Optimizing Total Knee Arthroplasty Rehabilitation with Telehealth Physical Activity Behavior Change Intervention: A Randomized Clinical Trial.

OBJECTIVE: Conventional total knee arthroplasty (TKA) rehabilitation has little impact on sedentary lifestyles that have negative long-term health consequences. The purpose of this trial was to determine the effect of telehealth-based physical activity behavior change intervention on physical activity and functional outcomes following TKA. METHODS: This study was a 2-arm, parallel randomized controlled superiority trial at a regional Veterans Affairs medical center. The participants were 92 US military Veterans (mean age = 65.7 [SD =7.8] y) undergoing unilateral TKA. The Physical Activity Behavior Change (PABC) intervention included telehealth-based self-management training (ten 30-minute sessions) delivered over 12 weeks. The control intervention included telehealth-based health education sessions that matched PABC frequency and duration. Both groups participated in standardized conventional outpatient rehabilitation. Physical activity, measured as average daily step count, was the primary outcome. Secondary outcomes were Life-Space Assessment questionnaire, 30-Second Chair-Stand test, Timed Up-and-Go Test, Six-Minute Walk test, Western Ontario and McMaster Universities Osteoarthritis Index, and Veterans RAND 12-Item Health Survey. The Self Efficacy for Exercise scale and daily time spent in different postures (sitting/lying, standing, stepping) were exploratory variables. Outcomes were measured at baseline (before surgery), mid-intervention (8 weeks after surgery), after the intervention (14 weeks after surgery; primary endpoint), and follow-up (38 weeks after surgery). RESULTS: The PABC group had an estimated 931 (95% CI = 42-1819) more daily steps than the control group from baseline to 14 weeks, though a between-group effect was not sustained at 38 weeks. There were no group differences in secondary outcomes. Participants included only military veterans using Veteran's Health Administration services. The intervention targeted self-management and did not include peer support. CONCLUSIONS: The PABC intervention improved physical activity for Veterans recovering from unilateral TKA at 14 weeks after surgery, though the effect was not sustained at 38 weeks. Physical function improved with rehabilitation but was not different between groups, indicating that physical function was not a primary driver of physical activity behavior. IMPACT: Conventional TKA rehabilitation has a negligible effect on free-living physical activity, which is relevant to long-term health outcomes. This trial identified telehealth physical activity self-management as effective in addressing activity behaviors, separate from conventional rehabilitation strategies.

Cumulative loading increases and loading asymmetries persist during walking for people with a transfemoral bone-anchored limb.

BACKGROUND: A bone-anchored limb (BAL) is an alternative to a traditional socket-type prosthesis for people with transfemoral amputation. Early laboratory-based evidence suggests improvement in joint and limb loading mechanics during walking with a BAL compared to socket prosthesis use. However, changes in cumulative joint and limb loading measures, which may be predictive of degenerative joint disease progression, remain unknown. RESEARCH QUESTION: Do cumulative total limb and hip joint loading during walking change using a BAL for people with unilateral transfemoral amputation, compared to prior socket prosthesis use? METHODS: A case-series cohort of eight participants with prior unilateral transfemoral amputation who underwent BAL hardware implantation surgery were retrospectively analyzed (4 M/4 F; BMI: 27.7 ± 3.1 kg/m2; age: 50.4 ± 10.2 years). Daily step count and whole-body motion capture data were collected before (using socket prosthesis) and one-year after BAL hardware implantation. Cumulative total limb and hip joint loading and between-limb loading symmetry metrics were calculated during overground walking at both time points and compared using Cohen's d effect sizes. RESULTS: One year after BAL hardware implantation, participants demonstrated bilateral increases in cumulative total limb loading (amputated: d = -0.65; intact: d = -0.72) and frontal-plane hip moment (amputated: d = -1.29; intact: d = -1.68). Total limb loading and hip joint loading in all planes remained asymmetric over time, with relative overloading of the intact limb in all variables of interest at the one-year point. SIGNIFICANCE: Despite increases in cumulative total limb and hip joint loading, between-limb loading asymmetries persist. Habitual loading asymmetry has been implicated in contributing to negative long-term joint health and onset or progression of degenerative joint diseases. Improved understanding of methods to address habitual loading asymmetries is needed to optimize rehabilitation and long-term joint health as people with transfemoral amputation increase physical activity when using a BAL.

Dynamic gait stability and stability symmetry for people with transfemoral amputation: A case-series of 19 individuals with bone-anchored limbs.

For some individuals with severe socket-related problems, prosthesis osseointegration directly connects a prosthesis to the residual limb creating a bone-anchored limb (BAL). We compared dynamic gait stability and between-limb stability symmetry, as measured by the Margin of Stability (MoS) and the Normalized Symmetry Index (NSI), for people with unilateral transfemoral amputation before and one-year after BAL implantation. The MoS provides a mechanical construct to assess dynamic gait stability and infer center of mass and limb control by relating the center of mass and velocity to the base of support. Before and one-year after BAL implantation, 19 participants walked overground at self-selected speeds. We quantified dynamic gait stability anteriorly and laterally at foot strike and at the minimum lateral MoS value. After implantation, we observed decreased lateral MoS at foot strike for the amputated (MoS mean(SD) %height; pre: 6.6(2.3), post: 5.9(1.3), d = 0.45) and intact limb (pre: 6.2(1.2), post: 5.8(1.0), d = 0.38) and increased between-limb MoS symmetry at foot strike (NSI mean(SD) %; anterior-pre: 10.3(7.3), post: 8.4(3.6), d = 0.23; lateral-pre: 18.8(12.4), post: 12.4(4.9), d = 0.47) and at minimum lateral stability (pre: 28.1(18.1), post: 19.2(6.8), d = 0.50). Center of mass control using a BAL resulted in dynamic gait stability more similar between limbs and may have reduced the adoption of functional asymmetries. We suggest that improved between-limb MoS symmetry after BAL implantation is likely due to subtle changes in individual limb MoS values at self-selected walking speeds resulting in an overall positive impact on fall risk through improved center of mass and prosthetic limb control.

The biomechanical influence of transtibial Bone-Anchored limbs during walking.

Individuals with unilateral transtibial amputation (TTA) using socket prostheses demonstrate asymmetric joint biomechanics during walking, which increases the risk of secondary comorbidities (e.g., low back pain (LBP), osteoarthritis (OA)). Bone-anchored limbs are an alternative to socket prostheses, yet it remains unknown how they influence multi-joint loading. Our objective was to determine the influence of bone-anchored limb use on multi-joint biomechanics during walking. Motion capture data (kinematics, ground reaction forces) were collected during overground walking from ten participants with unilateral TTA prior to (using socket prostheses) and 12-months after bone-anchored limb implantation. Within this year, each participant completed a rehabilitation protocol that guided progression of loading based on patient pain response and optimized biomechanics. Musculoskeletal models were developed at each testing timepoint (baseline or 12-months after implantation) and used to calculate joint kinematics, internal joint moments, and joint reaction forces (JRFs). Analyses were performed during three stance periods on each limb. The between-limb normalized symmetry index (NSI) was calculated for joint moments and JRF impulses. Discrete (range of motion (ROM), impulse NSI) dependent variables were compared before and after implantation using paired t-tests with Bonferroni-Holm corrections while continuous (ensemble averages of kinematics, moments, JRFs) were compared using statistical parametric mapping (p < 0.05). When using a bone-anchored limb, frontal plane pelvic (residual: pre = 9.6 ± 3.3°, post = 6.3 ± 2.5°, p = 0.004; intact: pre = 10.2 ± 3.9°, post = 7.9 ± 2.6°, p = 0.006) and lumbar (residual: pre = 15.9 ± 7.0°, post = 10.6 ± 2.5°, p = 0.024, intact: pre = 17.1 ± 7.0°, post = 11.4 ± 2.8°, p = 0.014) ROM was reduced compared to socket prosthesis use. The intact limb hip extension moment impulse increased (pre = -11.0 ± 3.6 Nm*s/kg, post = -16.5 ± 4.4 Nm*s/kg, p = 0.005) and sagittal plane hip moment impulse symmetry improved (flexion: pre = 23.1 ± 16.0 %, post = -3.9 ± 19.5 %, p = 0.004, extension: pre = 29.2 ± 20.3 %, post = 8.7 ± 22.9 %, p = 0.049). Residual limb knee extension moment impulse decreased compared to baseline (pre = 15.7 ± 10.8 Nm*s/kg, post = 7.8 ± 3.9 Nm*s/kg, p = 0.030). These results indicate that bone-anchored limb implantation alters multi-joint biomechanics, which may impact LBP or OA risk factors in the TTA population longitudinally.

Blood Flow Restriction and Veterans With Multiple Sclerosis and Advanced Disability: Protocol for a Randomized Controlled Trial.

OBJECTIVE: The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS). METHODS: This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05). IMPACT: There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS.

How Comprehensive and Efficient Are Patient-Reported Outcome Measures for Individuals with Lower Extremity Amputation Undergoing Implantation of Osseointegrated Bone Anchored Limbs?

¼ Patient-reported outcome measures (PROMs) are essential for measuring quality and functional outcomes after implantation of osseointegrated bone anchored limbs for patients with lower extremity amputation.¼ Using a novel assessment criterion with 8 domains, this study assessed all commonly used PROMs for their efficiency and comprehensiveness.¼ Comprehensiveness was scored according to the presence or absence of PROM questions related to these 8 domains (maximum score = 60): mobility (15 items), prosthesis (14 items), pain (10 items), psychosocial status (10 items), independence/self-care (4 items), quality of life/satisfaction (4 items), osseoperception (1 item), general information (1 item), and vitality (1 item).¼ The efficiency scores were calculated by dividing the comprehensiveness score by the total number of questions answered by the patients with higher scores being deemed more efficient.¼ The most comprehensive PROMs were Orthotics and Prosthetics User's Survey-Lower Extremity Functional Status (OPUS-LEFS) (score = 36), Prosthesis Evaluation Questionnaire (PEQ) (score = 31), and Questionnaire for Persons with a Transfemoral Amputation (score = 27).¼ The most efficient PROMs were the OPUS-LEFS (score = 1.8) and European Quality of Life (score = 1.4).

Lumbopelvic movement coordination during walking improves with transfemoral bone anchored limbs: Implications for low back pain.

BACKGROUND: Low back pain (LBP) is more prevalent in patients with transfemoral amputation using socket prostheses than able-bodied individuals, in part due to altered spinal loading caused by aberrant lumbopelvic movement patterns. Early evidence surrounding bone-anchored limb functional outcomes is promising, yet it remains unknown if this novel prosthesis influences LBP or movement patterns known to increase its risk. RESEARCH QUESTION: How are self-reported measures of LBP and lumbopelvic movement coordination patterns altered when using a unilateral transfemoral bone-anchored limb compared to a socket prosthesis? METHODS: Fourteen patients with unilateral transfemoral amputation scheduled to undergo intramedullary hardware implantation for bone-anchored limbs due to failed socket use were enrolled in this longitudinal observational cohort study (7 F/7 M, Age: 50.2±12.0 years). The modified Oswestry Disability Index (mODI) (self-reported questionnaire) and whole-body motion capture during overground walking were collected before (with socket prosthesis) and 12-months following bone-anchored limb implantation. Lumbopelvic total range of motion (ROM) and continuous relative phase (CRP) segment angles were calculated during 10 bilateral gait cycles. mODI, total ROM, CRP and CRP variabilities were compared between time points. RESULTS: mODI scores were significantly reduced 12-months after intramedullary hardware implantation for the bone-anchored limb (P = 0.013). Sagittal plane trunk and pelvis total ROM during gait were reduced after implantation (P = 0.001 and P < 0.001, respectively). CRP values were increased (more anti-phase) in the sagittal plane during single limb stance and reduced (more in-phase) in the transverse plane during pre-swing of the amputated limb gait cycle (P << 0.001 and P = 0.029, respectively). No differences in CRP values were found in the frontal plane. SIGNIFICANCE: Decreases in mODI scores and lumbopelvic ROM, paired with the changes in lumbopelvic coordination, indicate that bone-anchored limbs may reduce LBP symptoms and reduce compensatory movement patterns for people with unilateral transfemoral amputation.

Development and alpha testing of a patient shared decision aid for prosthesis design for new lower limb prosthesis users.

BACKGROUND: After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user's needs, values, and preferences. OBJECTIVE: To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility. STUDY DESIGN: Exploratory mixed methods. METHODS: PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10. RESULTS: The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users. DISCUSSION: The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users' informational needs. Future iterations of the PDA should undergo beta testing in clinical settings. CONCLUSIONS: A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

Chronotropic Incompetence During Exercise Testing as a Marker of Autonomic Dysfunction in Individuals with Early Parkinson's Disease.

BACKGROUND: An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker of autonomic dysfunction and a cause of exercise intolerance in early stages of PD. OBJECTIVE: To investigate the relationship between chronotropic incompetence, orthostatic blood pressure change (supine - standing), and exercise performance (maximal oxygen consumption, VO2peak) in individuals with early PD within 5 years of diagnosis not on dopaminergic medications. METHODS: We performed secondary analyses of heart rate and blood pressure data from the Study in Parkinson's Disease of Exercise (SPARX). RESULTS: 128 individuals were enrolled into SPARX (63.7±9.3 years; 57.0% male, 0.4 years since diagnosis [median]). 103 individuals were not taking chronotropic medications, of which 90 had a normal maximal heart rate response to exercise testing (155.3±14.0 bpm; PDnon-chrono) and 13 showed evidence of chronotropic incompetence (121.3±11.3 bpm; PDchrono, p < 0.05). PDchrono had decreased VO2peak compared to PDnon-chrono (19.7±4.5 mL/kg/min and 24.3±5.8 mL/kg/min, respectively, p = 0.027). There was a positive correlation between peak heart rate during exercise and the change in systolic blood pressure from supine to standing (r = 0.365, p < 0.001). CONCLUSIONS: A subgroup of individuals with early PD not on dopaminergic medication had chronotropic incompetence and decreased VO2peak, which may be related to autonomic dysfunction. Evaluation of both heart rate responses to incremental exercise and orthostatic vital signs may serve as biomarkers of early autonomic impairment and guide treatment. Further studies should investigate whether cardiovascular autonomic dysfunction affects the ability to exercise and whether exercise training improves autonomic dysfunction.

Walking Exercise Sustainability Through Telehealth for Veterans With Lower-Limb Amputation: A Study Protocol.

OBJECTIVE: This randomized controlled superiority trial will determine if an 18-month telehealth walking exercise self-management program produces clinically meaningful changes in walking exercise sustainability compared to attention-control education for veterans living with lower-limb amputation. METHODS: Seventy-eight participants with lower-limb amputation (traumatic or nontraumatic) aged 50 to 89 years will be enrolled. Two groups will complete 6 one-on-one intervention sessions, and 6 group sessions over an 18-month intervention period. The experimental arm will receive a self-management program focusing on increasing walking exercise and the control group will receive attention-control education specific to healthy aging. Daily walking step count (primary outcome) will be continuously monitored using an accelerometer over the 18-month study period. Secondary outcomes are designed to assess potential translation of the walking exercise intervention into conventional amputation care across the Veteran Affairs Amputation System of Care. These secondary outcomes include measures of intervention reach, efficacy, likelihood of clinical adoption, potential for clinical implementation, and ability of participants to maintain long-term exercise behavior. IMPACT: The unique rehabilitation paradigm used in this study addresses the problem of chronic sedentary lifestyles following lower-limb amputation through a telehealth home-based walking exercise self-management model. The approach includes 18 months of exercise support from clinicians and peers. Trial results will provide rehabilitation knowledge necessary for implementing clinical translation of self-management interventions to sustain walking exercise for veterans living with lower-limb amputation, resulting in a healthier lifestyle.

The Amputated Limb Gluteus Medius is Biomechanically Disadvantaged in Patients with Unilateral Transfemoral Amputation.

Patients with transfemoral amputation (TFA) are at an increased risk of secondary musculoskeleteal comorbidities, primarily due to asymmetric joint loading. Amputated limb muscle weakness is also prevalent in the TFA population, yet all factors that contribute to muscle strength and thus joint loading are not well understood. Our objective was to bilaterally compare gluteus medius (GMED) muscle factors (volume, fatty infiltration, moment arm) that all contribute to joint loading in patients with TFA. Quantitative magnetic resonance (MR) images of the hip were collected from eight participants with unilateral TFA (2M/6F; age: 47.3 ± 14.7 y/o; BMI: 25.4 ± 5.3 kg/m2; time since amputation: 20.6 ± 15.0 years) and used to calculate normalized GMED muscle volume and fatty infiltration. Six participants participated in an instrumented gait analysis session that collected whole-body kinematics during overground walking. Subject-specific musculoskeletal models were used to calculate bilateral GMED (anterior, middle, posterior) moment arms and frontal plane hip joint angles across three gait cycles. Differences in volume, fatty infiltration, hip adduction-abduction angle, and peak moment arms were compared between limbs using paired Cohen's d effect sizes. Volume was smaller by 36.3 ± 18.8% (d = 1.7) and fatty infiltration was greater by 6.4 ± 7.8% (d = 0.8) in the amputated limb GMED compared to the intact limb. The amputated limb GMED abduction moment arms were smaller compared to the intact limb for both overground walking (anterior: d = 0.9; middle: d = 0.1.2) and during normal range of motion (anterior: d = 0.8; middle: d = 0.8) while bilateral hip adduction-abduction angles were similar during overground walking (d = 0.5). These results indicate that in patients with TFA, the amputated limb GMED is biomechanically disadvantaged compared to the intact limb, which may contribute to the etiology of secondary comorbidities. This population might benefit from movement retraining to lengthen the amputated limb GMED abduction moment arm during gait.

Daily steps and stepping cadence increase one-year following prosthesis osseointegration in people with lower-limb amputation.

PURPOSE: People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes. This study evaluated the effect of lower-limb prosthesis osseointegration on physical activity, including daily steps and stepping cadence. METHODS: Free-living walking activity was assessed from 14 patients scheduled to undergo prosthesis osseointegration at two time points (within 2 weeks prior to osseointegration surgery and 12-months following). Daily step count, stepping time, number of walking bouts, average step cadence per bout, maximum step cadence per bout, and time spent in bands of step cadence were compared before and after osseointegration. RESULTS: Twelve months after prosthesis osseointegration, participants increased daily steps, daily stepping time, average step cadence, and maximum cadence per walking bout compared to pre-osseointegration. CONCLUSIONS: Participants engaged in more daily steps, higher stepping cadence, and longer bouts at higher cadence one year following osseointegration compared to when using a socket prosthesis. As a novel intervention that is becoming more common, it is important to understand walking activity outcomes as these are critical for long-term health.

People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes.Daily step count, walking bouts, and step cadence during free-living walking activity are promising measures to capture physical functional performance in patients with lower-limb amputation.This study shows that patients with osseointegrated prostheses increase their stepping activity, including daily steps, number of bouts, and stepping cadence compared to when using a socket prosthesis, which has positive implications on overall patient health.As a novel intervention that is becoming more common, it is important for clinicians, patients, and researchers to understand expectations for walking activity outcomes as a critical factor in long-term patient health after prosthesis osseointegration.

Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption.

OBJECTIVE: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. METHODS: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. RESULTS: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. CONCLUSION: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. IMPACT: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Incorporating Functional Strength Integration Techniques During Total Hip Arthroplasty Rehabilitation: A Randomized Controlled Trial.

OBJECTIVE: Total hip arthroplasty (THA) is a common orthopedic procedure that alleviates pain for millions of individuals. Yet, persistent physical function deficits, perhaps associated with movement compensations, are observed after THA. These deficits negatively affect quality of life and health for many individuals. Functional strength integration (FSI) techniques combine muscle strength training with specific movement retraining to improve physical function. This study aimed to determine if FSI would improve functional performance through remediation of movement compensations for individuals after THA. METHODS: A double-blind randomized controlled trial was conducted. Ninety-five participants were randomized to either the FSI or control (CON) group for an 8-week intervention. The FSI protocol included exercise to improve muscular control and stability around the hip to minimize movement compensation during daily activity. The CON protocol included low-load resistance exercise, range-of-motion activities, and patient education. Functional performance, muscle strength, and self-reported outcomes were measured preoperatively, midway and after intervention, and 6 months after THA. Change from preoperative assessment to each time point was measured, and between-group differences were assessed. RESULTS: There were minimal differences in outcomes between groups at the first postoperative assessment. There were no statistically significant between-group differences in the later assessments, including the primary endpoint. Both groups improved functional outcomes throughout the study period. CONCLUSION: The FSI intervention did not result in greater improvements in function after THA compared to the CON intervention. Future work should further investigate additional biomechanical outcomes, timing of the FSI protocol, effective dosing, and patient characteristics predictive of success with FSI. IMPACT: Recovery after THA is complex, and individuals after THA are affected by persistent movement deficits that affect morbidity and quality of life. The present study suggests that either approach to THA rehabilitation could improve outcomes for patients, and that structured rehabilitation programs may benefit individuals after THA.

Maximal daily stepping cadence partially explains functional capacity of individuals with end-stage knee osteoarthritis.

BACKGROUND: Individuals with end-stage knee osteoarthritis (OA) walk at a lower intensity (ie, slower step cadence) contributing to worse physical function. Previous literature reports daily step counts and sedentary time, with little information regarding stepping bouts or cadence. Determining relationships between daily higher stepping cadence duration and clinical outcomes can move the field toward optimal daily stepping prescription. OBJECTIVE: To quantify daily physical activity patterns of individuals with end-stage knee OA and determine the contribution of high stepping cadence to explain functional capacity variability. DESIGN: Cross-sectional analysis. SETTING: Veterans Administration medical center. PARTICIPANTS: U.S. military veterans (n = 104; age: 67.1 years [7.2]; mean [SD]; male [89.3%]) with end-stage knee OA were enrolled. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Functional capacity (6-Minute Walk Test [6MWT]). Physical activity (activPAL wearable sensor; cadence and time sitting, standing, and stepping), pain (Western Ontario and McMaster Universities Osteoarthritis Index-pain subscale) sociodemographic variables, and comorbidities (body mass index and Functional Comorbidity Index) are the main explanatory variables. RESULTS: Participants' wake time was mainly sitting (11.0 h/day) in ≥60-minute bouts (29.7% ± 12.7 of sitting time). Standing (3.4 hours/day) and stepping (1.4 h/day) primarily occurred in 0-5 minute bouts (standing: 87.7% ± 14.4 of standing time, stepping: 98.7% ± 12.7 of stepping time) and stepping cadence was predominantly incidental (1-19 spm; 52.9% ± 9.6 of total stepping time). Backward elimination model results indicated shorter medium-to-brisk cadence bout duration, older age, and higher pain significantly explained shorter 6MWT distance (Adj R2 =0.24, p < .01). CONCLUSIONS: Individuals with knee OA spend most of their waking hours sitting, while standing and stepping occurs in short bouts at very low stepping cadence. Decreased time in high stepping cadence is associated with lower functional capacity. Future studies should explore if increasing the daily time spent in higher step cadence can improve functional capacity in this population.

Unilateral transfemoral osseointegrated prostheses improve joint loading during walking.

People with unilateral transfemoral amputation using socket prostheses are at increased risk for developing osteoarthritis in both the residual hip and intact lower-limb joints. Osseointegrated prostheses are a surgical alternative to socket prostheses that directly attach to the residual femur via a bone-anchored implant, however their multi-joint loading effect is largely unknown. Our objective was to establish how osseointegrated prostheses influence joint loading during walking. Motion capture data (kinematics, ground reaction forces) were collected from 12 participants at baseline, with socket prostheses, and 12-months after prosthesis osseointegration during overground walking at self-selected speeds. Subject-specific musculoskeletal models were developed at each timepoint relative to osseointegration. Internal joint moments were calculated using inverse dynamics, muscle and joint reaction forces (JRFs) were estimated with static optimization. Changes in internal joint moments, JRFs, and joint loading-symmetry were compared using statistical parametric mapping (p≤ 0.05) before and after osseointegration. Amputated limb hip flexion moments and anterior JRFs decreased during terminal stance (p = 0.002, <0.001; respectively), while amputated limb hip abduction moments increased during mid-stance (p < 0.001), amputated hip rotation moment changed from internal to external throughout early stance (p < 0.001). Intact limb hip extension and knee flexion moments (p = 0.028, 0.032; respectively), superior and resultant knee JRFs (p = 0.046, 0.049; respectively) decreased during the loading response following prosthesis osseointegration. These results may indicate that the direct loading transmission of these novel prostheses create a more typical mechanical environment in bilateral joints, which is comparable with loading observed in able-bodied individuals and could decrease the risk of development or progression of osteoarthritis.

Changes in lower extremity joint moments one-year following osseointegration in individuals with Transfemoral lower-limb amputation: A case series.

BACKGROUND: Dissatisfaction with socket prostheses has led to the development of bone-anchored prostheses through osseointegration for people with transfemoral amputation, eliminating the need for a prosthetic socket. Gait deviations of transfemoral prosthesis users may be linked to increased risk of osteoarthritis, and it remains unknown if gait biomechanics change following osseointegration. The purpose of this case series was to evaluate the longitudinal changes in joint kinetics one year post-osseointegration in patients with transfemoral amputation during walking. METHODS: Knee, hip, and trunk internal moments were evaluated in the prosthetic and intact limbs during walking at a self-selected speed in four participants pre- and one-year post-osseointegration. Longitudinal changes were quantified using the percent change (%∆) in peak joint moments between the two time points and Cohen's d (d) effect size was used to determine the magnitude of effect on joint moments during walking one year following osseointegration. FINDINGS: Participants demonstrated increased peak knee extension moment (224 ± 308%∆, d = -1.31) in the prosthetic limb, while demonstrating reduced peak knee extension moment (-43 ± 34%∆, d = 1.82) in the intact limb post-osseointegration. Participants demonstrated bilateral reduction of peak hip extension moment (prosthetic: -22 ± 37%∆, d = 0.86; intact: -29 ± 10%∆, d = 1.27) and bilateral increase of peak hip abduction moment (prosthetic: 45 ± 40%∆, d = 1.20; intact: 23 ± 44%∆, d = 0.74) post-osseointegration. Participants demonstrated reduced peak trunk moments on both the prosthetic (extension: -31 ± 16%∆, d = 1.51; lateral flexion: -21 ± 20%∆, d = 0.63) and intact side (extension: -7 ± 22%∆, d = 0.38; lateral flexion: -22 ± 18%∆, d = 1.12) post-osseointegration. INTERPRETATION: This case series suggests improved gait symmetry in individuals with transfemoral amputation one year following osseointegration, justifying future investigation.

Reliability, Validity, and Responsiveness of the Patient-Specific Functional Scale for Measuring Mobility-Related Goals in People With Multiple Sclerosis.

BACKGROUND AND PURPOSE: This study's purpose was to investigate the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) for measuring mobility-related goals in people with multiple sclerosis (MS). METHODS: Data from 32 participants with MS who underwent 8 to 10 weeks of rehabilitation were analyzed (Expanded Disability Status Scale scores 1.0-7.0). For the PSFS, participants identified 3 mobility-related areas where they had difficulty and rated them at baseline, 10 to 14 days later (before starting intervention), and immediately after intervention. Test-retest reliability and response stability of the PSFS were calculated using the intraclass correlation coefficient (ICC 2,1 ) and minimal detectable change (MDC 95 ), respectively. Concurrent validity of the PSFS was determined with the 12-item Multiple Sclerosis Walking Scale (MSWS-12) and the Timed 25-Foot Walk Test (T25FW). PSFS responsiveness was determined using Cohen's d , and minimal clinically important difference (MCID) was calculated based on patient-reported improvements on a Global Rating of Change (GRoC) scale. RESULTS: The PSFS total score demonstrated moderate reliability (ICC 2,1 = 0.70, 95% CI: 0.46 to 0.84) and the MDC was 2.1 points. At baseline, the PSFS was fairly and significantly correlated with the MSWS-12 ( r = -0.46, P = 0.008) but not with the T25FW. Changes in the PSFS were moderately and significantly correlated with the GRoC scale (ρ = 0.63, P < 0.001), but not with MSWS-12 or T25FW changes. The PSFS was responsive ( d = 1.7), and the MCID was 2.5 points or more to identify patient-perceived improvements based on the GRoC scale (sensitivity = 0.85, specificity = 0.76). DISCUSSION AND CONCLUSIONS: This study supports the use of the PSFS as an outcome measure in people with MS to assess mobility-related goals.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A423 ).

Improvements in disability and function in people with lower-limb amputation one year after prosthesis osseointegration.

BACKGROUND: People with lower-limb amputation (LLA) are routinely prescribed a socket prosthesis; however, many socket prosthesis users experience severe complications with the fit of their prosthesis including residual limb wounds and pain. Osseointegration is a procedure that creates a direct connection between the bone and prosthetic limb through a bone-anchored prosthesis, eliminating the need for a socket interface. It is offered as a secondary procedure to people with LLA who experience significant complications with socket prostheses. OBJECTIVES: To evaluate change in disability and function 1 year postosseointegration compared with preosseointegration in people with LLA. STUDY DESIGN: Single group, pretest, and post-test. METHODS: Twelve participants (9 transfemoral and 3 transtibial amputations, age: 44 ± 10 years, 7 female participants, 14 ± 12 years since amputation) with unilateral LLA underwent osseointegration with press-fit implants. Disability was measured with the World Health Organization Disability Assessment Schedule 2.0, and function was measured with both Prosthetic Limb Users Mobility Survey and the Activities-Specific Balance Confidence Scale. Questionnaires were administered preosseointegration and 1 year postosseointegration. Paired t tests assessed change in outcomes between time points. RESULTS: Postosseointegration, participants demonstrated reduced disability measured with World Health Organization Disability Assessment Schedule 2.0 (%Δ = -52.6, p = 0.01), improved mobility measured with Prosthetic Limb Users Mobility Survey (%Δ = 21.8, P < 0.01), and improved balance confidence measured with the Activities-Specific Balance Confidence Scale (%Δ = 28.4, P < 0.01). CONCLUSIONS: Participants report less disability and greater function in their prosthesis postosseointegration. Osseointegration is a novel procedure for people experiencing complications with their socket prosthesis, and this study is the first to show improvements in disability postosseointegration.

Understanding decision-making in prosthetic rehabilitation by prosthetists and people with lower limb amputation: a qualitative study.

PURPOSE: Little has been published about the process of decision-making between prosthetists and people with lower limb amputation (LLA). The purpose of this study is to identify decisions and factors influencing decision-making in prosthetic rehabilitation from the perspectives of prosthetists and prosthesis users, to identify barriers and opportunities for shared decision-making (SDM). METHODS: Qualitative semi-structured individual interviews were conducted with 13 prosthetists and 14 prosthesis users from three clinics in three states of the Rocky Mountain and Southwest regions of the United States. Transcripts were analyzed using thematic analysis. RESULTS: Four main themes were identified: perceived decision points, importance of relationship, balancing competing priorities, and experience. Contrasts between perceptions of prosthetists and prosthesis users were related to prosthesis design decisions, and the purpose of communication (e.g., goals for a prosthesis vs. goals informing prosthesis design). Both prosthetists and prosthesis users described balancing priorities that contribute to prosthetic rehabilitation decisions, and the role of experience for informing realistic expectations and preferences necessary for participating in decision-making. CONCLUSION: Opportunities for improving SDM between prosthetists and prosthesis users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.IMPLICATIONS FOR REHABILITATIONMany people with lower limb amputation experience poor physical function and psychosocial outcomes, which may be further compounded by under informed prosthesis-user expectations for function with a prosthesis.Shared decision-making offers an opportunity for improving realistic prosthesis-user expectations, reducing healthcare costs, and improving prosthesis-user satisfaction and adherence to care plans.Opportunities for improving shared decision-making between prosthetists and prosthesis-users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.