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Purpose: to examine the association between physiotherapy access after hip fracture and discharge home, readmission, survival, and mobility recovery.Methods: a 2017 Physiotherapy Hip Fracture Sprint Audit was linked to hospital records for 5,383 patients. Logistic regression was used to estimate the association between physiotherapy access in the first postoperative week and discharge home, 30-day readmission post-discharge, 30-day survival and 120-days mobility recovery post-admission adjusted for age, sex, American Society of Anesthesiology grade, Hospital Frailty Risk Score and prefracture mobility/residence.Results: overall, 73% were female and 40% had high frailty risk. Patients who received ≥2 hours of physiotherapy (versus less) had 3% (95% Confidence Interval: 0-6%), 4% (2-6%), and 6% (1-11%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 3% (0-6%) lower adjusted probability of readmission. Recipients of exercise (versus mobilisation alone) had 6% (1-12%), 3% (0-7%), and 11% (3-18%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 6% (2-10%) lower adjusted probability of readmission. Recipients of 6-7 days physiotherapy (versus 0-2 days) had 8% (5-11%) higher adjusted probability of survival. For patients with dementia, improved probability of survival, discharge home, readmission and indoor mobility recovery were observed with greater physiotherapy access.Conclusion: greater access to physiotherapy was associated with a higher probability of positive outcomes. For every 100 patients, greater access could equate to an additional eight patients surviving to 30-days and six avoiding 30-day readmission. The findings suggest a potential benefit in terms of home discharge and outdoor mobility recovery.

Purpose Detecting pain in older people with dementia is challenging. Consequentially, pain is often under-reported and under-treated. There remains uncertainty over what measures should be promoted for use to assess pain in this population. The purpose of this paper is to answer this question. Methods A search of clinical trials registered on the ClinicalTrial.gov and ISRCTN registries was performed to identify outcome measures used to assess pain in people with dementia. Following this, a systematic review of published and unpublished databases was performed to 01 November 2021 to identify papers assessing the psychometric properties of these identified measures. Each paper and measure was assessed against the COSMIN checklist. A best evidence synthesis analysis was performed to assess the level of evidence for each measure. Results From 188 clinical trials, nine outcome measures were identified. These included: Abbey Pain Scale, ALGOPLUS, DOLOPLUS-2, Facial Action Coding System, MOBID-2, self-reported pain through the NRS or VAS/thermometer or Philadelphia Geriatric Pain Intensity Scale, PACSLAC/PACSLAC-2, Pain Assessment in Advanced Dementia (PAINAD), and Checklist for non-verbal pain behavior (CNPI). From these, 51 papers (5924 people with dementia) were identified assessing the psychometric properties of these measures. From these, there was strong- and moderate-level evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID, and MOBID-2 tools for the assessment of pain with people living with dementia. Conclusion Whilst these reflect measurement tools used in research, further consideration on how these reflect clinical practice should be considered. PROSPERO registration CRD42021282032

Background Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management. Methods A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework. Results Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the ‘best’ treatment options to offer. This was associated with poor training and understanding on how pain ‘should’ be managed. Conclusion The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.

Peer reviewed: True, OBJECTIVES: To determine if a newer design of total knee replacement (TKR) (Journey II BCS) produces superior patient-reported outcomes scores and biomechanical outcomes than the older, more established design (Genesis II). SETTING: Patients were recruited from an NHS University Hospital between July 2018 and October 2019 with surgery at two sites. Biomechanical and functional capacity measurements were at a University Movement and Exercise Laboratory. PARTICIPANTS: 80 participants undergoing single-stage TKR. INTERVENTIONS: Patients were randomised to receive either the Journey II BCS (JII-BCS) or Genesis II TKR. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was the Oxford Knee Score (OKS), at 6 months. Secondary outcomes were: OKS Activity and Participation Questionnaire, EQ-5D-5L and UCLA Activity scores, Timed Up and Go Test, 6 min walk test, lower limb kinematics and lower limb muscle activity during walking and balance. RESULTS: This study found no difference in the OKS between groups. The OKS scores for the JII-BCS and Genesis II groups were mean (SD) 42.97 (5.21) and 43.13 (5.20) respectively, adjusted effect size 0.35 (-2.01,2.71) p=0.771In secondary outcome measures, the Genesis II group demonstrated a significantly greater walking range-of-movement (50.62 (7.33) vs 46.07 (7.71) degrees, adjusted effect size, 3.14 (0.61,5.68) p=0.02) and higher peak knee flexion angular velocity during walking (mean (SD) 307.69 (38.96) vs 330.38 (41.40) degrees/second, adjusted effect size was 21.75 (4.54,38.96), p=0.01) and better postural control (smaller resultant centre of path length) during quiet standing than the JII-BCS group (mean (SD) 158.14 (65.40) vs 235.48 (176.94) mm, adjusted effect size, 59.91 (-105.98, -13.85) p=0.01.). CONCLUSIONS: In this study population, the findings do not support the hypothesis that the Journey II BCS produces a better outcome than the Genesis II for the primary outcome of the OKS at 6 months after surgery. TRIAL REGISTRATION NUMBER: ISRCTN32315753.

Objectives: Foot and ankle involvement is common in rheumatic and musculoskeletal diseases, yet high-quality evidence assessing the effectiveness of treatments for these disorders is lacking. The Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group is developing a core outcome set for use in clinical trials and longitudinal observational studies in this area. Methods: A scoping review was performed to identify outcome domains in the existing literature. Clinical trials and observational studies comparing pharmacological, conservative or surgical interventions involving adult participants with any foot or ankle disorder in the following rheumatic and musculoskeletal diseases (RMDs) were eligible for inclusion: rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathies, crystal arthropathies and connective tissue diseases. Outcome domains were categorised according to the OMERACT Filter 2.1. Results: Outcome domains were extracted from 150 eligible studies. Most studies included participants with foot/ankle OA (63% of studies) or foot/ankle involvement in RA (29% of studies). Foot/ankle pain was the outcome domain most commonly measured (78% of studies), being the most frequently specified outcome domain across all RMDs. There was considerable heterogeneity in the other outcome domains measured, across core areas of manifestations (signs, symptoms, biomarkers), life impact, and societal/resource use. The group's progress to date, including findings from the scoping review, was presented and discussed during a virtual OMERACT Special Interest Group (SIG) in October 2022. During this meeting, feedback was sought amongst delegates regarding the scope of the core outcome set, and feedback was received on the next steps of the project, including focus group and Delphi methods. Conclusion: Findings from the scoping review and feedback from the SIG will contribute to the development of a core outcome set for foot and ankle disorders in RMDs. The next steps are to determine which outcome domains are important to patients, followed by a Delphi exercise with key stakeholders to prioritise outcome domains. Refereed/Peer-reviewed

Aims This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery. Methods This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920.

Physiotherapists are often key decision-makers on when to refer patients with recurrent patellar dislocation for surgical opinion. Limited guidance exists to aid this decision. Differences in orthopaedic surgeons' and physiotherapists' views on which patients and when to refer people for surgical consideration or non-operative care may affect outcome. This study aimed to explore orthopaedic surgeons and physiotherapists decision-making surrounding treatment opinions for patients with recurrent patellar dislocation.An online survey performed. UK registered and practicing orthopaedic surgeons and physiotherapists were invited to participate. The survey utilised two vignettes and a series of related questions to ascertain respondents' views on decision-making to surgical referral for people with recurrent patellar dislocation. Data were analysed using descriptive statistics and inferential statistical tests to explore factors related to responses.Eighty four respondent surveys were analysed (38 surgeons, 46 physiotherapists). Overall, there was a low level of agreement amongst respondents for the management of the vignettes (k = 0.215, p = 0.0005). Some disparity existed between the professions on the definition of recurrent patellar dislocations and the clinical features which may require an early surgical assessment. Physiotherapists were three times more likely to delay a surgical opinion for the vignettes presented in this study than the surgeons.This is the first study to investigate orthopaedic surgeons' and physiotherapists' views on decision-making around surgical or non-operative management for recurrent patellar dislocations. High-quality research is required to underpin explicit guidance on decision-making regarding management of recurrent patellar dislocation.

OBJECTIVE: Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap. METHODS: The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted. RESULTS: Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women

Chondral injury is a serious consequence of patellar dislocation and patellofemoral instability (PFI). There is limited data on the relationship between radiological features such as sulcus angle and patellar height to the presence, location, and severity of chondral lesions. The purpose of this study was to determine the association of anatomical variants in patellofemoral instability with injuries sustained due to patellar dislocation. A cohort of 101 patients who had four or more episodes of dislocation or instability undergoing isolated arthroscopy or arthroscopies at the time of corrective realignment surgery were identified. The prevalence of chondral, ligamentous, and meniscal injuries was determined and correlated to the sulcus angle, tibial tubercle trochlear groove distance, and patellar height on magnetic resonance imaging (MRI) scans. A total of 101 patients was identified. At arthroscopy, the patella demonstrated the highest incidence of chondral injury (68%) followed by the trochlear groove (40%). Lateral meniscal injuries were noted in 6% of patients, medial meniscal injuries in 2%, and anterior cruciate ligament (ACL) injury in 3%. Chondral injuries were graded using the Outerbridge criteria and there was a correlation between more severe chondral injuries and a greater tilt angle (p = 0.05). The occurrence of injury to the lateral meniscus was associated with a higher Insall–Salvati ratio (p = 0.05). More severe chondral injuries are seen in patients with a greater tilt angle.

Aims This study aimed to examine if the cardiac changes associated with uraemic cardiomyopathy are reversed by renal transplantation. Methods and results MEDLINE, Embase, OpenGrey, and the Cochrane Library databases were searched from 1950 to March 2020. The primary outcome measure was left ventricular mass index. Secondary outcome measures included left ventricular dimensions and measures of diastolic and systolic function. Studies were included if they used any imaging modality both before and after successful renal transplantation. Data were analysed through meta‐analysis approaches. Weight of evidence was assessed through the Grading of Recommendations Assessment, Development and Evaluation system. Twenty‐three studies used echocardiography, and three used cardiac magnetic resonance imaging as their imaging modality. The methodological quality of the evidence was generally poor. Four studies followed up control groups, two using cardiac magnetic resonance imaging and two using echocardiography. Meta‐analysis of these studies indicated that there was no difference in left ventricular mass index between groups following transplantation {standardized mean difference −0.07 [95% confidence interval (CI) −0.41 to 0.26]; P = 0.67}. There was also no difference observed in left ventricular ejection fraction [mean difference 0.39% (95% CI −4.09% to 4.87%); P = 0.86] or left ventricular end‐diastolic volume [standardized mean difference −0.24 (95% CI −0.94 to 0.45); P = 0.49]. Inconsistent reporting of changes in diastolic dysfunction did not allow for any meaningful analysis or interpretation. Conclusions The evidence does not support the notion that uraemic cardiomyopathy is reversible by renal transplantation. However, the evidence is limited by methodological weaknesses, which should be considered when interpreting these findings.

BACKGROUND: Despite contributing to significant morbidity in working-age adults, there is no consensus on the optimal treatment for prepatellar bursitis. Much of the existing literature combines prepatellar and olecranon bursitis. This systematic review aims to determine the optimal management of prepatellar bursitis. STUDY DESIGN AND METHODS: A primary search of electronic published and unpublished literature databases from inception to November 2019 was completed. Articles over 25 years old, case reports with less than four patients, paediatric studies, and non-English language papers were excluded. Our primary outcome was recurrence after 1 year. Comparisons included endoscopic vs open bursectomy, duration of antibiotics. Methodological quality was assessed using the Institute of Health Economics and Revised Cochrane Risk of Bias scoring systems. Meta-analyses were conducted where appropriate. RESULTS: In total 10 studies were included (N = 702). Endoscopic and open bursectomy showed no difference in recurrence after 1 year (OR 0.41, 95% CI 0.05-3.53, p = 0.67), and surgical complications (OR 1.44, 95% CI 0.34-6.08, p = 0.44). 80% endoscopically-treated patients were pain free after 1 year. Patients treated with antibiotics for less than 8 days were not significantly more prone to recurrence (2/17 vs 10/114, OR 0.66, 95% CI 0.13-3.29, p = 0.64) compared to 8 days plus at minimum 1 year post injury. CONCLUSIONS: Our study represents the largest cohort of patients evaluating management strategies for prepatellar bursitis, and includes data not previously published. Endoscopic bursectomy is non-inferior to open bursectomy, enabling a shorter hospital stay. It also offers a relatively low risk of post-operative pain. Endoscopic bursectomy is a viable option to treat both septic and aseptic prepatellar bursitis. Our small cohort suggests recurrence and hospital stay are not improved with antibiotic treatment exceeding 7 days for septic prepatellar bursitis.

Introduction Previous evidence has established that early surgery is beneficial to improve outcomes for individuals with native hip fractures in the elderly population. Patients who sustain a periprosthetic fracture have been demonstrated to have similar demographics and outcomes as those with native fractures around the hip and knee. We therefore set out to determine if there is a similar difference in perioperative outcomes between early and delayed surgery for periprosthetic fractures of the hip and knee through a systematic review and meta-analysis. Methods Literature search outputs were screened for studies meeting the inclusion criteria. The groups of early surgery and delayed surgery were defined by study authors. The primary outcome measure was 30 day mortality. Where there was sufficient study homogeneity, a random-effects meta-analysis was performed. Individual study risk of bias was assessed using the ROBINS-I criteria, with the GRADE criteria used for independent outcome evaluation. The review protocol was registered on PROSPERO prior to commencement (Registration number CRD42019149360). Results The inclusion criteria was met in 11 studies (n = 3006). Mean time to surgery from admission for reporting studies was 64 h. 59.6% patients underwent early surgery as defined by the study authors. We identified a significantly lower risk of 30 day mortality for those with early surgery versus delayed surgery (RR 0.21; 95% CI 0.05, 0.90; p = 0.04, n = 2022). There were also significantly better outcomes for early versus delayed surgery regarding: medical complications, length of stay, transfusion risk, and reoperation. The quality of evidence for all the individual outcomes was low or very low. Conclusions There is evidence that delaying surgery in those with periprosthetic fractures of the hip and knee has a deleterious impact on mortality and other important patient outcomes. There are, however, notable limitations to the existing available literature, with further appropriately designed large-scale studies required to confirm these findings.

Objective: There is no validated radiographic measurement to diagnose prosthetic complication(s) following total ankle replacements (TARs) although a number of angular and linear measurements, used to define the TAR position on postoperative radiographs, have been recommended to detect prosthetic loosening. The aim of this study was to test the intra- and interobserver reliability of these measurements. Materials and methods: This is a prospective study embedded within a multicentre cohort study. Following sample size calculation, 62 patients were analysed. Six measurements were performed on the first postoperative anteroposterior and lateral ankle radiographs: angles α and β, and length “a” defined the craniocaudal position of the tibial component, while angle γ, and lengths “b” and “c” defined the angular position of the talar component. Measurements were recorded by three independent observers. Inter- and intraobserver reliability was assessed with intraclass correlation coefficient (ICC), Bland-Altman plots, and within-subject coefficients of variation (CV). Results: The intrarater ICC was “almost perfect” (ICC 0.83–0.97) for all six measurements. The interrater ICC was “substantial” to “almost perfect” (ICC 0.69–0.93). The mean difference in intrarater angular measurements was ≤ 0.6° and ≤ 0.8 mm for linear measurements, and ≤ 2.2° and ≤ 2.1 mm for interrater measurements. Maximum CV for the interrater linear measurements (≤ 17.7%) more than doubled that of the angular measurements (≤ 8.0%). The maximum width of the 95% limits of agreement was 6.5° and 8.4 mm for intrarater measures, and 8.9° and 10.6 mm for interrater measurements. Conclusion: Angular measures are more reliable than linear measures and have potential in routine clinical practice for TAR position assessment.

ObjectiveTo test the effectiveness of a behaviour change physiotherapy intervention to increase physical activity compared with usual rehabilitation after total hip replacement (THR) or total knee replacement (TKR).DesignMulticentre, pragmatic, two-arm, open, randomised controlled, superiority trial.SettingNational Health Service providers in nine English hospitals.Participants224 individuals aged ≥18 years, undergoing a primary THR or TKR deemed ‘moderately inactive’ or ‘inactive’.InterventionParticipants received either six, 30 min, weekly, group-based exercise sessions (usual care) or the same six weekly, group-based, exercise sessions each preceded by a 30 min cognitive behaviour discussion group aimed at challenging barriers to physical inactivity following surgery (experimental).Randomisation and blindingInitial 75 participants were randomised 1:1 before changing the allocation ratio to 2:1 (experimental:usual care). Allocation was based on minimisation, stratifying on comorbidities, operation type and hospital. There was no blinding.Main outcome measuresPrimary: University of California Los Angeles (UCLA) Activity Score at 12 months. Secondary: 6 and 12-month assessed function, pain, self-efficacy, kinesiophobia, psychological distress and quality of life.ResultsOf the 1254 participants assessed for eligibility, 224 were included (139 experimental: 85 usual care). Mean age was 68.4 years (SD: 8.7), 63% were women, 52% underwent TKR. There was no between-group difference in UCLA score (mean difference: −0.03 (95% CI −0.52 to 0.45, p=0.89)). There were no differences observed in any of the secondary outcomes at 6 or 12 months. There were no important adverse events in either group. The COVID-19 pandemic contributed to the reduced intended sample size (target 260) and reduced intervention compliance.ConclusionsThere is no evidence to suggest attending usual care physiotherapy sessions plus a group-based behaviour change intervention differs to attending usual care physiotherapy alone. As the trial could not reach its intended sample size, nor a proportion of participants receive their intended rehabilitation, this should be interpreted with caution.Trial registration numberISRCTN29770908.

Background & Objective Cervical spine radiculopathy (CSR) is a disabling condition which has significant negative impacts on a person’s mental health, physical functioning and social participation. Research has reported variable CSR incidence and prevalence among different populations. To date no systematic review has been completed investigating the prevalence or incidence of CSR, therefore our objective was to determine the incidence and/or prevalence of CSR in adults. Design and Method A systematic review was conducted including searches of PubMed (MEDLINE), EMBASE and CINAHL from inception to February 25th 2020. Studies including data on incidence and/or prevalence of CSR were included. Methodological quality was assessed using a modified Hayden, Cote and Bombardier (2006) appraisal checklist. Data was analysed narratively. Results Nine low to high-quality studies were included in the final review. Incidence ranged between 0.832 to 1.79 per 1000 person-years from two high quality and one low quality study. Prevalence values ranged from 1.21 to 5.8 per 1000 from four medium to high quality studies. Prevalence values of 1.14% (95% CI 0.45-1.82) and 1.31% (95% CI 0.66-1.96) for males and females respectively were reported from one medium quality study. One medium quality study reported an unadjusted prevalence value of 6.3% for males and females. Conclusions This is the first systematic review investigating the epidemiology of CSR in an adult population. This review reports a variable incidence rate and prevalence of CSR among specific populations, however, this was based on nine studies. There is a priority to investigate CSR epidemiology across other populations globally and standardising CSR diagnostic criteria. This is the peer reviewed version of the following article: Mansfield et al. (2020) Cervical Spine Radiculopathy Epidemiology. Systematic Review, Musculoskeletal Care which will be published in final form at https://onlinelibrary.wiley.com/journal/15570681. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.

Background: Core outcome sets are an agreed recommendation to inform the selection of outcome measures in clinical trials. There has been low uptake of the 2014 hip fracture core outcome set. The reasons for this remain unclear. The aim of this study was to understand the reasons for the non-adoption and approaches to increase adoption of the hip fracture core outcome set. Methods: Randomised controlled trials from PubMed (2017–2019) and ClinicalTrials.gov (2015–2019) were identified. Corresponding authors for each identified trial (n = 302) were surveyed using five questions on awareness of the hip fracture core outcome set, reasons for non-adoption and approaches to increase adoption. Data were analysed descriptively using frequencies, mean values and standard deviations. Results: Fifty-four percent of the respondents (n = 43) were aware of the concept of core outcome set. Only 15% (n = 12) based the outcome measure selection on the 2014 hip fracture core outcome set. Key reasons for non-adoption included the following: authors being unaware and perceived inappropriateness to their trial design. Eighty-six percent (n = 69) of respondents agreed to the need for increased awareness of core outcome sets through research training, academic and clinical journal requirements, and funding or publication stipulations. Eighty-eight percent (n = 70) of respondents indicated the current core outcome set required revision to focus on trials investigating people with cognitive impairment, caregivers, rehabilitation, surgical interventions and anaesthetic trial designs. Conclusion: Barriers to the adoption of the hip fracture core outcome set centre on education, awareness of the core outcome sets and applicability to the breath of hip fracture trial designs. Further consideration should be made to address these, to improve the harmonisation of outcome measures across hip fracture trials.

Background Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. Methods This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; ‘Personalised Knee Therapy’ (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. Results We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. Conclusion This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability. Trial registration The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). http://www.isrctn.com/ISRCTN14950321

Aims To investigate the incidence and pattern of injury in patients with a diagnosis of a fall from a stairlift. Methods Data was analysed from the Trauma Audit and Research Network (TARN) database from 2000 to 2018 for those recorded suffering stairlift related injuries between the ages of 40–100 years. Patient demographics, injury mechanism and pattern, mortality rate and height of fall were analysed. Results 1069 patients were identified in the initial search with 651 having an eligible mechanism of injury. The mean age was 82 (range 41.4–100.1) years. The most common site of injury was the limbs (49.2%) with the most severe injuries to the head (mean AIS 3.1). The mean ISS was 12.5 (Range 1–75). There was no relationship between height of fall and ISS (rs 0.054 p = 0.4). Individuals were 78% more likely to have an ISS score of 15 or more if they had a head injury, (OR: 0.12; 95% CI: 0.06–0.24) and 79% more likely to have sustained an injury to the thorax (OR: 0.21; 95% CI: 0.11–0.41). Injury to the head was 95% more likely in individuals with an ISS score greater than 25 points or more (OR: 0.05; 95% CI: 0.01–0.16) and 69% more likely for those who sustain injury to the thorax. Individuals with an ISS score of 25 points or more were 18 times more likely to have sustained injury getting off their stair lift compared to any other method of falling from their stair lift. Mortality was associated with injuries to the thorax in those aged 70 years or below, injuries to the face, spine and limb for those aged 71–85 years and with head injury in those over 85 years. The overall mortality rate was 15.7%. Conclusion Falls from stairlifts commonly result in limb injuries and most severe injuries are sustained to the head. When patients fall getting off from astairlift, have injuries to their head or thorax they have a higher ISS. The overall mortality is 15.7%. Given the increasing use of stairlifts in our ageing population, strategies should be considered to make these safer.

Background: People with chronic pain often seek support from friends and family for everyday tasks. These individuals are termed informal caregivers. There remains uncertainty regarding the lived experiences of these people who care for individuals with chronic musculoskeletal pain. The aim of this article is to synthase the evidence on the lived experiences of informal caregivers providing care to people with chronic musculoskeletal pain. Methods: A systematic literature review was undertaken of published and unpublished literature databases including EMBASE, MEDLINE, CINAHL, PubMed, the WHO International Clinical Trial Registry and ClinicalTrials.gov registry (to September 2019). Qualitative studies exploring the lived experiences of informal caregivers of people with chronic musculoskeletal pain were included. Data were synthesised using a meta-ethnography approach. Evidence was evaluated using the Critical Appraisal Skills Programme qualitative appraisal tool. Results: From 534 citations, 10 studies were eligible (360 participants: 171 informal caregivers of 189 care recipients). The evidence was moderate quality. Seven themes arose: the relationship of caregivers to healthcare professionals; role reversal with care recipients; acting the confidant to the care recipient; a constant burden in caregiving; legitimising care recipient’s condition; knowledge and skills to provide caregiving; and the perception of other family members and wider society to the caregiver/care recipient dyad. Conclusion: The lived experiences of caregivers of people with chronic musculoskeletal pain is complex and dynamic. There is an inter-connected relationship between caregivers, care recipients and healthcare professionals. Exploring how these experiences can be modified to improve a caregiving dyad’s lived experience is now warranted.

Background Total hip (THR) and knee replacement (TKR) are two of the most common elective orthopaedic procedures worldwide. Physiotherapy is core to the recovery of people following joint replacement. However, there remains uncertainty as to physiotherapy provision at a national level. Objectives To examine the relationship between patient impairment and geographical variation on the provision of physiotherapy among patients who undergo primary total hip or knee replacement (THR/TKR). Design Population-based observational cohort study. Methods Patients undergoing THR (n = 17,338) or TKR (n = 20,260) recorded in the National Joint Registry for England (NJR) between 2009 and 2010 and completed Patient Reported Outcome Measures (PROMs) questionnaires at Baseline and 12 months postoperatively. Data were analysed on the frequency of physiotherapy over the first postoperative year across England’s Strategic Health Authorities (SHAs). Logistic regression analyses examined the relationship between a range of patient and geographical characteristics and physiotherapy provision. Results Following THR, patients were less likely to receive physiotherapy than following TKR patients (‘some’ treatment by a physiotherapist within 1st post operative year: 53% vs 79%). People with worse functional outcomes 12 months postoperatively, received more physiotherapy after THR and TKR. There was substantial variation in provision of physiotherapy according to age (younger people received more physiotherapy), gender (females received more physiotherapy) ethnicity (non-whites received more physiotherapy) and geographical location (40% of patients from South West received some physiotherapy compared to 40 73% in London after THR). Conclusions There is substantial variation in the provision of physiotherapy nationally. This variation is not explained by differences in the patient’s clinical presentation.

ObjectivesAssess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI).DesignFeasibility trial undertaken between 2016 and 2018.SettingEleven acute hospitals from three UK regions.Participants284 participants (208 female:69 male). Inclusion criteria: aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a ‘suitable informant’ able to provide proxy measures, recruited within 7 days of hip fracture surgery. Exclusion criteria: no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial.InterventionPERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan–do–study–act model.Primary and secondary outcome measuresFeasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores.Results282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group.ConclusionThis trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture.Trial registration numberISRCTN99336264.

Objective To identify the clinical and biomechanical characteristics associated with falls in people with RA. Methods A total of 436 people ≥60 years of age with RA completed a 1 year prospective survey of falls in the UK. At baseline, questionnaires recorded data including personal and medical history, pain and fatigue scores, health-related quality of life (HRQoL), physical activity and medication history. The occurrence of falls wasmonitored prospectively over 12 months by monthly self-reporting. A nested sample of 30 fallers (defined as the report of one or more falls in 12 months) and 30 non-fallers was evaluated to assess joint range of motion (ROM), muscle strength and gait parameters. Multivariate regression analyses were undertaken to determine variables associated with falling. Results Compared with non-fallers (n = 236), fallers (n = 200) were older (P = 0.05), less likely to be married (P = 0.03), had higher pain scores (P Conclusion People with RA have distinct clinical and biomechanical characteristics that place them at increased risk of falling. Assessment for these factors may be important to offer more targeted rehabilitation interventions.

Summary: Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture. Introduction: To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital. Methods: We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death. Results: The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19–1.30) and 1.26 (95% CI 1.19–1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18–1.52) and 1.33 (95% CI 1.12–1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08–1.15) and 1.10 (95% CI 1.05–1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge. Conclusion: We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6–7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

Background The reporting of deprivation measures is typically poor in musculoskeletal (MSK) research. Aims To explore MSK researcher's perspectives on the deprivation indices and measures that are, or could be, collected and reported in their studies, and potential barriers and facilitators to collecting these data. Materials & methods An online international survey was undertaken to determine knowledge, use and reporting of deprivation indices and measures by MSK researchers and the factors which influence this. Data were analysed using descriptive statistics. Results 42 respondents from 16 countries completed the survey. The index of multiple deprivation was the most well-known measure (26%) although only 17% had reported data from this index. Most commonly reported markers of deprivation were: employment (60%), education (60%) and ethnicity (50%). Most common barriers to collecting these data included: uncertainty on perceived importance of deprivation measures (79%), what should be collected (71%), and concerns on missing data and sensitivities from participants reluctant to provide this information (33%). Consensus on necessary measures to be collected and reported (88%) and improved awareness of the relationship between deprivation and MSK health (79%) were considered key activities to improve deprivation recording in MSK research. Discussion & conclusion There is poor awareness of the collection and reporting of deprivation measures in MSK research. Greater understanding on the importance of these data in reducing inequalities in MSK care is needed to facilitate improvement. This would enable greater assessment of generalisability and to assess whether interventions have different effects in people from different socio-economic groups.

Purpose Spinal metastases are indicative of progressive cancer which can lead to vertebral body fractures and spinal cord compression. Radiofrequency ablation (RFA) treatment is infrequently used in patients with refractory pain. The aim of this systematic review is to determine the clinical efficacy of RFA, with the scope of using it as front-line management of spinal metastases. Methods Electronic databases were searched (to July 2020) for studies evaluating RFA treatment for spinal metastases in adults. Measured outcomes were pain (primary), disability, health-related quality of life (HRQOL), complications, tumour control and mortality. Study inclusion, data extraction and risk of bias using the ROBIN-I tool were assessed. Meta-analysis was conducted for pooled results with homogeneity, and narrative synthesis was conducted otherwise. Results 15 studies were included. RFA reduces pain scores at 3–5 weeks [standardised mean difference (SMD 2.24, 95% confidence intervals (CI) 1.55–2.93], 3–4 months (SMD 3.00, 95% CI 1.11–4.90) and 5–6 months (SMD 3.54, 95% CI 1.96–5.11). RFA is effective in reducing disability/improving HRQOL in the short-term but longer-term efficacy remains unclear. 13.2% cases reported local tumour control failure (2.5 months–5 year follow-up) whereas mortality was 23.6% (follow-up of up to 1 year). Conclusion Low quality evidence has proven RFA to be safe and effective in reducing pain and disability, especially in the short-term. RFA may be routinely implemented in all cases involving refractory pain or radiotherapy-resistant tumours but controlled trials are required to compare the efficacy of RFA to current frontline treatments. PROSPERO protocol registration number: CRD42020202377.

Objective: To explore the relationship between ankle dorsiflexion range of motion (ROM) and hip and knee muscle strength between patients with a history of patellar dislocation (PD) to healthy controls. Design: Case–control study. Setting: Orthopedical specialty outpatient clinic at a tertiary hospital. Participants: Eighty-eight individuals were recruited; 44 individuals aged 16 years or older, of both sexes, with a history of at least one episode of atraumatic unilateral or bilateral PD requiring emergency care (14 men; 30 women; mean age 20 years) and 44 healthy (control) individuals (11 men; 33 women; mean age 21 years) matched for age, weight, and height to PD cases. Intervention: Assessment of hip and knee strength and ankle dorsiflexion ROM. Outcome Measures: Ankle dorsiflexion ROM was assessed through the lunge test with a goniometer. Hip and knee muscle strength was evaluated through isometric hand-held dynamometry. Differences between healthy and control individuals were assessed using Student t Tests and Mann–Whitney U Test. Results: Patellar dislocation individuals presented with a reduced ankle dorsiflexion ROM [mean difference (MD): 9 degrees; effect size (ES): 1.39; P < 0.001] and generalized hip and knee weakness (MD range: 4.74 kgf to 31.4 kgf; ES range: 0.52-2.35; P < 0.05) compared with healthy subjects. Conclusion: Individuals with a history of PD have reduced ankle dorsiflexion ROM and hip and knee muscle strength compared with healthy controls.

ObjectiveThe Getting Recovery Right After Neck Dissection (GRRAND) intervention is a physiotherapy programme for patients with head and neck cancer who have undergone neck dissection. The aim of this qualitative study was to understand if the intervention was useful, acceptable and whether it was feasible to conduct a randomised controlled trial (RCT).DesignThis qualitative study was embedded within the GRRAND-Feasibility (GRRAND-F) Study.SettingParticipants were recruited from four acute National Health Service hospitals in England between 2020 and 2021.ParticipantsWe interviewed four usual care and four intervention patient-participants from a single study site (Oxford). Six were male, two were female. All were white British ethnicity. We interviewed two physiotherapists from Oxford who delivered the GRRAND-F intervention, and physiotherapists from Birmingham, Poole and Norwich who were trained to deliver the intervention but were not able to deliver it within the study time frame.ResultsThe analysis identified five themes: (1) Acceptability, (2) Adherence, (3) Outcomes, (4) Feasibility and (5) Stand-alone themes (prehabilitation, video consultations, healthcare use).Patient-participants and physiotherapist-participants agreed that usual care was not meeting patients’ rehabilitation needs. The GRRAND intervention provided biopsychosocial support. In comparison to the usual care group, patient-participants who received the intervention were more confident that they could perform rehabilitation exercises and were more motivated to engage in long-term adaptive behaviour change. Physiotherapists felt they needed more administrative support to participate in an RCT.ConclusionParticipants felt that usual care was insufficient. GRRAND provided much needed, biopsychosocial support to patients. Participants were supportive that it would be feasible to test GRRAND in an RCT.Trial registration numberISRCTN11979997.

Aim Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR. Method A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials. Results All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p Conclusions Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

Background Alcohol has been associated with 10-35% trauma admissions and 40% trauma-related deaths globally. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020. Restrictions were most significantly eased on 1st June 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions. Method All adult patients admitted as ‘trauma calls’ to a London Major Trauma Centre (MTC) during April 2018 and April 2019 (pre-lockdown; N = 316), and 1st April – 31st May 2020 (lockdown; N = 191) had electronic patient records analysed. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre- and post-lockdown cohorts were compared using multiple regression analyses. Results Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), versus pre-lockdown 62/316 (19.6%); (Odds Ratio (OR) 0.83, 95% CI 0.38 to 1.28, p 0.05). Conclusions UK lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of subsequent global ‘waves’ of Covid-19, the risk of long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.