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Post-traumatic elbow stiffness: Pathogenesis and current treatments. Zhang, D., Nazarian, A., & Rodriguez, E. (2018) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic, Therapeutic Topic: Post traumatic elbow stiffness - Aetiology and treatment This is a narrative review on aetiology and treatment of post-traumatic elbow stiffness. The aetiology of elbow stiffness is usually classified as intrinsic (e.g. osteophytes), extrinsic (e.g. heterotopic ossification), or mixed (intrinsic + extrinsic). The goal of treatment for elbow stifness is the re-establishment of 100° to 30° of elbow flexion/extension and 100° of pronation (50°) and supination (50°). Conservative treatment should aim at starting active mobilisation as soon as possible after the injury and introducing passive range of motion exercises at 6-12 weeks after injury/surgery. Delayed movemement interventions result in worse outcomes. Very little evidence supports the use of manual therapy in the recovery range of movement in post-traumatic elbow stiffness. Level 2b evidence (systematic review of cohort studies) supports the use of static progressive or dynamic bracing for post-traumatic elbow stiffness. It has been suggested that after 4 to 6 weeks of bracing, range of movement should improve by 30-40°. During the bracing period, care should be taken to avoid pressure sores and ulnar neuropathies (when splinting to regain elbow flexion). Surgical treatment is utilised when nonoperative treatments fails. Improvements following surgery range between 18° to 66° of elbow flexion/extension. Traumatic elbow osteoarthritis is a negative predicting factor for surgical success (surgery is less likely to be effective). The presence of heterotopic ossification is a positive predicting factor for surgical success (surgery is more likely to be effective). Clinical Take Home Message: Hand therapists may use a conservative trial of static progressive or dynamic bracing to treat post traumatic elbow stiffness. This should be trialled for 4-6 weeks to assess its effectiveness. Surgical intervention may be required if no improvements are noted with conservative treatment. URL: https://journals.sagepub.com/doi/abs/10.1177/1758573218793903

An exploratory investigation into the longevity of pain reduction following multisensory illusions designed to alter body perception. Barnard, A., Jansen, V., Swindells, M., Arundell, M., & Burke, F. (2020) Level of Evidence: 4 Follow recommendation: 👍 👍 Type of study: Therapeutic Topic: Hand osteoarthritis - Illusory resizing This is a case-series study assessing the effectiveness of illusory sensory resizing of the hand on pain in participants with hand osteoarthritis (OA). Participants (N = 38) were diagnosed with hand OA through clinical criteria. The illusory visual resizing was achieved through cameras and screens which the participants looked at. The visual resizing could either give the illusion of stretching or shrinking the hand. This visual illusion was coupled with either a gentle traction (for the stretching illusion) or compression (for the shrinking illusion) of the most painful finger to boost the illusion effect. Pain was assessed on a Numerical Rating Scale (NRS) immediately before and after the intervention. The intervention provided participants with an illusory sensory resizing (visual and traction/compression) lasting two minutes. Participants were also asked to report how long pain-relief lasted after the illusory resizing. The choice of which illusion (shrinking vs stretching) to utilise, was based on a baseline test identifying which provided the most pain relief. Out of 38 participants, 28 (74%) reported pain relief with one of the illusions. Of these 28 participants, 17 (60%) reported improvement with the stretching illusion and 11 (40%) with the shrinking illusion. The results showed that after two minutes of illusory resizing, the stretching illlusion improved pain by 1.5 points out of 10, and the shrinking illusion improved pain by 0.5 out of 10 points (difference between medians provided). The effect of the intervention lasted for four minutes in 16% of participants, 20 minutes in 68% of participants, and between 7 hours and 10 weeks in 16% of participants. There was no statistical difference between the two illusions on pain. Clinical Take Home Message: Hand therapists may trial imagery resizing coupled with gentle traction or compression of the most painful finger in people with hand OA. This intervention, may provide immediate small and short lasting pain relieving effects in people with hand OA. This regime may be trialled in patients that are unable to undergo other interventions supported by higher quality evidence (e.g. NSAIDs). URL: https://www.mskscienceandpractice.com/article/S2468-7812(19)30119-5/pdf

A randomized controlled trial of real versus sham acupuncture for basal thumb joint arthritis. Barnard, A., Jansen, V., Swindells, M., Arundell, M., & Burke, F. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Thumb osteoarthritis - Real vs Sham acupuncture This is a randomised double-blind placebo controlled trial assessing the effectiveness of acupuncture on pain in participants with thumb osteoarthritis (OA). Participants (N = 70) were diagnosed with 1st cmcj OA through clinical and/or radiological criteria. Participants were excluded if they had previously experienced acupuncture or if they presented any contraindications to acupuncture. Pain was assessed on a Visual Analogue Scale (VAS) 0 to 100 mm during thumb movement and gripping tasks. Treatment allocation was randomised. Participants and assessors were blinded to treatment allocation. Participants were provided with either real (n = 35) or telescopic (sham) (n = 35) acupuncture applied to 4-6 acupuncture points. The results showed that both groups improved to a statistically and clinically significant level in pain during thumb movement (Sham - Median change: 17; Interquarile range (IQR): -30 to 1; Real - Median change: -14; IQR: -38 to 11) and gripping (Sham - Median change: 19; IQR: -25 to 1; Real - Median change: -12; IQR: -26 to 1). No differences in pain during thumb movement or gripping were noticed between groups. Clinical Take Home Message: Acupuncture is as beneficial as sham acupuncture for pain relief. It appears that the effect of acupuncture is non specific and may be associated with the contextual effect of treatment and attention dedicated to the patient. URL: https://journals.sagepub.com/doi/full/10.1177/1753193420911326

Pain can be conditioned to voluntary movements through associative learning: An experimental study in healthy participants Alaiti, R., Zuccolo, P., Leite Hunziker, M., Caneiro, J., Vlaeyen, J., & Fernandes da Costa, M. (2020) Level of Evidence: 5 Follow recommendation: 👍 Type of study: Aetiologic Topic: Acute pain - Movement conditioning This is an experimental study assessing the effect of shoulder movement associated with a painful stimulus on the likelihood of perceiving pain in the presence of a non painful stimulus after the conditioning. A total of 34 healthy participants were included in the study. The assessment took place immediately before and after the pain conditioning. During the assessment, a non painful stimulus was delivered through an electrocutaneous current of low intensity at the acromion of the tested shoulder. During the assessment, participants were asked to report whether two shoulder movements (shoulder flexion/shoulder flexion with horizontal adduction) paired with the non painful stimuli were painful or not. During the conditioning, a painful stimuli (electrocutaneous current of high intensity) was delivered consistently to one of the shoulder movements described above (randomised among participants) for 50% of the trials. The conditioning phase lasted on average 2 minutes. The results showed that the painfully conditioned movement was reported as painful more often (85%; SD: 25%) compared to the non conditioned movement (73%; SD: 32%) when paired with the non painful stimuli after the conditioning. Clinical Take Home Message: Based on what we know today, our clients can develop a learned association between a specific movement and the perception of pain. It is possible that this leads to the experience of pain in the absence of tissue damage. Therapeutic interventions aiming to dissociate movement from pain may be useful in reducing the pain experience. URL: https://journals.lww.com/pain/Abstract/9000/zain_can_be_conditioned_to_voluntary_movements.98406.aspx publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Strain reduction of the extensor carpi radialis brevis tendon proximal origin following the application of a forearm support band. Takasaki, H., Aoki, M., Oshiro, S., Izumi, T., Hidaka, E., Fujii, M., & Tatsumi, H. (2008) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Forearm based orthosis This is an experimental study assessing extensor carpi radialis brevis (ECRB) tendon strain with or without a forearm based orthosis (strap) in cadavers. Eight cadavers' arms were prepared for this study. A strain gauge was positioned at the ECRB origin at the lateral epicondyle to measure tendon strain. The ECRB strain was measured under three different conditions, which included the sole application of a forearm based orthosis (∼ 5cm distal to lateral epicondyle) with a tension of 2 kg, a tensional load of 2.2 kg applied to the distal ECRB tendon, or with the combination of 2.2 kg tendon load and the forearm based orthosis. The study needs to be considered in the context of a few limitations. The experiment was performed in cadavers and in vivo studies may show different results. The load applied to ECRB (2.2 kg) equates to 10% of the maximum ECRB load. The results showed that the sole application of the forearm based orthosis did not cause any strain on the ECRB tendon. When ECRB was loaded with 2.2 kg, the tendon strain was 2.4%, indicating that the tendon was elongated 2.4% of its original lenght. When ECRB was loaded with 2.2 kg while the forearm based orthosis was applied, the tendon strain was 0.85%, indicating that the tendon was elonagated 0.85% of its original lenght (stretched on tendon was reduced by more than 50%). Clinical Take Home Message: Hand therapists may consider utilising a forearm based orthosis for patients with lateral epicondylalgia. This intervention appears to reduce the strain on ECRB proximal tendon through a mechanical effect. The effectiveness of this forearm based strap in reducing strain may be limited to light activities and not heavier manual tasks. URL: https://www.jospt.org/doi/abs/10.2519/jospt.2008.2672

Borderline nerve conduction velocities for median neuropathy at the carpal tunnel Kortlever, J., Becker, S., Zhao, M., & Ring, D. (2020) Level of Evidence: 3 Follow recommendation: 👍 👍 👍 Type of study: Diagnostic Topic: Uncertainty in carpal tunnel syndrome - Do nerve conduction studies help? This is a retrospective study assessing the number of patients presenting with a borderline nerve conduction study in patients suspected of having carpal tunnel syndrome (CTS). A total of 565 patients were included in the study. These patients had been referred by specialists or general practitiones for nerve conduction tests to confirm or exclude a diagnosis of CTS. Borderline nerve conduction studies were defined as results 10% above or 10% below the cutoff margin for CTS. The cutoff margins for the six different nerve conduction study criteria utilised were ≥3.6 ms (milliseconds) median nerve distal sensory latency (DSL), ≥4.4 ms median nerve distal motor latency (DML), ≤5mV (millivolt) median nerve motor amplitude, ≥0.4 ms difference in median-ulnar mixed nerve palmar latencies (sensory), ≥1 ms difference between sides on median DML, and ≥1.8 ms difference between median and ulnar DML on the same side. The results showed that if the cutoff values were utilised, 76% (n=407) of patients were diagnosed with CTS. When the criteria were extended to10% above or below the cutoff, 67% and 97.3% of the patients were diagnosed as having CTS respectively. All the nerve conduction studies criteria appeared to be highly specific (95-97%). If the test is specific and its result is positive, you can be more certain that the patient has the condition. The sensitivity of nerve conduction studies for CTS was low (21-97%). If a test is very sensitive and its result is negative, you can be more certain that the patient does not have the condition. Clinical Take Home Message: Hand therapists can be confident of a CTS diagnosis if nerve conduction studies identify a median nerve impairment. However, If nerve conduction studies are normal, it is not possible to exclude the presence of CTS. Often, mild compression neuropathies affect small nerve fibres (C and Aδ), which cannot be assessed by nerve conduction studies. If nerve conduction studies are negative, a thorough assessment to exclude proximal median neuropathies, radiculopathies, and polyneuropathies should be conducted. URL: https://www.jhandsurg.org/article/S0363-5023(20)30002-2/pdf

The influence of a positive empathetic interaction on conditioned pain modulation and manipulation induced analgesia in people with lateral epicondylalgia. Muhsen, A., Moss, P., Gibson, W., Walker, B., Jacques, A., Schug, S., & Wright, A. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Emphatic vs neutral interaction This is a randomised double-blind placebo controlled trial assessing the effect of empathy alone vs empathy and cervical mobilisations on endogenous analgesia and pain-free grip strength in participants with lateral epicondilalgia (LE). Participants (N = 68) were diagnosed with LE if they presented with pain on passive stretching of the wrist extensors, resisted contraction of the wrist and finger extensor, and experienced pain at the lateral epicondyle during palpation. If the clinical picture suggested the presence of any other pathology (e.g. cervical radiculopathy, other chronic pain conditions, or history of surgery/fracture in upper limb), participants were excluded. Endogenous analgesia was tested by assessing pain pressure thresholds at the elbow. Participants' pain-free grip strength was assessed on the pathological side only. The effect of empathy (n = 34) vs neutral interaction (n = 34) was measured both in isolation (at Time 1) or in combination with cervical lateral glides (at Time 2). In the empathic group, the interaction between research assistant and participants was supportive, positive, and friendly. For the neutral interaction, the research assistant did not pay much attention to the participants except for explaining the procedure associated with the testing and treatment. The results showed that the effect of an empathic interaction alone, improved endogenous analgesia by 13.5%, which almost doubled with the addition of cervical mobilisation to 25%. The effect of cervical mobilisations alone, without the adjunct of an emphatic interaction, improved endogenous analgesia by 9% from baseline. No differences in pain-free grip strength were noticed between groups. Clinical Take Home Message: A positive therapeutic interaction significantly improves the engodenous pain relieving abilities of patients with lateral epicondylalgia in the short term. When combined with cervical mobilisations, it appears that this effect is boosted. Empathetic bedside manners are a potent ally in patient care. URL: https://journals.lww.com/clinicalpain/Abstract/9000/The_Influence_of_a_Positive_Empathetic_Interaction.98726.aspx

Do multi-ingredient protein supplements augment resistance training-induced gains in skeletal muscle mass and strength? A systematic review and meta-analysis of 35 trials. O’Bryan, K., Doering, T., Morton, R., Coffey, V., Phillips, S., & Cox, G. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Strength gains - Multi-ingredient protein (MIP) vs protein only supplements This is a systematic review and meta-analysis assessing the effectiveness of multi-ingredient protein (MIP) vs protein only supplements on total body mass (kg), fat-free mass (kg), fat mass (kg), and maximum lifting ability (kg) after a strength straining period. Twelve studies were included for a total of 265 participants. The MIP included protein based supplements with the addition of creatine, creatine and carbohidrates, extra leucine or glutamine, β-Hydroxy β-methylbutyric acid (HMB), or polyunsaturated fatty acids (PUFAs). The protein only supplements included whey protein with or without caseine. Most studies provided participants with a dosage between 0.3 to 1.5g/kg/day of supplements in both groups. Assumption of the supplements was usually post-exercise. Strength training programs lasted on average 16(±14) weeks, with frequency of 3(±1)/week, 3(±1) sets, 9(±2) reps, with progressive overload during the training period. The results showed that there was no difference on total body mass (Mean difference-MD (kg): 0.65; 95%CI: -0.45 to 1.78), fat-free mass (MD (kg): 0.39; 95%CI: -0.28 to 1.05), and maximum lifting ability (MD (kg): 1.33; 95%CI: -3.81 to 6.48) between groups, although fat mass (MD (kg): 0.76; 95%CI: 0.13 to 1.40) was significantly greater in the MIP group. Clinical Take Home Message: There appears to be no benefit in taking multi-ingredient protein supplements when compared to protein only for strength gains. Hand therapists may advise their patients on these supplements if the aim of the rehabilitation is to increase muscle strength. Protein supplements may also be useful in patients over 40 years old in which sarcopenia leads to an average of 1% muscle mass loss per year. Hand therapists may also consider enquiring about protein intake in patients with healing wounds as their intake appears to help with scar formation. URL: https://bjsm.bmj.com/content/54/10/573.long

Evaluating the immediate effect of forearm and wrist orthoses on pain and function in individuals with lateral elbow tendinopathy: A systematic review Heales, L., McClintock, S., Maynard, S., Lems, C., Rose, J., Hill, C., Kean, C., & Obst, S. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Lateral epicondylalgia - Forearm and wrist orthoses This is a systematic review and meta-analysis assessing the short term effectiveness of wrist and forearm orthoses vs a control group on pain-free grip strength in people with lateral epicondylalgia. Seven studies were included for a total of 267 participants. Forearm orthoses included straps placed 2-5cm distally to the lateral epicondyle, or elbow sleves. Wrist orthoses were rigid splints supporting the wrist in extension. The control group wore either no orthoses, or a placebo orthoses. Pain-free grip strength was defined as the greates grip strength that participants could develop without pain. The assessment was completed immediately before and after the application of the orthoses. The results showed pain-free grip strength improved to a statistically significant level in participants wearing a forearm orthoses (mean difference: 2.5 kg; 95%CI: 0.5 to 4.5). No improvements in pain-free grip strength were noticed with wrist orthoses. These results suggest that the forearm orthosis improved pain-free grip, although the results may not be clinically meaningful. The quality of evidence supporting these results was low (GRADE) suggesting that the true effect may be substantially different from what has been presented. Clinical Take Home Message: Hand therapists may expect an immediate improvement in pain-free grip strength (between 0.5 and 4.5 kg) following the application of a forearm orthosis in patients with lateral epicondylalgia. This orthosis may be utilised as an adjunct to education and progressive upper limb strengthening in lateral epicondylalgia. URL: https://www.sciencedirect.com/science/article/abs/pii/S2468781219301419

Effect of weight-bearing wrist movement with carpal-stabilizing taping on pain and range of motion in subjects with dorsal wrist pain: A randomized controlled trial Kim, G., Weon, J., Kim, M., Koh, E., & Jung, D. (2020) Level of Evidence: 1b Follow recommendation: 👍 👍 👍 👍 Type of study: Therapeutic Topic: Non-specific dorsal wrist pain - Tight rigid vs elastic loose tape This is a randomised controlled trial on the effectiveness of tight rigid vs elastic tape on pain and wrist range of movement in people with non-specific dorsal wrist pain. A total of 30 participants with wrist extension limitation (<50°) and non-specific dorsal wrist pain were included. Non-specific dorsal wrist pain was defined as pain in absence of objective joint or soft tissue pathology that we can currently diagnose. Participants were randomised to a rigid tape (n = 15) or an elastic tape (n = 15) intervention. The rigid tape was applied tightly to the wrist, distally to the ulnar and radial styloid while the participant relaxed the hand in 45° of wrist flexion. The elastic tape (similar to kinesio tape) was applied in the same way but without any tension. Participants in both groups performed a wrist extension exercise, which was completed by moving the trunk while keeping the affected hand on a table. This exercise was performed pain-free once per day for 10 repetitions, holding for 10 seconds with 5 seconds rest in between repetitions. The intervention lasted for one week and outcomes were measured at baseline and after the intervention. Pain was assessed through the Visual Analogue Scale (VAS) while active wrist extension range of movement was assessed through an ultrasound-based motion-analysis system. One of the limitations of the study was that treatment allocation was not concealed. The results showed that pain reduced to a clinically significant level from baseline with the tight rigid tape (Mean difference: 2.4; 95%CI: 1.6 to 3.2 points out of 10), but not with the elastic tape (Mean difference: 0.7; 95%CI: 0.3 to 1.1 points out of 10). Active wrist extension range of movement improved to a clinically significant level with the tight rigid tape only (Mean difference: 12.6°; 95%CI: 9.9° to 15.4°). No adverse events were reported. Clinical Take Home Message: Hand therapists may consider utilising rigid tape as described above to improve pain and extension range of movement impairments in people with non-specific dorsal wrist pain. This treatment appears to have a short term analgesic effect and no evident adverse effects. URL: https://www.jhandtherapy.org/article/S0894-1130(18)30090-5/fulltext

Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: A systematic review with meta-analysis Chen, Z., & Baker, N. A. (2020) Level of Evidence: 1a- Follow recommendation: 👍 👍 👍 👍(4/4 Thumbs up) Type of study: Therapeutic Topic: Lateral epicondylalgia - Eccentric resistance training This is a systematic review and meta-analysis assessing the effectiveness of eccentric training vs other exercise interventions on pain, function, and strength in people with lateral epicondylalgia. Eight studies were included for a total of 504 participants. The eccentric training involved graded wrist extensors progressions, which lasted on average 4 weeks. The participants trained on average 6 times per week, performing 13 reps for 3 sets with one minute rest in between sets. The comparison groups performed mixed concentric-eccentric or concentric exercises without further training information being provided by the authors. Outcomes were measured before and after the training. The results showed that the eccentric training group improved to a statistically and clinically meaningful level compared to the group doing other forms of strength training on pain (Mean difference in pain: 2.7 points out of 10; 95% CI: 0 to 5.4 - Calculation based on Tyler et. al. 2010 standard deviation). The confidence intervals were large, suggesting that the analgesic response to eccentric exercises may be quite variable. No notable differences were noted in terms of function and strength between groups. Disclaimer: This publication was reviewed and assessed by one reviewer only and it reflects their interpretation. Readers should come to their own conclusions by reading the original article. Clinical Take Home Message: Based on what we know today, eccentric training exercises may be useful for patients with lateral epicondylalgia. Eccentric strengthening may provide greater pain relief compared to other forms of resistance training. Strengthening regimes involving concentric or a combination of eccentric-concentric contractions appear to be equally useful in improving strength and function. URL: https://doi.org/10.1016/j.jht.2020.02.002 Abstract Study Design: Meta-analysis. Introduction: Lateral elbow tendinopathy is a common condition with an annual incidence of up to 3% of the population. Eccentric strengthening has shown promise as a method to treat lateral elbow tendinopathy, but is unclear if it is superior to other forms of treatment. Purpose of the Study: The purpose of this study was to investigate the effectiveness of eccentric strengthening compared with other forms of strengthening and pain-relieving modalities on pain, strength, and function in people with lateral elbow tendinopathy. Methods: Five electronic databases were searched. Reference lists of selected articles were hand-searched. Outcomes were defined a priori. Meta-analyses were performed using a random effects model with standardized mean differences, test of heterogeneity, and sensitivity analyses. Results: Eight articles were included in this review. When comparing eccentric strengthening to other forms of strengthening and pain-relieving modalities, there were significant large effect size of 1.12 (CI: 0.31-1.93) and 1.22 (CI: 0.25-2.18) in reducing pain and improving function in the short-term, respectively. In long-term, results were inconclusive on all outcomes. Discussion: A treatment program using eccentric strengthening of adequate intensity and duration seemed to be most effective for treating lateral elbow tendinopathy. Conclusions: The state of science of best care for lateral elbow tendinopathy is still in its infancy. Large, high-quality randomized controlled trials with clearly defined strengthening regime are needed to determine optimal dosage to maximize treatment effects. Recommendations were provided based on careful synthesis of findings from this review and current evidence in literature. publications = Total number of papers citing this research supporting = Citation statements supporting the findings mentioning = Neutral citation statements contrasting = Citation statements not supporting the findings

Preseason shoulder range of motion screening and in-season risk of shoulder and elbow injuries in overhead athletes: systematic review and meta-analysis. Pozzi, F., Plummer, H. A., Shanley, E., Thigpen, C. A., Bauer, C., Wilson, M. L., & Michener, L. A. (2020) Level of Evidence: 1a Follow recommendation: 👍 👍 👍 👍 Type of study: Prognostic Topic: Elbow injury - risk factor This is a systematic review and meta-analysis assessing the usefulness of shoulder range of movement screening to predict upper limb injury in overhead athletes. The systematic review included prospective studies only. Shoulder flexion, shoulder internal and external rotation at 90° of shoulder abduction, and shoulder horizontal adduction were assessed. Injury was defined as any shoulder or elbow related complaint incurred in the season. A total of 7 studies were included in the meta-analysis. Overhead sports included baseball (n = 2471), handball (n = 535), softball (n = 103), swimming (n = 74), volleyball (n = 66), and tennis (n = 65). The results showed that shoulder external rotation on the throwing arm was a useful screening tool for professional baseball pitchers. Those players who did not present with an external rotation of the throwing arm of at least 5° greater than the contralateral, were twice as likely to injure their pitching shoulder or elbow. Limited evidence was available for the other overhead sports. This may be due to the small number of studies investigating athletes involved in other sports. Clinical Take Home Message: Hand therapists may test shoulder external rotation in professional baseball pitchers to assess their risk of developing an elbow or shoulder injury. Interventions aimed at modifying these impairments may be useful in reducing their risk of elbow and shoulder injury. URL: https://bjsm.bmj.com/content/early/2020/01/13/bjsports-2019-100698