Michael Storr

The Sympathetic Nervous System and Tendinopathy: A Systematic Review

BackgroundTendinopathy is a clinical diagnosis of localised tendon pain often confirmed by imaging findings. The pathophysiological cause of the pain is unknown and the sympathetic nervous system (SNS) may be implicated.ObjectiveTo review what is known regarding the role of the SNS in human tendinopathy.Study selectionPublished data describing sympathetic innervation or an index of sympathetic activity in human tendons were eligible for inclusion.Data sourcesBibliographical databases (AMED, Biological Abstracts, CINAHL Plus, EMBASE, MEDLINE, Scopus, SPORTDiscus and Web of Science) were searched for relevant articles. Reference lists from included articles were screened for additional articles.Study appraisalStudies were scored with a quality assessment tool to identify potential sources of bias. Each question had an explicit decision rule to guide assessment.ResultsNine case–control and four cross-sectional studies examined sympathetic innervation of tendons. There was evidence suggesting a lack of difference in sympathetic innervation of tendon proper between tendinopathy biopsies and healthy controls. In contrast, the paratendinous tissue showed evidence of increased sympathetic innervation in painful tendons. The most notable increase in SNS markers was seen in abnormal tenocytes from painful tendons. Data from two studies were suitable for meta-analysis. These heterogeneous studies revealed no difference in sympathetic innervation between painful and pain-free tendons. No studies recorded SNS activity in vivo.ConclusionSympathetic innervation in painful tendons depends on tissue type. Abnormal tenocytes may have increased capacity for self-production of sympathetic neurotransmitters. Future insight may be gained by measuring global in vivo sympathetic drive in tendinopathy.

Implementing student self-video of performance.

Background:  Resource and curriculum constraints within contemporary university programmes limit opportunities for supervision and feedback of student practice. This study investigated the technological challenges, solutions and educational rewards in implementing Web‐based student self‐video of performance as a method to foster the development of student self‐evaluation.

Registration factors that limit international mobility of people holding physiotherapy qualifications: A systematic review

INTRODUCTION There is no enforced international standardisation of the physiotherapy profession. Thus, registration is used in many countries to maintain standards of care and to protect the public. However, registration may also limit international workforce mobility. QUESTION What is known about the professional registration factors that may limit the international mobility of people holding physiotherapy qualifications? DESIGN Systematic review using an electronic database search and hand searching of the World Confederation for Physical Therapy and International Network of Physiotherapy Regulatory Authorities websites. Analysis was conducted using thematic analysis. RESULTS 10 articles and eight websites were included from the search strategy. Data is representative of high-income English speaking countries. Four themes emerged regarding limitations to professional mobility: practice context, qualification recognition, verification of fitness to practice, and incidental limitations arising from the registration process. CONCLUSION Professional mobility is limited by differences in physiotherapy education programmes, resulting in varying standards of competency. Thus, it is often necessary to verify clinical competencies through assessments, as well as determining professional attributes and ability to apply competencies in a different practice context, as part of the registration process. There has been little evaluation of registration practices, and at present, there is a need to re-evaluate current registration processes to ensure they are efficient and effective, thereby enhancing workforce mobility.

Understanding students’ and clinicians’ experiences of informal interprofessional workplace learning: an Australian qualitative study

Objectives While postgraduate studies have begun to shed light on informal interprofessional workplace learning, studies with preregistration learners have typically focused on formal and structured work-based learning. The current study investigated preregistration students’ informal interprofessional workplace learning by exploring students’ and clinicians’ experiences of interprofessional student-clinician (IPSC) interactions. Design A qualitative interview study using narrative techniques was conducted. Setting Student placements across multiple clinical sites in Victoria, Australia. Participants Through maximum variation sampling, 61 participants (38 students and 23 clinicians) were recruited from six professions (medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy). Methods We conducted 12 group and 10 individual semistructured interviews. Themes were identified through framework analysis, and the similarities and differences in subthemes by participant group were interrogated. Results Six themes relating to four research questions were identified: (1) conceptualisations of IPSC interactions; (2) context for interaction experiences; (3) the nature of interaction experiences; (4) factors contributing to positive or negative interactions; (5) positive or negative consequences of interactions and (6) suggested improvements for IPSC interactions. Seven noteworthy differences in subthemes between students and clinicians and across the professions were identified. Conclusions Despite the results largely supporting previous postgraduate research, the findings illustrate greater breadth and depth of understandings, experiences and suggestions for preregistration education. Educators and students are encouraged to seek opportunities for informal interprofessional learning afforded by the workplace.

Remote-online case-based learning: A comparison of remote-online and face-to-face, case-based learning - A randomized controlled trial

Background: Case-based learning (CBL) is an educational approach where students work in small, collaborative groups to solve problems. Computer assisted learning (CAL) is the implementation of computer technology in education. The purpose of this study was to compare the effects of a remote-online CBL (RO-CBL) with traditional face-to-face CBL on learning the outcomes of undergraduate physiotherapy students. Methods: Participants were randomized to either the control (face-to-face CBL) or to the CAL intervention (RO-CBL). The entire 3rd year physiotherapy cohort (n = 41) at Monash University, Victoria, Australia, were invited to participate in the randomized controlled trial. Outcomes included a postintervention multiple-choice test evaluating the knowledge gained from the CBL, a self-assessment of learning based on examinable learning objectives and student satisfaction with the CBL. In addition, a focus group was conducted investigating perceptions and responses to the online format. Results: Thirty-eight students (control n = 19, intervention n = 19) participated in two CBL sessions and completed the outcome assessments. CBL median scores for the postintervention multiple-choice test were comparable (Wilcoxon rank sum P = 0.61) (median/10 [range] intervention group: 9 [8–10] control group: 10 [7–10]). Of the 15 examinable learning objectives, eight were significantly in favor of the control group, suggesting a greater perceived depth of learning. Eighty-four percent of students (16/19) disagreed with the statement “I enjoyed the method of CBL delivery.” Key themes identified from the focus group included risks associated with the implementation of, challenges of communicating in, and flexibility offered, by web-based programs. Discussion: RO-CBL appears to provide students with a comparable learning experience to traditional CBL. Procedural and infrastructure factors need to be addressed in future studies to counter student dissatisfaction and decreased perceived depth of learning.

Pain duration is associated with increased muscle sympathetic nerve activity in patients with Achilles tendinopathy

Tendinopathy is a common condition, which has been linked to surrogate measures of sympathetic nervous system (SNS) activity and insulin resistance. This study aimed to compare in vivo measures of the SNS and insulin resistance between individuals with and without Achilles tendinopathy. This case–control study compared Achilles tendinopathy sufferers to healthy controls. SNS activity was quantified using muscle sympathetic nerve activity (MSNA), while metabolic status was assessed via a modified glucose tolerance test and fasting lipid panel. Ultrasound tissue characterization assessed tendon structure. Resting MSNA did not differ between the 15 cases and 20 controls. Tendon pain duration in tendinopathy patients was correlated with burst frequency (R2=.32, P=.02) and burst incidence (R2=.41, P=.01) of MSNA. After adjusting for multiple comparisons, there was a trend suggesting fasting glucose was greater in cases (median 4.80, IQR .70 in cases vs 4.51, .38 in controls) and correlated with pain severity (R2=.14, P=.03), but no other metabolic measures were associated with tendon pain/structure. This study indicates that SNS activity is associated with tendon pain duration, building on previous data indicating the SNS is involved in recalcitrant tendinopathy. Metabolic parameters had little relationship with Achilles tendinopathy in this metabolically homogenous sample. Prospective studies are required to uncover the precise relationship between SNS activity, insulin resistance, and tendinopathy.

46 The Sympathetic Nervous System In Tendinopathy – A Systematic Review

Introduction The pathophysiology of tendon pain is not fully understood, although preliminary data indicates involvement of the sympathetic nervous system (SNS). Large prospective studies identify sympathetic drive as a risk factor for development of metabolic conditions such as insulin resistance/type 2 diabetes mellitus. Therefore, SNS activity may underpin the association between metabolic factors and tendinopathy in sedentary populations. The objective of this systematic review was to examine the role of the SNS in human tendinopathy. Methods Published data describing sympathetic innervation or an index of sympathetic activity in a human tendon were eligible for inclusion. Bibliographical databases (AMED, Biological Abstracts, CINAHL Plus, EMBASE, MEDLINE, Scopus, SPORTDiscus and Web of Science) were searched for relevant articles. Reference lists from included articles were screened for additional articles. Studies were scored with a quality assessment tool to identify potential sources of bias. Each question had an explicit decision rule to guide assessment. Meta-analysis was performed on studies that gave appropriate statistical data. Results Nine case-control and 4 cross-sectional studies examined sympathetic innervation of tendons via biopsies. Sympathetic markers were found through immunohistochemistry (e.g. tyrosine hydroxylase (TH), neuropeptide Y or adrenoreceptors) or through in situ hybridisation (e.g. TH mRNA). There was evidence to suggest a lack of difference in SNS innervation of the tendon proper between painful and non-painful tendons. In contrast, the paratendinous tissue showed evidence of increased SNS innervation in painful tendons. The most notable increase in SNS markers was seen in abnormal tenocytes from painful tendons. Data from two studies were suitable for meta-analysis (fig 1).3,4 These heterogeneous studies revealed no difference in SNS innervation between painful and pain-free tendons when analysed together due to the different tissues being sampled (i.e. tendon proper vs. paratendinous tissue). No studies recorded SNS activity in vivo. Abstract 46 Figure 1 Meta-analysis and forest plot produced using Review Manager 5 Discussion Sympathetic innervation in tendinopathy appears to be dependent on the type of tissue being sampled. The findings in the tendon proper suggest that the SNS is not upregulated in tendinopathy. Findings of increased SNS in the paratendinous tissue are particularly relevant, as this tissue has been a target of new arthroscopic surgical therapies. The consistent change seen in tenocytes suggested that abnormal cells had an increased capacity to self-produce catecholamines, inferring a possible positive feedback loop with the SNS. Studies were limited by difficulty recruiting healthy controls and there was a limited quantitative data (demonstrated by the meta-analysis). Measuring global sympathetic activity in vivo will be an important area for future tendinopathy research. References 1 Flaa et al. Metabolism: Clinical and Experimental. 2008;57(10):1422–7 2 Gaida et al. Medicine and Science in Sports and Exercise. 2009;41(6):1194–7 3 Lian et al. American Journal of Sports Medicine. 2006;34(11):1801–8 4 Sasaki et al. Journal of Orthopaedic Scienc. 2013.18(4):528–35