Cost and outcomes of Hospital-based Usual cAre versus Tele-monitor self-directed Rehabilitation (HUATR) in patients with total knee arthroplasty: A randomized, controlled, non-inferiority trial.

OBJECTIVE: To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA). DESIGN: In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points). RESULTS: In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs. CONCLUSIONS: In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup.

Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention.

OBJECTIVE: To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA). METHODS: Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded. RESULTS: 110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group. CONCLUSION: CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.

Modifying the Mobility Scale for Acute Stroke (MSAS) for All Stroke Phases (MSAllS): Measurement Properties and Clinical Application.

OBJECTIVE: To develop and examine the measurement properties and interpretability of the Mobility Scale for "All" Stroke Phases (MSAllS) as a potential single outcome measure to capture improvements in physical function throughout the stroke continuum. DESIGN: Retrospective cross-sectional study. SETTING: Inpatient rehabilitation unit. PARTICIPANTS: People after stroke at discharge from rehabilitation (N=309). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE(S): We developed MSAllS by extending the highest MSAS level (walk 10 m independently) with 4 gait speed levels. To establish a clinical anchor, we extracted a 4-level discharge outcome. To assess the distributional properties and internal consistency of MSAllS, we evaluated its ceiling effects and calculated the Cronbach alpha, respectively. To assess structural validity, we performed a confirmatory factor analysis. To assess (i) its convergent validity with the FIM and (ii) its predictive validity with the clinical anchor, we used Spearman's rank correlations. To evaluate the clinical interpretability of MSAllS, we used an item-response theory-based method to estimate MSAllS thresholds associated with the clinical anchor. RESULTS: The MSAllS had lower ceiling effects compared with MSAS (0% vs 25%). Internal consistency of MSAllS was excellent (α=0.94). Structural validity of MSAllS demonstrated a good fit (Comparative Fit Index=0.95; Tucker-Lewis Index=0.92; Root Means Square Error of Approximation=0.17). MSAllS demonstrated a moderate correlation (rho=0.66) with FIM score and with the clinical anchor (rho=0.75). MSAllS thresholds for increasing levels of the clinical anchor were 22 (20.8 to 23.6) - at least moderate assistance with walking/transfers, 28 (27.5 to 29.4) - at most supervision with walking, and 33 (32.5 to 33.4) - able to walk unassisted. CONCLUSION: The MSAllS showed adequate measurement properties and clinical interpretability. MSAllS has the potential to be a single universal measure to evaluate physical function after stroke but further evaluation of clinical interpretability is required.

Effect of Context Specificity on Response to the Shortened WOMAC Function Scale in Patients Undergoing Total Knee Arthroplasty.

OBJECTIVE: To determine, in patients undergoing total knee arthroplasty (TKA), whether increasing context specificity of selected items of the shortened version of the Western Ontario and McMaster Universities Osteoarthritis Index function (WOMAC-F) scale (ShortMAC-F) (1) enhanced the convergent validity of the ShortMAC-F with performance-based mobility measures (ii) affected mean scale score, structural validity, reliability, and interpretability. DESIGN: Secondary analysis of randomized clinical trial data. SETTING: A tertiary teaching hospital. PARTICIPANTS: Patients undergoing TKA (N=114). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The ShortMAC-F was modified by specifying the "ascending stairs" and "rising from sitting" items to enquire about difficulty in performing the tasks without reliance on compensatory strategies, whereas the modified "level walking" item enquired about difficulty in walking 400 m. Before and 12 weeks after TKA, patients completed the WOMAC-F questionnaire, modified ShortMAC-F questionnaire, knee pain scale questionnaire, sit-to-stand test, fast gait speed test, and stair climb test. Interpretability was evaluated by calculating anchor-based substantial clinical benefit estimates. RESULTS: The modified ShortMAC-F correlated significantly more strongly than ShortMAC-F or WOMAC-F with pooled performance measures (differences in correlation values, 0.12-0.14). Increasing item context specificity of the ShortMAC-F did not influence its psychometric properties of unidimensionality (comparative fit and Tucker-Lewis indices, >0.95; root mean square error of approximation, 0.05-0.08), reliability (Cronbach's α, 0.75-0.83), correlation with pain intensity (correlation values, 0.48-0.52), and substantial clinical benefit estimates (16 percentage points); however, it resulted in lower mean score (4.5-4.8 points lower). CONCLUSIONS: The modified ShortMAC-F showed sufficient measurement properties for clinical application, and it seemed more adept than WOMAC-F at correlating with performance-based measures in TKA.

Discordance Between Self-Reported and Performance-Based Physical Function in Patients Who Have Knee Osteoarthritis: Associations With Pain Intensity and Negative Affect.

BACKGROUND: Although self-reported measures of physical disability are strong indication criterion for total knee arthroplasty (TKA) in painful knee osteoarthritis (OA), some patients may report greater-than-observed disability. Contributing factors to this discordance are relatively unexplored. We aimed to examine whether pain and negative affect, including anxiety and depression, were associated with the discordance of self-reported measures with performance-based measures (PPM) of physical function. METHODS: We used cross-sectional data (n = 212) from two randomized rehabilitation trials in knee OA. All patients were assessed for knee pain intensity and symptoms of anxiety and depression. Self-reported function was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical-function subscale. Objective performance-based measures (PPMs) of physical function were assessed by timed gait and stair tests. Continuous discordance scores were quantified by the difference in percentiles between WOMAC and PPMs (WOMAC-PPM), where a positive discordance, WOMAC-PPM >0, implied greater perceived than observed disability. RESULTS: Around 1 in 4 patients had >20 percentile units in WOMAC-PPM discordance. In Bayesian regression analyses, knee pain intensity had >99% posterior probability of positive associations with WOMAC-PPM discordance. Among patients awaiting TKA, anxiety intensity had approximately 99% probability of positive associations with discordance, and these associations had >65% probability of exceeding 10 percentile units. In contrast, depression had low (79% to 88%) probability of any association with discordance. CONCLUSION: In patients who have knee OA, a sizable proportion reported substantially greater physical disability than actually observed. Pain and anxiety intensity, but not depression, were meaningful predictors of this discordance. If validated, our findings may help in refining patient selection criteria for TKA.

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging.

Difficulty opening medication packaging can have serious consequences that can lead to patient harm via medication mismanagement or poor adherence. However, the quality of literature pertaining to these issues has yet to be collated and critiqued. This systematic review examined cross-sectional studies that objectively examined the ability of participants to open different medication packaging. Of the 8,692 studies identified, 12 met the inclusion criteria, all of which were direct observational studies given that prior research has identified a mismatch between self-report and actual ability. Scoring via the Appraisal Tool for Cross Sectional Studies revealed that the methodological quality of included studies was typically low. Study samples mostly consisted of older adults. All studies reported a non-negligible proportion of participants unable to open packaging, with the most difficulty associated with child-resistant containers. Several studies examined associations; however, no factor was consistently found to be significantly associated with the ability to open packaging. Despite these studies spanning >40 years, the packaging types examined remained largely the same. This suggests that, despite decades of research demonstrating that packaging is problematic, there has been a stagnation in medication packaging development. Whether this is attributed to a paucity of high-quality research, and therefore a lack of strong evidence that change is needed, is unclear. Future research should strive for better methodological quality, with generalisable cohorts assessed via observation in their home. If the problems identified in prior research persist, this may provide the impetus for change that is overdue in the medication packaging industry.

Developing the Freezing of Gait Severity Tool: A Delphi consensus study to determine the content of a clinician-rated assessment for freezing of gait severity.

OBJECTIVES: There is no standardisation of tasks or measures for evaluation of freezing of gait severity in people with Parkinson's disease. This study aimed to develop a clinician-rated tool for freezing of gait severity (i.e. Freezing of Gait Severity Tool), through determining clinicians' ratings of the most important triggering circumstances to be examined and aspects of freezing of gait to be measured. DESIGN: A three-round, web-based Delphi study. PARTICIPANTS: Healthcare professionals, with at least five years' experience in managing freezing of gait in people with Parkinson. MAIN OUTCOME MEASURES: Round 1 required participants (n = 28) to rate items on a 5-point Likert scale, based on priority for inclusion in the Freezing of Gait Severity Tool. In Round 2, participants (n = 18) ranked the items based on priority for inclusion. In Round 3, participants (n = 18) confirmed or rejected the shortlisted items by judging their ability, on a binary scale, to screen for freezing of gait, detect changes in freezing severity, and discriminate between degrees of severity. RESULTS: Participants agreed with the triggering circumstances of turning hesitation, narrow space hesitation, start hesitation, cognitive dual-tasking, and open space hesitation should be assessed; and the aspects of gait freezing to be measured included freezing type, number of freezing episodes during a task, and average duration of freezing episodes. CONCLUSIONS: This study attained a consensus for the items to be included in a clinician-rated tool for freezing of gait severity. Future studies should investigate psychometric properties and clinical feasibility of the Freezing of Gait Severity Tool.

Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore.

OBJECTIVES: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset. METHODS: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were "binned" and "winnowed" by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews. RESULTS: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset). CONCLUSIONS: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.

Calibration of a physical functioning item bank for measurement of health-related quality of life in Singapore.

PURPOSE: We aimed to develop and calibrate an item bank to measure physical function (PF) in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We recruited participants from community and hospital settings stratified for age and gender, with and without medical conditions to administer candidate pool of 61-items derived from the people's perspectives. We calibrated their responses using Samejima's graded response model of item response theory (IRT), including model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: 496 participants (50% male; 41% above 50 years old; 33.3% Chinese, 32.7% Malay and 34.1% Indian; 35% without chronic illness) were included in the calibration of item bank. 6 items were excluded due to mis-fit and local dependence. Redundancies in the response level was collapsed and re-scoring, while preserving the 5-level response structure. We found the final 55-item PF bank had adequate fit to IRT assumptions of unidimensionality, local independence and monotonicity. Items generally showed discernible ceiling effects with latent scores between - 3.5 to + 1.5. We found no DIF with gender, ethnicity or education. The PF scores correlated in the hypothesized direction with self-reported global health (Spearman's rho = - 0.35, 95% confidence intervals - 0.43 to - 0.27) and discriminated between groups stratified by age, gender and medical conditions. CONCLUSION: The 55-item Singapore PF item bank provides an adequate tool for measuring the lower end of PF, with greatest potential utility in healthcare settings where restoration to normal physical functioning is the goal of intervention.

Machine learning methods are comparable to logistic regression techniques in predicting severe walking limitation following total knee arthroplasty.

PURPOSE: Machine-learning methods are flexible prediction algorithms with potential advantages over conventional regression. This study aimed to use machine learning methods to predict post-total knee arthroplasty (TKA) walking limitation, and to compare their performance with that of logistic regression. METHODS: From the department's clinical registry, a cohort of 4026 patients who underwent elective, primary TKA between July 2013 and July 2017 was identified. Candidate predictors included demographics and preoperative clinical, psychosocial, and outcome measures. The primary outcome was severe walking limitation at 6 months post-TKA, defined as a maximum walk time ≤ 15 min. Eight common regression (logistic, penalized logistic, and ordinal logistic with natural splines) and ensemble machine learning (random forest, extreme gradient boosting, and SuperLearner) methods were implemented to predict the probability of severe walking limitation. Models were compared on discrimination and calibration metrics. RESULTS: At 6 months post-TKA, 13% of patients had severe walking limitation. Machine learning and logistic regression models performed moderately [mean area under the ROC curves (AUC) 0.73-0.75]. Overall, the ordinal logistic regression model performed best while the SuperLearner performed best among machine learning methods, with negligible differences between them (Brier score difference, < 0.001; 95% CI [- 0.0025, 0.002]). CONCLUSIONS: When predicting post-TKA physical function, several machine learning methods did not outperform logistic regression-in particular, ordinal logistic regression that does not assume linearity in its predictors. LEVEL OF EVIDENCE: Prognostic level II.

Predicting Mobility Limitations in Patients With Total Knee Arthroplasty in the Inpatient Setting.

OBJECTIVE: To develop a prediction model for postoperative day 3 mobility limitations in patients undergoing total knee arthroplasty (TKA). DESIGN: Prospective cohort study. SETTING: Inpatients in a tertiary care hospital. PARTICIPANTS: A sample of patients (N=2300) who underwent primary TKA in 2016-2017. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Candidate predictors included demographic variables and preoperative clinical and psychosocial measures. The outcome of interest was mobility limitations on post-TKA day 3, and this was determined a priori by an ordinal mobility outcome hierarchy based on the type of the gait aids prescribed and the level of physiotherapist assistance provided. To develop the model, we fitted a multivariable proportional odds regression model with bootstrap internal validation. We used a model approximation approach to create a simplified model that approximated predictions from the full model with 95% accuracy. RESULTS: On post-TKA day 3, 11% of patients required both walkers and therapist assistance to ambulate safely. Our prediction model had a concordance index of 0.72 (95% confidence interval, 0.68-0.75) when evaluating these patients. In the simplified model, predictors of greater mobility limitations included older age, greater walking aid support required preoperatively, less preoperative knee flexion range of movement, low-volume surgeon, contralateral knee pain, higher body mass index, non-Chinese race, and greater self-reported walking limitations preoperatively. CONCLUSION: We have developed a prediction model to identify patients who are at risk for mobility limitations in the inpatient setting. When used preoperatively as part of a shared-decision making process, it can potentially influence rehabilitation strategies and facilitate discharge planning.

Dynamic balance and instrumented gait variables are independent predictors of falls following stroke.

BACKGROUND: Falls are common following stroke and are frequently related to deficits in balance and mobility. This study aimed to investigate the predictive strength of gait and balance variables for evaluating post-stroke falls risk over 12 months following rehabilitation discharge. METHODS: A prospective cohort study was undertaken in inpatient rehabilitation centres based in Australia and Singapore. A consecutive sample of 81 individuals (mean age 63 years; median 24 days post stroke) were assessed within one week prior to discharge. In addition to comfortable gait speed over six metres (6mWT), a depth-sensing camera (Kinect) was used to obtain fast-paced gait speed, stride length, cadence, step width, step length asymmetry, gait speed variability, and mediolateral and vertical pelvic displacement. Balance variables were the step test, timed up and go (TUG), dual-task TUG, and Wii Balance Board-derived centre of pressure velocity during static standing. Falls data were collected using monthly calendars. RESULTS: Over 12 months, 28% of individuals fell at least once. The faller group had increased TUG time and reduced stride length, gait speed variability, mediolateral and vertical pelvic displacement, and step test scores (P < 0.001-0.048). Significant predictors, when adjusted for country, prior falls and assistance (i.e., physical assistance and/or gait aid use) were stride length, step length asymmetry, mediolateral pelvic displacement, step test and TUG scores (P < 0.040; IQR-odds ratio(OR) = 1.37-7.85). With comfortable gait speed as an additional covariate, to determine the additive benefit over standard clinical assessment, only mediolateral pelvic displacement, TUG and step test scores remained significant (P = 0.001-0.018; IQR-OR = 5.28-10.29). CONCLUSIONS: Reduced displacement of the pelvis in the mediolateral direction during walking was the strongest predictor of post-stroke falls compared with other gait variables. Dynamic balance measures, such as the TUG and step test, may better predict falls than gait speed or static balance measures.

Greater knee flexion excursion/moment in hopping is associated with better knee function following anterior cruciate ligament reconstruction.

PURPOSE: Individuals with impaired knee function after anterior cruciate ligament reconstruction (ACLR) may be at greater risk of developing knee osteoarthritis related to abnormal knee joint movement and loading. The aim of this study was to assess the association between knee biomechanics and knee laxity during hopping and clinically assessed knee function (i.e., patient-reported knee function and hop tests) following ACLR. METHODS: Sixty-six participants (23 women, mean age 28 ± 6 years, mean 18 ± 3 months following ACLR) completed a standardized single-leg hopping task. Three-dimensional movement analysis was used to assess knee flexion excursion and body weight/height normalized knee flexion moments during landing for the involved limb. Anterior-posterior knee laxity was assessed with a KT-1000 knee arthrometer. Participants then completed a patient-reported knee function questionnaire and three separate hop tests (% of uninvolved limb) and were divided into poor and satisfactory knee function groups (satisfactory: ≥85% patient-reported knee function and ≥ 85% hop test symmetry). Associations between knee function and hop biomechanics/knee laxity were assessed using logistic regression and interquartile range scaled odds ratios (ORIQR). RESULTS: Greater knee flexion excursion (ORIQR 2.9, 95%CI 1.1-7.8), greater knee flexion moment (ORIQR 4.9, 95%CI 1.6-14.3) and lesser knee laxity (ORIQR 4.7, 95%CI 1.5-14.9) were significantly associated with greater odds of having satisfactory knee function (≥ 85% patient-reported knee function and ≥ 85% hop test symmetry). CONCLUSION: Greater knee flexion excursion/moment during hop-landing and lesser knee laxity is associated with better patient-reported knee function and single-leg hop test performance following ACLR. Patients with lower levels of knee function following ACLR demonstrated hop-landing biomechanics previously associated with early patellofemoral osteoarthritis. Therefore, interventions aimed at improving hop landing biomechanics in people with poor knee function are likely required. LEVEL OF EVIDENCE: III, Cross-sectional study.

Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty.

Background and purpose - Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA), mainly because of pain and restricted physical function. We developed a prediction model for 6-month knee range of motion, knee pain, and walking limitations in patients undergoing TKA surgery. Patients and methods - We performed a prospective cohort study of 4,026 patients who underwent elective, primary TKA between July 2013 and July 2017. Candidate predictors included demographic, clinical, psychosocial, and preoperative outcome measures. The outcomes of interest were (i) knee extension and flexion range of motion, (ii) knee pain rated on a 5-point ordinal scale, and (iii) self-reported maximum walk time at 6 months post TKA. For each outcome, we fitted a multivariable proportional odds regression model with bootstrap internal validation. Results - At 6 months post TKA, around 5% to 20% of patients had a flexion contracture ³ 10°, range of motion < 90°, moderate to severe knee pain, or a maximum walk time £â€¯15 minutes. The model c-indices (the probabilities to correctly discriminate between 2 patients with different levels of follow-up TKA outcomes) when evaluating these patients were 0.71, 0.79, 0.65, and 0.76, respectively. Each postoperative outcome was strongly influenced by the same outcome measure obtained preoperatively (all p-values < 0.001). Additional statistically significant predictors were age, sex, race, education level, diabetes mellitus, preoperative use of gait aids, contralateral knee pain, and psychological distress (all p-values < 0.001). Interpretation - We have developed models to predict, for individual patients, their likely post-TKA levels of knee extension and flexion range of motion, knee pain, and walking limitations. After external validation, they can potentially be used preoperatively to identify at-risk patients and to help patients set more realistic expectations about surgical outcomes.

Age- and sex-based recovery curves to track functional outcomes in older adults with total knee arthroplasty.

Background: older adults with total knee arthroplasty (TKA) frequently undergo rehabilitation to address limited knee flexion range-of-motion, quadriceps weakness and gait speed limitations. This study aimed to develop age- and sex-specific recovery curves of knee flexion range-of-motion, quadriceps strength and fast gait speed post-TKA. Methods: a population-based sample of 2,987 patients undergoing primary TKA participated, of whom 2015 (68%) were 65 years of age or older. At 4, 8 and 12 weeks post surgery, knee flexion range-of-motion, quadriceps strength and fast gait speed were quantified. Quantile regression was used to determine the percentiles of the knee and gait measures. Results: the various knee and gait measures improved nonlinearly over time, with substantial improvements observed in the 1st 8-10 weeks post surgery. Age-specific, sex-specific recovery curves were developed to show the recovery patterns at multiple percentile levels. A web interface was created to facilitate easy computation of the percentile rank for a given outcome value. Conclusions: we have provided reference percentile values for knee flexion range-of-motion, quadriceps strength and gait speed recovery post-TKA. Such information may assist rehabilitation professionals in interpreting outcomes and quantifying deviations from the expected recovery pattern.

Factors Associated With Post-Stroke Physical Activity: A Systematic Review and Meta-Analysis.

OBJECTIVE: To integrate the literature investigating factors associated with post-stroke physical activity. DATA SOURCES: A search was conducted from database inception to June 2016 across 9 databases: Cochrane, MEDLINE, ProQuest, Web of Science, PsycINFO, Scopus, Embase, CINAHL, and Allied and Complementary Medicine Database. The reference lists of included articles were screened for secondary literature. STUDY SELECTION: Cohort and cross-sectional studies were included if they recruited community-dwelling stroke survivors and measured factors associated with physical activity. DATA EXTRACTION: Risk of bias was evaluated using the Quality in Prognosis Studies checklist. A meta-analysis was conducted for correlates where there were at least 2 studies that reported a correlation value. Correlation values were used in an effect size measure and converted to a standardized unit with Fisher r to z transformation and conversion back to r method. Results were described qualitatively for studies that could not be pooled. DATA SYNTHESIS: There were 2161 studies screened and 26 studies included. Age (meta r=-.17; P≤.001) and sex (meta r=-.01; P=.02) were the nonmodifiable factors that were found to be associated with post-stroke physical activity. The modifiable factors were physical function (meta r=.68-.73; P<.001), cardiorespiratory fitness (meta r=.35; P≤.001), fatigue (meta r=-.22; P=.01), falls self-efficacy (meta r=-.33; P<.001), balance self-efficacy (meta r=.37; P<.001), depression (meta r=-.58 to .48; P<.001), and health-related quality of life (meta r=.38-.43; P<.001). The effect of side of infarct, neglect, and cognition on post-stroke physical activity was inconclusive. CONCLUSIONS: Age, sex, physical function, depression, fatigue, self-efficacy, and quality of life were factors associated with post-stroke physical activity. The cause and effect of these relations are unclear, and the possibility of reverse causality needs to be addressed.

Association of wrist and forearm range of motion measures with self-reported functional scores amongst patients with distal radius fractures: a longitudinal study.

BACKGROUND: Patients with distal radius fractures (DRF) often have limited range-of-motion (ROM) in multiple planes of movement. No studies have comprehensively examined the impact of various ROM limitations on physical function. METHODS: We performed a multi-center, longitudinal study of 138 patients with conservatively managed DRF. ROM measures were taken at initial evaluation, and at 4 and 8 weeks later. Self-reported physical function was indexed by the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). RESULTS: Wrist extension, active thumb opposition and a full composite grip were amongst the strongest ROM measures associated with functional scores over time. However, wrist radial deviation and forearm pronation were non-significantly associated with functional scores. CONCLUSION: Given that ROM is potentially modifiable, the identification of important ROM measures associated with QuickDASH scores can potentially facilitate patient education and refine interventions to optimize functional recovery. Well-designed randomized intervention studies are however needed to confirm these association findings.

Three-dimensional assessment of squats and drop jumps using the Microsoft Xbox One Kinect: Reliability and validity.

The Microsoft Xbox One Kinect™ (Kinect V2) contains a depth camera that can be used to manually identify anatomical landmark positions in three-dimensions independent of the standard skeletal tracking, and therefore has potential for low-cost, time-efficient three-dimensional movement analysis (3DMA). This study examined inter-session reliability and concurrent validity of the Kinect V2 for the assessment of coronal and sagittal plane kinematics for the trunk, hip and knee during single leg squats (SLS) and drop vertical jumps (DVJ). Thirty young, healthy participants (age = 23 ± 5yrs, male/female = 15/15) performed a SLS and DVJ protocol that was recorded concurrently by the Kinect V2 and 3DMA during two sessions, one week apart. The Kinect V2 demonstrated good to excellent reliability for all SLS and DVJ variables (ICC ≥ 0.73). Concurrent validity ranged from poor to excellent (ICC = 0.02 to 0.98) during the SLS task, although trunk, hip and knee flexion and two-dimensional measures of knee abduction and frontal plane projection angle all demonstrated good to excellent validity (ICC ≥ 0.80). Concurrent validity for the DVJ task was typically worse, with only two variables exceeding ICC = 0.75 (trunk and hip flexion). These findings indicate that the Kinect V2 may have potential for large-scale screening for ACL injury risk, however future prospective research is required.

Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running.

PURPOSE: Poor knee function after anterior cruciate ligament reconstruction (ACLR) may increase the risk of future knee symptoms and knee osteoarthritis via abnormal knee joint loading patterns, particularly during high-impact activity. This study aimed to assess the relationship between poor self-reported or clinically measured knee function and knee moments/vertical ground reaction force (vGRF) in individuals following ACLR. METHODS: 61 participants (mean 16.5 ± 3 months following ACLR, 23 women) completed a patient-reported knee function questionnaire and three hop tests (% of uninvolved limb). Participants were divided into satisfactory and poor knee function groups (poor < 85% patient-reported knee function and/or < 85% hop test symmetry). The knee biomechanics of both groups were assessed with three-dimensional motion analysis during the stance phase of overland running at self-selected speeds, and the association between knee function and knee moments was assessed using analysis of covariance with running speed as a covariate. RESULTS: Participants with poor knee function (n = 30) ran with significantly smaller peak knee flexion moments (moderate effect size 0.7, p = 0.03) and significantly smaller peak vGRFs (large effect size 1.0, p = 0.002) compared to those with satisfactory knee function (n = 31). No significant differences were observed for knee adduction and knee external rotation moments or knee kinematics. CONCLUSION: Individuals following ACLR with poor self-reported knee function and/or hop test performance demonstrate knee moments during running that may be associated with lower knee joint contact forces. These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function. LEVEL OF EVIDENCE: III. Cross-sectional study.

Falls efficacy, postural balance, and risk for falls in older adults with falls-related emergency department visits: prospective cohort study.

BACKGROUND: Risk for falls in older adults has been associated with falls efficacy (self-perceived confidence in performing daily physical activities) and postural balance, but available evidence is limited and mixed. We examined the interaction between falls efficacy and postural balance and its association with future falls. We also investigated the association between falls efficacy and gait decline. METHODS: Falls efficacy, measured by the Modified Falls Efficacy Scale (MFES), and standing postural balance, measured using computerized posturography on a balance board, were obtained from 247 older adults with a falls-related emergency department visit. Six-month prospective fall rate and habitual gait speed at 6 months post baseline assessment were also measured. RESULTS: In multivariable proportional odds analyses adjusted for potential confounders, falls efficacy modified the association between postural balance and fall risk (interaction P = 0.014): increasing falls efficacy accentuated the increased fall risk related to poor postural balance. Low baseline falls efficacy was strongly predictive of worse gait speed (0.11 m/s [0.06 to 0.16] slower gait speed per IQR decrease in MFES; P < 0.001). CONCLUSION: Older adults with high falls efficacy but poor postural balance were at greater risk for falls than those with low falls efficacy; however, low baseline falls efficacy was strongly associated with worse gait function at follow-up. Further research into these subgroups of older adults is warranted. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01713543 .