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Head kinematics associated with off-field head injury assessment (HIA1) events in a season of English elite-level club men's and women's rugby union matches.Objectives: The purpose of this study was to investigate head kinematic variables in elite men's and women's rugby union and their ability to predict player removal for an off-field (HIA1) head injury assessment. Methods: Instrumented mouthguard (iMG) data were collected for 250 men and 132 women from 1865 and 807 player-matches, respectively, and synchronised to video-coded match footage. Head peak resultant linear acceleration (PLA), peak resultant angular acceleration (PAA) and peak change in angular velocity (dPAV) were extracted from each head acceleration event (HAE). HAEs were linked to documented HIA1 events, with ten logistical regression models for men and women, using a random subset of non-case HAEs, calculated to identify kinematic variables associated with HIA1 events. Receiver operating characteristic curves (ROC) were used to describe thresholds for HIA1 removal. Results: Increases in PLA and dPAV were significantly associated with an increasing likelihood of HIA1 removal in the men's game, with an OR ranging from 1.05-1.12 and 1.13-1.18, respectively. The optimal values to maximise for both sensitivity and specificity for detecting an HIA1 were 1.96 krad⋅s-2, 24.29 g and 14.75 rad⋅s-1 for PAA, PLA and dPAV, respectively. Only one model had any significant variable associated with increasing the likelihood of a HIA1 removal in the women's game-PAA with an OR of 8.51 (1.23-58.66). The optimal values for sensitivity and specificity for women were 2.01 krad⋅s-2, 25.98 g and 15.38 rad⋅s-1 for PAA, PLA and dPAV, respectively. Conclusion: PLA and dPAV were predictive of men's HIA1 events. Further HIA1 data are needed to understand the role of head kinematic variables in the women's game. The calculated spectrum of sensitivity and specificity of iMG alerts for HIA1 removals in men and women present a starting point for further discussion about using iMGs as an additional trigger in the existing HIA process.
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Brachial plexus neuropathies during the COVID-19 pandemic: a retrospective case series of 15 patients in critical careObjective: The use of the prone position to treat patients with COVID-19 pneumonia who are critically ill and mechanically ventilated is well documented. This case series reports the location, severity, and prevalence of focal peripheral nerve injuries involving the upper limb identified in an acute COVID-19 rehabilitation setting. The purpose of this study was to report observations and to explore the challenges in assessing these patients. Methods: Participants were patients with suspected peripheral nerve injuries following discharge from COVID-19 critical care who were referred to the peripheral nerve injury multidisciplinary team. Data were collected retrospectively on what peripheral neuropathies were observed, with reference to relevant investigation findings and proning history. Results: During the first wave of the COVID-19 pandemic in the United Kingdom, 256 patients were admitted to COVID-19 critical care of Queen Elizabeth Hospital, Birmingham, United Kingdom. From March to June 2020, a total of 114 patients required prone ventilation. In this subgroup, a total of 15 patients were identified with clinical findings of peripheral nerve injuries within the upper limb. In total, 30 anatomical nerve injuries were recorded. The most commonly affected nerve was the ulnar nerve (12/30) followed by the cords of the brachial plexus (10/30). Neuropathic pain and muscle wasting were identified, signifying a high-grade nerve injury. Conclusion: Peripheral nerve injuries can be associated with prone positioning on intensive care units, although other mechanisms, such as those of a neuroinflammatory nature, cannot be excluded. Impact: Proning-related upper limb peripheral nerve injuries are not discussed widely in the literature and could be an area of further consideration when critical care units review their proning protocols. Physical therapists treating these patients play a key part in the management of this group of patients by optimizing the positioning of patients during proning, making early identification of peripheral nerve injuries, providing rehabilitation interventions, and referring to specialist services if necessary. Lay summary: During the COVID-19 pandemic, patients who are very ill can be placed for long periods of time on their stomach to improve their chances of survival. The potential consequences of prolonged time in this position are weakness and pain in the arms due to potential nerve damage. There are some recommended treatments to take care of these problems.
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Safe and well-tolerated long-term parenteral nutrition regimen: Omega-3-fatty-acid-enriched medium chained/ long chained triglycerides emulsionBackground and aims: A limited number of randomized controlled trials (RCTs) have examined the use of lipid emulsions (LEs) of different compositions in home parenteral nutrition (HPN), and there are very few data on the long-term use of omega-3 (n-3) polyunsaturated fatty acids (PUFAs). The study's objective was to assess safety and tolerability of an n-3 PUFA-enriched LE in adult patients suffering from chronic intestinal failure (CIF) requiring long-term HPN. Methods: In this prospective, randomized, controlled, double-blind, multicentre, international clinical trial, which was conducted at eleven sites, adult patients in need of HPN including lipids received either the investigational product, an n-3 PUFA-enriched medium/long-chain triglyceride (MCT/LCT) LE, or the reference product, a standard MCT/LCT LE, for an average duration of eight weeks. The primary outcome was the sum of changes of liver function parameters (total bilirubin, aspartate transaminase and alanine transaminase) from baseline to final visit. Secondary objectives included fatty acid pattern in plasma and red blood cells (RBCs) and triene:tetraene ratio in plasma. Results: 74 patients were enrolled up to premature study termination. Liver function parameters showed no clinically relevant differences between study groups and remained within normal ranges. The n-3 PUFAs EPA and DHA increased in plasma and RBCs in the Lipidem group and were higher in the Lipidem group than the reference group at the end of the study resulting in an increased n-3-index in RBCs with Lipidem. Average n-3-index was >8. The plasma triene:tetraene ratio decreased in both groups. Conclusion: This study is one of the largest comparing two LEs in the complex setting of HPN treatment of adult patients. Although it has been early terminated its results considerably contribute to the evidence on safety and efficacy of longer-term use of LEs in HPN treatment. The n-3 PUFA-enriched LE Lipidem was safe and well-tolerated, particularly in terms of liver function. Lipidem provided an additional supply of n-3 PUFAs and led to positive changes in fatty acid profiles of plasma and RBCs. The n-3-index was in the desirable range at the end of the study in patients receiving Lipidem. There was no evidence of essential fatty acid deficiency with Lipidem.
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Use of commercially available wearable devices for physical rehabilitation in healthcare: a systematic reviewObjectives: To evaluate whether commercially available 'off-the-shelf' wearable technology can improve patient rehabilitation outcomes, and to categorise all wearables currently being used to augment rehabilitation, including the disciplines and conditions under investigation. Design: Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 statement checklist, and using the Grading of Recommendations, Assessment, Development and Evaluation approach. Data sources: Embase, MEDLINE, Web of Science and the Cochrane Library were searched up to and including July 2023. Eligibility criteria: We included trials and observational studies evaluating the use of consumer-grade wearables, in real patient cohorts, to aid physical therapy or rehabilitation. Only studies investigating rehabilitation of acute events with defined recovery affecting adult patients were included. Data extraction and synthesis: Two independent reviewers used a standardised protocol to search, screen and extract data from the included studies. Risk of bias was assessed using the Cochrane Methods Risk of Bias in Randomised Trials V.2 and Risk of Bias in Non-Randomised Studies of Interventions tools for randomised controlled trials (RCTs) and observational studies, respectively. Results: Eighteen studies encompassing 1754 patients met eligibility criteria, including six RCTs, six quasi-experimental studies and six observational studies. Eight studies used wearables in Orthopaedics, seven in Stroke Medicine, two in Oncology and one in General Surgery. All six RCTs demonstrated that wearable-driven feedback increases physical activity. Step count was the most common measure of physical activity. Two RCTs in orthopaedics demonstrated non-inferiority of wearable self-directed rehabilitation compared with traditional physiotherapy, highlighting the potential of wearables as alternatives to traditional physiotherapy. All 12 non-randomised studies demonstrated the feasibility and acceptability of wearable-driven self-directed rehabilitation. Conclusion: This review demonstrates that consumer-grade wearables can be used as adjuncts to traditional physiotherapy, and potentially as alternatives for self-directed rehabilitation of non-chronic conditions. Better designed studies, and larger RCTs, with a focus on economic evaluations are needed before a case can be made for their widespread adoption in healthcare settings.
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The role of first contact physiotherapists in the identification and management of vertebral fragility fractures and osteoporosis : a case reportPurpose: Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture and a powerful predictor of further future vertebral and/or hip fracture without treatment. These fractures cause significant morbidity and risk of mortality. Therefore, identification of a recent VFF is an indication to consider specialist osteoporosis anabolic drug treatment. However, recognition of the signs and symptoms of VFF remains a challenge, with up to 70% going undiagnosed. The evolving role of First Contact Physiotherapists (FCPs) in primary care presents an opportunity for physiotherapists to help reduce the Osteoporosis Care Gap, but little is known about their scope of practice for osteoporosis. Methods: A case report was written to demonstrate an example of the scope of practice of an Advanced Level FCP. A lady in her 70s presented to her GP surgery with lower back pain following a fall from a chair. Her medical history included hypothyroidism and hypercholesterolaemia. She had six consultations with various clinicians at the surgery and was prescribed analgesia, before being assessed by the FCP three months after onset. Despite having no tenderness to percussion over the thoracic or lumbar spinous processes, a diagnosis of VFF was suspected because of ongoing pain following low energy trauma, pain when sitting and lying supine, and an increased thoracic kyphosis. Results: The FCP referred the patient for urgent thoracic and lumbar x-rays, which confirmed VFF of T10 and L1. The patient was initially prescribed alendronic acid, calcium, and vitamin D. Blood tests were ordered to exclude secondary causes of osteoporosis. An urgent bone density scan was requested, alongside a referral to rheumatology for consideration of more potent anabolic drug treatment due to the high risk of future fracture. The patient was also referred to the falls service for exercise advice and home equipment. The patient was prescribed specialist osteoporosis drug treatment (romosozumab) under the care of rheumatology. One year later, she was not needing analgesia, and she had not had any further falls or fractures. Conclusion(s): This case report highlights the difficulty in diagnosing VFF, with several missed opportunities to refer for x-ray initially. A delayed diagnosis of VFF can result in suboptimal symptom management and subsequent increased healthcare utilisation, as well as missed opportunities to enact prompt secondary prevention and particularly specialist treatment, to reduce the risk of further fragility fractures. The FCP in this case report demonstrated advanced clinical reasoning, as well competency in radiology and bloods requesting and interpretation, non-medical independent prescribing, and timely appropriate onward referral. This highlights the valuable role FCPs can have in improving osteoporosis care. Impact: It is recognised that this case report cannot be used to demonstrate scope of practice and competency of all FCPs nationally. FCPs are required to complete a Roadmap to Practice demonstrating advanced level musculoskeletal knowledge and critical thinking, but there are no osteoporosis-specific competencies. Further research to ascertain osteoporosis knowledge and scope of practice amongst FCPs across the United Kingdom would be beneficial to highlight any training needs and establish best practice. 1st Keyword: “First Contact Physiotherapist” 2nd Keyword: “Vertebral fragility fracture” 3rd Keyword: Osteoporosis Ethics approval: The HRA decision-making tool was used, which confirmed that no ethical approval was required. Funding acknowledgements: This work was completed as part of the Birmingham Health Partners West Midlands Pre-Doctoral Bridging Programme but received no direct funding.
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Arachnoid cysts in athletes with sports-related concussion : a case series and literature reviewBackground: Arachnoid cysts (AC) are associated with a risk of rupture or haemorrhage following head impact and pose a potential predisposing factor for significant complications of sport-related concussion. Despite a recognised association between ACs and intracranial haemorrhage/cyst rupture, the risk profile of participating in contact sports with AC is not well defined. We report a retrospective case series of players presenting to the Birmingham Sports Concussion Clinic between 2017 and 2023 and underwent MRI head, with a comprehensive review of the prior literature. Results: 432 athletes underwent MRI of which 11 were identified to have AC (middle fossa n = 8; posterior fossa n = 2, intraventricular n = 1). Average maximal diameter was 4.1 ± 1.2 cm. 64% had a protracted recovery (≥ 3 months). 9% experienced an AC specific complication (cyst rupture, complete neurological recovery, maximal diameter 6.5 cm, Galassi II, 4 previous concussions). 91% of patients (mean maximal diameter 3.9 ± 1.0 cm) experienced no complications despite multiple previous accumulated sports-related concussions (mean 3.3, range 1-9). Case studies from the literature are summarised (n = 63), with 98% reporting complications, none of which resulted in adverse or unfavourable neurological outcomes. Across prospective and retrospective cohort studies, 1.5% had a structural injury, and (where outcome was reported) all had a favourable outcome. Conclusions: AC is an incidental finding in athletes, with the majority in our cohort having sustained serial concussions without AC complication. The single complication within this cohort occurred in the largest AC, and AC size is proposed as a tentative factor associated with increased risk of contact sports participation. Complications of AC appear to be a rare occurrence. This case series and review has not identified evidence to suggest that participation in sports with AC is of significant risk, though individualised assessment and discussion of the potential risks of contact sports participation should be offered.
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Exploring the experiences of people with obesity and post-bariatric surgery patients after three months using the mindful eating reflective practice: An interpretative phenomenological analysis.Background: Experiential dimensions of Mindful Eating Practices are scarce in the literature. Aim: The study focuses on thirteen individuals with clinical obesity and nine post-bariatric surgery patients who engaged in MERP over three months. Methods: The present research utilized Interpretative Phenomenological Analysis (IPA) as the analytical framework of interviews. Results: Four overarching themes emerged from the analysis: 1. "Enhanced Awareness of Eating": This theme underscores MERP's central emphasis on cultivating heightened mindfulness during food consumption, highlighting the importance of being present at the moment while eating; 2. "Facilitating the Transition to Healthier Eating Habits": This theme explores how MERP influences participants' dietary choices, eating pace, portion control, and overall enjoyment of meals. It reveals that MERP encourages individuals to reflect on their eating habits and transition towards healthier choices; 3. "Diverse Perspectives on Satisfaction with MERP": Within the context of MERP, participants held varied interpretations of satisfaction. Some encountered practical limitations or engaged in reflective self-examination, while others found sensory satisfaction, enhancing their overall eating experiences; and 4. "Utilization and Development of MERP": This theme delves into participants' patterns of using MERP. It reveals a tendency to avoid MERP in the morning, a gradual decline in its usage over time, and a preference for an electronic version of the practice. Conclusion: The MERP shows promise in improving overall eating habits by enhancing enjoyment of food, increasing awareness of body cues, promoting healthier choices, and encouraging mindful eating practices. These findings provide valuable insights for future research and the refinement of clinical tools aimed at effective weight management and the promotion of sustainable healthy eating practices by effectively addressing a significant gap in our understanding of the experiential facets of eating practices.
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Blood flow restriction training and its use in rehabilitation after anterior cruciate ligament reconstruction: a systematic review and meta-analysisBackground/Objectives: Anterior cruciate ligament (ACL) reconstruction (ACLR) is often followed by significant muscle atrophy and subsequent loss of strength. Blood flow restriction training (BFRT) has recently emerged as a potential mode of rehabilitation to mitigate these effects. The goal of this systematic review was to evaluate the efficacy of BFRT in functional recovery when compared to traditional rehabilitation methods. Methods: A literature review was conducted across July and August 2024 using multiple databases that reported randomised controlled trials comparing BFRT to traditional rehabilitation methods. Primary outcomes were changes to thigh muscle mass and knee extensor/flexor strength with secondary outcomes consisting of patient-reported functional measures (IKDC and Lysholm scores). The RoB-2 tool was used to assess the risk of bias. Results: Eight studies met the inclusion criteria; however, substantial heterogeneity prevented a meta-analysis being conducted for the primary outcomes. Three out of the five studies measuring muscle mass reported significant (p < 0.05) findings favouring BFRT. There was variation amongst the strength improvements, but BFRT was generally favoured over the control. Meta analysis of the secondary outcomes showed significant improvements (p < 0.05) favouring BFRT despite moderate heterogeneity. Conclusions: BFRT shows promise for maintaining muscle mass and improving patient reported outcomes following ACL reconstruction. However, the high risk of bias limits the strength of these conclusions. Further high-quality research needs to be conducted to establish optimal BFRT protocols for this cohort and to determine if BFRT has a place in ACL rehabilitation.
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National school food standards in England: a cross-sectional study to explore compliance in secondary schools and impact on pupil nutritional intake.Background: Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils' nutritional intake. Methods: We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes. Results: 36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0-70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake. Conclusions: English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered. Study registration: ISRCTN68757496 (17-10-2019).
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Player and match characteristics associated with head acceleration events in elite-level men's and women's rugby union matches.Objective: To examine the likelihood of head acceleration events (HAEs) as a function of previously identified risk factors: match time, player status (starter or substitute) and pitch location in elite-level men's and women's rugby union matches. Methods: Instrumented mouthguard data were collected from 179 and 107 players in the men's and women's games and synchronised to video-coded match footage. Head peak resultant linear acceleration (PLA) and peak resultant angular acceleration were extracted from each HAE. Field location was determined for HAEs linked to a tackle, carry or ruck. HAE incidence was calculated per player hour across PLA recording thresholds with 95% CIs estimated. Propensity was calculated as the percentage of contact events that caused HAEs across PLA recording thresholds, with a 95% CI estimated. Significance was assessed by non-overlapping 95% CIs. Results: 29 099 and 6277 HAEs were collected from 1214 and 577 player-matches in the men's and women's games. No significant differences in match quarter HAE incidence or propensity were found. Substitutes had higher HAE incidence than starters at lower PLA recording thresholds for men but similar HAE propensity. HAEs were more likely to occur in field locations with high contact event occurrence. Conclusion: Strategies to reduce HAE incidence need not consider match time or status as a substitute or starter as HAE rates are similar throughout matches, without differences in propensity between starters and substitutes. HAE incidence is proportional to contact frequency, and strategies that reduce either frequency or propensity for contact to cause head contact may be explored
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Achilles tendon ruptures related to fluoroquinolone use - How can we manage these patients? A case series.Background: Fluoroquinolone antibiotics can increase the risk of tendon rupture. Treatment of these Achilles ruptures can be difficult due to comorbidities. Methods: A case series of 13 consecutive patients with Achilles ruptures following fluoroquinolone use were identified over a 2 year period through the Achilles Tendon rupture clinic and managed conservatively using functional rehabilitation. Follow-up with the Achilles tendon rupture score (ATRS) was completed at 3 months, 6 months and 12 months. Results: Improvements were seen in ATRS scores over 12 months. Conclusions: This case series is the largest published. Improvements were seen in ATRS scores indicating that this cohort can be managed successfully using functional rehabilitation after fluoroquinolone-induced Achilles rupture.
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Special low protein foods prescribed in England for PKU patients: an analysis of prescribing patterns and cost.Patients with phenylketonuria (PKU) are reliant on special low protein foods (SLPFs) as part of their dietary treatment. In England, several issues regarding the accessibility of SLPFs through the national prescribing system have been highlighted. Therefore, prescribing patterns and expenditure on all SLPFs available on prescription in England (n = 142) were examined. Their costs in comparison to regular protein-containing (n = 182) and 'free-from' products (n = 135) were also analysed. Similar foods were grouped into subgroups (n = 40). The number of units and costs of SLPFs prescribed in total and per subgroup from January to December 2020 were calculated using National Health Service (NHS) Business Service Authority (NHSBSA) ePACT2 (electronic Prescribing Analysis and Cost Tool) for England. Monthly patient SLPF units prescribed were calculated using patient numbers with PKU and non-PKU inherited metabolic disorders (IMD) consuming SLPFs. This was compared to the National Society for PKU (NSPKU) prescribing guidance. Ninety-eight percent of SLPF subgroups (n = 39/40) were more expensive than regular and 'free-from' food subgroups. However, costs to prescribe SLPFs are significantly less than theoretical calculations. From January to December 2020, 208,932 units of SLPFs were prescribed (excluding milk replacers), costing the NHS £2,151,973 (including milk replacers). This equates to £962 per patient annually, and prescribed amounts are well below the upper limits suggested by the NSPKU, indicating under prescribing of SLPFs. It is recommended that a simpler and improved system should be implemented. Ideally, specialist metabolic dietitians should have responsibility for prescribing SLPFs. This would ensure that patients with PKU have the necessary access to their essential dietary treatment, which, in turn, should help promote dietary adherence and improve metabolic control.
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Protein source and quality for skeletal muscle anabolism in young and older adults: a systematic review and meta-analysisBackground: There is much debate regarding the source/quality of dietary proteins in supporting indices of skeletal muscle anabolism. Objective: We performed a systematic review and meta-analysis to determine the effect of protein source/quality on acute muscle protein synthesis (MPS) and changes in lean body mass (LBM) and strength, when combined with resistance exercise (RE). Methods: A systematic search of the literature was conducted to identify studies that compared the effects of ≥2 dose-matched, predominantly isolated protein sources of varying "quality." Three separate models were employed as follows: 1) protein feeding alone on MPS, 2) protein feeding combined with a bout of RE on MPS, and 3) protein feeding combined with longer-term resistance exercise training (RET) on LBM and strength. Further subgroup analyses were performed to compare the effects of protein source/quality between young and older adults. A total of 27 studies in young (18-35 y) and older (≥60 y) adults were included. Results: Analysis revealed an effect favoring higher-quality protein for postprandial MPS at rest [mean difference (MD): 0.014%/h; 95% CI: 0.006, 0.021; P < 0.001] and following RE (MD: 0.022%/h; 95% CI: 0.014, 0.030; P < 0.00001) in young (model 1: 0.016%/h; 95% CI: -0.004, 0.036; P = 0.12; model 2: 0.030%/h; 95% CI: 0.015, 0.045; P < 0.0001) and older (model 1: 0.012%/h; 95% CI: 0.006, 0.018; P < 0.001; model 2: 0.014%/h; 95% CI: 0.007, 0.021; P < 0.001) adults. However, although higher protein quality was associated with superior strength gains with RET [standardized mean difference (SMD): 0.24 kg; 95% CI: 0.02, 0.45; P = 0.03)], no effect was observed on changes to LBM (SMD: 0.05 kg; 95% CI: -0.16, 0.25; P = 0.65). Conclusions: The current review suggests that protein quality may provide a small but significant impact on indices of muscle protein anabolism in young and older adults. However, further research is warranted to elucidate the importance of protein source/quality on musculoskeletal aging, particularly in situations of low protein intake.
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Patient lived experiences of functioning and disability following lumbar discectomy: a secondary analysis of qualitative dataBackground: Knowledge of patient lived experiences of functioning and disability is limited. This study aims to address the gap in the literature by exploring patient lived experiences of functioning and disability following lumbar discectomy. Method: A secondary analysis, reported in line with the Standards for Reporting Qualitative Research, was conducted of qualitative data exploring patient journeys following lumbar discectomy surgery (DiscJourn). Adult patients (≥ 16 years) undergoing elective or emergency primary lumbar discectomy were recruited from one National Health Service secondary care centre in the UK. Semi-structured interviews were conducted at 1-3 weeks and 1-year post surgery. Participants who completed both semi-structured interviews were eligible for the secondary analysis. Transcripts from the semi-structured interviews were analysed using interpretative phenomenological analysis (IPA). IPA involved two independent reviewers identifying themes for individual data sets followed by an iterative process involving the wider research team to identify overarching themes that represented the whole date set. Subthemes generated from the IPA were mapped against the International Classification of Functioning, Disability and Health (ICF) framework at the level of chapters, in order to ascertain the ICF's utility in capturing experiences of functioning and disability. Strategies to enhance trustworthiness of data analysis included blind coding, peer examination and debrief, declaration of pre-conceived beliefs and active reflexivity throughout the study. Results: Nine participants met the eligibility criteria and their interview transcripts were analysed. Patient lived experiences of functioning and disability were captured by three overarching themes: Immediate impact following surgery, Multiple roads to recovery over 1 year, and Functioning influenced by personal loci of control. Each theme consisted of three subthemes which were subsequently mapped onto the ICF. Three subthemes mapped to the ICF's body component, 1 to activity and participation and 3 to environment. Two subthemes themes did not map onto the ICF. Conclusion: Findings provide valuable insights into patient experiences of functioning and disability following lumbar discectomy. Convergence in experiences of functioning and disability were identified immediately following surgery. Divergence in such experiences were identified with regards to the roads to recovery over 1 year and the individuals' locus of control. Findings build on the body of literature exploring patients functioning and disability following discectomy and make recommendations for future research and clinical practice.
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Multi-disciplinary implementation of sapropterin for treatment of phenylketonuria patients in a Regional Metabolic CentrePhenylketonuria (PKU) is a rare, autosomal recessive metabolic disorder caused by deficiency of phenylalanine hydroxylase affecting about 1/10,000 babies born in the UK, requiring lifelong treatment with an ultra-low protein diet to restrict phenylalanine intake. Sapropterin is an analogue of tetrahydrobiopterin, a PAH co-factor, indicated for the treatment of responsive patients of all ages with PKU, defined as a reduction of 30% or more in phenylalanine blood concentration. A pharmacist-dietitian multidisciplinary team led the Implementation of high-cost drug Sapropterin for PKU patients at Queen Elizabeth Hospital Birmingham. Sapropterin was recommended by NICE TA729, NHSE commissioning position and BIMDG consensus pathway for commencing sapropterin. From December 2021 to November 2023, 21 out of 35 patients with at least one PAH amenable variant responded after testing, with an average phenylalanine blood concentration reduction of 49% and a mean increase in natural protein intake of 126%. Multi-disciplinary management optimise Sapropterin prescription and increase natural protein intake. The service has expanded its capacity by developing the role of specialist dietitian supplementary prescriber. Use of pharmacogenomic data allowed personalised care for patients with Sapropterin amenable variants, improving their lives by allowing some a normal diet for the first time in their lives.
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Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability - a Delphi consensusBackground: There is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice. Method: Expert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement. Results: 11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined "safe zone." Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks. Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient's confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score. Conclusion: This consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. CONTRIBUTION OF THE PAPER.
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Omega-3 supplementation during unilateral resistance exercise training in older women: a within subject and double-blind placebo-controlled trial.Background & aims: The skeletal muscle anabolic effects of n-3 polyunsaturated fatty acids (n-3 PUFA) appear favoured towards women; a property that could be exploited in older women who typically exhibit poor muscle growth responses to resistance exercise training (RET). Here we sought to generate novel insights into the efficacy and mechanisms of n-3 PUFA alongside short-term RET in older women. Methods: We recruited 16 healthy older women (Placebo n = 8 (PLA): 67±1y, n-3 PUFA n = 8: 64±1y) to a randomised double-blind placebo-controlled trial (n-3 PUFA; 3680 mg/day versus PLA) of 6 weeks fully-supervised progressive unilateral RET (i.e. 6 × 8 reps, 75% 1-RM, 3/wk-1). Strength was assessed by knee extensor 1-RM and isokinetic dynamometry ∼ every 10 d. Thigh fat free mass (TFFM) was measured by DXA at 0/3/6 weeks. Bilateral vastus lateralis (VL) biopsies at 0/2/4/6 weeks with deuterium oxide (D2O) dosing were used to determine MPS responses for 0-2 and 4-6 weeks. Further, fibre cross sectional area (CSA), myonuclei number and satellite cell (SC) number were assessed, alongside muscle anabolic/catabolic signalling via immunoblotting. Results: RET increased 1-RM equally in the trained leg of both groups (+23 ± 5% n-3 PUFA vs. +25 ± 5% PLA (both P < 0.01)) with no significant increase in maximum voluntary contraction (MVC) (+10 ± 6% n-3 PUFA vs. +13 ± 5% PLA). Only the n-3 PUFA group increased TFFM (3774 ± 158 g to 3961 ± 151 g n-3 PUFA (P < 0.05) vs. 3406 ± 201 g to 3561 ± 170 PLA) and type II fibre CSA (3097 ± 339 μm2 to 4329 ± 264 μm2 n-3 PUFA (P < 0.05) vs. 2520 ± 316 μm2 to 3467 ± 303 μm2 in PL) with RET. Myonuclei number increased equally in n-3 PUFA and PLA in both type I and type II fibres, with no change in SC number. N-3 PUFA had no added benefit on muscle protein synthesis (MPS), however, during weeks 4-6 of RET, absolute synthesis rates (ASR) displayed a trend to increase with n-3 PUFA only (5.6 ± 0.3 g d-1 to 7.1 ± 0.5 g d-1 n-3 PUFA (P = 0.09) vs. 5.5 ± 0.5 g d-1 to 6.5 ± 0.5 g d-1 PLA). Further, the n-3 PUFA group displayed greater 4EBP1 activation after acute RE at 6 weeks. Conclusion: n3-PUFA enhanced RET gains in muscle mass through type II fibre hypertrophy, with data suggesting a role for MPS rather than via SC recruitment. As such, the present study adds to a literature base illustrating the apparent enhancement of muscle hypertrophy with RET in older women fed adjuvant n3-PUFA.
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Muscle and tendon adaptations to moderate load eccentric vs. concentric resistance exercise in young and older males.Resistance exercise training (RET) is well-known to counteract negative age-related changes in both muscle and tendon tissue. Traditional RET consists of both concentric (CON) and eccentric (ECC) contractions; nevertheless, isolated ECC contractions are metabolically less demanding and, thus, may be more suitable for older populations. However, whether submaximal (60% 1RM) CON or ECC contractions differ in their effectiveness is relatively unknown. Further, whether the time course of muscle and tendon adaptations differs to the above is also unknown. Therefore, this study aimed to establish the time course of muscle and tendon adaptations to submaximal CON and ECC RET. Twenty healthy young (24.5 ± 5.1 years) and 17 older males (68.1 ± 2.4 years) were randomly allocated to either isolated CON or ECC RET which took place 3/week for 8 weeks. Tendon biomechanical properties, muscle architecture and maximal voluntary contraction were assessed every 2 weeks and quadriceps muscle volume every 4 weeks. Positive changes in tendon Young's modulus were observed after 4 weeks in all groups after which adaptations in young males plateaued but continued to increase in older males, suggesting a dampened rate of adaptation with age. However, both CON and ECC resulted in similar overall changes in tendon Young's modulus, in all groups. Muscle hypertrophy and strength increases were similar between CON and ECC in all groups. However, pennation angle increases were greater in CON, and fascicle length changes were greater in ECC. Notably, muscle and tendon adaptations appeared to occur in synergy, presumably to maintain the efficacy of the muscle-tendon unit.
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Feasibility of a self-management intervention to improve mobility in the community after stroke (SIMS): A mixed-methods pilot study.Objective: To evaluate the feasibility of implementing a self-management intervention to improve mobility in the community for stroke survivors. Methods: A two-phase sequential mixed methods design was used (a pilot randomised controlled trial and focus groups). Participants were adult stroke survivors within six months post discharge from hospital with functional and cognitive capacity for self-management. The intervention included education sessions, goal setting and action planning, group sessions, self-monitoring and follow up. The control group received usual care and both groups enrolled for 3 months in the study. Feasibility outcomes (recruitment and retention rates, randomisation and blinding, adherence to the intervention, collection of outcome measures, and the fidelity and acceptability of the intervention). Participants assessed at baseline, 3 months and 6 months for functional mobility and walking, self-efficacy, goal attainment, cognitive ability, and general health. A descriptive analysis was done for quantitative data and content analysis for the qualitative data. Findings of quantitative and qualitative data were integrated to present the final results of the study. Results: Twenty-four participants were recruited and randomised into two groups (12 each). It was feasible to recruit from hospital and community and to deliver the intervention remotely. Randomisation and blinding were successful. Participants were retained (83%) at 3 months and (79.2%) at 6 months assessments. Adherence to the intervention varied due to multiple factors. Focus groups discussed participants' motivations for joining the programme, their perspectives on the intervention (fidelity and acceptability) and methodology, perceived improvements in mobility, facilitators and challenges for self-management, and suggestions for improvement. Conclusion: The self-management intervention seems feasible for implementation for stroke survivors in the community. Participants appreciated the support provided and perceived improvement in their mobility. The study was not powered enough to draw a conclusion about the efficacy of the program and a future full-scale study is warranted.
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Current thinking in physiotherapy for the management of idiopathic and postsurgical temporomandibular disorders: a narrative review.Temporomandibular disorders (TMDs) are the second most common form of orofacial pain after an odontogenic source. Despite their complex aetiopathology they are considered a musculoskeletal disorder. They can have a significant impact on the quality of life of those suffering from TMDs, but can be treated and managed through a mixture of conservative and surgical approaches. Physiotherapists specialising in musculoskeletal therapy and pain management can offer a variety of techniques to help in the treatment and management of TMDs. In this narrative review the evolution of physiotherapy practice in the United Kingdom will be outlined, along with a discussion about physiotherapeutic theoretical frameworks in the management of musculoskeletal disorders and idiopathic TMDs. Finally, a narrative review will be presented, outlining the literature exploring the use of physiotherapy post TMJ surgery, underpinned by a systematic literature search on the topic. After screening for inclusion in the narrative review, eight articles were included for narrative synthesis. The main findings were that there is a relative paucity of studies looking at the value of physiotherapy post TMJ surgery compared with the treatment of idiopathic TMDs, and there is heterogeneity in the physiotherapy programmes described in the literature, but the addition of physiotherapy post TMJ surgery seems to augment the patient's response to surgery. The article concludes by describing the domestic challenges and opportunities of integrating physiotherapy into TMD management pathways. Keywords: narrative review; physiotherapy; surgery; temporomandibular disorders.
