Human-centered design development of mHealth patient-to-peer referral tool in the emergency department.

Background: Given the steady increase of emergency department (ED) visits related to opioid overdoses, this study aims to determine the design and usability of an ED-centered mHealth patient-to-peer referral prototype tool that allows patients to refer peers to comprehensive HIV/HCV and opioid misuse prevention services. Methods: Two iterative focus group discussion (FDG) sessions and one use-case session were conducted. Eligible participants who were ≥18 years, had a history of injection drug use (IDU), and had utilized the ED in the past year were recruited through the distribution of flyers at the study institution, including the study ED. Human-centered design process was completed by using participant feedback on perceived utility, usability/accessibility, tool design, and clarity/readability to fine-tune prototype version and drive subsequent discussion sessions. Results: Sixteen consented individuals participated in at least one of the sessions. Feedback revealed that participants favored the inclusion of the webpage link on the referral card as means to bypass QR code if needed, more descriptions highlighting the exact services offered, and the fact that no personal information was required to complete the referral process. The prototype underwent several adjustments between user-centered FDG sessions, which ultimately ended in including features such as an online webpage with educational videos, SMS text-message communication system, and QR code usage into the final patient-to-peer referral tool prototype. Conclusion: The findings of this study suggest a human-centered designed patient-to-peer referral tool could be a feasible approach to linking community members at risk of IDU to HIV/HCV and opioid use-related preventive services from ED patients.

A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services.

BACKGROUND: The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings. METHODS: A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19). RESULTS: Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives. CONCLUSION: ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Short-term outcomes for total knee arthroplasty patients with active extension lag.

BACKGROUND: Despite the success of total knee arthroplasty (TKA), quadriceps strength can fail to recover. Active extension lag [quadriceps lag (Q-lag)] is a function of quadriceps weakness. Q-lag presents itself in patients who maintain a full passive range of motion (ROM), but are limited in active extension ROM. Few studies have evaluated the outcomes of post-TKA patients in the presence of post-operative Q-lag. Thus, this study aims to compare: (I) pain scores; and (II) rates of readmission to physical therapy (PT) in TKA patients with Q-lag of ≥15 degrees to patients without Q-lag. METHODS: A retrospective review of primary TKA patients between 2013 and 2015 was performed. A total of 150 patients (mean age 63.0 years) with a mean follow-up of 30.7 months were analyzed. All patients received an evidence-based protocol for PT at our institution. Patient readmission to PT was recorded if the orthopedic surgeon wrote an additional prescription for PT intervention following the standard of care following TKA. An independent samples t-test and chi-square analysis was conducted to assess the continuous and categorical variables, respectively. RESULTS: Fifty-one patients had Q-lag ≥15 degrees and 97 patients had Q-lag <15 degrees. Analysis of mean pain scores between the groups demonstrated a significant difference in mean pain scores (1.9 vs. 3.9; P=0.043). Chi-square analysis demonstrated no significant difference in rates of PT readmission between patients who presented with Q-lag, and patients without Q-lag (23.5% vs. 13.4%; P=0.118). CONCLUSIONS: There was no significant difference in readmission rates; however, patients with Q-lag experienced a clinically significant higher pain level. Since this is the first study of its kind, we suggest further investigations on the effect of Q-lag on patient outcomes following primary TKA.

Does Obesity Affect Outcomes in Patients Undergoing Innovative Multi-Modal Physical Therapy Following Primary Total Knee Arthroplasty?

INTRODUCTION: Knee stiffness following total knee arthroplasty (TKA) is a common complication, especially in obese patients. The initial, non-operative treatments for this complication includes splinting and physical therapy. If these measures fail, manipulation under anesthesia (MUA) or surgical exploration can be considered to restore range of motion (ROM). However, it is generally desirable to avoid these procedures. For these reasons, newer physical therapy protocols have been developed. However, it is unknown whether these protocols are efficacious for obese patients. Therefore, the purpose of this study was to evaluate and compare: 1) ROM; 2) the rate of MUA; 3) number of physical therapy visits; and 4) costs in patients who underwent innovative multimodal physical therapy (IMPT) and were either obese or non-obese. MATERIALS AND METHODS: A review of a consecutive series of patients undergoing TKA at a single center within a three-year period was performed. All patients received IMPT post-TKA. Patients were divided into obese (body mass index (BMI >30kg/m2) and non-obese (BMI <30 kg/m2) groups. One-hundred and forty-nine patients underwent TKA and had a mean age of 67 years (range, 42 to 88 years). There were 48 patients in the non-obese group and 101 in the obese group. The obese group was significantly younger (mean, 60 years; range 38 to 54 years vs. mean, 69 years; range, 50 to 88 years), with a similar gender distribution. Comparisons of ROM, MUA, number of physical therapy visits, and costs were performed using Student's t-tests and Chi-square tests as appropriate. Cost-analysis was also performed based on the number of visits to physical therapy (PT). RESULTS: At latest follow-up, there were no significant differences in mean flexion (mean, 115°, range, 90 to 130° vs. mean, 113°, range 60 to 130°) and extension (mean, 0.81°, range, 0 to 10° vs. 0.54°, range 0 to 10°, p=0.469) between the two groups. The obese group had a 14% (n = 12) rate of MUA compared to 2% (n=1) in the non-obese group (p=0.045). Obese patients had a significantly higher number of mean visits to PT. There was significantly higher mean healthcare costs in the obese (mean, $3,919, range $1,043 to $11,749) as compared to the non-obese (mean, $2,950, range $741 to $7,865) group. DISCUSSION: Although both cohorts have similar mean ROM at final follow-up, the obese cohort had a significantly higher proportion of patients who underwent MUAs following TKA as compared to non-obese patients, despite IMPT. At latest follow-up, the ROM achieved between the two groups was similar. Obese patients required more PT visits resulting in significantly higher mean healthcare costs.

Innovative Multimodal Physical Therapy Reduces Incidence of Repeat Manipulation under Anesthesia in Post-Total Knee Arthroplasty Patients Who Had an Initial Manipulation under Anesthesia.

Manipulation under anesthesia (MUA) is performed for knee stiffness following a total knee arthroplasty (TKA) when nonoperative treatments fail. It is important to develop an optimal outpatient physical therapy protocol following an MUA, to avoid a repeat procedure. The purpose of this study was to evaluate and compare: (1) range of motion and (2) the rate of repeat MUA in patients who either underwent innovative multimodal physical therapy (IMMPT) or standard-of-care physical therapy (standard) following an MUA after a TKA. We performed a retrospective database study of patients who underwent an MUA following a TKA between January 2013 to December 2014 (N = 57). There were 16 (28%) men and 41 (72%) women who had a mean age of 59 years (range, 32-81 years). The patients were stratified into those who underwent IMMPT (n = 22) and those who underwent standard physical therapy (n = 35). The 6-month range of motion and rate of repeat manipulation between the two cohorts was analyzed by using Student t-test and Chi-square tests. In addition, we performed a Kaplan-Meier analysis of time to repeat MUA. The IMMPT cohort had a statistically significant higher proportion of TKAs with an optimal range of motion as compared with the standard cohort. There was statistically significant lower proportion of patients who underwent a repeat MUA in the IMMPT as compared with the standard cohort. There was also a significantly lower incidence and longer time to MUA in the IMMPT cohort as compared with the standard cohort in the Kaplan-Meier analysis. The group who underwent IMMPT utilizing Astym therapy had a significantly higher proportion of patients with optimal range of motion, which implies the potential efficacy of this regimen to improve range of motion. Furthermore, the IMMPT cohort had a significantly lower proportion of repeat manipulations as compared with the standard cohort, which implies that an IMMPT approach could potentially reduce the need for a repeat MUA. These findings warrant further investigation into outcomes of different rehab approaches.

Innovative Multi-Modal Physical Therapy Reduces Incidence of Manipulation Under Anesthesia (MUA) in Non-Obese Primary Total Knee Arthroplasty.

INTRODUCTION: Patients may experience knee stiffness following total knee arthroplasty (TKA). Non-operative measures, such as more physical therapy and special splints are warranted in such cases. In the event of failure of these measures to restore knee range of motion, more invasive procedures with higher risks, such as manipulation under anesthesia (MUA) or repeat surgery, can be utilized. Thus, it becomes essential to optimize their non-operative measures in order to avoid more invasive, riskier options. Therefore, the purpose of this study was to evaluate and compare: 1) range of motion, and 2) the rate of MUA in patients who either underwent a multi-modal physical therapy regimen (IMMPT) or standard-of-care post-operative therapy (standard) following primary total knee arthroplasty. MATERIALS AND METHODS: We analyzed all non-obese patients who underwent primary TKAs between January 2013 and December 2014 at our institution who started an outpatient physical therapy program within six weeks of their surgery (n = 127 knees). There were 86 women and 41 men who had a mean age of 67 years (range, 42 to 88 years). This cohort was stratified into those who underwent an IMMPT regimen at our institution (n= 47) and those who underwent standard therapy at an outside institution (N = 80). The range of motion and rate of manipulation between the two groups was compared by using Chi-square and Student's t-test, as appropriate. RESULTS: There were similar proportions of those who had an optimal range of motion (≥110 degrees flexion and ≤5 degrees extension) in the IMMPT group as compared to the standard physical therapy cohort (81% vs. 82%). The IMMPT cohort had a significantly lower proportion of patients who underwent MUA as compared to the standard therapy cohort (2% vs. 13%). CONCLUSIONS: This study shows an IMMPT protocol utilizing Astym® therapy (Performance Dynamics, Inc. Muncie, Indiana) is able to significantly reduce the rate of manipulation following a total knee arthroplasty. Furthermore, this IMMPT approach was also able to achieve similar range of motion to the standard physical therapy group while reducing the rate of manipulation, which may indicate similar efficacy in restoring range of motion. Comparative randomized studies are needed to determine the true benefit of this IMMPT protocol.

Rehabilitative Guidelines after Total Knee Arthroplasty: A Review.

Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for both patients and providers. In addition, guidelines vary considerably between institutions, which often leave therapy regimens to the discretion of the provider. The lack of clear guidelines for rehabilitation may contribute to inadequate recovery of strength and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities currently available and to provide evidence regarding efficacy and practicality. Specifically, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance training, continuous passive motion, cold therapy and compression, neuromuscular electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-assisted soft-tissue therapy. Additionally, we proposed general recommendations for rehabilitation after TKA, and as we specifically described active and obese patients, we have included guidelines for these subsets as well. Our review examines the various rehabilitative modalities to offer suggestions for recovery of strength and range-of-motion after TKA, with a focus on the early incorporation of exercise therapy, balance training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation. Dedication and commitment to rehabilitation may help patients attain and exceed their preoperative activity levels.

Nonpharmacologic Pain Management and Muscle Strengthening following Total Knee Arthroplasty.

Despite technological advances in total knee arthroplasty (TKA), management of postoperative muscle weakness and pain continue to pose challenges for both patients and health care providers. Nonpharmacologic therapies, such as neuromodulation in the form of neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS), and other modalities, such as cryotherapy and prehabilitation, have been highlighted as possible adjuncts to standard-of-care pharmacologic management to treat postoperative pain and muscle weakness. The aim of this review was to discuss existing evidence for neuromodulation in the treatment of pain and muscular weakness following TKA, and to shed light on other noninvasive and potential future modalities. Our review of the literature demonstrated that NMES, prehabilitation, and some specialized exercises are beneficial for postoperative muscle weakness, and TENS, cooling therapies, and compression may help to alleviate post-TKA pain. However, there are no clear guidelines for the use of these modalities. Further studies should be aimed at developing guidelines or delineating indications for neuromodulation and other nonpharmacologic therapies in the management of post-TKA pain and muscle weakness.