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

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

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

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

Feasibility, correlates, and validity of the one-leg sit-to-stand test in individuals following anterior cruciate ligament reconstruction.

OBJECTIVE: Regular quadriceps strength assessment is important following anterior cruciate ligament reconstruction (ACLR). The one-leg sit-to-stand (OLSTS) test potentially overcomes the barrier of accessibility to specialised testing equipment. However, feasibility and validity testing of OLSTS is lacking in the ACLR population. This study aims to examine the feasibility, correlates, and predictive validity of OLSTS with self-reported running and jumping difficulty in individuals post-ACLR. DESIGN: Retrospective longitudinal study. METHODS: 20 patients with primary unilateral ACLR were tested at 6-months and 1-year post-ACLR. Feasibility was assessed by the number of patients who had safely performed OLSTS at both timepoints. Cross-sectional gender-adjusted Spearman correlations of OLSTS with quadriceps strength, physical impairments, and psychological variables were measured at 6-months. Predictive validity was assessed via ordinal regression, quantifying the associations of OLSTS with self-reported running and jumping difficulty across time-points. RESULTS: All patients understood the instructions to and were able to self-administer the OLSTS test safely. OLSTS is a valid measure of quadriceps strength (gender-adjusted Spearman's ρ = 0.53, P = 0.02). Knee pain (ρ = 0.44, P = 0.046) and readiness to return-to-sport (ρ = 0.55, P = 0.02) were additional correlates. Greater OLSTS performance was associated with greater odds of better self-reported running and jumping function (interquartile-range ORs, 12.0 [95% CI: 3.6-45] and 18.5 [95% CI: 5-67], respectively). CONCLUSION: OLSTS is a feasible and valid test of quadriceps strength, demonstrating predictive validity with self-reported running and jumping post-ACLR. OLSTS potentially allows independent tracking of ACLR rehabilitation progress at home - an increasingly urgent necessity in the face of a global pandemic.

Knee performance and self-efficacy trajectory curves after ACL reconstruction: A longitudinal study.

OBJECTIVES: To examine knee flexion range-of-motion, quadriceps strength, and knee self-efficacy trajectory curves over 6 months after anterior cruciate ligament reconstruction (ACLR), stratified by patients' Month-6 sports activity level. DESIGN: Prospective longitudinal study. SETTING: Hospital outpatient physiotherapy department. PARTICIPANTS: 595 individuals after unilateral ACLR (mean age, 27 years). MAIN OUTCOME MEASURES: At 2-, 3-, and 6-months post-surgery, knee flexion range-of-motion, quadriceps strength, and self-efficacy were quantified. Flexion range-of-motion was additionally measured at 2- and 4-weeks post-surgery. Sports activity levels were assessed using the Tegner Activity Score at 6-months post ACLR. RESULTS: The various measures improved nonlinearly over time, with substantial improvements observed in the first 2-4 months post-surgery. In multivariable generalized least squares models, greater knee flexion range-of-motion, quadriceps strength, and self-efficacy over time were significantly associated with higher Month-6 Tegner levels (all P values < 0.01). Additionally, receiving a bone-patellar-tendon-bone graft or meniscal repair was associated with lower quadriceps strength trajectories (P-values<0.001) while female sex was associated with lower knee self-efficacy trajectories (P = 0.02). CONCLUSIONS: Greater knee flexion range-of-motion, quadriceps strength, and self-efficacy were associated with higher Month-6 Tegner levels. The derived trajectory curves may be useful for effective management decision making and adequate results interpretation during the rehabilitation process.

Shear wave elastography of the cervical arteries: A novel approach to the assessment of cervical arterial wall stiffness. An investigation of psychometric properties and intra-rater reliability.

BACKGROUND: Cervical arterial dissection, can occur spontaneously and is a rare but catastrophic adverse event associated with neck manipulation. Pathophysiology involves altered integrity of the arterial wall increasing its vulnerability to minor trauma. Those at risk are difficult to detect. Previous screening investigated blood flow but altered mechanical properties as stiffness of cervical arterial wall could provide a more valid indication of arterial integrity or even early dissection. OBJECTIVES: To investigate suitability and intra-rater reliability of shear wave ultrasound elastography to measure mechanical properties of the cervical arterial wall. Suitability was assessed by ability to track arteries along their length and measurement accuracy. DESIGN: Observational and intra-rater reliability study. METHODS: Internal carotid (ICA) and vertebral arteries (VA) of healthy participants were examined with shear wave elastography. Shear wave velocity (m/s) indicative of wall stiffness was measured with the head in the neutral position: proximally (C3-4) and distally (C1-2) where injuries have been more commonly reported. Proximal measures were repeated to assess intra-rater reliability. RESULTS: Thirty healthy participants (13 female), mean age of 29 (±12.8) years were imaged. Mean VA wall stiffness (3.4 m/s) was greater than ICA (2.3 m/s) (p < 0.000). Intra-rater reliability for ICA was ICC 0.81 (CI 0.52 to 0.92) and for VA ICC 0.76 (CI 0.38 to 0.9). Standard error of measurement was 0.16 for ICA and 0.34 for VA. CONCLUSIONS: Shear wave ultrasound elastography appears a suitable and reliable method to measure cervical arterial wall stiffness, justifying further research into its use for screening arterial integrity.