Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction: de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise. Method(s): This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength. Result(s): Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences. Conclusion(s): Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.Copyright © The Author(s) 2023.

Disorganised patellar tendon structure remains inert despite continued exposure to high loading environments

Introduction: Ultrasound tissue characterisation (UTC) is a unique imaging modality used to investigate structural changes of the patellar tendon. Adolescent athletes who load their knees may be susceptible to patellar tendon abnormality(s) (PTA), characterised by areas of structural disorganisation. Presence of a PTA is a risk factor for the development of pain and dysfunction. This longitudinal study aimed to investigate patellar tendon structural changes in adolescent athletes with PTA. Method(s): Adolescent basketball, volleyball and Australian Rules football athletes aged 11-14 years were recruited between March and November 2017. Data collection occurred biannually over a 2.5-year period or until ceased with the covid-19 pandemic. Bilateral UTC scans of the patellar tendon were collected at each time point. Tendon structure was quantified into four echotypes (echotype I to IV), with echotype I representing the highest structural integrity and echotype IV representing the least amount of structural integrity. The proportion of each echotype was calculated using UTC software for a region of interest (2cm distal from the disappearance of the inferior patella pole). Statistical analysis was conducted for athletes who presented at the initial data collection session with a PTA(s). Maturity status was defined by Mirwald et al. (2002). Generalised additive modelling and generalised additive mixed modelling were used to investigate the relationship between tendon structure and maturity status. Result(s): Of the 173 adolescent athletes recruited for this longitudinal study, nine athletes presented with a PTA at the initial testing session (n=9/173 = 5.2%). When measured against maturity offset (years away from the peak growth spurt of adolescence) echotype 1 (healthy aligned tendon structure) increased in proportions (df=2.25, f=4.43, p=<0.05) while echotype II decreased (df =2.59, f=3.80, p=<0.05). Echotypes III and IV (representing disorganised tendon structure) remained stable in proportions throughout the duration of this longitudinal study (df =1.0, f=0.24 p=0.6 and df=1.0, f =0.27, p=0.6 respectively). Discussion(s): This longitudinal study demonstrates that despite adolescent athletes having the presence of areas of disorganised tendon structure, the proximal patellar tendon structure improves as seen via an increase in echotype I and decrease in echotype II. Areas of disorganised tendon structure (echotypes III and IV) appear inert during the adolescent growth spurt, that is, proportions of echotypes neither increase nor decrease despite continued exposure to high loading environments. Impact and application to the field * Imaging of the patellar tendon for adolescent athletes after the initial identification of tendon abnormality may not be useful given these areas of structural disorganisation appear inert. * Management and intervention strategies for adolescent athletes experiencing tendon problems should focus on clinical outcomes rather than imaging as areas of disorganisation are unlikely to change post development of PTA. * Adolescent athletes may continue to train and compete in high loading environments without further increases to areas of structural disorganisation of the tendon. Conflict of Interest Statement: The authors of this were financially supported with an Australian Government Research Training Program (PhD) scholarship and the General Electric and National Basketball Association Orthopaedics and Sports Medicine Collaboration. The authors certify that they have no affiliations or financial involvement with any entity that has a direct financial interest in the subject matter of this research. Copyright © 2022

Male and female adolescent athletes develop patellar tendon abnormalities at different maturity stages: a longitudinal study of 173 athletes

Introduction: Patellar tendon abnormalities have been reported to occur in adolescent athletes who load the patellar tendon. The adolescent growth spurt has been suggested as a critical time-point for the formation of a healthy patellar tendon. Presence of a patellar tendon abnormality has been identified as a risk factor for the development of pain and dysfunction in later life. This longitudinal study aims to investigate factors associated with the development of patellar tendon abnormality during the critical time period of adolescence. Method(s): 173 athletes were recruited from the specialised sporting programs of basketball, volleyball, and Australian Rules football. Athletes were tested biannually for up to 2.5 years or until data collection ceased due to the covid-19 pandemic. To be eligible for inclusion, athletes had to be active in a selected sporting program and be between the ages of 11-14 at the initial data collection. Bilateral patellar tendon ultrasound tissue characterisation scans were conducted at each data collection point for each athlete to identify patellar tendon abnormality. Descriptive analysis was conducted for any athlete that had or went to develop a patellar tendon abnormality during the longitudinal study period. Maturity status of each athlete was calculated via the maturity offset equations (Mirwald et al (2002). Result(s): Seventeen of the 173 (9.8%) athletes developed a patellar tendon abnormality during this longitudinal study. Nine out of 10 male athletes were post-peak height velocity (PHV) when a patellar tendon abnormality developed. All female athletes (n=7) were peri-PHV (one year either side of the peak growth spurt) when they developed a patellar tendon abnormality. Male athletes who developed abnormality reached PHV at 14.5+/-0.5 vs. normative data of 13.7+/-1.4 years. Female athletes who developed abnormality reached PHV at 15.5+/-0.5 vs. normative data of 12.1+/-1.4 years. Discussion(s): The development of patellar tendon abnormalities appears to differ between male and female athletes with female athletes developing abnormality peri-PHV and male athletes developing abnormalities post-PHV. This raises the important question of sex differences in the development of patellar tendon abnormality during the adolescent growth spurt and suggests that adolescent athletes who develop patellar tendon abnormality achieve their peak growth spurt at a later chronological age as opposed to athletes that do not develop patellar tendon abnormality. Impact and application to the field * This longitudinal study is the first to highlight sex differences in the development of patellar tendon abnormality in adolescent athletes, suggesting that aetiology of this condition may differ by sex. * Adolescent athletes who achieve PHV at a later chronological age may be more susceptible to development of patellar tendon abnormalities and thus risk of future knee pain and dysfunction. * Clinicians should consider and monitor maturity status of adolescent athletes identified as being at risk of developing patellar tendon problems, paying particular attention to athletes who experience a delayed peak growth spurt so that early identification of tendon problems and effective management strategies can be implemented. Conflict of Interest Statement: The authors of this were financially supported with an Australian Government Research Training Program (PhD) scholarship and the General Electric and National Basketball Association Orthopaedics and Sports Medicine Collaboration. The authors certify that they have no affiliations or financial involvement with any entity that has a direct financial interest in the subject matter of this research. Copyright © 2022

Integrating pragmatism and rigor - impact of the pandemic on a randomized controlled trial of a complex intervention

The objectives here were to present a model of transparent reporting and pragmatic RCT design adaptation, and to promote discussion regarding best practices for overcoming the challenge of detecting intervention-specific changes in pain within the context of variable psychosocial factors due to the pandemic. Methods included an ongoing randomized, double-blind, placebo-controlled trial is examining the effect of pain education combined with exercise on pain in patients with chronic Achilles tendinopathy. We hypothesized that a biopsychosocial approach to patient education would reduce movement-evoked pain more than standard care (biomedical education and exercise). Since March 2020, challenges have included a temporary halt of in-person human subjects research, adapting virtual screening procedures to maintain confidentiality and safety, need to obtain telehealth license in multiple states, inability to use specialized laboratory equipment to evaluate secondary outcomes, and gradual resumption of in-person visits with PPE. As COVID-19 prevented the trial from proceeding as planned, we adapted our design to both exploit new opportunities and maintain high standards of transparency and rigor. We maintained study enrollment by modifying screening, evaluation, and treatment to accommodate virtual participation with consistent content. We adjusted our aims to include an a priori hypothesis that differential effects of a biopsychosocial versus biomedical approach on pain may be magnified during a pandemic. Additionally, strategies developed to adapt to an altered research-environment may be useful tools for future RCTs to facilitate participant recruitment and retention. We logged changes in a time-stamped manner on Open Science Framework;full disclosure will be ensured in final reports at Clinicaltrials.gov and publications. Adaptive designs are at risk of low confidence unless full transparency is integrated into research processes. Our own efforts to integrate changes to research design and conduct, with contemporary standards of transparency and rigor, provide opportunities for future research practice during and post-COVID. Funding for this study was provided by the National Institute of Arthritis Musculoskeletal and Skin Disease (NIAMS) research grant R00 AR071517 and by the Collaborative Research Grant from the International Association for the Study of Pain (IASP). Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002537. These funding sources had no role in study design, collection, analysis/interpretation of data, or decision on submission for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.