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To assess the cost-effectiveness of app-based treatment for female stress, urgency or mixed urinary incontinence (UI) compared with care-as-usual in Dutch primary care.A pragmatic, randomised controlled, superiority trial.Primary care in the Netherlands from 2015 to 2018, follow-up at 12 months.Women with ≥2 UI-episodes per week, access to mobile apps, wanting treatment.The standalone app included conservative management for UI with motivation aids (e.g. reminders). Care-as-usual delivered according to the Dutch GP guideline for UI.Costs and cost-effectiveness and -utility were assessed from a societal perspective, based on incontinence impact adjusted life years (IIALYs), quality adjusted life years (QALYs) and medical, non-medical and productivity costs. Information on costs was obtained with the iMCQ and iPCQ questionnaires (medical consumption and productivity cost questionnaires).In all, 262 women were andomised equally to app or care-as-usual; 89 (68%) and 83 (63%) attended follow-up, respectively. Costs were lower for app-based treatment with € -161 (95% confidence interval [CI -180 to -151) per year. Cost-effectiveness showed small mean differences in effect for IIALY (0.04) and QALY (-0.03) and thus larger incremental cost-effectiveness ratios (ICER: -€3696) and incremental cost-utility ratios (ICUR: €6379).App-based treatment is a cost-effective alternative to care-as-usual for women with UI in Dutch primary care.App-treatment for female urinary incontinence cost-effective compared to care-as-usual in general practice after 12 months.

Nina Grotenhuis,1 Miranda C Schreuder,1 Tine WL van den Bos,2 Henk van der Worp,1 Marco H Blanker1 1Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; 2Foundation Bekkenbodem4All, Tiel, the NetherlandsCorrespondence: Miranda C Schreuder, Department of General Practice and Elderly Care medicine, University Medical Center Groningen, University of Groningen, FA21, PO Box 196, Groningen, 9700AD, the Netherlands, Tel +31 625647144, Email m.c.schreuder@umcg.nlPurpose: We aimed to examine how supply source affects satisfaction with continence products and care among individuals with urinary incontinence (UI). Supply source was compared among pharmacies, national suppliers, and shops. The secondary aim was to compare participant characteristics between the three groups.Patients and Methods: A survey questionnaire was distributed via social media between April and June 2020. This included the international consultation on incontinence questionnaire (ICIQ) UI short form (ICIQ-UI-SF), the ICIQ-PadPROM, and the ICIQ-LUTSqol, together with questions about respondent characteristics and satisfaction with continence products.Results: Of the 1045 respondents, 706 fully completed and 339 partially completed the survey. Among these, 322 (45.6%), 199 (28.1%), and 185 (26.2%) made purchases from shops, national suppliers, and pharmacies, respectively. The mean ICIQ-UI-SF sum scores were comparable for the pharmacy (13.3 ± 3.7) and national supplier (13.8 ± 3.5) groups, but were significantly lower for the shop group (12.0 ± 3.3). Mean sum scores for satisfaction with continence products and satisfaction with continence care were also significantly lower in the shop group (7.9 ± 2.6 and 6.4 ± 2.7, respectively) compared with the pharmacy (9.1 ± 2.7 and 7.9 ± 2.6, respectively) and national supplier (9.3 ± 2.6 and 8.1 ± 3.0, respectively) groups. There were no statistically significant differences in the ICIQ-PadPROM and ICIQ-LUTSqol scores. Respondents’ characteristics were similar, apart from the significantly lower number of males in the shop group.Conclusion: Satisfaction with continence products and continence care is lower for people with UI who purchase materials from a shop than from a pharmacy or national supplier.Keywords: incontinence care, health insurance, incontinence pads, urinary loss

The evaluation of teleconsultations on the Prisma platform revealed differences in type of questions posted by Dutch general practitioners (GP), and advices received from dermatologists between people with skin of colour or White skin. A survey among users of this interdisciplinary platform confirmed low competence at recognizing and treating problems in SOC and a felt need for additional education to provide care for people with skin of colour.

IntroductionOptimal collaboration between general practice and hospital care is crucial to maintain affordable and sustainable access to healthcare for the entire population. General practitioners (GPs) are the gatekeepers to specialist care and patients will visit hospitals mostly only after referral. However, a substantial part of these referrals may be inappropriate, as communication between GPs and medical specialists can be challenging and referring patients may be the most obvious action for a GP to perform.A new digital platform (Prisma) connects GPs and specialists in interdisciplinary groups and facilitates asynchronous, accessible and fast teleconsultation within the group. No previous research has been done to evaluate the impact of this new platform on the referral rates to the hospital.Methods and analysisA stepped-wedge randomised controlled trial (RCT) will be performed in Zwolle region in the Netherlands to analyse the effect of introduction of the platform on rate of inappropriate referrals to orthopaedic surgery. In four steps, GPs in the region will be given access to the platform. GPs will be part of the control condition until randomisation to the intervention. According to our sample size calculation, we need to include 18 practices with 1008 patients presenting with hip and knee symptoms. Routine care data of hospital registrations will be analysed to calculate the rate of inappropriate referrals (primary outcome). Secondary outcome are costs, primary and secondary care workload, posted cases and user satisfaction. Alongside this quantitative analysis, we will evaluate patient experience, facilitators and barriers for use of the platform.Ethics and disseminationThe medical ethics review board of University Medical Center Groningen (UMCG), the Netherlands (METc-number: 2021/288) has confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the process evaluation because the study does not involve randomisation of patients or different medical treatments (letter number: M21.275351).Trial registration numberNL9704.

ObjectivesTo improve continence care in the Netherlands, a new framework has been developed in which a shift has been made from incontinence severity as the sole criterion for selecting incontinence products to a focus on patient need for daily life activities. The impact of the framework on daily care has not been assessed. We aimed to compare treatment effectiveness and costs between participants who did and did not undergo re-evaluation according to the new framework.DesignCohort studySettingTwelve pharmacies in the NetherlandsParticipantsExisting users of absorbent incontinence materials for urinary incontinence.InterventionsParticipants were offered the option to have their incontinence products re-evaluated within the new framework at their pharmacy.Primary and secondary outcome measuresEffectiveness and cost outcomes were assessed at 3 and 6 months through questionnaires. These questionnaires included the International Consultation on Incontinence Questionnaire (ICIQ) Lower Urinary Tract Symptoms Quality of Life Module, ICIQ Urinary Incontinence Short Form, ICIQ Absorbent Pads, questions about satisfaction and the iPCQ and iMCQ.Results303 users consented and 279 completed the baseline questionnaire. Of these participants, 72 agreed to a re-evaluation of their incontinence materials. There was a small improvement at 3 months in the re-evaluation group compared with the other group on most outcomes. However, these improvements were not clinically relevant. Moreover, these differences did not change much from 3 to 6 months. Small differences were also observed in the changes in costs, but with very wide CIs on both sides of zero (€99.38; 95% CI −633.48 to 832.23).ConclusionsThe current study showed no clinically relevant effect of a newly implemented framework for selecting incontinence materials in pharmacies when compared with an existing method. Given that the study also showed no differences in effectiveness and costs, introducing the new framework in pharmacies may not lead to better incontinence care.

Variability in the results of randomized trials presents challenges to the interpretation and application of the evidence to patient care. Understanding how systematic reviews deal with this problem of "heterogeneity" will help clinicians in applying results in their patient management. This manuscript offers a review of heterogeneity from the clinical urological perspective. PATIENT SUMMARY: Systematic reviews of the literature are necessary to accurately summarize the available evidence to inform clinical decisions. In this mini-review, we explain how to understand and deal with the differences between studies-which we call heterogeneity-included in these types of reviews.

ObjectiveTo develop a prediction model and illustrate the practical potential of personalisation of treatment decisions between app-based treatment and care as usual for urinary incontinence (UI).DesignA prediction model study using data from a pragmatic, randomised controlled, non-inferiority trial.SettingDutch primary care from 2015, with social media included from 2017. Enrolment ended on July 2018.ParticipantsAdult women were eligible if they had ≥2 episodes of UI per week, access to mobile apps and wanted treatment. Of the 350 screened women, 262 were eligible and randomised to app-based treatment or care as usual; 195 (74%) attended follow-up.PredictorsLiterature review and expert opinion identified 13 candidate predictors, categorised into two groups: Prognostic factors (independent of treatment type), such as UI severity, postmenopausal state, vaginal births, general physical health status, pelvic floor muscle function and body mass index; and modifiers (dependent on treatment type), such as age, UI type and duration, impact on quality of life, previous physical therapy, recruitment method and educational level.Main outcome measurePrimary outcome was symptom severity after a 4-month follow-up period, measured by the International Consultation on Incontinence Questionnaire the Urinary Incontinence Short Form. Prognostic factors and modifiers were combined into a final prediction model. For each participant, we then predicted treatment outcomes and calculated a Personalised Advantage Index (PAI).ResultsBaseline UI severity (prognostic) and age, educational level and impact on quality of life (modifiers) independently affected treatment effect of eHealth. The mean PAI was 0.99±0.79 points, being of clinical relevance in 21% of individuals. Applying the PAI also significantly improved treatment outcomes at the group level.ConclusionsPersonalising treatment choice can support treatment decision making between eHealth and care as usual through the practical application of prediction modelling. Concerning eHealth for UI, this could facilitate the choice between app-based treatment and care as usual.Trial registration numberNL4948t.

PURPOSE: Electronic application (app)-based treatment is promising for common diseases with good conservative management options, such as urinary incontinence (UI) in women, but its effectiveness compared with usual care is unclear. This study set out to determine if app-based treatment for women with stress, urgency, or mixed UI was noninferior to usual care in the primary care setting.METHODS: The URinControl trial is a pragmatic, noninferiority randomized controlled trial in Dutch primary care including adult women with 2 episodes of UI per week. From July 2015 to July 2018, we screened 350 women for eligibility. A stand-alone app-based treatment with pelvic floor muscle and bladder training (URinControl) was compared with usual care according to the Dutch general practitioner guideline for UI treatment. Outcomes measured were change in symptom severity score from baseline to 4 months (primary outcome), impact on disease-specific quality of life, patient-perceived improvement, and number of UI episodes. Noninferiority (RESULTS: A total of 262 eligible women were randomized equally; 195 of them had follow-up through 4 months. The change in symptom severity with app-based treatment (-2.16 points; 95% CI, -2.67 to -1.65) was noninferior to that with usual care (-2.56 points; 95% CI, -3.28 to -1.84), with a mean difference of 0.058 points (95% CI, -0.776 to 0.891) between groups. Neither treatment was superior to the other, and both groups showed improvements in outcome measures after treatment.CONCLUSIONS: App-based treatment for women with UI was at least as effective as usual care in the primary care setting. As such, app-based treatments, with their potential advantages of privacy, accessibility, and lower cost, may provide women with a good alternative to consultation.

OBJECTIVE: To assess the long-term effectiveness of app-based treatment for female stress, urgency, or mixed urinary incontinence (UI) compared to care-as-usual in primary care.DESIGN: A pragmatic, randomised controlled, superiority trial.SETTING: Primary care in the Netherlands from 2015 to 2018, follow-up at 12 months.POPULATION: Women with ≥2 UI-episodes per week, access to mobile apps, wanting treatment. 262 women randomised equally to app or care-as-usual; 89 (68%) and 83 (63%) attended one year follow-up.INTERVENTIONS: The standalone app included conservative management for UI with motivation aids (e.g., reminders). Care-as-usual delivered according to the Dutch GP guideline for UI.MAIN OUTCOME MEASURES: Effectiveness assessed by the change in symptom severity score (ICIQ-UI-SF) and the change in quality of life (ICIQ-LUTS-QoL) with linear regression on an intention-to-treat basis.RESULTS: Clinically relevant improvement of UI severity for both app (-2.17 ± 2.81) and care-as-usual (-3.43 ± 3.6), with a non-significant mean difference of 0.903 (-0.66 to 1.871).CONCLUSION: App-based treatment is a viable alternative to care-as-usual for UI in primary care in terms of effectiveness after one year.

Background Complexity of health problems and aging of the population create an ongoing burden on the health care system with the general practitioner (GP) being the gatekeeper in primary care. In GPs daily practice, collaboration with specialists and exchange of knowledge from the secondary care play a crucial role in this system. Communication between primary and secondary care has shortcomings for health care workers that want to practice sustainable patient-centered health care. Therefore, a new digital interactive platform was developed: Prisma. Objective This study aims to describe the development of a digital consultation platform (Prisma) to connect GPs with hospital specialists via the Siilo application and to evaluate the first year of use, including consultations, topic diversity, and number of participating physicians. Methods We conducted a mixed methods observational study, analyzing qualitative and quantitative data for cases posted on the platform between June 2018 and May 2020. Any GP can post questions to an interdisciplinary group of secondary care specialists, with the platform designed to facilitate discussion and knowledge exchange for all users. Results In total, 3674 cases were posted by 424 GPs across 16 specialisms. Most questions and answers concerned diagnosis, nonmedical treatment, and medication. Mean response time was 76 minutes (range 44-252). An average of 3 users engaged with each case (up to 7 specialists). Almost half of the internal medicine cases received responses from at least two specialisms in secondary care, contrasting with about one-fifth for dermatology. Of note, the growth in consultations was steepest for dermatology. Conclusions Digital consultations offer the possibility for GPs to receive quick responses when seeking advice. The interdisciplinary approach of Prisma creates opportunities for digital patient-centered networking.

BACKGROUND Complexity of health problems and aging of the population create an ongoing burden on the health care system with the general practitioner (GP) being the gatekeeper in primary care. In GPs daily practice, collaboration with specialists and exchange of knowledge from the secondary care play a crucial role in this system. Communication between primary and secondary care has shortcomings for health care workers that want to practice sustainable patient-centered health care. Therefore, a new digital interactive platform was developed: Prisma. OBJECTIVE This study aims to describe the development of a digital consultation platform (Prisma) to connect GPs with hospital specialists via the Siilo application and to evaluate the first year of use, including consultations, topic diversity, and number of participating physicians. METHODS We conducted a mixed methods observational study, analyzing qualitative and quantitative data for cases posted on the platform between June 2018 and May 2020. Any GP can post questions to an interdisciplinary group of secondary care specialists, with the platform designed to facilitate discussion and knowledge exchange for all users. RESULTS In total, 3674 cases were posted by 424 GPs across 16 specialisms. Most questions and answers concerned diagnosis, nonmedical treatment, and medication. Mean response time was 76 minutes (range 44-252). An average of 3 users engaged with each case (up to 7 specialists). Almost half of the internal medicine cases received responses from at least two specialisms in secondary care, contrasting with about one-fifth for dermatology. Of note, the growth in consultations was steepest for dermatology. CONCLUSIONS Digital consultations offer the possibility for GPs to receive quick responses when seeking advice. The interdisciplinary approach of Prisma creates opportunities for digital patient-centered networking.

Introduction Abnormal kinematics have been implicated as one of the major risk factors for lower limb tendinopathy (LLT). Objective To systematically review evidence for kinematic risk factors for LLT in runners. Methods Individual electronic searches in PubMed, EMBASE and Web of Science were conducted. Two reviewers screened studies to identify observational studies reporting kinematic risk factors in runners with LLT compared to healthy controls. The Down and Black appraisal scale was applied to assess quality. A meta-analysis was performed provided that at least two studies with similar methodology reported the same factor. Results Twenty-eight studies were included: Achilles tendinopathy (AT) (9), iliotibial band syndrome (ITBS) (17), plantar fasciopathy (PF) (2), patellar tendinopathy (PT) (1), posterior tibial tendon dysfunction (PTTD) (1). Eighteen studies were rated high-quality and ten medium-quality. The meta-analyses revealed strong evidence of higher peak knee internal rotation, moderate evidence of lower peak rearfoot eversion and knee flexion at heel strike and greater peak hip adduction in runners with ITBS. Very limited evidence revealed higher peak ankle eversion in runners with PF and PTTD or higher peak hip adduction in PT. Significance Peak rearfoot eversion was the only factor reported in all included LLTs; it is a significant factor in ITBS, PT and PTTD but not in AT and PF. More prospective studies are needed to accurately evaluate the role of kinematic risk factors as a cause of LLT. Taken together, addressing rearfoot kinematic and kinematic chain movements accompanied by peak eversion should be considered in the prevention and management of LLT.

Objectives: To determine the proportion of participants of a running program for novice runners that discontinued running and investigate the main reasons to discontinue and characteristics associated with discontinuation.Design: Prospective cohort study.Methods: The study included 774 participants of Start to Run, a 6-week running program for novice runners. Before the start of the program, participants filled-in a baseline questionnaire to collect information on demographics, physical activity and perceived health. The 26-weeks follow-up questionnaire was used to obtain information on the continuation of running (yes/no) and main reasons for discontinuation. To determine predictors for discontinuation of running, multivariable logistic regression was performed.Results: Within 26 weeks after the start of the 6-week running program, 29.5% of the novice runners (n = 225) had stopped running. The main reason for discontinuation was a running-related injury (n = 108, 48%). Being female (OR 1.74; 95% CI 1.13-2.68), being unsure about the continuation of running after the program (OR 2.06; 95% CI 1.31-3.24) and (almost) no alcohol use (OR 1.62; 95%CI 1.11-2.37) were associated with a higher chance of discontinuation of running. Previous running experience less than one year previously (OR 0.46; 95% CI 0.26-0.83) and a higher score on the RAND-36 subscale physical functioning (OR 0.98; 95% CI 0.96-0.99) were associated with a lower chance of discontinuation.Conclusions: In this group of novice runners, almost one-third stopped running within six months. A running-related injury was the main reason to stop running. Women with a low perceived physical functioning and without running experience were prone to discontinue running. (C) 2018 Published by Elsevier Ltd on behalf of Sports Medicine Australia.

This study examined the criterion validity of self-reported running-related injuries (RRI) by novice runners. Fifty-eight participants (41 females; age 46 ± 11 yrs) of the "Start-to-Run" program provided self-reports on their RRIs using an online questionnaire. Subsequently, they attended injury consultations with sports medicine physicians who provided physician-reports (blinded for the self-reports) as a reference standard. Self-reports and physician-reports included information on injury location (i.e., hip/groin, upper leg, knee, lower leg, and ankle/foot) and injury type (i.e., muscle-tendon unit, joint, ligament, or bone). Sensitivity, specificity, and positive predictive values were 100% for all five injury locations. For injury type, sensitivity was low (66% for muscle-tendon unit, 50% for ligament, and 40% for bone) and lowest for joint injuries (17%). In conclusion, the validity of self-reported RRIs by novice runners is good for injury locations but not for injury types. In particular for joint injuries, the validity of novice runners' self-reports is low.ABBREVIATIONS: RRI: Running Related Injury; SMC: Sports Medicine Centre; MTU: Muscle Tendon Unit; PPV: Positive Predictive Value.

Objective: Long-term cost-effectiveness of app-based treatment for female stress, urgency, or mixed urinary incontinence (UI) compared to care-as-usual in primary care. Design: A pragmatic, randomised controlled, superiority trial. Setting: Primary care in the Netherlands from 2015 to 2018, follow-up at 12 months. Population: Women with ≥2 UI-episodes per week, access to mobile apps, wanting treatment. 262 women randomised equally to app or care-as-usual; 89 (68%) and 83 (63%) attended follow-up. Methods: The standalone app included conservative management for UI with motivation aids (e.g., reminders). Care-as-usual delivered according to the Dutch GP guideline for UI. Main outcome measures: Effectiveness assessed by the change in symptom severity score (ICIQ-UI-SF) and the change in quality of life (ICIQ-LUTS-QoL, EQ-5D-5L) on superiority with linear regression on an intention-to-treat basis. Cost-effectiveness and -utility from a societal perspective, based on Incontinence Impact Adjusted Life Years (IIALYs) and Quality Adjusted Life years (QALYs). Results: Clinically relevant improvement of UI severity for both app (-2.17 ± 2.81) and care-as-usual (-3.43 ± 3.6), with a non-significant mean difference of 0.903 (-0.66 to 1.871). Costs were lower for app-based treatment with \euro-161 (95%CI: -180 to -151) per year. Cost-effectiveness showed small mean differences in effect for IIALY (0.04) and QALY (-0.03) and thus larger ICER (-3,696) and ICUR (\euro6,379). Conclusion: App-based treatment is a viable alternative to care-as-usual for UI in primary care in terms of long-term cost-effectiveness. Funding: Dutch Organisation for Health Research and Development (ZonMw: 837001508), sub-funding P.W. Boer Foundation Dutch Trial Register identifier: Trial NL4948 (www.trialregister.nl/trial/4948).

BACKGROUND App-based treatment for urinary incontinence is a proven effective and cost-effective alternative to care as usual, but successful implementation requires that we identify and address the barriers and facilitators associated with app use. OBJECTIVE The goal of the research was to explore the factors influencing app-based treatment for urinary incontinence and identify which barriers or facilitators are associated with treatment success or failure. METHODS We used a sequential explanatory mixed methods design to connect the results of a randomized controlled trial with data from semistructured interviews. This previous RCT had shown the noninferiority of app-based treatment compared with care as usual for urinary incontinence over 4 months. Participants who reported success or failure with app-based treatment, as measured by the change in International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form symptom score, were selected for telephone interview by purposive sampling (n=17). This study reports mainly on the qualitative component of our mixed methods study. Qualitative analyses were conducted in two ways. First, we analyzed the qualitative data of all interviewed participants and discussed the relationships between the main themes. Second, the experiences between the success (n=9) and failure group (n=8) were compared and contrasted to explore factors that were positively or negatively associated with the quantitative effect of app-based treatment. These factors were then interpreted as barriers to and facilitators of successful app-based treatment. RESULTS Four interrelated themes were identified as affecting the app based treatment effect: adherence, personal factors, app factors, and awareness. Qualitative analyses of the relationships between the themes showed that adherence-related factors directly influenced treatment effect in both a positive and negative matter. In turn, adherence was also positively and negatively influenced by the other 3 themes. Additionally, awareness was positively influenced by the treatment effect. Within these themes, several factors were identified that acted as barriers (eg, unrealistic expectation of time investment and interfering personal circumstances), facilitators (eg, strict integration of exercises and prior pelvic floor muscle therapy), or both (eg, personality traits and increased awareness of symptoms). CONCLUSIONS This study shows that the effect of app-based treatment for urinary incontinence is mainly influenced by adherence, which in turn is affected by personal factors, app-based factors, and awareness. The identified factors could function as both facilitators and barriers depending on the user and interaction with other themes. Insight into these facilitators and barriers could lead to improved implementation and increased treatment effectiveness by targeting women most likely to benefit and through further development of the app. INTERNATIONAL REGISTERED REPORT RR2-10.1002/nau.23507

BACKGROUND Although several apps are available to support the treatment of urinary incontinence (UI), little has been reported about the experiences and preferences of their users. OBJECTIVE The objective of this study was to explore the experiences and preferences of women using a mobile app for the treatment of UI and to identify potential improvements to the app. We developed this app for three types of UI: stress UI, urgency UI, and mixed UI. METHODS The participants in this qualitative study were women with self-reported stress UI, urgency UI, or mixed UI who used an app-based treatment to manage their condition for at least six weeks. Following the intervention, semistructured interviews were conducted to explore the participants’ experiences and preferences regarding the app. All interviews were audio-recorded, transcribed verbatim, and analyzed separately by two researchers. RESULTS Data saturation was reached after interviewing 9 women (aged 32-68 years) with stress UI (n=1, 11%), urgency UI (n=3, 33%), or mixed UI (n=5, 56%). Accessibility, awareness, usability, and adherence emerged as the main themes. On the one hand, participants appreciated that the app increased their accessibility to care, preserved their privacy, increased their awareness of therapeutic options, was easy to use and useful, and supported treatment adherence. On the other hand, some participants reported that they wanted more contact with a care provider, and others reported that using the app increased their awareness of symptoms. CONCLUSIONS This qualitative study indicates that women appreciate app-based treatment for UI because it can lower barriers to treatment and increase both awareness and adherence to treatment. However, the app does not offer the ability of face-to-face contact and can lead to a greater focus on symptoms.

Objectives: To observe the changes in Achilles tendon structure in novice runners, with loading prescriptions of 100% body weight compared to 20% body weight.Design: Randomised crossover.Methods: Twenty novice runners participated in two separate running bouts spaced 14 days apart, one of high load at 100% body weight, and one of low load at 20% body weight. Tendon structure was measured by ultrasonographic tissue characterisation on 6 occasions; immediately prior to each run, 2 and 7 days after each run.Results: The interaction effect of time and condition was not found to be significant for echotypes I-IV [Wald chi-square = 2.8, d.f. = 2, P=0.247; Wald chi-square=2.888, d.f. = 2, P=0.236; Wald chi-square=1.385, d.f. = 2, P=0.5; Wald chi-square=4.19, d.f. = 2, P=0.123], respectively. A significant effect of time was found for echotypes Ill [Wald chi-square=6.785, d.f. = 2, P=0.0.034] and IV [Wald chi-square=7.491, d.f. = 2, P=0.0.024].Conclusions: The decrease in echotypes III and IV suggest that moderate loads can be applied to the Achilles tendon without compromising tendon structure. Low to moderate loads may be beneficial in the management of Achilles tendinopathy. Further studies should focus on protocols with higher loading and/or repetitive loading in athletic populations with and without Achilles tendinopathy to assess any differences in tendon structure. (C) 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Context: Previous research has shown a weak relationship between intended and actual training load in various sports. Due to variety in group and content, this relationship is expected to be even weaker during group rehabilitation. Objective: The goal of this study was to examine the relationship between intended and actual training load during sport-specific rehabilitation in a group setting. Design: Observational study. Setting: Three outdoor rehabilitation sessions. Participants: Nine amateur soccer players recovering from lower limb injury participated in the study (age 22 ± 3 y, height 179 ± 9 cm, body mass 75 ± 13 kg). Main Outcome Measures: We collected physiotherapists’ ratings of intended exertion (RIE) and players’ ratings of perceived exertion (RPE). Furthermore, Zephyr Bioharness 3 equipped with GPS-trackers provided heart rate and distance data. We computed heart rate–based training loads using Edwards’ method and a modified TRIMP. Results: Overall, we found weak correlations (N = 42) between RIE and RPE (r = 0.35), Edwards’ (r = 0.34), TRIMPMOD (r = 0.07), and distance (r = 0.26). Conclusions: In general, physiotherapists tended to underestimate training loads. To check whether intended training loads are met, it is thus recommended to monitor training loads during rehabilitation.

ObjectiveTo identify the preferences of women regarding management of urinary tract infections (UTIs).DesignA discrete choice experiment of the preferences for certain treatment attributes was conducted by survey. Attributes included treatment duration, time to complaint resolution, complication risk, side effect risk and contribution to antimicrobial resistance.SettingGeneral population in the Netherlands, recruited via social media.ParticipantsWomen aged 18 years or older.Primary and secondary outcome measuresThe primary outcome was the relative importance of the attributes for treatment choice, using a conditional logit model. The secondary outcome was the heterogeneity in these preferences.ResultsThe discrete choice experiment was completed by 833 women. Most attributes were important to decisions for UTI treatment. Women were willing to accept management with, for example, a higher chance of complications or longer time to resolution, if it could help avoid antimicrobial resistance. However, there was heterogeneity in the preferences. Women who had one previous UTI had a stronger preference for faster symptom resolution compared with those who had no previous UTI. Younger women also preferred faster symptom resolution. Finally, women with a low or middle education level gave less importance to preventing antimicrobial resistance than women with a high education level.ConclusionsThe current study indicated that a considerable part of women valued alternatives to antimicrobial treatment and were prepared to tolerate management that was less optimal in certain respects to avoid antimicrobial treatment.

Objective: To investigate the validity and reliability of a smartphone application for selected lower-limb kinematics during treadmill running. Design: Validity and reliability study. Setting: Biomechanics laboratory. Participants: Twenty healthy female runners. Main outcome measure(s): Sagittal-plane hip, knee, and ankle angle and rearfoot eversion were assessed using the Coach's Eye Smartphone application and a 3D motion capture system. Paired t-test and intraclass correlation coefficients (ICC) established criterion validity of Coach's Eye; ICC determined test-retest and intrarater/interrater reliability. Standard error of measurement (SEM) and minimal detectable change (MDC) were also reported. Results: Significant differences were found between Coach's Eye and 3D measurements for ankle angle at touchdown and knee angle at toe-off (p < 0.05). ICCs for validity of Coach's Eye were excellent for rearfoot eversion at touchdown (ICC = 0.79) and fair-to-good for the other kinematics (range 0.51–0.74), except for hip at touchdown, which was poor (ICC = 0.36). Test-retest (range 0.80–0.92), intrarater (range 0.95–0.99) and interrater (range 0.87–0.94) ICC results were excellent for all selected kinematics. Conclusion: Coach's Eye can be used as a surrogate for 3D measures of knee and rearfoot in/eversion at touchdown, and hip, ankle, and rearfoot in/eversion at toe-off, but not for hip and ankle at touchdown or knee at toe-off. Reliable running kinematics were obtained using Coach's Eye, making it suitable for repeated measures.

HYPOTHESIS/AIMS OF STUDY: Over 100 apps for urinary incontinence are available in the app store and google play, but evidence on their effective-ness is scarce. Available studies focused on the treatment of stress urinary incontinence only (1). Mobile applications may support women with urinary continence, but it is unclear if the effect of such treatment equals care as usual. In many countries, general practitioners (GPs) provide frst line treatment of urinary incontinence. We studied if the effectiveness of an app-based treatment for stress-urgency-and mixed urinary incontinence is non-inferior to care as usual provided by GPs after 4 months. To assess the beneft of an app in real clinical practice, we chose a non-inferiority comparison to care as usual. STUDY DESIGN, MATERIALS AND METHODS: This trial was a pragmatic, block-randomized, two arm, parallel, non-inferiority design with participants receiving app-based treatment or care as usual for stress-, urgency-or mixed urinary incontinence (UI). We recruited participants through primary care practices, lay press and social media. Adult woman, with ≥ 2 urinary incontinence episodes per week, with access to a smartphone or tablet and willing to receive treatment were eligible. We excluded woman with conditions possibly related to stress-, urgency-or mixed incontinence, those who had previous surgery for incontinence or any other treatment for incontinence in the previous year, or those that were unable to complete a questionnaire in Dutch or had a terminal or mental illness. Participants signed an informed consent form before entering the study. The app contains a step-by-step program for the self-management of urinary incontinence. The app ofered information on incontinence and lifestyle advices, exercises focusing on awareness of the pelvic foor muscle and exercises to train the pelvic foor muscle and/or bladder. The type of incontinence directed treatment advices. Care as usual consisted of any or more of the following: instructions on pelvic foor muscle and/or bladder training; prescribing a pessary, drugs, or absorbent products; or referral to a continence nurse, a pelvic physiotherapist, or to secondary care. After inclusion and baseline assessment, the randomization was carried out using the validated web-based computer program ALEA to ensure full allocation concealment. The primary outcome was diference in change in urinary incontinence severity (assessed with the ICIQ-UI-short form) from baseline to 4 months. We used linear regression to compare the change of ICIQ-UI-SF symptom score between groups, in a per-protocol analysis, which is the most conservative for the non-inferiority design. For this, we included women from the app-group that logged in in the app at least once and women from the care as usual group that visited their GP for incontinence at least once. The non-inferiority margin is set at 1.5 points diference of change in UI severity between groups. This is based on the 1.58 points between-treatment minimum important difer-ence in change (MID) for the ICIQ-UI-SF, previously identifed among participants with stress UI (2). Assuming a power of 0.80 with a one-sided type I error of 0.025, we needed a sample of 100 evaluable participants per group. RESULTS: Participants were recruited through 88 GPs (n=201) and through (social) media (n=149). Of 350 participants screened, 262 were eligible and randomly allocated to either App-based treatment (n=131) or care as usual (n=131). The mean age of included women was 53 years (range 20-86), median duration of incontinence was 7 years (Interquartile range 4-14). Fifty percent of participants reported a mixed type of incontinence, 42% stress incontinence and 8% urgency incontinence.The incontinence severity was slight (10%) moderate (64%) or severe (26%). The per-protocol analysis included 96 (app-group) and 75 participants (care as usual). Both groups showed improvement after treatment with a mean change in incontinence severity of-2.15 (SD 2.56) points in the app group and-2.75 (3.62) points in the care as usual group. The mean diference of change of incontinence severity between both groups was 0.071 points (95% CI:-0.837 to 0.979), which did not reach the pre-specifed boundary of 1.5 points but did cross zero (Figure1). This means that the app-based treatment effect was non-inferior to the care as usual treatment effect, but not superior. INTERPRETATION OF RESULTS: This RCT shows that an app-based treatment for woman with stress-, urgency and mixed urinary incontinence is at least as effective as the best current treatment provided by GPs at 4 months. This is the frst study with a pragmatic comparison of an app-based treatment for urinary incontinence to care as usual and we believe our results provide a realistic reffec-tion of the treatment effect in a real life setting. Symptom improvement shown was clinically relevant in both groups. The three main types of incontinence can be treated by the same app, therefore increasing the applicability and relevance of app treatment. CONCLUDING MESSAGE: This is the frst study on an app-based treatment for women with stress-, urgency-, and mixed UI, showing that it is non-inferior compared to care as usual in primary care after 4 months. Further research is needed to study long-term effectiveness, and the cost-effectiveness of app-based treatment, and to understand the process underlying treatment success.

Objectives The objective of the study was to assess the impact of recruitment strategy on the baseline characteristics of patients recruited in a randomized controlled trial for treating women with urinary incontinence. Study Design and Setting We conducted a cross-sectional analysis of baseline data from an earlier trial. Women were recruited through the media (including social media) or from participating general practices. Baseline characteristics were compared by univariate testing. Logistic regression analysis was performed to study the association between recruitment type and multiple baseline characteristics. Results The only differences between recruitment methods were in patient age, with those recruited through the media being significantly older than those recruited through general practice. The mean age difference was 5.0 years (95% confidence interval: 2.2–7.9). Conclusion Samples recruited through the media and through case identification were largely comparable. Therefore, recruitment through the media may be a viable alternative to recruitment through primary care. This may be especially relevant for research on eHealth treatment for conditions with which patients experience barriers when seeking health care.

AIMS: To explore the effect of an online self-management program in secondary care for men with lower urinary tract symptoms (LUTS).METHODS: We performed a prospective nonrandomized double-cohort pilot study of consecutive adult men referred with uncomplicated LUTS to three urology outpatient departments. Men in both cohorts received care as usual from a urologist, but men in the intervention cohort also had access to an online self-management program. Outcomes were assessed after 6 and 12 weeks: LUTS severity was assessed with the International Prostate Symptom Score (IPSS), the Overactive Bladder Questionnaire (OABq), and the Perceived Global Impression of Improvement (PGI-I). The main outcome of interest was a clear improvement in the PGI-I scores ("much better" or "very much better").RESULTS: Age, symptom severity, and quality of life scores were comparable between the intervention (n = 113) and standard care (n = 54) cohorts. Clear improvement in the PGI-I scores was reported after 12 weeks in 19.4% and 26.1% of men in the intervention and standard care cohorts, respectively. However, logistic regression analysis indicated that the difference between cohorts was not significant. Multivariable linear regression analysis also indicated no significant differences between cohorts for the IPSS or the OABq score at either assessment point. Notably, the uptake of the intervention was low (53%).CONCLUSIONS: We found no significant benefit from adding an online self-management program to standard care for men with LUTS, probably due to the low uptake of the intervention that may have resulted from the timing in the care pathway.

OBJECTIVE: Currently, no treatments exist for patellar tendinopathy (PT) that guarantee quick and full recovery. Our objective was to assess which treatment option provides the best chance of clinical improvement and to assess the influence of patient and injury characteristics on the clinical effect of these treatments.DESIGN: A secondary analysis was performed on the combined databases of 3 previously performed double-blind randomized controlled trials.PATIENTS: In total, 138 patients with PT were included in the analysis.INTERVENTIONS: Participants were divided into 5 groups, based on the treatment they received: Extracorporeal shockwave therapy (ESWT) (n = 31), ESWT plus eccentric training (n = 43), eccentric training (n = 17), topical glyceryl trinitrate patch plus eccentric training (n = 16), and placebo treatment (n = 31).MAIN OUTCOME MEASURES: Clinical improvement (increase of ≥13 points on the Victorian Institute of Sport Assessment-Patella score) after 3 months of treatment.RESULTS: Fifty-two patients (37.7%) improved clinically after 3 months of treatment. Odds ratios (ORs) for clinical improvement were significantly higher in the eccentric training group (OR 6.68, P = 0.009) and the ESWT plus eccentric training group (OR 5.42, P = 0.015) compared with the other groups. We found evidence that a high training volume, a longer duration of symptoms, and older age negatively influence a treatment's clinical outcome (trend toward significance).CONCLUSIONS: Our study confirmed the importance of exercise, and eccentric training in particular, in the management of PT. The role of ESWT remains uncertain. Further research focusing on the identified prognostic factors is needed to be able to design patient-specific treatment protocols for the management of PT.

Objectives: To investigate the economic burden of running-related injuries (RRI) occurred during the 6-week 'Start-to-Run' program of the Dutch Athletics Federation in 2013.Design: Prospective cohort study.Methods: This was a monetary cost analysis using the data prospectively gathered alongside the RRI registration in the NLstart2run study. RRI data were collected weekly. Cost diaries were applied two and six weeks after the RRI registration to collect data regarding healthcare utilisation (direct costs) and absenteeism from paid and unpaid work (indirect costs). RRI was defined as running-related pain that hampered running ability for three consecutive training sessions.Results: From the 1696 participants included in the analysis, 185 reported a total of 272 RRIs. A total of 26.1% of the cost data (71 RRIs reported by 50 participants) were missing. Therefore, a multiple imputation procedure was performed. The economic burden (direct plus indirect costs) of RRIs was estimated at (sic)83.22 (95% CI(sic)50.42-(sic)116.02) per RRI, and (sic)13.35 (95% CI(sic)7.07-(sic)19.63) per participant. The direct cost per RRI was (sic)56.93 (95% CI (sic)42.05-(sic)71.81) and the indirect cost per RRI was (sic)26.29(95% CI (sic)0.00-(sic)54.79). The indirect cost was higher for sudden onset RRIs than for gradual onset RRIs, with a mean difference of (sic)33.92 (95% CI (sic)17.96-(sic)49.87).Conclusions: Direct costs of RRIs were 2-fold higher than the indirect costs, and sudden onset RRIs presented higher costs than gradual onset RRIs. The results of this study are important to provide information to public health agencies and policymakers about the economic burden of RRIs in novice runners. (C) 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Objectives: The incidence of running-related injuries is high. Some risk factors for injury were identified in novice runners, however, not much is known about the effect of training factors on injury risk. Therefore, the purpose of this study was to examine the associations between training factors and running-related injuries in novice runners, taking the time varying nature of these training-related factors into account.Design: Prospective cohort study.Methods: 1696 participants completed weekly diaries on running exposure and injuries during a 6-week running program for novice runners. Total running volume (min), frequency and mean intensity (Rate of Perceived Exertion) were calculated for the seven days prior to each training session. The association of these time-varying variables with injury was determined in an extended Cox regression analysis.Results: The results of the multivariable analysis showed that running with a higher intensity in the previous week was associated with a higher injury risk. Running frequency was not significantly associated with injury, however a trend towards running three times per week being more hazardous than two times could be observed. Finally, lower running volume was associated with a higher risk of sustaining an injury.Conclusions: These results suggest that running more than 60 min at a lower intensity is least injurious. This finding is contrary to our expectations and is presumably the result of other factors. Therefore, the findings should not be used plainly as a guideline for novices. More research is needed to establish the person-specific training patterns that are associated with injury. (C) 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Objectives: The primary aim of this study is to investigate the effect of the use of a patellar strap on knee joint proprioception in both healthy participants and in patients with patellar tendinopathy (PT). Secondary aims are to examine whether there is a difference in effectiveness of the use of a patellar strap between participants with low and high proprioceptive acuity and if possible predictors of effectiveness can be determined.Design: Case-control.Methods: The threshold to detect passive motion with and without a patellar strap was assessed in 22 healthy participants and 21 unilateral PT patients.Results: The results from the mixed model analysis show that in both groups of participants a small but statistically significant improvement in proprioception was found, primarily in those who had low proprioceptive acuity. A notable finding was that in the symptomatic leg of the PT group no improvement in proprioception by wearing a strap could be determined. Male gender and having fewer symptoms were possible predictors of effectiveness in PT patients.Conclusions: As proprioception plays a role in optimising movements and reducing load to joint-related structures like tendons and ligaments, it is considered an important protection mechanism. Although the improvements in proprioception as a result of wearing the strap are small, it might be that the use of a patellar strap can potentially play a role in injury prevention since poor proprioception can be a risk factor for (re)-injury. (C) 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Objectives: To investigate the prognosis and possible prognostic factors of running-related injuries (RRIs) in novice runners.Design: Prospective cohort study.Methods: Participants of Start to Run, a 6-weeks course for novice runners in The Netherlands, were asked to participate in this study. Before the start of the course a baseline questionnaire, on demographics, physical activity and perceived health, was sent to runners willing to participate. The 26- or 52-weeks follow-up questionnaires assessed information on RRIs and their duration. Only participants that sustained a RRI during follow-up were included in the analyses. An injury duration of 10 weeks or shorter was regarded as a relatively good prognosis, while an injury duration of more than 10 weeks was defined as a poor prognosis. To determine the associations between baseline characteristics and injury prognosis and between injury location and injury prognosis, multivariable logistic regression analyses were performed.Results: 347 participants (48.8%) sustained an RRI during follow-up. The RRIs had an overall median duration of eight weeks (range: 1-52 weeks). Participants with a previous RRI were more likely to have a poor prognosis (OR 2.31; 95%CI 1.12-4.79), while a calf injury showed a trend towards an association with a relatively good prognosis (OR 0.49; 95%CI 0.22-1.11).Conclusions: The duration of RRIs in novice runners is relatively long, with only calf injuries being associated with a good prognosis. This emphasizes the need of injury prevention measures in novice runners and adequate support during and after an RRI, especially in runners with a previous injury. (C) 2018 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Although injury surveillance in athletics is routinely conducted, discipline-specific Achilles and patellar tendinopathy prevalence remains unknown. The purpose of this study was to explore discipline-specific tendinopathy prevalence and identify whether injury-specific risk factors differed in athletes. Elite athletes were recruited and provided information on their sport training including Achilles and patellar tendon pain history. In order to ascertain whether between-discipline differences existed, data were categorized into discipline groups. Middle-distance athletes reported the highest prevalence of Achilles tendinopathy and the combined athletes reported the highest patellar tendinopathy prevalence. Greater calf stiffness was reported in athletes who experienced Achilles tendinopathy compared to those who did not. A substantial portion of athletes believed their performance decreased as a result of their tendon pain. In order to develop discipline-specific evidence-based injury prevention programmes, further discipline-specific research is required to quantify the mechanism for Achilles and patellar tendinopathy development in elite athletics.

Greater insight into sports and work performance of athletes with patellar tendinopathy (PT) will help establish the severity of this common overuse injury. Primary aim of this study is to investigate the impact of PT on sports and work performance. Seventy seven active athletes with PT (50 males; age 28.1 +/- 8.2years; Victorian Institute of Sports Assessment Patella 56.4 +/- 12.3) participated in this survey. Sports performance, work ability and work productivity were assessed using the Oslo Sports Trauma Research Center overuse injury questionnaire, the single-item Work Ability Index and the Quantity and Quality questionnaire, respectively. Reduced sports performance was reported by 55% of the participants; 16% reported reduced work ability and 36% decreased work productivity, with 23% and 58%, respectively, for physically demanding work. This study shows that the impact of PT on sports and work performance is substantial and stresses the importance of developing preventive measures.

ObjectivesClinicians should not only know how many patients will benefit from alpha-blocker therapy but should also be able to identify who will benefit. We studied the changes in patient symptoms following alpha-blocker therapy and the predictors of symptom improvement in clinical practice.DesignThis was a single-arm, open-label observational cohort study with a 6-week follow-up.SettingTwenty-two pharmacies in the Netherlands.ParticipantsPatients were eligible for inclusion if they attended a pharmacy with a new prescription for an alpha-blocker from a general practitioner or urologist.Primary and secondary outcomesOutcomes were assessed using the International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire Short Form (OAB-q SF), and Patient Global Impression of Improvement (PGI-I). Demographic, disease-related, and drug-related information were collected to identify predictors of symptom improvement. These predictors were then assessed by logistic and linear regression analyses of both the original data set and an imputed data set that accounted for the missing variables.ResultsDuring the study, 37% of patients with lower urinary tract symptoms perceived clear symptomatic improvement based on the results of the PGI-I. Improvement was more likely in those who still used alpha-blockers at the end of the 6-week study period and in those who used multiple medications. Although symptom scores decreased significantly on the IPSS and OAB-q SF, the only predictor of change was the pretreatment symptom severity.ConclusionsApproximately one-third of our cohort perceived symptom improvement on alpha-blocker therapy. However, we identified no clear predictors of who might benefit from alpha-blocker treatment, indicating that alpha-blockers should still be prescribed on a trial basis.

OBJECTIVE:: To describe absenteeism and health care utilization (HCU) within 6 weeks after occurrence of running-related injuries (RRIs) among novice runners and to explore differences relating to injury and personal characteristics. DESIGN:: Prospective cohort study. SETTING:: Primary care. PARTICIPANTS:: One thousand six hundred ninety-six novice runners (18-65 years) participating in a 6-week running program (“Start-to-Run”). MAIN OUTCOME MEASURES:: Injury characteristics were assessed by weekly training logs and personal characteristics by a baseline questionnaire. Data on absenteeism and HCU were collected using questionnaires at 2 and 6 weeks after the RRI occurred. RESULTS:: A total of 185 novice runners (11%) reported an RRI during the 6-week program. Of these injured novice runners, 78% reported absence from sports, whereas only 4% reported absence from work. Fifty-one percent of the injured novice runners visited a health care professional, mostly physical therapists (PTs) rather than physicians. Absenteeism was more common among women than men and was also more common with acute RRIs than gradual-onset RRIs. As regards HCU, both the variety of professionals visited and the number of PT visits were higher among runners with muscle–tendon injuries in the ankle/foot region than among those with other RRIs. CONCLUSIONS:: Among novice runners sustaining an RRI during a 6-week running program, over three quarters reported short-term absence from sports, whereas absence from work was very limited, and over half used professional health care. Both absence and HCU are associated with injury characteristics. CLINICAL RELEVANCE:: In future running promotion programs (eg in Start-to-Run programs), specific attention should be paid to acute injuries and to muscle–tendon injuries in the ankle/foot region.

Shockwave treatments are commonly used in the management of tendon injuries and there is increasing evidence for its clinical effectiveness. There is a paucity of fundamental (in vivo) studies investigating the biological action of shockwave therapy. Destruction of calcifications, pain relief and mechanotransduction-initiated tissue regeneration and remodeling of the tendon are considered to be the most important working mechanisms. The heterogeneity of systems (focussed shockwave therapy vs. radial pressurewave therapy), treatment protocols and study populations, and the fact that there seem to be responders and non-responders, continue to make it difficult to give firm recommendations with regard to the most optimal shockwave therapy approach. Specific knowledge with regard to the effects of shockwave therapy in patients with metabolic tendon disorders is not available. Further fundamental and clinical research is required to determine the value of shockwave therapy in the management of tendinopathy.

Objectives: Despite several consensus statements, different injury definitions are used in the literature. This study aimed to identify the impact of different injury definitions on the nature and incidence of complaints captured during a short-term running program for novice runners.Design: Prospective cohort study.Methods: 1696 participants completed weekly diaries on running exposure and musculoskeletal complaints during a 6-week running program. These data were used to compare six different injury definitions (presence of running-related pain, training-reduction, time-loss of.one day or one week). Injuries were registered under these different definitions. Consequently incidence and the nature of complaints were compared between definitions.Results: The different injury definitions resulted in incidences that varied between 7.5% and 58.0%, or 18.7 and 239.6 injuries per 1000 h of running. The median duration of injury complaints was 4-7 days for injuries registered under a 'day definition', while complaints registered under a 'week definition' lasted 20-22 days. For running-related pain injuries the median of the maximum amount of pain was 3.0. In training-reduction and time-loss injuries these median values were scored between 5.0 and 7.0. No significant differences in anatomical locations between injuries that were registered under a 'day definition' or a 'week definition' were found. Injuries registered under a time-loss definition were located relatively more often at the knee, while complaints at the pelvis/sacrum/buttock were captured more often under a running-related pain definition.Conclusions: Injury definitions largely impact injury incidence. Location of injury is also affected by choice of injury definition. This stressed the need for standardized injury registration methods. (C) 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Background Vertical ground reaction force (VGRF) parameters have been implicated as a cause of several running-related injuries. However, no systematic review has examined this relationship. Aim We systematically reviewed evidence for a relation between VGRF parameters and specific running-related injuries. Methods MEDLINE, Web of Science and EMBASE databases were searched. Two independent assessors screened the articles and rated the methodological quality. The 3 key VGRF parameters we measured were vertical loading rate, impact/passive peak (Fz1) and propulsive/active peak (Fz2). Standardised mean differences of these parameters were calculated using a random-effects model. Meta-regression was performed using injury type, study type and methodological quality as factors. Results The search yielded 2016 citations and 18 met the inclusion criteria for the systematic review. The loading rate was higher in studies that included patients with a history of stress fractures and patients with all injury types, both compared with controls. Only studies that included patients with a history of symptoms at the time of kinetic data collection showed higher loading rates overall in cases than in controls. There were no differences between injured subjects and controls for the active and passive peaks of the VGRF. Summary The loading rate is higher in respondents with a history of stress fractures than in respondents without running injuries. Owing to the absence of prospective studies on other injury types, it is not possible to draw definite conclusions regarding their relation with loading rate.

Patellar tendinopathy (PT) is an injury with a high prevalence in sports. Knowledge of risk factors is essential for developing preventive measures and rehabilitation programmes. However, risk factors associated with PT have not yet been systematically studied. This review was undertaken to identify risk factors associated with PT. The literature was systematically searched to identify articles that investigated risk factors for PT. There was no strong or moderate evidence that any investigated risk factor was associated with PT. For nine risk factors there was some evidence: weight, body mass index, waist-to-hip ratio, leg-length difference, arch height of the foot, quadriceps flexibility, hamstring flexibility, quadriceps strength and vertical jump performance. Based on the present evidence, reducing body weight, increasing upper-leg flexibility and quadriceps strength and the use of orthotics may be beneficial treatment options. However, it should be stressed that the evidence for the nine identified risk factors was only limited. Therefore, there is a clear need for high-quality studies in order to identify the exact risk factors associated with PT.