About

Dr Karen Hambly gained a first class degree in Sports Science before qualifying as a Chartered Physiotherapist from the University of Southampton. After an initial time in the NHS she moved to work full time within sport as physiotherapist/sports medicine coordinator for British Cycling before joining UKSport as sports medicine coordinator for Olympic and Paralympic programmes on her return from the Sydney 2000 Paralympics. 

Karen has over 20 years' experience working within sports rehabilitation and has a post-graduate diploma in sports and exercise medicine from the University of Wales College of Medicine. Karen moved into higher education in 2004 and joined the School for Sport and Exercise Sciences at the University of Kent in 2008 where she is currently senior lecturer. 

Karen has developed a primary research focus in knee articular cartilage repair rehabilitation and in 2011 she completed her PhD on outcome measurement in articular cartilage repair. Karen has published and presented internationally on musculoskeletal rehabilitation and has successfully supervised several PhD students to completion. Karen is currently the Chair of the School’s Research and Ethics Advisory Group. 

Research interests

Dr Karen Hambly's research to date has focused on postoperative rehabilitation and return to sport after knee articular cartilage repair with a specific focus on the patient perspective and the role of online health communities. Karen’s current research involves prevention, rehabilitation and participation in sports and exercise in musculoskeletal injuries and non-communicable diseases.

Publications

Article

  • Poomsalood, S. and Hambly, K. (2019). Prevalence of patellofemoral pain syndrome in young Thai athletes registered in Phitsanulok Provincial Administrative Organization Sports School, Thailand. Journal of Associated Medical Sciences [Online] 52:150-157. Available at: https://www.tci-thaijo.org/index.php/bulletinAMS/article/view/155215.
    Background: Patellofemoral pain syndrome (PFPS) is one of the most common knee pain diagnoses in sports medicine clinics. The disorder is usually related with sports and activities of daily living and the condition may affect up to 25% of males and females who participate in sporting activities. However, only researchers in Europe, Australia, USA, and a few Asian countries have conducted studies of prevalence of PFPS. There is still a lack of good epidemiological evidence studying incidence or prevalence of PFPS in most countries. PFPS is also often related to overuse so recent changes in activities and changes in frequency, intensity, and duration of training should be considered.

    Objectives: Primary aim of the study was to estimate the prevalence of PFPS in young Thai athletes and the secondary aim was to investigate the relationship between PFPS and training duration per week.

    Materials and methods: Three hundred and sixty-two young Thai athletes (12-18 years) were recruited in the study. The participants completed a self-reported questionnaire known as “Anterior Knee Pain Scale (AKPS)” for the initial screening process. Participants who provided a score of less than 100 underwent further physical examination for PFPS. Details of their training schedule according to training frequency per week and types of training were given by sports coaches at school.

    Results: Three hundred and ten athletes (mean age: 14.8±1.6 years) completed the Anterior Knee Pain Scale (AKPS) questionnaire. There were 51 (35 males and 16 females) out of 310 participants who reported a questionnaire score of less than 100. Nineteen (12 males and 7 males) out of 51 participants presented with PFPS with a greater prevalence in females. However, no significant difference of PFPS prevalence was found between males and females (males: 12/35 = 34%, females: 7/16 = 44%, p=0.521). The overall prevalence of PFPS was 6% (19 out of 310). PFPS was weakly related to longer sports training duration (r=0.115, p=0.042) for the overall population. When genders were considered, PFPS was weakly related to both longer general training duration (r=0.174, p=0.011) and sports training duration (r=0.147, p=0.033) for males.

    Conclusion: The overall prevalence of PFPS in young Thai athletes was 6% which was a lower rate compared to previous studies. Sports training duration and sum of both training duration significantly presented weak correlation with PFPS. The results of the current study may have implications for coaches or sports teachers for planning the schedule of sports training duration for the young Thai athletes.
  • Tektonidou, M., Andreoli, L., Limper, M., Amoura, Z., Cervera, R., Costedoat-Chalumeau, N., Cuadrado, M., Dörner, T., Ferrer-Oliveras, R., Hambly, K., Khamashta, M., King, J., Marchiori, F., Meroni, P., Mosca, M., Pengo, V., Raio, L., Ruiz-Irastorza, G., Shoenfeld, Y., Stojanovich, L., Svenungsson, E., Wahl, D., Tincani, A. and Ward, M. (2019). EULAR recommendations for the management of antiphospholipid syndrome in adults. Annals of the Rheumatic Diseases [Online] 78:1296-1304. Available at: https://doi.org/10.1136/annrheumdis-2019-215213.
    The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. Based on evidence from a systematic literature review and expert opinion, overarching principles and recommendations were formulated and voted. High-risk antiphospholipid antibody (aPL) profile is associated with greater risk for thrombotic and obstetric APS. Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. Patients with APS and first unprovoked venous thrombosis should receive long-term treatment with vitamin K antagonists (VKA) with a target international normalised ratio (INR) of 2–3. In patients with APS with first arterial thrombosis, treatment with VKA with INR 2–3 or INR 3–4 is recommended, considering the individual’s bleeding/thrombosis risk. Rivaroxaban should not be used in patients with APS with triple aPL positivity. For patients with recurrent arterial or venous thrombosis despite adequate treatment, addition of LDA, increase of INR target to 3–4 or switch to low molecular weight heparin may be considered. In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. In patients with recurrent pregnancy complications, increase of heparin to therapeutic dose, addition of hydroxychloroquine or addition of low-dose prednisolone in the first trimester may be considered. These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.
  • Poomsalood, S., Muthumayandi, K. and Hambly, K. (2019). Can stretch sensors measure knee range of motion in healthy adults?. Biomedical Human Kinetics [Online] 11:1-8. Available at: https://doi.org/10.2478/bhk-2019-0001.
    Study aim: There are currently limited methods available to access dynamic knee range of motion (ROM) during free-living activities. This type of method would be valuable for monitoring and progressing knee rehabilitation. Therefore, the aim of this study was to evaluate the functioning of stretch sensors for the measurement of knee ROM and to assess the level of the measurement error.
    Material and methods: Nine healthy participants were included in the study. Three stretch sensors (StretchSense?, Auckland, NZ) were attached on the participants’ right knees by Kinesiotape®. A Cybex dynamometer was used to standardise movement speed of the knee joint. Data was recorded through the StretchSense? BLE application. Knee angles were obtained from the video clips recorded during the testing and were analysed by MaxTraq® 2D motion analysis software. The knee angles were then synchronised with the sensor capacitance through R programme.
    Results: Seven out of the nine participants presented with high coefficient of determination (R2)
    (>0.98) and low root mean square error (RMSE) (<5°) between the sensor capacitance and knee angle. Two participants did not confirm good relationship between capacitance and knee angle as they presented high RMSE (>5°). The equations generated from these 7 participants’ data were used individually to predict knee angles.
    Conclusions: The stretch sensors can be used to measure knee ROM in healthy adults during a passive, non-weight-bearing movement with a clinically acceptable level of error. Further research is needed to establish the validity and reliability of the methodology under different conditions before considered within a clinical setting.
  • Bright, P. and Hambly, K. (2018). What Is the Proportion of Studies Reporting Patient and Practitioner Satisfaction with Software Support Tools Used in the Management of Knee Pain and Is This Related to Sample Size, Effect Size, and Journal Impact Factor?. Telemedicine and e-Health [Online] 24:562-576. Available at: https://doi.org/10.1089/tmj.2017.0207.
    Introduction: E-health software tools have been deployed in managing knee conditions. Reporting of patient and practitioner satisfaction in studies regarding e-health usage is not widely explored. The objective of this review was to identify studies describing patient and practitioner satisfaction with software use concerning knee pain.

    Materials and Methods: A computerized search was undertaken: four electronic databases were searched from January 2007 until January 2017. Key words were decision dashboard, clinical decision, Web-based resource, evidence support, and knee. Full texts were scanned for effect of size reporting and satisfaction scales from participants and practitioners. Binary regression was run; impact factor and sample size were predictors with indicators for satisfaction and effect size reporting as dependent variables.

    Results: Seventy-seven articles were retrieved; 37 studies were included in final analysis. Ten studies reported patient satisfaction ratings (27.8%): a single study reported both patient and practitioner satisfaction (2.8%). Randomized control trials were the most common design (35%) and knee osteoarthritis the most prevalent condition (38%). Electronic patient-reported outcome measures and Web-based training were the most common interventions. No significant dependency was found within the regression models (p > 0.05).

    Discussion and Conclusions: The proportion of reporting of patient satisfaction was low; practitioner satisfaction was poorly represented. There may be implications for the suitability of administering e-health, a medium for capturing further meta-evidence needs to be established and used as best practice for implicated studies in future. This is the first review of its kind to address patient and practitioner satisfaction with knee e-health.
  • Hambly, K. (2018). The patients perspective on physical activity and work participation in rmds. Annals of the Rheumatic Diseases [Online] 77. Available at: http://dx.doi.org/10.1136/annrheumdis-2018-eular.7700.
    Fatigue and musculoskeletal symptoms are shared features of many rheumatic
    and musculoskeletal diseases (RMDs) that often impact on physical activity and
    work participation. Physical activity is particularly important in the management
    and quality of life of people with RMDs. Participation in regular exercise can facilitate
    positive adaptations1, but people with RMDs tend to be less physically active
    than the general population.
    Two hundred and sixty-eight individuals with antiphospholipid syndrome (APS)
    participated in a cross-sectional online survey (85% female, mean age 47±11
    years, 59% primary APS) on physical activity and exercise. It was found that 82%
    of participants wanted to increase the amount of physical activity and exercise
    that they do and 71% of participants were either motivated or very motivated to
    participate in physical activity and exercise. However, a range of barriers to
    increasing levels of physical activity and exercise were expressed as summarised
    in table 1.
  • De Coninck, K., Hambly, K., Dickinson, J. and Passfield, L. (2018). Measuring the morphological characteristics of thoracolumbar fascia in ultrasound images: an inter-rater reliability study. BMC Musculoskeletal Disorders [Online] 19. Available at: http://dx.doi.org/10.1186/s12891-018-2088-5.
    BACKGROUND: Chronic lower back pain is still regarded as a poorly understood multifactorial condition. Recently, the thoracolumbar fascia complex has been found to be a contributing factor. Ultrasound imaging has shown that people with chronic lower back pain demonstrate both a significant decrease in shear strain, and a 25% increase in thickness of the thoracolumbar fascia. There is sparse data on whether medical practitioners agree on the level of disorganisation in ultrasound images of thoracolumbar fascia. The purpose of this study was to establish inter-rater reliability of the ranking of architectural disorganisation of thoracolumbar fascia on a scale from ‘very disorganised’ to ‘very organised’. METHODS: An exploratory analysis was performed using a fully crossed design of inter-rater reliability. Thirty observers were recruited, consisting of 21 medical doctors, 7 physiotherapists and 2 radiologists, with an average of 13.03 ± 9.6 years of clinical experience. All 30 observers independently rated the architectural disorganisation of the thoracolumbar fascia in 30 ultrasound scans, on a Likert-type scale with rankings from 1 = very disorganised to 10 = very organised. Internal consistency was assessed using Cronbach’s alpha. Krippendorff’s alpha was used to calculate the overall inter-rater reliability. RESULTS: The Krippendorf’s alpha was .61, indicating a modest degree of agreement between observers on the different morphologies of thoracolumbar fascia.The Cronbach’s alpha (0.98), indicated that there was a high degree of consistency between observers. Experience in ultrasound image analysis did not affect constancy between observers (Cronbach’s range between experienced and inexperienced raters: 0.95 and 0.96 respectively). CONCLUSIONS: Medical practitioners agree on morphological features such as levels of organisation and disorganisation in ultrasound images of thoracolumbar fascia, regardless of experience. Further analysis by an expert panel is required to develop specific classification criteria for thoracolumbar fascia.
  • Bright, P. and Hambly, K. (2018). Patients Using an Online Forum for Reporting Progress When Engaging With a Six-Week Exercise Program for Knee Conditioning: Feasibility Study. JMIR Rehabilitation and Assistive Technologies [Online] 5. Available at: http://dx.doi.org/10.2196/rehab.8567.
    Background: The use of electronic health (eHealth) and Web-based resources for patients with knee pain is expanding. Padlet is an online noticeboard that can facilitate patient interaction by posting virtual “sticky notes.”

    Objective: The primary aim of this study was to determine feasibility of patients in a 6-week knee exercise program using Padlet as an online forum for self-reporting on outcome progression.

    Methods: Undergraduate manual therapy students were recruited as part of a 6-week study into knee conditioning. Participants were encouraged to post maximum effort readings from quadriceps and gluteal home exercises captured from standard bathroom scales on a bespoke Padlet. Experience and progression reporting were encouraged. Posted data were analyzed for association between engagement, entry frequency, and participant characteristics. Individual data facilitated single-subject, multiple-baseline analysis using statistical process control. Experiential narrative was analyzed thematically.

    Results: Nineteen participants were recruited (47%, 9/19 female); ages ranged from 19 to 53 years. Twelve individuals (63%) opted to engage with the forum (range 4-40 entries), with five (42%) reporting across all 6 weeks. Gender did not influence reporting (odds ratio [OR] 0.76, 95% CI 0.06-6.93). No significant difference manifested between body mass index and engagement P=.46); age and entry frequency did not correlate (R2=.054, 95% CI –0.42 to 0.51, P=.83). Statistically significant conditioning profiles arose in single participants. Themes of pain, mitigation, and response were inducted from the experiences posted.

    Conclusions: Patients will engage with an online forum for reporting progress when undertaking exercise programs. In contrast to related literature, no significant association was found with reporting and gender, age, or body mass index. Individual posted data allowed multiple-baseline analysis and experiential induction from participants. Conditioning responses were evident on visual inspection. The importance of individualized visual data to patients and the role of forums in monitoring patients’ progress in symptomatic knee pain populations need further consideration.
  • Logerstedt, D., Scalzitti, D., Bennell, K., Hinman, R., Silvers-Granelli, H., Ebert, J., Hambly, K., Carey, J., Snyder-Mackler, L., Axe, M. and McDonough, C. (2018). Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018. Journal of Orthopaedic & Sports Physical Therapy [Online] 48:A1-A50. Available at: https://doi.org/10.2519/jospt.2018.0301.
    The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions.
  • Poomsalood, S. and Hambly, K. (2017). Does McConnell tapping or the stability through external rotation of the femur (SERF) strap affect rearfoot plantar loading patterns during walking in healthy adults?. International Journal of Physiotherapy and Research [Online] 5:2314-2319. Available at: https://dx.doi.org/10.16965/ijpr.2017.197.
    Background: Changes in patellofemoral joint biomechanics have the potential to influence function of the lower extremity. McConnell taping has been proposed to reduce pain in individuals with patellofemoral pain syndrome (PFPS). It is also believed to improve vastus medialis oblique (VMO) muscle, patellofemoral alignment, and stride length. The stability through external rotation of the femur (SERF) strap has been developed to pull the femur externally to stabilise the patellofemoral joint, in order to reduce patellofemoral pain and improve lower limb kinematics. A lack of literature has examined effects of these two treatment methods on plantar pressures. Therefore, the aim of this study was to investigate the effects of McConnell taping and the SERF strap on rearfoot plantar loading patterns during walking in healthy adults.

    Materials and Methods: Twenty-three participants (12 males and 11 females, age: 26.52±6.4 years) were randomly tested under 3 conditions: 1) no tape, 2) McConnell taping, and 3) SERF strap. Each participant was instructed to walk on a 2 m pressure plate at their own natural pace. Three valid stance phases of the right foot were recorded for each condition. Maximum pressures of medial heel and lateral heel, contact area of medial heel and lateral heel, initial heel contact, foot axis angle, and centre of pressure were collected.

    Results: There were significant differences of maximum pressures of lateral heel (p = 0.011) with McConnell taping condition and the SERF strap condition demonstrating higher pressures than the no-tape condition (p = 0.042, p = 0.010 respectively). However, significant differences of other variables were not found.

    Conclusion: The differences of maximum pressures of lateral heel between the conditions could be a clinical role for McConnell taping or SERF strap use in reducing rearfoot pronation in individuals with lower extremity problems especially PFPS.
  • Hambly, K., Poomsalood, S. and Mundy, E. (2017). Return to running following knee osteochondral repair using an anti-gravity treadmill: A case report. Physical Therapy in Sport [Online] 26:35-40. Available at: http://dx.doi.org/10.1016/j.ptsp.2017.05.004.
    Background: The purpose of this study was to assess the impact of an anti-gravity treadmill return to running programme on self-efficacy and subjective knee function following knee osteochondral surgery.

    Case Description: A 39-year-old otherwise healthy female endurance runner with a left knee femoral cartilage grade 3-4 defect 3cm2. The patient underwent single step arthroscopic microfracture with Bone Marrow Aspirate Concentrate. An AlterG® anti-gravity treadmill was used to manipulate loading during a graduated phased return to running over 8 weeks. Self-efficacy was evaluated using the Self-Efficacy for Rehabilitation outcomes scale (SER) and the Knee Self-Efficacy Scale (K-SES). Subjective knee function was evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective Knee Form (IKDC).

    Outcomes: The programme resulted in improvements in SER (57%), K-SES present (89%) and K-SES future (65%) self-efficacy domains. The IKDC score demonstrated a clinically important improvement with an increase from 62.1 in week 1 to 86.2 in week 8 (39%). Only the KOOS Sport/Rec subscale showed a clinically important improvement from week 1 to week 8.

    Discussion: The programme resulted in improved knee and rehabilitation self-efficacy and subjective knee function following osteochondral repair of the knee. This case report illustrates the importance of considering self-efficacy in rehabilitation after knee osteochondral surgery and highlights the potential role for anti-gravity treadmills in enhancing self-efficacy and subjective knee function in preparation for a return to sport.
  • Bright, P., Hambly, K. and Tamakloe, S. (2016). Exploring Cross-Curriculum Content of Undergraduate Musculoskeletal Therapy Courses Regarding Articular Cartilage; Implications of Surveying UK Healthcare Curriculum Providers. Journal of Musculoskeletal Disorders and Treatment [Online] 2. Available at: http://clinmedjournals.org/articles/jmdt/journal-of-musculoskeletal-disorders-and-treatment-jmdt-2-010.php?jid=jmdt.
  • Bright, P., Hambly, K. and Tamakloe, S. (2016). What is the Profile of Individuals Joining the KNEEguru Online Health Community? A Cross-Sectional Mixed-Methods Study. Journal of medical Internet research [Online] 18:e84. Available at: http://dx.doi.org/10.2196/jmir.5374.
    BACKGROUND

    The use of the Internet for seekers of health-related information provides convenience and accessibility to diverse sources (of variable quality) for many medical conditions. There is a suggestion that patients may find empowerment by engaging with Internet health care strategies and communities. The profile of consumers of online health information on knee pain has not been explored.

    OBJECTIVE

    Our objective was to identify the characteristics and motivations of online health information-seekers accessing the online health community, KNEEguru (KG). The study was designed to obtain the respondents' sociodemographic profile, together with their main reasons and motivations for joining such a community, their health information-seeking behavior, the extent of their knee problems, and their general Internet usage.

    METHODS

    We undertook an online questionnaire survey, offered to users of the KG website from June to July 2012. A mix of open and closed questions was used to facilitate inductive enquiry. Quantitative responses were analyzed using univariate analysis; qualitative thematic analysis of the open responses was completed and a conceptual model was developed.

    RESULTS

    One-hundred and fifty-two respondents took part (11.56% response rate, 152/1315), with a mean age of 40.1 years. Of this cohort, 61.2% were female, 68.4% were in domestic partnerships, 57.2% were employed, 75.0% had higher education qualifications, and 80.3% were of white/Caucasian ethnicity. Females were associated with joining KG in order to get emotional support from other users (OR 2.11, 95% CI 1.04 - 4.27, P=.04). Respondents' self-perception of health was associated with reported quality of life (OR 10.86, 95% CI 3.85 - 30.43, P<.001). Facebook users were associated with joining KG to share experiences (OR 2.34, 95% CI 1.04 - 5.56, P=.03). Post-surgery respondents were associated with joining KG to compare symptoms with other users (OR 7.31, 95% CI 2.06 - 39.82, P<.001). Three key themes were induced: condition, emotion and support. Respondents expressed distress and frustration at uncertainty of prognosis around various knee conditions, with some users preferring to initially observe rather than engage. Conversely, a strong desire to inform and support other community members was stated with reciprocation of ideas and experiences. KG was conceptualized as a filter that takes an individual's condition and emotional response to that condition as basis for support; this filter facilitated validation as the outcome of engagement.

    CONCLUSIONS

    This study, in line with wider literature, suggests that users of an online knee-specific community are typically female, middle-aged, white/Caucasian, married, employed, and have attained a level of higher education. These users demonstrate a pragmatic approach to health care information with altruistic motivations and a desire to share experiences as a means of validation. This finding emphasizes a means of promoting efficient and appropriate online health care, and demonstrates the benefits of the Internet as a viable complement to clinical engagement.
  • Bright, P. and Hambly, K. (2014). A Systematic Review of Reporting of Rehabilitation in Articular-Cartilage-Repair Studies of Third-Generation Autologous Chondrocyte Implantation in the Knee. Journal of Sport Rehabilitation [Online] 23:182-191. Available at: http://doi.org/10.1123/JSR.2013-0045.
  • Howard, J., Ebert, J. and Hambly, K. (2014). Current concepts in cartilage management and rehabilitation. Journal of sport rehabilitation [Online] 23:169-70. Available at: http://journals.humankinetics.com/doi/10.1123/JSR.2014-0246.
  • Santos-Magalhaes, A. and Hambly, K. (2014). Measuring physical activity and sports participation after autologous cartilage implantation: a systematic review. Journal of sport rehabilitation [Online] 23:171-181. Available at: http://dx.doi.org/10.1123/JSR.2013-0044.
    CONTEXT

    The assessment of physical activity and return to sport and exercise activities is an important component in the overall evaluation of outcome after autologous cartilage implantation (ACI).

    OBJECTIVE

    To identify the patient-report instruments that are commonly used in the evaluation of physical activity and return to sport after ACI and provide a critical analysis of these instruments from a rehabilitative perspective.

    EVIDENCE ACQUISITION

    A computerized search was performed in January 2013 and repeated in March 2013. Criteria for inclusion required that studies (1) be written in English and published between 1994 and 2013; (2) be clinical studies where knee ACI cartilage repair was the primary treatment, or comparison studies between ACI and other techniques or between different ACI generations; (3) report postoperative physical activity and sport participation outcomes results, and (4) have evidence level of I-III.

    EVIDENCE SYNTHESIS

    Twenty-six studies fulfilled the inclusion criteria. Three physical activity scales were identified: the Tegner Activity Scale, Modified Baecke Questionnaire, and Activity Rating Scale. Five knee-specific instruments were identified: the Lysholm Knee Function Scale, International Knee Documentation Committee Score Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Modified Cincinnati Knee Score, and Stanmore-Bentley Functional Score.

    CONCLUSIONS

    Considerable heterogeneity exists in the reporting of physical activity and sports participation after ACI. Current instruments do not fulfill the rehabilitative needs in the evaluation of physical activity and sports participation.
  • Ebert, J., Hambly, K., Joss, B., Ackland, T. and Donnelly, C. (2013). Does an unloader brace reduce knee loading in normally aligned knees?. Clinical orthopaedics and related research [Online] 472:915-22. Available at: http://dx.doi.org/10.1007/s11999-013-3297-8.
    BACKGROUND

    Unloading knee braces often are used after tibiofemoral articular cartilage repair. However, the experimental basis for their use in patients with normal tibiofemoral alignment such as those undergoing cartilage repair is lacking.

    QUESTIONS/PURPOSES

    The purpose of this study was to investigate the effect of varus and valgus adjustments to one commercially available unloader knee brace on tibiofemoral joint loading and knee muscle activation in populations with normal knee alignment.

    METHODS

    The gait of 20 healthy participants (mean age 28.3 years; body mass index 22.9 kg/m(2)) was analyzed with varus and valgus knee brace conditions and without a brace. Spatiotemporal variables were calculated as were knee adduction moments and muscle activation during stance. A directed cocontraction ratio was also calculated to investigate the relative change in the activation of muscles with medial (versus lateral) moment arms about the knee. Group differences were investigated using analysis of variance. The numbers available would have provided 85% power to detect a 0.05 increase or decrease in the knee adduction moment (Nm/kg*m) in the braced condition compared with the no brace condition.

    RESULTS

    With the numbers available, there were no differences between the braced and nonbraced conditions in kinetic or muscle activity parameters. Both varus (directed cocontraction ratio 0.29, SD 0.21, effect size 0.95, p = 0.315) and valgus (directed cocontraction ratio 0.28, SD 0.24, effect size 0.93, p = 0.315) bracing conditions increased the relative activation of muscles with lateral moment arms compared with no brace (directed cocontraction ratio 0.49, SD 0.21).

    CONCLUSIONS

    Results revealed inconsistencies in knee kinetics and muscle activation strategies after varus and valgus bracing conditions. Although in this pilot study the results were not statistically significant, the magnitudes of the observed effect sizes were moderate to large and represent suitable pilot data for future work. Varus bracing increased knee adduction moments as expected; however, they produced a more laterally directed muscular activation profile. Valgus bracing produced a more laterally directed muscular activation profile; however, it increased knee adduction moments.

    CLINICAL RELEVANCE

    When evaluating changes in knee kinetics and muscle activation together, this study demonstrated conflicting outcomes and questions the efficacy for the use of unloader bracing for people with normally aligned knees such as those after articular cartilage repair.
  • Ebert, J., Smith, A., Edwards, P., Hambly, K., Wood, D. and Ackland, T. (2013). Factors Predictive of Outcome 5 Years After Matrix-Induced Autologous Chondrocyte Implantation in the Tibiofemoral Joint. American Journal of Sports Medicine [Online] 41:1245-1254. Available at: http://dx.doi.org/10.1177/0363546513484696.
    Background: Matrix-induced autologous chondrocyte implantation (MACI) has become an established technique for the repair of full-thickness chondral defects in the knee. However, little is known about what variables most contribute to postoperative clinical and graft outcomes as well as overall patient satisfaction with the surgery.

    Purpose: To estimate the improvement in clinical and radiological outcomes and investigate the independent contribution of pertinent preoperative and postoperative patient, chondral defect, injury/surgery history, and rehabilitation factors to clinical and radiological outcomes, as well as patient satisfaction, 5 years after MACI.

    Study Design: Cohort study; Level of evidence, 3.

    Methods: This study was undertaken in 104 patients of an eligible 115 patients who were recruited with complete clinical and radiological follow-up at 5 years after MACI to the femoral or tibial condyles. After a review of the literature, a range of preoperative and postoperative variables that had demonstrated an association with postoperative clinical and graft outcomes was selected for investigation. These included age, sex, and body mass index; preoperative 36-item Short Form Health Survey (SF-36) mental component score (MCS) and physical component score (PCS); chondral defect size and location; duration of symptoms and prior surgeries; and postoperative time to full weightbearing gait. The sport and recreation (sport/rec) and knee-related quality of life (QOL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used as the patient-reported clinical evaluation tools at 5 years, while high-resolution magnetic resonance imaging (MRI) was used to evaluate graft assessment. An MRI composite score was calculated based on the magnetic resonance observation of cartilage repair tissue score. A patient satisfaction questionnaire was completed by all patients at 5 years. Regression analysis was used to investigate the contribution of these pertinent variables to 5-year postoperative clinical, radiological, and patient satisfaction outcomes.

    Results: Preoperative MCS and PCS and duration of symptoms contributed significantly to the KOOS sport/rec score at 5 years, while no variables, apart from the baseline KOOS QOL score, contributed significantly to the KOOS QOL score at 5 years. Preoperative MCS, duration of symptoms, and graft size were statistically significant predictors of the MRI score at 5 years after surgery. An 8-week postoperative return to full weightbearing (vs 12 weeks) was the only variable significantly associated with an improved level of patient satisfaction at 5 years.

    Conclusion: This study outlined factors such as preoperative SF-36 scores, duration of knee symptoms, graft size, and postoperative course of weightbearing rehabilitation as pertinent variables involved in 5-year clinical and radiological outcomes and overall satisfaction. This information may allow orthopaedic surgeons to better screen their patients as good candidates for MACI, while allowing treating therapists to better individualize their preoperative preparatory and postoperative rehabilitation regimens for a best possible outcome.
  • Ebert, J., Smith, A., Edwards, P., Hambly, K., Wood, D. and Ackland, T. (2013). Factors predictive of outcome 5 years after matrix-induced autologous chondrocyte implantation in the tibiofemoral joint. The American journal of sports medicine [Online] 41:1245-54. Available at: http://dx.doi.org/10.1177/0363546513484696.
    BACKGROUND

    Matrix-induced autologous chondrocyte implantation (MACI) has become an established technique for the repair of full-thickness chondral defects in the knee. However, little is known about what variables most contribute to postoperative clinical and graft outcomes as well as overall patient satisfaction with the surgery.

    PURPOSE

    To estimate the improvement in clinical and radiological outcomes and investigate the independent contribution of pertinent preoperative and postoperative patient, chondral defect, injury/surgery history, and rehabilitation factors to clinical and radiological outcomes, as well as patient satisfaction, 5 years after MACI.

    STUDY DESIGN

    Cohort study; Level of evidence, 3.

    METHODS

    This study was undertaken in 104 patients of an eligible 115 patients who were recruited with complete clinical and radiological follow-up at 5 years after MACI to the femoral or tibial condyles. After a review of the literature, a range of preoperative and postoperative variables that had demonstrated an association with postoperative clinical and graft outcomes was selected for investigation. These included age, sex, and body mass index; preoperative 36-item Short Form Health Survey (SF-36) mental component score (MCS) and physical component score (PCS); chondral defect size and location; duration of symptoms and prior surgeries; and postoperative time to full weightbearing gait. The sport and recreation (sport/rec) and knee-related quality of life (QOL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used as the patient-reported clinical evaluation tools at 5 years, while high-resolution magnetic resonance imaging (MRI) was used to evaluate graft assessment. An MRI composite score was calculated based on the magnetic resonance observation of cartilage repair tissue score. A patient satisfaction questionnaire was completed by all patients at 5 years. Regression analysis was used to investigate the contribution of these pertinent variables to 5-year postoperative clinical, radiological, and patient satisfaction outcomes.

    RESULTS

    Preoperative MCS and PCS and duration of symptoms contributed significantly to the KOOS sport/rec score at 5 years, while no variables, apart from the baseline KOOS QOL score, contributed significantly to the KOOS QOL score at 5 years. Preoperative MCS, duration of symptoms, and graft size were statistically significant predictors of the MRI score at 5 years after surgery. An 8-week postoperative return to full weightbearing (vs 12 weeks) was the only variable significantly associated with an improved level of patient satisfaction at 5 years.

    CONCLUSION

    This study outlined factors such as preoperative SF-36 scores, duration of knee symptoms, graft size, and postoperative course of weightbearing rehabilitation as pertinent variables involved in 5-year clinical and radiological outcomes and overall satisfaction. This information may allow orthopaedic surgeons to better screen their patients as good candidates for MACI, while allowing treating therapists to better individualize their preoperative preparatory and postoperative rehabilitation regimens for a best possible outcome.
  • Hambly, K., Sibley, R. and Ockendon, M. (2012). Agreement between a novel smartphone application and a long arm goniometer for assessment of knee flexion. International Journal of Physiotherapy and Rehabilitation 2.
  • Mithoefer, K., Hambly, K., Logerstedt, D., Ricci, M., Silvers, H. and Della Villa, S. (2012). Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete. The Journal of orthopaedic and sports physical therapy [Online] 42:254-273. Available at: http://dx.doi.org/10.2519/jospt.2012.3665.
    Articular cartilage injury is observed with increasing frequency in both elite and amateur athletes and results from the significant acute and chronic joint stress associated with impact sports. Left untreated, articular cartilage defects can lead to chronic joint degeneration and athletic and functional disability. Treatment of articular cartilage defects in the athletic population presents a therapeutic challenge due to the high mechanical demands of athletic activity. Several articular cartilage repair techniques have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impact sports. Postoperative rehabilitation is a critical component of the treatment process for athletic articular cartilage injury and should take into consideration the biology of the cartilage repair technique, cartilage defect characteristics, and each athlete's sport-specific demands to optimize functional outcome. Systematic, stepwise rehabilitation with criteria-based progression is recommended for an individualized rehabilitation of each athlete not only to achieve initial return to sport at the preinjury level but also to continue sports participation and reduce risk for reinjury or joint degeneration under the high mechanical demands of athletic activity.
  • Hambly, K., Silvers, H. and Steinwachs, M. (2012). Rehabilitation after Articular Cartilage Repair of the Knee in the Football (Soccer) Player. Cartilage [Online] 3:50S-56S. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297172/.
    BACKGROUND

    Participation in football can put both male and female players at an increased risk for knee osteoarthritis. There is a higher prevalence of focal chondral defects in the knee of athletes compared to nonathletes. The management of chondral defects in the football player is complex and multifactorial.

    OBJECTIVE

    The aim of this study is to provide an overview of the current strategies for rehabilitation after articular cartilage repair of the knee in the football player.

    DESIGN

    A review of current literature and the scientific evidence for rehabilitation after articular cartilage repair of the knee.

    CONCLUSIONS

    Articular cartilage repair has been shown to allow return to sport but rehabilitation timescales are lengthy. Successful rehabilitation for a return to football after articular cartilage repair of the knee requires the player to be able to accept the load of the sport. This necessitates a multidisciplinary approach to rehabilitation, especially in the transition from therapy to performance care. It should be recognized that not all players will return to football after articular cartilage repair. The evidence base for rehabilitative practice after articular cartilage repair is increasing but remains sparse in areas.
  • Hambly, K. (2011). Activity Profile of Members of an Online Health Community After Articular Cartilage Repair of the Knee. Sports Health: A Multidisciplinary Approach [Online] 3:275-282. Available at: http://doi.org/10.1177/1941738111402151.
  • Hambly, K. and Griva, K. (2010). IKDC or KOOS: which one captures symptoms and disabilities most important to patients who have undergone initial anterior cruciate ligament reconstruction?. American journal of sports medicine [Online] 38:1395-1404. Available at: http://dx.doi.org/10.1177/0363546509359678.
    Background: Knee-specific patient-reported outcome measures are frequently used after anterior cruciate ligament reconstruction but little is known about whether they measure outcomes important to patients.

    Purpose: The aim of this study was to identify which instrument, the Knee injury and Osteoarthritis Outcome Score (KOOS) or the International Knee Documentation Committee Subjective Knee Form (IKDC), captures symptoms and disabilities most important to patients who have undergone initial anterior cruciate ligament reconstruction.

    Study Design: Cross-sectional study; Level of evidence, 3.

    Methods: Data were collected from 126 participants of an Internet knee forum. A self-reported online questionnaire was developed consisting of demographic and surgical data, the Tegner Activity Scale, and 49 consolidated items from the KOOS and the IKDC. Item importance, frequency, and frequency-importance product were calculated.

    Results: Seventy-eight percent of the items from the IKDC were experienced by more than half of the patients, compared with 57% from the KOOS. Items extracted from the Function in Sports/Recreation and Quality of Life KOOS subscales were highly important to this group of patients. For patients 12 months or more after anterior cruciate ligament reconstruction, 94% of the IKDC items had a frequency-importance product of 1 or less compared with 86% of the KOOS items.

    Conclusion: Overall, the IKDC items outperformed the KOOS items on all of the 5 criteria with the exception of the frequency-importance product for patients who were 12 months after anterior cruciate ligament reconstruction. The KOOS Function in Sports/Recreation and Knee-Related Quality of Life subscales outperformed the IKDC for the total cohort as well as for male and female subgroups. However, differences in individual items were not always evident from either total scale or subscale ratings. Studies should use patient-reported outcomes that reflect patients' most important concerns and further prospeptive longitudinal research is required in this area.
  • Hambly, K. (2010). The use of the Tegner Activity Scale for articular cartilage repair of the knee: a systematic review. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA [Online] 19:604-614. Available at: http://dx.doi.org/10.1007/s00167-010-1301-3.
    PURPOSE: The Tegner Activity Scale (TAS) was developed in 1984 and has been widely used in studies on knee populations. The primary objective of this study was to undertake a systematic review on the use of the TAS for articular cartilage repair (ACR) of the knee. METHODS: A systematic review was conducted using electronic databases (MEDLINE, CINAHL, SPORTDiscus™, NHS Evidence, ISI Web of Knowledge, AMED, BNI, PEDro and The Cochrane Collaboration of Systematic Reviews) and reference lists from extracted articles. Studies were selected that were published between 1984 and 2009 in which the TAS was reported for patients who had undergone ACR of the knee. RESULTS: The search strategy identified 442 citations of which 34 articles met the inclusion criteria. There was a large degree of study heterogeneity especially regarding data reporting a wide variation in the number of participants (range 5-137), participant age (range 12-76 years), follow-up time (range 3-120 months) and male-to-female participant ratio. Where pre- to postoperative TAS change was analysed, 88% of studies demonstrated a significant improvement in postoperative TAS scores. CONCLUSIONS: In general, TAS data were inconsistently reported and methodological detail was often lacking. Caution is advised in the interpretation of TAS scores following ACR of the knee where there are large ranges in postoperative follow-up times, mixed gender cohorts and wide ranges in participant ages. TAS data should be presented and analysed fully and ideally in a standardised fashion to facilitate the comparison of outcomes between studies.
  • Mithoefer, K., Hambly, K., Della Villa, S., Silvers, H. and Mandelbaum, B. (2009). Return to Sports Participation After Articular Cartilage Repair in the Knee: Scientific Evidence. American journal of sports medicine [Online] 37:1675-1765. Available at: http://dx.doi.org/10.1177/0363546509351650.
    BACKGROUND: Articular cartilage injury in the athlete's knee presents a difficult clinical challenge. Despite the importance of returning injured athletes to sports, information is limited on whether full sports participation can be successfully achieved after articular cartilage repair in the knee. HYPOTHESIS: Systematic analysis of athletic participation after articular cartilage repair will demonstrate the efficacy of joint surface restoration in high-demand patients and help to optimize outcomes in athletes with articular cartilage injury of the knee. STUDY DESIGN: Systematic review. METHODS: A comprehensive literature review of original studies was performed to provide information about athletic participation after articular cartilage repair. The athlete's ability to perform sports postoperatively was assessed by activity outcome scores, rate of return to sport, timing of the return, level of postoperative sports participation, and the continuation of athletic activity over time. RESULTS: Twenty studies describing 1363 patients were included in the review, with an average follow-up of 42 months. Return to sports was possible in 73% overall, with highest return rates after osteochondral autograft transplantation. Time to return to sports varied between 7 and 18 months, depending on the cartilage repair technique. Initial return to sports at the preinjury level was possible in 68% and did not significantly vary between surgical techniques. Continued sports participation at the preinjury level was possible in 65%, with the best durability after autologous chondrocyte transplantation. Several factors affected the ability to return to sport: athlete's age, preoperative duration of symptoms, level of play, lesion size, and repair tissue morphology. CONCLUSION: Articular cartilage repair in the athletic population allows for a high rate of return to sports, often at the preinjury level. Return to sports participation is influenced by several independent factors. The findings provide pertinent information that is helpful for the clinical decision-making process and for the management of the athlete's postoperative expectations.
  • Roos, E., Davis, A., Beynnon, B., Hambly, K. and Griva, K. (2009). Letter to the Editor - IKDC or KOOS? Which measures symptoms and disabilities most important to postoperative articular cartilage repair patients? Author’s Response. American Journal of Sports Medicine [Online] 37:1042-1043. Available at: http://dx.doi.org/10.1177/0363546509334226.
    Dear Editor:

    We have with interest read the article by Hambly and Griva titled “IKDC or KOOS? Which Measures Symptoms and Disabilities Most Important to Postoperative Articular Cartilage Repair Patients?” (September 2008, pages 1695-704) and the accompanying editorial by Bruce Reider. As pointed out in the article, there is no agreement regarding a gold-standard patient-assessed measure of the effect of cartilage repair surgery, and it is important to compare possible questionnaires. It would indeed improve interpretation of outcome in cartilage repair in particular, and in knee surgery in general, if consensus could be reached on a preferred patient-reported outcomes measure.
  • Hambly, K. (2009). Articular cartilage repair for athletes. SportEx Medicine 39.
  • Hambly, K. (2009). Rehabilitation - Is it important or not?. Cartilage [Online] 1:IS-63. Available at: http://dx.doi.org/10.1177/194760350900101S01.
  • Hambly, K. and Griva, K. (2008). IKDC or KOOS? Which measures symptoms and disabilities most important to postoperative articular cartilage repair patients?. American journal of sports medicine [Online] 36:1695-704. Available at: http://dx.doi.org/10.1177/0363546508317718.
    BACKGROUND: The relevance of knee-specific subjective measures of outcome to patients has not been evaluated for cartilage repair procedures. PURPOSE: The aim of this study was to identify which instrument out of the Knee injury Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form measures symptoms and disabilities most important to postoperative articular cartilage repair patients. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Data were collected from 58 participants of an Internet knee forum via a self-reported online questionnaire consisting of demographic and surgical data, the Tegner activity scale, and 49 consolidated items from the Knee injury Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form. Item importance, frequency, and frequency-importance product were calculated. RESULTS: Overall, the International Knee Documentation Committee Subjective Knee Form was the highest scoring instrument in all categories. However, 2 of the Knee injury Osteoarthritis Outcome Score subscales ("function in sport and recreation" and "knee-related quality of life") scored higher on mean importance and frequency-importance product than the overall International Knee Documentation Committee Subjective Knee Form score. CONCLUSION: The International Knee Documentation Committee Subjective Knee Form provided the best overall measure of symptoms and disabilities that are most important to this population of postoperative articular cartilage repair patients. This brings into question the validity of using the Knee injury Osteoarthritis Outcome Score in shorter-term--less than 10 years--studies. Issues related to sports activity appear to be highly valued and very pertinent to evaluation of outcomes for this patient group.
  • Hambly, K. (2007). Cartilage repair rehabilitation: chondrocyte to cerebrum. Osteoarthritis and Cartilage [Online] 15:B7-B8. Available at: http://dx.doi.org/10.1016/S1063-4584(07)61227-8.
  • Hambly, K. (2007). Articular cartilage repair rehabilitation - the need for consensus. Physiotherapy [Online] 93:S774. Available at: http://dx.doi.org/10.1016/S0031-9406(07)60001-7.
  • Hambly, K., Bobic, V., van Assche, D., Wondrasch, B. and Marlovits, S. (2006). Autologous chondrocyte implantation postoperative care and rehabilitation: science and practice. American Journal of Sports Medicine 34:1020-1038.
    Autologous chondrocyte implantation is an advanced, cell-based orthobiological technology used for the treatment of chondral defects of the knee. It has been in clinical use since 1987 and has been performed on 12 000 patients internationally; but despite having been in clinical use for more than 15 years, the evidence base for rehabilitation after autologous chondrocyte implantation is notably deficient. The authors review current clinical practice and present an overview of the principles behind autologous chondrocyte implantation rehabilitation practices. They examine the main rehabilitation components and discuss their practical applications within the overall treatment program, with the aim of facilitating the formulation of appropriate, individualized patient rehabilitation protocols for autologous chondrocyte implantation.

Book section

  • Hambly, K., Mithoefer, K., Silvers, H. and Mandelbaum, B. (2012). Autologous Chondrocyte Implantation. In: Maxey, L. and Magnusson, J. eds. Rehabilitation for the Postsurgical Orthopedic Patient. Mosby Elsevier. Available at: http://store.elsevier.com/Rehabilitation-for-the-Postsurgical-Orthopedic-Patient/Lisa-Maxey/isbn-9780323077477/.
  • Silvers, H. and Hambly, K. (2010). Post-operative cartilage repair rehabilitation. In: Brittberg, M. and Gersoff, W. eds. Cartilage Surgery: An Operative Manual. Saunders Elsevier.
    Cartilage Surgery: An Operative Manual by Mats Brittberg, MD and Wayne Gersoff, MD is your guide to applying the most recent advances in cartilage repair, and performing cutting-edge surgical procedures. An internationally diverse collection of authors offers a global perspective on timely topics such as cartilage biologics. Clinical pearls, operative video clips, and detailed, full-color intraoperative photographs offer step-by-step guidance on essential techniques. You can access the full content and videos online at expertconsult.com, and the videos are included on a bound-in DVD.
  • Hambly, K., van Assche, D., Wondrasch, B., Bobic, V. and Marlovits, S. (2006). Current status and prospects for rehabilitation following cell-based cartilage repair. In: Basic Science and Clinical Repair of Articular Cartilage Defects: Current Status and Prospects. Italy: Timeo Editore.

Conference or workshop item

  • Hambly, K., Mundy, E., Poomsalood, S. and Stephens, D. (2018). Return to running following knee osteochondral repair using an anti-gravity treadmill (P03-581). In: ESSKA Congress 2018. Springer, p. S174. Available at: https://doi.org/10.1007/s00167-018-4867-9.
    Objectives: The purpose of this study was to assess the impact of an anti-gravity treadmill return to running programme on self-efficacy and subjective knee function following knee osteochondral surgery.
    Methods: Two otherwise healthy female endurance runners who had undergone knee osteochondral surgery were recruited. Patient A was 9 months post-surgery for a left knee femoral cartilage grade 3–4 defect 3 cm2. Patient B was 11 weeks post-surgery for a partial lateral menisectomy and chondroplasty. An anti-gravity treadmill was usedto manipulate loading during a graduated phased return to running. Self-efficacy was evaluated using the Self-Efficacy for Rehabilitation outcomes scale (SER) and the Knee Self-Efficacy Scale (K-SES). Subjective knee function was evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS).
    Results: The programmes resulted in improvements in SER (Patient A 57%; Patient B 18%) and K-SES present (Patient A 89%; Patient B 33%) and K-SES future (Patient A 65%; Patient B 33%). Only the KOOS Sport/Rec (Patient A and B) and the Quality of Life (Patient B) subscales showed clinically important improvements.
    Conclusions: The programmes resulted in improved knee and rehabilitation self-efficacy and subjective knee function following osteochondral repair of the knee. These case reports illustrate the importance of considering self-efficacy in individualising rehabilitation after knee osteochondral surgery and highlights the potential role for anti-gravity treadmills in enhancing self-efficacy and subjective knee function in preparation for a return to sport.
  • De Coninck, K., Hambly, K., Passfield, L., Dickinson, J. and Muthumayandi, K. (2015). Inter-observer agreement of thoracolumbar fascia morphology: an exploratory analysis of ultrasound images. In: Fourth International Fascia Research Congress. Elsevier, pp. 668-669. Available at: https://doi.org/10.1016/j.jbmt.2015.07.005.
    BACKGROUND: Ultrasound imaging (USI) has been shown to be a valid method to investigate the morphology of the thoracolumbar fascia (TLF) [1]. A USI-based study has demonstrated that the TLF of subjects with chronic lower back pain (LBP) is on average 25% thicker and more disorganised compared to a control group [1]. The aim of this study is to explore inter-observer agreement between a range of clinicians on (dis)organisation of TLF in ultrasound images. There are currently no validated methods for the evaluation of USI of TLF.
    METHODS: Design: an exploratory analysis using a fully crossed design of inter-observer agreement. This study was approved by the University of Kent’s School of Sport and Exercise Sciences Research and Ethics Committee (Prop. 163 – 2013). Participants: Thirty observers consisting of 21 (70%) Medical Doctors, 7 (23%) physiotherapists and 2 (6%) radiologists, with a combined total average of 13 years of clinical experience (± SD 9.4). 57% had no experience in USI, 36% had experience ranging from monthly to daily evaluations of USI, no observers had experience in evaluating USI of TLF. Protocol: A sub-set of thirty ultrasound scans of TLF were randomly selected from a data set of 308 scans of subjects with and without LBP (from a larger study conducted by the first author). All scans were anonymised and displayed on a desktop computer, or projected on a screen. All observers viewed and rated each of the 30 scans independently on a Likert-type scale from 1(very disorganised) to 10 (very organised). Inter-observer agreement was assessed using a two-way mixed, consistency, average measures intra-class correlation (ICC), the Cronbach’s Alpha, to assess consistency among observers. The Krippendorff’s Alpha (Kalpha) [2] reliability estimate was used to assess agreement.
    RESULTS: The resulting ICC was in the excellent range, ICC = 0.98, indicating that observers had a high degree of consistency, suggesting that (dis)organisation was rated similarly across observers. Observers without USI experience scored an ICC = 0.96, observers with USI experience scored an ICC = 0.95, again both in the excellent range. In this small cohort, experience in USI does not appear to impact on consistency. The Krippendorff’s ordinal alpha ? was .621, indicating a modest degree of agreement.
    CONCLUSIONS: The high ICC and modest Kalpha suggest that a minimal amount of measurement error was introduced by the independent observers, and therefore statistical power for subsequent analyses is not substantially reduced. This will allow for further analysis of USI images of TLF in terms of morphology and classification. This could ultimately, lead to a meaningful evaluation of treatments of TLF.
  • De Coninck, K., Hambly, K., Passfield, L., Dickinson, J. and Muthumayandi, K. (2015). Inter-observer agreement of thoracolumbar fascia morphology: An exploratory analysis of ultrasound images. In: pp. 668-669.
  • Hambly, K. and Cohen, J. (2011). Using Programme Assessment to Promote Reflective Learning and Clinical Reasoning Skills in Sports Therapy: A Case Study. In: Assessment in HE Conference.
    This paper considers the impact of cross-modular assessment on student learning of both
    professional competencies and academic skills within an allied health field.
    Assessment is central to higher education. However, recent research has consistently shown
    that assessment is frequently over-used to ‘warrant' achievement (Knight 2007) despite its
    potential to influence student learning by directing attention and effort (Gibbs & Simpson
    2004; Boud & Falchikov, 2007). It had been noted that students persistently had trouble appreciating how the theoretical
    knowledge gained at Level 2 would be integral to applied practice at Level 3. In addition,
    previous modular assessment regimes did not always provide sufficient opportunity for
    students to feed-forward from one assessment to the next. Therefore, it was considered that a
    shift in focus towards ‘assessment for learning' to address these potential issues may
    facilitate students' ability to optimise clinical reasoning skill acquisition.
    An alternative approach was piloted to establish whether effective learning of the required
    clinical reasoning skills would indeed be facilitated by an assessment that would provide
    regular practise of the required skills and opportunities for reflection (Gibbs & Simpson 2004;
    Kolb's Reflective Learning Cycle 1984). Student attitudes to the perceived effectiveness of the
    cross-modular assessment are considered, along with identification of aspects of good
    practice in the development of critical reflective learning skills necessary for professional
    practice. This paper explores the effect of the revised assessment and suggests possible
    considerations and strategies for wider implementation in programmes with professional
    accreditation requirements.

Internet publication

  • Hambly, K. (2007). NHS Evidence - Musculoskeletal: What Is the Evidence That Muscle Strength Training Matters in the Management of OA? [Online]. Available at: https://www.evidence.nhs.uk/document?ci=http%3A%2F%2Farms.evidence.nhs.uk%2Fresources%2FHub%2F25281&ReturnUrl=%2Fsearch%3Fq%3DMusculoskeletal%253A%2Bwhat%2Bis%2Bthe%2Bevidence%2Bthat%2Bmuscle%2Bstrength%2Btraining%2Bmatters.
    Osteoarthritis (OA) is not an inevitable consequence of human aging but age-associated sarcopenia is. Loss of strength in healthy men and women begins around the fourth decade initially proceeding at a rate of loss of around 1% per year before accelerating from the seventh decade onwards. This loss of skeletal muscle mass and strength can result in decreased mobility and an increased potential for disability.

Thesis

  • Poomsalood, S. (2018). Lower Extremity Variables and Extrinsic Factors Associated With Patellofemoral Pain Syndrome.
  • Santos Magalhães, A. (2016). Subjective and Objective Assessment of Physically Active People With Knee Injury.
    Knee injuries are highly prevalent in physically active individuals and are frequently associated with sport participation. Independently of the nature of the injury, subjective and objective clinical measures are used to assess, monitor and evaluate treatment outcomes in this population. To be clinically meaningful, these outcome measures should be relevant to the condition, the anatomical area, the individual or population, and importantly, possess adequate psychometric properties. Despite a high prevalence of knee injuries, there are several aspects of the subjective and objective knee evaluation in physically active individuals that remain unclear or have not been considered in previous research.The main aim of the present thesis was to fill some of the gaps identified in the literature regarding both subjective and objective knee measures in physically active individuals. Therefore, this thesis was divided into two distinct parts. The first part looked at the patient-reported outcome (PRO) measures of the knee and physical activity, and consisted of two studies. The first study was a systematic review conducted to explore the PRO measures that are commonly used in the evaluation of physical activity and return to sport following autologous chondrocyte implantation (ACI). Aiming as well, to provide a critical analysis of these instruments from a rehabilitative perspective. This review revealed not only the heterogeneity in the selection, but also in the timing and reporting of patient-reported activity scoring instruments following ACI, which makes a systematic comparison difficult and introduces bias into the interpretation of these outcomes. Another important finding of this review, was that the instruments currently used to evaluate postoperative outcomes in an articular cartilage repair population do not always fulfil the rehabilitative needs of physically active individuals. The second study was conducted in recreational marathon runners and aimed to provide normative values for a widely used knee specific PRO measure in athletes with knee injury, the Knee Injury Osteoarthritis Outcome Score (KOOS). Alongside the normative KOOS subscales values stratified by age group and history of knee injury that were presented, this study also showed that recent history of knee running-related injury (RRI) has a negative impact on the KOOS scores. In runners with no history of knee RRI, the results observed suggested a lack of interaction between KOOS subscale values and age. Furthermore, the KOOS values seen were substantially higher compared to previously published normative population-based KOOS values.
    The second part of the present thesis comprised three experimental studies concerning single-leg cycling (SLC) exercise testing, in particular assessing the potential use of the self-paced test (SPT) concept as an objective measure following knee surgery. The first study analysed the reliability of a 5x2 min stages SPT anchored to the rate of perceived exertion (RPE) for SLC exercise testing. This study showed that this test protocol elicits reliable cardiorespiratory and metabolic responses. The second study examined the validity of the SPT protocol used in the previous study, through a concurrent comparison against a conventional fixed power incremental SLC exercise test. This investigation showed that the 5x2 min SPT provides a valid objective means for assessing peak aerobic capacity in SLC exercise testing. Moreover, it may be associated with increased activity enjoyment comparatively to conventional testing. The third and last experimental study investigated the effect of a 10 kg counterweight device (CW10) on cardiorespiratory, metabolic and perceptual responses to SLC exercise testing. The results of this study demonstrated that the CW10 despite eliciting an improvement in the activity enjoyment, did not affect peak cardiorespiratory and metabolic responses to SLC exercise testing. When matched for test duration the SPT elicited higher peak power output and peak oxygen consumption than conventional incremental testing, regardless of the CW10 usage or not. In conclusion, the original work of the present thesis increases the body of knowledge of two distinct, but complementary fields in the subjective and objective knee assessment of physically active individuals. The outcomes provided both on PRO measures and SLC exercise testing, may have impact on the clinical practice of clinicians, sport rehabilitation professionals and researchers.
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