RESULTS: Women with hip OA exhibited a greater external hip adduction moment (mean difference 0.8-1.3 N m/BW.Ht(%), P

Background Knee osteoarthritis is common in people who have undergone partial meniscectomy, and a higher external knee flexion moment during gait may be a potential contributor. Although the peak external knee flexion moment has been shown to increase from 3 months to 2 years following partial meniscectomy, mechanisms underpinning the increase in the peak knee flexion moment are unknown. Methods Sixty-six participants with partial meniscectomy completed three-dimensional gait (normal and fast pace) and quadriceps strength assessment at baseline (3 months following partial meniscectomy) and again 2 years later. Variables included external knee flexion moment, vertical ground reaction force, knee flexion kinematics, and quadriceps peak torque. Findings For normal pace walking, the main significant predictors of change in peak knee flexion moment were an increase in peak vertical ground reaction force (R2 = 0.55), mostly due to an increase in walking speed, and increase in peak knee flexion angle (R2 = 0.19). For fast pace walking, the main significant predictors of change in peak knee flexion moment were an in increase in peak vertical ground reaction force (R2 = 0.51) and increase in knee flexion angle at initial contact (R2 = 0.17). Change in peak vertical force was mostly due to an increase in walking speed. Interpretation Findings suggest that increases in vertical ground reaction force and peak knee flexion angle during stance are predominant contributors to the 2-year change in peak knee flexion moment. Future studies are necessary to refine our understanding of joint loading and its determinants following meniscectomy.

As the growth of online education offered by universities accelerates and spreads, universities are increasingly grappling with concerns related to widespread availability and the maintenance of academic quality. The Quality Matters at Southeastern Program fosters quality through a peer review process and offers a certification process to help assure quality in the Universitys online and blended course offerings. This report is a look at perceived impacts of the internal certification process by faculty.

A new, citizen science based, aurora observing and reporting platform has been developed with the primary aim of collecting auroral observations made by the general public to further improve the modeling of the aurora. In addition, the real-time ability of this platform facilitates the combination of citizen science observations with auroral oval models to improve auroral visibility nowcasting. Aurorasaurus provides easily understandable aurora information, basic gamification, and real-time location-based notification of verified aurora activity to engage citizen scientists. The Aurorasaurus project is one of only a handful of space weather citizen science projects and can provide useful results for the space weather and citizen science communities. Early results are promising with over 2,000 registered users submitting over 1,000 aurora observations and verifying over 1,700 aurora sightings posted on Twitter.

Objective People with meniscal tears are at high risk to develop or progress to knee osteoarthritis. Knee extensor weakness is considered a risk factor for osteoarthritis and is often reported in these individuals. The purpose of this systematic review and meta-analysis was to investigate knee extensor strength in people undergoing an arthroscopic partial meniscectomy (APM). Methods Six databases (Medline, CINAHL, SPORTDiscus, Embase, PEDro, and AMED) were searched up to June 22, 2014. Studies that measured knee extensor muscle strength in people age ≥30 years undergoing APM for a meniscal tear and used either a healthy control group or the contralateral leg to compare knee extensor muscle strength were included. Methodological quality was assessed using guidelines from the Centre for Reviews and Dissemination. Results Eleven studies, in which participants were predominantly male, were included (n = 596). A moderate reduction in muscle strength was observed prior to APM compared to controls (standardized mean difference [SMD] 0.58, 95% confidence interval [95% CI] 0.04, 1.13) and continued up to 6 months postsurgery (SMD range −2.42 to −0.47). There was no difference in muscle strength at 2 years post-APM (SMD −0.01 [95% CI −0.36, 0.35]), while a moderate reduction was again apparent at 4 years post-APM (SMD −0.56, [95% CI −1.20, 0.08]) compared to controls. Conclusion Our findings suggest that middle-aged and older individuals undergoing APM have reduced knee extensor muscle strength in the operated leg compared to control data. As meniscus pathology and knee extensor muscle weakness are risk factors for osteoarthritis, these results highlight the clinical importance of addressing muscle weakness in these individuals.

AB Purpose: This study aimed to evaluate the effects of a 12-wk, home-based, physiotherapist-guided neuromuscular exercise program on the knee adduction moment (an indicator of mediolateral knee load distribution) in people with a medial arthroscopic partial meniscectomy (APM) within the past 3-12 months. Methods: An assessor-blinded, randomized controlled trial including people age 30-50 yr with no to mild pain after medial APM was conducted. Participants were randomly allocated to either a 12-wk neuromuscular exercise program that targeted neutral lower limb alignment or a control group with no exercise. The exercise program included eight individual sessions with one of seven physiotherapists in private clinics, together with home exercises. Primary outcomes were the peak external knee adduction moment during normal-paced walking and during one-leg sit-to-stand. Secondary outcomes included additional measures of knee joint load distribution, patient-reported outcomes, maximal knee and hip muscle strength, and physical function measures. Results: Of 62 randomized participants, 60 (97%) completed the trial. There were no significant between-group differences in the change in peak knee adduction moment during normal-paced walking (mean difference (95% confidence interval), 0.22 (-0.11 to 0.55) N[middle dot]m/body weight x height %, P =0.19) or during one-leg sit-to-stand (-0.01 (-0.33 to 0.31) N[middle dot]m/body weight x height %, P = 0.95). There were also no significant between-group differences for any of the secondary outcomes. Conclusions: In patients 3-12 months after a medial APM, a neuromuscular exercise program did not alter the peak knee adduction moment, a key predictor of osteoarthritis structural disease progression. (Australia and New Zealand Clinical Trials Registry, #ACTRN12612000542897.)

Research on sustainability programs within universities consistently emphasizes that sustainability requires a combination of factors so as to move beyond the significant-but-often-limited activities such as recycling and energy saving to achieve systemic implementation. This study applied Brennan and Binney’s 9Ps Framework for Organizational Sustainability to investigate sustainability practices of member universities of ACTS (Australian Campuses Towards Sustainability). A questionnaire based on qualitative research obtained data from 25 of the 27 member universities. Data analysis including descriptive statistics, ANOVA, correlation analysis, and gap analysis was used to determine the relationships between “importance” and “performance” of the behaviors under investigation.Over the 9Ps, 27 items were used to identify important aspects of environmental sustainability. The same items were assessed for whether or not these actions were being performed in the university. It was generally found that while ma...

The purpose of this paper is to describe how a series of one-shot or single class library instruction webinars were created for on-campus and distance education students at Virginia Tech, a land grant institution in rural southwestern Virginia. Virginia Tech's distance learning department on campus trained in Centra 7.6 software and the lead librarian collaborated with peer librarians to offer a wide range of instructional sessions. In this study, interviews were conducted one-on-one with five webinar participants at Virginia Tech. Interviews were digitally audio-taped and transcribed. These interviews were used to gain feedback and information regarding the library-based webinars. Results were organized into thematic codes using NVivo 10 software. Results showed strong interest in the library webinars, especially in the playback or archiving features and interactivity.

Background Most adults fail to meet global physical activity guidelines set out by the World Health Organization. In recent years, behavioural economic principles have been used to design novel interventions that increase physical activity. Immediate financial rewards, for instance, can motivate an individual to change physical activity behaviour by lowering the opportunity costs of exercise. This systematic review will summarise the evidence about the effectiveness of financial incentive interventions for improving physical activity in adults. Methods We will search MEDLINE, Embase, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, PsycINFO, EconLit, SPORTDiscus, the National Health Service Economic Evaluation Database, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform from inception using a comprehensive, electronic search strategy. The search strategy will include terms related to ‘financial incentive’ and ‘physical activity’. Only randomised controlled trials that investigate the effect of financial incentives on physical activity in adult populations and that are written in the English language will be included. Two review authors will independently screen abstracts and titles, complete full text reviews and extract data on objective and self-reported physical activity outcomes. The authors will also assess the study quality using the Cochrane risk of bias tool and provide a systematic presentation and synthesis of the included studies’ characteristics and results. If more than two studies are sufficiently similar in population, settings and interventions, we will pool the data to conduct a meta-analysis. If we are unable to perform a meta-analysis, we will conduct a narrative synthesis of the results and produce forest plots for individual studies. Our subgroup analyses will examine the differential effects of an intervention in healthy populations compared to populations with disease pathology and compare the effects of interventions using financial rewards to interventions using financial penalties. Discussion This systematic review will determine the effectiveness of positive and negative financial incentives on physical activity in adults. Findings will help inform the development of public health interventions and research in this field. Systematic review registration PROSPERO 2017:CRD42017068263 Electronic supplementary material The online version of this article (10.1186/s13643-018-0687-8) contains supplementary material, which is available to authorized users.

Background:\ud Femoroacetabular impingement syndrome (FAI), a hip disorder affecting active young adults, is believed to be a leading cause of hip osteoarthritis (OA). Current management approaches for FAI include arthroscopic hip surgery and physiotherapy-led non-surgical care; however, there is a paucity of clinical trial evidence comparing these approaches. In particular, it is unknown whether these management approaches modify the future risk of developing hip OA. The primary objective of this randomised controlled trial is to determine if participants with FAI who undergo hip arthroscopy have greater improvements in hip cartilage health, as demonstrated by changes in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to those who undergo physiotherapy-led non-surgical management.\ud \ud Methods:\ud This is a pragmatic, multi-centre, two-arm superiority randomised controlled trial comparing hip arthroscopy to physiotherapy-led management for FAI. A total of 140 participants with FAI will be recruited from the clinics of participating orthopaedic surgeons, and randomly allocated to receive either surgery or physiotherapy-led non-surgical care. The surgical intervention involves arthroscopic FAI surgery from one of eight orthopaedic surgeons specialising in this field, located in three different Australian cities. The physiotherapy-led non-surgical management is an individualised physiotherapy program, named Personalised Hip Therapy (PHT), developed by a panel to represent the best non-operative care for FAI. It entails at least six individual physiotherapy sessions over 12 weeks, and up to ten sessions over six months, provided by experienced musculoskeletal physiotherapists trained to deliver the PHT program. The primary outcome measure is the change in dGEMRIC score of a ROI containing both acetabular and femoral head cartilages at the chondrolabral transitional zone of the mid-sagittal plane between baseline and 12 months. Secondary outcomes include patient-reported outcomes and several structural and biomechanical measures relevant to the pathogenesis of FAI and development of hip OA. Interventions will be compared by intention-to-treat analysis.\ud \ud Discussion:\ud The findings will help determine whether hip arthroscopy or an individualised physiotherapy program is superior for the management of FAI, including for the prevention of hip OA.\ud \ud Trial registration:\ud Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015 (retrospectively registered).