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.

The impact of being overweight or obese on 12 month clinical recovery in patients following lumbar microdiscectomy for radiculopathy.

BACKGROUND CONTEXT: The proportion of patients who undergo lumbar microdiscectomy due to lumbar radiculopathy who are also overweight or obese is high. However, whether high body mass index (BMI) affects clinical outcomes is not well-studied. PURPOSE: To investigate the difference in the clinical course between normal weight, overweight, and obese patients with radiculopathy who underwent lumbar microdiscectomy followed by physical therapy and to evaluate whether high BMI is associated with poor recovery. STUDY DESIGN/SETTING: A prospective cohort study with a 12-month follow-up was conducted in a multidisciplinary clinic. PATIENT SAMPLE: We included 583 patients (median [IQR] age: 45 [35-52] years; 41% female) with clinical signs and symptoms of lumbar radiculopathy, consistent with magnetic resonance imaging findings, who underwent microdiscectomy followed by postoperative physical therapy. OUTCOME MEASURES: Outcomes were leg pain and back pain intensity measured with a visual analogue scale, disability measured with the Roland Morris Disability Questionnaire at 3 and 12-month follow-ups, and complications. METHODS: Patients were classified as being normal weight (46.9%), overweight (38.4%), or obese (14.7%). A linear mixed-effects model was used to assess the difference in the clinical course of pain and disability between the three BMI categories. The association between BMI and outcomes was evaluated using univariable and multivariable logistic regression analyses. RESULTS: All three patient groups experienced a significant improvement in leg pain, back pain, and disability over 3 and 12-month follow-up. Patients who were overweight, obese, or normal weight experienced comparable leg pain (p=.14) and disability (p=.06) over the clinical course (p=.14); however, obese patients experienced higher back pain (MD=-6.81 [95%CI: -13.50 to -0.14]; p=.03). The difference in back pain scores was not clinically relevant. CONCLUSIONS: In the first year following lumbar microdiscectomy, patients demonstrated clinical improvements and complications that were unrelated to their preoperative BMI.

Personalized Reference Values for the Two-Minute Walk Test: An Analysis of Cross-Sectional Data From the National Institutes of Health Toolbox Study.

OBJECTIVES: To develop reference values for the Two-Minute Walk Test (TMWT) via 2 previously untested methods: (1) smooth age-based statistical models and (2) a neighbors-based approach accounting for age, sex, and height. DESIGN: Cross-sectional observational study. SETTING: National Institutes of Health Toolbox study sites across the United States. PARTICIPANTS: A total of 1385 healthy, community dwelling adult participants (age 18-85 years) in the National Institutes of Health Toolbox study were included in this analysis. INTERVENTION: None. MAIN OUTCOME MEASURES: Reference values for TMWT were generated using 2 approaches: (1) Generalized Additive Models for Location Scale and Shape, wherein TMWT values were modeled as a smooth function of age, and (2) a semiparametric neighbors-based approach. The performance of references values was then adjudicated by examining precision (ie, the average interquartile or interdecile range of reference values), and coverage (ie, the proportion of realized values included within a given inter-percentile interval). Agreement between methods was examined by intraclass correlation coefficient. RESULTS: Neighbors-based reference values demonstrated a smaller average interquartile range (149 ft; 95% confidence interval [CI], 146-152 ft), compared with age-based reference values (158 ft; 95% CI, 155-162 ft), but similar average interdecile range (neighbors-based: 369 ft; 95% CI, 360-377 ft; age-based: 374 ft; 95% CI, 366-383 ft). Coverage appeared accurate via both approaches. Agreement between approaches was high (intraclass correlation coefficient=0.96), although differences were apparent on a case-by-case basis. CONCLUSIONS: Both age-based and neighbors-based reference values offer viable options for interpreting a person's TMWT performance. In this analysis, the neighbors-based approach (adjusting for height) yielded potentially clinically relevant differences in reference values for persons at extremes of height.

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.

Improving shared decision-making for prosthetic care: A qualitative needs assessment of prosthetists and new lower-limb prosthesis users.

BACKGROUND: Prosthesis design is complex and multiple appropriate options exist for any individual with lower-limb amputation. However, there is insufficient evidence for guiding decision-making. Shared decision-making (SDM) offers an opportunity to incorporate patient-specific values and preferences where evidence is lacking for prosthesis design decisions. To develop resources to facilitate SDM, and consistent with the International Patient Decision Aid Standards, it is necessary to identify the decisional needs of prosthetists and prosthesis users for prosthesis design decisions. OBJECTIVES: To assess the needs of prosthetists and new prosthesis users for SDM about the first prosthesis design. STUDY DESIGN: Qualitative descriptive design. METHODS: Six focus groups were conducted with 38 prosthetists. Individual semistructured interviews were conducted with 17 new prosthesis users. Transcripts were analyzed using directed content analysis, with codes defined a priori using existing frameworks for SDM: the Three Talk Model for SDM and the Ottawa Decision Support Framework. RESULTS: Four main themes were identified among prosthetists and prosthesis users: acknowledging complexity in communication, clarifying values, recognizing the role of experience to inform preferences , and understanding the prosthetic journey . CONCLUSIONS: Resources that support SDM for the first prosthesis design should consider methods for identifying individual communication needs, support with clarifying values, and resources such as experience for achieving informed preferences, within the context of the overall course of rehabilitation and recovery following lower-limb amputation. The themes identified in this work can inform SDM to promote collaborative discussion between prosthetists and new prosthesis users when making prosthesis design decisions.

Impact of Personalized Outcomes Forecasts on Clinical Reasoning of Physical Therapists in Intermittent Claudication: A Vignette Study.

OBJECTIVE: Guidelines recommend supervised exercise therapy and lifestyle counseling by a physical therapist as initial treatment for patients with intermittent claudication. However, guidelines provide only a crude estimate of the outcomes that therapists and patients might expect from treatment. The purpose of this study was to explore the impact of personalized outcomes forecasts (POFs) on the decision-making process of physical therapists and to learn lessons on facilitating the use of forecasts in daily practice. METHODS: A vignette-based, think-aloud interview study design was used. The participants were physical therapists trained in treating patients with intermittent claudication. Vignettes described fictitious patients diagnosed with intermittent claudication and included POFs. A directed approach was used to code, organize, and describe the data. Transcripts were analyzed using a thematic approach. RESULTS: Sixteen therapists participated in the study. Three themes were identified: (1) setting and contextualizing treatment expectations, (2) setting (shared) goals and (de)motivating the patient, and (3) establishing and monitoring the treatment plan. Therapists mentioned that POFs could be useful for setting expectations and realistic treatment goals, contextualizing expected treatment response, stimulating patients to achieve their goals, and deciding on treatment frequency and treatment timing. Therapists thought POFs would be of less use for changing treatment goals during follow-up visits or for establishing intensity or type of training. CONCLUSION: To overcome challenges that may arise when adopting POFs in daily practice, adequate training of physical therapists should be conducted. Potential areas to address with training include statistical and data literacy as well as guidance on integrating POFs with existing treatment protocols. IMPACT: The use of POFs by physical therapists might contribute to a more person-centered care approach. The insights provided by this study on the first use of POFs by physical therapists can serve as an example and lesson on how to optimally implement such supporting tools into daily practice.

Development of a reference chart for monitoring cancer-related fatigue throughout a supervised exercise program.

BACKGROUND: Cancer-related fatigue (CRF) is one of the most reported and functionally limiting symptoms experienced by individuals living with and beyond cancer. Exercise is effective at reducing CRF, though currently it is not possible to predict the magnitude and time course of improvement for an individual participating in an exercise program. OBJECTIVE: To develop a reference chart of CRF improvement for individuals participating in a 3-month cancer-specific exercise program. METHODS: In this retrospective cohort study, CRF was assessed every two weeks (using the FACIT - Fatigue scale, range: 0 - 52 with lower scores indicating greater fatigue) in 173 individuals participating in a 3-month supervised exercise program (741 observations). No cancer types were excluded and individuals were either undergoing chemotherapy and/or radiation, or within 6 months of completing treatment. The reference chart was developed using Generalized Additive Models for Location Scale and Shape. RESULTS: Each participant had an average of four CRF observations. Lower centiles demonstrated greater improvement than higher centiles (11 points over the duration of the program for the 10th and 4 points for the 90th percentiles). LIMITATIONS: The population is biased to individuals self-selecting or being referred to a clinical exercise program. CONCLUSIONS: This reference chart provides a novel method of monitoring CRF improvement during a cancer-specific exercise program. Setting appropriate expectations and informing exercise prescription adaptation are discussed in the context of representative data from three participants. Future research can investigate improvements in clinical outcomes and the remote monitoring of CRF through the implementation of the reference chart.

"This is not negotiable. You need to do this ": A directed content analysis of decision making in rehabilitation after knee arthroplasty.

PURPOSE: To understand patients' and physical therapists' perspectives related to decision making during outpatient rehabilitation after total knee arthroplasty (TKA), and to describe potential barriers and opportunities for shared decision making (SDM) in this setting. METHODS: A qualitative study examined the beliefs, thoughts, and experiences of patients and physical therapists regarding decision making in outpatient rehabilitation after TKA. Semi-structured interviews were conducted and analysed using directed content analysis. RESULTS: Thirty-five participants were interviewed (20 patients, 15 physical therapists). Three main themes emerged from the data: (1) there is variability among physical therapists in how patients are involved in care decisions, (2) several features of the outpatient care paradigm are not supportive of SDM, and (3) preoperative patient-clinician interactions may facilitate SDM in postoperative rehabilitation, but these interactions are not typically utilized. CONCLUSION: Physical therapists described using decision-making strategies with varying levels of patient involvement. Both patients and physical therapists described barriers to routine use of SDM in the outpatient setting. Several actionable strategies for overcoming these barriers were identified for providers and organizations seeking to consistently use SDM in outpatient TKA rehabilitation.

Neighbors-based prediction of physical function after total knee arthroplasty.

The purpose of this study was to develop and test personalized predictions for functional recovery after Total Knee Arthroplasty (TKA) surgery, using a novel neighbors-based prediction approach. We used data from 397 patients with TKA to develop the prediction methodology and then tested the predictions in a temporally distinct sample of 202 patients. The Timed Up and Go (TUG) Test was used to assess physical function. Neighbors-based predictions were generated by estimating an index patient's prognosis from the observed recovery data of previous similar patients (a.k.a., the index patient's "matches"). Matches were determined by an adaptation of predictive mean matching. Matching characteristics included preoperative TUG time, age, sex and Body Mass Index. The optimal number of matches was determined to be m = 35, based on low bias (- 0.005 standard deviations), accurate coverage (50% of the realized observations within the 50% prediction interval), and acceptable precision (the average width of the 50% prediction interval was 2.33 s). Predictions were well-calibrated in out-of-sample testing. These predictions have the potential to inform care decisions both prior to and following TKA surgery.

Development of a physical mobility prediction model to guide prosthetic rehabilitation.

BACKGROUND: Prosthetic rehabilitation decisions depend on estimating a patient's mobility potential. However, no validated prediction models of mobility outcomes exist for people with lower-limb amputation (LLA). OBJECTIVES: To develop and test predictions for self-reported mobility after LLA, using the Prosthetic Limb Users Survey of Mobility (PLUS-M). STUDY DESIGN: This is a retrospective cohort analysis. METHODS: Eight hundred thirty-one patient records (1,860 PLUS-M observations) were used to develop and test a neighbors-based prediction model, using previous patient data to predict the 6-month PLUS-M T-score trajectory for a new patient (based on matching characteristics). The prediction model was developed in a training data set (n = 552 patients) and tested in an out-of-sample data set of 279 patients with later visit dates. Prediction performance was assessed using bias, coverage, and precision. Prediction calibration was also assessed. RESULTS: The average prediction bias for the model was 0.01 SDs, average coverage was 0.498 (ideal proportion within the 50% prediction interval = 0.5), and prediction interval was 8.4 PLUS-M T-score points (40% improvement over population-level estimates). Predictions were well calibrated, with the median predicted scores falling within the standard error of the median of observed scores, across all deciles of the data. CONCLUSIONS: This neighbors-based prediction approach allows for accurate estimates of PLUS-M T-score trajectories for people with LLA.

Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice.

OBJECTIVE: Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients. METHODS: Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models. RESULTS: 2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts. CONCLUSIONS: Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes. This suggests that both clinical and research populations may recover similarly from TKA.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation.

OBJECTIVE: The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables. METHODS: Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space. RESULTS: Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space. CONCLUSION: The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA. IMPACT: The CD-RISC may be an appropriate tool to measure resilience following LLA.

Determination of Pain Phenotypes in Knee Osteoarthritis Using Latent Profile Analysis.

OBJECTIVE: To identify clinical phenotypes of knee osteoarthritis (OA) using measures from the following domains: 1) multimorbidity; 2) psychological distress; 3) pain sensitivity; and 4) knee impairment or pathology. DESIGN: Data were collected from 152 people with knee OA and from 31 pain-free individuals. In participants with knee OA, latent profile analysis (LPA) was applied to the following measures: normalized knee extensor strength, Functional Comorbidity Index (FCI), Pain Catastrophizing Scale (PCS), and local (knee) pressure pain threshold. Comparisons were performed between empirically derived phenotypes from the LPA and healthy older adults on these measures. Comparisons were also made between pheonotypes on pain intensity, functional measures, use of health care, and history of knee injury. RESULTS: LPA resulted in a four-group solution. Compared with all other groups, group 1 (9% of the study population) had higher FCI scores. Group 2 (63%) had elevated pain sensitivity and quadriceps weakness relative to group 4 and healthy older adults. Group 3 (11%) had higher PCS scores than all other groups. Group 4 (17%) had greater leg strength, except relative to healthy older adults, and reduced pain sensitivity relative to all groups. Groups 1 and 3 demonstrated higher pain and worse function than other groups, and group 4 had higher rates of knee injury. CONCLUSION: Four phenotypes of knee OA were identified using psychological factors, comorbidity status, pain sensitivity, and leg strength. Follow-up analyses supported the replicability of this phenotype structure, but future research is needed to determine its usefulness in knee OA care.

Reliability, responsiveness, and validity of handheld dynamometry for assessing quadriceps strength in total knee arthroplasty.

PURPOSE: To determine the reliability, responsiveness, validity, and agreement of handheld dynamometry, relative to electromechanical dynamometry, for assessing quadriceps strength surrounding total knee arthroplasty. METHODS: Fifty-six patients (48% female) undergoing total knee arthroplasty were assessed prior to surgery and at 2 and 6 weeks following surgery. Maximum isometric quadriceps force was assessed at each time point by handheld dynamometry and electromechanical dynamometry. Within-session test-retest reliability was determined by intraclass correlation coefficient (ICC). Standard error of measurement and relative standard error (RSE) values were calculated. Standardized response means were used to describe responsiveness. Pearson's correlations examined construct validity. Agreement was assessed by the Bland-Altman method. RESULTS: Both handheld dynamometry and electromechanical dynamometry demonstrated excellent test-retest reliability (ICC >0.90) and RSE (<15%). Both methods were responsive, with large postoperative standardized response means of 1.57 (handheld dynamometry) and 1.37 (electromechanical dynamometry). Pearson's correlations were moderate to strong. The Bland-Altman analysis revealed underestimation of force by handheld dynamometry, although this effect was diminished in the early postoperative period. CONCLUSIONS: Our results suggest handheld dynamometry is a promising tool for monitoring quadriceps strength in patients pre- and post-total knee arthroplasty.IMPLICATIONS FOR REHABILITATIONThis study provides evidence of high reliability and responsiveness of handheld dynamometry for assessing quadriceps strength throughout a clinically relevant time frame for patients with total knee arthroplasty.There is construct validity of handheld dynamometry for measuring quadriceps strength, with moderate to high correlations between handheld dynamometry and electromechanical dynamometry, both pre- and post-total knee arthroplasty.Rehabilitation professionals should be aware that handheld dynamometry and electromechanical dynamometry do not agree in terms of the force measurement itself; particularly at higher force values, handheld dynamometry underestimates force output relative to electromechanical dynamometry.Overall, this study supports the use of handheld dynamometry for monitoring quadriceps strength in clinical settings for patient with total knee arthroplasty.

Reference chart for knee flexion following total knee arthroplasty: a novel tool for monitoring postoperative recovery.

BACKGROUND: Clinicians and patients lack an evidence-based framework by which to judge individual-level recovery following total knee arthroplasty (TKA) surgery, thus impeding personalized treatment approaches for this elective surgery. Our study aimed to develop and validate a reference chart for monitoring recovery of knee flexion following TKA surgery. METHODS: Retrospective analysis of data collected in routine rehabilitation practice for patients following TKA surgery. Reference charts were constructed using Generalized Additive Models for Location Scale and Shape. Various models were compared using the Schwarz Bayesian Criterion, Mean Squared Error in 5-fold cross validation, and centile coverage (i.e. the percent of observed data represented below specified centiles). The performance of the reference chart was then validated against a test set of patients with later surgical dates, by examining the centile coverage and average bias (i.e. difference between observed and predicted values) in the test dataset. RESULTS: A total of 1173 observations from 327 patients were used to develop a reference chart for knee flexion over the first 120 days following TKA. The best fitting model utilized a non-linear time trend, with smoothing splines for median and variance parameters. Additionally, optimization of the number of knots in smoothing splines and power transformation of time improved model fit. The reference chart performed adequately in a test set of 171 patients (377 observations), with accurate centile coverage and minimal average bias (< 3 degrees). CONCLUSION: A reference chart developed with clinically collected data offers a new approach to monitoring knee flexion following TKA.

Development of a reference chart to monitor postoperative swelling following total knee arthroplasty.

Title: Development of a reference chart to monitor postoperative swelling following total knee arthroplasty.Purpose: Lower extremity swelling is a feature of total knee arthroplasty. Until recently, clinicians lacked tools to accurately measure swelling in clinical settings, but bioelectrical impedance assessment has shown promise in this regard. The purpose of this study was to develop a reference chart of lower extremity swelling following total knee arthroplasty.Method: Fifty-six participants (54% male, mean age = 64 years) were followed for the first 7 weeks following total knee arthroplasty, during which frequent lower extremity bioelectrical impedance assessments were performed. Using Generalized Additive Models for Location Scale and Shape, a reference chart for swelling was developed with bioelectrical impedance assessment data from the first 40 patients enrolled in the study (223 observations) and preliminarily tested for performance in the remaining 16 patients' data (96 observations).Results: The reference chart illustrates approximately 10% per day increase for the first 3 days following surgery. Peak swelling occurs 6-8 days following surgery; the 10th percentile demonstrates a peak of 25%, whereas the 90th percentile peaks at 47%. In the test data, this reference chart demonstrated accurate coverage at each estimated centile.Conclusion: The reference chart provides a novel framework for monitoring swelling following total knee arthroplasty and may augment clinical decisions to improve postoperative swelling management.Implications for rehabilitationThe use of bioelectrical impedance assessment provides an accurate and easily implemented approach for rehabilitation professionals to measure swelling.The reference chart provided allows for monitoring of patient recovery of swelling following total knee arthroplasty.Precise depictions of where a patient's swelling is in reference to others will improve clinical decision making at the individual level.

Person-Centered Care and Physical Therapy: A "People-Like-Me" Approach.

In health care, "person centeredness" is a valued (though nebulous) concept. In physical therapy, clinical interactions often strive to be person-centered, for example, by focusing on participation and valuing patient empowerment. However, the available evidence has mostly been constructed around populations (or study samples) rather than individuals. In this perspective, an alternative evidence framework is described, constructed around measurements in routine practice. Specifically, the authors propose developing "people-like-me" reference charts, generated with historical outcomes data, to provide real-time information on an individual's status relative to similar people. The authors present an example of how this could work using their experience with people rehabilitating after total knee arthroplasty. They also describe several challenges that must be addressed to bring this innovation into practice. First, the most important outcome measures for stakeholders (eg, patients, clinicians) need to be identified and monitored longitudinally to ensure that "people-like-me" estimates are useful and support the goals of person-centered care. Statistical methods for selecting "people-like-me" need to be examined and refined. Finally, the "people-like-me" information needs to be packaged in such a way that it is accessible, intuitive, and helpful at the point of care. Ideally, the entire process should recognize from the outset that practice patterns evolve, so databases, statistical models, and decision tools should be dynamic by design. Ultimately, the authors propose this framework as a practical mechanism to advance person-centered decisions in physical therapy according to the ideals of evidence-based practice.

Characteristics of young and lower functioning patients following total knee arthroplasty: a retrospective study.

BACKGROUND: Rates of total knee arthroplasty (TKA) procedures in younger, more medically complex patients have dramatically increased over the last several decades. No study has examined categorization of lower and higher functioning subgroups within the TKA patient population. Our study aimed to determine preoperative characteristics of younger patients who are lower functioning following TKA. METHODS: Patients were categorized into higher and lower functioning subgroups defined using a median split of 1) postoperative Timed Up and Go (TUG) test times and 2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale scores. A split in age (65 years) was used to further classify patients into four categories: younger lower functioning, younger higher functioning, older lower functioning and older higher functioning. Measures from preoperative domains of health, psychological, physical performance and pain severity were examined for between-group differences. RESULTS: Comparing mean values, the younger lower functioning subgroup using the TUG had significantly weaker knee extensor, slower gait speed, higher body mass index and greater pain compared to other subgroups. The younger lower functioning subgroup using the WOMAC physical function subscale demonstrated higher pain levels and Coping Strategies Questionnaire-Catastrophizing Subscale scores compared to the older lower functioning subgroup. CONCLUSIONS: Poorer preoperative physical performance and pain severity appear to have the largest influence on early postoperative TKA recovery in younger lower functioning patients relative to both younger and older higher functioning patients.

Peripheral Nociception Is Associated with Voluntary Activation Deficits and Quadriceps Weakness Following Total Knee Arthroplasty.

BACKGROUND: Quadriceps weakness is a hallmark of total knee arthroplasty and is driven by reduced voluntary muscle activation following the surgical procedure. The mechanisms underlying postoperative activation deficits are not well established, although nociception has been implicated via both spinal reflex and supraspinal pathways. The purpose of this study was to assess the role of nociception in postoperative recovery of strength and activation. METHODS: A total of 53 participants were assessed prior to total knee arthroplasty and at 6 weeks postoperatively. Quadriceps strength was measured by maximum voluntary isometric contraction, and activation was measured by the doublet interpolation technique. The pressure-pain threshold was used to measure local sensitization (at the knee joint) and systemic sensitization (at the forearm). Changes in outcomes (strength and activation) were regressed against pressure-pain threshold measurements. Mediation analyses were planned for significant associations to investigate whether deficits in voluntary activation were implicated on a causal pathway between pressure-pain threshold measures and postoperative strength loss. RESULTS: Knee pressure-pain threshold measures were significantly associated with reduced voluntary quadriceps activation (beta = -0.04; p = 0.009) and diminished quadriceps strength after total knee arthroplasty (beta = -0.07; p = 0.001). There was also a mediation effect of voluntary activation on the relationship between the knee pressure-pain threshold and quadriceps strength. After correcting for multiple comparisons, relationships between the forearm pressure-pain threshold and strength and activation did not reach significance. CONCLUSIONS: The measures of local nociceptor sensitization were related to reduced strength and activation following total knee arthroplasty. This is consistent with a causal pathway linking increased firing of knee joint nociceptors to reduced activation and reduced strength. Future randomized studies should investigate whether peripherally directed pain therapies reduce pain while also promoting the recovery of quadriceps strength via an improved capacity for voluntary activation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.