Aims. An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise. Methods. A smartwatch was used to collect inertial data from 42 patients performing shoulder physiotherapy exercises for rotator cuff injuries in both in-clinic and at-home settings. A two-stage ML approach was used to detect out-of-distribution (OOD) data (to remove non-exercise data) and subsequently for classification of exercises. We evaluated the performance impact of grouping exercises by motion type, inclusion of non-exercise data for algorithm training, and a patient-specific approach to exercise classification. Algorithm performance was evaluated using both in-clinic and at-home data. Results. The patient-specific approach with engineered features achieved the highest in-clinic performance for differentiating physiotherapy exercise from non-exercise activity (area under the receiver operating characteristic (AUROC) = 0.924). Including non-exercise data in algorithm training further improved classifier performance (random forest, AUROC = 0.985). The highest accuracy achieved for classifying individual in-clinic exercises was 0.903, using a patient-specific method with deep neural network model extracted features. Grouping exercises by motion type improved exercise classification. For at-home data, OOD detection yielded similar performance with the non-exercise data in the algorithm training (fully convolutional network AUROC = 0.919). Conclusion. Including non-exercise data in algorithm training improves detection of exercises. A patient-specific approach leveraging data from earlier patient-supervised sessions should be considered but is highly dependent on per-patient data quality. Cite this article: Bone Joint Res 2023;12(3):165–177

Aims. A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care. Methods. A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods. Results. ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses. Conclusion. While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective. Cite this article: Bone Jt Open 2021;2(8):685–695

Aims. This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. Methods. A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. Results. A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. Conclusion. Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate. Cite this article: Bone Joint Res. 2020;9(5):250–257

Aims. The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears. Methods. We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective. Results. A total of 100 patients were included: 49 were randomized to arthroscopic partial meniscectomy and 51 to physical therapy. In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in the arthroscopic partial meniscectomy group had a mean 0.005 QALYs lower quality of life (95% confidence interval -0.13 to 0.14). The cost-utility ratio was €-160,000/QALY from the healthcare perspective and €-223,372/QALY from the societal perspective, indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit. Conclusion. Arthroscopic partial meniscectomy is arthroscopic partial meniscectomy is unlikely to be cost-effective in treating young patients with isolated traumatic meniscal tears compared to physical therapy as a primary health intervention. Arthroscopic partial meniscectomy leads to a similar quality of life, but higher costs, compared to physical therapy plus optional delayed arthroscopic partial meniscectomy. Cite this article: Bone Joint J 2023;105-B(11):1177–1183

Background: Neck pain is a common problem accounting for up to 22% of the workload of physiotherapists. Many different approaches are used and the evidence for these is unclear. Purpose: To evaluate the effectiveness of a brief physiotherapy intervention (1–3 sessions) for patients with neck pain in the primary care setting, taking preferences into account. Method: A Randomised controlled trial (n=268) compared a brief physiotherapy intervention based on cognitive-behavioural principles with ‘usual’ physiotherapy. Patients from physiotherapy waiting lists aged 18 – 87 years with neck pain of musculoskeletal origin of more than 2 weeks duration were invited to participate. Their preferences for type of treatment were elicited independently of randomisation. The brief intervention aimed to facilitate problem-solving, encourage self-management and early return to normal function. Physiotherapists undertook a one-day training programme in communication skills and cognitive-behavioural approaches. In the ‘Usual’ physiotherapy intervention treatment was provided at the discretion of the individual physiotherapist. The main outcome measures were the Neck Pain Questionnaire, a specific measure of functional disability due to neck pain, the SF-36 a generic health-related quality of life measure, the Tampa Scale for Kinesophobia, a measure of fear- and-avoidance of movement and the use of healthcare services. Data was collected at baseline, at 3 months and at 12 months. Results: Patients randomised to the ‘Usual’ physiotherapy group were significantly improved compared with the Brief Intervention group, 12 months after randomisation. However, the differences were small and patients randomised to the Brief Intervention who preferred that arm of the study also improved to a similar degree. In contrast, patients who wanted ‘Usual’ physiotherapy but got the brief Intervention did not improve. Conclusions: The Brief intervention may be effective for patients who prefer the option of a one-off treatment of advice. It is also cheaper and should therefore be offered as an option.ot

Abstract. 20% of patients are severely dis-satisfied following total knee arthroplasty (TKA). Arthrofibrosis is a devastating complication preventing normal knee range of motion (ROM), severely impacting patient's daily living activities. A previous RCT demonstrated superiority of a high intensity stretching programme using a novel device the STAK tool compared with standard physiotherapy in TKA patients with arthrofibrosis. This study analyses the results when the previous “standard physiotherapy” group were subsequently treated with the STAK tool. Methods. 15 patients post TKA with severe arthrofibrosis and mean ROM 71° were recruited, (three cases had previously failed manipulation under anaesthetic (MUA). Patients received 8 weeks standard physiotherapy, then treatment with the STAK at home for 8 weeks. ROM, extension, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at various time-points. Results. Following standard physiotherapy there were small improvements in ROM (8°) (p<0.01), but no significant improvements in extension, OKS or WOMAC (p=0.39). Following the STAK treatment all outcomes significantly improved (p<0.01). STAK group; mean ROM (21° versus 8°, p < 0.001), extension 9° versus 2° (p < 0.01), WOMAC (18 points versus 3, p < 0.01), and OKS (8 points versus 4, p<0.01). No patients suffered any complications relating to the STAK. Conclusions. The STAK is effective in increasing ROM, extension and function, whilst reducing pain and stiffness. The device can be considered a cost-effective and valuable treatment following TKA. This is likely to increase the overall satisfaction rate and has potential to reduce the need for MUA

Purpose of the study. The purpose of this project was to evaluate whether OHEIs could facilitate student physiotherapy placement training in their educational outpatient clinics. Background. The National Health Service (NHS) is actively promoting Allied Health Professionals (AHPs) to have a greater role in supporting healthcare delivery. There are challenges to increasing AHP numbers and one of these is providing enough student training placements to meet demand. Methods. This evaluation used quantitative and qualitative methods. The OHEI clinical tutors and students collected activity data Anonymised questionnaires for physiotherapy students examining expectation were completed online before placement and an experience questionnaire after placement. Interviews and focus groups were conducted to investigate the experiences of stakeholders involved in the project. This included physiotherapy and osteopathy students, clinic tutors, and placement coordinators in OHEIs and physiotherapy HEIs. Results. Four universities with physiotherapy courses participated, and 37 students in 2 cohorts completed either five- or six-week placements at three OHEI clinics between April and August 2021. Cohort 1 expressed uncertainties about roles and integration in clinic and with patients. Concerns were addressed for Cohort 2 and physiotherapy student learning experiences were much better with 83% of physiotherapy students satisfied or very satisfied with their placement. Conclusion. The placement of physiotherapists in OHEI clinics is feasible. Careful expectation management is essential. Future sustainability is dependent upon managing costs to the OHEIs as it is unlikely placements will generate income. The learning environment could be made more reciprocal with time and experience leading to better understanding of the different professions and enhanced multidisciplinary working. Conflicts of interest: Dawn Carnes and Carol Fawkes are both trained osteopaths. Sources of funding: Health Education England grant to the Institute of Osteopathy (the professional association for UK osteopaths)

Access to health care, including physiotherapy, is increasingly occurring through virtual formats. At-home adherence to physical therapy programs is often poor and few tools exist to objectively measure low back physiotherapy exercise participation without the direct supervision of a medical professional. The aim of this study was to develop and evaluate the potential for performing automatic, unsupervised video-based monitoring of at-home low back physiotherapy exercises using a single mobile phone camera. 24 healthy adult subjects performed seven exercises based on the McKenzie low back physiotherapy program while being filmed with two smartphone cameras. Joint locations were automatically extracted using an open-source pose estimation framework. Engineered features were extracted from the joint location time series and used to train a support vector machine classifier (SVC). A convolutional neural network (CNN) was trained directly on the joint location time series data to classify exercises based on a recording from a single camera. The models were evaluated using a 5-fold cross validation approach, stratified by subject, with the class-balanced accuracy used as the performance metric. Optimal performance was achieved when using a total of 12 pose estimation landmarks from the upper and lower body, with the SVC model achieving a classification accuracy of 96±4% and the CNN model an accuracy of 97±2%. This study demonstrates the feasibility of using a smartphone camera and a supervised machine learning model to effectively assess at-home low back physiotherapy adherence. This approach could provide a low-cost, scalable method for tracking adherence to physical therapy exercise programs in a variety of settings

The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome. Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score. Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001). Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively

Physiotherapy is generally accepted as an important component in the care pathway surrounding total knee replacement. Therapy interventions can be delivered prior to surgery, as part of the inpatient stay, and post-operation through outpatient appointments. Though ‘physiotherapy’ is generally promoted there is considerable national and international variation in actual therapy provision. Specific rehabilitation protocols are strongly entrenched at individual physiotherapy departments however the wider efficacy of varying physiotherapeutic interventions is poorly established. This uncertainty as to effectiveness of physiotherapy makes it difficult for commissioning organisations, healthcare providers, and patients to make decisions as to what therapy is ‘needed’ and therefore the correct level and mechanism of funding for such services. This talk will explore the variation in physiotherapy service provision and evidence for different interventions surrounding total knee replacement

Purpose of the study. To investigate the feasibility of undertaking a definitive Randomised Controlled Trial (RCT) to determine the effectiveness of early physiotherapy for sciatica. Methods. Patients over 18 presenting to their G.P with sciatica were eligible to participate in the study, those without a clear understanding of English or had co-morbidities preventing rehabilitation were ineligible. Process and patient reported outcomes including self-rated disability, pain and general health, were collected at baseline, 6,12 and 26 weeks post randomisation. Participants were randomised into either early physiotherapy, receiving treatment within 2 weeks after randomisation or usual care with physiotherapy commencing 6 weeks post randomisation. Both groups received up to 6 treatment sessions of a patient-centred, goal orientated physiotherapy programme specific to their needs. Results. 80 participants were recruited in 10 G.P practices over 34 weeks and randomised to either early physiotherapy (n= 42) or usual care (n=38). Follow-up rates at 26 weeks were 36 (86%) in the early intervention physiotherapy group and 32 (84%) in the usual care. All feasibility objectives were achieved. The mean area under the curve for the Oswestry Disability Index (ODI) over the 26 weeks was and 16.0 (SD 14.0) in the early physiotherapy group and 16.6 (SD 11.4) in the usual care group. A difference of −0.6 (95% CI: −0.68 to 5.6) in favour of the intervention group. Conclusion. The results of the study suggest a full RCT is feasible and will provide evidence as to the optimal timing of physiotherapy for patients with sciatica. No conflicts of interest for any authors. Sources of funding: MR is the recipient of a HEE/NIHR Clinical Doctoral Research Fellowship, which funded the study

Introduction. Traditionally, limb reconstruction physiotherapy consisted of face to face group rehabilitation. During the COVID-19 pandemic OP physiotherapy service provision was significantly reduced and delivery methods limited due to staff redeployment, service prioritisation and restriction of footfall within the hospital. A virtual exercise group for acute limb reconstruction patients was set up to maintain contact and clinical support. Materials and Methods. A small single centre study was performed over two 4 week periods capturing the experience of 35 patients. A patient reported questionnaire was used and revised post-pandemic to gather quantitative and qualitative data about the patients experience of the Limb Reconstruction Physiotherapy Service at each point in time. The qualitative data was analysed using an inductive thematic analysis. Results. Four key themes emerged from the qualitative data: Sense of community through shared experience, support & encouragement from staff and peers, increasing confidence with the frame – fostering independence, the challenging nature of the class. Recommendation of the service, positive functional impact and overall experience remained >88% of the population (face to face & virtual). Conclusions. The results highlight the benefits of group physiotherapy (face to face & virtual) to patients recovery with improvements in confidence, mobility, function, psychosocial factors and overall QoL. Peer support is paramount in the rehabilitation and progression of limb reconstruction patients. Virtual platforms for rehabilitation are helpful in maintaining participation and should be offered where possible to facilitate ongoing inclusion, however face to face contact is preferred

Introduction. Legg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively. Methodology. This is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of:. Age – Patient must be part of the Paediatric Service, i.e., under the age of 16. Diagnosis – Patient must have a diagnosis of Perthes Disease with a Herring Classification documented. Application of a Hip Distractor Frame formed part of the patient's surgical management. Surgery was completed by Mr Connor Green. Surgery was completed between January 2021 and December 2022. Patient were required to have their external hip distractor frame removed by December 2022. Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results. Results. From analysing the data, the following results were identified:. 80% of the sample cohort had a length of stay of 5 days following surgery. There were two outliers due to infection who had a length of stay of 14 days. 90% of the sample received a pre-operative Physiotherapy and Occupational Therapy assessment. This assessment included information gathering regarding the child's home and social environment; their functional baseline and anticipated post-operative needs. Standardised and non-standardised assessments were used. 88.89% of those who completed a pre-operative assessment required referral to community Occupational Therapy teams for equipment provision (wheelchair, transfer aids) to allow for timely discharge. On average, each patient in the sample required 17 physiotherapy outpatient sessions prior to handover to the community teams. 100% of our sample required post operation onward referral for MDT input in the community (Occupational Therapy and Physiotherapy). Conclusions. The importance of a multi-disciplinary approach towards family and children was highlighted in this study. A comprehensive pre-operative therapy assessment optimizes care for this cohort by preparing them in terms of equipment provisions, local team input and expectations for therapy. The data suggests future Limb Reconstruction team should include Physiotherapy and Occupational Therapy as part of the multi-disciplinary team, in the treatment of children with Perthe's Disease. We suggest an MDT pre-assessment is completed to optimize patient care, reduce length of stay and improve patient satisfaction in the acute hospital setting

Purpose/Background. Health inequalities are defined as unfair and avoidable differences in health across the population. People belonging to inclusion health groups are most at risk of experiencing these inequalities and tackling them is an NHS priority. Inclusion health groups include ‘people in contact with the justice system’ and BCHC NHS FT is commissioned to provide physiotherapy to prisoners at HMP Birmingham. The purpose of this study was to better understand the MSK health-status and MSK conditions affecting this minoritised patient population. Methods/Results. The MSK service at HMP Birmingham collects the MSK-HQ PROM for all prisoners attending physiotherapy. A retrospective analysis of the electronic patient record was performed using convenience sampling, with baseline MSK-HQ scores of prisoners seen between 01/04/2023 and 01/02/2024 captured alongside the primary presenting MSK condition. Simple descriptive statistics were used to evaluate the data. A total of 129 patients attended initial physiotherapy appointments within the time-period. Baseline MSK-HQ was collected for 62 patients (48%) with a mean (SD) score of 23.08(11.38). The most common MSK condition was Back pain with a count of 12(19.35%). The mean (SD) MSK-HQ score for prisoners with back pain was 22.08(9.98). Conclusion. This is the first known evaluation in the published literature of the baseline MSK health-status and primary MSK conditions affecting prisoners. A published evaluation of baseline MSK health-status for patients attending a community MSK service reported a mean (SD) MSK-HQ of 28.59(10.80) indicating that, a poorer MSK health-status is experienced by this minoritised group. Further work, co-produced with prisoners, is planned to explore further. Conflicts of interest. None. Sources of funding. None

Background: The main aim of this study was to compare the effectiveness of a brief intervention based on cognitive-behavioural principles (Solution Finding Approach – SFA) with the McKenzie approach (McK). A secondary aim was to determine if there were any clinical characteristics that distinguished patients who responded best to the McKenzie method. Methods: Eligible patients who were referred by GPs to physiotherapy departments in the UK with neck or back pain were randomly allocated to McK (n= 161) or to SFA (n=154) and their outcome compared at 6 weeks, 6 and 12 months. In addition, putative predictors within the McKenzie group were compared using univariate analysis to examine the relationship between variables and outcomes. Significant variables were assessed using multiple logistic regression analyses. Results: Both groups demonstrated modest improvements in outcomes. There were no statistically significant differences in outcomes, except 2 small but significant differences at 6 weeks. At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). The number of treatment successes in the McK group depended upon the definition used, but were limited. Less chronic back pain (rather than neck pain) in patients demonstrating centralisation responded best. Conclusion: In the original RCT there were few differences between McK and SFA though modest improvements in both. In a secondary analysis of the results for the McK group there were few treatment successes according to our definition of success; these were most likely to occur in back pain patients with shorter duration symptom who demonstrated centralisation response

Aims. There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery. Methods. Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis. Results. A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity. Conclusion. This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group. Cite this article: Bone Jt Open 2022;3(10):815–825

Participation in a physical therapy program is considered one of the greatest predictors for successful conservative management of common shoulder disorders, however, adherence to standard exercise protocols is often poor (around 50%) and typically worse for unsupervised home exercise programs. Currently, there are limited tools available for objective measurement of adherence and performance of shoulder rehabilitation in the home setting. The goal of this study was to develop and evaluate the potential for performing home shoulder physiotherapy monitoring using a commercial smartwatch. We hypothesize that shoulder physiotherapy exercises can be classified by analyzing the temporal sequence of inertial sensor outputs from a smartwatch worn on the extremity performing the exercise. Twenty healthy adult subjects with no prior shoulder disorders performed seven exercises from a standard evidence-based rotator cuff physiotherapy protocol: pendulum, abduction, forward elevation, internal/external rotation and trapezius extension with a resistance band, and a weighted bent-over row. Each participant performed 20 repetitions of each exercise bilaterally under the supervision of an orthopaedic surgeon, while 6-axis inertial sensor data was collected at 50 Hz from an Apple Watch. Using the scikit-learn and keras platforms, four supervised learning algorithms were trained to classify the exercises: k-nearest neighbour (k-NN), random forest (RF), support vector machine classifier (SVC), and a deep convolutional recurrent neural network (CRNN). Algorithm performance was evaluated using 5-fold cross-validation stratified first temporally and then by subject. Categorical classification accuracy was above 94% for all algorithms on the temporally stratified cross validation, with the best performance achieved by the CRNN algorithm (99.4± 0.2%). The subject stratified cross validation, which evaluated classifier performance on unseen subjects, yielded lower accuracies scores again with CRNN performing best (88.9 ± 1.6%). This proof-of concept study demonstrates the feasibility of a smartwatch device and machine learning approach to more easily monitor and assess the at-home adherence of shoulder physiotherapy exercise protocols. Future work will focus on translation of this technology to the clinical setting and evaluating exercise classification in shoulder disorder populations

Physiotherapy is a critical element in successful conservative management of low back pain (LBP). The aim of this study was to develop and evaluate a system with wearable inertial sensors to objectively detect sitting postures and performance of unsupervised exercises containing movement in multiple planes (flexion, extension, rotation). A set of 8 inertial sensors were placed on 19 healthy adult subjects. Data was acquired as they performed 7 McKenzie low-back exercises and 3 sitting posture positions. This data was used to train two models (Random Forest (RF) and XGBoost (XGB)) using engineered time series features. In addition, a convolutional neural network (CNN) was trained directly on the time series data. A feature importance analysis was performed to identify sensor locations and channels that contributed most to the models. Finally, a subset of sensor locations and channels was included in a hyperparameter grid search to identify the optimal sensor configuration and the best performing algorithm(s) for exercise classification. Models were evaluated using F1-score in a 10-fold cross validation approach. The optimal hardware configuration was identified as a 3-sensor setup using lower back, left thigh, and right ankle sensors with acceleration, gyroscope, and magnetometer channels. The XBG model achieved the highest exercise (F1=0.94±0.03) and posture (F1=0.90±0.11) classification scores. The CNN achieved similar results with the same sensor locations, using only the accelerometer and gyroscope channels for exercise classification (F1=0.94±0.02) and the accelerometer channel alone for posture classification (F1=0.91±0.03). This study demonstrates the potential of a 3-sensor lower body wearable solution (e.g. smart pants) that can identify proper sitting postures and exercises in multiple planes, suitable for low back pain. This technology has the potential to improve the effectiveness of LBP rehabilitation by facilitating quantitative feedback, early problem diagnosis, and possible remote monitoring

Aims. Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures. Methods. This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation. Conclusion. This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024. Cite this article: Bone Jt Open 2024;5(6):499–513

The present study was conducted to evaluate the cost of physiotherapy both for inpatient and outpatient services. Significant physiotherapy resources are required to rehabilitate patients with an Ilizarov or Taylor Spatial Frame (TSF). Within Hull and East Yorkshire Hospitals NHS Trust Physiotherapy department the average number of outpatient treatment sessions per routine patient is 6. In comparison, the average number of treatment sessions required for a patient with an ilizarov (or TSF) is 24 for a trauma patient and 33 for a patient undergoing an elective procedure. Seventy three (73) patients received physiotherapy treatment with an Ilizarov frame or a Taylor spatial frame between April 2008 and April 2010. Physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient (if the patient received their treatment within Hull and East Yorkshire NHS trust). Data collection was divided into either trauma or elective procedure for analytical purposes. The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an inpatient with an ilizarov frame is £121.82 per case (trauma) and £133.15 per case (elective). The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an outpatient for a trauma case was calculated as £404.65 and £521.41for an average elective case. This is in comparison to a routine patient costing the service £60.29 (when treated by a Band 7 physiotherapist). The present study gives valuable data for future business planning and assistance with the setting of local or national tariffs for the treatment of this patient group