Impact case study database

The annual prevalence of patellofemoral pain (PFP) in the general population is estimated to be around 23%. No standardised treatment for PFP exists, therefore physiotherapy treatment varies widely and comprises of a mixed package, or multimodal approach, which is delivered on a trial-and-error basis and leads to poor outcomes, with 90% of people reporting pain for at least four years following diagnosis. Our work demonstrates a paradigm shift by identifying specific patient sub-groups using six low cost, quick and simple clinical assessments requiring minimal equipment. This allows clinicians to identify subgroups and therefore provide targeted interventions for specific presentations, with the goal of improving patient outcomes in those unresponsive to treatment.

In order to implement the subgrouping, the app “Appatella” was developed [A]. This offers a direct link with our subgrouping algorithm without the need for complex calculations and incorporates instructions on how to perform the clinical assessments without the need for additional training. Appatella is a GDPR compliant, digital clinical tool available in both Android and Apple iOS formats, which consists of three main components. Firstly, a clinician interface, which allows subgrouping to guide treatment decision-making through the algorithm. Secondly, a clinician/patient interface which delivers clinical interventions, including outcome measures and reminders. Finally, a web-based database tool for clinicians and researchers that allows the creation and storage of clinical interventions with outcome measures. This uses a variety of media which can be deployed and implemented through the mobile app. The feedback received to date shows that clinicians recognise the subgroups and strongly support the need to develop a quick and simple system to allocate patients to these subgroups [B, C]. Since 2018 the beta version of Appatella has been downloaded by over 1,000 clinicians across 30 countries and is due to be released fully in late 2020. This will facilitate the assessment and subgrouping as well as the delivery of targeted treatments for this problematic condition.

In 2015 we presented the concept of a “ladder of intervention” for musculoskeletal knee problems at the World Confederation for Physical Therapy. This led to the development of the concept of assessing four key factors: Pain, Alignment, Strength and Stability (PASS). Our work has shown there are a number of interventions that can have a positive effect on all these factors. These include functional and proprioceptive knee bracing which we have demonstrated can help patients with Patellofemoral Pain, Anterior Cruciate Ligament injuries and knee Osteoarthritis [1,2,4,5]. The PASS concept has gained considerable clinical and commercial interest and has been incorporated into the marketing strategy for DJO inc., one of the largest providers of medical devices and services in the world [D]. We have had a significant impact on practitioners through over 200 invited talks to clinical groups, sports clubs, companies and academic groups in over 30 different countries across six continents since 2013, and a series of YouTube videos which have been viewed over 15,000 times [E]. This has had a positive effect on the prescription of knee bracing; for example, a seminar tour by Professor Richards in New Zealand in 2018 resulted in a 23% increase in knee brace sales, indicating a change in clinical practice with an increase in the prescription of knee bracing, this was directly attributed to the presentation of our research findings and was described as “a direct and measurable positive impact on our business” by the New Zealand sales manager for DJO Global [F]. This has subsequently produced a “noticeable shift of treatment in the rehabilitation space towards the use of functional bracing to aid in the improvement of movement patterns, reduce pain and immobility secondary to fear avoidance” which has led to changes in New Zealand’s Accident Compensation Corporation (ACC) policy, which now funds the prescription of lower limb bracing through physiotherapy and podiatry [F]. This is a significant development that emphasises the acceptance of bracing as an important part of the rehabilitation process and a way to get people back to work in less time than without bracing. Furthermore, seminars by Richards across the Asia Pacific region between 2014-2020, which considered the prescription of bracing for knee instability, has influenced the management of over 50,000 patients across Southeast Asia and has been directly attributed to our work [B, C, D, G]. Additionally, in South Africa in 2019, Richards ran a similar seminar series. In a survey of approximately 300 delegates, 88% indicated they would be likely or very likely to change their clinical practice as a result of what they had learned.

Up until 2017, South Korea has used Plaster of Paris casting for treating ankle fractures. In 2017, our work on Orthotic Walkers was submitted as evidence along with nine other papers to the National Health Insurance system in South Korea to promote the use of Orthotic Walkers over traditional treatment methods [D, I]. As a result, these devices were approved for use in clinical practice which included financial reimbursement. Estimates based on sales indicate that around 20,000 patients per year, who would have been treated using Plaster of Paris casting, are now been treated using Orthotic Walkers, which have been shown to provide a faster and more effective recovery [I]. In addition, our work features strongly in the marketing materials from DJO Inc., which has been used as marketing evidence on the efficacy of these devices [I]. DJO Inc. sell millions of these devices each year globally. These marketing materials are distributed to clinicians and consumers worldwide to help them make informed treatment choices.