Real-time video telerehabilitation shows comparable satisfaction and similar or better attendance and adherence compared with in-person physiotherapy: a systematic review.

QUESTION: How does physiotherapy delivered by real-time, video-based telerehabilitation compare with in-person delivery for the outcomes of attendance, adherence and satisfaction? DESIGN: Systematic review of randomised control trials indexed in PubMed, CINAHL, Embase, Cochrane and PEDro on 12 March 2024. PARTICIPANTS: Adults aged > 18 years. INTERVENTION: Physiotherapy delivered via real-time video telerehabilitation. OUTCOME MEASURES: Attendance, adherence and satisfaction. RESULTS: Eight studies were included for attendance (n = 1,110), nine studies for adherence (n = 1,190) and 12 studies for satisfaction (n = 1,247). Telerehabilitation resulted in attendance at treatment sessions that was 8% higher (95% CI -1 to 18) and adherence to exercise programs that was 9% higher (95% CI 2 to 16) when compared with in-person physiotherapy. Satisfaction was similar with both modes of delivery (SMD 0.03 in favour of telerehabilitation, 95% CI -0.23 to 0.28). The level of certainty assessed by GRADE ranged from very low to low, primarily due to inconsistency and high risk of bias. DISCUSSION: Attendance at appointments among participants assigned to telerehabilitation was somewhere between similar to and considerably higher than among control participants. Adherence to self-management with telerehabilitation was better than with in-person delivery, although with some uncertainty about the magnitude of the effect. Reported satisfaction levels were similar between the two modes of treatment delivery. Given the significance of attendance, adherence and satisfaction for successful outcomes, telerehabilitation offers a valuable alternative mode for physiotherapy delivery. CONCLUSION: Real-time telerehabilitation has potentially favourable effects on attendance at treatment appointments and adherence to exercise programs, with similar satisfaction when compared with traditional in-person physiotherapy. REGISTRATION: PROSPERO CRD42022329906.

An exploration of footwear preferences, attitudes and beliefs in people with knee osteoarthritis: A qualitative study.

BACKGROUND: Although footwear can improve pain and function in individuals with knee osteoarthritis (OA), perspectives about footwear in this population have not been explored. OBJECTIVES: This qualitative study explored preferences, attitudes and beliefs about footwear in adults with knee OA. METHODS: Twenty individuals with a clinical diagnosis of knee OA (aged 45-79 years, 65% women) participated in semi-structured interviews about factors which influence footwear selection, the effect of footwear on knee symptoms, and footwear modifications. Data were analysed thematically. RESULTS: Four themes, with sub-themes, were identified: i) there are specific footwear characteristics people look for, with comfort as their top priority; ii) shoe appearance is important; iii) footwear can aggravate or ease symptoms; and iv) people with knee OA find footwear in a variety of ways. Participants related built-in arch support, a cushioned insole and low/no heel, without addition of foot orthoses, to comfort, and were willing to pay more for comfort and quality. Appearance was also a consideration, and participants indicated they would tolerate short periods of symptom aggravation for aesthetic shoes. Participants felt that footwear choice affected their knee symptoms and risk of slipping/twisting. Participants reported that their footwear choices were determined through trial-and-error, and sometimes on advice from health professionals or shoe store salespersons. CONCLUSIONS: There are specific footwear features important to individuals with knee OA. Knowledge of these features can be used by health professionals to inform footwear discussions with knee OA patients and serve as considerations when developing footwear targeted for this population.

Experiences of Working with Lower Limb Osteoarthritis: A Qualitative Study.

PURPOSE: Pain and disability associated with lower limb osteoarthritis (OA) may contribute to difficulties at work. This study aimed to understand the perspectives of workers with lower limb OA on difficulties, concerns, and coping strategies used at work. METHODS: Twenty-two individuals with lower limb OA who were working in paid employment participated in semi-structured interviews. Data were qualitatively analyzed using an inductive thematic approach. Codes were identified and refined through review of interview transcripts and discussion with the research team. RESULTS: Six themes were identified in relation to experiences working with lower limb OA. Themes were as follows: weight-bearing physical demands are challenging; lower limb OA can affect work performance; emotional consequences of pain; concerns about work in the future; positive experiences of supportive colleagues and managers; and minimal effects on sedentary work. Three themes were identified relating to strategies to manage at work: adjustments at work help manage pain and avoid exacerbations; regular strategies to manage pain; and healthcare professionals are consulted, but usually not specifically for work. CONCLUSIONS: Workers with lower limb OA experience physical and emotional difficulties at work that can impact work performance. Workers are concerned about longevity and job security and use a range of strategies to manage symptoms and remain at work. Employers, employees, and healthcare professionals may need to work together to create workplace accommodations to help workers with lower limb OA confidently remain in work.

"It's just as remarkable as being left-handed, isn't it?": exploring normativity through Australian physiotherapists' perspectives of working with LGBTQIA+ patients.

INTRODUCTION: Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) experience challenges with healthcare, including physiotherapy. To understand potential contributions to poor experiences, this study explored physiotherapists' experiences and perspectives about working with members of LGBTQIA+ communities. METHODS: This study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within the physiotherapy context. The sample consisted of physiotherapists working in Australia who participated in a larger survey study. Data were collected via semi-structured interviews which were audio-recorded and transcribed verbatim. Data analysis was conducted using a relativistic and queer theoretical framework with a reflexive thematic approach. RESULTS: Eighteen physiotherapists with diverse sexual orientations participated in the interviews. While all participants identified as women or men, not all used binary gender pronouns. Five key themes were developed: 1) "anti-discrimination" regarding choice of language and providing safe environments; 2) "current and historical discrimination" against LGBTQIA+ individuals; 3) "taking an equality approach" when working with LGBTQIA+ patients; 4) "knowledge of LGBTQIA+ health" in a broad sense and specifically with transgender and gender-diverse people; and 5) "managing own reactions" with respect to individual biases and discomfort. CONCLUSION: Underpinning all themes was the overarching concept of cis/hetero/endonormativity. Assuming normativity when working with LGBTQIA+ patients, is likely to have negative effects on patients' mental health, the therapeutic relationship and quality of care. In order to improve diversity, safety, inclusion and equity of care for LGBTQIA+ individuals, it is vital that normativity within physiotherapy is challenged.

Technical issues occur but are infrequent and have little impact on physiotherapist-delivered videoconferencing consultations for knee osteoarthritis: A descriptive study.

INTRODUCTION: Clinicians often report technical issues as a barrier to adopting videoconferencing service models. This descriptive study nested within a randomised controlled trial investigated the frequency, nature and impact of technical issues during video consultations. METHODS: Physiotherapists (n = 15) underwent training to deliver knee osteoarthritis care focussed on education, strengthening and physical activity. In the randomised controlled trial, participants received five physiotherapy consultations either in-person or via videoconferencing (via Zoom) over 3-months; consultations were recorded and physiotherapists documented technical difficulties. In this study, available notes were audited (n = 169 initial and n = 147 final consultations) and nature and frequency of technical issues coded. Based on whether the clinician reported technical difficulties, three subgroups were created for analysis 1) in-person, 2) videoconferencing without technical issues, 3) videoconferencing with technical issues. Forty participants were randomly selected for each subgroup (n = 120). Duration of consultation components (set-up and introduction, assessment, exercise, physical activity, education and wrap-up), total consultation duration and duration of technical issues were compared across subgroups using one-way multivariate analyses of variance with mean differences (MD) and 95% confidence intervals (CIs). RESULTS: Technical issues were documented in 37% (initial) and 19% (final) of video consultations. Problems with audio/video were most frequent, occurring in 36-21% (initial) and 18-24% (final) consultations. Audio/video problems were predominantly experienced during set-up, but did not significantly increase videoconferencing consultation duration compared to in-person consultation duration (MD (95% CI) 0.72 (-3.57 to 5.01) minutes). DISCUSSION: While technical issues with videoconferencing consultations frequently occur, they are typically minor, transient and resolved quickly.

Physiotherapists vary in their knowledge of and approach to working with patients who are LGBTQIA+: a qualitative study.

QUESTION: What are the attitudes, beliefs and knowledge gaps of physiotherapists in Australia regarding working with patients who identify as LGBTQIA+? DESIGN: Qualitative design using a custom online survey. PARTICIPANTS: Physiotherapists currently practising in Australia. METHODS: Data were analysed using reflexive thematic analysis. RESULTS: A total of 273 participants met the eligibility criteria. Participating physiotherapists were predominantly female (73%), aged between 22 and 67 years, residing in a large Australian city (77%) and working in musculoskeletal physiotherapy (57%), in private practice (50%) and hospital (33%) settings. Almost 6% self-identified as part of the LGBTQIA+ community. Only 4% of the participants had received training related to healthcare interactions or cultural safety for working with patients who identify as LGBTQIA+ in the context of physiotherapy. Three main themes regarding approaches to physiotherapy management were identified: treating the whole person in context, treating everyone the same, and treating the body part. Gaps in knowledge were primarily related to understandings of the relevance of sexual orientation and gender identity to physiotherapy and health issues specific to LGBTQIA+ patients. CONCLUSION: Physiotherapists can be considered to approach gender identity and sexual orientation in three distinct ways and suggest a range of knowledge and attitudes about working with patients who identify as LGBTQIA+. Physiotherapists who consider gender identity and sexual orientation to be relevant to physiotherapy consultations appear to have higher levels of knowledge and understanding of this topic and may also understand physiotherapy as multifactorial and not only biomedical.

Characterising tibialis posterior tendinopathy using the International Classification of Functioning, Disability and Health: a cross sectional study.

BACKGROUND: Tibialis posterior tendinopathy (TPT) is characterised by pain around the medial foot/ankle and difficulties weightbearing. OBJECTIVE: Compare individuals who have TPT with asymptomatic controls across the International Classification of Functioning, Disability and Health (ICF) domains of body structure and function, activity, participation and personal factors. METHODS: Twenty-two individuals meeting the selection criteria for TPT (86% female, mean ± SD age:43 ± 13 years; body mass index [BMI]:28 ± 7 kg/m2) were compared to 27 controls (93% female, age:44 ± 16 years, BMI:23 ± 5 kg/m2). Standardised differences (and 95% confidence intervals [CIs]) between groups were estimated for outcomes under each ICF domain using Cliff's delta to allow for comparison of the magnitude of deficits across outcomes (>0.47 considered large). RESULTS: Impairments in body structure and function in individuals with TPT were accompanied by activity limitations including difficulties due to foot problems (-1.0 (-1.0, -1.0)) and with independent living (-0.8 (-1.0, -0.3)) and greater time to complete stair descent/ascent (-0.6 (-0.8, -0.3)). Considering participation, overall foot-related function (-1.0 (-1.0, -1.0)), ability to participate in activities (-0.7 (-0.08, -0.3)), social restrictions (-0.8 (-1.0, -0.4)) and quality of life (-0.7 (-0.9, -0.5)) were poorer in individuals with TPT. CONCLUSION: Individuals with TPT have large impairments in body structure and function, activity limitations and participation restrictions, particularly relating to independent living, mental health and pain. Personal factors appear to contribute to a lesser extent to the TPT presentation. Treatment plans should consider activity and participation limitations in addition to body structure and function.

Inclusion of Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Other Related Identities Content in Australian Physical Therapy Curricula: Perceived Barriers and Priorities for Inclusive Education.

INTRODUCTION: Providing culturally responsive, patient-centered care is crucial for ensuring safe and positive health care experiences for individuals with diverse gender identities and sexual orientations. Doing so requires adequate training and knowledge of the health professionals involved in those health care experiences. REVIEW OF LITERATURE: Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) experience significant barriers to health and positive health care experiences. In physical therapy, research has identified that individuals who identify as LGBTQIA+ experience discrimination, discomfort, and lack of practitioner knowledge about health needs. The aim of this study was to determine how, and to what extent, content related to LGBTQIA+ individuals is included in Australian physical therapy curricula as well as perceived barriers to inclusion. SUBJECTS: Physical therapy program directors (PDs) as of January 2022 for all Australian universities that deliver physical therapy programs (n = 24). METHODS: A Qualtrics survey was emailed to PDs to collect quantitative and qualitative data regarding the inclusion and mode of delivery of LGBTQIA+ content, as well as the perceived importance, and barriers to inclusion, of LGBTQIA+ curricula. RESULTS: Twenty-four (100%) universities (PD or proxy) responded to the survey. More than 62% (15/24) of PDs reported that their programs included LGBTQIA+ content with 88% (21/24), indicating that LGBTQIA+ content is relevant to the physical therapy curriculum. Time devoted to LGBTQIA+ content ranged from 0 to 6 (median 2-4) hours across any year, delivered primarily in general or foundational courses (37%). Perceived lack of trained faculty (14/22; 64%) and time (13/22; 59%) were barriers to the integration of LGBTQIA+ specific content into the curriculum. DISCUSSION: Our results indicate that the physical therapy curriculum may be contributing to ongoing negative experiences of individuals identifying as LGBTQIA+ with physical therapy encounters. Although most (87%) physical therapy program leaders in Australia believe that LGBTQIA+ specific content is relevant to the training of new graduates, content is included in only 62% of curricula. Perceived barriers to inclusion of LGBTQIA+ specific curriculum were a lack of time and appropriately trained faculty. Externally developed content is available to address limited expertise within programs, but faculty may require guidance on how to overcome perceived lack of time (ie, space in the curriculum). CONCLUSION: Most Australian physical therapy programs include LGBTQIA+ content to a limited extent in their curricula, indicating a lack of perceived importance relative to other topics. In this way, Australian universities are maintaining the pervasive heteronormativity of the physical therapy profession and are complicit in the ongoing health disparities between the LGBTQIA+ and heteronormative communities.

Staff perspectives on the key elements to successful rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments.

BACKGROUND AND PURPOSE: During the COVID-19 pandemic, hospital physiotherapy departments transitioned to telerehabilitation to ensure continuity of care for patients. The purpose of this study is to determine the key elements to successful, rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments in response to COVID-19. METHODS: This study used a qualitative design. Physiotherapists who delivered telerehabilitation consultations during the COVID-19 restriction period in two Brisbane public hospital physiotherapy departments were eligible to participate in semi-structured interviews. Data were analysed thematically. RESULTS: Twenty-five physiotherapists (22-60 years of age; 68% female) with 1-40 years of clinical experience provided insights into their perceptions of the rapid uptake of telerehabilitation in the provision of clinical care. Physiotherapists worked across musculoskeletal outpatient (72%), inpatient, community, paediatrics and pelvic health departments. Qualitative analyses in relation to the physiotherapist perceptions of the key elements of rapid transition to telerehabilitation, revealed four key themes underpinning success: (1) 'it requires a whole team approach', (2) 'technology issues will be encountered and can be overcome', (3) 'optimise the situation while understanding the differences' and (4) 'modifying your approach doesn't imply inferior quality of care'. CONCLUSION: Rapid implementation of telerehabilitation in a hospital setting is possible, and is facilitated by organisational, administrative and management support, willingness of physiotherapists to adopt, shared learning experience, quality software and connection, availability of equipment and space and optimised systems and processes. Key factors facilitating successful telerehabilitation consultations include effective communication, demonstration, involving a third party to help, and clients who are well prepared and willing to engage.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials.

OBJECTIVE: To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research. DESIGN: Scoping review. LITERATURE SEARCH: We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors. STUDY SELECTION: Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation. DATA SYNTHESIS: We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field. RESULTS: Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct. CONCLUSION: There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Supervising Students During a Global Pandemic: Clinical Educators' Perceptions of a Student-Led Telerehabilitation Service During Covid-19.

Scope: In March 2020, COVID-19 restrictions prompted services delivered by student-led clinics in the university sector to transition to telehealth. This provided a unique opportunity to explore the challenges and opportunities faced by clinical educators when supervising students to deliver telehealth. Methodology: Semi-structured interviews were conducted with allied health clinical educators who supervised students on clinical placement who were required to provide services via telehealth. Clinical educators across the disciplines of audiology, occupational therapy, physiotherapy, and speech pathology were asked to reflect on their experiences and perceptions of the rapid transition to a telehealth model for student clinical placements. A content analysis approach was used to analyse qualitative data. Conclusions: From the perspective of clinical educators, student-led telehealth services can effectively meet client needs while achieving student learning outcomes. This study highlights many opportunities for student learning via telehealth in the clinical education environment and the role of the clinical educator in the learning experience.

An Exploration of the Experiences of Physical Therapists Who Identify as LGBTQIA+: Navigating Sexual Orientation and Gender Identity in Clinical, Academic, and Professional Roles.

OBJECTIVE: The purpose of this study was to explore physical therapy through the stories of physical therapists who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other related identities (LGBTQIA+) to consider how the profession enacts and constructs gender and sexual orientation. METHODS: Physical therapists with clinical, academic, and professional roles who identify as LGBTQIA+ were recruited from Australia, the United Kingdom, Canada, and the United States. In-depth data were collected via narrative interviews. An iterative group discourse analysis was used to examine key discourses underpinning interview narratives and how these relate to the physical therapy profession. RESULTS: Twenty-two physical therapists were interviewed. Participants had between 1.5 and 40 years of experience across various clinical areas and settings. Participants identified with varying sexual orientations and gender identities. Analysis identified discourses discussed under the following headings: (1) normativity, which related to hetero-normative assumptions about sexual orientation and cisnormative assumptions about gender identity and the intersectionality among sexual orientation, gender identity, and other forms of marginalization; (2) stress and labor, which explored the stress experienced by physical therapists who are LGBTQIA+ (due to fear of discrimination or actual discrimination) and additional emotional and other types of labor or work done in the workplace to hide aspects of their lives to feel safe, educate colleagues, and be a role model; and (3) professionalism, which related to the heterosexual/cisnormative (and other) "norms" that comprised participants' ideas of presenting as "professional" and positioning physical therapists who are LGBTQIA+ as "unprofessional." CONCLUSION: Findings suggest that cultural norms may need to be reconceptualized in physical therapy to promote inclusion and belonging of individuals who identify as LGBTQIA+. Approaches to upskill new and existing physical therapists may include elements such as individual and institutional reflexivity, learning and implementing appropriate terminology, displaying indicators of inclusivity, and cultural safety training. These elements may provide the first steps to promote inclusive and culturally safe environments for individuals who identify as LGBTQIA+ within the profession. IMPACT: This is the first known study to explore the lived experiences of those who identify as LGBTQIA+ in the physical therapy profession. The findings highlight how prevailing normative discourses in Western society are also present in physical therapy and impact those who identify as LGBTQIA+.

Comparative effectiveness of exercise programs for psychological well-being in knee osteoarthritis: A systematic review and network meta-analysis.

OBJECTIVES: The benefits of exercise are well established for psychological well-being, but it is unknown whether one type of exercise can be recommended over another for psychological well-being in knee osteoarthritis (OA). This study aimed to compare the effectiveness of different types of exercise on psychological well-being in people with knee OA. METHODS: Five databases including MEDLINE, EMBASE, Cochrane Register of Controlled Trials, CINAHL and PEDro) were searched from inception until April 2021. Randomised controlled trials comparing the effect of exercise with a non-exercise control or another type of exercise on overall mental health, depressive symptoms or anxiety in people with knee OA. Trial data were extracted independently by two researchers. Network meta-analyses using random-effect models were conducted. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to appraise evidence certainty. RESULTS: Strengthening exercise was more beneficial for overall mental health on the Short Form survey compared to aerobic (mean difference 15.88, 95%CI [6.77, 24.99]), mixed (12.77, 95%CI [5.12, 20.42]) and mind-body (12.51, [4.25, 20.77]) exercise based on 13 trials (n = 796). Strengthening exercise (standardised mean difference 6.81, [5.03, 8.58]), and mixed exercise (6.64, [4.88, 8.40]),) were more beneficial for depressive symptoms than stretching exercise based on 6 trials (n = 627). No differences were observed for anxiety based on 4 trials (n = 557). Certainty of the evidence ranged from very low to low. CONCLUSION: The available evidence supports the recommendation of strengthening exercise as the most beneficial for overall mental health, and strengthening exercise or mixed exercise over stretching exercise for depressive symptoms. No exercise recommendations can be made for anxiety.

Clinical Tests of Tibialis Posterior Tendinopathy: Are They Reliable, and How Well Are They Reflected in Structural Changes on Imaging?

OBJECTIVE: To determine the reliability of common clinical tests for tibialis posterior tendinopathy (TPT) and to investigate their relationship with grayscale ultrasound findings in individuals who have medial foot/ankle pain. DESIGN: Prospective cohort. METHODS: Fifty-two individuals reporting medial foot/ankle pain were clinically examined by 2 physical therapists using 4 clinical tests for TPT: pain on tendon palpation, swelling around the tendon, pain/weakness with tibialis posterior contraction, and pain during or inability to perform a single-leg heel raise (SLHR). Individuals also underwent an ultrasound examination by a sonographer. Physical therapists and the sonographer were blind to each other's findings. Positive ultrasound examination included at least 1 of the following grayscale changes: hypoechogenicity, fibrillar disruption, or thickening of the tendon. For reliability between the 2 physical therapists, we calculated kappa coefficients and 95% confidence intervals (CIs). To assess relationships between clinical and imaging findings, we calculated odds ratios and 95% CIs. RESULTS: The SLHR was the most reliable test, with substantial agreement between physical therapists (κ = 0.74; 95% CI: 0.54, 0.93), while the other tests had moderate levels of reliability. Of all clinical tests, the SLHR was most related to grayscale findings on ultrasound (odds ratio = 5.8), but was imprecisely so, with a 95% CI of 1.7 to 20.4. CONCLUSION: Of all tests, the SLHR was the most reliable between clinicians and best related to imaging findings in individuals presenting with TPT, aligning with contemporary thinking of tendinopathy as a load-related clinical presentation. There was a disconnect between clinical findings and ultrasound grayscale changes in the tibialis posterior tendon in individuals with TPT. J Orthop Sports Phys Ther 2021;51(5):253-260. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9707.

People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey.

QUESTIONS: What are the experiences of people who identify as lesbian, gay, bisexual, transgender, intersex, queer or related identities (LGBTIQ+) and attend physiotherapy? How could those experiences of physiotherapy be improved? DESIGN: Primarily qualitative design using a purpose-built online survey. PARTICIPANTS: People aged 18 years or older, who self-identified as LGBTIQ+, and had attended physiotherapy in Australia. METHODS: Open responses were analysed with thematic analysis and quantitative responses with descriptive statistics. RESULTS: One hundred and fourteen participants responded to the survey, with 108 meeting all eligibility criteria. Four main themes were identified in the analysis, with almost all participants reporting experiences during physiotherapy interactions relating to at least one of the following themes: 'assumptions' about participants' sexuality or gender identity; 'proximity/exposure of bodies', including discomfort about various aspects of physical proximity and/or touch and undressing and/or observing the body; 'discrimination', including reports of overt and implicit discrimination as well as a fear of discrimination; and 'lack of knowledge about transgender-specific health issues'. Positive experiences were also evident across the first, third and fourth themes. Participants suggested or supported a number of ways to improve LGBTIQ+ experiences with physiotherapy, including: LGBTIQ+ diversity training for physiotherapists, education specific to the LGBTIQ+ population (particularly transgender health), and open options for gender provided on forms. CONCLUSION: People who identify as LGBTIQ+ can experience challenges when attending physiotherapy, including: erroneous assumptions by physiotherapists, discomfort, explicit and implicit discrimination, and a lack of knowledge specific to their health needs. Positive findings and participant-suggested changes offer ways to improve physiotherapy for LGBTIQ+ people across educational and clinical settings.

Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines.

OBJECTIVE: To systematically review all randomised clinical trials to determine the efficacy of local strengthening exercises compared with other forms of conservative management for adults with posterior tibial tendon dysfunction. DESIGN: Systematic review. DATA SOURCES: Four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase and PubMed) were searched up to June 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: The study included randomised clinical trials investigating individuals with posterior tibial tendon dysfunction where local strengthening was compared with other forms of conservative management with respect to pain, function and/or physical impairment outcome measures. Standardised mean differences (SMDs) were used to compare change scores between groups and descriptors of exercise prescription assessed according to the Template for Intervention Description and Replication and the Toigo and Boutellier recommendations. RESULTS: 3 studies (n=93) were eligible for inclusion in the review. Varying strengthening exercises were compared with stretching and foot orthoses (n=2) or no intervention (n=1). Moderate effects (SMD 0.6-1.2) were found for reducing pain and disability with eccentric strengthening in conjunction with stretching and orthoses compared with concentric exercises, stretching and orthoses combined, and stretching and orthoses alone. Evaluation of exercise prescription parameters demonstrated minimal reporting, with the only consistent parameters being the number of sets and repetitions of the exercises, and the duration of the experimental period. CONCLUSION: This review demonstrates the paucity of high-quality research for the conservative management of posterior tibial tendon dysfunction, and highlights the lack of exercise prescription parameters reported in clinical trials. TRIAL REGISTRATION NUMBER: CRD42017076156.

Self-reported social and activity restrictions accompany local impairments in posterior tibial tendon dysfunction: a systematic review.

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a painful, progressive tendinopathy that reportedly predominates in middle-age, overweight women. There is no evidence based guidelines that clinicians can use to guide treatment planning, which leaves clinicians to make decisions on the basis of presenting clinical impairments and self-reported pain and disability. The purpose of this systematic review was to quantify clinical impairments, pain and disability in individuals with PTTD compared with controls. METHODS: Five databases were searched for terms referring to the posterior tibial tendon and flatfoot up to and including 11 March 2018. The systematic review was registered with PROSPERO (CRD: 42016046951). Studies were eligible if they were published in the English language and contained data on clinical impairments, pain or disability compared between participants diagnosed with PTTD and pain-free individuals. Standardised mean differences (SMDs) were calculated where possible and meta-analysis was performed when homogeneity of outcomes allowed. RESULTS: Ten eligible studies were identified and pooled in the meta-analyses. Strong effects were revealed for poor heel rise endurance (SMD -1.52, 95% CI -2.05 to - 0.99), less forefoot adduction-inversion strength (SMD -1.19, 95% CI -1.68 to - 0.71) and lower arch height (SMD -1.76, 95% CI -2.29 to - 1.23). Compared to controls, individuals with PTTD also had more self-reported stiffness (SMD 1.45, 95% CI 0.91 to 1.99), difficulties caused by foot problems (SMD 1.42, 95% CI 0.52 to 2.33) and social restrictions (SMD1.26, 95% CI 0.25 to 2.27). CONCLUSION: There is evidence of impaired tibialis posterior capacity and lowered arch height in individuals with PTTD compared to controls. Further to addressing the expected impairments in local tendon function and foot posture, pain, stiffness, functional limitations and social participation restrictions should be considered when managing PTTD.

Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review.

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) and adult acquired flatfoot deformity (AAFD) are used interchangeably, although both suggest quite different pathological processes. OBJECTIVE: To investigate key differences in selection criteria used for inclusion into research studies. METHODS: An electronic database search was performed from inception to June 2016. All primary research articles with clear inclusion/diagnostic criteria for PTTD or AAFD were included in the review. All criteria were extracted and synthesised into one aggregate list. Frequencies of recurring criteria were calculated and reported for each stage of the conditions. RESULTS: Of the potentially eligible papers, 148 (65%) did not specify inclusion/selection criteria for PTTD or AAFD and were excluded. Eligibility criteria were reported 82 times in the 80 included papers, with 69 descriptions for PTTD and 13 for AAFD. After synthesis of criteria from all papers, there were 18 key signs and symptoms. Signs and symptoms were considered to be those relating to tendon pathology and those relating to structural deformity. The total number of individual inclusion/diagnostic criteria ranged from 2 to 9. The majority of articles required signs of both tendon dysfunction and structural deformity (84% for AAFD and 81% for PTTD). Across both groups, the most frequently reported criteria were abduction of the forefoot (11.5% of total criteria used), the presence of a flexible deformity (10.2%) and difficulty performing a single leg heel raise (10.0%). This was largely the case for the PTTD articles, whereas the AAFD articles were more focused on postural issues such as forefoot abduction, medial arch collapse, and hindfoot valgus (each 16.7%). CONCLUSION: As well as synthesising the available literature and providing reporting recommendations, this review has identified that many papers investigating PTTD/AAFD do not state condition-specific selection criteria and that this limits their clinical applicability. Key signs and symptoms of PTTD and AAFD appear similar, except in early PTTD where no structural deformity is present. We recommend that PTTD is the preferred terminology for the condition associated with signs of local tendon dysfunction with pain and/or swelling along the tendon and difficulty with inversion and/or single leg heel raise characterising stage I and difficulty with single leg heel raise and a flexible flatfoot deformity characterizing stage II PTTD. While AAFD may be useful as an umbrella term for acquired flatfoot deformities, the specific associated aetiology should be reported in studies to aid consolidation and implementation of research into practice. TRIAL REGISTRATION: Prospero ID: 42016046943.