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Objectives Globally, 20–25% of people will experience chronic pain in their lifetimes. Dance is a physical activity with psychosocial benefits that might positively impact pain. This review aimed to investigate the effect of dance interventions on the experience of pain by quantitative measures and qualitative themes. Methods Seven major databases were searched from inception to January 2021. Two independent reviewers screened articles at each stage. Qualitative and quantitative studies were included if the dance interventions lasted more than 6 weeks, participants reported pain of duration longer than 3 months, and pain was an outcome of the study. All articles were critically appraised with appropriate Joanna Briggs Institute tools, and data were collated through the use of results-based convergent synthesis. Results From 23,628 articles, 34 full papers were included, with a total of 1,254 participants (75.2% female). Studies predominantly investigated individuals with fibromyalgia (26%) and generalized chronic pain (14%), with aerobic dance (20.7%) and Biodanza (20.7%) being the most common dance genres investigated. Overall, 74% of studies noted either reduced pain through quantitative pain measures or qualitative themes of improved pain experience (88% for chronic primary pain and 80% for chronic secondary musculoskeletal pain). Discussion There were positive effects of dance on chronic primary and secondary musculoskeletal pain across diverse populations. A variety of study designs and interventions noted improved pain measures and themes around pain coping and acceptance, with all dance therapies showing improvements, particularly when performed for 60–150 minutes’ duration weekly. Dance should be considered as an effective adjunct in the management of chronic pain.

BackgroundPersistent pain impacts 30% of people worldwide. Evidence on the effectiveness of visual arts in treating persistent pain seems to be emerging. Thus, the aim of this systematic review was to investigate the impact of visual arts on patients with persistent pain.MethodsStudies were identified by searching seven databases from perception until Jan-2019, then screened by two independent reviewers. Studies were included if they were published controlled trials investigating the impact of visual arts on participants with persistent pain. Studies were excluded if they were abstracts, sampled participants who could not express pain, did not report relevant outcome measures, or did not have a comparator group. The study qualities were assessed by the PEDro scale.ResultsAfter removing duplicates, 2,732 titles and abstracts were screened. Of 125 full-texts, four satisfied the eligibility criteria; all published within the last decade. Three of four controlled studies were randomised-controlled trials. Studies were conducted in inpatient settings (n=2) and outpatient clinics (n=2). Three studies included elderly participants (>60y/o), while one included patients with HIV (>18y/o). Visual arts interventions included painting, drawing, crafting, and others. Two studies utilised visual arts as the sole treatment, while two studies used visual arts as part of a multimodal treatment. Comparators received usual care in two studies, a music intervention in one, and an art-therapy video in another. The common outcome measure in all studies was pain level (0-to-10 scale). All studies also included psychosocial outcome measures. Quality of studies ranged from grade four to eight on PEDro scale; two had “high” quality, and two had “fair” quality. All studies reported statistically significant improvements in pain within intervention groups.ConclusionsVisual arts seem to benefit patients with persistent pain. Further investigation on the clinical significance of these positive findings on pain and other biopsychosocial factors are required.

Introduction Persistent pain significantly impacts daily living. Visual arts interventions can have positive outcomes, but little is known about benefits for people with persistent pain. This study aimed to explore participant experiences of utilising visual art in expressing and managing their persistent pain experience through a visual diary. Method As part of a small exploratory study nested in a larger project, participants with a history of persistent pain were recruited from a local pain management clinic. Six participants with persistent pain attended five weekly intervention sessions involving art observation, creation and discussion, at the Art Gallery of NSW. Participants explored their ideas about their pain experience through artmaking using visual and written data from self-reported pain diaries. Thematic analysis was used. Results Analysis of five diaries was conducted. Visual and written expressions of the pain experience varied. Colour was used by participants to represent ideas and emotions. Capital letters were used to convey tone, or emphasis. Three main themes emerged from the written and visual data: ‘The lived experience of pain’, ‘The powerful drive for growth beyond change itself’ and ‘Personal values and perceptions guiding daily living and decision-making’. Conclusion This study provides insights into the potential benefits of using visual arts to help manage persistent pain experiences and improve health outcomes.

Aim: To report the experience of chronic pain participants after a well-formulated ketogenic diet (WFKD) or whole-food diet (WFD). The quantitative outcomes for this trial have been published separately (clinical trial registration number ACTRN12620000946910). Patients & methods: The experience of 24 participants was evaluated after 12 and 24 weeks of dietary intervention using survey responses and open questions. Results & conclusion: Retention rates for the WFKD and WFD groups were 93 and 89%, respectively. Average adherence to the WFKD was 82% and to the WFD was 87%. The WFKD enjoyment was rated at 66 and 81% for the WFD group. The ease of adhering to the diet varied more widely for the WFKD group. Barriers included knowledge integration, time management, navigating social food environments and emotional attachment to eliminated foods. Facilitators included structured support and coaching, and comprehensive learning materials. The WFKD was shown to be a feasible and effective treatment option for chronic pain.

Purpose To investigate the dosages of swallowing exercises reported in intervention studies on post-stroke dysphagia through systematic review. Methods Five electronic databases were searched from inception until February 2022 with reference tracing of included studies. Studies were included, where adults with post-stroke dysphagia received rehabilitative, behavioural swallowing exercises, pre/post outcomes were reported, and intervention dosage was described in detail, including frequency, intensity, time, and type of exercise. Two reviewers independently screened studies and rated quality using ASHA Levels of Evidence tool. Data was tabulated and narratively described. Results 54 studies were included with a total 1501 participants. Studies included 28 randomised controlled trials, 8 non-randomised controlled trials, 12 pre/post studies, 3 retrospective case controls and 3 case studies. Results showed inconsistent reporting of intervention dosage, with intensity the least consistently reported dosage component. While swallowing intervention was most commonly provided five times per week for four weeks, there was a wide breadth of type, frequency, intensity and duration of swallowing exercises reported. Dosage under-reporting and variation was particularly observed in “standard care” co-interventions or control groups. Study strengths included following PRISMA guidelines, providing a comprehensive review of swallowing exercise methodology and dosages, and including non-English studies. The limitation was lack of meta-analysis due to the heterogeneity of included studies. Conclusions Dosages of swallowing exercises are inconsistently reported and vary significantly in post-stroke dysphagia studies. Results indicate the need for consistent and comprehensive dosage reporting in dysphagia studies, and for further research into evidence-based principles to optimise swallowing exercise dosages. Systematic review registration number 131294

Dietary restriction of carbohydrate has been demonstrated to be beneficial for nervous system dysfunction in animal models and may be beneficial for human chronic pain. The purpose of this review is to assess the impact of a low-carbohydrate/ketogenic diet on the adult nervous system function and inflammatory biomarkers to inform nutritional research for chronic pain. An electronic database search was carried out in May 2021. Publications were screened for prospective research with dietary carbohydrate intake n = 394, sport/performance n = 51, cancer n = 33, general n = 30, neurological with non-neuro outcomes n = 12, or gastrointestinal n = 4). The second screen identified sixty-three studies reporting on inflammatory biomarkers, with 71% reporting a reduction in inflammation. The overall results suggest a favourable outcome on the nervous system and inflammatory biomarkers from a reduction in dietary carbohydrates. Both nervous system sensitisation and inflammation occur in chronic pain, and the results from this review indicate it may be improved by low-carbohydrate nutritional therapy. More clinical trials within this population are required to build on the few human trials that have been done.

Aim: To explore the reported diet of Australians with chronic pain and their perceived role of food within their pain experience. Methods: A cross-sectional study of 50 participants reporting chronic pain was undertaken using pain and nutritional questionnaires as well as anthropometric measures. Results: Participants rated their diet between ‘good’ and ‘excellent' (76%) and one that promoted well-being (62%), however 74% were overweight or obese (average BMI 30) with multiple co-morbidities. There was no correlation between measures of dietary adherence and knowledge with reported pain. Conclusion: Participants generally reported their diets to be good, however, this was not reflected in their habitual diet. There was a low perceived role of food altering pain perception.

Introduction: The present study aimed to investigate the immediate effects of two types of Kinesio taping on the temporal and spatial variables of gait initiation in individuals with and without Functional Ankle Instability (FAI). Materials and Methods: Thirty semi-professional athletes (15 with and 15 without FAI [control]) were recruited for this study. The gait initiation task was examined before and after the two types of Kinesio taping on a force plate. Temporal (Reaction Phase [RP], Anticipatory Postural Adjustment Phase [APAP]), and spatial variables were recorded and compared between Groups, before and after the tape application. Results: The results of multiple repeated-measure analyses of variance showed no significant differences for “factor” and “Group by factor” interaction effects for any outcome measure (P>0.05). There were no significant differences for Group effects except for the APAP (F=10.27, P=0.003). The APAA was 71.95 ms longer in the FAI Group (476.95±15.87 ms) compared to the control Group (405.04±15.87 ms). Conclusion: Kinesio taping application does not influence any of the gait initiation parameters on the force plate. Participants with FAI demonstrated longer APAP which might be due to recurrent injury and instability during sports or physical activity.

Purpose Lateral ankle sprains are one of the most prevalent musculoskeletal injuries, with one of the highest recurrence rates. One in five people develops chronic ankle instability (CAI) after a lateral ankle sprain. CAI is mainly described as a subjective phenomenon, but is associated with recurrent symptoms, reduced dynamic stability, and reduced physical activity and quality of life. Understanding the relationship between perception of stability and effect on performance for people with CAI could inform rehabilitative strategies in clinical practice. This study aimed to investigate the relationship between the perception of stability and objective performance of dynamic stability this population. Methods This study is a sub-analysis of data from four separate studies in Australia and the United Kingdom. Participants were screened and categorised as a CAI, coper, or healthy participant. Each participant completed the Star Excursion Balance Test (SEBT) and Cumberland ankle instability tool (CAIT). Distances reached in the anterior, posterior-medial, and posterior-lateral directions, and average, of the SEBT were analysed. Results Data from 95 participants with CAI, 45 copers, and 101 healthy participants was analysed. There was a significant moderate correlation between CAIT score and SEBT reach distance in all directions for the CAI group (p p Conclusion This study highlights the discrepancies between the perception of stability and objective dynamic stability, and reinforces the importance of using both types of measures for continual assessment in practice to optimise selecting rehabilitative strategies.

This study investigated how swallowing exercise dosage is recorded, and what swallowing exercise dosages are reported in a stroke rehabilitation setting. We additionally explored the relation between mean daily swallowing repetitions and likelihood of improvement in functional swallowing status and considered how swallowing exercise dosages in practice compared to evidence-based principles of neural plasticity and strength training. We audited medical records for 42 patients with post-stroke dysphagia admitted to an inpatient rehabilitation unit over 18 months. Data were collected on participant characteristics, swallowing exercises and dosages, and clinical outcomes. The relation between dosage and outcomes was investigated using logistic regression analysis. On average, patients were seen for a median of 2.4 swallowing intervention sessions per week (IQR: 1.7) over 21 days (IQR: 16) and received a median 44.5 swallowing exercise repetitions per session (IQR: 39.6). Results indicated variable reporting of swallowing exercise dosages. Frequency, intervention duration, exercise type, and number of repetitions were routinely recorded in medical records, while intensity, session length, content, and adherence to home exercise programs were not. Frequency of swallowing intervention was lower in practice compared to research studies, and swallowing exercises did not follow specificity or progressive resistance principles. Likelihood of improvement in swallowing status was partially explained by age (B = -.015, p = .007) but not by mean daily swallowing exercise repetitions. This study illustrates dosages of swallowing exercises used in clinical practice. Results highlight the need for improved consideration and reporting of dosage, and application of evidence-based principles to swallowing exercise dosages.

Background A low-carbohydrate ketogenic diet has been reported to improve chronic pain by reducing inflammation, oxidative stress, and sensitivity within the nervous system. The main aim of this trial is to evaluate the effects of a ketogenic diet on reported pain, blood biomarkers and quality of life in patients with chronic pain. Methods Participants with chronic musculoskeletal pain were recruited for a 12-week diet intervention that commenced with a 3-week run-in diet removing ultra-processed foods, followed by randomization to either a whole-food/well-formulated ketogenic diet (WFKD) or to continue with the minimally processed whole-food diet (WFD). Outcome measures included: average pain (visual analogue scale VAS), blood biomarkers, anthropometrics, adherence, depression, anxiety, sleep, ketones, quality of life, diet satisfaction, and macronutrient intake. Results Average weekly pain improved for both groups. WFKD group VAS reduced by 17.9 ± 5.2 mm (P = .004) and the WFD group VAS reduced 11.0 ± 9.0 mm (P = .006). Both groups also reported improved quality of life (WFKD = 11.5 ± 2.8%, P = .001 and WFD = 11.0 ± 3.5%, P = .014). The WFKD group also demonstrated significant improvements in pain interference (P = 0.013), weight (P Conclusions The implementation of a whole-food diet that restricts ultra-processed foods is a valid pain management tool; however, a low-carbohydrate ketogenic diets may have potentially greater pain reduction, weight loss and mood improvements.

Objectives:Ketogenic diets have reported efficacy for neurological dysfunctions; however, there are limited published human clinical trials elucidating the mechanisms by which nutritional ketosis produces therapeutic effects. The purpose of this present study was to investigate animal models that report variations in nervous system function by changing from a standard animal diet to a ketogenic diet, synthesise these into broad themes, and compare these with mechanisms reported as targets in pain neuroscience to inform human chronic pain trials.Methods:An electronic search of seven databases was conducted in July 2020. Two independent reviewers screened studies for eligibility, and descriptive outcomes relating to nervous system function were extracted for a thematic analysis, then synthesised into broad themes.Results:In total, 170 studies from eighteen different disease models were identified and grouped into fourteen broad themes: alterations in cellular energetics and metabolism, biochemical, cortical excitability, epigenetic regulation, mitochondrial function, neuroinflammation, neuroplasticity, neuroprotection, neurotransmitter function, nociception, redox balance, signalling pathways, synaptic transmission and vascular supply.Discussion:The mechanisms presented centred around the reduction of inflammation and oxidative stress as well as a reduction in nervous system excitability. Given the multiple potential mechanisms presented, it is likely that many of these are involved synergistically and undergo adaptive processes within the human body, and controlled animal models that limit the investigation to a particular pathway in isolation may reach differing conclusions. Attention is required when translating this information to human chronic pain populations owing to the limitations outlined from the animal research.

Background Lower limb muscle cramps are common and painful. They can limit exercise participation, and reduce quality of sleep, and quality of life. Many interventions are available for lower limb cramps; some are controversial or could cause harm, and often, people experience no benefit from the interventions used. This is an update of a Cochrane Review first published in 2012. We updated the review to incorporate new evidence. Objectives To assess the effects of non-drug, non-invasive therapies for lower limb muscle cramps. Search methods In August 2018 and May 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of included studies. We imposed no restrictions by language or publication date. Selection criteria We included all randomised controlled trials (RCTs) of non-drug, non-invasive interventions tested over at least four weeks, for lower limb muscle cramps in any group of people, except pregnant women. The primary outcome was cramp frequency. Secondary outcomes were cramp pain severity, cramp duration, health-related quality of life, quality of sleep, participation in activities of daily living, proportion of participants reporting lower limb muscle cramps, and adverse events. Data collection and analysis Two review authors independently selected trials, assessed risk of bias, and cross-checked data extraction and analyses according to standard Cochrane procedures. Main results We included three trials, with 201 participants, all 50 years of age and older; none had neurological disease. All trials evaluated a form of stretching for lower limb muscle cramps. A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps (measured on a 10 cm visual analogue scale (VAS) where 0 = no pain and 10 cm = worst pain imaginable) in people aged 55 years and older, compared to no intervention (mean difference (MD) -1.30, 95% confidence interval (CI) -1.74 to -0.86; 1 RCT, 80 participants; low-certainty evidence). The certainty of evidence was very low for cramp frequency (change in number of cramps per night from week zero to week six) comparing the stretching group and the no intervention group (MD -1.2, 95% CI -1.8 to -0.6; 80 participants; very low-certainty evidence). Calf stretching alone for 12 weeks may make little to no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older (stretching group median number of cramps in the last four weeks (Md) 4, interquartile range (IQR) 8; N = 48; sham stretching group Md 3, IQR 7.63; N = 46) (U = 973.5, z = -0.995, P = 0.32, r = 0.10; 1 RCT, 94 participants; low-certainty evidence). This trial did not report cramp severity. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome (N = 24). It was not possible to fully analyse the frequency data and the scale used to measure cramp severity is not validated. No study reported health-related quality of life, quality of sleep, or participation in activities of daily living. No participant in these three studies reported adverse events. The evidence for adverse events was of moderate certainty as the studies were too small to detect uncommon events. In two of the three studies, outcomes were at risk of recall bias, and tools used to measure outcomes were not validated. Due to limitations in study designs that led to risks of bias, and imprecise findings with wide CIs, we cannot be certain that findings of future studies will be similar to those presented in this review. Authors' conclusions A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps in people aged 55 years and older, but the effect on cramp frequency is uncertain. Calf stretching alone compared to sham stretching for 12 weeks may make little or no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome. Overall, use of unvalidated outcome measures and inconsistent diagnostic criteria make it difficult to compare the studies and apply findings to clinical practice. Given the prevalence and impact of lower limb muscle cramps, there is a pressing need to carefully evaluate many of the commonly recommended and emerging non-drug therapies in well-designed RCTs across all types of lower limb muscle cramps. A specific cramp outcome tool should be developed and validated for use in future research.

Background The standard Western diet is high in processed hyperpalatable foods that displace nutrient-dense whole foods, leading to inflammation and oxidative stress. There is limited research on how these adverse metabolic drivers may be associated with maladaptive neuroplasticity seen in chronic pain and whether this could be attenuated by a targeted nutritional approach. The aim of this study was to review the evidence for whole-food dietary interventions in chronic pain management. Method A structured search of eight databases was performed up to December 2019. Two independent reviewers screened studies and evaluated risk of bias by using the National Institutes of Health assessment tool for controlled or pre–post studies and the Joanna Briggs checklist for case reports. A meta-analysis was performed in Review Manager. Results Forty-three studies reporting on 48 chronic pain groups receiving a whole-food dietary intervention were identified. These included elimination protocols (n = 11), vegetarian/vegan diets (n = 11), single-food changes (n = 11), calorie/macronutrient restriction (n = 8), an omega-3 focus (n = 5), and Mediterranean diets (n = 2). A visual analog scale was the most commonly reported pain outcome measure, with 17 groups reporting a clinically objective improvement (a two-point or 33% reduction on the visual analog scale). Twenty-seven studies reported significant improvement on secondary metabolic measures. Twenty-five groups were included in a meta-analysis that showed a significant finding for the effect of diet on pain reduction when grouped by diet type or chronic pain type. Conclusion There is an overall positive effect of whole-food diets on pain, with no single diet standing out in effectiveness. This suggests that commonalities among approaches (e.g., diet quality, nutrient density, weight loss) may all be involved in modulating pain physiology. Further research linking how diet can modulate physiology related to pain (such as inflammation, oxidative stress, and nervous system excitability) is required.

Introduction A ketogenic diet has been shown to influence the nervous system and can potentially improve maladaptive changes occurring with chronic pain, specifically neuroinflammation and nervous system sensitisation. However, there is limited research on whether altering a standard western diet high in ultra-processed foods to a well-formulated ketogenic diet (WFKD) may reduce chronic pain. The aim of this clinical trial is to evaluate the effects of a WFKD on patients with chronic pain. Methods This is a 12-week pilot randomised clinical trial of adults with chronic musculoskeletal pain. All participants will commence with a 3-week run in whole-foods diet removing ultra-processed foods. At week 4 they will be randomised to either continue the whole food diet or start a WFKD (carbohydrate intake Conclusion This trial will evaluate the effects of a whole-food well formulated ketogenic diet on chronic pain perception. It attempts to address the commonalties between reported dietary approaches (diet quality and nutrient density) by using a comparator of equal food quality to allow the clinical evaluation of the ketogenic diet specifically on pain mechanisms. It will further the research on how a ketogenic diet may modulate physiology linked to chronic pain mechanisms such as metabolic dysregulation and inflammation.

Objective:To generate a reference dataset of commonly performed functional outcome measures in 1,000 children and adults and investigate the influence of demographic, anthropometric, strength, and flexibility characteristics.Methods:Twelve functional outcome measures were collected from 1,000 healthy individuals aged 3–101 years: 6-minute walk test, 30-second chair stand test, timed stairs test, long jump, vertical jump, choice stepping reaction time, balance (Star Excursion Balance Test, tandem stance eyes open and closed, single-leg stance eyes closed), and dexterity (9-hole peg test, Functional Dexterity Test). Correlation and multiple regression analyses were performed to identify factors independently associated with each measure.Results:Age- and sex-stratified reference values for functional outcome measures were generated. Functional performance increased through childhood and adolescence, plateaued during adulthood, and declined in older adulthood. While balance did not differ between the sexes, male participants generally performed better at gross motor tasks while female participants performed better at dexterous tasks. Height was the most consistent correlate of functional performance in children, while lower limb muscle strength was a major determinant in adolescents and adults. In older adults, age, lower limb strength, and joint flexibility explained up to 63% of the variance in functional measures.Conclusions:These normative reference values provide a framework to accurately track functional decline associated with neuromuscular disorders and assist development and validation of responsive outcome measures for therapeutic trials.

Objectives To provide reference data for the Cumberland Ankle Instability Tool (CAIT) and to investigate the prevalence and correlates of perceived ankle instability in a large healthy population. Design Cross-sectional observational study. Setting University laboratory. Participants Self-reported healthy individuals (N=900; age range, 8–101y, stratified by age and sex) from the 1000 Norms Project. Interventions Not applicable. Main Outcome Measures Participants completed the CAIT (age range, 18–101y) or CAIT-Youth (age range, 8–17y). Sociodemographic factors, anthropometric measures, hypermobility, foot alignment, toes strength, lower limb alignment, and ankle strength and range of motion were analyzed. Results Of the 900 individuals aged 8 to 101 years, 203 (23%) had bilateral and 73 (8%) had unilateral perceived ankle instability. The odds of bilateral ankle instability were 2.6 (95% confidence interval [CI], 1.7–3.8; P P =.001) for each year of increasing age, increased by 3% (95% CI, 0%–6%; P =.041) for each degree of ankle dorsiflexion tightness, and increased by 4% (95% CI, 2%–6%, P Conclusions Perceived ankle instability was common, with almost a quarter of the sample reporting bilateral instability. Female sex, younger age, increased abdominal adiposity, and decreased ankle dorsiflexion range of motion were independently associated with perceived ankle instability.

ObjectiveTo identify the prevalence of pain in people with chronic ankle instability (CAI) and how pain is related to the impairments of CAI.Data SourcesWe searched the databases of AMED, CINAHL, EMBASE, MEDLINE, PubMed, Scopus, SPORTDiscus, and Web of Science from inception to March 2017.Study SelectionEligible studies were peer-reviewed research in which investigators reported the presence of ankle pain or assessed the effects of pain on impairments in participants with CAI. Age and language were not restricted. Studies that included only surgical interventions were excluded.Data ExtractionStudies identified by the search strategy were screened according to the eligibility criteria, and 2 independent reviewers extracted the data. Outcome measurements were (1) pain ratings using measures such as a visual analog scale and (2) other residual impairments, such as feelings of weakness, giving way, or deficits in functional performance.Data SynthesisOf the 5907 records identified through the database search, 14 studies were included in this review. All authors assessed ankle pain by self-report questionnaires or physical examination, or both. Pain was self-reported by 23% to 79% of participants and present on physical examination in 25% to 75% of participants, depending on the test applied. Among these studies, the highest reported pain level was 4.9 on the 11-point visual analog scale. Studies were heterogeneous for pain measures, participant groups, interventions, and follow-up periods. The relationship between pain and the structural and functional impairments associated with CAI was not investigated in the included studies.ConclusionsPain was present in a large proportion of people who had CAI, but pain levels were low. Information about the effects of pain was not reported, so researchers should examine the association between pain and function, balance, or other activities in people with CAI.

Background Clinical decision-making regarding diagnosis and management largely depends on comparison with healthy or ‘normal' values. Physiotherapists and researchers therefore need access to robust patient-centred outcome measures and appropriate reference values. However there is a lack of high-quality reference data for many clinical measures. The aim of the 1000 Norms Project is to generate a freely accessible database of musculoskeletal and neurological reference values representative of the healthy population across the lifespan. Methods/design In 2012 the 1000 Norms Project Consortium defined the concept of ‘normal', established a sampling strategy and selected measures based on clinical significance, psychometric properties and the need for reference data. Musculoskeletal and neurological items tapping the constructs of dexterity, balance, ambulation, joint range of motion, strength and power, endurance and motor planning will be collected in this cross-sectional study. Standardised questionnaires will evaluate quality of life, physical activity, and musculoskeletal health. Saliva DNA will be analysed for the ACTN3 genotype (‘gene for speed'). A volunteer cohort of 1000 participants aged 3 to 100 years will be recruited according to a set of self-reported health criteria. Descriptive statistics will be generated, creating tables of mean values and standard deviations stratified for age and gender. Quantile regression equations will be used to generate age charts and age-specific centile values. Discussion This project will be a powerful resource to assist physiotherapists and clinicians across all areas of healthcare to diagnose pathology, track disease progression and evaluate treatment response. This reference dataset will also contribute to the development of robust patient-centred clinical trial outcome measures.

The first step to identifying factors that increase the risk of recurrent ankle sprains is to identify impairments after a first sprain and compare performance with individuals who have never sustained a sprain. Few researchers have restricted recruitment to a homogeneous group of patients with first sprains, thereby introducing the potential for confounding.Context:To identify impairments that differ in participants with a recent index lateral ankle sprain versus participants with no history of ankle sprain.Objective:Cross-sectional study.Design:We recruited a sample of convenience from May 2010 to April 2013 that included 70 volunteers (age = 27.4 ± 8.3 years, height = 168.7 ± 9.5 cm, mass = 65.0 ± 12.5 kg) serving as controls and 30 volunteers (age = 31.1 ± 13.3 years, height = 168.3 ± 9.1 cm, mass = 67.3 ± 13.7 kg) with index ankle sprains.Patients or Other Participants:We collected demographic and physical performance variables, including ankle-joint range of motion, balance (time to balance after perturbation, Star Excursion Balance Test, foot lifts during single-legged stance, demi-pointe balance test), proprioception, motor planning, inversion-eversion peak power, and timed stair tests. Discriminant analysis was conducted to determine the relationship between explanatory variables and sprain status. Sequential discriminant analysis was performed to identify the most relevant variables that explained the greatest variance.Main Outcome Measure(s):The average time since the sprain was 3.5 ± 1.5 months. The model, including all variables, correctly predicted a sprain status of 77% (n = 23) of the sprain group and 80% (n = 56) of the control group and explained 40% of the variance between groups ( = 42.16, P = .03). Backward stepwise discriminant analysis revealed associations between sprain status and only 2 tests: Star Excursion Balance Test in the anterior direction and foot lifts during single-legged stance ( = 15.2, P = .001). These 2 tests explained 15% of the between-groups variance and correctly predicted group membership of 63% (n = 19) of the sprain group and 69% (n = 48) of the control group.Results:Balance impairments were associated with a recent first ankle sprain, but proprioception, motor control, power, and function were not.Conclusions

Study Design Retrospective cohort study. Objectives To identify prevalence and characteristics of pain in people with chronic ankle instability (CAI) and determine if there is an association between presence of pain and age and gender. Background Up to 74% of people with a history of ankle sprain develop CAI. One common residual impairment is reported to be pain, however; it has not been included in models or inclusion criteria for CAI. Methods and Measures Retrospective data from 1147 participants with CAI (age mean=26.6±10.7, range 10–86 years, 59% female) were collected from previous studies that used the Cumberland Ankle Instability Tool (CAIT) as an assessment tool. Pain was assessed from item 1 of the CAIT which asks participants about pain in their ankles. Responses were divided in to three categories: people who reported constant pain, people who had pain during physical activities and people who reported no pain. Presence of pain was analysed with descriptive statistics and correlation between pain category and gender or age (10–20, 21–30, 31–40,>40 years) was by Chi- Square tests. Results Of 1147 participants, 60.1% (n=689) reported ankle pain. Of these, 12.4% (n=142) reported constant pain, 47.7% (n=547) pain during physical activities and 39.9% (n=458) no pain. The proportion of constant pain was higher in participants over the age of forty than the other groups (p Conclusions The prevalence of pain in people with CAI is high and does not differ between genders. There is large gap in current knowledge about the impact of pain in people with CAI which needs further investigation.

Study Design Cross-sectional study. Objectives This study aimed to investigate whether measures of balance correlate with measures of ankle proprioception — ankle joint position sense and movement detection sense. Background It is suggested that balance impairments following ankle sprains are the result of damage to the joint mechanoreceptors, which in turn, disrupts ankle proprioception. Evidence regarding the presence of balance and proprioceptive deficits in various groups of participants with a history of ankle sprain has been inconsistent; proprioception has been regarded as a significant factor in balance outcomes and the two are often used interchangeably in the literature. No study has investigated the correlation between the commonly used measures of balance and proprioception at the ankle joint. Methods and Measures The study was a secondary analysis of existing data from two cross-sectional studies (n=80, female=54%, age (average ±standard deviation (SD)=31±10.4). Three measures of balance (star excursion balance test (%reach), response to perturbation (sec), and foot lifts during single-leg stance (no)) were correlated with two measures of proprioception (inversion/eversion movement detection sense and joint position sense (deg)). Correlations between each balance and proprioception test were calculated. The normal distribution of data was tested using Kolmogorove-Smirnova. For the normally distributed data, Pearson’s correlation coefficient was used and for the data without normal distribution, Spearman’s rank correlation coefficient was used. Results There was no significant positive correlation (p>0.05) between any of the balance and proprioceptive measures. There was only a weak negative correlation between the movement detection sense test and number of foot lifts during single-leg stance (r=−0.30, p=0.008). Conclusion This study found only one weak correlation between common measures of balance and ankle joint proprioception. This suggests that there is a need to re-evaluate our current understanding of the relationship between ankle sensorimotor assessments and rehabilitation.

Objective To explore and identify the predictors of ankle sprain after an index (first) lateral ankle sprain. Design Prospective cohort study, Level of evidence II. Setting Musculoskeletal research laboratory at the University of Sydney. Participants A sample of convenience (70 controls, 30 with an index sprain) was recruited. Methods Potential predictors of ankle sprain were measured including: demographic measures, perceived ankle instability, ankle joint ligamentous laxity, passive range of ankle motion, balance, proprioception, motor planning and control, and inversion/eversion peak power. Participants were followed up monthly and the number of ankle sprains was recorded over 12 months. Results Ninety-six participants completed the study; 10 participants sustained an ankle sprain. A combination of 10 predictors including: a recent index sprain, younger age, greater height and weight, perceived instability, increased laxity, impaired balance, and greater inversion/eversion peak power explained 27 to 56% of the variance in occurrence of ankle sprain (χ211,95 = 30.67, p = 0.001). The regression model correctly classified 90% of cases. The strongest independent predictors were history of an index sprain (odds ratio (OR) = 8.23, 95% confidence interval (CI) = 1.66 to 40.72) and younger age (OR = 8.41, 95%CI = 1.48 to 47.96). Conclusion A recent index ankle sprain and younger age were the only independent predictors of ankle sprain. The combination of greater height or weight, feeling of instability, peak power and impaired balance predicted the occurrence of ankle sprain in almost 90% of participants. These findings could form the basis for intervention targeted at reducing recurrence of sprain after an index sprain.

Objectives To identify the predictors of chronic ankle instability after an index lateral ankle sprain. Design Systematic review. Methods The databases of MEDLINE, CINAHL, AMED, Scopus, SPORTDiscus, Embase, Web of Science, PubMed, PEDro, and Cochrane Register of Clinical Trials were searched from the earliest record until May 2013. Prospective studies investigating any potential intrinsic predictors of chronic ankle instability after an index ankle sprain were included. Eligible studies had a prospective design (follow-up of at least three months), participants of any age with an index ankle sprain, and had assessed ongoing impairments associated with chronic ankle instability. Eligible studies were screened and data extracted by two independent reviewers. Results Four studies were included. Three potential predictors of chronic ankle instability, i.e., postural control, perceived instability, and severity of the index sprain, were investigated. Decreased postural control measured by number of foot lifts during single-leg stance with eyes closed and perceived instability measured by Cumberland Ankle Instability Tool were not predictors of chronic ankle instability. While the results of one study showed that the severity of the initial sprain was a predictor of re-sprain, another study did not. Conclusions Of the three investigated potential predictors of chronic ankle instability after an index ankle sprain, only severity of initial sprain (grade II) predicted re-sprain. However, concerns about validity of the grading system suggest that these findings should be interpreted with caution.

Functional testing is particularly useful in the clinic and for making research translatable; however, finding measures relevant across ages and different conditions can be difficult. A systematic review was conducted to investigate timed stair tests as an objective measure of functional abilities and musculoskeletal integrity. Data were analyzed for their ability to differentiate between controls and patient groups and between different patient groups. Literature was reviewed using the Medline, CINAHL, and PubMed databases until February 2012. Data were grouped according to methodology, ages, and medical conditions. Time per step was calculated to allow comparison between studies. Eighty-eight studies were included in this review. Methodologies varied considerably with stair ascent, stair descent, or a combination of the two being used across a wide range of ages and medical conditions. Times increased with age for ascent, descent, and combined and for a variety of medical problems. Timed stair tests appear to be sensitive to medical conditions but further data are required to obtain normative values for this test. We suggest that timed stair tests should follow a more standardized methodology using a combination of ascent and descent and asking participants to complete the stairs as quickly and safely as possible.

Objective:To establish reference values for isometric strength of 12 muscle groups and flexibility of 13 joint movements in 1,000 children and adults and investigate the influence of demographic and anthropometric factors.Methods:A standardized reliable protocol of hand-held and fixed dynamometry for isometric strength of ankle, knee, hip, elbow, and shoulder musculature as well as goniometry for flexibility of the ankle, knee, hip, elbow, shoulder, and cervical spine was performed in an observational study investigating 1,000 healthy male and female participants aged 3–101 years. Correlation and multiple regression analyses were performed to identify factors independently associated with strength and flexibility of children, adolescents, adults, and older adults.Results:Normative reference values of 25 strength and flexibility measures were generated. Strong linear correlations between age and strength were identified in the first 2 decades of life. Muscle strength significantly decreased with age in older adults. Regression modeling identified increasing height as the most significant predictor of strength in children, higher body mass in adolescents, and male sex in adults and older adults. Joint flexibility gradually decreased with age, with little sex difference. Waist circumference was a significant predictor of variability in joint flexibility in adolescents, adults, and older adults.Conclusions:Reference values and associated age- and sex-stratified z scores generated from this study can be used to determine the presence and extent of impairments associated with neuromuscular and other neurologic disorders, monitor disease progression over time in natural history studies, and evaluate the effect of new treatments in clinical trials.

The purpose of this study was to evaluate knee joint position sense (JPS) in athletes with patellofemoral pain syndrome (PFPS) and compare it with healthy participants under non-weight bearing (sitting) and weight bearing (standing) conditions. Twenty patients and 20 healthy athletes participated in this study. JPS was evaluated by active replication of knee angles with visual cues eliminated. Two target angles in sitting and one in standing were tested. Each test and replication was repeated three times. By subtracting the test angle from the replicated angle, the absolute error was calculated as a dependent variable. No significant difference in knee JPS was found between groups either in the sitting or in the standing tests. It seems that PFPS does not affect the knee JPS in athletes. The lack of deficiency in patients could possibly be attributed to their severity of knee pathology, pain intensity and their physical activity level. Case–control study, Level III.

The aim of this study was to investigate the effect of menstrual cycle on knee joint position sense (JPS) in healthy female athletes.Sixteen healthy female athletes participated in this study. Serum estrogen and progesterone levels were collected during the three phases of menstrual cycle. The knee JPS was also measured during the same phases using a system comprise of skin markers, digital photography, and AutoCAD software. Absolute angular errors were calculated as well as changes in hormone levels between the three phases.Serum estrogen concentration was significantly higher during the mid-luteal (179.5 Pg/ml) and mid-follicular (125.6 Pg/ml) phases as compared with the early-follicular (menses) (22.8 Pg/ml) phase (P = 0.0001). Also serum progesterone concentration was significantly higher during the mid-luteal phase (7.35 Ng/ml) as compared with the menses (0.58 Ng/ml) and mid-follicular (0.5 Ng/ml) phases (P = 0.0001). The greatest amount of mean (SD) value of absolute error was at menses (4.2°), and the least amount of it was at mid-luteal (2.5°) phase. Also, a significant difference was observed within three phases of menstrual cycle (P = 0.025).The result of this study suggests that healthy female athletes have different levels of knee JPS across a menstrual cycle. JPS accuracy decreases in menses, when circulating sex-hormones levels are low. Therefore, female athletes are at higher risk of injury at menses and improving their awareness regarding the knee injury risk factors can be a fundamental step toward preventing injuries.Case series, Level IV.

Background It is not known why continuing instability exists after ankle sprain. The most common hypotheses include impairments in proprioception, muscle power or postural control [1] but a relationship has not been established. Therefore, the aim of this study was to investigate the relationship between functional instability and invertor/evertor peak power, accuracy of movement detection and threshold for position sense in the ankle. Materials and methods Sixty three participants with history of either no ankle sprain or only one ankle sprain were recruited. Functional ankle instability was measured using the Cumberland Ankle Instability Tool (CAIT), a highly reliable measure of functional ankle instability [2]. Invertor/evertor power testing was performed using a Biodex isokinetic dynamometer at speeds of 30, 60 and 120°/sec and the scores were normalised using participants’ BMI. Joint position sense was measured by actively matching the 3 test angles in inversion and eversion with the contra lateral ankle. Movement detection sense was tested at three velocities, 0.1, 0.5, and 2.5°/sec, in a random order. The relationship between perceived ankle instability and proprioception or inversion/eversion peak power was investigated using Pearson product-moment correlation coefficient. Preliminary analyses were performed to ensure the assumptions of normality, linearity and homoscedasticity were not violated. Results No correlation was found between the CAIT scores and the three measured variables. The strongest correlation was between CAIT score and inversion peak power at 30°/s (r=0.220, p= 0.083). Conclusion

Background Chronic ankle instability (CAI) is a disabling condition often encountered after ankle injury. Three main components of CAI exist; perceived instability; mechanical instability (increased ankle ligament laxity); and recurrent sprain. Literature evaluating CAI has been heavily focused on adults, with little attention to CAI in children. Hence, the objective of this study was to systematically review the prevalence of CAI in children. Methods Studies were retrieved from major databases from earliest records to March 2013. References from identified articles were also examined. Studies involving participants with CAI, classified by authors as children, were considered for inclusion. Papers investigating traumatic instability or instability arising from fractures were excluded. Two independent examiners undertook all stages of screening, data extraction and methodological quality assessments. Screening discrepancies were resolved by reaching consensus. Results Following the removal of duplicates, 14,263 papers were screened for eligibility against inclusion and exclusion criteria. Nine full papers were included in the review. Symptoms of CAI evaluated included perceived and mechanical ankle instability along with recurrent ankle sprain. In children with a history of ankle sprain, perceived instability was reported in 23-71% whilst mechanical instability was found in 18-47% of children. A history of recurrent ankle sprain was found in 22% of children. Conclusion Due to the long-lasting impacts of CAI, future research into the measurement and incidence of ankle instability in children is recommended.