Feasibility, reliability and validity of self-measurement of knee range-of-motion using an accelerometer-based smartphone application by patients with total knee arthroplasty.

AIMS: Limited knee range-of-motion (ROM) is common following total knee arthroplasty (TKA). It is associated with functional limitations and patient dissatisfaction. Regular knee ROM assessment is important but accurate testing traditionally requires timely access to trained healthcare professionals. Although accelerometer-based smartphone goniometry has shown to provide reliable and valid joint angles, current evidence of its use still positions healthcare providers as end users instead of patients themselves. Therefore, to maximize the impact of smartphone goniometry on post-TKA care, our study aimed to examine the feasibility, reliability, and validity of patients' self-measurement of knee ROM using an accelerometer-based smartphone goniometry application. METHODS: Patients were given standard instructions with a practice trial before the actual measurements. Passive knee flexion and extension ROM was measured on 2 sessions in 30 patients with TKA using 4 block-randomized methods: (i) smartphone self-assessment, (ii) long-arm goniometry by physiotherapist, (iii) smartphone assessment by physiotherapist, and (iv) extendable-arm goniometry by physiotherapist with placement adjudication. Feasibility was assessed by the number of participants who could independently perform the self-measurement. To assess intra- and inter-session reliability, we computed intraclass correlation coefficients (ICCs) from random-effects models. To assess intra- and inter-session agreement, we computed mean absolute differences (MADs) and minimum detectable change (MDC). To assess concurrent validity, we designated extendable-arm goniometry as the "gold standard" and compared other methods against it using ICCs and MADs. RESULTS: All patients were able to comprehend and execute the assessment. 87% (n = 26) found the application easy to administer. Smartphone goniometry by patients showed excellent intra- and inter-session reliability (ICCs>0.97) and minimum variability (MAD = 0.9°-3.9°; MDC95 = 3.1°-9.0°). Smartphone or long-arm goniometry by physiotherapists did not outperform patients' self-assessment (ICC = 0.96-0.99, MAD = 0.7°-3.1°; MDC95 = 2.2°-8.0°). Compared against extendable-arm goniometry, smartphone goniometry by patients measured knee flexion and extension ROM with a MAD of 4.5° (ICC, 0.97) and 2.2° (ICC = 0.98), respectively. CONCLUSION: Our study demonstrates that smartphone goniometry is feasible, reliable and accurate, and can be used with confidence in the self-assessment of knee ROM post-TKA. Future studies should further explore its utility in telemonitored rehabilitation, and its possible integration into mobile health applications to enhance accessibility to care following TKA.

Clinical outcome measures reporting in randomized trials evaluating Tuina therapy for chronic nonspecific low back pain: A systematic review.

BACKGROUND: Tuina has gained widespread attention and utilization for the management of chronic nonspecific low back pain (CNLBP). However, evidence-based guidance for choosing accurate and appropriate outcome measures of Tuina is lacking. The objective of this study is to systematically synthesize the existing outcome measures reported in randomized controlled trials (RCTs) evaluating Tuina therapy in CNLBP. METHODS: Electronic literature searches were conducted in multiple English and Chinese databases from their inception to May 2022. RCTs were included if they involved clinical outcome measures in Tuina treatment for patients with CNLBP. Outcome instruments for each study were extracted and analyzed. Evidence from included studies were assessed using the Cochrane risk-of-bias tool. RESULTS: Of the 735 identified articles, 17 articles with 1628 participants were included. Measurement domains in these RCTs were mainly reported in terms of pain (94%) and physical activity (71%), followed by safety (41%), Chinese medicine outcome (35%), and quality of life (12%). Moreover, several limitations with existing outcomes were reported, including lack of emphasis on the evaluation of quality of life, inadequate safety monitoring, as well as insufficient and vague Chinese medicine outcome measures. All trials were deemed to be of poor methodological quality. CONCLUSION: Pain and physical disability were the most frequently studied outcome domains in CNLBP treated by Tuina therapy. More rigorous and high-quality trials with appropriately selected outcome measures are needed in the future.

Efficacy and safety of Tuina for chronic nonspecific low back pain: A PRISMA-compliant systematic review and meta-analysis.

OBJECTIVE: Chronic nonspecific low back pain (CNLBP) is a serious medical and social problem resulting in functional decline and decreased work ability. Tuina, a form of manual therapy, has been sparsely used to treat patients with CNLBP. To systematically assess the efficacy and safety of Tuina for patients with CNLBP. METHODS: Multiple English and Chinese literature databases were searched until September 2022 for randomized controlled trials (RCTs) of Tuina in the treatment of CNLBP. The methodological quality was assessed using the Cochrane Collaboration's tool, and certainty of the evidence was determined with the online Grading of Recommendations, Assessment, Development and Evaluation tool. RESULTS: Fifteen RCTs with 1390 patients were included. Tuina demonstrated a significant effect on pain (SMD: -0.82; 95% CI -1.12 to -0.53; P < .001; I2 = 81%) and physical function (SMD: -0.91; 95% CI -1.55 to -0.27; P = .005; I2 = 90%) when compared to control. However, Tuina resulted in no significant improvement for quality of life (QoL) (SMD: 0.58; 95% CI -0.04 to 1.21; P = .07; I2 = 73%;) compared to control. The Grading of Recommendations, Assessment, Development and Evaluation evidence quality was determined to be low level for pain relief, physical function, and QoL measurements. Only six studies reported adverse events; none were serious. CONCLUSION: Tuina might be an effective and safe strategy for treating CNLBP in terms of pain and physical function, but not for QoL. The study results should be interpreted with caution for their low-level evidence. More multicenter, large-scale RCTs with a rigorous design are required to further confirm our findings.

A Systematic Review and Meta-Analysis Protocol on How Best to Use Non-Pharmacologic Therapies to Manage Chronic Low Back Pain and Associated Depression.

Purpose: To evaluate the efficacy of different non-pharmacologic therapies (NPTs) on relieving depressive symptoms and pain intensity in individuals living with chronic low back pain (LBP) and associated depression. Methods: A comprehensive search of seven English databases and two Chinese databases from inception to the search date will be undertaken. The reference lists of previously published relevant reviews and included trials will also be searched. Only peer-reviewed and published moderate-to-high quality randomized controlled trials (RCTs) for chronic LBP and associated depression treated with NPTs will be considered. Two independent reviewers will identify studies, extract data, assess risk of bias, and evaluate the strength of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis will be conducted to estimate the treatment effect of various NPTs. Heterogeneity will be assessed using Cochrane's Q and the I-squared statistics. Subgroup and sensitivity analyses will be performed to assess the robustness of findings. A funnel plot will be developed to evaluate reporting bias, and Begg's and Egger's tests will be used to assess funnel plot symmetries. Results: This protocol outlines the planned scope and methodology for an upcoming systematic review and meta-analysis, which will provide up-to-date evidence on 1) which NPTs are associated with improvements in depressive symptoms and pain intensity and 2) whether the effects of NPTs on chronic LBP and associated depression vary according to clinical condition, participant, and treatment characteristics. Conclusion: Our meta-analyses of moderate-to-high quality RCTs will help to develop specific recommendations on prescribing NPTs in patients with chronic LBP and associated depression. Study Registration: This protocol is registered on the International Platform of Registered Systematic Review and Meta-analysis (INPLASY) protocols platform as record No. INPLASY202260055.

Brief introductory group education programs for chronic disease patients in chronic disease management: a scoping review protocol.

OBJECTIVE: This review will scope the literature and map the features of brief introductory group education programs implemented in chronic disease management. INTRODUCTION: Brief introductory group education programs are resource-efficient interventions used in chronic disease management to educate patients about basic disease concepts, self-management strategies, and to introduce specialist services. There is a lack of published research that synthesizes the characteristics, guiding principles, and outcomes reported in brief group education programs in chronic disease management. This scoping review will seek to identify brief introductory group education programs and describe the i) scope of literature available on such programs, ii) characteristics of the programs, iii) guiding self-management principles used and the extent to which programs follow such principles, and iv) types of outcomes reported. INCLUSION CRITERIA: This review will consider studies describing an introductory or brief group patient education program (one to four sessions, no more than eight hours) for the management of chronic disease in adults with ongoing chronic disease. METHODS: MEDLINE, Scopus, CINAHL, Emcare, Web of Science, and PsycINFO will be searched for English-language articles published from 2001 to the present. Titles and abstracts will be screened against inclusion/exclusion criteria, followed by full-text review, independently assessed by two reviewers. Eligible articles will be extracted and charted using a standardized data extraction form. A descriptive review to summarize and contextualize the extracted data will be conducted.

Tui Na for Chronic Nonspecific Low Back Pain: Protocol for a Systematic Review and Meta-analysis.

BACKGROUND: Chronic nonspecific low back pain (CNLBP) is one of the most common complex pain conditions, and it is strongly associated with high rates of disability. Even though several studies on Tui na for CNLBP have been reported, to our knowledge there has been no systematic review of the currently available publications. OBJECTIVE: This study aims to develop a protocol for a systematic review and meta-analysis that will evaluate the effectiveness and safety of Tui na therapy for patients with CNLBP. METHODS: An electronic literature search of PubMed, Embase, MEDLINE, Cochrane Library, Springer, Scopus, World Health Organization International Clinical Trials Registry Platform, Physiotherapy Evidence Database (PEDro), Clarivate Analytics, and Chinese biomedical databases (the China National Knowledge Infrastructure, Wan-fang database, Chinese Scientific Journals Database, and Chinese Biomedical Literature Databases) will be conducted. Studies will be screened by two reviewers independently based on titles and abstracts, followed by a full-text reading with eligibility criteria. Randomized controlled trials involving Tui na for patients with CNLBP will be reviewed. The primary outcomes of the study are improvement of pain, analgesic medication reduction, improvement of functional disability, and degree of satisfaction with the intervention. A secondary outcome is any adverse event of Tui na intervention. Methodological quality and risk of bias will be assessed with the Cochrane Collaboration Risk of Bias Tool. If studies are sufficient, a meta-analysis of the effectiveness will be performed. If possible, we will evaluate publication bias using funnel plots. If substantial heterogeneity between studies is present, and there are sufficient studies, subgroup analyses will be conducted to explain the study findings. RESULTS: The review database searches will be initiated in December 2020, with findings expected by January 2021. CONCLUSIONS: This protocol will establish a framework of a high-quality literature synthesis on the impact of Tui na treatment in patients with CNLBP. The proposed review will determine whether Tui na is effective and safe for CNLBP patients. TRIAL REGISTRATION: PROSPERO CRD42020166731; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=166731. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/20615.

Immediate effects of valgus bracing on knee joint moments during walking in knee-healthy individuals: Potential modifying effects of body height.

BACKGROUND: The goal of valgus knee brace treatment is to reduce medial knee joint loading during walking, often indicated by external knee adduction moment (KAM) measures. However, existing healthy-subjects studies have been equivocal in demonstrating KAM reduction with valgus knee bracing. RESEARCH QUESTION: What are the immediate effects of valgus bracing at different tension levels on KAM during walking at a controlled speed and does body height modify the brace-KAM associations? METHODS: Data from 32 knee-healthy participants were analysed in this randomized crossover trial. Participants performed walking trials at controlled speed (1.3 ± 0.065 m/s) both with and without an Ossür Unloader One® brace. During the bracing condition, valgus tension was incrementally increased, from zero tension to normal tension and to maximum tolerable tension. RESULTS: Valgus bracing minimally increased knee flexion at heel-strike (P < 0.001) in a dose-dependent manner and minimally reduced gait velocity (∼0.015m/s) across all tension levels. Valgus bracing, overall, did not significantly reduce the various KAM measures. However, brace use at maximal tension was associated with a 0.04Nm/kg (9.2 %) increase in first peak KAM amongst participants with a body height of 1.75 m and a 0.03Nm/kg (7.6 %) decrease in first peak KAM amongst participants with a body height of 1.55 m. SIGNIFICANCE: Valgus bracing did not reduce the various KAM measures during walking; however, body height may play a moderating role. Given knee brace sizes vary more in circumference than length, this result may be due to the ratio between effective moment arm length relative to limb length. A deeper understanding of the potential neuro-biomechanical effects of valgus knee bracing and how these effects are potentially modified by body height may be critical to the design of effective knee braces.

Test-retest reliability and variability of knee adduction moment peak, impulse and loading rate during walking.

BACKGROUND: Previous studies have reported good test-retest reliability for peak knee adduction moment (KAM) during walking. However, reliability of other KAM measurements has not been established. RESEARCH QUESTION: What is the test-retest reliability of peak KAM, KAM impulse, and KAM loading rate measurements during walking in knee-healthy individuals? METHODS: Data from 32 knee-healthy participants were analysed in this test-retest reliability study. Various KAM measurements were reported for two sessions with kinematic and kinetic data obtained from a motion capture system synchronised with force plates, with a median of 1 week between sessions. RESULTS: For all KAM measures, intra-class correlation coefficients were above 0.90 and their lower bound 95 % confidence limits exceeded 0.81. However, absolute measurement variability differed across measures, with normalized SEM (8 %-15 %), normalized MDC95 (20 %-40 %), intra-session MAD (10 %-18 %), and inter-session MAD (12 %-22 %) varying over a 2-fold range. Overall and first peak KAM, KAM impulse over 50 % stance, and KAM loading rate (15 frame window) showed ≤10 % and ≤15 % intra- and inter-session MAD, respectively. SIGNIFICANCE: This study provided previously undefined test-retest reliability estimates for various KAM measures during walking. Researchers and clinicians should not assume that the various aspects of the KAM curve share similar reliability.

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.

Cancer Supportive and Survivorship Care in Singapore: Current Challenges and Future Outlook.

Despite being a relatively young nation, Singapore has established itself as a leading multifaceted medical hub, both regionally and globally. Although Singapore continues to pursue excellence in oncology care, cancer supportive care and survivorship care remain in the infancy stage. In an effort to advance this important aspect of oncology care in Singapore, the first cancer supportive and survivorship care forum was held in December 2016, involving 74 oncology practitioners. The primary goals of this forum were to raise awareness of the importance of cancer supportive and survivorship care and to provide a platform for oncology practitioners of diverse backgrounds to converge and address the challenges associated with the delivery of cancer supportive and survivorship care in Singapore. Key challenges identified during this forum included, but were not limited to, care fragmentation in an oncologist-centric model of care, poor integration of allied health and rehabilitation services, passive engagement of community partners, lack of specialized skill sets and knowledge in supportive and survivorship care, and patient-related barriers such as poor health literacy. The survivorship care model commonly used in Singapore places an imbalanced emphasis on surveillance for cancer recurrence and second primary cancers, with little attention given to the supportive and survivorship needs of the survivors. In summary, these challenges set the stage for the development and use of a more survivor-centric model, one that focuses not only on cancer surveillance, but also on the broad and unique physical and psychosocial needs of survivors of cancer in Singapore.

Predicting outcomes of acute low back pain patients in emergency department: A prospective observational cohort study.

Low back pain (LBP) is a common complaint among patients presenting to emergency department (ED) in Singapore. The STarT Back Screening Tool (SBT) was recently developed and validated for triage of LBP patients in primary care settings. This study aimed to investigate whether the SBT could provide prognostic information for long-term outcomes of acute LBP patients visiting the ED, who might benefit from appropriate and timely management at an earlier stage.Data were collected in a prospective observational cohort study from 177 patients who consulted emergency physicians for acute LBP and completed 6-month follow-up. Patients were administered the SBT and assessed at baseline. Follow-up assessments were conducted at 6 weeks and 6 months.A multiple linear regression model incorporating SBT total score, age, employment status, LBP history, and 6-week pain score was constructed to predict 6-month pain score. In the model, SBT total score and 6-week pain score were significantly associated with 6-month pain score (P < .05) with respective coefficients of 0.125 and 0.500. The model explained 40.1% of the variance for 6-month pain score.This study demonstrated that the multiple linear regression model showed predictive performance in determining long-term outcomes for acute LBP patients presenting to the ED.

Associations of self-report physical function with knee strength and knee range-of-motion in total knee arthroplasty possible nonlinear and threshold effects.

This study aims to examine, in patients before and following a total knee arthroplasty (TKA), whether knee extensor strength and knee flexion/extension range-of-motion (ROM) were nonlinearly associated with physical function. Data from 501 patients with TKA were analyzed. Knee extensor strength was assessed preoperatively and 6 months postoperatively. Knee ROM and Short Form-36 (SF-36) physical function data were collected from each patient preoperatively, and at 6 and 24 months postoperatively. Knee strength was measured by handheld dynamometry and knee ROM by goniometry. Restricted cubic spline regression was used to examine possible nonlinear associations. At all assessment points, the associations between knee measures and function were not always linear. Some of the associations revealed distinct threshold points. These findings have potential clinical and research implications.

Knee extension range of motion and self-report physical function in total knee arthroplasty: mediating effects of knee extensor strength.

BACKGROUND: Knee extensor strength and knee extension range of motion (ROM) are important predictors of physical function in patients with a total knee arthroplasty (TKA). However, the relationship between the two knee measures remains unclear. The purpose of this study was to examine whether changes in knee extensor strength mediate the association between changes in knee extension ROM and self-report physical function. METHODS: Data from 441 patients with a TKA were collected preoperatively and 6 months postoperatively. Self-report measure of physical function was assessed by the Short Form 36 (SF-36) questionnaire. Knee extensor strength was measured by handheld dynamometry and knee extension ROM by goniometry. A bootstrapped cross product of coefficients approach was used to evaluate mediation effects. RESULTS: Mediation analyses, adjusted for clinicodemographic measures, revealed that the association between changes in knee extension ROM and SF-36 physical function was mediated by changes in knee extensor strength. CONCLUSIONS: In patients with TKA, knee extensor strength mediated the influence of knee extension ROM on physical function. These results suggest that interventions to improve the range of knee extension may be useful in improving knee extensor performance.

Age-related changes in collagen, pyridinoline, and deoxypyridinoline in normal human thoracic intervertebral discs.

Human thoracic discs were analyzed for collagen and collagen cross-links to determine the distribution due to segmental, age, and gender influences. Thoracic discs from 26 cadaveric spines (1 to 90 years old) were graded macroscopically, then separated into anular and nuclear samples. Only grade I (i.e., normal) disc samples were selected (n=209). Pyridinoline and deoxypyridinoline cross-links were initially separated by column chromatography and analyzed by reverse-phase high-pressure liquid chromatography. The collagen content was lower and the extent of pyridinoline and deoxypyridinoline were significantly higher in the nucleus compared with the anulus (p <.001). The collagen content and extent of pyridinoline were significantly lower with increasing age in the anulus and nucleus (p <.001). Young male discs had a significantly higher extent of pyridinoline compared with females (p <.001). Age, gender, and disc region differences were found to have a significant influence on the biochemical composition of the normal disc extracellular matrix.