British medical bulletin最新文献

Introduction: Periodized rehabilitation for tendinopathies integrates principles of athletic training into structured protocols to optimize tendon healing and functional recovery minimizing recurrence. This review explores the role of concurrent and phasic periodization strategies in tendon rehabilitation, focusing on optimizing strength, power, and neuromuscular control.

Areas of agreement: Early phases prioritize pain management and load capacity through prolonged isometric contractions, to improve neuromuscular engagement without exacerbating symptoms. Heavy, slow resistance exercises, central to progressive loading, facilitate tendon remodeling and strength development. Subsequent phases incorporate energy storage and release, sport-specific exercises tailored to individual goals, using externally paced movements to enhance motor control and corticospinal drive. Neuroplastic training is promising, aligning physical rehabilitation with cognitive engagement to optimize motor learning and reduce maladaptive patterns.

Areas of controversy: At present, no randomized controlled trials have tested the periodization concept in the management of tendinopathy conditions.

Growing points: Systematic evaluation, including range of motion, tissue flexibility, and limb biomechanics, is necessary to identify and address kinetic chain dysfunctions in patients with tendon ailments. Reintegration into sport or activity should follow clear benchmarks, such as symmetrical strength, pain-free function, and tolerance for high-intensity loads.

Source of data: Analysis of the current literature, and expert opinion.

Areas timely for developing research: This evidence-based framework offers clinicians a practical roadmap for tendon rehabilitation, combining physiological and biomechanical considerations to support safe return to sport or activity. A structured individualized approach ensures optimal recovery by addressing movement dysfunctions, monitoring load tolerance, and reducing the risk of re-injury.

Background: All-inside arthroscopic procedures are now frequently employed to manage chronic lateral ankle instability (CLAI) with satisfactory functional outcomes. Currently, no evidence-based guidelines exist for all-inside arthroscopic procedures for CLAI. Many surgical decisions remain uncertain and challenging.

Sources of data: Published scientific literature in PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

Areas of agreement: All-inside arthroscopic repair and reconstruction procedures are reliable treatments for CLAI.

Areas of controversy: The all-inside arthroscopic procedures for CLAI present significant challenges, particularly in the following aspects.

Growing points: Given the lack of guidelines for the all-inside arthroscopic procedures for CLAI, this evidence-based clinical practice guideline provides 11 recommendations to address the controversy.

Areas timely for developing research: In patients with CLAI undergoing all-inside arthroscopic procedures, comparative studies are urgently needed to establish the optimal timing for weight-bearing, as well as return to work and sports.

Introduction: Extracorporeal shock wave therapy (ESWT) for erectile dysfunction (ED) presents a challenging paradox. While numerous clinical studies, systematic reviews, and meta-analyses have been published, indicating a substantial body of evidence supporting the efficacy and safety of ESWT, significant questions remain. Notably, the American Urological Association (AUA) continues to classify ESWT for ED as investigational (Evidence Level: Grade C), suggesting that the true therapeutic effect of ESWT may differ considerably from current estimates. This review aims to critically assess the evidence and propose strategies to address this unresolved discrepancy.

Source of data: We systematically searched two electronic databases (PubMed and Ovid/Embase) and published systematic reviews on ESWT for ED and compiled a systematic literature review and meta-analysis based on 87 relevant studies.

Areas of agreement: There is clear evidence that ESWT for ED is effective and can therefore be a valuable treatment modality in the management of ED.

Areas of controversy: Current assessments of ESWT for ED as investigational by, e.g. the AUA may not stem from a lack of clinical studies, insufficient related basic science, or an inadequate number of systematic reviews and meta-analyses. Instead, the deficits lie in the area of the scientific quality of the clinical studies published to date.

Growing points: We hypothesize that this unfortunate situation will only change if the following aspects are rigorously considered in future clinical studies on ESWT for ED: adequate characterization and reporting of extracorporeal shock waves, appropriate handling of missing data and intercurrent events, and comprehensive classification of ESWT in the overall context of the available treatment options for ED.

Areas timely for developing research: We are convinced that the consistent implementation of these aspects will significantly contribute to establishing ESWT as the first truly regenerative therapy in the management of ED. This overall aim justifies the corresponding efforts for the benefit of our patients.

Background: Loaded ruck marching is a common workout and selection tool for military schools.

Source of data: Analysis of the current literature and expert opinion.

Areas of agreement: Soldiers performing loaded marches are prone to overuse injuries such as stress fractures, foot blisters, foot infections, brachial plexus lesions, digitalgia paresthetica, and meralgia paresthetica, knee pain, back pain, metatarsalgia.

Areas of controversy: At present, risk factors needed to be addressed to reduce the rate of injuries.

Growing points: Speed of march, terrain grade, and task type and duration, together with safety risk checks, such as administrative checks and physical conditioning, may all impact injury risks and have to be evaluated in military training programs.

Areas timely for developing research: Although noncombat injuries in the military have historically been a hidden epidemic, they are now being recognized as a major health problem for the military services. Risks for soldier health, tactical performance, and mission success related to military load carriage have been analyzed. Risk modifiers have been also addressed.Speed and load combinations of military marches have to be analysed to optimize marching pace and reduce energy expenditure. Load and speed should be managed to maintain an exercise intensity of ~45% VO2 max to delay the time to fatigue during prolonged marches.

Introduction: This narrative review sets out to explore the current literature surrounding the mental health of serving personnel and veterans.

Sources of data: UK literature published in peer-reviewed scientific journals and publicly available UK Ministry of Defence reports.

Areas of agreement: Evidence suggests that common mental disorders are more prevalent in the UK serving and veteran personnel than in the general population. Risk factors include being female, adverse childhood events, combat exposure, and physical combat injury.

Areas of controversy: Post-traumatic stress disorder rates are broadly similar between UK serving personnel and the general population, though certain groups are at increased risk, such as veterans who deployed to Iraq/Afghanistan in combat roles.

Growing points: Understanding ways to maximize positive psychological outcomes, address poor sleep, and support those with combat injuries and chronic pain are key priorities for research/interventions. The prevalence of moral injury and military sexual trauma in the UK Armed Forces is currently unknown.

Areas timely for developing research: A longitudinal study following recruits including those who are part of the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning or other sexualities and gender identities (LGBTQ+) community, or who have a neurodivergent condition, from entry to post-service would enhance our understanding of how serving in the Armed Forces impacts the mental health and wellbeing.

Background: Rehabilitation is a crucial component of comprehensive disease management and functional recovery. Despite advancements in surgical techniques for chronic lateral ankle instability (CLAI), there is still a lack of standardized, evidence-based rehabilitation protocols.

Source of data: After nine clinical questions were proposed by the guidance steering group, an independent search strategy was conducted for all clinical questions, encompassing the PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane databases.

Areas of agreement: Rehabilitation is crucial to optimize surgical outcomes and patient recovery. An appropriate and well-structured rehabilitation plan can optimize a safe return to sports and daily activities.

Areas of controversy: Rehabilitation for surgical management of CLAI poses significant challenges, especially in the areas of preoperative preparation, control of postoperative swelling and pain, early-stage rehabilitation, advanced rehabilitation, and return to exercise.

Growing points: Given the lack of established guidelines for rehabilitation following surgical management of CLAI, this clinical practice guideline presents nine key recommendations aimed at addressing the existing controversies in this area. For CLAI patients undergoing surgery, preoperative rehabilitation should include exercise and education, followed by postoperative focus on pain and swelling management. Early rehabilitation emphasizes nonweight-bearing functional training, with gradual progression to weight-bearing exercises, dynamic balance, and strength training over the first 18 weeks. Regular follow-up visits are essential to monitor recovery and promote functional restoration.

Areas timely for developing research: In patients undergoing surgery for CLAI, there is a pressing need for comparative studies to assess the necessity of immobilization and to determine the optimal selection of braces.

Introduction: Knee osteoarthritis (OA) is a common degenerative joint condition and a major cause of disability in the general population.

Source of data: Recent published literature identified from PubMed, EMBASE, Google Scholar, and Scopus.

Areas of agreement: Orthobiological therapies try to regenerate articular cartilage and stop the progression of the degenerative lesion. Intra-articular injections of biological derivates have been increasingly used in the last decade.

Areas of controversy: The indications for the use of bone marrow aspirate concentrate (BMAC) are still unclear.

Growing points: We systematically reviewed the current literature on BMAC in the management of knee OA, giving an update on the current indications for the selection of the ideal patient and the preparations and efficacy of BMAC compared to other biological alternatives.

Areas timely for developing research: BMAC is a valuable source of mesenchymal stem cells, offering potential benefits in attenuating the inflammatory pathway associated with knee OA. Intra-articular injection of BMAC has shown effectiveness in clinical trials improving functional outcomes of knee OA patients. The superiority of BMAC over other orthobiological treatments cannot be assessed because of conflicting results.

Introduction: This article reviews the ethical issues surrounding obesity in public health and clinical contexts. We examine how obesity intersects with medical and social norms that raise questions of liberty, fairness, safety, and effectiveness or consequences.

Sources of data: PubMed, Cochrane Library, and Google Scholar.

Areas of agreement: We identify three main areas of agreement that are pertinent to ethical analysis of obesity: stigma is considered harmful, there needs to be a more-than personal responsibility approach, and a general acceptance of a global rise in body weight.

Areas of controversy: There are many areas of controversy, we limit our focus to four: conflicts of interest in the creation of guidelines and policies, mortality rates, whether weight is a meaningful proxy for health, and how to treat childhood obesity.

Areas timely for developing research: Post-genomic explanations, such as exposure to endocrine disrupting toxins, and development of epigenomics and microbiomics in the form of personalized nutrition are two developing areas we identify.

Introduction: The complex phenomenon of the athlete's heart (AH) describes the chronic physiological structural and functional adaptation secondary to repeated exposure of an acute exercise stimulus.

Sources of data: This narrative review is based on published evidence.

Areas of agreement: Highly trained athletic individuals frequently display cardiac parameters which are suggestive of an AH and can exceed the traditional 'normal' limits.

Area of controversy: The physiological processes underpinning the extent of cardiac adaption and how this is closely linked to exercise type, but also sex, ethnicity, and body size.

Growing points: Since its seminal description by Morganroth and colleagues in 1975, our understanding of the AH has evolved in tandem with improvements in cardiac imaging techniques alongside the exploration of more diverse athletic populations. This narrative review aims to provide a balanced discussion of the multi-factorial nature of structure and function of the AH with specific reference to the unique physiological exercise stimuli.

Areas timely for developing research: Despite great interest in cardiac adaptations across a broad spectrum of athletic populations, future research designs should consider the use of new and novel imaging techniques to enhance our understanding of the acute cardiovascular responses which ultimately mediates such adaptations, especially in athletic populations underrepresented in the literature.

Purpose: The present prospective comparative study included patients with acute Achilles tendon rupture (ATR) who underwent percutaneous repair with one knot compared to percutaneous repair with two knots.

Methods: All patients underwent the procedure under local anesthesia. A total of 29 patients underwent percutaneous repair with two knots (Group A), and 33 patients underwent percutaneous repair with one knot (Group B). All patients were treated by a single surgeon between 2019 and 2021 and were followed prospectively for 24 months.

Results: Patients' characteristics at baseline were similar between the two groups, except for age [38.0(15.0) vs 32.0(15.0) years, P = 0.028]. The procedure took longer for the two knots technique [19.0(4.0) vs 13.0(3.0) min, P < 0.001]. The Achilles tendon total rupture score was not different between the two techniques (90.7 ± 3.26 vs 90.5 ± 2.18, P = 0.737), as was the elongation of the gastrosoleus-Achilles tendon complex measured by the Achilles tendon resting angle [-1.0(2.0) vs - 1.0(2.0), P < 0.380]. The calf circumference of the injured and non-injured leg did not differ between the groups. Plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups. The European Foot and Ankle Society and patient reported outcome measures score by Piedade et al. scores were not statistically significant different between the two groups. No patient experienced a re-rupture, a venous thrombo-embolism episode, or injury to the sural nerve.

Conclusion: The modified technique offered similar objective and subjective outcome measures, in addition to reduced operative time.