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Background: The existence of pain-related fear appears to present an obstacle for health promoting behaviour change, particularly among younger adults with obesity. Measures developed and validated for middle-and-older age groups lack validity in younger adults under 45 years of age. This paper reports on the development and psychometric properties of a new instrument, based on a conceptual framework, to measure pain-related fear in younger adults. Methods: A cross sectional survey design was employed. 236 participants aged 18 to 45 years were recruited to participate. Participants completed three existing pain-related fear instruments mapped to a conceptual framework. Exploratory and confirmatory factor analysis identified the dimensions of the new Pain-Related Fear Scale. Construct validity was assessed by comparing scores between physical activity groups; criterion validity by correlation with the Tampa Scale of Kinesiophobia and reliability by Cronbach’s alpha. Differences in scores in the Pain-Related Fear Scale were explored across BMI subgroups. Results: A four-factor model with 12 items met the most acceptability thresholds for a good fitting model (CFI = 0.983; GFI = 0.953; RMSEA = 0.046; SRMR = 0.0301). Higher mean scores on the PainRelated Fear Scale were seen among those reporting low activity compared to high activity levels (F= 4.684; P= 0.01). Modest correlation was observed between the new instrument and Tampa Scale of Kinesiophobia (r= 0.508;95% CI= 0.389-0.612). Cronbach’s alpha was 0.842. Scores were higher in the obese subgroup compared to the healthy bodyweight group (mean difference= -7.42; CI= -12.26 - -2.58; P= 0.001). Conclusion: The Pain-Related Fear Scale is a psychometrically valid measurement of pain-related fear for adults with obesity aged between 18 to 45 years. The instrument can support research relating to barriers to physical activity, and potentially has clinical utility as a screening and outcome measurement.

Obesity continues to be a growing public health problem worldwide. In adults with obesity, physical activity has health benefits beyond those directly attributable to weight loss. However, adults with obesity encounter various barriers to physical activity. Some barriers including fear, have received little academic attention, particularly in adults under 45 years. The aim of this qualitative study was to explore how fears about physical activity are experienced by, and impact on, adults with obesity aged 18 to 45 years. Semi-structured interviews were undertaken in a sample of 10 participants with a body mass index greater than 30 kg/m2. Analysis was conducted using the six phases of thematic analysis from the guidelines of Braun and Clarke. Participants gave detailed accounts of their experiences of fear and how it impacted on physical activity. Three themes were extracted: (1) fear as a barrier to physical activity; (2) threats, concerns and worries about weight underpinning fear(s) of activity; and (3) the consequences of fear(s). The findings suggest that the emotion of fear, particularly pain-related fear(s), were a frequent and important barrier to physical activity among younger adults with obesity. This is an important finding because of the risk it poses to health behaviour change. The findings provide some evidence that younger adults experience fear avoidance beliefs aligned to the conceptual principles of the Fear Avoidance Model. Further research is needed to further explore this relationship in a larger sample of younger adults with obesity, and explore its implications for promoting behaviour change in this group.

Background: Total hip arthroplasty (THA) patients have been shown to not achieve normal sagittal plane hip kinematics. However, previous studies have only conducted group level analysis and as such lack the sensitivity to highlight whether individual patients do achieve normal hip kinematics. As such this study looked to determine whether some patients with well-functioning THA achieve typical sagittal plane hip kinematics. Methods: Sagittal plane hip kinematics were collected on 11 well-functioning THA patients (Oxford Hip Score = 46 ± 3) and 10 asymptomatic controls using a 3-dimensional motion analysis system during self-paced walking. High-functioning THA patients were identified as those who displayed sagittal plane hip kinematics that were within the variance of the control group on average, and low-functioning patients as those who did not. Results: 5 THA patients were identified as high-functioning, displaying hip kinematics within the variance of the control group. High-functioning THA patients displayed peak hip flexion and extension values more closely aligned to asymptomatic control group than low-functioning patients. However, hip range of motion was comparable between high- and low-functioning total hip arthroplasty patients and reduced compared to controls. Conclusion: The presence of high-functioning THA patients who display comparable sagittal plane hip kinematics to controls suggests these patients do achieve normative function and challenges the conclusions of previous group level analysis. Understanding why some patients achieve better function post-operatively will aid pre- and post-operative practices to maximise functional recovery.

Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.

Lower-limb running injuries are common. Running shoes have been proposed as one means of reducing injury risk. However, there is uncertainty as to how effective running shoes are for the prevention of injury. It is also unclear how the effects of different characteristics of running shoes prevent injury. To assess the effects (benefits and harms) of running shoes for preventing lower-limb running injuries in adult runners. We searched the following databases: CENTRAL, MEDLINE, Embase, AMED, CINAHL Plus and SPORTDiscus plus trial registers WHO ICTRP and ClinicalTrials.gov. We also searched additional sources for published and unpublished trials. The date of the search was June 2021. We included randomised controlled trials (RCTs) and quasi-RCTs involving runners or military personnel in basic training that either compared a) a running shoe with a non-running shoe; b) different types of running shoes (minimalist, neutral/cushioned, motion control, stability, soft midsole, hard midsole); or c) footwear recommended and selected on foot posture versus footwear not recommended and not selected on foot posture for preventing lower-limb running injuries. Our primary outcomes were number of people sustaining a lower-limb running injury and number of lower-limb running injuries. Our secondary outcomes were number of runners who failed to return to running or their previous level of running, runner satisfaction with footwear, adverse events other than musculoskeletal injuries, and number of runners requiring hospital admission or surgery, or both, for musculoskeletal injury or adverse event. Two review authors independently assessed study eligibility and performed data extraction and risk of bias assessment. The certainty of the included evidence was assessed using GRADE methodology. We included 12 trials in the analysis which included a total of 11,240 participants, in trials that lasted from 6 to 26 weeks and were carried out in North America, Europe, Australia and South Africa. Most of the evidence was low or very low certainty as it was not possible to blind runners to their allocated running shoe, there was variation in the definition of an injury and characteristics of footwear, and there were too few studies for most comparisons. We did not find any trials that compared running shoes with non-running shoes. Neutral/cushioned versus minimalist (5 studies, 766 participants) Neutral/cushioned shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with minimalist shoes (low-certainty evidence) (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.59 to 1.01). One trial reported that 67% and 92% of runners were satisfied with their neutral/cushioned or minimalist running shoes, respectively (RR 0.73, 95% CI 0.47 to 1.12). Another trial reported mean satisfaction scores ranged from 4.0 to 4.3 in the neutral/ cushioned group and 3.6 to 3.9 in the minimalist running shoe group out of a total of 5. Hence neutral/cushioned running shoes may make little or no difference to runner satisfaction with footwear (low-certainty evidence). Motion control versus neutral / cushioned (2 studies, 421 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral / cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.92, 95% CI 0.30 to 2.81). Soft midsole versus hard midsole (2 studies, 1095 participants) Soft midsole shoes may make little or no difference to the number of runners sustaining a lower-limb running injuries when compared with hard midsole shoes (low-certainty of evidence) (RR 0.82, 95% CI 0.61 to 1.10). Stability versus neutral / cushioned (1 study, 57 participants) It is uncertain whether or not stability shoes reduce the number of runners sustaining a lower-limb running injuries when compared with neutral/cushioned shoes because the quality of the evidence has been assessed as very low certainty (RR 0.49, 95% CI 0.18 to 1.31). Motion control versus stability (1 study, 56 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with stability shoes because the quality of the evidence has been assessed as very low certainty (RR 3.47, 95% CI 1.43 to 8.40). Running shoes prescribed and selected on foot posture (3 studies, 7203 participants) There was no evidence that running shoes prescribed based on static foot posture reduced the number of injuries compared with those who received a shoe not prescribed based on foot posture in military recruits (Rate Ratio 1.03, 95% CI 0.94 to 1.13). Subgroup analysis confirmed these findings were consistent between males and females. Therefore, prescribing running shoes and selecting on foot posture probably makes little or no difference to lower-limb running injuries (moderate-certainty evidence). Data were not available for all other review outcomes. Most evidence demonstrates no reduction in lower-limb running injuries in adults when comparing different types of running shoes. Overall, the certainty of the evidence determining whether different types of running shoes influence running injury rates was very low to low, and as such we are uncertain as to the true effects of different types of running shoes upon injury rates. There is no evidence that prescribing footwear based on foot type reduces running-related lower-limb injures in adults. The evidence for this comparison was rated as moderate and as such we can have more certainty when interpreting these findings. However, all three trials included in this comparison used military populations and as such the findings may differ in recreational runners. Future researchers should develop a consensus definition of running shoe design to help standardise classification. The definition of a running injury should also be used consistently and confirmed via health practitioners. More researchers should consider a RCT design to increase the evidence in this area. Lastly, future work should look to explore the influence of different types or running shoes upon injury rates in specific subgroups.

Background\ud Stroke can affect people’s ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties.\ud \ud Objectives\ud Primary objective\ud \ud • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke\ud \ud Secondary objectives\ud \ud • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia\ud \ud ‐ Patient demographics (e.g. age, gender)\ud \ud ‐ Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified\ud \ud ‐ Definition of dysphagia used by the study\ud \ud ‐ Level of training of nursing staff (both grade and training in the screening tool)\ud \ud ‐ Low‐quality studies identified from the methodological quality checklist\ud \ud ‐ Type and threshold of index test\ud \ud ‐ Type of reference test\ud \ud Search methods\ud In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy.\ud \ud Selection criteria\ud We included studies that were single‐gate or two‐gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital.\ud \ud Data collection and analysis\ud Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS‐2) tool. We identified insufficient studies for each index test, so we performed no meta‐analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests.\ud \ud Main results\ud Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty‐one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)).\ud \ud We assessed a total of six studies as low risk across all four QUADAS‐2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains.\ud \ud No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR‐BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests.\ud \ud Authors' conclusions\ud We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high‐quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

Physical activity is a health behavior contributing to successful weight management. Adults with overweight and obesity find it challenging to meet recommended activity guidelines because of a range of barriers, some of which are not yet fully understood. A barrier receiving limited consideration, compared with other literature within this field, is that of fear. The purpose of this scoping review was to establish the extent of literature on fear-related barriers to physical activity in adults with overweight or obesity and to identify gaps in this literature. The review followed the scoping review framework outlined by Arksey and O'Malley and adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. The findings of the identified papers were charted thematically using a framework of fears and age group. In total, 34 studies were included that identified nine different fears related to barriers to activity in this population. However, only a small number of studies (n = 5) had explicitly intended to explore fear-related barriers. There were notable knowledge gaps including activity-related fear of pain and movement in adults under 45 years of age. There is a strong rationale to further explore these fears because they may restrict health promoting behavior.

Variations in access to health care are known to contribute to differences in life expectancy, morbidity and health-related quality-of-life across population subgroups. We undertook a scoping review to identify what is known about in-country variations in access to services for adults with multiple sclerosis and to identify gaps in the literature to inform future research and national policies. We searched MEDLINE, CINAHL, EMBASE, PSYCHINFO, SocINDEX and Social Science Abstracts from inception to end of December 2016 for quantitative studies which had investigated differences in access to prevention services, healthcare services, treatments and social care between inequality groups, defined using the PROGRESS-PLUS framework. A total of 4959 unique abstracts yielded 36 papers which met our eligibility criteria. Only 3 studies were cohort studies and only 4 were population-based; most were from the United States (n = 27). There were 6 studies on access to MS focused care and 6 on access to Disease Modifying drugs. There were 3 studies on access to prevention/lifestyle programmes and none on access to welfare services or information support. There were no papers examining inequalities in access for 'vulnerable' groups, such as, those with learning disability. In the available studies, there was evidence of inequalities in access to services with a trend for worse access among men, older age groups, those from lower socio-economic groups or the least educated, non-caucasians, those with mental health problems and those from rural areas. In the studies on access to disease modifying treatments, older age and lower socioeconomic status were consistently associated with a lower rate of uptake, while race and gender were not. Inequalities or disparities in access to all levels of services and treatments will need to be addressed through a strategic research agenda with an emphasis on population-based studies and development and evaluation of interventions to reduce inequality. [Abstract copyright: Copyright © 2019 Elsevier B.V. All rights reserved.]

This thesis establishes the feasibility and validity of using digital surveys to collect population-based data. Subsequently, the thesis reports on the utilisation of a digital questionnaire determine the prevalence of patellofemoral pain (PFP) at mass-participant running events within the UK. In Chapter 2, to determine the feasibility creating a digital Survey instrument for Natural history, Aetiology and Prevalence of Patellofemoral pain Studies (SNAPPS) questionnaire, a systematic review comparing the response rate and completeness of digital and paper-based epidemiological surveys was conducted. The review found paper-based surveys to have a slightly higher response rate than digital surveys. As digital surveys offer several other benefits including lower costs per response, ease of data collection and automation of results coding, a pragmatic and practical approach was taken and, the paper version of the SNAPPS questionnaire was converted to a digital online version. In Chapter 3, eSNAPPS was developed and then validated against the original paper SNAPPS. Results showed that eSNAPPS was equivalent to paper SNAPPS and was valid against the paper version in determining the presence of PFP. Subsequently, in Chapter 4, eSNAPPS was utilised to evaluate the prevalence of PFP in individuals from the general population who attended mass-participation events in the UK. In this chapter, a cross-sectional study was conducted. There were over 1,080 responses, and with no missing data within the returned surveys. Furthermore, from the largest study in the UK and second largest in the world, the prevalence of PFP of those within the community attending mass-participant events was 17.4%. The results in this chapter highlighted that it was feasible to collect population-based data using eSNAPPS and that the adaptation of SNAPPS questionnaire has a positive outcome on the quality of data whilst also minimising the logistical demand surrounding data entry and data management. The findings from this thesis confirm the role that digital surveys can play in data collections for large scale epidemiology studies and the role of eSNAPPS in establishing the prevalence of PFP in the general population.

Background: The palliative care needs of people with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance and breathing. Examining these needs would help provide guidance about developing relevant models of care and identify gaps in research knowledge. Aim: To identify and map out the palliative care needs and experiences for people with advanced head and neck cancer. Design: A scoping literature review following the methods described by the Joanna Briggs Institute. Data sources: An electronic search of the literature was undertaken in MEDLINE (Ovid), EMBASE and CINAHL covering the years January 1996 to January 2019. Results: People with advanced head and neck cancer often had palliative care needs but there was variability in the timing and access to relevant services. A high prevalence of interventions, for example hospital admissions were needed even during the last month of life. This was not necessarily negated with early engagement of palliative care. Dissonance between patients and family carers about information needs and decision-making was an additional complexity. Studies tended to be descriptive in nature, and often involved a single centre. Conclusion: This scoping review demonstrates the complexity of care for people with advanced head and neck cancer and the issues related to the current healthcare systems. Focus on appropriate referral criteria, increased integration and coordination of care and robust evaluation of specific care components seems key. Linkage between research and service design delivery across teams, disciplines and care settings seems pertinent.

© 2020 Chartered Society of Physiotherapy Objectives: To investigate the distribution of patella skin temperature (Tsk) measurements and to explore the presence of temperature subgroups in patellofemoral pain (PFP) patients. Design: Cross-sectional observational study design. Participants: One dataset of 58 healthy participants and 232 PFP patients from three different datasets. Main outcome measures: Patella skin temperature, measured by physiotherapists using a low cost hand held digital thermometer. The distribution of patella skin temperature was assessed and compared across datasets. To objectively determine the clinically meaningful number of subgroups, we used the average silhouette method. Finite mixture models were then used to examine the presence of PFP temperature subgroups. Receiver operating characteristic curves were used to estimate optimal patella Tsk thresholds for allocation of participants into the identified subgroups. Results: In contrast to healthy participants, the patella skin temperature had an obvious bimodal distribution with wide dispersion present across all three PFP datasets. The fitted finite mixture model suggested three temperature subgroups (cold, normal and hot) that had been recommended by the average silhouette method with discrimination cut-off thresholds for subgroup membership based on receiver operating curve analysis of Cold =

Objective: A quarter of people diagnosed with cancer lack social support. Online cancer communities could allow people to connect and support one another. However, the current proliferation of online support communities constitutes a range of online environments with differing communication capacities and limitations. It is unclear what is perceived as online cancer community support and how different features can help or hinder supportive group processes. This study aimed to explore how perceived support is influenced by the different features and formats of online support environments. \ud \ud Methods: In-depth qualitative interviews were conducted with 23 individuals affected by a range of cancer diagnoses, including both cancer survivors and family members. Data were analysed using deductive thematic analysis guided by a constructivist epistemological perspective.\ud \ud Findings: Online supportive communities were defined and differentiated by two themes. Firstly, 'Open forums' were identified with thematic properties which facilitated a uniquely informative environment including 'Safety in anonymity', 'Perceived reliability' and 'Exposure and detachment'. Secondly, 'Secret groups' were identified with thematic properties which enhanced an emotionally supportive environment including ‘Personalised interactions’, an overt 'Peer hierarchy', and 'Crossing the virtual divide'.\ud \ud Conclusions: Properties of groups can engender different degrees of interpersonal relations and different supportive interactions. In particular, support community designers may want to adapt key features such as anonymity, trustworthiness of websites, and the personalised nature of conversations to influence the development of supportive environments. In personalised peer-led groups, it may be prudent to provide guidance on how to reassert a positive environment if arguments break out online.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects (benefits and harms) of running shoes for preventing lower‐limb running injuries in adult runners.

© 2019 The Author(s). Background: Obesity and sedentary behaviour, risk factors for knee osteoarthritis in middle-age, are increasing in younger adults. The objectives of this study were to estimate the prevalence of knee problems in young adults, to characterise these problems and explore the relationship with physical activity, physical inactivity and obesity. Methods: Presence of knee problems was collected through self-report questionnaire from staff and students of one university aged 18-39; direct measurement of weight and height was taken and activity measured using the International Physical Activity Questionnaire. Twelve-month prevalence of knee problems was estimated. Logistic regression was used to investigate the relationship between knee problems and physical activity levels, sitting time and body mass index. Results: The prevalence of knee problems was high (31.8% [95% CI 26.9 to 37.2%]) among the 314 participants; knee pain was the most common dominant symptom (65%). Only high physical activity levels (OR 2.6 [95% CI 1.4-4.9]) and mental distress (OR 2.3 [95% CI 1.2-4.6]) were independent risk factors for knee problems. Conclusions: Knee problems were common among young adults, who were staff and students of a university. With increasing obesity prevalence, populations are being encouraged to become more active. More attention may need to be paid towards prevention of knee problems in such programmes, and further research is warranted.

Background An understanding of capacity for physical activity in obese populations should help guide interventions to promote physical activity. Fear of falling is a phenomenon reported in the elderly, which is associated with reduced mobility and lower physical activity levels. However, although falls are reportedly common in obese adults, fear of falling and its relationship with activity has not been investigated in younger obese populations. Methods In a cross-sectional study, fear of falling was measured in 63 women aged 18 to 49 years, with mean BMI 42.1 kg/m2 (SD 10.3) using the Modified Falls Efficacy (MFES), the Consequences of Falling (COF) and the Modified Survey of Activities and Fear of Falling in the Elderly (MSAFFE) scales. The choice of scales was informed by prior qualitative interviews with obese younger women. Physical activity levels were measured at the same time using the International Physical Activity Questionnaire. The mean score for fear of falling scales, with 95% confidence intervals, were estimated. Chi-square tests and t-tests were used to explore differences in age, body mass index and fear of falling scores between fallers and non-fallers. For each fear of falling scale, binomial logistic regression was used to explore its relationship with physical activity. Results Mean scores suggested high levels of fear of falling: MFES [mean 7.7 (SD 2.7); median 8.5]; COF [mean 31.3 (SD 9.4)]; MSAFFE [mean 25.9 (SD 8.7); median 23]. Scores were significantly worse in fallers (n = 42) compared to non-fallers (n = 21). MFES and MSAFFE were independently associated with lower levels of physical activity [odds ratio = 0.65, 95% Cl 0.44 to 0.96 and odds ratio = 1.14, 95% CI 1.01 to 1.28 respectively], when adjusted for age, BMI and depression. Conclusions This study confirms that fear of falling is present in obese women under 50 years of age. It suggests that it is associated with low levels of physical activity. These novel findings warrant further research to understand capacity for physical and incidental activity in obese adults in both genders and suggest innovative interventions to promote lifestyle changes and/or consideration of falls prevention in this population.

© 2019 - IOS Press and the authors. All rights reserved. INTRODUCTION: Patellar mobility is often routinely assessed in people with patellofemoral pain (PFP) in clinical practice. This study assessed the stability of the data when measuring patellar mobility using the total medial-lateral patellar glide test across multiple repetitions. It also compared patellar mobility of people with healthy knees to people with PFP and within subgroups of PFP. METHODS: Twenty-two people without knee problems underwent five repetitions of the total medial-lateral patellar glide test. Differences in mean value for each repetition and the intra-class correlations (ICC) between the first assessment and the average values of additional repetitions were calculated. Mean patellar mobility was compared with 127 participants with PFP who took part in a previously published subgrouping study. Differences between the healthy knee group and PFP subgroups were also explored using a one-way ANOVA with pairwise comparisons. RESULTS: The mean patellar mobility in healthy individuals was 16.4mm (SD 5.3), difference in mean patellar mobility across repetitions was minimal and the ICC ranged between 0.93 and 0.95. People with PFP had significantly lower patellar mobility than the healthy knee group. Two of three PFP subgroups had statistically significantly lower mean patellar mobility (difference in mean -5.6mm and -6.5mm; P

ObjectivesTo estimate knee and chronic knee pain prevalence in the adult population of one region of Nepal and compare rates across plain, hilly and mountainous landscapes.MethodsA cross-sectional multistage cluster survey was undertaken in seven sites across the Western Development Region of Nepal. Regional and zonal weighted 12-month prevalence rates of knee and chronic knee pain were estimated. Logistic regression was used to investigate if the ecological landscape was an independent risk factor for knee pain and/or chronic knee pain. ResultsThe weighted 12-month prevalence of knee pain was 21.5% (95% CI 18.3% to 23.9%) in the 694 recruited participants, about half had chronic knee pain (10.9%, 95% CI 7.3% to 12.4%). Living in a mountainous landscape was an independent risk factor for both knee and chronic knee pain.ConclusionFurther research is needed to understand the reasons for much higher rates in the mountainous landscape.

Introduction Most evaluations of field epidemiology training programmes (FETP) are limited to process measures, but stakeholders may need evidence of impact. Objective To ascertain if the United Kingdom (UK) FETP met its objectives to: (i) strengthen capacity and provision of national epidemiology services, (ii) develop a network of highly skilled field epidemiologists with a shared sense of purpose working to common standards and (iii) raise the profile of field epidemiology through embedding it into everyday health protection practice. Methods The evaluation consisted of: (i) focus groups with training site staff, (ii) individual interviews with stakeholders and (iii) an online survey of FETP fellows and graduates. Findings were synthesised and triangulated across the three evaluation components to identify cross-cutting themes and subthemes. Findings Eight focus groups were undertaken with 38 staff, ten stakeholders were interviewed and 28 (76%) graduates and fellows responded to the survey. Three themes emerged: confidence, application and rigour. FETP was perceived to have contributed to the development, directly and indirectly, of a skilled workforce in field epidemiology, increasing stakeholders’ confidence in the service. Graduates applied their learning in practice, collaborating with a wide range of disciplines. Fellows and graduates demonstrated rigour by introducing innovations, supporting service improvements and helping supervisors maintain their skills and share good practice. Conclusion The UK FETP appears to have met its three key objectives, and also had wider organisational impact. FETPs should systematically and prospectively collect information on how they have influenced changes to field epidemiology practice.

BACKGROUND: A number of research papers and theoretical clinical models summarising how temperature of the skin over\ud the knee may be altered according to different pathological processes have been published. Thermal imaging (TI) is generally\ud regarded as the ‘Gold’ or ‘reference’ standard for measuring skin temperature, however this technology is not widely accessible\ud to most musculoskeletal physiotherapists working in clinical environments. This is largely due to the time required for analysis\ud of the thermal images and the high cost of the equipment. A digital thermometer (DT) is portable with a convenient display of\ud results which could offer an inexpensive substitute.\ud \ud PURPOSE: The aim of this study was to determine the interchangeability between thermal imaging and a digital thermometer, using Bland-Altman limits of agreement, to determine skin temperature differences between right and left knees.\ud \ud METHODS: Seventy-one healthy participants in the age group of 8 to 40 participated in the study. Data were collected in two\ud phases. The first phase was as part of a public engagement event at the Lancashire Science Festival where school children were\ud invited to learn about science. The second phase of data collection took place as part of a PhD study where staff and students at the university were recruited via electronic advert and posters displayed around the campus. All subjects were free from lower back or lower limb problems and had not had any previous lower limb surgery.\ud \ud RESULTS: Matched paired t tests showed no significant difference between temperature difference between right and left using\ud DT and TI (t = 1.41, df = 69, P = 0.08). The DT and TI were interchangeable to measure knee skin temperature difference with a limit of agreement of –0.64 and 0.75; this limit of agreement is acceptable based on previous literature where skin temperature\ud differences between affected and non-affected knees are equal to or greater than 1◦C.\ud \ud CONCLUSION: This study concludes that an inexpensive handheld digital thermometer shows acceptable agreement with a\ud thermal imaging camera. Clinically a handheld digital thermometer has the potential to play an important role in the localized\ud assessment of skin temperature in physiotherapy and can offer an inexpensive substitute to thermal imaging; due to the massive\ud difference in cost it is worth considering the adoption of digital thermometry in routine musculoskeletal physiotherapy practice.

Identification of subgroups within the patellofemoral pain (PFP) population has gained a lot of interest and attention from the research community in recent years due to the recognition of the relatively poor patient outcomes associated with the multimodal approach and following the success of subgrouping approaches used in the management of low back pain. This paper reviews early attempts at PFP subgrouping and introduces readers to some of the modern methodological approaches employed to derive subgroups. Summaries of the results of two research projects illustrating the use of these more robust methods to derive subgroups in the PFP population are provided. In conclusion, it appears there are probably 3 or 4 discrete subgroups within the PFP population that may require a more personalised approach to treatment. However, to date no definitive randomized controlled trials (RCTs) have been conducted to evaluate the potential benefits of targeted interventions for PFP subgroups in terms of improved patient outcomes so this warrants further research.

Purpose People affected by cancer often have unmet emotional and social support needs. Online cancer communities are a convenient channel for connecting cancer survivors, allowing them to support one another. However, it is unclear whether online community use makes a meaningful contribution to cancer survivorship, as little previous research has examined the experience of using contemporary cancer communities. We aimed to explore the experiences of visitors to online cancer communities.\ud \ud Methods \ud Twenty-three in-depth interviews were conducted with online cancer community visitors, including cancer survivors (n = 18), family members (n = 2), and individuals who were both a survivor and family member (n = 3). Interviews were analysed using a grounded theory approach.\ud \ud Results \ud A theory developed explaining how individuals ‘navigated’ the experience of cancer using online cancer communities. Online advice and information led participants on a ‘journey to become informed’. Online friendships normalised survivorship and cast participants on a ‘journey to recreate identity’. Participants navigated a ‘journey through different worlds’ as they discovered relevant and hidden communities.\ud \ud Conclusions \ud This theory highlights virtual paths people affected by cancer can take to self-manage their experience of the disease. Online community experiences can be improved by promoting online evaluation skills and signposting visitors to bereavement support. Implications for cancer survivors Cancer survivors can benefit through both lurking and posting in online communities. However, individuals risk becoming distressed when they befriend\ud individuals who may soon die. Additionally, people affected by rarer cancers can struggle to find shared experiences online and may need to look elsewhere for support.

Background Stroke can affect people's ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties. Objectives Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia - Patient demographics (e.g. age, gender) - Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified - Definition of dysphagia used by the study - Level of training of nursing staff (both grade and training in the screening tool) - Low-quality studies identified from the methodological quality checklist - Type and threshold of index test - Type of reference test SEARCH METHODS: In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy. Selection criteria We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital. Data collection and analysis Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests. Main results Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)). We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests. Authors' conclusions We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

Objectives: This study explored the relationship between propensity for conscious control of movement (assessed by the Movement-Specific Reinvestment Scale) and self-reported knee pain. Design: Cross-sectional study. Setting: General population. Subjects: Adults aged 18 to 55 years of age. Measures: Participants completed the movement-specific reinvestment scale and a self-report questionnaire on knee pain at the same time on one occasion. Results: Data was collected on 101 adults of whom 34 (33.7%) self-reported knee pain. Mean scores on the conscious motor processing subscale of the movement-specific reinvestment scale, but not the movement self-consciousness subscale, were significantly higher for participants who reported knee pain within the previous year compared with those who did not (mean difference 3.03; t-test 2.66, df = 97, P = 0.009; 95% confidence interval (CI) 0.77 to 5.30). The association between self-reported knee pain and propensity for conscious motor processing was still observed, even after controlling for movement self-consciousness subscale scores, age, gender and body mass index (adjusted odds ratio 1.16, 95% CI 1.04 to 1.30). Conclusions: Propensity for conscious control of movement may play a role in knee pain.

BackgroundCurrent multimodal approaches for the management of non-specific patellofemoral pain are not optimal, however, targeted intervention for subgroups could improve patient outcomes. This study explores whether subgrouping of non-specific patellofemoral pain patients, using a series of low cost simple clinical tests, is possible.MethodThe exclusivity and clinical importance of potential subgroups was assessed by applying à priori test thresholds (1 SD) from seven clinical tests in a sample of adult patients with non-specific patellofemoral pain. Hierarchical clustering and latent profile analysis, were used to gain additional insights into subgroups using data from the same clinical tests.ResultsOne hundred and thirty participants were recruited, 127 had complete data: 84 (66%) female, mean age 26 years (SD 5.7) and mean BMI 25.4 (SD 5.83), median (IQR) time between onset of pain and assessment was 24 (7-60) months. Potential subgroups defined by the à priori test thresholds were not mutually exclusive and patients frequently fell into multiple subgroups. Using hierarchical clustering and latent profile analysis three subgroups were identified using 6 of the 7 clinical tests. These subgroups were given the following nomenclature: (i) ‘strong’, (ii) ‘weak and tighter’, and (iii) ‘weak and pronated foot’.ConclusionsWe conclude that three subgroups of patellofemoral patients may exist based on the results of six clinical tests which are feasible to perform in routine clinical practice. Further research is needed to validate these findings in other datasets and, if supported by external validation, to see if targeted interventions for these subgroups improve patient outcomes.

Background:\ud Studies have shown limited awareness about cancer risk factors among hospital-based staff. Less is known about general cancer awareness among community frontline National Health Service and social care staff.\ud \ud Methods:\ud A cross-sectional computer-assisted telephone survey of 4664 frontline community-based health and social care staff in North West England.\ud \ud Results:\ud A total of 671 out of 4664 (14.4%) potentially eligible subjects agreed to take part. Over 92% of staff recognised most warning signs, except an unexplained pain (88.8%, n=596), cough or hoarseness (86.9%, n=583) and a sore that does not heal (77.3%, n=519). The bowel cancer-screening programme was recognised by 61.8% (n=415) of staff. Most staff agreed that smoking and passive smoking ‘increased the chance of getting cancer.’ Fewer agreed about getting sunburnt more than once as a child (78.0%, n=523), being overweight (73.5%, n=493), drinking more than one unit of alcohol per day (50.2%, n=337) or doing less than 30 min of moderate physical exercise five times a week (41.1%, n=276).\ud \ud Conclusion:\ud Cancer awareness is generally good among frontline staff, but important gaps exist, which might be improved by targeted education and training and through developing clearer messages about cancer risk factors.

Abnormal reactions to environmental cold have been observed in some patients with Anterior Knee Pain (AKP). The aims of this study were to investigate whether palpation of the knee could classify patients into those with and those without cold knees; whether this classification could be objectively validated using thermal imaging; whether the cold and not cold knee groups varied in response to a cold stress test and in patient-reported measures. Fifty eight patients were recruited; palpation classified them into cold and not cold groups. Twenty-one (36%) patients were classified as having a cold knee by palpation: fourteen (36%) females and seven males (37%). Preliminary analysis suggested gender might be an effect modifier and the number of men was small, therefore the analysis focussed on females. Women with cold knees had a significantly smaller patellar skin fold, lower levels of activity and worse scores on the MFIQ, there also appeared to be an association with a traumatic onset. Women with cold knees were more likely to report cold weather affected their knees and they preferred a hot water bottle compared to an ice-pack on their knee; there was also a trend towards having to wear extra tights/long johns in the winter. This study has helped to define a clinical profile for a group of females with AKP and cold knees. This group appears to demonstrate a mild form of Reflex Sympathetic Dystrophy.

Background: \ud In the UK, overall stroke mortality has declined. A similar trend has been seen in coronary heart disease, although recent reports suggest this decline might be levelling off in middle-aged adults.\ud \ud Aim: \ud To investigate recent trends in stroke mortality among those aged 40–69 years in England.\ud \ud Methods: \ud The authors used routine annual aggregated stroke death and population data for England for the years 1979–2005 to investigate time trends in gender-specific mortalities for adults aged 40 to 69 years. The authors applied log-linear modelling to isolate effects attributable to age, linear ‘drift’ over time, time period and birth cohort.\ud \ud Results; \ud Between 1979 and 2005, age-standardised stroke mortality aged 40 to 69 years dropped from 93 to 30 per 100 000 in men and from 62 to 18 per 100 000 in women. Mortality was higher in older age groups, but the difference between the older and younger age groups appears to have decreased over time for both sexes. Modelling of the data suggests an average annual reduction in stroke deaths of 4.0% in men and 4.3% in women, although this decrease has been particularly marked in the last few years. However, we also observed a relative rate increase in mortality among those born since the mid-1940s compared with earlier cohorts; this appears to have been sustained in men, which explains the levelling off in the rate of mortality decline observed in recent years in the younger middle-aged.\ud \ud Conclusions: \ud If observed trends in middle-aged adults continue, overall stroke mortalities may start to increase again.

Background\ud Patellofemoral Pain (PFP) is a musculoskeletal disorder causing significant pain and dysfunction around the knee, commonly leading to long term limitations. People with PFP are commonly referred for physiotherapy, although current multimodal physiotherapy approaches tend to be rather ad-hoc and are failing in the long term. Identification of patient strata (or subgroups) who may respond differentially to interventions has been recognised as an international priority. It has been proposed that there are PFP patient strata, classified based on clinical tests, who would respond to modes of interventions targeted at the individual's stratum.\ud \ud Methods\ud Participants with PFP underwent clinical assessment of muscle weakness, muscle length, patellar mobility and foot posture. The presence of strata was explored using two classification techniques: hierarchical cluster analysis and latent profile analysis (LPA); for LPA, the Bayesian Information Criterion was used to guide model selection.\ud \ud Results\ud One hundred and twenty seven (of 130) recruited participants had complete assessment data. A three strata solution appeared optimal from modelling and clinical perspectives. The three suggested strata were characterised as: stronger; weaker and tighter; weaker with pronated feet. However, although membership of the stronger stratum was consistent, there were substantial differences in the other composition of the other two strata between the two classification approaches.\ud \ud Conclusion\ud PFP patients can be classified into clinical strata, although further investigation is needed to identify thresholds upon which stratification should be performed. Interventions are currently being mapped onto the strata and feasibility and evaluation trials of these interventions should then be performed.

Background: Healthcare-associated infections are costly and are increasingly viewed as an indicator of the quality of care. Although strategies to reduce infections have become widespread, few studies have formally investigated the role of undernutrition on the development of infection-related complications in children after surgery. \ud \ud Aim: To perform a systematic review of the literature to determine if undernutrition is prognostic of postoperative infection complications in children.\ud \ud Methods: Electronic bibliographic and research databases were searched from 1950 to 2014. Inclusion criteria were studies in children (age

Background: it is not known if mobile stroke teams can achieve the good results seen in trials of geographically discrete stroke wards (stroke units). Objective: to establish the effectiveness of mobile stroke teams. Design: systematic review of controlled clinical trials that compared peripatetic systems of organised stroke care (stroke team care) with alternative hospital services. Methods: systematic review and meta-analysis (using Cochrane Collaboration methodology and involving the primary trialists). Clinical outcomes included death, dependency, the need for institutional care and measures of the process of care such as the delivery of key investigations and treatments. Results: six clinical trials (1,085 patients) were identified; five (781 patients) compared some form of stroke team care with conventional care in general medical wards and one (304 patients) compared team care with a comprehensive stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Compared with a comprehensive stroke unit, stroke team patients were significantly less likely to survive (P < 0.001), return home (P < 0.001) or regain independence (P < 0.0001). Most aspects of the process of care were also poorer than in the stroke unit. Conclusions: care from a mobile stroke team had no major impact on death, dependency or the need for institutional care.

Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services.We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up.Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability.Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.

Background and Purpose— Different modes of administration are used to collect stroke outcomes, even within the same study, potentially leading to different results. We investigated the effect of administration mode (postal questionnaire; face-to-face interview) on self-reports of activities of daily living and mood. Methods— The study was nested within a poststroke motivational interviewing trial. Activities of daily living (Barthel; Nottingham Extended) and mood (General Health Questionnaire; Yale) were collected at 3 and 12 months via postal questionnaire. Participants were approached to respond again via face-to-face interview. Paired t tests (McNemar test) and intraclass correlation coefficients (Cohen κ) were used, with 95% CI, to compare scores (items). Results— Forty-four participants consented. Only Barthel scores were significantly different; they were 1.0 (95% CI, 0.5–1.6) higher face-to-face. The intraclass correlation coefficient for the Barthel was 0.90; for the other scales it was between 0.83 and 0.87. The Yale κ was 0.72. Conclusions— Modes of administration might be used interchangeably, albeit in conjunction with corrections for the Barthel.

Following a stroke, patients may have deficits that affect their ability to drive. The Royal College of Physicians recommend that health professionals provide advice to promote adherence to Driver and Vehicle Licensing Agency (DVLA) guidelines. The authors surveyed 46 participants who had had a stroke at least 1year ago to determine whether they received and complied with current advice. When compared to those who did not receive advice, those who did were significantly more likely to obtain medical permission before driving, but there were no significant differences in the frequency with which they complied with other recommendations. Many who notified the DVLA benefited from an assessment. Driving status and advice should be recorded in medical records and hospital staff should emphasize the positive benefits that may follow assessments and compliance with current guidance.

Objective To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia. Design Randomised controlled trial. Population Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment. Setting Seven colposcopy units in the North West Region. Methods Loop diathermy excision of the transformation zone and laser vaporisation. Main outcome measure Smear reported as moderate dyskariosis or worse following treatment. Results Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone. Conclusions Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.

Background Recent national guidelines emphasize the requirement for all general practitioners to manage drug users within a shared care scheme and suggest that a primary health care liaison worker (PHCLW) may facilitate these arrangements. We undertook a group-randomized, randomized controlled trial to determine the effectiveness of a PHCLW in promoting shared care. Methods Primary health care teams in Stockport Health Authority, North West England, were randomly allocated to either an intervention arm, who were offered the services of a PHCLW, or to a control arm, who were offered standard support from the community drug team (CDT). The proportion of CDT clients with a history of regular opiate misuse who were in shared care 12 months after randomization was compared across study arms. Results Eighteen (24.0 per cent) of the 75 CDT clients in the intervention arm but none of the 80 CDT clients in the control arm were in shared care at 12 months (� 2 � 9.37, df � 1, p � 0.01; 95 per cent confidence interval 8.6‐39.4 per cent). Conclusion A PHCLW can significantly increase the number of CDT clients in shared care arrangements.

Background: Patellofemoral pain (PFP) is a specific musculoskeletal disorder that causes significant pain and dysfunction around the knee cap and knee joint, which can lead to long term limitation in societal participation and physical activity. There is a consensus that conservative intervention should be the first treatment option so PFP is a condition that is commonly referred for physiotherapy. Unfortunately, however, current multi modal approaches to intervention in PFP are failing in the long term. Purpose: Given the poor outcome of current treatment regimens, identification of patellofemoral subgroups is an international priority. Large individual variation in outcome results is consistently reported in response to conservative management, therefore understanding whether subgroups have different outcomes has become imperative. However it is unknown whether subgrouping is possible in PFP. The main purpose of this study was to describe the distribution of PFP patients into different subgroups using six routine clinical assessment test criteria. Methods: Design: Cross-sectional with single point assessment prior to commencement of physiotherapy. Participants with PFP underwent clinical assessment of muscle strength (quadriceps and hip abductor), muscle length (quadriceps, hamstrings, gastrocnemius), patellar mobility and foot posture. The presence of subgroups was explored using two classification techniques: Hierarchical Clustering and Latent Profile Analysis. Results: One hundred and twenty seven of 130 recruited participants had complete assessment data: 66% were female, mean (SD) age was 26 (5.7) years, BMI 25.5 (5.8), and Modified Functional Index Questionnaire (MFIQ) was 34 (17). A three subgroup solution appeared optimal from a modelling and clinical perspective. The three suggested clinical subgroups were characterised as: Strong subgroup (n = 44), weak and tight subgroup (n = 58), pronated feet subgroup (n = 25). An ANOVA and post hoc tests confirmed significant differences between subgroups. Strong subgroup: quadriceps strength 1.5 Nm/kg (0.51), hip abductor strength 1.5 Nm/kg (0.51), lowest patellar mobility of the three groups 9.6 mm (3.43). Weak and tight subgroup: hip abductor strength 0.7 Nm/kg (0.27), shortest quadriceps length 118° (17.9). Pronated feet subgroup: highest FPI 7 (3.0), highest patellar mobility 17.6 mm (4.75). Conclusion(s): This study is the largest conducted to date on subgrouping of PFP. The results lend support to the idea that clinical subgroups exist within the patellofemoral population, with three potential subgroups emerging. The key clinical tests for identifying the three subgroups are strength measurement of the quadriceps and hip abductors, and foot posture index. Patellar mobility and quadriceps flexibility contributed to subgroup profiles, so also appear important to consider when identifying PFP subgroups. Implications: These results fit well with other findings in musculoskeletal research where subgrouping has been successful in informing targeted intervention in low back pain patients and is being increasingly adopted as a strategy for managing patients with shoulder problems. Our next step is explore variation in outcome across the identified PFP subgroups and whether subgroup targeted intervention improves overall patient outcomes.

Background: Patellofemoral pain (PFP) is a specific musculoskeletal disorder that causes significant pain and dysfunction around the knee cap and knee joint leading to long term limitation in societal participation and physical activity. PFP is a condition commonly referred for physiotherapy intervention, however long term outcomes are poor. We have undertaken a study to explore the presence of clinical subgroups within the PFP population based on the scores of 6 tests that could be used within routine clinical practice. Our research study identified 3 clinical subgroups: Strong subgroup; Weak and Tight subgroup; Pronated feet subgroup. Purpose: There is mounting evidence that factors such as gender and activity levels influence development and outcome in PFP. There is also interest in whether psychosocial factors and different pain mechanisms play a role in determining potential subgroups. Therefore the main objective of this study was to explore interactions between demographic, clinical and psychosocial characteristics and clinical subgroups. Methods: Observational study, at one time point (commencement of physiotherapy). Demographic (Age; Body Mass Index (BMI)), clinical (Time since onset; Patellar skin fold; Tibialis anterior/patella temperature index; Cold Knees questions), and psychosocial characteristics (numeric pain rating scale (NPRS); International physical activity questionnaire (IPAQ); Modified functional index questionnaire (MFIQ); Short Leeds assessment neuropathic sign and symptoms (SLANSS); EQ-5D-5L; Hopkins symptoms check list (HSCL); Movement specific reinvestment scale (MSRS)) were assessed. Differences between the three clinical subgroups were explored using ANOVA, with post hoc tests, or chi-squared tests. Results: Of 127 participants, 66% were female and the mean age was 26 years (SD 5.7), BMI 25.5 (SD 5.8), time since onset 45 months (SD 55) and MFIQ was 34 (SD 17). The strong subgroup had significant higher function, quality of life and there were proportionally more males in this subgroup. The weak and tight subgroup significantly had the highest BMI, and there was a trend towards the lowest levels of activity. The pronated feet subgroup was significantly younger at time of first assessment and there was a trend for higher mean scores for neuropathic pain (SLANSS). There was no difference in mean scores of other characteristics across the subgroups. Conclusion(s): This study, the largest on PFP subgrouping, provides data on other characteristics of PFP patients and suggests significant differences in non-clinical factors between clinical subgroups. The latter provides support for the existence of clinical subgroups and possible insight into potential intervention strategies. For example, higher function and quality of life in the strong subgroup may suggest a focus on movement control is required whereas the higher BMI in the weak and tight subgroup may suggest adjunct weight management strategies may be needed. The neuropathic pain in the pronated feet subgroup may warrant desensitisation interventions. Implications: Demographic and psychosocial characteristics may be important factors to consider in addition to clinical factors in PFP patients. Such factors are increasingly important in managing patients with other musculoskeletal problems. The next step is to understand the relationship between these factors and treatment outcome. Keywords: Patellofemoral pain; Psychosocial; Subgrouping

The cluster-randomized controlled trial is a design increasingly used in prevention and health care evaluation studies and is highly relevant to stroke research. However, there are methodological issues that make it complex to implement. These are not always fully appreciated, with reviews continuing to reveal deficiencies. We searched PUBMED and CENTRAL databases to March 31, 2011 for cluster-randomized controlled trials in stroke. Two investigators independently reviewed citations for eligibility and extracted data on key aspects of each trial. Fifteen trials met the eligibility criteria. No trial fully met CONSORT cluster-randomized controlled trial guidelines, although good design and reporting practice were usually present. Twelve trials included the term ‘cluster-randomized’ (or ‘group-randomized’) in the title, and 12 trials stated the intraclass correlation coefficient used to plan the number of clusters and cluster size. However, few provided a clear, evidence-based justification for the choice of intraclass correlation coefficient, and only two-thirds reported the intraclass correlation coefficient for primary outcomes. Several trials appeared underpowered because of problems in determining an appropriate sample size, defining appropriate clusters, and recruiting and retaining clusters and patients. Cluster-randomized controlled trials are difficult to design and perform due to the combination of methodological and practical difficulties. It is important that further improvements are made to reporting cluster-randomized trials and intraclass correlation coefficients should be estimated using a standardized approach and reported consistently; this would be beneficial for stroke researchers when designing future cluster-randomized trials.

Background Newspaper readership in the UK is high. Exposure to media stories has been shown to influence reader perceptions and newspapers are frequently used as part of cancer awareness campaigns. However we don’t know what happens to the cancer awareness message when it reaches the print media or whether people featured in cancer-related personal interest stories reflect current cancer inequalities. This study forms the first stage of a PhD and looks at the people featured and the language used to see how cancer is currently reported in the UK print media and how this might influence the public’s awareness and perception of the disease. Methods UK national and regional/local newspaper articles featuring a personal interest story about an individual’s journey with ovarian cancer over a seven-and-a-half year period were identified from the Nexis database. Content analytical methods were used to code information about the newspaper, demographic information about the people featured, and key cancer awareness information such as whether a list of symptoms was provided, or whether early detection was linked to better survival. WMatrix3 was used to conduct corpus linguistic analyses of the language used in the articles including key words, themes, and patterns of words appearing together by comparing the articles to a corpus of standard written English (British National Corpus Written Sampler). Results Newspaper coverage decreased with increasing age; only 34.51% (n=156) of articles featured individuals aged over 50. Managers/professionals were featured twice as often as non-professionals (14.82%, n=67 vs 29.8%, n=68). Only a quarter (26.77%, n=121) of articles provided a list of symptoms and even fewer linked early detection and survival (16.81%, n=76) or described the age group most at risk (13.05%, n=59). Corpus linguistic analyses utilising log likelihood (LL) across the years revealed distinctly negative use of language reflecting sadness (LL=+17.03, n=36 [2006] to LL=+72.13, n=105 [2009]) and death (LL=+16.27, n=92 [2012] to LL=+114.29, n=139 [2007]), as well as frequent use of battle language. Conclusions Stories about an individual’s journey with ovarian cancer in UK newspapers tend to be negative, lack educational content and do not reflect those most at risk. The next steps of the project are: 1) tracking specific campaigns through the print media to see what happens to the message and how any related personal interest stories are presented 2) understanding why articles are presented in this way through interviewing press release officers, journalists and editors.

to offer a critical discussion from a public health perspective of service user's experiences of antenatal care services.a qualitative, descriptive study using 18 group (n = 86) and six individual semi-structured interviews (n = 6) with thematic networks analysis conducted.ninety-two participants recruited from organisations/groups who work with vulnerable populations and/or community groups were consulted in the North West of England.analysis from a public health perspective suggested four key areas: antenatal care attendance, the frequency of antenatal appointments, the location of antenatal care and the provision of risk information. The benefits of universal access to antenatal care were mainly evident to participants. The need for targeting those with identified clinical risk was valued, but participants expressed frustration at a 'one-size fits all' approach for others, which failed to adequately consider their psychosocial and educational needs. In some women, this failure prompted non-compliant behaviour. Concerns were somewhat compensated for by community-based antenatal services.inequities in antenatal care persist with service users from vulnerable population groups continuing to express that these services do not meet their needs. Neither a targeted approach based on clinical needs nor a population-based approach, which service users feel limits access, meet their expectations. Proportionate universalism offers a new paradigm in public health with level of service proportionate to need. Such an approach may facilitate health-care staff to meet the expectations of vulnerable families who may require more psychosocial and educational support.