Royal Rehabilitation Centre

Combat-related traumatic injury (CRTI) has been linked to reduced myocardial blood-flow- reserve (MBFR), measured using the subendocardial viability ratio (SEVR). We aimed to assess the mediating role of known cardiovascular risk factors on SEVR. We examined 1018 UK servicemen (prospective ADVANCE Cohort Study) comprising 504 with CRTI (140 amputees) and 514 uninjured men, frequency-matched at sampling, by age, rank and deployment (Afghanistan 2003-2014). We examined the mediating role of cardiovascular risk factors, shown to significantly greater with CRTI at study baseline (~8 years post-injury/deployment), on SEVR, measured three-years later (FU1). The cardiovascular risk measures were heart-rate variability (HRV, root-mean-square-of-successive-differences [RMSSD]), visceral-fat-mass (VFM, using DEXA), venous-blood high-sensitivity C-reactive protein (Hs-CRP, inflammation), six-minute walk distance (6MWD, physical function) and weekly leisure-time moderate-to-vigorous physical activity (LT-MVPA, physical activity). At baseline, VFM was significantly greater and RMSSD, 6MWD and LT-MVPA lower with CRTI compared to the uninjured. VFM and Hs-CRP were significantly greater and RMSSD, 6MWD and LT-MVPA lower in the injured amputees versus the injured non-amputees and uninjured. The SEVR at FU1 was significantly lower in the injured (mean ± standard deviation; 187.2 ± 39.7) compared to the uninjured (194.1 ± 31.5) and lowest in the amputee sub-group (181.9 ± 30.0). The association between CRTI and SEVR was mediated by VFM (natural indirect effect -1.80: 95%CI: -2.90, -0.67), RMSSD (-1.82: -3.45, -0.19) and 6MWD (-1.79: -3.16, -0.41) but not Hs-CRP and LT-MVPA. The association between traumatic amputation and SEVR was mediated by VFM, HRV and LT-MVPA. VFM, HRV and physical function/activity were significant mediators of the link between CRTI and SEVR. Interventions on physical activity/function could mitigate the association between CRTI and SEVR. Data from longer-term follow up are required to robustly determine the temporal effects of this relationship.

A descriptive quantitative study. To determine how much and what type of exercises and training were provided as part of usual physiotherapy and occupational therapy to participants of the SCI-MT Trial (the Early and Intensive Motor Training for People with Spinal Cord Injuries Trial). This information is important because the SCI-MT Trial concluded that additional motor training is redundant if people with SCI receive equivalent usual care as what was provided to participants of the SCI-MT Trial. Fifteen spinal injury units across Europe and Australia. Data were collected on the time participants of both groups of the SCI-MT Trial (n = 220) attended physiotherapy and occupational therapy provided as part of usual care over the 10-week intervention period. The International Spinal Cord Injury Physical Therapy and Occupational Therapy Basic Data Set was used to capture time spent on activity and impairment directed categories of exercises and training. Participants attended a median (interquartile range) of 8.3 (6.2 to 11.4) hours of physiotherapy and occupational therapy per week. Approximately 70% of therapy time was spent actively exercising or training with a median of 3.8 h per week spent on activity-directedand 1.9 h per week spent on impairment-directedexercises and training. The results of this study detail the amount and type of physiotherapy and occupational therapy that needs to be provided as part of usual rehabilitation care to render additional motor training redundant.

Neglected intra-articular fractures of the proximal interphalangeal (PIP) joint pose significant challenges due to joint stiffness, malalignment, and compromised function. Traditional management often yields suboptimal outcomes, especially in delayed presentations. We report a novel application of the Suzuki frame-conventionally used for distal interphalangeal (DIP) joint injuries-in the treatment of a neglected PIP joint intra-articular fracture in a young male patient. The fracture was managed using a dynamic external fixator constructed with K-wires and rubber bands, allowing controlled distraction and early mobilization. A modified Suzuki frame was applied across the PIP joint, achieving stable fixation and facilitating gradual distraction. The construct enabled early range-of-motion exercises while maintaining reduction. Radiological and functional outcomes were assessed over a 12-week follow-up. The patient demonstrated excellent clinical recovery, with restoration of joint alignment, pain-free range of motion, and return to pre-injury activity levels. Radiographs confirmed satisfactory fracture healing and joint congruity. This case highlights the versatility of the Suzuki frame in managing complex PIP joint injuries, especially in neglected cases. The technique offers a minimally invasive, cost-effective, and function-preserving alternative that warrants further exploration in larger cohorts.

Both obesity and cardiorespiratory fitness are crucial determinants of symptoms and prognosis. However, interpreting the gold-standard cardiopulmonary exercise test (CPET) is complicated by increasing body size and varying body composition. We hypothesised that the 'metabolic cost of external work' (or oxygen uptake (ml/min)/workload (Watts); V̇O2/W), a body weight-independent determinant of endurance capacity, would reflect metabolic health more accurately than V̇O2 alone. A test cohort of 160 fit individuals underwent anthropomorphic and metabolic assessment, maximal bicycle ergometer CPET, and six-minute walk test (6MWT). V̇O2/W was calculated at VT1 and peak. The performance of V̇O2/W was validated in 62 older, less fit individuals, undergoing the same protocol. 24 obese volunteers were assigned a weight loss intervention, and the impact on V̇O2/W examined. In both test and validation cohort, V̇O2/W at VT1 and peak correlated with 6MWT distance, more strongly than standard CPET parameters. Including V̇O2/W improved the accuracy of predicting 6MWT distance. V̇O2/W correlated with BMI, insulin sensitivity and waist-to-hip ratio. Metabolic cost falls with weight loss, in parallel to metabolic and functional improvements, in contrast to other CPET parameters. Metabolic cost is strongly associated with functional capacity and metabolic health across a range of body weight and fitness, outperforming standard CPET metrics. It is a simple measure which may improve our assessment of the extent to which exertional symptoms are determined by metabolic factors in an individual, and thereby target the most appropriate intervention to those who will benefit most.

Qualitative design. The aim of the study was to (i) determine the perspectives of therapists and people with spinal cord injury (SCI) on our recently developed Australian and New Zealand Clinical Practice Guidelines for the physiotherapy management of people with SCI, and (ii) understand the barriers and facilitators to the rollout of the Guidelines and identify implementation strategies to support their uptake. Hospital and community SCI services, Australia. Twenty-one therapists and 10 people with SCI were interviewed one-on-one or within focus groups. The interviews captured perspectives of therapists and people with SCI on the Guidelines as well as barriers and facilitators to the rollout of the Guidelines. The interviews with therapists were guided by the Theoretical Domains Framework (TDF). All interviews were transcribed and thematically coded. Barriers and facilitators were then linked to the COM-B model (Capability, Opportunity, Motivation - Behaviour) to identify implementation strategies. The barriers to implementation of the Guidelines identified by therapists were lack of knowledge and skill, lack of resources and challenges associated with working within large organisations. Facilitators to the uptake of the Guidelines were providing education, skill training, Guideline champions, awareness, and two-way communication between patient and therapist. Fourteen implementation strategies were identified. Both therapists and people with SCI thought the Guidelines were a useful tool to improve the quality of care provided to people with SCI across various health settings. Facilitators identified in this study are being used to guide current implementation projects to enhance the uptake of the Guidelines.

Osteoarthritis (OA) is considered to be a condition attributable to ageing; however, symptoms can start under 45 years old in one-fifth of patients. Exercise therapy is recommended as first-line treatment in all OA guidance; however, uncertainty remains regarding optimal exercise programmes (including strength, aerobic or mind-body interventions) as different populations might respond better to one intervention than another. This review aims to understand the evidence surrounding exercise interventions for OA in younger adults (18-50 years old). An umbrella review methodology was adopted. Individual studies included in 50 systematic reviews (±meta-analyses) published in the last decade were reviewed and those involving participants aged 18-50 were selected. Five papers, from a potential 1046, involved appropriate participants and underwent full-text review. Two were excluded due to pathology and language; therefore, three studies with 265 participants were included. Exercise interventions included strength-based, neuromuscular control and aerobic and were delivered under supervision or via sensor or virtual reality technology. Interventions improved pain, functional, cartilage composition and inflammatory outcomes measures; however, study heterogeneity prevented direct comparison and meta-analysis. There is a clear bias in the literature for an older population, with research and clinical interventions required for a younger adult population with, or at risk of, OA.

BackgroundPersistent pain is a complicated phenomenon associated with a wide array of complex pathologies and conditions (e.g., complex regional pain syndrome, non-freezing cold injury), leading to extensive disability and reduced physical function. Conventional resistance training is commonly contraindicated in load compromised and/or persistent pain populations, compromising rehabilitation progression and potentially leading to extensive pharmacological intervention, invasive procedures, and reduced occupational status. The management of persistent pain and utility of adjunct therapies has become a clinical and research priority within numerous healthcare settings, including defence medical services.Main BodyBlood flow restriction (BFR) exercise has demonstrated beneficial morphological and physiological adaptions in load-compromised populations, as well as being able to elicit acute hypoalgesia. The aims of this narrative review are to: (1) explore the use of BFR exercise to elicit hypoalgesia; (2) briefly review the mechanisms of BFR-induced hypoalgesia; (3) discuss potential implications and applications of BFR during the rehabilitation of complex conditions where persistent pain is the primary limiting factor to progress, within defence rehabilitation healthcare settings. The review found BFR application is a feasible intervention across numerous load-compromised clinical populations (e.g., post-surgical, post-traumatic osteoarthritis), and there is mechanistic rationale for use in persistent pain pathologies. Utilisation may also be pleiotropic in nature by ameliorating pathological changes while also modulating pain response. Numerous application methods (e.g., with aerobic exercise, passive application, or resistance training) allow practitioners to cater for specific limitations (e.g., passive, or contralateral application with kinesiophobia) in clinical populations. Additionally, the low-mechanical load nature of BFR exercise may allow for high-frequency use within residential military rehabilitation, providing a platform for conventional resistance training thereafter.ConclusionFuture research needs to examine the differences in pain modulation between persistent pain and pain-free populations with BFR application, supporting the investigation of mechanisms for BFR-induced hypoalgesia, the dose-response relationship between BFR-exercise and pain modulation, and the efficacy and effectiveness of BFR application in complex musculoskeletal and persistent pain populations.

Accelerated sub-lesional bone loss is common in the first 2–3 years after traumatic spinal cord injury (TSCI), particularly in the distal femur and proximal tibia. Few studies have explored efficacy of antiresorptives for acute bone loss prevention post-TSCI, with limited data for knee bone mineral density (BMD) or beyond two years follow-up. An open-label non-randomized study was performed at Royal North Shore Hospital and Royal Rehab Centre, Sydney between 2018 and 2023. An ‘acute interventional cohort’ (n = 11) with TSCI (duration ≤ 12-weeks) received a single infusion of 4 mg zoledronic acid (ZOL) at baseline. A ‘chronic non-interventional cohort’ (n = 9) with TSCI (duration 1–5-years) did not receive ZOL. All participants underwent baseline and 6-monthly blood tests (including CTx and P1NP) and 12-monthly DXA BMD scans (including distal femur and proximal tibia). Participants were predominantly Caucasian and male (mean age 38.4 years). At baseline, the ‘acute’ cohort had higher serum CTx, P1NP and sclerostin concentrations, while the ‘chronic’ cohort had lower left hip and knee BMD. Majority with acute TSCI experienced an acute phase reaction after ZOL (9/11; 82%). In the acute cohort, left hip BMD fell by mean ~ 15% by 48 months. Left distal femoral and proximal tibial BMD declined by mean ~ 6–13% at 12 months and ~ 20–23% at 48 months, with a tendency towards greater BMD loss in motor-complete TSCI. A single early ZOL infusion in acute TSCI could not attenuate rapidly declining hip and knee BMD. Prospective controlled studies are required to establish the optimal strategy for preventing early bone loss after acute TSCI.

The provision of mobility exercises through a smartphone application (app) for people undertaking neurological rehabilitation may improve mobility outcomes. However, it is difficult for clinicians and consumers to select high-quality, appropriate apps. This review aimed to identify (1) which mobile health (mHealth) apps are suitable for prescribing mobility exercises for adults with neurological health conditions, (2) how well these apps incorporate telehealth strategies, and (3) how well these apps rate in terms of quality and capacity for behaviour change. The Australian Apple iTunes Store was systematically searched, by using a search code and manually, for apps suitable for training mobility in neurological rehabilitation. Additional searches were conducted in known app repositories and for web-based apps. Trained reviewers extracted data from the included apps, including population-specific characteristics; quality, by using the Mobile App Rating Scale (MARS); and behaviour change potential, by using the App Behaviour Change Scale (ABACUS). The included apps (n = 18) provided <50 to >10,000 exercises, many incurred a subscription fee (n = 13), and half included telehealth features. App quality was moderate (mean MARS score of 3.2/5 and SD of 0.5), and potential for behaviour change was poor (mean ABACUS score of 5.7/21 and SD of 2.1). A limited number of high-quality apps are available for the prescription of mobility exercises in people with neurological conditions.