Assessing biomechanics and associated factors in individuals with patellofemoral pain in a clinical setting: A qualitative study based on interviews with expert clinicians.

OBJECTIVES: To explore the perspectives of ten clinicians from different medical disciplines with experience in managing PFP on how to conduct biomechanical assessments in individuals with PFP in a clinical setting. METHODS: An explorative qualitative design was used to explore the perspectives of ten clinicians with at least five years of experience managing patients with patellofemoral pain. A series of semi-structured interviews were done over Zoom video chat. The participants were from six different medical disciplines (physiotherapy, biokinetics, podiatry, sport science, sports medicine, orthopaedic surgery). Data was analysed thematically. RESULTS: Four main themes emerged from the data. These were: 1) biomechanical contributing factors that clinicians routinely screen for in patients with PFP; 2) relevant functional activities for biomechanical screening in patients with PFP; 3) conducting gait analysis assessments in a clinical setting; and 4) challenges of biomechanical assessment in patients with PFP. The clinicians expressed conflicting opinions on the usefulness of clinical gait analysis. The clinicians questioned the clinical applicability of some of the biomechanical factors identified as important in the evidence. CONCLUSIONS: It is important for clinicians to include the biomechanical assessment of functional activities linked to pain when managing patients with PFP. However, some of the biomechanical factors identified in the evidence are too difficult to observe without 3D movement analysis equipment and should not be considered clinically relevant. Expert clinical opinion is important to provide contextual information when addressing biomechanics in individuals with PFP.

Joint position sense in individuals with anterior knee pain.

BACKGROUND: Anterior knee pain (AKP) commonly affects both physically active and sedentary individuals and the aetiology is unknown. Altered joint position sense (JPS) impacts accurate motor action and knee joint stability. It is unclear whether people with AKP have altered JPS. OBJECTIVE: The aim of our study was to investigate JPS in the knees of individuals with AKP. METHOD: A descriptive cross-sectional study measured JPS in 25 participants with unilateral or bilateral AKP. JPS was measured using active JPS testing during single leg squat (SLS) and active knee extension (AKE) in sitting. Target angles (TA) were self-determined based on each participant's capabilities. The absolute error (AE) was the main outcome measure. Impaired JPS was classified as an AE equal to or greater than five degrees. RESULTS: There were no significant differences in JPS when comparing the affected and unaffected knees in participants with AKP (p > 0.05). However, a subgroup of participants with altered knee JPS was identified. There was a tendency towards greater knee flexion in the TAs of knees without AKP. CONCLUSION: Our results showed that JPS is not significantly more impaired in knees with AKP compared with knees without AKP in a group of individuals with AKP. A subgroup with altered JPS in knees with and without AKP was identified. This finding could be because of compensatory gait patterns and the precision of the Vicon 3D motion analysis system. CLINICAL IMPLICATIONS: Joint position sense should be assessed bilaterally in individuals with AKP.

Hop Performance After Return to Sport in Anterior Cruciate Ligament-Reconstructed Gaelic Football and Hurling Athletes.

PURPOSE: Anterior cruciate ligament (ACL) injuries are among the most severe injuries in the Gaelic Athletic Association. Hop tests measure functional performance after ACL reconstruction as they replicate the key requirements for a match situation. However, research examining functional recovery of ACL-reconstructed Gaelic athletes is lacking. The objective of this study is to determine if athletes restore normal hop symmetry after ACL reconstruction and to examine if bilateral deficiencies persist in hop performance following return to sport. METHODS: A cross-sectional design was used to evaluate hop performance of 30 ACL-reconstructed Gaelic athletes who had returned to competition and 30 uninjured controls in a battery of hop tests including a single, 6-m, triple, and triple-crossover hop test. RESULTS: In each test, the mean symmetry score of the ACL reconstruction group was above the cutoff for normal performance of 90% adopted by this study (98%, 99%, 97%, and 99% for the single, 6-m, triple, and triple-crossover hop, respectively). No significant differences in absolute hop scores emerged between involved and control limbs, with the exception of the single-hop test where healthy dominant limbs hopped significantly further than ACL-reconstructed dominant limbs (P = .02). No significant deficits were identified on the noninvolved side. CONCLUSIONS: The majority of ACL-reconstructed Gaelic athletes demonstrate normal levels of hop symmetry after returning to competition. Suboptimal hop performance can persist on the involved side compared with control limbs. Targeted rehabilitation may be warranted after returning to competition to restore performance to levels of healthy uninjured athletes.

Health system challenges affecting rehabilitation services in South Africa.

BACKGROUND: The World Health Organization (WHO) recommends that access to rehabilitation is a human right. To date, however, rehabilitation in South Africa has not been a health priority. The focus has rather been on saving lives from communicable diseases such as HIV/AIDs and TB, which has been increasingly successful. Whilst more South Africans are now living with pharmacologically managed chronic, communicable diseases, they often suffer significant challenges to their physical and mental health. Moreover, there are many health conditions in South Africa that have not attracted as much attention, and which also compromise individuals' capacity to contribute effectively to their own wellbeing, that of their families and communities, and to the general economy. These include birth trauma, degenerative neurological conditions, acquired injuries such as spinal cord damage, limb amputation or head trauma, and chronic noncommunicable diseases (heart or kidney disease, stroke). In the absence of robust prevalence studies, it is estimated that one-in-three adults suffer from at least one chronic health challenge. For South Africa not to invest in rehabilitation is counter-productive, as it means that a significant percentage of its population cannot contribute to its economy. In the face of scant health resources to underpin equitable rehabilitation services, evidence needs to be provided to demonstrate that for increased expenditure on rehabilitation, there will be increased return at individual, family, society, and country levels. PURPOSE: This article presents challenges and solutions to ensure that South Africa can meet WHO 2030 Rehabilitation Goals for equitable provision of effective public rehabilitation services using the WHO's health system building block framework.IMPLICATIONS FOR REHABILITATIONTo meet the challenge of providing rehabilitation for those in need requires country-specific, strategic, evidence-informed, and planned decisions in terms of best investment for highest return.Whilst there is sound international evidence for best-practice rehabilitation care, country-specific strategies are required to identify and address local barriers to evidence implementation.In South Africa, where rehabilitation has not been a priority to date, it is important that a planned and well-costed approach is taken to ensure provision of equitable, accessible, affordable, and evidence-based rehabilitation.Measuring social, economic, and educational return on investment from rehabilitation should be part of the South African service-delivery planning process.National data could be obtained through adding additional questions on disability to the national census and through local surveys and reports at various public health care facilities.

Current knowledge of idiopathic scoliosis among practising physiotherapists in South Africa.

BACKGROUND: Idiopathic scoliosis (IS) is a common musculoskeletal condition with a multi-factorial aetiology characterised by a three-dimensional torsional deformity of the spine. OBJECTIVES: To ascertain the current level of knowledge on IS among registered practising physiotherapists who expressed an interest in orthopaedic, muscular, manual and manipulative therapy in South Africa (SA). METHOD: An online survey was used to collect the data. The questions were based on an existing questionnaire, validated by a South African panel of experts in the field of musculoskeletal physiotherapy and updated based on the 2016 Society of Scoliosis Orthopaedic Rehabilitation Treatment (SOSORT) guidelines for the assessment and management of IS. RESULTS: Two hundred and twenty-three physiotherapists spread across the nine provinces of SA met the inclusion criteria and were included in our study. Our findings showed that about one-third (33.6%) of the physiotherapists could answer more than 50% of these questions correctly, and 16.5% could answer 70% of the questions correctly in relation to the widely accepted guidelines on IS management. CONCLUSION: The participants had a poor understanding of the diagnosis and treatment involved in managing patients with IS and a lack of knowledge regarding the methods of conservative treatment for scoliosis. Future studies should be aimed at assessing intervention strategies to improve the knowledge of IS in physiotherapists in SA, especially regarding diagnosis and identifying appropriate management strategies. CLINICAL IMPLICATIONS: Physiotherapists are often the first contact practitioners for patients presenting with scoliosis and therefore need to have the necessary clinical knowledge on the assessment and management of IS. Our study can improve the awareness among the South African physiotherapists regarding IS and its complex presentation and management.

Estimating the costs and benefits of stroke rehabilitation in South Africa.

OBJECTIVE: This paper explores the economic value of rehabilitation to South Africa, using a costed example of cerebrovascular accident (CVA) (stroke) rehabilitation. DESIGN: We report an economic modelling approach using a worked cost-effectiveness to validate the argument for the cost-saving benefits of stroke rehabilitation. SETTING: South African health care, employing analysis of available secondary data from South African research and government reports. PARTICIPANTS: In line with international trends in stroke epidemiology, we focused on people who were employed prior to having their stroke, with return-to-work as the desired rehabilitation outcome. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): We used information on stroke rehabilitation and secondary data derived from grey and published literature, to determine if early stroke rehabilitation represents value for money from the government perspective. For our worked example, we used return-to-work rates, intervention costs, and the cost of rehabilitation services to estimate cost-savings as a result of an individualized workplace intervention. RESULTS: The cost of delivering the individualized intervention was estimated at R5633/patient. Combining survivor rates, return-to-work rate, and costs of the programme, a work intervention programme could result in a net saving of R133.1 million over 5 years (or about R26.6 per year (discount 3%). CONCLUSION: The value of rehabilitation should not be considered in terms of cost-effectiveness alone, but also as an investment for the country. A staged, prioritized approach should be considered in future South African national health budget.

Patients' perceptions of recovery following a 6-week exercise intervention for the treatment of patellofemoral pain: A mixed methods study.

BACKGROUND: Patellofemoral pain (PFP) is a common and complex condition. The diagnosis and causal mechanisms are not well understood and therefore the long-term prognosis tends to be poor. Exercise is currently the only evidence-based treatment strategy suggested to improve pain and function in the long term. However, no qualitative studies have been conducted to establish patients' perceptions of recovery in the long term following an exercise intervention. OBJECTIVES: To measure self-reported recovery on a 7-point Likert scale in 31 participants with PFP 6 months after a 6-week physiotherapy intervention. To explore the subjective accounts of patients who received a physiotherapy intervention for PFP, regarding their expectations and perceptions of recovery. METHOD: Semi-structured exit interviews were conducted electronically 6 months after intervention to ascertain the patients' perspectives on whether expectations of treatment were met, and factors that influenced their recovery experience. RESULTS: Quantitative analysis of self-reported recovery on a 7-point Likert scale showed that 48.4% of participants felt that they were 'recovered'. Qualitative analysis showed three main categories: expectations of treatment, perceptions of recovery and changes in functional abilities. CONCLUSION: Clinicians should address patients' expectations of treatment and include the patients in decision-making regarding their treatment. Long-term follow-up is essential to ensure that treatment effects have been maintained, and this should include information about patients' self-reported recovery. CLINICAL IMPLICATIONS: This study suggests that patients' expectations of treatment and perceptions of recovery from PFP may influence prognosis. Clinicians need to collaborate with patients and involve them in decision-making to achieve their goals. An individualised treatment approach is essential to adequately address patients' experiences, priorities and beliefs.

The effect of an individualised functional retraining intervention on pain, function and biomechanics in participants with patellofemoral pain: a series of n of 1 trial.

[Purpose] To determine the effect of an individualised functional retraining intervention on pain, function, kinematics and self-reported recovery in participants with PFP. [Participants and Methods] Thirty-one participants with unilateral PFP between the ages of 14-40 were included. Data collection and treatment sessions were conducted at the Tygerberg 3D Motion Analysis Laboratory and Physiotherapy Clinic at the University of Stellenbosch Medical School in Cape Town, South Africa. Participants underwent motion analysis testing pre- and post-intervention and attended physiotherapy weekly for a 6-week individualised intervention. [Results] Thirty of the thirty-one participants (96.8%) demonstrated improved pain levels (NPRS) post intervention. Participants demonstrated a statistically significant improvement in function (AKPS) immediately post intervention and continued to improve with greater functional scores at 6-month follow up. Fifteen participants (48.4%) rated themselves as fully recovered on a 7-point Likert scale at 6-month follow up. Nineteen of the 31 participants (61.3%) demonstrated a clinically significant improvement in their priority kinematic outcome post intervention. [Conclusion] Individualised functional retraining may improve pain, function, kinematics and long-term recovery in participants with PFP presenting with kinematic contributing factors. Clinicians need to be educated on common biomechanical contributing factors and how to tailor treatment accordingly.

The test retest reliability of gait outcomes in subjects with anterior knee pain.

INTRODUCTION: Anterior knee pain (AKP) is a common condition frequently causing young, athletic patients to attend sports rehabilitation centres. Abnormal biomechanics are thought to contribute towards the development and chronicity of the condition. Gait analysis is commonly used to identify abnormal biomechanics in subjects with AKP, however the reliability of these measurements are unknown. Therefore, the aim of this study was to quantify the test retest reliability of hip, knee and ankle kinematics during gait in an AKP population so the true effects of an intervention can be established. METHODS: Thirty-one subjects with AKP attended the 3D Motion Analysis Laboratory at Tygerberg Medical Campus of Stellenbosch University in Cape Town, South Africa, for gait analysis. Participants returned seven days later at approximately the same time to repeat the gait analysis assessment from day one. The same assessor tested all subjects on both occasions. The intra-class correlation coefficients (ICC) and standard error of measurement (SEM) were calculated for hip, knee and ankle kinematic outcomes on the affected side and used for analysis. RESULTS: All outcomes obtained were acceptable to excellent test retest reliability scores for both measures of relative reliability (ICC = 0.78-0.9) and measures of absolute reliability (SEM = 0.94-4.2°). Hip frontal plane and ankle sagittal plane outcomes were the most reliable and had the lowest measurement error. Hip transverse plane outcomes were least reliable and demonstrated the highest measurement error. CONCLUSION: Hip, knee and ankle kinematic factors that are commonly associated with AKP can be measured reliably using gait analysis. Daily and weekly variation in symptoms in an AKP population may influence the reliability of knee sagittal plane outcomes. Therefore, it is important to document factors that could influence the kinematics such as pain, activity levels and the use of pain medication.

Targeted Functional Movement Retraining to Improve Pain, Function, and Biomechanics in Subjects With Anterior Knee Pain: A Case Series.

CONTEXT: Anterior knee pain (AKP) is a common condition, especially in a young active population. The clinical presentations of this condition vary considerably, and therefore, an individualized approach to treatment is needed. OBJECTIVE: The primary objective of this study was to assess the effect of a novel targeted biomechanical intervention on subjects with AKP. DESIGN: A case series was conducted on 8 participants with AKP. SETTING: The study was conducted at the Tygerberg Motion Analysis Laboratory and Tygerberg Physiotherapy Clinic in Cape Town, South Africa. PARTICIPANTS: Eight subjects (5 females and 3 males) diagnosed with AKP were included in this case series. INTERVENTION: Participants received a 6-week subject-specific functional movement retraining intervention. MAIN OUTCOME MEASURES: Three-dimensional hip, knee, and ankle kinematics were used for analysis for each participant preintervention and postintervention. Pain was measured weekly using the Numeric Pain Rating Scale. Two functional scales (Lower-Extremity Functional Scale and Anterior Knee Pain Scale) were used to assess pain and function the preintervention and postintervention. RESULTS: All 8 subjects demonstrated improved pain levels (Numeric Pain Rating Scale) and functional outcomes (Anterior Knee Pain Scale and Lower-Extremity Functional Scale). Seven of the 8 participants (87.7%) demonstrated improvements in their main biomechanical outcome. CONCLUSION: A subject-specific functional movement retraining intervention may be successful in the treatment of subjects with AKP presenting with biomechanical risk factors. Research on a larger sample is required to further investigate this approach.

The development of an evidence-based clinical checklist for the diagnosis of anterior knee pain.

BACKGROUND: Anterior knee pain (AKP) or patellofemoral pain syndrome is common and may limit an individual's ability to perform common activities of daily living such as stair climbing and prolonged sitting. The diagnosis is difficult as there are multiple definitions for this disorder and there are no accepted criteria for diagnosis. It is therefore most commonly a diagnosis that is made once other pathologies have been excluded. OBJECTIVES: The aim of this study was to create an evidence-based checklist for researchers and clinicians to use for the diagnosis of AKP. METHODS: A systematic review was conducted in July 2016, and an evidence-based checklist was created based on the subjective and objective findings most commonly used to diagnose AKP. For the subjective factors, two or more of the systematic reviews needed to identify the factor as being important in the diagnosis of AKP. RESULTS: Two systematic reviews, consisting of nine different diagnostic studies, were identified by our search methods. Diagnosis of AKP is based on the area of pain, age, duration of symptoms, common aggravating factors, manual palpation and exclusion of other pathologies. Of the functional tests, squatting demonstrated the highest sensitivity. Other useful tests include pain during stair climbing and prolonged sitting. The cluster of two out of three positive tests for squatting, isometric quadriceps contraction and palpation of the patella borders and the patella tilt test were also recommended as useful tests to include in the clinical assessment. CONCLUSION: A diagnostic checklist is useful as it provides a structured method for diagnosing AKP in a clinical setting. Research is needed to establish the causes of AKP as it is difficult to diagnose a condition with unknown aetiology.

The use of McConnell taping to correct abnormal biomechanics and muscle activation patterns in subjects with anterior knee pain: a systematic review.

[Purpose] The aim of this review was to present the available evidence for the effect of McConnell taping on knee biomechanics in individuals with anterior knee pain. [Methods] The PubMed, Medline, Cinahl, SPORTDiscus, PEDro and ScienceDirect electronic databases were searched from inception until September 2014. Experimental research on knee biomechanical or EMG outcomes of McConnell taping compared with no tape or placebo tape were included. Two reviewers completed the searches, selected the full text articles, and assessed the risk of bias of eligible studies. Authors were contacted for missing data. [Results] Eight heterogeneous studies with a total sample of 220 were included in this review. All of the studies had a moderate to low risk of bias. Pooling of data was possible for three outcomes: average knee extensor moment, average VMO/VL ratio and average VMO-VL onset timing. None of these outcomes revealed significant differences. [Conclusion] The evidence is currently insufficient to justify routine use of the McConnell taping technique in the treatment of anterior knee pain. There is a need for more evidence on the aetiological pathways of anterior knee pain, level one evidence, and studies investigating other potential mechanisms of McConnell taping.