University of Essex School of Sport, Rehabilitation and Exercise Sciences SE720 Using Evidence in Healthcare Practice Assignment Workbook

University of Essex
School of Sport, Rehabilitation and Exercise Sciences
SE720 Using Evidence in healthcare Practice
Assignment Workbook
Student Number: 1900702

Task 1
Peer Review Grade: Pass
Don’t forget to add a copy of Task 1 to Appendix 1 below
Task 2
MCQ Certificate Number: yZaDgeEueZ
MCQ Percentage: 82.13%
Task 3
Total Word Count: 1737
Page 1 of 16
Task 3 – Synthesis of Evidence
This task reflects the process for reviewing evidence for evidence-based healthcare
practice.
(Check marking criteria for this task).
• Select 4 papers based on empirical research most directly related to your

area of interest,
• Provide a summary table for those 4 papers showing: study design,
significant characteristics, strengths and limitations, main findings, (etc.) as
appropriate,
• Utilise appropriate critical appraisal tools (e.g. CASP) providing a rationale as
to why those particular tools were chosen,
• Synthesise an appraisal of quality, research methodology, data collection
methods (this may or may not include ethical issues, bias, generalisability
etc.), to create a critical commentary of content / themes / findings.
(Write your answer here - 1,750 words - the full summary table can be included in an appendix and
will not be included in the word count).
Spinal Cord Injury (SCI) impacts on the conduction of sensory and motor information across
the site of a lesion due to the spinal cord being partially or fully severed (1). In the UK it is
estimated between 1100 and 1200 people suffer a SCI per year (2).Up to sixty percent of
spinal injuries affect young males between the ages of 15-35, with motor vehicle accidents,
falls and sports injuries the leading causes (3). The patients ability to recover function of the
lower limb is seen as a predictor for independence and quality of life for the individual (4).
Increasing exercise and activity is recommended for individuals with SCI as patients are at
higher risk of heart disease, diabetes and obesity (5). Cardiovascular, strengthening and
range of movement exercises are all recommended (5). With this in mind, the ability of a SCI
patient to walk would be of utmost importance. The aim of this review of evidence is to
discover if gait training improves return to walking in a population of patients with spinal cord
injuries.
The selection of studies for this review was aided by the PICO search strategy (population,
Intervention, Comparison, Outcome). 4 randomized controlled trials (RCTs) met the criteria
and were included. Randomized controlled trials have been suggested to provide robust
levels of evidence in the research world (6) and are often seen situated at the top of the
evidence pyramid (7). 4 articles (8–11) included have been appraised using the PEDro
scoring tool. The PEDro scale appraises RCTs based on their level of bias and reporting of
statistics using a score of 0-10 (12). The higher the number means the article is a higher
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level of evidence (12). The PEDro scale has been seen to be both reliable and valid (12,13).
For this reason, it was chosen as an appropriate appraisal tool. These articles have been
scored 7 (9) ,7 (10) ,5 (8) and 4 (11) respectively. A score of 7 would be deemed ‘good’,
while score of 4 and 5 would be interpreted as ‘fair’ methodologically (14).
Body Weight Supported Treadmill Training vs Body Weight Supported Overground

Training:
Body weight supported locomotor training is widely used as a form of rehabilitation for
patients with Spinal Cord Injuries (10). Improvements in walking ability have been seen in
incomplete SCI injuries (15). Body weight supported walking training can aid the patient to
return to near their pre-injury walking level, this can be achieved using a treadmill or over flat
ground (10).
Two good quality randomised controlled trials compared bodyweight supported treadmill
training with body weight supported over ground training (9,10). A total of 42 individuals
completed the two studies. Intervention durations ranged from 8 weeks consisting of 5 daily
sessions of 30 minutes durations to 13 weeks consisting of 3 sessions a week lasting a
maximum of 60 minutes. While one study looked at specific outcomes related to gait such as
speed and balance (9), the other measured walking ability using the Walking Index for Spinal
Cord Injury II WISCI (10). The measurement of balance and speed is more objective forms
of measurement and therefore would appear to be less risk of bias, while the WISCI is more
subjective and involves the therapist interpretation. Sentilvelkumar et al (10) found that body
weight supported treadmill training was comparable to over ground treadmill training with
neither seen to be superior. However, it is unknown whether either is an effective form of
rehabilitation as no control was used. Alexeeva et al (9) found no significant difference in
walking speed between both groups, but there was an increase in maximum speed
compared with baseline. The 10m timed test was viewed as a valid test to assess patient
walking function and correlates with the WISCI II (16). There was also no difference seen
between either intervention group or the control group. Significant increases were seen in
Tinetti Balance Scores in the over-ground group from pretesting to post testing however, no
significant difference was seen with the treadmill group.
Functional Electrical Stimulation Vs Conventional Physiotherapy
For many years Functional Electrical Stimulation (FES) has been used to aid in the
contraction of paralytic muscles in Patients who have suffered spinal Cord Injuries in order to
achieve functional goals such as improvements in gait (17). Loss of upright mobility is likely
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to impact on a number of aspects such as function, independence and quality of life
(18,19).FES is seen as a possible tool to influence positive outcomes for walking in patients
with SCI (20). FES uses small, short electrical shocks to generate muscle contraction, when
timed properly can aid in an individual’s walking ability (8). The use of FES is primarily to
achieve an individual’s basic stepping once more (17).
Two randomized controlled trials of fair quality were chosen to compare the use of
Functional Electrical Stimulation to conventional physiotherapy techniques for improving the
gait of patients with spinal cord injuries (8,11). The studies were conducted in 2014 and
2004 respectively. A total of 48 participants completed the two studies. The duration of
studies ranged from 5 days a week for 8 weeks to 16 weeks, with 3 days of 45-minute
sessions per week. Between both studies outcomes of walking speed, stride length, balance,
mobility functionality and spasticity were measured. All outcomes were objective with little
risk of bias coming from these alone. Kapadia et al., (2014) also measure functionality using
a scale, this is somewhat subjective. One study required participants to undertake time in the
intervention and control groups, while the other had a more conventional intervention and
control group design. It is reasonable to think results from the intervention may be attributed
to lasting effects that occurred during the control period, and vice versa. Results from both
studies differ slightly with Kapdadia et al (8) only seeing improvements in the functionality
measurements while no significant differences were seen for speed, spasticity balance and
mobility. Postans et al (11) found slight improvements in walking endurance and speed after
FES treadmill training. Results from both studies should be interpreted with caution as
positive results have only been seen in subjective measures and after subjects completed
both experimental groups. Based on this and the ‘fair’ PEDro scores the studies received,
more research is needed on the intervention before it may be seen as an efficient treatment.
Treadmill training with body weight support Vs Conventional Physiotherapy
Body weight support systems aim to reduce weight bearing on individuals, allowing for
support to be given to posture and aiding in coordination of the lower limbs (21). As
demands on the muscles are reduced, it allows the patient to practice effective movement
while providing a safe environment for the patient (21).
Two ‘fair’ (8,11) and one ‘good’ quality (9) randomised controlled trial evaluated the use of
body weight supported treadmill training against the use of conventional physiotherapy for
patients who had s SCI. A total of 83 participants were gathered across the three studies
with a total of 8 dropping out. Six participants dropped out of Kapadia et al (8) while Postans
et al (11) had two dropouts. Alexeeva et al (9) lost no participants to follow up. Study
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durations ranged from 8 weeks to 16 weeks, with numbers of weekly sessions ranging from
3 to 6. While two studies (8,11) investigated the use of body weight supported treadmill
training in conjunction with functional electrical stimulation, the other investigated body
weight supports over treadmills and fixed ground (9). A design whereby participants spent 4
weeks each in the control and intervention group was chosen by one study whereas
participants were randomly allocated to either 2 or 3 different experimental groups in the
remaining RCTs. Common parameters that were measure were walking speed, balance,
mobility and spasticity, which all may influence walking efficacy. As previously mentioned,
Kapadia et al (8)also measured functionality using a scale. This is subjective as each
participant is different and may have differing opinions. No significant difference in walking
speed was seen in one study (9), while another reported improvements in walking speed
and endurance (11). In Postans et al(11) the improvements in walking speed and endurance
may be seen due to a design which required participants to partake in both intervention and
control groups, therefore results should be interpreted with caution. The final study (8)
creates more doubt over the benefit of body weight supported treadmill training, as only
functionality was seen to improve significantly while parameters such as spasticity, walking
speed and balance did not. Based on the contrasting results along with PEDro scores,
additional high-quality research is needed to determine if body weight support treadmill
training can have a positive impact on walking efficacy and whether it is superior to
conventional physiotherapy.
Conclusion
Based on the studies included in this review, the evidence in unclear whether gait training is
effective for improving walking efficacy in patients with a spinal cord injury. Based on
outcomes such as balance, mobility, walking speed and walking endurance it would appear
that over ground walking training may be as good as treadmill training as seen in one study,
while it could also be argued that it is superior with Tinetti balance scores improving more
over ground (9). A further 2 studies (8,11) pointed towards treadmill training in conjunction
with functional electrical stimulation to be beneficial as it was seen to improve walking
speed, endurance and the spinal cord independence measure scale, which is a scale of
functionality. However, these study’s designs and results may not offer a huge weight of
evidence and have both been rated ‘fair’ by PEDro, meaning there is a likelihood the
evidence is not of the highest standard and may contain bias. While the strongest studies
(9,10) included do point to some benefits of gait training of some kind, it is unclear which
type offers the best results. What is also unclear is whether these modes of gait training offer
clinically significant improvements for gait when compared with conventional physiotherapy
or standard care. More evidence is needed to justify the use of certain equipment used with
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gait training as there may be a more cost-effective method to achieve similar results with a
patient who has suffered a spinal cord injury. Future clinical practice should take into
consideration not just the findings of the study, but the benefitted uses of treadmills and
support harness. While outcome may not be clearly better than conventional physiotherapy,
these types of support may be useful for safety and building a patient’s confidence (21) in
the initial stages of injury. However, when a patient becomes more independent – the
usefulness of these supports appears to diminish.
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REFERENCES
1. Creasey G, Marino R, Tator C, Wilberger J. International Standards for Neurological

and Functional Classification of Spinal Cord Injury. American Spinal Injury Association
Comparison of DOACs View project Microglial Roles in Pain View project. 1997 [cited
2020 Apr 14]; Available from: https://www.researchgate.net/publication/14059061
2. Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord

injury: A systematic review. Vol. 94, Archives of Physical Medicine and Rehabilitation.
W.B. Saunders; 2013. p. 2297–308.
3. van Den Hauwe L, Sundgren PC, Flanders AE. Spinal Trauma and Spinal Cord Injury
(SCI). In Springer, Cham; 2020. p. 231–40.
4. Ditunno PL, Patrick M, Stineman M, Ditunno JF. Who wants to walk? Preferences for
recovery after SCI: A longitudinal and cross-sectional study. Spinal Cord. 2008
Jul;46(7):500–6.
5. Evans N, Wingo B, Sasso E, Hicks A, Gorgey AS, Harness E. Exercise

Recommendations and Considerations for Persons With Spinal Cord Injury. Arch
Phys Med Rehabil. 2015 Sep 1;96(9):1749–50.
6. Rajasekar A, Today VK-DI, 2019 undefined. Randomized controlled trials: Gold

standard of evidence. pdfs.semanticscholar.org [Internet]. [cited 2020 Apr 14];
Available from:
https://pdfs.semanticscholar.org/d3e8/8d7d59b2f0a6df11e1d866fa9c036b357dac.pdf
7. Murad M, Asi N, … MA-BE-B, 2016 undefined. New evidence pyramid. ebm.bmj.com

[Internet]. [cited 2020 Apr 14]; Available from:
https://ebm.bmj.com/content/21/4/125.short
8. Kapadia N, Masani K, Craven BC, Giangregorio LM, Hitzig SL, Richards K, et al. A
randomized trial of functional electrical stimulation for walking in incomplete spinal
cord injury: Effects on walking competency. J Spinal Cord Med. 2014 Sep
1;37(5):511–24.
9. Alexeeva N, Sames C, Jacobs PL, Hobday L, DiStasio MM, Mitchell SA, et al.
Comparison of training methods to improve walking in persons with chronic spinal
cord injury: A randomized clinical trial. J Spinal Cord Med. 2011 Jul;34(4):362–79.
10. Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of
Page 7 of 16
body weight-supported treadmill training versus body weight-supported overground
training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil
[Internet]. 2015 Jan 25 [cited 2020 Apr 15];29(1):42–9. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/24965958
11. Postans N, Hasler J, … MG-A of physical, 2004 undefined. Functional electric

stimulation to augment partial weight-bearing supported treadmill training for patients
with acute incomplete spinal cord injury: a pilot study. Elsevier [Internet]. [cited 2020
Apr 15]; Available from:
https://www.sciencedirect.com/science/article/pii/S000399930301027X?casa_token=h
ntdUb5vTxUAAAAA:MFqeBMpJhiVwGWPvNbdwBM3TJKVpWH7RP5q08RDjGqRb1
Na8ml3y-6wAAEcMGyW8Dt5kMboI1Q
12. Physiotherapy N de M-AJ of, 2009 undefined. The PEDro scale is a valid measure of
the methodological quality of clinical trials: a demographic study. Elsevier [Internet].
[cited 2020 Apr 14]; Available from:
https://www.sciencedirect.com/science/article/pii/S0004951409700431
13. Maher C, Sherrington C, … RH-P, 2003 undefined. Reliability of the PEDro scale for
rating quality of randomized controlled trials. academic.oup.com [Internet]. [cited 2020
Apr 14]; Available from: https://academic.oup.com/ptj/article-
abstract/83/8/713/2805287
14. Foley N, Teasell R, … SB-T in stroke, 2003 undefined. Stroke rehabilitation

evidence-based review: methodology. Taylor Fr [Internet]. [cited 2020 Apr 15];
Available from: https://www.tandfonline.com/doi/abs/10.1310/Y6TG-1KQ9-LEDQ-
64L8
15. Wirz M, Bastiaenen C, Bie R de, neurology VD-B, 2011 undefined. Effectiveness of
automated locomotor training in patients with acute incomplete spinal cord injury: a
randomized controlled multicenter trial. Springer [Internet]. [cited 2020 Apr 15];
Available from: https://link.springer.com/article/10.1186/1471-2377-11-60
16. Marino R, Scivoletto G, … MP-A journal of, 2010 undefined. Walking index for spinal
cord injury version 2 (WISCI-II) with repeatability of the 10-m walk time: inter-and
intrarater reliabilities. journals.lww.com [Internet]. [cited 2020 Apr 15]; Available from:
https://journals.lww.com/ajpmr/Fulltext/2010/01000/Aerobic_Work_Capacity_in_Elite_
Wheelchair.2.aspx
17. Nightingale EJ, Raymond J, Middleton JW, Crosbie J, Davis GM. Benefits of FES gait
in a spinal cord injured population. Vol. 45, Spinal Cord. Nature Publishing Group;
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2007. p. 646–57.
18. Gallien P, Brissot R, Eyssette M, Tell L, Barat M, Cord LW-S, et al. Restoration of gait
by functional electrical stimulation for spinal cord injured patients. nature.com
[Internet]. [cited 2020 Apr 20]; Available from:
https://www.nature.com/articles/sc1995138
19. Agarwal S, Triolo RJ, Kobetic R, Miller M, Bieri C, Kukke S, et al. Long-term user
perceptions of an implanted neuroprosthesis for exercise, standing, and transfers
after spinal cord injury [Internet]. Vol. 40, Journal of Rehabilitation Research and
Development. [cited 2020 Apr 20]. Available from:
https://pdfs.semanticscholar.org/ea52/7297149bb827935f9e0fbcfd19795d04d662.pdf
20. Masani K, Popovic MR. Functional Electrical Stimulation in Rehabilitation and

Neurorehabilitation. In: Springer Handbook of Medical Technology. Springer Berlin
Heidelberg; 2011. p. 877–96.
21. Miller E, Quinn M, Therapy PS-P, 2002 undefined. Body weight support treadmill and
overground ambulation training for two patients with chronic disability secondary to
stroke. academic.oup.com [Internet]. [cited 2020 Jun 11]; Available from:
https://academic.oup.com/ptj/article-abstract/82/1/53/2837010
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Appendix
Table 1
Author Year Population Sample Intervention Outcomes measured

size
Kapadia et al 2014 Individuals 34 16-week • Spinal cord
with a SCI Functional independence
between electrical measure
c2- t12 stimulation on • balance/mobility
a BWS • walking speed and
treadmill endurance
• spasticity
Senthilvelkumar 2011 Individuals 35 8 weeks of • walking index for

et al with a SCI bws treadmill spinal cord injury II
between training or • Lower limb muscle
c5-c8 bws over strength
ground
training
Alexeeva et al 2015 Individuals 16 13 weeks of • Walking speed
with a SCI treadmill • Balance
training, over • Fitness
ground • Muscle strength
training or • Functional
convention independence
physiotherapy
Postans et al 2004 Individuals 14 4 weeks FES • Walking endurance
with a SCI with BWS • Cadence, stride
treadmill + 4 length,walking
weeks speed
receiving
conventional
physiotherapy
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APPENDIX 1 – Copy of Task 1 Assignment
“The conscientious and judicious approach of maintaining the highest standards of care
by putting into practice the best current evidence. Along with gained clinical experience,
expertise and patient values, these practices should shape healthcare” (1).
The intervention I have chosen for the purpose of this review, is exercise and education for
the improvement of function and reduction in pain in patients with Osteoarthritis of the Knee.
Osteoarthritis is the most common rheumatic disease which mainly affects the articular
cartilage and subchondral bone of a synovial joint, a common cause of chronic disability in
individuals older than 50 (2–4). Regular exercise has been associated with improvement in
symptoms of OA such as pain and loss of function (5,6).
Bruce- Brand et al.,(2012)(7) conducted a single centre single blind prospective randomized
control trial. The conclusion of the study was that exercise helped improve function in
individuals with knee osteoarthritis. The article was published to the BioMed Central
Journal(peer-reviewed). The author is an orthopaedic and trauma consultant at Cappagh
Hospital, so it is relatively straight forward to see his motivation to conduct this study.
Sample size for this study is small. Also, while supervising 2 sessions per week may seem
like a good idea in the setting of a research study, this would not be practical in day to day
clinical practice, as patients would need to be competent to complete all 6 exercises
correctly themselves and adhere to this process. Also, with the more exercises and
movements a patient must do, the easier it will be for a patient to forget some. There was
little consistency between treatments. Duration of home treatments differed between the
NMES and strengthening group, as did quantity of sessions per week. While functional tests
such as the stair climb and walk test have established validity(8,9), parameters such as
distance and numbers of steps have not reached a consensus (7).While this study did carry
out a follow up, this was carried out a relatively short duration after the completion of
intervention. Although no real effort was made to blind patients as to what group they were
in, investigators were blinded as to which group, they were testing. While this is not ideal,
investigators have at least been blinded, which will help keep bias as minimal as possible.
Although this research study was undertaken as a randomized controlled trial, there are
several discrepancies within the study design that could have been improved on, which may
have strengthened the findings of the research.
Page 12 of 16
Bennell et al.,(2016)(10) conducted a multisite, assessor blinded, parallel group randomized
control trial. The conclusion of the study was that exercise combined with Pain Coping
Strategy Training (PCST) was more efficacious than either of the other 2 interventions for
improving function in individuals with knee OA.
The study was published to the Journal of The American College of Rheumatology(peer-
reviewed), which is a well-known publisher of arthritis research, with the author being a
research physiotherapist who is a professor at the University of Melbourne. This particularly
study is strong in a number of areas such as therapist training and adherence, patient
retention and has a reasonable length of intervention combined with a follow up 52 weeks
after the start of the intervention. The study has also recruited a reasonable number of
subjects which make outcomes mean that much more, with a bigger population. The study
also made respectable attempts to eliminate the possibility of bias as much as possible. It
wasn’t possible to blind patients to which group they were assigned to, but blinding occurred
for researcher’s hypothesis. Investigators were also blinded to which group they were testing
for outcome measures.
However, there are several areas the study may have improved. The lack of a control group
in the study means there is nothing to compare to the interventions. Although a high quantity
of subjects completed the interventions, 17% were lost to week 52 follow-up. These
individuals had several different baseline characteristics to individuals that completed the
study and one cannot say whether their completion of the study would have had any effect
on interpretation of results. Finally, contact times between interventions differed. Where this
mimics a real-life scenario, it wouldn’t be ideal in the sense of keeping all conditions
consistent to minimise bias.
The four elements of evidence-based practise are the use of evidence/research, patient
preferences/values, professional opinion/intuition and health system guidelines (11,12). For
the research of Bruce-Brand et al.,(2012)(7) and Bunnell et al.,(2016) (10) the positive
effects of exercise may stem from confidence gained in the patient’s own ability, realising
that they are not detrimental to health and using them to provide coping strategies which can
be used to improve self-efficacy (13). There is also a high volume of evidence that exercise
and indeed education will improve function and reduce pain (2,14,15).
Neither study particularly addresses patient preference. Bunnell et al (2016) (10)offers more
means of education and coping mechanisms to participants which may influence
preferences and adherence. Although informed consent has been received neither study
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takes the time to discuss the treatment plan with their subjects and are never made part of
the decision-making process. This is perhaps something future studies could include an
element of given recent debates into the importance of shared-decision making (11,12)
Both studies use professional judgement to a degree. They use this to from their hypothesis
and appear to use their own judgement about the characteristics of the exercise programs.
The idea of education and exercise to improve pain and function has arisen from their
research, the application of the research is attributable to professional judgement (11,12).
Exercise (strength, aerobic) and education are recommended as forms of treatment for
Osteoarthritis by both the NICE guidelines 2014 (16) and by the NHS (17). Based on a body
of evidence and recommendations both education and exercise appear beneficial for many
individuals with osteoarthritis. It is also worth remembering however, that this is not a one fits
all approach and patient’s treatment plans must be created carefully on a case by case
basis.
1. Livingstone DS-C, 2000 undefined. Evidence-Based Medicine, Edinburgh, UK.

2. Fransen M, Mcconnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise
[Type here]
for osteoarthritis of the knee. Vol. 2015, Cochrane Database of Systematic Reviews.
John Wiley and Sons Ltd; 2015.
3. Therapy AG-P, 1994 undefined. Arthritis and the process of disablement.
academic.oup.com [Internet]. [cited 2019 Oct 16]; Available from:
https://academic.oup.com/ptj/article-abstract/74/5/408/2729275
4. Woolf A, Health BP-B of the W, 2003 undefined. Burden of major musculoskeletal
conditions. SciELO Public Heal [Internet]. [cited 2019 Oct 16]; Available from:
https://www.scielosp.org/scielo.php?pid=S0042-
96862003000900007&script=sci_arttext&tlng=pt
5. Devos-Comby L, Cronan TA, Roesch S. Do exercise and self-management
interventions benefit patients with osteoarthritis of the knee? A metaanalytic review
Does the Sex of Mentors and Students Affect Students’ Perceptions of Research
Mentors? View project Identification and diagnosis of FASD View project [Internet].
Article in The Journal of Rheumatology. 2006 [cited 2019 Oct 16]. Available from:
https://www.researchgate.net/publication/7197349
6. Fransen M, McConnell S. Exercise for osteoarthritis of the knee Cochrane Database
Syst Rev CD004376. 2008;
7. Bruce-Brand RA, Walls RJ, Ong JC, Emerson BS, Obyrne JM, Moyna NM. Effects of
home-based resistance training and neuromuscular electrical stimulation in knee
osteoarthritis: A randomized controlled trial. BMC Musculoskelet Disord. 2012;13.
8. Terwee C, Mokkink L, Rheumatology MS-, 2006 undefined. Performance-based
methods for measuring the physical function of patients with osteoarthritis of the hip or
knee: a systematic review of measurement properties. academic.oup.com [Internet].
[cited 2019 Oct 16]; Available from: https://academic.oup.com/rheumatology/article-
abstract/45/7/890/1788526
9. Kennedy D, … PS-B, 2005 undefined. Assessing stability and change of four
performance measures: a longitudinal study evaluating outcome following total hip
and knee arthroplasty. bmcmusculoskeletdisord … [Internet]. [cited 2019 Oct 16];
Available from:
https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-6-3
10. Bennell KL, Ahamed Y, Jull G, Bryant C, Hunt MA, Forbes AB, et al. Physical
Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis:
Randomized Controlled Trial. Arthritis Care Res. 2016 May 1;68(5):590–602.
11. Melnyk BM, Gallagher-Ford L, Thomas BK, Troseth M, Wyngarden K, Szalacha L. A
Study of Chief Nurse Executives Indicates Low Prioritization of Evidence-Based
Practice and Shortcomings in Hospital Performance Metrics Across the United States.
Worldviews Evidence-Based Nurs. 2016 Feb 1;13(1):6–14.
[Type here]
12. Aveyard H, Sharp P. A beginner’s guide to evidence-based practice in health and
social care [Internet]. 2013 [cited 2019 Oct 16]. Available from:
https://books.google.com/books?hl=en&lr=&id=72JHsf9R2UIC&oi=fnd&pg=PR1&dq=
Helen+Aveyard+and+Pam+Sharp&ots=wu9rDyk3FT&sig=UvtLCyw1iyERt5F9UksGT
VCoaoM
13. Hurley M V., Walsh N, Bhavnani V, Britten N, Stevenson F. Health beliefs before and
after participation on an exercised-based rehabilitation programme for chronic knee
pain: Doing is believing. BMC Musculoskelet Disord. 2010;11.
14. Somers T, Blumenthal J, Guilak F, Pain VK-, 2012 undefined. Pain coping skills
training and lifestyle behavioral weight management in patients with knee
osteoarthritis: a randomized controlled study. Elsevier [Internet]. [cited 2019 Oct 16];
Available from: https://www.sciencedirect.com/science/article/pii/S0304395912001182
15. Keefe F, Blumenthal J, Baucom D, Affleck G, Pain RW-, 2004 undefined. Effects of
spouse-assisted coping skills training and exercise training in patients with
osteoarthritic knee pain: a randomized controlled study. Elsevier [Internet]. [cited 2019
Oct 16]; Available from:
16. National Institute for Health and Clinical Excellence. NICE guideline on osteoarthritis:
The care and management of osteoarthritis in adults, NICE clinical guideline 177,
2014. 2014;177(February 2014).
17. Osteoarthritis - Treatment and support [Internet]. nhs.uk. 2019 [cited 22 October
2019]. Available from: https://www.nhs.uk/conditions/osteoarthritis/treatment/
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University of Essex
School of Sport, Rehabilitation and Exercise Sciences
SE726 - Research Activity
Is There a Sex Correlation Between Knee Valgus Angle on Sports Specific Landing
Manoeuvres and Rate of Anterior Cruciate Ligament Injuries in Elite Sporting Populations?
A research Project submitted as part a Master of Science (MSc) Physiotherapy Degree (Pre-
Reg)
26th May 2021
Word count: 7974
Student number:1900702
Name: Peter Smith
Academic Supervisor: Adrian Mallows

Student Number:1900702
Contents: Page Number:
i. Contents page …………………………………………….. 1

ii. List of terms………………………………………………………. 2
A. Review of Literature
1. Introduction …………………………………………………………………. 3
2. Methods………………………………………………………………………. 4
3. Results………………………………………………………………………… 6
4. Discussion……………………………………………………………………. 8
5. Conclusion……………………………………………………………………. 12
B. Is There a Sex Correlation Between Knee Valgus Angle on Sports Specific Landing
Manoeuvres and Rate of Anterior Cruciate Ligament Injuries in Elite Sporting
Populations?
6. Background ……………………………………………………………………. 13
7. Aims……………………………………………………………………………… 13
8. Methodology……………………………………………………………………. 14
9. Methods…………………………………………………………………………. 15
10. Statistical Analysis………………………………………………………………. 19
11. Limitations………………………………………………………………………... 20
12. Ethics……………………………………………………………………………... 20
13. Clinical Application………………………………………………………………. 21
14. Bibliography………………………………………………………………………. 23
15. Appendices………………………………………………………………………. 35
1
List of Terms:
ACL - Anterior Cruciate ligament
CI - Confidence Interval
CSP - Chartered Society of Physiotherapy
MCL - Medial Collateral Ligament
NCAA - National Collegiate Athletic Association
OA - Osteoarthritis
PICO - Population, Intervention, Comparison, Outcome
PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-analyses
Q Angle - Quadriceps angle
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How strong is the correlation between knee valgus on landing activities and sex in an active
population? A review of Literature.
1.Introduction:
Anterior Cruciate Ligament (ACL) injuries commonly occur during landing, pivoting or
changing direction (1). The role of the ACL is to provide stability for the knee joint in limiting
the tibia sliding anteriorly in relation to the femur (2). Typical ACL injuries will present as a
planted foot, extended knee, trunk lean and knee valgus (3,4). The position of the knee joint
during these types of movements can sometimes be a predictor for how likely an ACL injury
is (5). Knee valgus has historically been thought of as a dangerous position for the knee
(6)and has also been linked to ACL injuries, as it is a position which places high demands on
the structure of the ACL (7). In vitro studies have demonstrated that pure knee abduction
and a combination of knee abduction/internal rotation place more strain on the ACL than
other direction of forces(8). The Medial Collateral ligament primarily limits knee valgus of the
knee (9), this may explain why MCL injuries occurs in 30-40% of ACL strains (8).
The ACL injury is one of the most common in sporting and active populations (10–12). It is
one of the most studied injuries due to its incidence rate, which is significant in the
recreationally active population as well as sporting populations(13). These injuries are
particularly prevalent in young individuals in the 15-25 years age bracket (11,14). Prevalence
of injury at this age range, with individuals involved in pivoting and cutting sports such as
American football, soccer and basketball may be higher than the general populations (12).
Females are 3-4 times more at risk of suffering an ACL injuries in the same sports as their
fellow male athletes (15). These types of injuries are often painful, disabling and come with
an increased risk of developing early onset Knee Osteoarthritis (OA) (16).
In general, females demonstrate a greater knee valgus angle than their male counterparts
(7). ACL injuries in women have been shown to occur at greater knee valgus angles on
landing(7). This increased knee valgus position may offer an explanation as to why females
suffer ACL injuries at a greater rate (17). Etiological influences believed to be involved in the
differing incidence rates among sexes include hormonal, anatomical and neuromuscular
factors (18). Factors such as Q angle (19), femoral notch size(20) and intercondylar notch
size (21) have previously been discussed as anatomical influence, with much of the
evidence being contradictory (18). Another potential mechanism for knee injury in females is
that of quadricep contraction. Female athletes may first contract the quadriceps on anterior
tibial translation, whereas their male counterparts first engage the hamstrings to stabilise
(22). The quadriceps act as an antagonist to the ACL and increase strain at angles of 45
degrees and above (18). Another observation is that females stabilise more using their
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ligaments while males use their musculature more (18).By understanding the difference
between male and female knee biomechanics, more tailored, specific injury prevention
strategies can be put in place to best cater for both sexes (17).
Hewett et al (18) demonstrated a correlation between knee valgus angle / moment and ACL
injuries in females. Quite a number of studies have demonstrated that the knee was in a
valgus at time of ACL injuries (1,5,23). Bendjaballah et al(24) found that knee valgus of even
5 degrees can cause as much as a 6 times increase in strain on the ACL. Therefore, the
purpose of this literature review to examine the correlation between sex and knee valgus on
landing activities in active populations. Studied individuals will be healthy, free from injury
and be accustomed to some level of sport participation. The findings will secondarily help to
inform whether knee valgus has a correlation with the increased rates of ACL injuries in
active females.
2.Methods:
A literature review was conducted aided by the PICO strategy and PRISMA guidelines(25).
Literature Search and Study Selection:
Search Strategy
A scoping search of the literature was carried out prior to any formal searches. A systematic
search was conducted in Medline, CINAHL and SPORTDiscus with the final search taking
place in February 2021 using the following search terms:
“Knee valgus” OR “Knee Abduction” AND “moment” OR “angle” AND “gender” OR “sex”
AND “landing” OR “Drop jump” AND “Anterior Cruciate Ligament” OR “ACL”.
Titles were screened using inclusion and exclusion criteria. Reference lists of search results
were also screened for possible selections. Study selection was confined to results which
returned in the English language. Studies that didn’t meet inclusion but had relevant findings
were used to inform on the secondary aim of the study.
Eligibility Criteria
Inclusion criteria were: 1) Quantitative In Vivo cross-sectional studies -due to the nature of
comparing sex and requiring living human beings to be relevant to this reviews objectives.
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Observational studies represent a good source of information when an experimental design

is not possible(26), with valuable findings gained on the relationship of exposure and
outcomes (26), 2) include healthy men and women or adolescent boys and girls – It was
decided that to get the most meaningful results healthy individuals that were free from injury
would be selected. This avoids certain results occurring due to individuals having prior
injuries. Adolescents were included as it has previously been mentioned that the 15-25 age
bracket suffer the greatest rates of ACL injuries, 3) assess and record either knee valgus
angle, knee valgus angular velocity or knee valgus force– the aim of the review is to
examine whether there is a correlation between knee valgus and sex, 4) measure using
cameras or image capturing technology – this has been previously shown to be a valid and
reliable method of recording lower extremity dynamic knee valgus (27,28) 5) must measure
subjects on landing activities – due to ACL injuries common occurring during landing
activities, and 6) participants must be at least recreationally active – this was due to previous
research linking experience level of athlete to increasing levels of knee valgus (29), so
participants should at least be familiar with the landing movement A quite wide range of
experience levels are being included to demonstrate results across a number of levels so
that influence on results can be minimal. Animal studies, in vitro studies, qualitative
research, studies older than eighteen years and studies using any other type of testing
procedure other than landing activities were excluded.
Quality Appraisal
Abstracts of studies were first screened for inclusion and exclusion criteria followed by
screening of entire studies. A checklist adapted from Downs and Black(10,30) has been
used to appraise potential included studies and assess them methodologically. This checklist
was adapted by Cronstrom, Creaby and Ageberg(10) recently in a systematic review. It
consists of a series of yes or no questions with each answer representing a score, the
maximum score being 19. The results of this checklist allowed each study to receive a score.
This score then informed how results were interpreted, for example a poor score would
mean any result would be interpreted with caution while a high score would indicate the
study was of a high standard and its results can be viewed to reflect that. The Downs and
Black checklist was found to have high internal consistency, good test retest and interrater
reliability and also good face and criterion validity (30). It was demonstrated that it worked
equally on non-randomised studies and randomised studies (30). For these reasons it was
found to be an appropriate measure to aid in the interpretation of the results of this literature
review.
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3.Results:
Study Selection
A total of 9 studies were identified from our systematic search (17,31–38). On further
screening of full articles this was narrowed down to 6 articles (32–35,37,39). Two articles
(31,38)were excluded as they measured ‘dynamic knee valgus’ and one study contained
participants with unknown activity levels (17) so was also excluded. For study characteristics
please see appendix 3 table 2.
Records identified through Additional records identified

database searching through screening reference lists
Medline, CINNAHL, SPORTSDiscus (n = 5)
Identification
(n =35)
Records after duplicates removed

(n = 38)
Screening
Records screened Records excluded

(n = 38) (n =27)
Full-text articles assessed

for eligibility
(n = 11)
Full-text articles excluded,
measuring dynamic knee
Eligibility
valgus, single leg

activities, non-landing
Studies included in activities, activity level not
synthesis of evidence stated, previous knee
assessing knee valgus injuries, no gender
angle, moment, or velocity comparison, non-cross
in active populations on sectionals
landing activities and (n =5)
identify gender
correlations (n=6)
Included
Figure 1: Flow diagram of included studies
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Appraisal of Included studies
The 6 included studies were critically appraised using a modified checklist which has
recently been used by Cronstrom, Creaby & Ageberg (10), and originally created by Downs
and Black(30). Studies included ranged from 58%-73%, demonstrating moderate
methodological quality as reported by Cronstrom, Creaby & Ageberg (10). Results can be
seen in table 1.
Table 1: Critical Appraisal
Author of Study and Score Percentage Methodological

year published Quality as per
Cronstrom,
Creaby & Ageberg
2020
Prieske et al 2017 11/19 58% moderate
Joseph et al 2011 11/19 58% moderate
Pappas et al 2007 13/19 68% moderate
Ford, Meyer & 14/19 74% moderate
Hewett 2003
Kernozek et al 2005 12/19 63% moderate
Cortes et al 2007 13/19 68% moderate
Knee valgus angle
Of the studies included, 5 investigated knee valgus angles following a landing activity (33–
37).Of these only one study (35) found no significant differences between sexes at initial
contact (p=0.65), maximum knee flexion (p=0.94) or maximum vertical ground reaction force
(p=0.79). However, this study was the joint second highest scoring study on quality
appraisal, with 68%. Three studies found significantly greater peak or maximum knee valgus
angles on landing (34,36,37).Ford, Meyer and Hewett(39) found significant differences in
maximum valgus (P=0.007) and total knee valgus motion(P=0.005). Pappas et al(34) found
a significant difference for peak knee valgus (P=0.001,95%CI). A significant difference in
peak knee valgus angles (P<0.05) was found by Kernozek et al(37). Ford, Meyer &
Hewett(39), which scored 73%, Pappas et al(34), which scored 68% and Kernozek et al
(37), which scored 63% were all deemed to have moderate methodological quality on the
Downs and Black checklist (30). Prieske et al (33) found an effect for sex for onset of knee
valgus angles during drop jumps, with females generally demonstrating a higher knee valgus
angle than males (P ≤ 0.054). However, this was the joint lowest scoring study of the review
with 58%.
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Other knee valgus measures
Two studies investigated the sex correlation with other valgus measures (32,37). Both
studies were quality appraised using the Downs and Black Checklist previously mentioned –
both studies were deemed to have moderate methodological quality with scores of 58% and
63%. These were 2 of the 3 lowest scores included in this review. Joseph et al (32)found
that there was a significant correlation with sex and angular valgus velocity at the knee
(mean diff =25.53 deg/sec [95% CI 8.30-42.77 deg/sec ])(P ≤ 0.01) on landing in 10 NCAA
female athletes and 10 competitive male athletes. Angular velocity in the female participants
demonstrating nearly twice that of their male counterparts. Kernozek et al (37) found a
significantly lower peak varus moment during the landing phase (P < 0.05) in a population of
30 recreational university athletes.
4.Discussion:
The results of this literature review point towards a correlation between knee valgus and sex
when landing from a jump. Five of the six included studies found a positive correlation
between knee valgus measures and the female sex on landing. Only one of the six found no
significant difference between sexes. The results are based on a moderate sample size
containing 232 physically active participants across 6 different studies. These studies were
indicated to have moderate methodological quality based on the downs and black checklist
(30).Therefore, based on the included population of this study, active females are deemed to
land with greater magnitudes of knee valgus .
As hypothesises knee valgus angle on landing was seen to be greater in females in all but
one study (34). The other 4 studies that measured knee valgus angle found that there was a
sex difference (32,33,35–37). This is not a surprising finding, as increased knee valgus in
females, has previously been hypothesised as a reason to why females suffer a greater
incidence of ACL injuries (7,17).However, it must be taken into consideration that Pappas et
al (34) found no significant difference between sexes and importantly, this was seen to be
the study with the highest methodological quality. While two studies (32,33) that found a
positive association scored at the lower end of ‘moderate methodological quality’ on the
downs and black checklist(30). These two studies, Prieske et al (33) and Joseph et al (32)
also had the joint lowest number of participants at 20. Another study of a similar nature,
required 32 participants to answer their hypothesis with a power of 0.8 (34).The mean ages
of females compared with males also appeared lower in these two studies (33) along with a
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study by Kernozek et al (37). Physical maturation has previously been linked with knee
valgus, particularly in young females (3,31) . As females in these two studies are younger on
average, physical maturation may influence the amount of knee valgus they present with.
Variations in age, with a number of quite young individuals and some older participants (40
years old), variations in sport (hockey/soccer/basketball) and level of participation may
influence results. Age has been investigated previously as a risk factor and found that older
individuals tend to suffer more injuries due to having more exposure. Two studies support
this(40,41), with findings of greatest incidence rates amongst participants aged 25 or older.
A study (42) found that athletes with lower skill levels suffer greater injury rates. In relation to
participation level, increased levels of physical activity are believed to be a risk factor for
knee injuries (43). It must be stated that the above-mentioned examples primarily look at
injury rate.
Of the two studies that examined alternative valgus measures, moment and valgus velocity
at the knee, both arrive at similar conclusions. Kernozek et al(37) found increased peak knee
valgus moment in the first 30-50% of landing and reduced knee varus moment in females,
suggesting that this may lead to a greater valgus moment due to less resistance of valgus. It
must be voiced that this study used recreational athletes. Joseph et al (32)found significant
association between sex and valgus angular velocity – with females demonstrating
approximately a two-fold increase in valgus angular velocity. A limitation of this study was
that males were recreational basketball players while females were NCAA athletes.
However, significant correlations were still witnessed between sex and valgus angular
velocity. Recreational athletes have previously been seen to have greater knee abduction at
the end of stance phase and increased knee abduction torque at the beginning of landing
compared with elite athletes during cutting manoeuvres (29). This was thought to occur due
to more experienced athletes having an ability to anticipate and respond to change of stimuli
in their sports (44). This identifies an interesting topic. Does exposure to both anticipated
and unanticipated dynamic cutting movements reduce the risk of ACL injury (45)? This
raises questions whether Kernozek et al’s (37) results are just impacted by sex or by
experience level also. Joseph et al (32) appears to add clarity to this debate, as the females
in this study still demonstrated greater knee valgus magnitudes even though they
participated at a higher competitive level.
Biomechanical/neuromuscular factors have been suggested to be important factors

associated with higher ACL incidence in female populations (46). The findings of this review
included studies that tend to support this statement, in that females appear to land with
altered knee biomechanics compared with males. A couple of video analysis studies on
female handball players appear to support this mechanism – seemingly pointing towards an
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association with knee valgus and ACL injury (47,48). Although with these studies, it is
difficult to pinpoint the point of when the damage to ACL occurs and whether the knee
valgus occurred before or after damage. These findings are particularly meaningful for this
review as it shows the potential link between females exhibiting greater knee valgus and
therefore being at greater risk of ACL injuries.
There are a number of proposed reasons why a correlation between the female sex and
knee valgus may exist. The first possibility is increased ligamentous laxity and recruitment of
muscular strength caused by regular hormonal changes that occur with females (18).
Female hormones estrogen, progesterone and relaxin have been suggested as factors in
female knee injury (18). Estrogen levels fluctuate during the menstrual cycle in females,
while estrogen is known to have an influence on tendon and ligament strength and
neuromuscular function (49).Increased accessory movement may occur due to ligamentous
laxity and reduced recruitment of muscular strength when landing from a jump. Levels of
performance are believed to differ in females during the menstrual cycle, which may occur
due to decreases in neuromuscular control (50). However, no consensus exists that these
such hormones play a role in increased ACL injury rate in females (1).Another possibility is
that females are more ligament dominant in providing stabilisation to the knee joint. The
concept of this theory is that females may not adequately dissipate forces using the
musculature surrounding the knee, meaning greater loads on the ligamentous structures of
the knee which aim to limit movements such as knee valgus (36).By increasing the
ligamentous load on a continuous basis, there is potential for weakening of the ligaments. A
third theory is that there may be neuromuscular differences between males and females due
to both having similar injury rates, but females being far more susceptible to joint injuries,
particularly knee injuries (18,51). It is suggested by one study that these differences are born
of training differences and level of competition between male and female(18). However, this
review included females of varying degrees of skill level, and still came to the same findings.
It is widely thought that the ACL injury is multifactorial (7,36,37). There is likely no one cause
for ACL injuries – with a wide variety of anatomical and hormonal factors hypothesised (36).
However, that is not to say that the association knee valgus and sex do not play a primary
role in females suffering ACL injuries at a greater rate to males. A number of in vivo studies
have associated knee valgus moment to ACL injury (52,53), while knee valgus angle has
been seen to identify individuals with ACL deficiency (54). These are interesting findings, but
do not necessarily link the increased knee valgus moment/angle to living individuals.
Discovering that an ACL deficiency is present in individuals with greater knee valgus is
useful but does not directly translate as greater knee valgus has caused the deficiency.
There are also other movements associated with ACL injury. Sudden deceleration when
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landing, a near extended knee, knee abduction, trunk lean, and pivoting are thought to be a
mechanism for non-contact ACL injury (10,55). This would imply that knee valgus alone may
not cause these injuries but elements such as pivoting, trunk lean, and an extended knee
also have a role. This information may also be significant to the method of testing. While
drop jumps and 3D motion may identify individuals that are exhibiting greater knee valgus, it
may not be enough to adequately stress the ACL as a number of elements such as pivoting,
and an extended knee may not be present.
Adding to debate surrounding knee valgus and its role in ACL injuries, a recent systematic
review found no correlation between knee valgus kinetics or kinematics and future ACL
injury (10). It was acknowledged by Cronstrom, Creaby and Ageberg (10) however, that
individuals did not exhibit sufficient magnitudes of knee valgus/knee abduction to portray an
association, perhaps down to improvements in injury prevention exercises(56). The other
possibly theory was perhaps the relationship between knee valgus and risk of ACL injury is
not linear, with a cut-off point existing, after which risk increases. What is known is that after
sustaining an ACL injury (57)– greater magnitudes of knee valgus can be recorded following
drop jumps, up to 2 years after sustaining the injury(58). MRI studies have discovered bone
bruises laterally following ACL injuries which may imply knee abduction occurring before
injury, however it was stated that the abduction occurred after and not before the injury (59).
Therefore, whether knee valgus alone is a genuine risk factor for suffering an ACL injury
remains uncertain. Perhaps the findings of Cronstom, Creaby and Ageberg(10), reinforce the
point that knee valgus alone is not a risk factor, but combined with other factors – it may well
be.
The findings of this study combined with other research in the same area may have a
number of implications for future research. For one drop jumps and 3D motion appears to be
an adequate way to identify individuals who exhibit greater amounts of knee valgus. Whether
this alone will be enough to help reduce ACL injury rates is unknown, however it does allow
us as clinicians to identify a potential area of weakness in active individuals and attempt to
put in place a strengthening programme to limit this effect. The review also learned that
females land with more knee valgus. In recent times more influence has come from injury
prevention strategies – may it be a case that while women also employ these – they may
need to do a higher volume than their male colleagues to reduce incidence of ACL injuries.
Finally and most importantly, as this review discovered that females do land with greater
knee valgus from drop jumps – and have higher incidence of ACL injuries in sport, further
investigation is needed to investigate whether greater knee valgus alone is the risk factor,
which Cronstrom, Ageberg and Creaby (10) have discounted. Perhaps this study didn’t
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include studies which produced enough knee valgus or perhaps knee valgus alone is not the
primary cause of higher incidence rates. Research that can identify other modifiable risk
factors for ACL injury in females will be very useful as female elite sport continues to grow.
There are a number of limitations of this review. Firstly, this review is limited to six studies,
all of which have only been deemed to have moderate methodological quality. There are a
wide age range of participants across the studies with some participants as young as 15/16
(33,36) and as old as 40 (34). The ages of 15-25 are believed to be the age bracket most
ACL injuries occur, and so some participants included in this review outlie this. While we do
have participants at the lower end of this age bracket in this review, previous research has
linked stage of maturation to magnitude of dynamic knee valgus (31) therefore, there is
some risk of an association not solely being related to sex but also the participants
maturation. There is a big variation in sports of participants, with hockey, basketball and
soccer being described. There is also a big difference in participation level with studies using
NCAA athletes, high school athletes, elite professional athletes, and recreational athletes. It
has been suggested that injury prevention programmes may play a role in reduced knee
abduction in athletes (3). In this case, it is unknown what level of injury prevention strategies
have been used across the different sports and different participation levels in the included
studies.
5.Conclusion:
Based on the studies included in this review it can be stated that females demonstrate
greater magnitudes of knee valgus when participating in landing activities. This has been
demonstrated across a variety of sports, ages, and skill levels. What is still unknown is
whether the findings of this study can equate for the increased incidence rates of ACL
injuries in females compared with their male counterparts or whether it is one of many
factors that play a significant role in females suffering greater rates of the injury.
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6.Background / Rationale:
The anterior cruciate ligament (ACL) injury is among the most debilitating in sport and leads
to osteoarthritis (OA) of the knee in later life(60,61). The ACL injury can be a cause of long-
term disability and significant burden financially due to cost of procedures and
consultations(60). It has been widely accepted that the females’ sex suffers a higher rate of
ACL injuries among athletes than their male counterparts. For the purpose of this research
sex is defined as human biological attributes that are associated with a number physiological
and physical attributes, namely gene expressions, reproductive anatomy and hormonal
function(62). A literature review was previously conducted to inform this proposal which
determined that active females land with greater magnitudes of knee valgus than males.
Knee valgus has historically been seen as a dangerous position for the knee joint(6) and a
position that creates high loads for the ACL to withstand(7). However, controversy exists
around the planes of motion believed to lead to noncontact ACL injuries(60). Supporting
this a recent systematic review found no correlation between knee valgus on landing
activities and ACL injury rate(10). The argument against these findings is that the ACL was
not stressed with sufficient valgus forces during the testing procedures(10). This may also be
the case for studies included in the literature review, as similar landing activities were used
as a testing protocol. Other limitations found in the literature review were that ages varied
outside the age range ACL injury is most prevalent, 15-25(11,63).With participants younger
than this being included there is a risk of maturation stage having an association with risk of
injury(31). A percentage of participants were recreational athletes, with less experienced,
less skilled athletes believed to be at higher risk of knee injury(64).
7.Aims:
Therefore, the primary aim of this study is to investigate whether a sex correlation exists
between knee valgus magnitudes on sports specific landing manoeuvres and incidence of
ACL injury in elite Athletes engaging in contact team sports. The landing activity should
mimic in game activities such as landing from a jump and pivoting. Participants should be
both male and female within the age ranges of 15-25 and playing for semi-
professional/professional football/soccer. Football involves regularly jumping, landing, and
quickly changing direction which could in theory stress the ACL. Football has one of the
highest risks of ACL injury among sports(65). Incidence rates range for 0.15%-3.67% per
person per year for ACL injuries in football(66), with female players up to 3 times greater
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likelihood of suffering the injury(67). The majority of these ACL injuries in football have been
reported to be non-contact from various sources(65,68,69). The secondary aim is to identify
if knee valgus is a true risk factor for ACL injuries.
7.1-Hypothesis
Null Hypothesis: There will be an equal distribution of ACL injuries between males and
females and no sex correlation with knee valgus
Alternative Hypothesis: There will be a greater proportion of female ACL injuries and a
positive sex correlation with knee valgus
8.Methodology
Researchers study and investigate complex and diverse topics. Therefore researchers must
use different research methodologies, namely quantitative and qualitative research
methodology(70). No research method is ideal and there are pros and cons of each
method(70). Based on the findings of the prior literature review, mixed methods, qualitative
or quantitative research could address different parts of the conclusion that may require
further investigation. If one wished to get the perspective of the participant on why females
land with more knee valgus or what they believe puts them at greater risk of ACL injury, a
qualitative interview style study may be appropriate. This would be seen as an interpretivist
perspective(71).The belief of interpretivism is that research should involve individuals
perceptions and options and be based around social interactions, this is the hallmark of
qualitative methodology(70). A positivist belief is that empirical facts exists separately to
individual ideas and that within the research, variables interact to influence outcomes
through experimental means(72). Positivists view studies in an objective manner, meaning
they believe outcomes exist naturally and require being quantified and recorded to
decipher(73). Quantitative research is underpinned by a methodology that is objective a has
a focus on measuring variables and examining hypothesis to gain an understanding about a
topic(70). Hard data is gathered in this instance to ensure results can be demonstrated in a
quantitative form(72). With regards to this study, it is felt that a quantitative approach was
warranted as figures would be needed to justify any sex correlation present between knee
valgus angles and ACL incidence. Sex differences will be measured for knee valgus angle
and whether this subsequently has an influence on incidence of ACL injuries. Therefore, a
positivist ideology will be used for much of this research proposal.
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9.Methods
9.1-Study Design
The study will use a prospective cohort design. Cohort studies are observational in nature
and do not have an intervention(74). Justification for this design lies in that the results will be
applicable to a defined population(75). Observational studies can represent a good source of
information when an experimental design is not possible(26). This type of design can
demonstrate valuable findings on the relationship of exposure and outcomes(26). This
design meets the study needs as it allows for the comparison of two groups of interest
(male/female) over a specified period of time to identify if correlations between knee valgus
angle on landing and ACL injuries exist. Within this design all participants will take part in the
testing procedure which will involve measurement of knee valgus angle during a jump
landing activity. Measurements will be gathered using motion analysis cameras and
computer software. Participants will be followed longitudinally for a period of 18 months post
testing, with any ACL injuries being recorded. Usually a longer duration of follow up is used
in order to give time for certain outcomes to occur(74).
9.2-Study Setting
The setting for testing will be laboratory based using a biomechanics lab within The
University of Essex. The University of Essex has been chosen as the testing site as it is the
primary researchers place of study and due to it being somewhat central to the surrounding
football clubs that will particiapte. Follow up recording of injury will be limited to trainings
sessions and competitive fixtures involving the Professional Football Clubs in the East Anglia
region.
9.3-Recruitment
Participants will be recruited from the male and female professional football teams in East
Anglia. Football clubs in the area will be contacted about their willingness to participate in the
study. Clubs that are willing to participate will receive emails containing full details of the
study which will be forwarded on to all players. A face to face session will be organised with
clubs to communicate all the important details of the study along with answering any
questions. Individuals who are considering registering will be requested to attend.
Registration for the study will take place by registering willingness to participate by replying
15
to the email invitation or signing up at the face to face meeting. Face to face recruitment has
previously been used in similar study designs(75). Potential candidates will volunteer for
selection and give informed consent to participate. For individuals under the age of 18,
informed consent of the individual and the individual’s parent/guardian will be required to
participate. Interviews with potential candidates will then take place to ensure these
individuals are suitable for this study and meet inclusion and exclusion criteria. This will take
place via phone call for candidates that have registered an interest via email and face to face
following in person sign ups. Recruitment strategies will entail ensuring key results and
objectives of are translated into plain language and communicated with participants. For a
study like this where a certain number of individuals will be expected to suffer an ACL injury,
home visits, zoom meetings, or online forms may allow follow up data to be collected when
an individual is less likely to attend any study clinics(75). For the purpose of this study, an
online survey will be used to collect injury data.
9.4-Participants
Participants will be professional footballers in East Anglia area, of both male and female
sexes. The East Anglia region has been chosen out of convenience for testing for the
researcher and due to the presence of a number of professional football clubs in the region
(Cambridge United, Peterborough United, Ipswich Town Football Club, Norwich City Football
Club, Colchester United and South End United). Football is included as the main sport as it
is a sport which ACL injuries are common in, with landing and pivoting shown to have a high
incidence rate of ACL injuries, which also are common manoeuvres in football(11,12).
Football has one of the highest risks of ACL injury among sports(65). Incidence rates range
for 0.15%-3.67% per person per year for ACL injuries in football (66), with female players up
to 3 times greater likelihood of suffering the injury(67). The majority of these ACL injuries in
football have been reported to be non-contact from various sources(65,68,69). Participants
will be both male and female as this study aims to investigate if there are any correlations
between sex, knee valgus angle and ACL incidence rate. Participants will be within the ages
of 15-25 years old. The 15-25 age group has previously been stated as the approximate age
range which ACL incidence is at its highest(11,14). Participants will be free from lower limb
injury at time of testing, the previous 18 months and not previously suffered an ACL injury.
Participants should not have previously participated in studies of similar nature that used a
landing activity as a testing procedure to avoid familiarisation bias. An a priori power
analysis(76)will be conducted to find the minimum number of participants needed for the
study to have statistical power of 0.8, used in a studies of similar nature (33,77) and seen to
16
be an acceptable power level for research(78). An alpha level of 0.05 will be used. This has
been demonstrated to be acceptable in academic studies(78). Previous studies of a similar
nature have used between 20-32(33,34) participants in order to reach a power of 0.8.
9.41-Eligibility of Trial Participants
Potential participants/participants parent/guardian that have initially consented to partake in

the study will undertake a short interview with the primary investigator to make sure they are
eligible for the study. Interview questions will be based around inclusion and exclusion
criteria.
Inclusion
For an individual to be included in the study they needed to meet the following criteria:
• Granted informed consent to participate and had the capacity to do so, for individuals
over 18 years of age
• Granted informed consent from the participant and parent guardian in individuals
under 18 years of age
• The participant must be no older than 25 years of age
• The participant is a playing member for either academy or first team/reserves of a
professional football club in the East Anglia Region of the United Kingdom
• The individual is actively training or competing at least 3 times per week for at least
45 mins per session
Exclusion
The participant may not take part any further if any of the following apply:
• The individual has any injuries to the lower limb at time of enrolling resulting in them
being unable to train or compete
• The participant has previously suffered an ACL injury
This is due to individuals with ACL deficiency previously been identified to present with
greater knee valgus angles(54,79)
• The participant has not been a member of a similar research study in the past or at
present
This is to avoid the participant trying to avoid ‘high risk’ activities such as single leg lands
that may lead to injury, that they previously would not have been aware of
17
• The participant will not be away and unreachable for a period greater than one month
9.5-Testing Protocol
Participants will be given the chance to familiarise themselves with the tasks on day of
testing. A similar procedure was allowed in a study by Joesph et al(32) and Cortes et al(35)
to eliminate learning effects of the experimental procedure. Body weight and height
measurements will be taken during the familiarisation period .A standardised warm up
similar to one discussed in a previous study(33)will be used consisting of 5 minutes of
cycling, 3 minutes of skipping and 2 minutes of drop jumps and cutting manoeuvres. The
drop jump landing task will consist of dropping off a 60 cm hang bar. A hang bar has been
chosen, as more reliable kinetic and kinematic data have previously been gathered from
using a hang bar as opposed to dropping off a box(80). Participants were instructed to land
with both feet approximately shoulder with apart. On landing from the hang bar a cutting
manoeuvre was immediately initiated in a planned direction using a self -selected angle with
a dummy opponent present, previously used in a recent study investigating knee abduction
moment and ACL injury(81). The mean value of 3 attempts will be taken for each individual.
Knee valgus data will be collected between the point the participant makes initial contact
with the ground and when they push off into their cutting manoeuvre.
9.6-Data Collection
During these activities knee valgus will be measured. Knee valgus will be measured at the
point the participant lands and immediately makes a cutting manoeuvre in a chosen
direction. The data will be collected by the primary researcher at biomechanics Laboratories
at the University of Essex and stored on a secure password protected laptop which only the
primary researcher and an academic supervisor at the University of Essex will have access
to. Data will be collected for 2D knee joint kinematics using a camera, motion analysis
software and reflective anatomical markers. Reflective markers will be positioned using the
‘Liverpool John Moores University Model’ which has previously been demonstrated to be
reliable for measuring kinematic data(82). Placement sites of markers include the trunk,
pelvis, upper legs, lower legs and feet. A total of 44 markers would be used(83). The use of
2D motion analysis was demonstrated to be reliable and valid when investigated by McLean
et al(84). The use of 2D motion analysis technology in running has been shown to be valid
and reliable(85) and also has been used in a recent study by Sigurdsson et al(81).
18
9.7-Follow Up
Each participant in the study will be have a randomly generated unique number assigned to
them. Before the beginning of the study, coaches/medical staff will be informed of the
purpose of the study and what is expected of them in terms of reporting of injuries. The
medical staff and coaches will inform participants who have suffered ACL injuries in the 18
months post testing that they must complete a word document survey using their unique ID
and submit it to their coaches, who will email to the primary investigator. The survey will
contain no Identifiable information other than the team they play for and their unique ID.
Data captured from these surveys will be encrypted and stored on a secure device. Access
to the data will only be available for authorised users previously mentioned. Injuries reported
must cause the participant to be unable to participate in trainings/competitions(86) and must
be confirmed via Magnetic Resonance Imaging (MRI). Injuries will also be required to be
defined as contact or noncontact on reporting, with only non-contact being statistically
analysed.
9.8-Outcome measures
The outcome measures chosen to be used in this study will be knee valgus angle measured
in degrees and number of ACL injuries recorded during the follow up period. Knee valgus
angle was chosen as it is relatively straightforward to measure and has both been identified
and discounted as a risk factor for ACL injuries in different studies(7,8,87). These will be the
primary outcome measures for this study.
10.Statistical analysis
Once the follow up of period of 18 months is completed, the injury data can be analysed.
The primary researcher will conduct the statistical analysis in consultation with a statistician.
The software package SPSS(88) will be used to analyse the data gathered from the data
collection phase and follow up. The data that will be used, will be both continuous and
categorical/dichotomous. The type of data that will be produced will influence which
statistical tests can be used and which will be most meaningful.
The mean and standard deviation for descriptive data (age, height, weight) will be calculated
and placed in a table. The Shapiro wilks test will be carried out to ensure the descriptive data
and joint angles are normally distributed (P > 0.5 95% confidence Interval (CI)). The Mann
19
Whitney U test may be used on data that is found to be not normally distributed. Levenes
test for equality of variance will be used to detect the variance between male and female
groups for descriptive data and knee valgus angle, ensuring they are deemed equal within
the population. Variance can be treated as equal if P > 0.5 .If variances are unequal
between sexes this may affect the type I error rate and lead to false positives(89). If data is
normally distributed and there is a homogeneity of variance between groups an independent
t test will be carried out to identify whether there is a significant difference between sexes for
knee valgus angles. The t-statistic, degrees of freedom (df) and significance level of the test
will be reported as t(df)= t statistic, p = significance value. The 2x2 Pearson Chi Square: Test
of Association will be carried out on sex and ACL injury status (injured/uninjured), in order to
identify the association between sex and suffering an ACL injury. The magnitude of
association will be reported using a Phi value ranging from 0.00 – 1.0, with a value closer to
1.0 indicating a stronger association between variables(90). A point biserial correlation will
be used to assess correlations between knee valgus angle and number of ACL injuries by
sex. A Pearson r correlation test will be used to determine if there is a correlation between
sex and degrees of knee valgus angle observed on landing. If the data is not normally
distributed a Spearman rank correlation test will be used to investigate this same correlation.
Cohens d will be used to interpret the effect size, with above 0.50 deemed a large effect,
0.30-0.49 deemed as a moderate effect and 0.10-0.29 deemed as a small effect(91).
11.Limitations:
This study is not without limitations. Some limitations include inadequate timeframe to detect
the true correlations, participants being lost to follow up due to long duration, testing
primarily looking at double leg landing when single leg landing demonstrate greater knee
valgus scores and the possibility of not recruiting senior players due to their busy schedules.
12.Ethics
Prior to commencement of this study, ethical approval will be sought from the University of
Essex through the Ethics Review Application Management System. The ethical approval will
be sought for the structure of the study but also for all participant facing material. Copies of
informed consent documents, plain language summaries and recruitment emails will all be
provided for review. The University Ethical Guidelines(92) will be thoroughly read and
understood prior to commencing the study. Protecting the participants personal data,
respecting individuals rights to decline participation, respecting individuals right to withdraw
20
at any time, reporting any adverse reactions such as knee pain following testing and
ensuring there are no undeclared conflicts of interests are just a few of the principles that will
always be treated with the utmost importance during the period of the research activity. The
overall purpose of the study is to identify biomechanics that may predispose individuals to
injury and whether this differs based on sex. Plain language summaries and informed
consent forms will be provided to all prospective participants ensuring they are completely
aware what their participation entails and what risks they may encounter. This will also be
provided to parents/guardians of prospective participants under the age of 18 years. All
participants will be made fully aware that a certain number of people are likely to suffer
injuries to their ACL within the time frame of this study. In the event a participant suffers an
injury during the course of the study, they will be signposted to services that can offer
relevant physical and psychological supports. Consent must also be given for the sharing
and publication of data, with prospective participants being made aware how their data will
be used and stored and how their anonymity will be upheld. This will be relevant if an urgent
medical matter needs to be shared with the patients GP or if the study was to be published
in an academic journal. All participants will receive a copy of their informed consent form
prior to commencement of study and no participant may take part unless they have signed
an informed consent form and had capacity to do so. There will be no monetary incentives to
encourage participation in this study. The objective of this is to conduct all research openly
and without deception.
13.Clinical Application
Should this study find positive correlations between knee valgus and ACL injuries, it will
demonstrate good cause for funding to be placed into research on strategies to limit knee
valgus on landing. Promising findings have previously been seen with plyometric and agility
exercises with a verbal or video feedback component to reduce the effects of knee valgus
(93). Similar interventions to these may pay dividends in the reduction of ACL injuries if knee
valgus is seen to be a true risk factor. With regards to females, research may be required to
identify what the most causative factor is for their ACL injury incidence rate and trial more
strategies which can help to minimise this. Should this study find no correlation between
knee valgus angle on landing and ACL injuries then other factors that have previously been
identified such as the combination of knee abduction and internal rotation(8), engaging of
the quadriceps instead of the hamstrings during tibial translation(22) and ligament dominant
stabilisation as opposed to stabilisation primarily occurring through musculature(18) should
be researched further as risk factor for ACL injuries and if there is an effective intervention to
21
limit these effects. Identification of true risk factors of ACL injury and whether this differs
across sexes has the benefit of allowing more specific tailor-made prevention programmes
to reduce the effects of these risks.
13.1-Methods of Dissemination
Engaging in research allows for the enhancement of people’s health and lives through
adaptions of clinical practice(94). For this to occur research findings should be
disseminated(94). Researchers have an ethical obligation to attempt to disseminate
research(95). The most common methods for dissemination of research findings are through
publications in journals and through presentations at academic meetings(94). To reach a
wide audience and ensure an author’s findings can be accessed with ease at any time,
publication to a journal is favourable(94,96). Presentations at conferences are also an option
for dissemination with posters and oral presentations commonly used(96). The benefits of
this method are that findings can be quickly communicated to a group of people without
delay following completion of the study,(94) leaders in the field are commonly present who
are more likely to implement research into practice and the author can answer questions on
the study(94). and the author can answer questions on the study(97)
This study will attempt to disseminate its findings through the use of peer reviewed journals
and through poster presentations at conferences in order to ensure key stake holders and
the public may have access to the research. Stake holders who may wish to be present at
presentations include the included football clubs’ representatives, researchers in the field of
ACL injuries and injury prevention, biomechanics researchers, the CSP and relevant football
bodies such as The Football Association. Results of this study being disseminated in the
appropriate channels are not dependent on conclusion the study arrives at.
22
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Appendices
Appendix 1 :Figure 1: Flow Diagram of included studies
Records identified through

database searching
Additional records identified
Identification
Medline, CINNAHL, SPORTSDiscus through screening reference lists

(n =35) (n = 5)
Records after duplicates removed

(n = 38)
Screening
Records screened Records excluded

(n = 38) (n =27)
Full-text articles assessed Full-text articles excluded,

for eligibility
Eligibility
measuring dynamic knee

(n = 11) valgus, single leg activities,
non-landing activities,
activity level not stated,
previous knee injuries, no
gender comparison, non-
cross sectionals
(n =5)
Included
Studies included in
synthesis of evidence
assessing knee valgus
angle, moment, or
velocity in active
populations on landing
activities and identify
gender correlations
(n=6)
35
Appendix 2: Table 1:
Quality Appraisal of included studies
Author of Study and Score Percentage Methodological

year published Quality as per
Cronstrom,
Creaby & Ageberg
2020
Prieske et al 2017 11/19 58% moderate
Joseph et al 2011 11/19 58% moderate
Pappas et al 2007 13/19 68% moderate
Ford, Meyer & 14/19 74% moderate
Hewett 2003
Kernozek et al 2005 12/19 63% moderate
Cortes et al 2007 13/19 68% moderate
Appendix 3: Table 2:
Study Characteristics:
36
AUTHOR & STUDY DESIGN SAMPLE STUDY OBJECTIVES METHODS USED RESULTS
DATE CHARACTERISTICS
Prieske et al Cross sectional 20 Elite German Volleyball Examine the combined Drop off a 39cm box using non Greater knee valgus
2017 Observational players (M=10), F=10) aged effects of fatigue and dominant and land with both feet angles in females than
between 15-21 surface on knee on a force plate and immediately males and greater
kinetics/kinematics during perform a maximal jump. 3 jumps. angles on unstable
drop jumps and Motion analysis cameras were surfaces.
countermovement jumps used to capture 2D knee
kinematics. Reflective markers
placed on anterior superior iliac
spine, patella, and malleolus
medialis of the dominant side.
Joseph, Rahl Cross sectional 10 F (mean age 19.5 years) Compare the timing of hip 3 drops off a 31 cm box onto two Females scored higher
& Sheehan Observational NCAA athletes (basketball, abduction, tibial abduction, force plates. 7- camera 3D motion for max knee valgus
2011 volleyball, soccer) and 10 foot eversion and the analysis cameras with reflective and also for angular
highly competitive M (mean resultant angular velocity markers on the anterior and velocity of knee valgus
age 20.1 years) that trained during drop jump landing posterior iliac spines, sacrum, on landing
with female basketball greater trochanters, thigh and
players shank triads, medial and lateral
malleoli, and over the shoe
representing the locations of the
first and fifth metatarsals, toe, and
heel
Pappas, Cross Sectional 32 male/female university Effect of gender and Bilateral landings on a force plate Females exhibited
Sheihzadeh & Observational recreationally sporting fatigue on NEMG, kinetic after dropping from a 40cm box. R significantly greater
Norin 2007 individual (20-40 years) and kinematic measures leg only was measured. 8 motion knee valgus on drop
during bilateral drop jumps analysis cameras were used and jump landing than
reflective markers placed using males
‘The Helen Hayes System’
(Richards, 2002)
Cortes et al Cross Sectional 25 male and 25 female (m Compare differences 3 differing techniques were No significant gender
2007 Observation =24.40 ± 2.3 years, f=23.28 between genders and recorder. Forefoot landing, rearfoot differences found on
± 2.5 years) recreationally between different landing landing and personal preference off drop jump landing
active university students techniques during drop a 30 cm box onto force plates
followed by a maximal vertical
37
jump landings and quantify jump. Only R leg was recorded.

kinematic data Prompts from examiners were
given on techniques.
Electromagnetic sensors were
placed on the medial-lateral
malleoli, medial-lateral
epicondyles, the second phalanx
and both trochanters. Motion
monitor software used to record
data.
Ford, Meyer & Cross Sectional 47 female and 34 male Determine any gender Drop off a 35cm box onto force Significantly greater
Hewett 2003 Observational highschool basketball differences during landing plates and immediately perform a knee valgus angle in
players from 4 different manoeuvres maximal vertical jump imagining females on landing
schools in Cincinnati (16 ± that the participants were trying to than males. Trend
0.2 years) score a basket with their hands. 3 towards greater knee
successful trials were recorded.8 valgus on initial contact
digital cameras were used for but not significant in
motion analysis which was females
connected to a data collection
computer. 23 retroreflective
markers placed on the sacrum and
bilaterally on the shoulder, ASIS,
greater trochanter, mid-thigh,
medial and lateral knee, mid shank,
medial and lateral ankle, and heel
and toe (between second and third
metatarsals).
Kernozek et al Cross Sectional 15 males (24.5 ± 2.26) & Compare if gender Dropping from a 60 cm hang bar Lower peak knee varus
2004 Observational female (23.6 ± 1.76) differences exist in kinetic onto a force plate. One foot would moment on landing
recreational athletes from a and kinematic knee land on the force plate and the suggesting females will
University measures during drop other beside on the landing land in more valgus as
landing activities in young platform. Right side was examined less Varus resistance
recreational athletes only. 18 reflective markers using
the Helen Hayes Configuration of
markers. These include: right and
38
left anterior superior iliac spine

(ASIS), sacrum, right and left thigh
approximately 15 cm superior to
the superior pole of the patella (at
the estimated line of the knee joint
center), right and left lateral
femoral condyles, right and left
lateral tibia (half way between
ankle and knee), right and left tibial
tuberosity, right and left lateral and
medial malleoli, right and left
posterior portion of the calcaneus
(on shoe), right and left superior
navicular of the foot, and the right
and left web space between
metatarsals 1 and 2. 6 JCL
cameras recorded kinematic data
at 60 degree intervals around
performance area
39
Appendix 4: Figure 2:
Downs and Black Modified checklist for appraisal of studies
40
Appendix 5: Informed consent form
Name of candidate:
Date:
You are interested in participating as part of a research study. It is important for all prospective
participants to be made fully aware of the proposed study procedures prior to commencing the
study. Before agreeing to participate you should identify any potential risks and benefits and may an
informed decision. This document is split into two parts (informative statement, consent form) to
allow you to gain a deeper understanding of all relevant aspects of the study. Please ensure anything
that is contained within the document is understood and explained if not. Ensure you have all
potential questions, or any worries addressed prior to giving your consent to participate.
Introduction:
My name is Peter Smith. I am a final year MSc Physiotherapy student at the University of Essex
partaking in this research activity as part of my degree. I am conducting research on Anterior
Cruciate Ligament injuries to identify if certain movement patterns place individuals at a higher risk
of injury. I also wish to identify if a person’s sex has a major impact on both the movement patterns
and the risk for suffering an Anterior Cruciate Ligament injury. As you are aware injuries to the ACL is
common in football and the results of this study may offer means to help reduce this. More
information about the different studies will now be talked through. Please feel free to ask any
questions you wish or have anything that is not clearly explained again.
Purpose:
As previously touched on, this research will help to identify certain movements that are considered
risk factors for ACL injuries. It will also help to identify if these risks differ greatly between sexes. ACL
injuries are common in jumping sports, including football. These injuries cause a significant loss to
participation time with an extensive rehabilitation period and increased risk of osteoarthritis. The
findings of this study allow can dictate which direction injury prevention exercises will need to take
in order to help reduce these injuries.
Requirement of participants:
Participants will be required to be available for one testing session and will be responsible for
reporting ACL injuries back to the researchers. The testing session will consist of measuring height
and weight, a warmup and a sports specific exercise. The sport specific exercise will involve dropping
a distance of 60cm from a hangbar and landing on both feet followed by a sharp sprint in a different
direction avoiding a dummy opponent. The reporting of injuries will be completed in a word
document which will be emailed to your teams’ coaches and then returned to this research study.
Selection of participants and participation:
41
Participants from Pro Football Clubs around the East Anglia region of the United Kingdom are being
invited to participate. Participants can be male or female and within the ages of 15-25 years. All
participants will be required to sign acknowledging they meet the criteria to be included in the study
which has previously been completed. It is important to know that your participation in this study is
completely voluntary and can be withdrawn at any time by the participant.
Duration:
The duration of initial testing will be a single afternoon. The duration that ACL injuries will be
required to be recorded after testing is a period of 18 months. After this period no recording is
necessary.
Risk/benefits:
The main risk of being involved in this study is that of suffering an ACL injury. The nature of the study
is to investigate relationships with ACL injuries so it is clear that some individuals may get injured. It
is important to note that participating in this study does not increase the risk of this occurring, but it
is important to be aware of. There is a small risk of injury during testing sessions, but this is to be
minimised through a thorough warm up and close supervision during testing. The benefits of this
study will not be evident immediately but may be important in the emergence of means of reducing
the risk of ACL injuries in football in the future.
Payment:
Participants will receive no money or gifts/incentives to participate in this study
Confidentiality:
There will be a requirement for participants to provide some personal details. These include name,
date of birth and sex. Other data will be gathered as part of testing such as height, weight, joint
angles and injury status. All this data will be collected and securely stored on a password protected
device. Individuals will be assigned a randomly generated unique ID number for the study which will
be present on all of your data to replace your name. Only authorised individuals involved in the
study will have access to your information.
Within the study you will not be named or identified in any way. Any information that in future may
be forwarded on to publishers will never contain an identifiable information and you will never be
named in any future reports, presentations, or articles.
Publication of results:
When the study has been completed results will be divulged and discussed in meetings with other
academic researchers. Publication of results in a research journal will be sought to allow for
interested parties to be able to have access to the work and make an impact on this particular field
of work. No personal identifiable information of the participants will be shared.
42
Consent to contact GP:
You will also be giving permission for the researcher to contact your GP if any adverse reaction
occurs over the process of the study or a risk to your health has been identified. You may refuse to
consent this or withdraw your consent at any time.
Contact details:
If you have any further questions regarding the study, what it entails or any worries moving forward
you can contact me directly through email - [email protected]. I will get back to your query as
promptly as possible.
This study is pending ethics approval from the University of Essex. If you have queries about the
ethics approval you can contact the University directly.
43
Title of the Project:
Researchers: Peter Smith
Please initial box
1. I confirm that I have read and understand the Information Sheet

dated xx for the above study. I have had the opportunity to consider
the information, ask questions and have had these questions
answered satisfactorily.
2. I understand that my participation is voluntary and that I am free to

withdraw from the project at any time without giving any reason and
without penalty.
3. I understand that, due to the nature of the study, a certain percentage

of individuals are expected to injure their Anterior Cruciate Ligament. I
understand the study does not play a role in the injury and is simply
observing and recording injuries.
4. I understand that the identifiable data provided will be securely stored

and accessible only to the members of the research team directly
involved in the project, and that confidentiality will be maintained.
5. I understand that data collected in this project might be shared as

appropriate and for publication of findings, in which case data will
remain completely anonymous.
6. I agree to take part in the above study.
44
Participant Name Date Participant Signature
____________________ ______________ ___________________________
Researcher Name Date Researcher Signature
____________________ ______________ ___________________________
45
Appendix 6: Inclusion/Exclusion Form Question
Name:
DOB:
Please initial box
I confirm that I am between the ages of 15 and 25 years.
I confirm I have never suffered a previous ACL injury and am currently

free from injury
I confirm that I am a member of playing staff at Football Club
I confirm that I have never been a participant in a similar study

investigating ACL risk factors
I confirm I train/compete at least three times per week for a duration of a

least 45 mins
I confirm I will not be unreachable for a period of greater than one month
during the duration of the study
46
Participant Name Date Participant Signature / Guardian Signiture
____________________ ______________ ___________________________
Researcher Name Date Researcher Signature
____________________ ______________ ___________________________
47
Appendix 7: Budget and Resources
Resource Cost£
Testing equipment 1000
Miscellaneous costs including travel 500
Staff costs (biomechanist, statistician) 7,000
Printing and advertising costs Free (university printing)
Total: 8,500
48
Appendix 8:
Recruitment Email:
49
Appendix 9: Gant Chart:
50
SE705 Patient Pathways Resource Creation
Word count: 1999

Student ID: 1900702
Contents:
Review of Evidence
Bibliography
Appendix including resource in pdf format
Review of Evidence for Resource:
*names changed for the purpose of anonymity
For the purpose of this review, I have chosen to create a poster for a paediatric footballer
with ADHD who has suffered a grade 2 Anterior Cruciate Ligament tear.
A laminated poster was chosen for James. The patient’s age along with his ADHD mean that
any resource chosen must engage the patient. Restlessness, inability to complete tasks,
poorly coping with stress and lack of focus are all seen as obstacles for an individual with
ADHD (1). A poster format with a football theme was chosen as it was seen as a way of
potentially easing James’ anxiety, which is common for a child who comes in contact with a
healthcare setting (2). The bold colours and pictures were chosen to help engage a child
with ADHD.The use of non- threatening and age appropriate language is used throughout
the poster with words limited where possible. Appropriate language has been seen to help
children get through medical procedures (3). It was decided the poster would be laminated
so the point scoring system that was recording the patient’s adherence could be wiped clean
at the beginning of each week. The football theme was chosen as James is a big football fan
and I felt it would engage him, especially with his ADHD. The form of a poster was chosen
as it was felt it would help minimise the patient’s anxiety while keeping James adherent to
physical and psychological exercises. The content of the resource consisted of some brief
pieces of information about the patient’s injury and a table to record how adherent the
patient was being to his pre-operative exercise programme.
A description of the patient’s knee injury was outline in the poster. This included some
information about how this injury occurred, what structure was damaged and other well-
known footballers who had also encountered the injury. Traumatic injuries can be a cause of
great anxiety to all individuals, particularly with paediatrics (3). Simply explaining the
situation in non-threatening age appropriate language can lead to a more positive patient
outlook(3). Often children’s verbal communication skills are not fully developed, they show
their emotions through behaviour (4). Common signs of anxiety can be withdrawal, lack of
cooperation and aggression(5). Communicating information about the patient’s injury and
their potential emotional response can help to normalise a daunting experience for them and
reduce the chances of the patient developing long term anxiety or depression (4). By
minimising levels of anxiety, we then minimise withdrawal and lack of cooperation, leading to
a better chance the patient will engage with the rehabilitation process.
A couple of paragraphs discuss what James can do to help himself and why his prescribed
activities will be so important to his recovery. Once more the purpose of the information is to
help reduce an anxiety and improve James’ engagement in the programme. The aim of the
information is to focus the patients attention on an objective, which may form a distraction to
worries the patient may harbour (4). Stating that the patient has the biggest part to play in
the success of his recovery should empower the patient while also showing the expectations
that have been placed on him. It is believed through giving the patient power in a powerless
situation and clearly setting out expectations can minimise healthcare induced distress for a
child (4). Focusing paediatric patients on one element of care can enable a better recovery
to an individual who has avoidant behaviours (4). Avoidant behaviours are associated with
an external locus of control – the patient believing that outcomes are outside of their
power(6–8). By promoting an internal locus of control, the patient is likely to feel empowered
and look for age specific information from their caregiver(4,6–8). Positive coping strategies
pre surgery are likely to relate to postoperative recovery (6). This is the reasoning behind
giving basic information as well as queues on how important the patients prescribed
activities are.
Authors Lerwick (4) and Stock, Hill and Babl (3) both qualitatively discuss the experiences of
children In healthcare settings. Both studies put an emphasis on the importance of
communication and methods to minimise anxiety in the child’s encounter. Neither study
measured levels of anxiety or how effective techniques are to minimise it. However both
studies create a step by step narrative of useful techniques to implement in healthcare
settings such as using the correct language, informing the patient about what is going to take
place and empowering the patient (3,4). Rodriguez et al. (5) carried out a multi-informant
multimethod assessment delving into behaviour distress of children caused by non-invasive
and non-painful procedures. 53 children between ages 4-10 were recruited who were
deemed ‘medically experienced’. The child’s distress along with the parent’s anxiety and
attitudes towards procedures were measured using a combination of scales and
questionnaires. A main finding from the study was that a child lacking in information and
knowledge around a procedure is likely to experience more distress.
LaMontagne (6,7) conducted two cohort studies both investigating the correlation between a
paediatric patient’s locus of control and their ability to cope preoperatively. A total of 93
subjects were recruited, with 51 and 42 subjects in each study. Participant ages ranged from
8- 18 years of age. Both studies conducted interviews and questionnaires with their subject
and were unanimous in their view that an internal locus of control correlated with a better
ability to cope. While both studies do measure outcome quantitatively, they are largely
subjective measures which may be open to interpretation. These studies do provide a
sufficient level of evidence, however, are relatively old studies.
The two qualitative studies (3,4) draw on a large body of evidence to support their narrative
and belong to peer reviewed Journals. While no treatment effectiveness is measured, the
studies do draw on ideas that could be seen as ‘common sense’, take testaments from
patients/parents and from other fields where these methods have been seen to be effective.
To make the evidence in favour of some of these techniques more compelling, controlled
trials could be carried out to determine their overall effectiveness in reducing patient anxiety.
Rodriguez et al (5)study does demonstrate more compelling evidence that lack of
information can lead to anxiety for the paediatric patient. It must be stated however, the
sample size is small with participants all being selected from the same hospital in New
Zealand.
While anxiety can be common for paediatrics in a healthcare setting (2), anxiety is also
commonly associated with patients who have ADHD (9). This means that minimising the
patient’s anxiety around the procedure will be all that more important. Lack of focus and
attention is seen as a symptom of ADHD. Due to this, a reminder for the patient to carry out
their mindfulness activities is included. Mindfulness involves encouraging the patient to keep
their thoughts in the present, while re-focusing back on the present if it wanders off (10). This
practise of refocusing the mind on the present may be of benefit to individuals with
ADHD(11). Along with this mindfulness interventions have been seen to have a positive
impact on individuals with anxiety and depression (12).
The evidence base in favour of using mindfulness exercises for children with ADHD and/or
suffering from anxiety consists of a two meta-analysis (11,13). Zoogman et al (11)conducted
a meta-analysis of published studies on mindfulness exercises on individuals under the age
of 18 years. The study’s purpose was to discover the effect size, most effective mode to
deliver and optimum frequency and duration for an intervention. 20 studies were included
with various outcomes such as levels of anxiety and depression, quality of life and attention.
Of the 20 studies, 12 had a control group. The study found an overall small effect size over
the broad range of studies with psychological symptoms exhibiting the greatest change. It
must be stated there was a high level of variety between study interventions and outcomes
that were measured which may affect the validity. There was also a relatively small number
of studies included. Khoury et al (13) conducted a similar meta-analysis with a larger number
of 209 studies being included. The study also pointed to a large effect on symptoms such as
anxiety and depression. It is worth nothing that this study included a range of ages and
clinical presentations, however the evidence for the use of mindfulness exercises to treat
anxiety is compelling.
The other main purpose of the resource and the information provided is to highlight the
importance of “prehabilitation” prior to the patience surgery and to actively encourage the
patient to adhere through documenting their work. The frequency of Anterior Cruciate
ligament Injuries is believed to be increasing in a number of populations including paediatrics
and adolescents(14). These two populations may have problems with adhering to a
rehabilitation programme (14). It is the belief of many surgeons that the reconstruction of the
ACL should not take place until the patient has regained full Range of Motion (ROM) (15).
Therefore, it would appear that an exercise programme will be an important element in
helping to restore ROM. Certain reports suggest that a time frame of greater than 12 weeks
post injury can increase the risk of meniscal damage (16). For this reason, it should be
treated more urgently, which is why a patient’s exercise programme will be of great
significance.
Prehabilitiation is defined as a process whereby functional capacity of a patient is improved

in order to allow them to withstand inactivity(17). Preoperative quadriceps strength may be
related to functionality of the knee post operatively (18). By improving the strength of the
quadriceps prior to surgery, patients may experience better outcomes post-surgery (18).
Adherence is important if a medical intervention is to be successful (19). Finding a way of
monitoring adherence in paediatric populations will be important, without appearing
judgemental to the child (19). Information related to the condition and the importance of the
treatment can allow paediatrics to become more adherent (19). The patient should receive
this information verbally but also with a written reminder (19). Visual reminders and notes to
be adherent can also serve as a great aid to the patient (19). Based on this information it
was decided to include information about the patient’s treatment and diagnosis and a table
to track adherence. The purpose of this was to act as a reminder while also allowing
adherence to be tracked.
Shaarani et al (18) examined the effects of a 6-week pre-operative resistance programme on

outcomes of the knee post ACLR. Single leg hop test and modified Cincinnati scores were
used as outcome measures and were found statistically significant compared to the control
group. However, this study had a relatively small sample size and follow up ended 3 months
post-surgery. In order to really gauge if pre-operative strengthening improves a patient’s
outcomes post-surgery a longer follow up would be more ideal, although the evidence is
promising. It must be stated this was not conducted on a paediatric population. Taddeo,
Egedy and Frappier (19) authored a qualitative study based around guidelines how to
identify low adherence in adolescents, the risk factors, how to monitor it as a clinician and
how to improve adherence. Although nothing is evaluated quantitively it offers a large body
of evidence, identifying the effects of low adherence and specific techniques clinicians can
take to treat adherence. The study is 12 years old and based on adolescents, however I felt
it could apply similarly to paediatrics and therefor was included in my resource.
To conclude, I have created a resource for a complex patient with little research available
that matches his exact clinical features. However, I have drawn on a significant body of
evidence based on individual conditions/features. The resource is unique to the patient – but
can easily be converted to suit many paediatric conditions. Based on the available evidence,
I feel the resource will be an effective tool the patient can use to support him during this
phase of recovery. As the patient progresses, particularly after surgery, the resource may
need to be altered.
Bibliograpy:
1. Kidd P, Health B. Attention Deficit/Hyperactivity Disorder (ADHD) in children:

Rationale for its integrative management Article in Alternative medicine review: a
journal of clinical therapeutic · November 2000 Cell biology View project Herbal
Nutraceutical Assessments View project [Internet]. [cited 2020 Jul 30]. Available from:
2. Lerwick J. Title: The Impact of Child-Centered Play Therapy on Anxiety Levels in Pre-
Neurosurgical Pediatric Patients [Internet]. 2011 [cited 2020 Jul 30]. Available from:
https://ir.library.oregonstate.edu/concern/graduate_thesis_or_dissertations/q237hv93
w
3. Stock A, Hill A, Babl FE. Practical communication guide for paediatric procedures.
Emerg Med Australas [Internet]. 2012 Dec 1 [cited 2020 Jul 30];24(6):641–6.
Available from: http://doi.wiley.com/10.1111/j.1742-6723.2012.01611.x
4. Lerwick JL. Minimizing pediatric healthcare-induced anxiety and trauma. World J Clin
Pediatr [Internet]. 2016 [cited 2020 Jul 8];5(2):143. Available from:
/pmc/articles/PMC4857227/?report=abstract
5. Rodriguez C, Clough V, psychology AG-… of pediatric, 2012 undefined. Multimethod

assessment of children’s distress during noninvasive outpatient medical procedures:
Child and parent attitudes and factors. academic.oup.com [Internet]. [cited 2020 Aug
5]; Available from: https://academic.oup.com/jpepsy/article-abstract/37/5/557/970258
6. Research LL-N, 1984 undefined. Children’s locus of control beliefs as predictors of

preoperative coping behavior. psycnet.apa.org [Internet]. [cited 2020 Aug 5]; Available
from: https://psycnet.apa.org/record/1985-07548-001
7. Research LL-N, 1987 undefined. Children’s preoperative coping: Replication and

extension. psycnet.apa.org [Internet]. [cited 2020 Aug 5]; Available from:
https://psycnet.apa.org/record/1988-24344-001
8. Rudolph KD, Dennig MD, Weisz JR. Determinants and Consequences of Children’s
Coping in the Medical Setting: Conceptualization, Review, and Critique. Vol. 118,
Psychological Bulletin. 1995.
9. Jarrett M, Wolff J, … TDI-J of attention, 2016 undefined. Characteristics of children

with ADHD and comorbid anxiety. journals.sagepub.com [Internet]. 2016 Jul 1 [cited
2020 Aug 6];20(7):636–44. Available from:
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HPYnskAAAAA:2i5eccxtndfqy93cI2os9StgHf4AsXqE6NvXwtZov9wCrOXmEBUxk1bZ
jXnlSkYQu3Y5ybMyprYz
10. Meppelink R, de Bruin EI, Bögels SM. Meditation or Medication? Mindfulness training
versus medication in the treatment of childhood ADHD: A randomized controlled trial.
BMC Psychiatry [Internet]. 2016 Jul 26 [cited 2020 Aug 6];16(1):1–16. Available from:
https://link.springer.com/articles/10.1186/s12888-016-0978-3
11. Goldberg SB, Hoyt WT. Mindfulness Interventions with Youth: A Meta-Analysis.
Springer [Internet]. [cited 2020 Aug 6]; Available from:
12. Hofmann SG, Gómez AF. Mindfulness-Based Interventions for Anxiety and
Depression [Internet]. Vol. 40, Psychiatric Clinics of North America. W.B. Saunders;
2017 [cited 2020 Aug 7]. p. 739–49. Available from:
/pmc/articles/PMC5679245/?report=abstract
13. Khoury B, Lecomte T, Fortin G, Masse M, Therien P, Bouchard V, et al. Mindfulness-

based therapy: A comprehensive meta-analysis. Vol. 33, Clinical Psychology Review.
Pergamon; 2013. p. 763–71.
14. Mall NA, Paletta GA. Pediatric ACL injuries: Evaluation and management. Curr Rev
Musculoskelet Med [Internet]. 2013 Jun [cited 2020 Jul 8];6(2):132–40. Available
from: /pmc/articles/PMC3702779/?report=abstract
15. Cipolla M, Scala A, Gianni E, Puddu G. Different patterns of meniscal tears in acute
anterior cruciate ligament (ACL) ruptures and in chronic ACL-deficient knees. Knee
Surgery, Sport Traumatol Arthrosc [Internet]. 1995 Sep [cited 2020 Aug 9];3(3):130–4.
Available from: http://link.springer.com/10.1007/BF01565470
16. Todd Lawrence JR, Argawal N, Ganley TJ. Degeneration of the Knee Joint in
Skeletally Immature Patients With a Diagnosis of an Anterior Cruciate Ligament Tear
Is There Harm in Delay of Treatment? journals.sagepub.com [Internet]. 2011 Dec 14
[cited 2020 Aug 9];39(12):2582–7. Available from:
https://journals.sagepub.com/doi/abs/10.1177/0363546511420818?casa_token=r2RQ
usm0Ze8AAAAA:xKSJbDEv6IU6fixsGViwaiF7TB3EA1kTmFFLUsCvY3qydwIVAqbLJ
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17. Ditmyer M, Topp R, Nursing MP-O, 2002 undefined. Prehabilitation in preparation for
orthopaedic surgery. journals.lww.com [Internet]. [cited 2020 Aug 9]; Available from:
https://journals.lww.com/orthopaedicnursing/Fulltext/2002/09000/Prehabilitation_in_Pr
eparation_for_Orthopaedic.8.aspx
18. Shaarani SR, Quinn A, Moyna N, Moran R, O JM. Effect of Prehabilitation on the
Outcome of Anterior Cruciate Ligament Reconstruction. [cited 2020 Aug 9]; Available
from: http://ajsm.sagepub.com/supplemental
19. Taddeo D, Egedy M, Frappier J-Y. Adherence to treatment in adolescents [Internet].

Vol. 13, Paediatr Child Health. Oxford University Press; 2008 [cited 2020 Jul 8].
Available from: /pmc/articles/PMC2528818/?report=abstract
Appendix:
Patient profile/bio
Name: James Douglas
DOB: 10/07/2006
Age: 14
P/C: R knee swelling and pain secondary to ACL injury 2/52 ago. Limited ROM and strength
deficits in quadriceps evident. Awaiting swelling to be eliminated and full ROM to return to
knee to have ACLR
HPC: Football game 2/52 ago. Challenging opponent player in the air. Got put off balance in
the air and landed on R knee which planted and hyperextend at time of injury. Immediate
pop and 7/10 pain felt. Couldn’t continue. ++swelling present. Went hospital next day and
had MRI. ACL rupture diagnosed. Patient is now at home and able to walk around. Feels
slight pains when turning sometime 2/10. He is now at a stage where he can work on Range
of Motion and strength prior to his surgery.
PMH: patient has previously been diagnosed with ADHD
DH: Methylphenidate, paracetamol, ibuprofen
SH: James is a big football fan and supports Chelsea and loves watching England. He is
also an academy footballer at Chelsea and hopes to make it professionally one day. He
attends the local school and likes meeting with his friends and gaming in his spare time
Patients perspective: James is feeling very anxious after his injury and is worried about his
leg, the surgery and whether he will be able to get back to playing at a high level
Goals: To get the patient into a positive mindset about the surgery and injury and encourage
them to adhere to the programme in order for the best outcomes
Resource:
Final Patient
Final Patient Pathways Resource.pdf Pathways Resource.pdf
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University of Essex

School of Sport, Rehabilitation and Exercise Sciences

SE720 Using Evidence in healthcare Practice

Student Number: 1900702

• Select 4 papers based on empirical research most directly related to your

Body Weight Supported Treadmill Training vs Body Weight Supported Overground

Functional Electrical Stimulation Vs Conventional Physiotherapy

Treadmill training with body weight support Vs Conventional Physiotherapy

1. Creasey G, Marino R, Tator C, Wilberger J. International Standards for Neurological

2. Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord

5. Evans N, Wingo B, Sasso E, Hicks A, Gorgey AS, Harness E. Exercise

6. Rajasekar A, Today VK-DI, 2019 undefined. Randomized controlled trials: Gold

7. Murad M, Asi N, … MA-BE-B, 2016 undefined. New evidence pyramid. ebm.bmj.com

10. Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of

11. Postans N, Hasler J, … MG-A of physical, 2004 undefined. Functional electric

14. Foley N, Teasell R, … SB-T in stroke, 2003 undefined. Stroke rehabilitation

20. Masani K, Popovic MR. Functional Electrical Stimulation in Rehabilitation and

Author Year Population Sample Intervention Outcomes measured

Senthilvelkumar 2011 Individuals 35 8 weeks of • walking index for

1. Livingstone DS-C, 2000 undefined. Evidence-Based Medicine, Edinburgh, UK.

School of Sport, Rehabilitation and Exercise Sciences

SE726 - Research Activity

26th May 2021

Word count: 7974

Name: Peter Smith

Academic Supervisor: Adrian Mallows

Contents: Page Number:

i. Contents page …………………………………………….. 1

ACL - Anterior Cruciate ligament

CSP - Chartered Society of Physiotherapy

MCL - Medial Collateral Ligament

NCAA - National Collegiate Athletic Association

PICO - Population, Intervention, Comparison, Outcome

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-analyses

Q Angle - Quadriceps angle

Literature Search and Study Selection:

Observational studies represent a good source of information when an experimental design

Records identified through Additional records identified

Records after duplicates removed

Records screened Records excluded

Full-text articles assessed

valgus, single leg

Figure 1: Flow diagram of included studies

Appraisal of Included studies

Table 1: Critical Appraisal

Author of Study and Score Percentage Methodological

Knee valgus angle

Other knee valgus measures

Biomechanical/neuromuscular factors have been suggested to be important factors

9.41-Eligibility of Trial Participants

Potential participants/participants parent/guardian that have initially consented to partake in

1. Griffin L, Agel J, Albohm M, … EA-J-J of the, 2000 undefined. Noncontact anterior

5. Olsen O-E, Myklebust G, Engebretsen L, Bahr R. Injury Mechanisms for Anterior

9. Nesbitt R, Herfat S, Boguszewski D, … AE-J of, 2014 undefined. Primary and

31];41(2):166–71. Available from: www.journalofathletictraining.org

26. Hammoudeh S, Gadelhaq W, Janahi I. Prospective Cohort Studies in Medical

27. Munro C. Reliability of two-dimensional video assessment of frontal plane dynamic

33. Prieske O, Demps M, Lesinski M, Granacher U. Combined Effects of Fatigue and

42. Peterson L, Junge A, Chomiak J, Graf-Baumann T, Dvorak J. Incidence of Football

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