People with quadriplegia have a high risk for respiratory illness, social isolation and depression. Previous research has demonstrated that therapeutic singing interventions can not only improve breathing function and speech loudness, but also improve mood and social connectedness for people with quadriplegia. Face-to-face group attendance is difficult for this population due to difficulties with distance and travel. Online environments offer an accessible and cost-effective solution for people to connect with others without leaving their home. In a two-phase iterative design, we explored and tested different approaches for delivering online music therapy sessions with 12 patients from an inpatient spinal cord injury rehabilitation service. Six participants in Phase 1 trialled different virtual reality headsets and completed a short interview about their experience of the equipment and online singing trials. Outcomes from Phase 1 testing led to the development of a custom-built virtual reality application for online group music therapy sessions with low-latency audio. We tested the acceptability and feasibility of this platform in comparison to face-to-face and teleconference options for music therapy with six different patients. These participants completed three validated questionnaires: System Usability Scale, Quebec User Evaluation of Satisfaction with assistive Technology, and Psychosocial Impact of Assistive Devices Scale, and an interview about their experience. Questionnaire scores were good with mean ratings of 4.4 for Quebec User Evaluation of Satisfaction with assistive Technology, 53 for System Usability Scale and positive mean Psychosocial Impact of Assistive Devices Scale scores of 1.5 for competence, 2 for adaptability and 1.5 for self-esteem. Thematic analysis of post-session qualitative interviews revealed five themes: virtual reality was a positive experience, virtual reality was immersive and transportative, virtual reality reduced inhibitions about singing in front of others, virtual reality may reduce social cues, and the virtual reality equipment was comfortable, accessible and easy to use. Telehealth options, including a custom-designed virtual reality program, with low-latency audio are an acceptable and feasible mode of delivery for therapeutic singing interventions for people with spinal cord injury. Future non-inferiority research is needed to test online delivery modes for music therapy in comparison to face-to-face treatment.

BACKGROUND AND PURPOSE: We aimed to estimate the prevalence of perceived cognitive impairment (PCI) and explore its associations with lifestyle and disease characteristics in a large international cohort of people with multiple sclerosis (MS). METHODS: This study was a cross-sectional analysis. Participants rated their cognitive function over the preceding 4 weeks using four questions in a subscale within the Multiple Sclerosis Quality of Life questionnaire (MSQOL-54). These questions assessed perceived concentration, attention and memory by the patient and family/friends. Four definitions of PCI were derived, ranging from lowest to highest specificity. Associations with PCI were assessed by log-binomial regression. RESULTS: The prevalence of PCI in our sample ranged from 41.0% (95% confidence interval, 39.0-43.0) using the least-specific definition to 11.6% (95% confidence interval, 10.3-12.9) using the most specific definition. A number of factors were associated with PCI, increasing in magnitude as the definition specificity increased, including positive associations for smoking and body mass index, whereas physical activity, dietary quality and use of vitamin D/omega-3 supplements were inversely associated with PCI. CONCLUSIONS: Our study reports associations between healthy lifestyle behaviours and PCI in people with MS. Although reverse causality is a potential explanation for our findings, previous studies have shown comparable associations with healthy lifestyle and MS onset and progression. Subject to external validation, these results suggest benefits realized from a healthy lifestyle in people with MS.

BACKGROUND: There is no physiotherapy-specific quality indicator tool available to evaluate physiotherapy care for people with hip and/or knee osteoarthritis (OA). This study aimed to develop a patient-reported quality indicator tool (QUIPA) for physiotherapy management of hip and knee OA and to assess its reliability and validity. METHODS: To develop the QUIPA tool, quality indicators were initially developed based on clinical guideline recommendations most relevant to physiotherapy practice and those of an existing generic OA quality indicator tool. Draft items were then further refined using patient focus groups. Test-retest reliability, construct validity (hypothesis testing) and criterion validity were then evaluated. Sixty-five people with hip and/or knee OA attended a single physiotherapy consultation and completed the QUIPA tool one, twelve- and thirteen-weeks after. Physiotherapists (n = 9) completed the tool post-consultation. Patient test-retest reliability was assessed between weeks twelve and thirteen. Construct validity was assessed with three predefined hypotheses and criterion validity was based on agreement between physiotherapists and participants at week one. RESULTS: A draft list of 23 clinical guideline recommendations most relevant to physiotherapy was developed. Following feedback from three patient focus groups, the final QUIPA tool contained 18 items (three subscales) expressed in lay language. The test-retest reliability estimates (Cohen's Kappa) for single items ranged from 0.30-0.83 with observed agreement of 64-94%. The intraclass correlation coefficient (ICC) and 95% confidence interval (CI) for the Assessment and Management Planning subscale was 0.70 (0.54, 0.81), Core Recommended Treatments subscale was 0.84 (0.75, 0.90), Adjunctive Treatments subscale was 0.70 (0.39, 0.87) and for the total QUIPA score was 0.80 (0.69, 0.88). All predefined hypotheses regarding construct validity were confirmed. However, agreement between physiotherapists and participants for single items showed large measurement error (Cohen's Kappa estimates ranged from - 0.04-0.59) with the ICC (95% CI) for the total score being 0.11 (- 0.14, 0.34). CONCLUSIONS: The QUIPA tool showed acceptable test-retest reliability for subscales and total score but inadequate reliability for individual items. Construct validity was confirmed but criterion validity for individual items, subscales and the total score was inadequate. Further research is needed to refine the QUIPA tool to improve its clinimetric properties before implementation.

OBJECTIVES: To evaluate in a 12 month longitudinal study changes in hip and ankle range of motion and hip muscle strength in young female novice ballet dancers. METHODS: Fifty three of the original 77 (69%) female dancers aged 8-11 years and 40 of the original 49 (82%) controls returned for follow up measurements one year later. Supine right active hip external (ER) and internal (IR) rotation were measured using an inclinometer. A turnout protractor was used to assess standing active turnout range. Range of right weight bearing ankle dorsiflexion and calf muscle length were measured in a standing lunge position using an inclinometer. A manual muscle tester was used to assess right hip flexor, IR, ER, abductor and adductor strength. RESULTS: The mean (SD) 12 month change in hip ER did not differ between dancers (11.7 (11.3)degrees) and controls (8.1 (17.6)degrees). Dancers gained 12.5 (13.5)degrees hip IR which was significantly greater than controls (0.5 (13.9)degrees). Greater IR change was associated with improved IR strength (r = 0.34, p<0.001). Dancers increased total turnout (12.0 (16.7)degrees) significantly more than controls (2.2 (20.0)degrees). There was no significant change in ankle dorsiflexion range in either group. Dancers and controls increased in all measures of hip muscle strength (p<0.001) and dancers achieved significantly greater gains in three out of five muscle groups (all, p<0.05). CONCLUSIONS: Total hip range of motion increased in both ballet students and controls at this young age. However, ankle dorsiflexion did not, which is probably due to this movement being blocked by bony apposition, rather than soft tissue stretch. This has implications for ballet teachers, as it has long been accepted that this movement could be improved with training. Dancers had greater increases in hip strength after 12 months compared with controls in muscles specific for ballet, suggesting that hip strength can be trained at this young age. Whether these gains are permanent requires further study.

Objective: The aim of this project was to adapt the English, French, German and Russian versions of the International Olympic Committee (IOC) injury and illness surveillance form to be sport-specific for use in biathlon. Methods: 23 medical representatives from 16 of the 55 biathlon federations participated in this project to adapt the form and create disease coding relevant to biathlon. The English version of the IOC injury and illness surveillance form was used as the primary template. Four review rounds were used to develop electronic fillable PDF forms. The changes were then forward translated onto the Russian, French and German forms. Results: Changes were made to event type to biathlon-specific events. A weekly reporting format was adopted in line with the race week format of World Cup events. Wherever possible, coding replaced free-text format to avoid translation issues. New codes were created to describe the time of injury/illness. A new symptom code was added to reflect the prevalence of respiratory infection: sore throat/cold symptoms. As the number of athletes in a team differs between weeks in the season, an additional question was added to ask for the 'number of athletes in the team for the week' and for the season. Conclusion: This project provides a biathlon-specific injury and illness surveillance form in English, French, German and Russian. This forms the basis for surveillance that will contribute to a greater understanding of the illness and injury rate in elite biathletes and ultimately to enhanced athlete well-being and success in biathlon, and winter sports more generally.

BACKGROUND: First metatarsophalangeal (MTP) joint osteoarthritis (OA) is a common and painful problem that causes significant disability. There is limited research on assessment and treatment options, and the efficacy of current management strategies is unknown. The aim of this study was to determine how podiatrists and physical therapists in Australia and the United Kingdom (UK) manage people with first MTP joint OA. METHODS: A survey of podiatrists and physiotherapists was conducted. Potential respondents were recruited through professional representative organisations in Australia and the UK. Participants completed a bespoke online survey regarding the assessment and treatment approaches they most commonly use for patients with first MTP joint OA. Descriptive statistics were calculated and differences between professions compared using chi-square. RESULTS: Two hundred respondents (n = 113 (57%) podiatrists and n = 140 (70%) from Australia) completed the survey. Assessment tests were similar between professions and included x-ray (n = 151/164; 92%), range of motion (n = 127/141; 90%), and a pain scale (n = 78/99; 79%). Podiatrists were more likely than physical therapists to discuss over-the-counter medication (42% vs 17%; p < 0.001), prescribe orthoses (97% vs 66%; p < 0.001), particularly custom orthoses (78% vs 42%; p < 0.001), and provide advice on footwear (92% vs 78%; p < 0.01) when treating first MTP joint OA. In contrast, physical therapists used more exercise-based approaches to treatment, including exercise therapy (91% vs 34%; p < 0.001), increasing general activity (70% vs 49%; p < 0.01), and advice to pace activities (83% vs 48%; p < 0.001). CONCLUSION: Podiatrists and physical therapists use an array of assessment and treatment approaches for people with first MTP joint OA, albeit there is limited evidence to support their clinical utility. Treatment strategies differ between professions, particularly with respect to medication, orthoses and exercise. It is unclear whether these commonly-used strategies improve symptoms associated with first MTP joint OA.

INTRODUCTION: This protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER) study. PARTNER is a randomised controlled trial to evaluate a new model of service delivery (the PARTNER model) against 'usual care'. PARTNER is designed to encourage greater uptake of key evidence-based non-surgical treatments for knee osteoarthritis (OA) in primary care. The intervention supports general practitioners (GPs) to gain an understanding of the best management options available through online professional development. Their patients receive telephone advice and support for OA management by a centralised, multidisciplinary 'Care Support Team'. We will conduct concurrent process and feasibility evaluations to understand the implementation of this new complex health intervention, identify issues for consideration when interpreting the effectiveness outcomes and develop recommendations for future implementation, cost effectiveness and scalability. METHODS AND ANALYSIS: The UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks inform the design of these evaluations. We use a mixed-methods approach including analysis of survey data, administrative records, consultation records and semistructured interviews with GPs and their enrolled patients. The analysis will examine fidelity and dose of the intervention, observations of trial setup and implementation and the quality of the care provided. We will also examine details of 'usual care'. The semistructured interviews will be analysed using thematic and content analysis to draw out themes around implementation and acceptability of the model. ETHICS AND DISSEMINATION: The primary and substudy protocols have been approved by the Human Research Ethics Committee of The University of Sydney (2016/959 and 2019/503). Our findings will be disseminated to national and international partners and stakeholders, who will also assist with wider dissemination of our results across all levels of healthcare. Specific findings will be disseminated via peer-reviewed journals and conferences, and via training for healthcare professionals delivering OA management programmes. This evaluation is crucial to explaining the PARTNER study results, and will be used to determine the feasibility of rolling-out the intervention in an Australian healthcare context. TRIAL REGISTRATION NUMBER: ACTRN12617001595303; Pre-results.

BACKGROUND: Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese. METHODS: Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m2 and < 41 kg/m2 and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed. DISCUSSION: This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).

BACKGROUND: Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people, giving rise to pain and loss of function. Many people experience progressive worsening of the disease over time, particularly those with varus malalignment and increased medial knee joint load. Therefore, interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression. Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load. A neuromuscular exercise program, emphasising optimal alignment of the trunk and lower limb joints relative to one another, as well as quality of movement performance, while dynamically and functionally strengthening the lower limb muscles, may be able to reduce medial knee load. Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature. This randomised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading, pain and function in individuals with medial knee joint osteoarthritis. We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program. METHODS/DESIGN: 100 people with medial knee pain, radiographic medial compartment osteoarthritis and varus malalignment will be recruited and randomly allocated to one of two 12-week exercise programs: quadriceps strengthening or neuromuscular exercise. Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home. The primary outcomes are medial knee load during walking (the peak external knee adduction moment from 3D gait analysis), pain, and self-reported physical function measured at baseline and immediately following the program. Secondary outcomes include the external knee adduction moment angular impulse, electromyographic muscle activation patterns, knee and hip muscle strength, balance, functional ability, and quality-of-life. DISCUSSION: The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load, pain and physical function in people with medial knee osteoarthritis and varus malalignment. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12610000660088.

BACKGROUND: Knee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) particularly in other chronic pain conditions. Though typically provided separately, there are symptom, resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The primary aim of this multisite randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA. METHODS/DESIGN: This will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and randomized into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Randomisation will be stratified by city (Melbourne or Brisbane) and gender. Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes include global rating of change, muscle strength, functional performance, physical activity levels, health related quality of life and psychological factors. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. Relative cost-effectiveness will be determined from health service usage and outcome data. DISCUSSION: The findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone.