Whole body coordination and knee movement control during five rehabilitation exercises

Knee rehabilitation exercises to improve motor control, target movement fluency and displacement variability. Although knee movement in the frontal plane during exercise is routinely assessed in clinical practice, optimal knee control remains poorly understood. In this study, twenty-nine healthy participants (height: 1.73±0.11 m, mass: 73.5±16.4 kg, age: 28.0±6.9 years) performed four repetitions of five rehabilitation exercises whilst motion data were collected using the VICON PlugInGait full body marker set. Fluency and displacement variability were calculated for multiple landmarks, including Centre of Mass (CoM) and knee joint centres. Fluency was calculated as the inverse of the average number of times a landmark velocity in the frontal plane crossed zero. Variability was defined as the standard deviation of the frontal plane movement trajectories. CoM fluency and displacement variability were significantly different between tasks (p<0.001). CoM displacement variability was consistently smallest compared to the constituent landmarks (p<0.005). This was interpreted as a whole body strategy of compensatory variability constraining CoM frontal plane movement. Ipsilateral knee fluency (p<0.01) and displacement variability (p<0.001) differed substantially between tasks. The role of the weight-bearing knee seemed dependent on task constraints of the overall movement and balance, as well as constraints specific for knee joint stability

Musculoskeletal care pathways for adults

Background: Musculoskeletal (MSK) conditions are the most frequently reported chronic conditions and one of the biggest causes of disability in the UK. Given the ageing population and the impact of these problems, the demand for MSK treatment will rise. Despite reduced waiting times, MSK pathways have remained variable and inconsistent and need to be improved to meet patient needs. The aim of this systematic review is to understand the evidence for the effectiveness of current models of service delivery and care pathways for adult hip/knee pain patients accessing secondary care for specialist opinions. Methods: MEDLINE, MEDLINE In-Process, CINAHL, Embase, PEDro, PubMed, Web of Science, Cochrane Central and HMIC databases will be searched without language restrictions for papers published from 1990 onward. Websites will be reviewed for grey literature including care pathways, policy documents and unpublished MSK research. Additionally, reference lists will be checked and citations tracked for included studies. Discussion: The following evidence will be included: research considering care pathways at the intersection between primary and secondary care for adults with hip and/or knee pain in countries with an established clinical pathway. Studies considering generalised inflammatory arthropathy and post-surgical care pathways will be excluded. Screening for included data will be conducted independently by two reviewers. After benchmarking, quality assessment and data extraction will be conducted by one reviewer and checked by a second. A mixed method analysis will be conducted. This systematic review will be used as part of a programme of research to identify best practice for MSK hip and knee pain care pathways. It will provide recommendations for pathway re-design to meet patient needs and ensure efficient streamlining of the patient journey. The review will combine a wide range of information sources including patient and clinician opinion, clinical guidelines, health service delivery research and stakeholder requirements. This should result in a pathway that provides better patient experience and outcomes, whilst meeting the demands placed on the NHS for high-quality evidence-based interventions with efficient use of resources

Acceptability of a digital healthintervention alongside physiotherapy to support patients following anterior cruciateligament reconstruction

Background: Physiotherapy rehabilitation following surgical reconstruction to the Anterior Cruciate Ligament (ACL) can take up to 12 months to complete. Given the lengthy rehabilitation process, a blended intervention can be used to compliment face-to-face physiotherapy with a digital exercise intervention. In this study, we used TRAK, a web–based tool that has been developed to support knee rehabilitation, which provides individually tailored exercise programs with videos, instructions and progress logs for each exercise, relevant health information and a contact option that allows a patient to email a physiotherapist for additional support. The aim of this study was to evaluate the acceptability of TRAK–based blended intervention in post ACL reconstruction rehabilitation. Methods: A qualitative research design using semi-structured interviews was used on a convenience sample of participants following an ACL reconstruction, and their treating physiotherapists, in a London NHS hospital. Participants were asked to use TRAK alongside face-to-face physiotherapy for 16 weeks. Interviews were carried out, audio recorded, transcribed verbatim and coded by two researchers independently. Data were analyzed using thematic analysis. Results: Of the 25 individuals that were approached to be part of the study, 24 consented, comprising 8 females and 16 males, mean age 30 years. 17 individuals used TRAK for 16 weeks and were available for interview. Four physiotherapists were also interviewed. The six main themes identified from patients were: the experience of TRAK rehabilitation, personal characteristics for engagement, strengths and weaknesses of the intervention, TRAK in the future and attitudes to digital healthcare. The main themes from the physiotherapist interviews were: potential benefits, availability of resources and service organization to support use of TRAK. Conclusions: TRAK was found to be an acceptable method of delivering ACL rehabilitation alongside face-to-face physiotherapy. Patients reported that TRAK, specifically the videos, increased their confidence and motivation with their rehabilitation. They identified ways in which TRAK could be developed in the future to meet technological expectations and further support rehabilitation. For Physiotherapists time and availability of computers affected acceptability. Organization of care to support integration of digital exercise interventions such as TRAK into a blended approach to rehabilitation is required

Integrating self-management support for knee injuries into routine clinical practice: TRAK intervention design and delivery

Background TRAK is a web-based intervention that provides knee patients with health information, personalised exercise plans and remote clinical support. The aim of this study was to fully define TRAK intervention content, setting and context and develop the training through an implementation study in a physiotherapy out-patient service. Methods A mixed methods study. Phase 1 was a qualitative interview study, whereby fifteen physiotherapists used TRAK for 1 month with a patient of their choice. Interviews explored patient and physiotherapist views of TRAK intervention and training requirements. In Phase 2 seventy-four patients were recruited, all received conventional physiotherapy, a subset of 48 patients used TRAK in addition to conventional Physiotherapy. Aspects of feasibility measured included: uptake and usage of TRAK. Results Patients and physiotherapists reported that TRAK was easy to use and highlighted the therapeutic benefit of the exercise videos and personalised exercise plans to remind them of their exercises and the correct technique. Patients reported needing to use TRAK with the guidance of their treating physiotherapist initially. Physiotherapists highlighted appointment time constraints and lack of familiarity with TRAK as factors limiting engagement. In Phase 2, 67% patients accessed TRAK outside of the clinical environment. A total of 91% of patients were given a personalised exercise plan, but these were only updated in 34% of cases. Conclusion A comprehensive training package for patients and clinicians has been defined. The refined TRAK intervention is reported using the ‘Template for Intervention Description and Replication in preparation for a definitive randomised control trial

Inertial measurement units for clinical movement analysis: reliability and concurrent validity

The aim of this study was to investigate the reliability and concurrent validity of a commercially available inertial-sensor-based motion capture system, Xsens MVN BIOMECH, during clinically relevant functional activities. A clinician with no prior experience of motion capture technologies and an experienced clinical movement scientist each assessed 26 healthy participants within each of two sessions using a camera-based motion capture system and the MVN BIOMECH system. Participants performed overground walking, squatting, and jumping. Sessions were separated by 4 ± 3 days. Reliability was evaluated using intraclass correlation coefficient and standard error of measurement, and validity was evaluated using the coefficient of multiple correlation and the linear fit method. Day-to-day reliability was generally fair-to-excellent in all three planes for hip, knee, and ankle joint angles in all three tasks. Within-day (between-rater) reliability was fair-to-excellent in all three planes during walking and squatting, and poor-to-high during jumping. Validity was excellent in the sagittal plane for hip, knee, and ankle joint angles in all three tasks and acceptable in frontal and transverse planes in squat and jump activity across joints. Our results suggest that the MVN BIOMECH system can be used by a clinician to quantify lower-limb joint angles in clinically relevant movements

Augmented feedback approach to double-leg squat training for patients with knee osteoarthritis: a preliminary study

The aim of this preliminary study was to explore the effects of two types of augmented feedback on the strategy used by healthy participants and patients with knee osteoarthritis (OA) to perform a double-leg squat. Seven patients with knee OA and seven healthy participants performed three sets of eight double-leg squats: one without feedback, one with real-time kinematic feedback and one with real-time kinetic feedback. Kinematic and kinetic outcome measures (peak knee flexion angle, peak knee extensor moment, and symmetry of the support knee moment between the injured and non-injured knees) demonstrate the potential influence of real-time kinetic feedback on the motor strategy used to perform a double-leg squat in both groups. This feedback could be used to develop more efficient and effective motor strategies for squatting in patients with knee OA and further evaluation is warranted

Patient triage by topic modelling of referral letters: Feasibility study

Background: Musculoskeletal conditions are managed within primary care but patients can be referred to secondary care if a specialist opinion is required. The ever increasing demand of healthcare resources emphasizes the need to streamline care pathways with the ultimate aim of ensuring that patients receive timely and optimal care. Information contained in referral letters underpins the referral decision-making process but is yet to be explored systematically for the purposes of treatment prioritization for musculoskeletal conditions. Objective: This study aims to explore the feasibility of using natural language processing and machine learning to automate triage of patients with musculoskeletal conditions by analyzing information from referral letters. Specifically, we aim to determine whether referral letters can be automatically assorted into latent topics that are clinically relevant, i.e. considered relevant when prescribing treatments. Here, clinical relevance is assessed by posing two research questions. Can latent topics be used to automatically predict the treatment? Can clinicians interpret latent topics as cohorts of patients who share common characteristics or experience such as medical history, demographics and possible treatments? Methods: We used latent Dirichlet allocation to model each referral letter as a finite mixture over an underlying set of topics and model each topic as an infinite mixture over an underlying set of topic probabilities. The topic model was evaluated in the context of automating patient triage. Given a set of treatment outcomes, a binary classifier was trained for each outcome using previously extracted topics as the input features of the machine learning algorithm. In addition, qualitative evaluation was performed to assess human interpretability of topics. Results: The prediction accuracy of binary classifiers outperformed the stratified random classifier by a large margin giving an indication that topic modelling could be used to predict the treatment thus effectively supporting patient triage. Qualitative evaluation confirmed high clinical interpretability of the topic model. Conclusions: The results established the feasibility of using natural language processing and machine learning to automate triage of patients with knee and/or hip pain by analyzing information from their referral letters

Early detection and rehabilitation of functional recovery for acutely injured anterior cruciate ligament deficient individuals using clinical and biomechanical outcomes

BACKGROUND: The purpose of this study was firstly to evaluate functional recovery following anterior cruciate ligament (ACL) rupture from acute injury over the course of rehabilitation. Insights from this analysis were then used to integrate movement feedback into rehabilitation to investigate if this resulted in improved functional outcome and participation level following this injury. METHOD: In the initial modelling phase a prospective repeated measures longitudinal design was used to measure functional recovery from acute injury over time of 63 ACL patients and 61 matched controls, using a two dimensional (2D) video based analysis system. Time-distance variables and joint angles for gait, jog, distance hop and run and stop were analysed monthly. A least squares 3rd order polynomial was used to model the functional recovery of ACLD (anterior cruciate ligament deficient) individuals and functional sub-groups. A second exploratory study using a prospective cohort design compared recovery between 115 ACLD individuals randomized into movement feedback (FB) and no feedback (no-FB) rehabilitation. The feedback criterion was based on the movement data from the longitudinal analysis of functional recovery. Independent t-tests were used to evaluate group differences at 5 months post injury. Semi structured interviews evaluated the physiotherapists usage of the feedback and rehabilitation given to the ACLD patients. RESULTS: Functional recovery was found on average to take 3 months for gait and 5 months for hopping. ACLD non-copers were distinguishable at 40 days post injury due to failure of gait variables to recover to within 'normal limits'. In study two 52 ACLD subjects were followed up at 5 months post injury. No statistically significant differences in functional performance between the FB and no-FB groups were found (p&lt;0.05), for any of the movement variables for gait, one legged squat, distance hop or run and stop. Physiotherapists treating the FB group reported difficulties interpreting the movement feedback, incorporating it into rehabilitation due to its timing and identified a perceived learning effect on treatment. DISCUSSION: Functional recovery was successfully modelled and shown to take longer than expected. This has implications for advising patients on recovery times and length of time for attendance at rehabilitation. Further clarification is required but failure of simple gait variables to recover by 40 days post injury could direct ACLD management. If the potential for recovery can be identified early then the appropriate treatment can be given. Incorporating this type of movement feedback into rehabilitation did not result in improved functional outcome or level of participation. Factors related to its application and insufficient patient numbers at follow-up may have weakened the experimental treatment effect and the power of the study. The modelling and exploratory phases of this investigation need to be revisited to identify the most relevant variables for feedback, refine functional cut-off scores, develop methods that allow feedback to be delivered immediately and more focused training for physiotherapists before progress to a randomized control trial can be considered. This study demonstrated that the clinically based video analysis system provided detailed insight at all stages of rehabilitation on the speed, timing and completeness of recovery for functional tasks that are directly relevant to the rehabilitation goals

A scoping review of the resources needed to deliver anterior cruciate ligament physiotherapy rehabilitation in randomised controlled trials

Background: The Anterior Cruciate Ligament (ACL) stabilises the knee and is commonly injured in sport. Surgical repair and rehabilitation are common. However, rehabilitation randomised controlled trials do not always report the resources used to deliver ACL rehabilitation. This may lead to suboptimal availability of resources for evidence based care. Objective: To identify the resources used to deliver multimodal ACL rehabilitation in randomised controlled trials Methods: Comprehensive searches, combining ‘anterior cruciate ligament’, and ‘rehabilitation’ with the Cochrane RCT filter, were conducted of Medline, Embase, Cinahl, PeDro, Sports Discus and the Cochrane Library. Adults post ACL reconstruction were included. The intervention and comparator were physiotherapy for post-operative rehabilitation. Outcomes were the resources required to deliver rehabilitation, and study type was randomised controlled trials. Papers were screened against the criteria; data were charted and narrative synthesis applied. Results: Fourteen studies reported on 599 patients. The interventions ranged from 4 to 36 weeks. Physiotherapy was typically an hour and ranged from 1 to 5 sessions/week. Resources included a gym environment with rehabilitation equipment such as resistance machines, free weights, cardiovascular and neuromuscular control equipment, and an experienced physiotherapist. Conclusions: Implications for future studies include the need for a more detailed report of the resources used in RCTs. Accurate reporting would help healthcare decision makers to effectively manage resources when implementing evidence based care. Findings can be considered as criteria against which to audit resource provision