David J. Keene

Ageing, Muscle Power and Physical Function: A Systematic Review and Implications for Pragmatic Training Interventions.

BackgroundThe physiological impairments most strongly associated with functional performance in older people are logically the most efficient therapeutic targets for exercise training interventions aimed at improving function and maintaining independence in later life.ObjectivesThe objectives of this review were to (1) systematically review the relationship between muscle power and functional performance in older people; (2) systematically review the effect of power training (PT) interventions on functional performance in older people; and (3) identify components of successful PT interventions relevant to pragmatic trials by scoping the literature.MethodsOur approach involved three stages. First, we systematically reviewed evidence on the relationship between muscle power, muscle strength and functional performance and, second, we systematically reviewed PT intervention studies that included both muscle power and at least one index of functional performance as outcome measures. Finally, taking a strong pragmatic perspective, we conducted a scoping review of the PT evidence to identify the successful components of training interventions needed to provide a minimally effective training dose to improve physical function.ResultsEvidence from 44 studies revealed a positive association between muscle power and indices of physical function, and that muscle power is a marginally superior predictor of functional performance than muscle strength. Nine studies revealed maximal angular velocity of movement, an important component of muscle power, to be positively associated with functional performance and a better predictor of functional performance than muscle strength. We identified 31 PT studies, characterised by small sample sizes and incomplete reporting of interventions, resulting in less than one-in-five studies judged as having a low risk of bias. Thirteen studies compared traditional resistance training with PT, with ten studies reporting the superiority of PT for either muscle power or functional performance. Further studies demonstrated the efficacy of various methods of resistance and functional task PT on muscle power and functional performance, including low-load PT and low-volume interventions.ConclusionsMaximal intended movement velocity, low training load, simple training methods, low-volume training and low-frequency training were revealed as components offering potential for the development of a pragmatic intervention. Additionally, the research area is dominated by short-term interventions producing short-term gains with little consideration of the long-term maintenance of functional performance. We believe the area would benefit from larger and higher-quality studies and consideration of optimal long-term strategies to develop and maintain muscle power and physical function over years rather than weeks.

Close contact casting vs surgery for initial treatment of unstable ankle fractures in older adults: A randomized clinical trial

Importance Ankle fractures cause substantial morbidity in older persons. Surgical fixation is the contemporary intervention but is associated with infection and other healing complications. Objective To determine whether initial fracture treatment with close contact casting, a molded below-knee cast with minimal padding, offers outcome equivalent to that with immediate surgery, with fewer complications and less health resource use. Design, Setting, and Participants This was a pragmatic, equivalence, randomized clinical trial with blinded outcome assessors. A pilot study commenced in May 2004, followed by multicenter recruitment from July 2010 to November 2013; follow-up was completed May 2014. Recruitment was from 24 UK major trauma centers and general hospitals. Participants were 620 adults older than 60 years with acute, overtly unstable ankle fracture. Exclusions were serious limb or concomitant disease or substantial cognitive impairment. Interventions Participants were randomly assigned to surgery (n = 309) or casting (n = 311). Casts were applied in the operating room under general or spinal anesthesia by a trained surgeon. Main Outcomes and Measures The primary 6-month, per-protocol outcome was the Olerud-Molander Ankle Score at 6 months (OMAS; range, 0-100; higher scores indicate better outcomes and fewer symptoms), equivalence prespecified as ±6 points. Secondary outcomes were quality of life, pain, ankle motion, mobility, complications, health resource use, and patient satisfaction. Results Among 620 adults (mean age, 71 years; 460 [74%] women) who were randomized, 593 (96%) completed the study. Nearly all participants (579/620; 93%) received allocated treatment; 52 of 275 (19%) who initially received casting later converted to surgery, which was allowable in the casting treatment pathway to manage early loss of fracture reduction. At 6 months, casting resulted in ankle function equivalent to that with surgery (OMAS score, 66.0 [95% CI, 63.6-68.5] for surgery vs 64.5 [95% CI, 61.8-67.2] for casting; mean difference, -0.6 [95% CI, -3.9 to 2.6]; P for equivalence = .001). Infection and wound breakdown were more common with surgery (29/298 [10%] vs 4/275 [1%]; odds ratio [OR], 7.3 [95% CI, 2.6-20.2]), as were additional operating room procedures (18/298 [6%] for surgery and 3/275 [1%] for casting; OR, 5.8 [95% CI, 1.8-18.7]). Radiologic malunion was more common in the casting group (38/249 [15%] vs 8/274 [3%] for surgery; OR, 6.0 [95% CI, 2.8-12.9]). Casting required less operating room time compared with surgery (mean difference [minutes/participant], -54 [95% CI, -58 to -50]). There were no significant differences in other secondary outcomes: quality of life, pain, ankle motion, mobility, and patient satisfaction. Conclusions and Relevance Among older adults with unstable ankle fracture, the use of close contact casting compared with surgery resulted in similar functional outcomes at 6 months. Close contact casting may be an appropriate treatment for such patients. Trial Registration isrctn.com Identifier: ISRCTN04180738.

Early Ankle Movement Versus Immobilization in the Postoperative Management of Ankle Fracture in Adults: A Systematic Review and Meta-analysis

STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES To compare early ankle movement versus ankle immobilization after surgery for ankle fracture on clinical and patient-reported outcomes. BACKGROUND A significant proportion of patients undergoing surgery for ankle fracture experience postoperative complications and delayed return to function. The risks and benefits of movement of the ankle in the first 6 weeks after surgery are not known, and clinical practice varies widely. METHODS We searched bibliographic databases and reference lists to identify eligible trials. Two independent reviewers conducted data extraction and risk-of-bias assessments. RESULTS Fourteen trials (705 participants) were included in the review, 11 of which were included in the meta-analysis. The quality of the trials was universally poor. The pooled effect of early ankle movement on function at 9 to 12 weeks after surgery compared to immobilization was inconclusive (standardized mean difference, 0.46; 95% confidence interval: -0.02, 0.93; P = .06; I(2) = 72%), and no differences were observed between groups at 1 year. The odds of venous thromboembolism were significantly lower with early ankle movement compared to immobilization (Peto odds ratio = 0.12; 95% confidence interval: 0.02, 0.71; P = .02; I(2) = 0%). Deep surgical site infection (Peto odds ratio = 7.08; 95% confidence interval: 1.39, 35.99; P = .02; I(2) = 0%), superficial surgical site infection, fixation failure, and reoperation to remove metalwork were more common after early ankle movement compared to immobilization. CONCLUSION The quality of evidence is poor. The effects of early movement after ankle surgery on short-term functional outcomes are unclear, but there is no observable difference in the longer term. There is a small reduction in risk of postoperative thromboembolism with early ankle movement. Current evidence suggests that deep and superficial surgical site infections, fixation failure, and the need to remove metalwork are more common after early ankle movement. Level of Evidence Therapy, level 1a-.

The application of multilevel modelling to account for the influence of walking speed in gait analysis.

Differences in gait performance can be explained by variations in walking speed, which is a major analytical problem. Some investigators have standardised speed during testing, but this can result in an unnatural control of gait characteristics. Other investigators have developed test procedures where participants walking at their self-selected slow, preferred and fast speeds, with computation of gait characteristics at a standardised speed. However, this analysis is dependent upon an overlap in the ranges of gait speed observed within and between participants, and this is difficult to achieve under self-selected conditions. In this report a statistical analysis procedure is introduced that utilises multilevel modelling to analyse data from walking tests at self-selected speeds, without requiring an overlap in the range of speeds observed or the routine use of data transformations.

Platelet rich Plasma in Achilles Tendon Healing 2 (PATH-2) trial: protocol for a multicentre, participant and assessor-blinded, parallel-group randomised clinical trial comparing platelet-rich plasma (PRP) injection versus placebo injection for Achilles tendon rupture.

Background Achilles tendon injuries give rise to substantial long-lasting morbidity and pose considerable challenges for clinicians and patients during the lengthy healing period. Current treatment strategies struggle to curb the burden of this injury on health systems and society due to lengthy rehabilitation, work absence and reinjury risk. Platelet-rich plasma (PRP) is an autologous preparation that has been shown to improve the mechanobiological properties of tendons in laboratory and animal studies. The use of PRP in musculoskeletal injuries is on the increase despite the lack of adequately powered clinical studies. Methods and design This is a multicentre randomised controlled trial to evaluate the efficacy and mechanism of PRP in patients with acute Achilles tendon rupture (ATR). All adults with acute ATR presenting within 12 days of the injury who are to be treated non-operatively are eligible. A total of 230 consenting patients will be randomly allocated via a remote web-based service to receive PRP injection or placebo injection to the site of the injury. All participants will be blinded to the intervention and will receive standardised rehabilitation to reduce efficacy interference. Participants will be followed up with blinded assessments of muscle–tendon function, quality of life, pain and overall patient’s functional goals at 4, 7, 13, 24 weeks and 24 months post-treatment. The primary outcome is the heel-rise endurance test (HRET), which will be supervised by a blinded assessor at 24 weeks. A subgroup of 16 participants in one centre will have needle biopsy under ultrasound guidance at 6 weeks. Blood and PRP will be analysed for cell count, platelet activation and growth factor concentrations. Ethics and dissemination The protocol has been approved by the Oxfordshire Research Ethics Committee (Oxfordshire Research Ethics Committee A, reference no 14/SC/1333). The trial will be reported in accordance with the CONSORT statement and published in peer-reviewed scientific journals. Trial registration number ISRCTN: 54992179, assigned 12 January 2015. ClinicalTrials.gov: NCT02302664, received 18 November 2014. UK Clinical Research Network Study Portfolio Database: ID 17850.

Intrarater reliability and agreement of linear encoder derived heel-rise endurance test outcome measures in healthy adults

A linear encoder measuring vertical displacement during the heel-rise endurance test (HRET) enables the assessment of work and maximum height in addition to the traditional repetitions measure. We aimed to compare the test-retest reliability and agreement of these three outcome measures. Thirty-eight healthy participants (20 females, 18 males) performed the HRET on two occasions separated by a minimum of seven days. Reliability was assessed by the intraclass correlation coefficient (ICC) and agreement by a range of measures including the standard error of measurement (SEM), coefficient of variation (CV), and 95% limits of agreement (LoA). Reliability for repetitions (ICC=0.77 (0.66, 0.85)) was equivalent to work (ICC=0.84 (95% CI 0.76, 0.89)) and maximum height (ICC=0.85 (0.77, 0.90)). Agreement for repetitions (SEM=6.7 (5.8, 7.9); CV=13.9% (11.9, 16.8%); LoA=-1.9±37.2%) was equivalent to work (SEM=419J (361, 499J); CV=13.1% (11.2, 15.8%); LoA=0.1±34.8%) with maximum height superior (SEM=0.8cm (0.6, 1.0cm); CV=6.6% (5.7, 7.9%); LoA=1.3±17.1%). Work and maximum height demonstrated acceptable reliability and agreement that was at least equivalent to the traditional repetitions measure.

Upper extremity deep vein thrombosis (Paget-Schroetter syndrome) after surfing: A case report

This case report summarises the presentation of a 28-year-old female with signs and symptoms characteristic of thoracic outlet syndrome, but who was later found to have an effort-induced Upper Extremity Deep Vein Thrombosis (UEDVT), otherwise known as Paget-Schroetter syndrome. Effort-induced UEDVT is rare, but the similarity between the signs and symptoms of thoracic outlet syndrome and this type of thrombosis can result in patients with this condition presenting to musculoskeletal therapists. The key features of the case are described, followed by an overview of UEDVT and the importance of recognising this condition in musculoskeletal therapy practice. The role of therapists in referring for early medical diagnostics is key to ensuring management of the thrombosis is instigated early, therefore reducing the risk of life threatening consequences such as pulmonary embolism.

Quantitative biomechanical comparison of ankle fracture casting methods

Abstract The incidence of ankle fractures is increasing rapidly due to the ageing demographic. In older patients with compromised distal circulation, conservative treatment of fractures may be indicated. High rates of malunion and complications due to skin fragility motivate the design of novel casting systems, but biomechanical stability requirements are poorly defined. This article presents the first quantitative study of ankle cast stability and hypothesises that a newly proposed close contact cast (CCC) system provides similar biomechanical stability to standard casts (SC). Two adult mannequin legs transected at the malleoli, one incorporating an inflatable model of tissue swelling, were stabilised with casts applied by an experienced surgeon. They were cyclically loaded in torsion, measuring applied rotation angle and resulting torque. CCC stiffness was equal to or greater than that of SC in two measures of ankle cast resistance to torsion. The effect of swelling reduction at the ankle site was significantly greater on CCC than on SC. The data support the hypothesis that CCC provides similar biomechanical stability to SC and therefore also the clinical use of CCC. They suggest that more frequent re-application of CCC is likely required to maintain stability following resolution of swelling at the injury site.

Three-Year Follow-up of a Trial of Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults

A randomized clinical trial of close contact casting vs the usual practice of surgery for treating unstable ankle fractures in older adults found equivalent ankle function outcomes at 6 months.1 Higher rates of radiological ankle malunion in the casting vs surgical groups (15% vs 3%, respectively) and nonunion (medial malleolus: 7% vs 1%, respectively) suggested that equivalence between the 2 groups may be lost if symptoms or functional limitations from posttraumatic arthritis manifest later.2 A follow-up at least 3 years after randomization was conducted to determine if equivalence persisted over time. Methods: This study was a prespecified extended follow-up of a pragmatic, multicenter, equivalence randomized clinical trial.1 The National Research Ethics Service, Oxfordshire, gave approval; written informed consent was obtained. Participants were adults older than 60 years with acute unstable malleolar fracture(s) from 24 UK centers. Participants had received surgery (usual local practice internal fixation) or close contact casting, in which a minimally padded cast was applied after closed fracture reduction by an orthopedic surgeon in an operating room under anesthesia. Data were collected for at least 3 years after randomization using patient-reported postal questionnaires. The primary outcome measure for the original trial was the Olerud and Molander Ankle Score (OMAS; range, 0-100, higher scores = better ankle function) at 6 months,3 with a prespecified equivalence margin of ±6 points. Extended follow-up used the same primary outcome and equivalence margin and assessed quality of life and pain as secondary outcomes (Table 1). A post hoc analysis of additional operations after 6 months was also conducted. Per-protocol primary analysis was used, consistent with the main trial.1 Random-effects models estimated mean differences and 95% CIs between treatments adjusted for age, sex, fracture pattern, baseline score, and time to follow-up, including the center variable as a random effect. The random-effects model was also used post hoc to assess differences in OMAS for participants with vs without radiological malunion and nonunion at 6 months. Change from baseline score was analyzed for outcomes without normal distribution. The primary outcome at extended follow-up assessed equivalence with the null hypothesis that the 2 groups were not equivalent. For all other outcomes, tests were 2-sided with a P value of .05 or less for significance. Analyses were conducted with Stata (StataCorp), version 15.0. Results: From September 2013 through November 2016, 450 of the 620 randomized participants (73%) responded to follow-up at a median of 3 years (range, 2.9-9.5). Responders and nonresponders had similar characteristics (Table 1). Most responders lived in their own home (209 of 222 participants [94%] in the surgery group and 196 of 206 participants [95%] in the casting group). Surgery and casting participants had equivalent ankle function (mean OMAS: 79.4 in the surgery group vs 76.3 in the casting group; difference, −1.3 [95% CI, −5.6 to 3.0]) and no significant differences in quality of life or pain (Table 2). Twenty-two of 222 surgery participants (10%) and 17 of 206 casting participants (8%) had operations after 6 months, including surgical implant removals (15 in the surgery group [7%] vs 8 in the casting group [4%]), arthrodesis (1 in the surgery group [0.5%] vs 3 in the casting group [1.5%]), arthroplasty (1 in the surgery group [0.5%] and 1 in the casting group [0.5%]), and infection-related procedures (2 in the surgery group [1%] and 0 in the casting group). Five casting participants (2%) had internal fixations for nonunion after 6 months. There was 1 internal fixation revision, 1 arthroscopy, and 1 hindfoot osteotomy among surgery participants. In post hoc analysis, from randomization to extended follow-up, mean total operating room procedures per participant (per protocol) were 1.2 (SD, 0.5) in the surgery group and 1.3 (SD, 0.6) in the casting group, and mean total surgical procedures per participant were 1.2 (SD, 0.5) in the surgery group and 0.3 (SD, 0.6) in the casting group. Of 67 participants with radiological abnormalities at 6 months, 43 (64%) provided extended follow-up data. Those with malleolar malunion at 6 months had significantly lower OMAS scores (n = 30; mean, 58.7 [SD, 33.1]) than those without (n = 372; mean, 79.8 [SD, 23.5]; mean difference, −16.4 [95% CI, −25.0 to −7.8]; P < .001). Participants with medial malleolar nonunion at 6 months also had significantly lower OMAS scores (n = 13; mean, 55.4 [SD, 38.5]) than those without (n = 388; mean, 79.1 [SD, 23.9]; mean difference, −13.9 [95% CI, −26.6 to −1.2]; P = .03). Treatment was not a significant covariate in these analyses. Discussion: Equivalence in function between casting and immediate surgery strategies was maintained at 3 years. In post hoc analyses, participants with radiological malunion and medial malleolar nonunion at 6 months had lower OMAS scores at 3-year follow-up. These longer-term outcomes will support surgeon and patient decision making. The findings indicate that treatment of ankle fractures in older adults should focus on obtaining and maintaining a reduction until union, by the most conservative means possible. The study was limited by its reliance on self-reported events requiring participant recall and by loss to follow-up. However, there were sufficient data to estimate and conclude equivalence in the primary outcome.

Research priorities in fragility fractures of the lower limb and pelvis: a UK priority setting partnership with the James Lind Alliance

Objective To determine research priorities in fragility fractures of the lower limb and pelvis which represent the shared priorities of patients, their friends and families, carers and healthcare professionals. Design/setting A national (UK) research priority setting partnership. Participants Patients over 60 years of age who have experienced a fragility fracture of the lower limb or pelvis; carers involved in their care (both in and out of hospital); family and friends of patients; healthcare professionals involved in the treatment of these patients including but not limited to surgeons, anaesthetists, paramedics, nurses, general practitioners, physicians, physiotherapists and occupational therapists. Methods Using a multiphase methodology in partnership with the James Lind Alliance over 18 months (August 2016–January 2018), a national scoping survey asked respondents to submit their research uncertainties. These were amalgamated into a smaller number of research questions. The existing evidence was searched to ensure that the questions had not been answered. A second national survey asked respondents to prioritise the research questions. A final shortlist of 25 questions was taken to a multistakeholder workshop where a consensus was reached on the top 10 priorities. Results There were 963 original uncertainties submitted by 365 respondents to the first survey. These original uncertainties were refined into 88 research questions of which 76 were judged to be true uncertainties following a review of the research evidence. Healthcare professionals and other stakeholders (patients, carers, friends and families) were represented equally in the responses. The top 10 represent uncertainties in rehabilitation, pain management, anaesthesia and surgery. Conclusions We report the top 10 UK research priorities in patients with fragility fractures of the lower limb and pelvis. The priorities highlight uncertainties in rehabilitation, postoperative physiotherapy, pain, weight-bearing, infection and thromboprophylaxis. The challenge now is to refine and deliver answers to these research priorities.