Development and Implementation of an Evidenced-Based Practice (EBP) Educational Program for a Multidisciplinary Rehabilitation Department.

OBJECTIVE: Describe the development and implementation of an evidence-based practice (EBP) training program for occupational and physical therapists in a large pediatric hospital. CONTEXT: EBP is valued, but a known knowledge-to-practice gap between academic training and clinical practice limits routine use. This gap was addressed through an academic-clinical partnership to develop an EBP training program. RESULTS: Sixty-one therapists completed the program. Therapists demonstrated improved EBP skills, knowledge, and confidence following training and a positive trend in change score for clinical outcomes and decision-making scores was noted. CONCLUSION: Academic-clinical partnerships have a unique and valuable role to support professional EBP knowledge and skill development. Stakeholder support and engagement supported program development, execution, and meaningful outcomes. IMPACT STATEMENT: The knowledge-to-practice gap for EBP is a challenge to regular EBP use. The described program addressed this challenge and improved therapists' knowledge, skills, and confidence. It provides a model for professional development.

Meeting the Health Needs of Society Through Curricular Innovation in Physical Therapist Education: Examples From 3 Entry-Level Programs.

BACKGROUND AND PURPOSE: Entry-level physical therapist (PT) education programs play a critical role in inspiring future leaders to become moral change agents, capable of understanding and addressing evolving societal health needs. Social reconstructionism represents an educational philosophy focused on alleviating pervasive inequities and improving the health of society; however, its application in PT education is not well understood. The purpose of this article is to describe the approach 3 entry-level PT programs used to manifest social reconstructionism within their curricula to foster social consciousness and strengthen moral agency. METHOD/MODEL DESCRIPTION AND EVALUATION: The Framework for Educating Health Professionals to Address the Social Determinants of Health informed the development of a conceptual framework that illustrates the role of PT education programs in creating transformative learning environments and preparing learners to meet societal health needs. Concepts within this framework were operationalized according to 5 domains put forth by Jensen et al. and related competencies put forth by the Association of American Medical Colleges. OUTCOMES: Narratives from each program demonstrate how the design and implementation of curricula, grounded in social reconstructionism, can be accomplished through 1) ongoing modifications, 2) thoughtful reconstruction, and 3) initial design. Sample learning activities, objectives, and assessment strategies are provided. DISCUSSION AND CONCLUSION: The proposed method was effective in guiding meaningful objectives, learning activities, and assessment strategies grounded in social reconstructionism. Such findings can inform the design of curricula that inspire the next generation of transformative leaders who work to alleviate pervasive inequities and improve the health of society.

A blended approach to developing psychomotor skills in novice learners in a doctor of physical therapy curriculum.

PURPOSE: Psychomotor skill performance is central to effective clinical practice across health professions. These complex skills are challenging to teach, particularly in the novice learner. As many health professions programs have increased blended course offerings, educators must establish best practices for teaching psychomotor skills in this evolving learning environment. The purpose of this paper is to describe the innovative application of an evidence-based framework to teaching psychomotor skills to novice learners in a blended learning environment. MATERIALS AND METHODS: Using a modified 9-step framework, two novice clinical skills courses in a Doctor of Physical Therapy Program were redesigned to teach psychomotor skills in a blended format, using online and in-person class sessions. Online coursework consisted of synchronous and asynchronous learning activities that preceded an immersive lab experience. Formative and summative assessments occurred during lab immersion. RESULTS AND CONCLUSIONS: The learning framework provided a central evidence-based pillar for novel course design, guiding development of learning activities for teaching psychomotor skills to novice learners in a blended learning environment. Initial student outcomes appear favorable when compared with previous traditional course structures and satisfaction was high. These preliminary findings align with prior research using similar frameworks for learning complex skills and provide an archetype curricular model for a blended learning environment.

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.

Clinical utility of the Trendelenburg Test in people with multiple sclerosis.

BACKGROUND: The clinical utility of the Trendelenburg Test remains unknown in people with multiple sclerosis (MS). OBJECTIVE: To measure (1) intra-rater reliability, (2) agreement of goniometer-assessed Trendelenburg pelvis-on-femur angle (POF) with motion capture, and (3) concurrent validity of Trendelenburg POF and hip abduction strength with POF during walking and step negotiation. METHODS: Trendelenburg POF was measured in 20 people with MS using goniometry and motion analysis. In addition, peak POF was measured using motion analysis during walking, step ascent, and step descent. Intra-rater reliability of goniometer-assessed Trendelenburg POF and agreement with motion analysis-assessed POF were analyzed. Pearson's r was used to determine the relationships between Trendelenburg POF and hip abduction strength with peak POF during each functional activity. RESULTS: Goniometer-assessed Trendelenburg POF demonstrated very strong reliability (ICC: 0.948), strong agreement with 3D motion analysis (ICC: 0.792), correlated moderately with peak POF during walking (r = 0.519) and step ascent (r = 0.572), and weakly with step descent (r = 0.463). Hip abductor strength correlated weakly with peak POF during step ascent (r = -0.307) and negligibly during walking (r = -0.270) and step descent (r = -0.249). CONCLUSIONS: Goniometer-assessed Trendelenburg POF was reliable, agreed with motion analysis, and may provide insight into hip abduction muscle performance during functional activities in people with MS.

A Framework for Movement Analysis of Tasks: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force.

The American Physical Therapy Association's Vision Statement of 2013 asserts that physical therapists optimize movement in order to improve the human experience. In accordance with this vision, physical therapists strive to be recognized as experts in movement analysis. However, there continues to be no accepted method to conduct movement analysis, nor an agreement of key terminology to describe movement observations. As a result, the Academy of Neurologic Physical Therapy organized a task force that was charged with advancing the state of practice with respect to these issues, including the development of a proposed method for movement analysis of tasks. This paper presents the work of the Task Force, which includes (1) development of a method for conducting movement analysis within the context of the movement continuum during 6 core tasks (sitting, sit to stand, standing, walking, step up/down, and reach/grasp/manipulate); (2) glossary of movement constructs that can provide a common language for movement analysis across a range of tasks: symmetry, speed, amplitude, alignment, verticality, stability, smoothness, sequencing, timing, accuracy, and symptom provocation; and (3) recommendations for task and environmental variations that can be systematically applied. The expectation is that this systematic framework and accompanying terminology will be easily adapted to additional patient or client-specific tasks, contribute to development of movement system diagnostic labels, and ultimately improve consistency across patient/client examination, evaluation, and intervention for the physical therapy profession. Next steps should include validation of this framework across patient/client groups and settings.

Incorporating Specific Functional Strength Integration Techniques to Improve Functional Performance for Veterans After Total Hip Arthroplasty: Protocol for a Randomized Clinical Trial.

BACKGROUND: Total hip arthroplasty (THA) is a common procedure, yet persistent deficits in functional performance exist after surgery. These deficits may be related to movement compensations observed after THA, which negatively affect quality of life and may increase morbidity and health care utilization, including in the veteran population. However, the best rehabilitative approach to remediating movement compensations and physical function deficits has not been determined. OBJECTIVE: The objective is to determine if a functional strength integration intervention (FSI), as part of a post-THA rehabilitation program, improves movement compensation, physical function, muscle strength, and self-reported outcome measures more than a control group (CON) undergoing a standard of care exercise program. DESIGN: This is a 2-arm randomized, controlled clinical trial. SETTING: The Veteran Affairs outpatient physical therapy clinics and academic research laboratory will be the settings. PARTICIPANTS: One hundred veterans undergoing THA for hip osteoarthritis will be included in the study. INTERVENTIONS: Participants will be randomized to either the FSI or CON group and participate in visits of physical therapy over 8 weeks. The FSI protocol will include targeted exercise to improve muscular control and stability around the hip and trunk to minimize movement compensation during daily activity combined with progressive resistance exercise. The CON protocol will include patient education, flexibility activity, and low load resistance exercise. MEASUREMENTS: Functional performance, muscle strength and endurance, and self-reported outcomes will be measured at baseline (prior to surgery), midway through intervention (6 weeks after surgery), at the end of intervention (10 weeks after surgery), and 26 weeks after THA. LIMITATIONS: The inability to blind treating therapists to study arm allocation is a limitation. CONCLUSIONS: The proposed study aims to determine if targeted FSI can affect movement compensation to improve functional outcomes after THA more than traditional rehabilitation paradigms.

Trajectories of functional performance and muscle strength recovery differ after total knee and total hip replacement: a performance-based, longitudinal study.

Total joint replacement is indicated to alleviate pain and disability associated with hip and knee osteoarthritis. Arthroplasty outcomes are typically reported together, or anecdotal comparisons are made between total knee arthroplasty (TKA) and total hip arthroplasty (THA) recovery. Limited data quantifies differences in recovery trajectories, especially with respect to performance-based outcomes. Seventy-nine people undergoing total knee or THA were followed over 6 months. Functional performance was measured using the stair climb test, timed-up-and-go test, and 6-min walk test. Surgical limb isometric strength was also measured. All outcomes significantly declined 1 month after surgery. Participants in the TKA group showed a greater decline in climbing stairs (P < 0.001), timed-up-and-go (P = 0.01), and 6-min walk distance (P < 0.01). Further, the TKA group lost more strength (P < 0.001) and were weaker than those after THA (P < 0.001). Differences in postoperative outcomes between groups at 3 and 6 months were also observed. The TKA group experiences a greater decline in measured outcomes than the THA group, and muscle strength and functional recovery occurred differently in each group. These findings should be considered in rehabilitation priorities after arthroplasty surgery.

Simulated hip abductor strengthening reduces peak joint contact forces in patients with total hip arthroplasty.

Lower extremity muscle strength training is a focus of rehabilitation following total hip arthroplasty (THA). Strength of the hip abductor muscle group is a predictor of overall function following THA. The purpose of this study was to investigate the effects of hip abductor strengthening following rehabilitation on joint contact forces (JCFs) in the lower extremity and low back during a high demand step down task. Five THA patients performed lower extremity maximum isometric strength tests and a stair descent task. Patient-specific musculoskeletal models were created in OpenSim and maximum isometric strength parameters were scaled to reproduce measured pre-operative joint torques. A pre-operative forward dynamic simulation of each patient performing the stair descent was constructed using their corresponding patient-specific model to predict JCFs at the ankle, knee, hip, and low back. The hip abductor muscles were strengthened with clinically supported increases (0-30%) above pre-operative values in a probabilistic framework to predict the effects on peak JCFs (99% confidence bounds). Simulated hip abductor strengthening resulted in lower peak JCFs relative to pre-operative for all five patients at the hip (18.9-23.8 ±â€¯16.5%) and knee (20.5-23.8 ±â€¯11.2%). Four of the five patients had reductions at the ankle (7.1-8.5 ±â€¯11.3%) and low back (3.5-7.0 ±â€¯5.3%) with one patient demonstrating no change. The reduction in JCF at the hip joint and at joints other than the hip with hip abductor strengthening demonstrates the dynamic and mechanical interdependencies of the knee, hip and spine that can be targeted in early THA rehabilitation to improve overall patient function.

The impact of hip implant alignment on muscle and joint loading during dynamic activities.

BACKGROUND: Component alignment is an important consideration in total hip arthroplasty. The impact of changes in alignment on muscle forces and joint contact forces during dynamic tasks are not well understood, and have the potential to influence surgical decision making. The objectives of this study were to assess the impact of femoral head/stem and cup component placement on hip muscle and joint contact forces during tasks of daily living and to identify which alignment parameters have the greatest impact on joint loading. METHODS: Using a series of strength-calibrated, subject-specific musculoskeletal models of patients performing gait, sit-to-stand and step down tasks, component alignments were perturbed and joint contact and muscle forces evaluated. FINDINGS: Based on the range of alignments reported clinically, variation in head/stem anteversion-retroversion had the largest impact of any degree of freedom throughout all three tasks; average contact forces 413.5 (319.1) N during gait, 262.7 (256.4) N during sit to stand, and 572.7 (228.1) N during the step down task. The sensitivity of contact force to anteversion-retroversion of the head/stem was 31.5 N/° for gait, which was similar in magnitude to anterior-posterior position of the cup (34.6 N/m for gait). Additionally, superior-inferior cup alignment resulted in 16.4 (4.9)° of variation in the direction of the hip joint contact force across the three tasks, with the most inferior cup placements moving the force vector towards the cup equator at the point of peak joint contact force. INTERPRETATION: A quantitative understanding of the impact and potential tradeoffs when altering component alignment is valuable in supporting surgical decision making.

Influence of Hip Abductor Strength on Functional Outcomes Before and After Total Knee Arthroplasty: Post Hoc Analysis of a Randomized Controlled Trial.

BACKGROUND: Total knee arthroplasty (TKA) is associated with declines in hip abductor (HA) muscle strength; however, a longitudinal analysis demonstrating the influence of TKA on trajectories of HA strength change has not been conducted. OBJECTIVE: The purpose of this study was to quantify changes in HA strength from pre-TKA through 3 months post-TKA and to characterize the relationship between HA strength changes and physical performance. DESIGN: This study is a post hoc analysis of a randomized controlled trial. METHODS: Data from 162 participants (89 women, mean age = 63 y) were used for analysis. Data were collected by masked assessors preoperatively and at 1 and 3 months following surgery. Outcomes included: Timed "Up and Go" test (TUG), Stair Climbing Test (SCT), Six-Minute Walk Test (6MWT), and walking speed. Paired t tests were used for between- and within-limb comparisons of HA strength. Multivariable regression was used to determine contributions of independent variables, HA and knee extensor strength, to the dependent variables of TUG, SCT, 6MWT, and walking speed at each time point. RESULTS: Hip abductor strength was significantly lower in the surgical limb pre-TKA (mean = 0.015; 95% CI = 0.010-0.020), 1 month post-TKA (0.028; 0.023-0.034), and 3 months post-TKA (0.02; 0.014-0.025) compared with the nonsurgical limb. Hip abductor strength declined from pre-TKA to 1 month post-TKA (18%), but not at the 3-month time point (0%). Hip abductor strength independently contributed to performance-based outcomes pre-TKA; however, this contribution was not observed post-TKA. LIMITATIONS: The post hoc analysis prevents examining all outcomes likely to be influenced by HA strength. CONCLUSIONS: Surgical limb HA strength is impaired prior to TKA, and worsens following surgery. Furthermore, HA strength contributes to performance-based outcomes, supporting the hypothesis that HA strength influences functional recovery.

Effects of neuromuscular reeducation on hip mechanics and functional performance in patients after total hip arthroplasty: A case series.

BACKGROUND: Following total hip arthroplasty, patients demonstrate compensatory movement strategies during activities of daily living such as walking and stair climbing. Movement compensations are important markers of functional decline in older adults and are related to poor functional capacity. Despite increased utilization of hip arthroplasty, persistent movement compensation, and functional performance deficits, no consensus on postoperative rehabilitation exists. Neuromuscular reeducation techniques offer a strategy to improve movement quality by emphasizing hip abductor performance and pelvic stability. This case series illustrates changes in movement strategy around the hip in response to targeted neuromuscular reeducation techniques after hip arthroplasty. METHODS: Five participants received an 8-week exercise program following total hip arthroplasty, emphasizing targeted neuromuscular reeducation techniques hallmarked by specific, weight-bearing exercise to improve hip abductor performance and pelvic stability. Five additional participants were supervised and followed for comparison. FINDINGS: Participants in the neuromuscular reeducation program improved their internal hip abductor moments and vertical ground reaction forces during walking and stair climbing. They also improved their functional performance and hip abductor strength outcomes. INTERPRETATION: Targeted neuromuscular reeducation techniques after total hip arthroplasty provided a positive effect on biomechanical outcomes, functional performance, and muscle strength. Through focused use of the hip abductor muscles, increased internal hip abductor moments were observed. This intervention potentially promotes pelvic stability, and may contribute to improved performance on tasks such as stair climbing, fast walking, and balance. The results suggest that neuromuscular reeducation offers a unique effect on movement strategy and function for patients following total hip arthroplasty.

Performance-Based Versus Self-Reported Outcomes Using the Hip Disability and Osteoarthritis Outcome Score After Total Hip Arthroplasty.

OBJECTIVE: The purpose of this study was to explore the relationship between patients' self-reported and performance-based function after total hip arthroplasty (THA). DESIGN: Twenty-three patients (age, 61.4 ± 8.3 yrs) undergoing primary THA for hip osteoarthritis participated. Self-reported function and recovery was measured using the Hip Disability and Osteoarthritis Outcome Score activities of daily living and pain subscales. Performance-based functional measures included the timed up and go test, the stair climbing test, and the 6-minute walk test. Outcome measures were assessed preoperatively and postoperatively at 1 and 6 mos. RESULTS: One month after THA, performance-based function declined compared with baseline as follows: timed up and go test, -22.1% ± 25.4%; stair climbing test, -58.5% ± 63.6%; and 6-minute walk test, -22.6% ± 31.7%. In contrast, self-reported function on the Hip Disability and Osteoarthritis Outcome Score Activities of Daily Living significantly improved 1 mo after THA compared with baseline: 40.8% ± 33.3%. One to 6 mos after THA, there were significant improvements in timed up and go test, stair climbing test, and 6-minute walk test, which paralleled improvements on the Hip Disability and Osteoarthritis Outcome Score subscales, although changes were not significantly correlated. CONCLUSION: The disparity between changes in Hip Disability and Osteoarthritis Outcome Scores and functional performance postoperatively suggests that patients may overestimate their functional capacity early after THA, likely in response to pain improvements over the same time period. Therefore, outcomes assessment after THA should include both self-report and performance-based functional measures.

Quadriceps/hamstrings co-activation increases early after total knee arthroplasty.

UNLABELLED: Quadriceps and hamstrings weakness and co-activation are present following total knee arthroplasty (TKA) and may impair functional performance. How surgery and post-operative rehabilitation influence muscle activation during walking early after surgery is unclear. PURPOSE: Examine muscle strength and activation during walking before and one and 6-months post-TKA. METHODS: Ten patients (n=6 female; age: 64.7 ± 7.9 years; body mass index[BMI]:29.2 ± 2.5 kg/m(2)) and 10 healthy adults (n=6 female; age: 60.6 ± 7.4 years; BMI: 25.5 ± 4.0 kg/m(2)) participated. The patients underwent bilateral quadriceps and hamstrings strength testing and assessment of quadriceps/hamstrings co-activation and on/off timing using surface electromyography during a six-minute walk test (6MW). Groups, limbs, and changes with TKA surgery were compared. RESULTS: Patients reported greater 6MW knee pain pre- versus post-TKA and compared to controls (P<0.05). Patients had weaker surgical limb hamstrings (P<0.05) and bilateral quadriceps (P<0.05) strength than controls pre- and post-TKA. Before and 1-month post-TKA, patients had side-to-side differences in quadriceps and hamstrings strength (P<0.05). Controls walked farther than patients (P<0.01). Patients demonstrated greater surgical limb co-activation pre-operatively than controls (P<0.05). Co-activation was higher bilaterally one-month post-TKA compared to controls (P<0.05). Patients turned off their quadriceps later during stance than controls before and 1-month post-TKA (P<0.05). CONCLUSIONS: Muscle strength, co-activation, and timing differed between patients and controls before and early after surgery. Rehabilitation to improve strength and muscle activation seems imperative to restore proper muscle firing patterns early after surgery.

Strength and functional deficits in individuals with hip osteoarthritis compared to healthy, older adults.

PURPOSE: Hip osteoarthritis (OA) compromises quality of life for many individuals. This study quantified deficits in functional capacity for use in rehabilitation goal setting by combining assessments of muscle strength, function and physical activity in patients with hip OA and healthy adults. METHOD: Twenty-six patients with end-stage hip OA and 18 healthy adults participated. Isometric muscle strength around the hip and knee was measured. Function was assessed using stair climbing, five-time-sit-to-stand, timed-up-and-go and 6-minute walk tests. The UCLA activity rating scale assessed physical activity. Analyses of covariance (ANCOVA) were used to assess differences between groups. RESULTS: Patients had 30% less knee extensor (p < 0.001), 38% less knee flexor (p < 0.001), 10% less hip flexor (p = 0.47), 23% less hip extensor (p = 0.24) and 17% less hip abductor strength (p = 0.23) than healthy adults. Hip adductor strength was equal between groups (p = 0.93). Patients were 50% slower on the stair climbing test (p = 0.001), 34% slower on the timed-up-and-go test (p = 0.004), 34% slower on the five-time-sit-to-stand test (p = 0.001), and walked 28% less during the 6-min walk test (p < 0.001). Patients were less physically active (p = 0.001). CONCLUSIONS: Patients had deficits in muscle strength, function and physical activity compared to healthy adults. Quantifying these deficits provides benchmarks for improvement during rehabilitation. IMPLICATIONS FOR REHABILITATION: Hip osteoarthritis (OA) affects up to 28% of adults over the age of 65 and many individuals report functional and activity limitations directly related to their arthritic condition, posing a risk for future morbidity Total hip arthroplasty (THA) is the treatment of choice for decreasing pain and improving function, however, some individuals suffering from end-stage hip OA are not candidates for THA, and effective rehabilitation interventions to improve physical function are crucial Establishing estimates of the deficits in muscle strength, physical function and physical activity in people with and without hip OA can aid rehabilitation professionals in their goal setting and intervention planning Rehabilitation interventions should not only consist of muscle strengthening and functional training, but interventions to improve physical activity levels are required to improve overall physical functioning and to decrease risks for additional health complications.

Muscle strength and functional recovery during the first year after THA.

BACKGROUND: Patients undergoing total hip arthroplasty (THA) often are satisfied with the decrease in pain and improvement in function they achieve after surgery. Even so, strength and functional performance deficits persist after recovery, but these remain poorly characterized; knowledge about any ongoing strength or functional deficits may allow therapists to design rehabilitation programs to optimize recovery after THA. QUESTIONS/PURPOSES: The purposes of this study were to (1) evaluate postoperative muscle strength, function, and quality of life during the first year after THA; and (2) compare strength and function in patients 1 year after THA with a cohort of healthy peers. METHODS: Twenty-six patients undergoing THA were assessed 1, 3, 6, and 12 months postoperatively, and 19 adults with no hip pathology were tested as a control group. Isometric muscle strength (hip flexors, extensors, abductors, knee extensors, and flexors), functional performance (stair climbing, five times sit-to-stand, timed-up-and-go, 6-minute walk, and single-limb stance tests), and self-reported function (Hip Disability and Osteoarthritis Score, SF-36, and UCLA activity score) were compared. RESULTS: One month after THA, patients had 15% less hip flexor and extensor torque, 26% less abductor torque, 14% less knee extensor and flexor torque, and worse performance on the stair climbing, timed-up-and-go, single-limb stance, and 6-minute walk. Compared with healthy adults, patients 12 months after THA had 17% less knee extensor and 23% less knee flexor torque; however, the functional testing (including stair climbing, five times sit-to-stand, and the 6-minute walk) showed no significant differences with the patient numbers available between individuals undergoing THA and healthy control subjects. SF-36 Physical Component Scores, although significantly improved from preoperative levels, were significantly worse than healthy adults 1 year after THA (p < 0.01). CONCLUSIONS: Patients experience early postoperative strength losses and decreased functional capacity after THA, yet strength deficits may persist after recovery. This may suggest that rehabilitation may be most effective in the first month after surgery.

Muscle activation and coactivation during five-time-sit-to-stand movement in patients undergoing total knee arthroplasty.

Quadriceps weakness is prevalent with knee osteoarthritis (OA) and after total knee arthroplasty (TKA). To compensate for quadriceps dysfunction, patients often alter movement strategies. Little is known about muscle coordination during sit-to-stand (concentric) and stand-to-sit (eccentric) movements in the acute postoperative period. This investigation characterized the distribution of muscle activation between the concentric and eccentric phases during a five-time-sit-to-stand (FTSTS) movement in late stage OA and one month after TKA. Patients and healthy participants performed a FTSTS while recording bilateral ground reaction forces (GRFs) and electromyography (EMG). Concentric and eccentric ensemble averages of the GRF and EMG were calculated for the concentric and eccentric phases. Coactivation indices, integrated EMG, and GRF were calculated for each limb and phase. Patients demonstrated higher eccentric coactivation than the healthy group. Postoperative loading was higher in the nonsurgical limb. Postoperative quadriceps activity was lower in the concentric phase and higher in the eccentric phase than the healthy group. Higher coactivation in the patients resulted from sustained distribution of quadriceps activity throughout the eccentric phase. This indicated an inability to coordinate muscle firing when rapidly lowering to a chair and occurred despite unloading of the surgical limb. Although these patterns may serve as a protective strategy, they may also impede recovery of muscle function after TKA.

Muscle strength loss in the lower limb after total knee arthroplasty.

OBJECTIVE: This study aimed to examine functional mobility and strength loss in the ankle plantarflexors and dorsiflexors and knee extensors and flexors after total knee arthroplasty. DESIGN: This was a prospective, longitudinal cohort study. Maximal voluntary isometric contractions and gait speed assessments were performed before and after total knee arthroplasty. RESULTS: Twenty patients undergoing primary total knee arthroplasty were followed. Repeated-measures analysis of variance results indicated an effect of time on muscle strength, with all muscle groups being significantly weaker (knee extensors, P < 0.001; knee flexors, P < 0.001, ankle plantarflexors, P = 0.004; ankle dorsiflexors, P < 0.001) 1 mo postoperatively. Knee extensors were 42% weaker than preoperative levels, and knee flexors were 34% weaker, whereas the ankle plantarflexors were 17% weaker, and the dorsiflexors were 18% weaker. Three and 6 mos after surgery, strength in all muscle groups was similar to preoperative levels (P > 0.05 for all muscle groups). Patient function followed a similar trend, with patients walking slower 1 mo postoperatively (P < 0.001) and recovering to preoperative levels by 3 and 6 mos after surgery (P > 0.05). CONCLUSIONS: Patients may benefit from early postoperative rehabilitation, including strengthening of the plantarflexors and dorsiflexors, although strengthening of the quadriceps and hamstrings muscles should continue to be a priority.

Weight-bearing asymmetry during sit-stand transitions related to impairment and functional mobility after total knee arthroplasty.

OBJECTIVES: To examine changes in weight-bearing (WB) asymmetry during sit-stand transitions for individuals during the first 6 months after unilateral total knee arthroplasty (TKA). Relationships between WB asymmetry, clinical measures of knee impairment, and functional mobility also were evaluated. DESIGN: Prospective repeated-measures design. SETTING: Clinical research laboratory. PARTICIPANTS: People (N=36) with knee osteoarthritis (OA) scheduled to undergo unilateral TKA and a control (CTL) group (N=17 healthy people) were enrolled. INTERVENTION: The TKA group participated in acute, home, and outpatient phases of exercise-based rehabilitation. MAIN OUTCOME MEASURES: WB asymmetry measured during a 5-Times Sit-to-Stand Test (FTSST) based on average vertical ground reaction force under each foot, self-reported knee pain using a numerical pain rating scale, knee active range of motion symmetry, knee extensor strength symmetry, FTSST time, 6-minute walk test distance, and Stair Climbing Test time. RESULTS: Compared with preoperative values, the TKA group showed greater WB asymmetry at 1 month after surgery (P<.001). By 6 months, the TKA group had less WB asymmetry than preoperative values (P<.001), which was not different from the CTL group. Symmetry in WB correlated with functional outcomes and symmetry of quadriceps strength for the TKA group 6 months postoperatively. CONCLUSIONS: Patients with unilateral knee OA showed WB asymmetry during sit-stand transitions early after unilateral TKA that improved by 6 months after surgery and was no different from that for healthy people of similar age. For people in the first 6 months after TKA, greater symmetry was related to better function and strength symmetry.