The quality of reporting in randomized controlled trials investigating exercise for individuals with whiplash-associated disorders; a systematic review.

BACKGROUND: Whiplash-associated disorders are a common sequela of road traffic accidents. Exercise therapy is considered an effective intervention, and it is recommended for the management of such condition. However, the application of research findings to everyday clinical practice is dependent on sufficient details being reported. OBJECTIVES: To explore the quality of reporting in studies investigating the effectiveness of exercise for whiplash-associated disorders. METHODS: A literature search was conducted to identify studies testing the effectiveness of exercise for whiplash-associated disorders. Two reporting checklists were used to evaluate reporting completeness. The median positive scores for each study and overall percentage of positive scores for each item were calculated. Percentage agreement and the Cohen's Kappa coefficient were calculated. RESULTS: Twenty-one studies were included. According to the Template for Intervention Description and Replication checklist, items were reported appropriately with a median of 29% (range 0-95%, IQR 40.5). The median number of adequately reported items per study was 5 (range 1-10, IQR 3). For the Consensus on Exercise Reporting Template checklist, items were reported appropriately with a median of 29% (range 0-57%, IQR 29). The median number of adequately reported items per study was 4 (range 0-16, IQR 8). Percentage agreement ranged from 57% to 100% while Cohen's Kappa from -0.17 to 1.00. CONCLUSIONS: The study reveals significant gaps in the quality of reporting in studies investigating exercise for whiplash-associated disorders as both checklists showed a median reporting adequacy of only 29%. Overall, the inter-rater agreement for both checklists was acceptable.

Training healthcare professionals to be ready for practice in an era of social distancing: a realist evaluation.

BACKGROUND: Programme changes due to the COVID-19 pandemic have impacted variably on preparation for practice of healthcare professional students. Explanations for such variability need exploration. The aim of our study was to understand what clinical learning, whilst under socially distanced restrictions, worked and why (or why not). METHODS: We conducted a realist evaluation of the undergraduate healthcare programmes at one UK university in 2020-21. Initial programme theories to be tested in this study were derived from discussions with programme leads about the changes they implemented due to the pandemic. Study participants were students and teaching faculty. Online interview transcripts were coded, identifying why interventions had worked or not. This resulted in a set of 'context-mechanism-outcome' (CMO) statements about each intervention. The initial programme theories were refined as a result. RESULTS AND DISCUSSION: 29 students and 22 faculty members participated. 18 CMO configurations were identified relating to clinical skills learning and 25 relating to clinical placements. Clinical skills learning was successful whether in person, remote or hybrid if it followed the steps of: demonstration-explanation-mental rehearsal-attempt with feedback. Where it didn't work there was usually a lack of observation and corrective feedback. Placements were generally highly valued despite some deficiencies in student experience. Being useful on placements was felt to be good preparation for practice. If student numbers are to expand, findings about what works in distance learning of clinical skills and the value of various modes of induction to clinical workplace activity may also be relevant post-pandemic.

Diagnostic clinical prediction rules for categorising low back pain: A systematic review.

BACKGROUND: Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision-making. A review of LBP diagnostic-CPRs by Haskins et al. (2015) identified six diagnostic-CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic-CPRs and evaluate their readiness for implementation. METHODS: A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand-searching and citation-tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies-2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive). RESULTS: Of 5021 studies screened, 11 diagnostic-CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic-CPRs include the Lumbar-Spinal-Stenosis-Self-Administered-Self-Reported-History-Questionnaire and Diagnosis-Support-Tool-to-Identify-Lumbar-Spinal-Stenosis, and the StEP-tool which differentiates radicular from axial-LBP. CONCLUSIONS: This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision-making.

Study of the measurement and predictive validity of the Functional Movement Screen.

OBJECTIVE: The aim of the study was to evaluate the reported measurement capabilities and predictive validity of the Functional Movement Screen (FMS) for injury. METHODS: This was a prospective observational longitudinal study of 24 male footballers from a single team in England, alongside analysis of an existing database over one season (September 2015-May 2016). A preseason FMS was carried out with scores recorded by an experienced assessor and derived, retrospectively, from the three-dimensional movement data that were simultaneously captured. The assessor scores were compared with the photogrammetric system to determine measurement validity, and predictive validity was quantified by assessing sensitivity and specificity (cut-off score of 14). RESULTS: The real-time assessor score matched the photogrammetric score awarded for one of the participants, was higher than the photogrammetric system for 22 participants and was lower than the photogrammetric system in 1 participant. There was no discernible relationship between FMS scores and the competencies required to be met as per the rules articulated for the allocation of a score. A higher number of total injuries were associated with higher FMS scores, whether determined through real-time assessment or codification of kinematic variables. Additionally, neither method of score determination was able to prospectively identify players at risk of serious injury. CONCLUSION: The FMS does not demonstrate the properties essential to be considered as a measurement scale and has neither measurement nor predictive validity. A possible reason for these observations could be the complexity in the instructions associated with the scale. Further work on eliminating redundancies and improving the measurement properties is recommended.

Feasibility study of a take-home array-based functional electrical stimulation system with automated setup for current functional electrical stimulation users with foot-drop.

OBJECTIVE: To investigate the feasibility of unsupervised community use of an array-based automated setup functional electrical stimulator for current foot-drop functional electrical stimulation (FES) users. DESIGN: Feasibility study. SETTING: Gait laboratory and community use. PARTICIPANTS: Participants (N=7) with diagnosis of unilateral foot-drop of central neurologic origin (>6mo) who were regular users of a foot-drop FES system (>3mo). INTERVENTION: Array-based automated setup FES system for foot-drop (ShefStim). MAIN OUTCOME MEASURES: Logged usage, logged automated setup times for the array-based automated setup FES system and diary recording of problems experienced, all collected in the community environment. Walking speed, ankle angles at initial contact, foot clearance during swing, and the Quebec User Evaluation of Satisfaction with Assistive Technology version 2.0 (QUEST version 2.0) questionnaire, all collected in the gait laboratory. RESULTS: All participants were able to use the array-based automated setup FES system. Total setup time took longer than participants' own FES systems, and automated setup time was longer than in a previous study of a similar system. Some problems were experienced, but overall, participants were as satisfied with this system as their own FES system. The increase in walking speed (N=7) relative to no stimulation was comparable between both systems, and appropriate ankle angles at initial contact (N=7) and foot clearance during swing (n=5) were greater with the array-based automated setup FES system. CONCLUSIONS: This study demonstrates that an array-based automated setup FES system for foot-drop can be successfully used unsupervised. Despite setup's taking longer and some problems, users are satisfied with the system and it would appear as effective, if not better, at addressing the foot-drop impairment. Further product development of this unique system, followed by a larger-scale and longer-term study, is required before firm conclusions about its efficacy can be reached.

Arterial compression during overhead throwing: a risk for arterial injury?

Case studies reporting aneurysm formation in the axillary artery have been described in overhead throwing athletes, possibly due to repetitive arterial compression by the humeral head that has been transiently observed during sonographic diagnostic arm manoeuvres. Whether compression negatively alters arterial health has not been investigated and was the focus of this study. The throwing arm of elite overhead athletes was screened for inducible axillary artery compression. Compressors (COMP, n = 11, mean age: 20 (SD: 2) year, 7 male, 4 female) were age and sex matched with noncompressing (NONCOMP) athlete controls. Four indices of arterial health (flow mediated dilation [FMD], conduit artery vasodilatory capacity [CADC], glyceryl-trinitrate [GTN]-induced vasodilation and intima-media thickness [IMT]) were assessed with high-resolution ultrasound at the brachial and the axillary, artery. No significant between-group differences were observed at the brachial, or axillary, artery for FMD (brachial: COMP: mean (SD) 6.2 (3.1)%, NONCOMP: 6.1 (3.5)%, p = 0.967, axillary: COMP: 8.0 (5.5)%, NONCOMP: 9.0 (3.6)%, p = 0.602), CADC (brachial: COMP: 10.4 (3.4)%, NONCOMP: 10.4 (5.4)%, p = 0.999, axillary: COMP: 9.6 (4.2)%, NONCOMP: 8.5 (3.2)%, p = 0.492), GTN-induced vasodilation (brachial: COMP: 17.9 (5.1)%, NONCOMP:14.1 (7.2)%, p = 0.173, axillary: COMP: 9.5 (4.3)%, NONCOMP: 7.7 (3.1)%, p = 0.302) or IMT (brachial: p = 0.084, axillary: p = 0.581). These results suggest that transient arterial compression, observed during diagnostic arm manoeuvres in overhead throwing athletes, is not associated with abnormal indices of artery function or structure and that other mechanisms must be responsible for the published cases of aneurysm formation in elite athletes performing overhead throwing actions.

Sonographic evaluation of the subclavian artery during thoracic outlet syndrome shoulder manoeuvres.

Clinical tests for vascular thoracic outlet syndrome (vTOS) generally incorporate shoulder horizontal flexion/extension (HF/HE), abduction (ABD) and external rotation (ER). The effect of these clinical tests on blood flow characteristics and the most effective arm positions for detecting arterial compromise are, however, unknown. The aims of this study are to establish normative vascular responses in the subclavian artery (i.e. arterial diameter [D] and peak systolic blood flow velocity [PSV]) to various arm positions, and determine the incidence of abnormal physiological responses. Ten male and twenty-one female (mean age: 25 yr) healthy volunteers were rigorously screened prior to testing. With the subject seated the arm was passively supported in a randomised series of 12 standardised shoulder positions incorporating varying degrees of HF/HE, ABD and ER. Doppler ultrasound insonated the subclavian artery D (mm) and PSV (cms(-1)) in each position. Data comparisons were made using ANOVAs with bonferroni adjustment for multiple comparisons. Alpha level was set at p=0.01. Significant decreases (p=0.008) in PSV were recorded from 120 degrees , 90 degrees and 45 degrees ABD (92+/-10, 89+/-11 and 88+/-14 cm s(-1), respectively) to 180 degrees ABD (mean+/-95% CI: 52+/-16 cm s(-1)). Similarly, post-hoc comparisons revealed a significant decrease (p=0.008) in PSV from 120 degrees ABD (94+/-14 cm s(-1)) to 120 degrees ABD with 30 degrees HE and 90 degrees ER (69+/-12 cm s(-1)). Complete lack of blood flow was demonstrated by six subjects and two subjects at end of range ABD and combined end of range ER and HE, respectively. The heterogenous response of asymptomatic individuals with no past history of TOS symptoms raises uncertainty of the validity of positive test responses from extreme arm positions. Clinical decisions based on false positive outcomes have serious implications for mistreatment such as inappropriate surgical intervention; therefore it is imperative that clinical decision is not based on test outcomes alone. Further research is required to determine the cause of heterogenous responses in asymptomatics and discover means to improve test specificity.

Sonographic evaluation of the axillary artery during simulated overhead throwing arm positions.

OBJECTIVES: The aim of this study was to determine changes in axillary artery diameter and peak systolic velocity in asymptomatic individuals during upper limb positioning commonly used to assess vascular pathology in athletes. DESIGN: Repeated measures observational study. SETTING: Physiology laboratory. PARTICIPANTS: Subjective and objective screening excluded individuals with past, or present, conditions related to neurovascular compression syndromes. Thirty-one subjects (21 females, 10 males; mean age: 25+/-4 years) were included in the final analysis. MAIN OUTCOME MEASURES: Sonographically determined axillary artery diameter and peak systolic velocity, as well as symptom production, were recorded for a series of 12 randomised arm positions, incorporating varying degrees of abduction, external rotation, and horizontal flexion/extension. RESULTS: The majority of arm positions revealed no change in artery diameter and peak systolic velocity. However, at the extreme of abduction, and arm positions incorporating 120 degrees abduction, significant (p<0.0005) reductions in axillary artery diameter were noted. All mean results masked wide heterogeneity: 13% demonstrating a greater than 50% reduction in diameter, 10%, a doubling of peak systolic velocity, and 42%, reporting symptoms. CONCLUSIONS: The number of individual clinically "positive" responses questions the specificity of individual diagnostic tests, such as the hyperabduction manoeuvre, and highlights the need to interpret test results in conjunction with the subjective assessment and other physical findings from the objective assessment.

Anterior translation at the glenohumeral joint: a cause of axillary artery compression?

BACKGROUND: Lesions to the axillary artery are reported in overhead athletes. One speculated cause is repeated transient compression by the humeral head due to excessive laxity at the glenohumeral joint. HYPOTHESES: (1) Anterior translation of the glenohumeral joint alters axillary artery diameter and blood flow characteristics, and (2) individuals demonstrating inducible axillary artery compression with the arm in an overhead position (as indicated by diameter and blood flow characteristics) will demonstrate greater magnitudes of anterior translation. STUDY DESIGN: Descriptive laboratory study. METHODS: After receiving ethical approval and screening for problematic conditions/injuries, 26 subjects were tested (10 men and 16 women; mean age [standard deviation], 25 years [4]). Axillary artery diameter and peak systolic velocity were measured with B-mode and Doppler ultrasound before, during, and after glenohumeral anterior translation at 90 degrees of abduction, 60 degrees of external rotation, and 30 degrees of horizontal flexion, and at baseline and a simulated overhead throwing position (120 degrees of abduction, 90 degrees of external rotation, and 30 degrees of horizontal extension). The magnitude of anterior translation was captured with B-mode ultrasound using a posterior transverse approach. RESULTS: Application of the glide resulted in a significant (F(2,21) = 9.965, P = .001) reduction in axillary artery diameter and a significant increase in peak systolic velocity (F(2,21) = 5.286, P = .014). Subjects demonstrating clinically significant levels of axillary artery compression ( > 50% reduction in vessel diameter with the arm in the overhead throwing position) exhibited significantly (t = -2.260, P = .040) greater ranges of anterior translation at the glenohumeral joint than the 9 subjects who exhibited < 10% reduction in arterial diameter. CONCLUSIONS: This investigation provides the first empirical support for the clinical opinion that glenohumeral anterior translation could be a mechanism for inducible axillary artery compression. CLINICAL RELEVANCE: The response of axillary artery hemodynamics in normal, healthy individuals is the first step in the process of determining whether the finding of inducible axillary artery compression in overhead athletes with arterial pathology is related to glenohumeral translation.