Evaluating the importance of a core competency and capability framework for advanced practice physiotherapy: A cross-sectional survey.

INTRODUCTION: The need for a global core competency and capability framework for advanced practice physiotherapy is important due to the rapidly changing nature of health care delivery internationally and the need to standardize advanced practice physiotherapy. OBJECTIVE: To determine the importance of a proposed international core competency and capability framework for advanced practice physiotherapy. METHODS: We conducted a cross-sectional online survey of advanced practice physiotherapists across seven countries. The importance of each competency and capability was rated on a five-point agreement Likert scale. Participants were from the United Kingdom, Ireland, Australia, New Zealand, Canada, Switzerland and Argentina. RESULTS: A total of 99 participants completed the survey, comprising 63% (57/90) females and 33% (30/90) males. Sixty percent, 60% (54/90), had over 20 years of experience. The survey participants represented a diverse geographic distribution, with 25% (23/90) from Australia, 25% (23/90) from Canada, 18% (6/90) from New Zealand, and 18% (6/90) from the United Kingdom. Four percent 4% (4/90) from Ireland, and 4% (4/90) from other countries (Switzerland and Argentina). The survey revealed a strong consensus among participants, with all competencies and capabilities ranked as high and considered important to advanced practice. CONCLUSION: This study demonstrates a consensus among advanced practice physiotherapists across seven countries on the importance of a proposed competency and capability framework. The findings highlight the need for a global standard in advanced practice physiotherapy, particularly in light of the rapidly changing healthcare landscape.

Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis.

INTRODUCTION: The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy. OBJECTIVES: This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review. DESIGN: The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach. RESULTS: Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains. CONCLUSION: The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

Exercise and Behavior: Adjuncts to Pro-Myogenic Compounds for Enhancing Mobility in Older Adults.

Physical activity and exercise training exert multiple and varied beneficial effects on a wide array of human tissues, making them therapeutic modalities that can prevent and treat age-related decline in physical function. The Molecular Transducers of Physical Activity Consortium is currently working to elucidate the molecular mechanisms underlying how physical activity improves and preserves health. Exercise training, especially when task specific, is an effective intervention for improving skeletal muscle performance and physical function in everyday activities. As seen elsewhere in this supplement, its adjunctive use with pro-myogenic pharmaceuticals may prove to be synergistic in effect. Behavioral strategies aiming to promote exercise participation and sustain adherence are being considered as additional adjuncts to further improve physical function in comprehensive, multicomponent interventions. One application of this combined strategy may be to target multimodal pro-myogenic therapies in prehabilitation to optimize physical preoperative health to enhance functional recovery postsurgery. We summarize here recent progress on biological mechanisms of exercise training, behavioral approaches to exercise participation, and the role task-specific exercise plays in synergy with pharmacologic therapies with a particular focus on older adults. Physical activity and exercise training in multiple settings should serve as the baseline standard of care around which other therapeutic interventions should be considered when the goal is restoring or increasing physical function.

The sensitivity and specificity of using the McGill pain subscale for diagnosing neuropathic and non-neuropathic chronic pain in the total joint arthroplasty population.

BACKGROUND: The purpose of this study was to describe the diagnostic performance of the Neuropathic Pain Subscale of McGill [NP-MPQ (SF-2)] and the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire in differentiating people with neuropathic chronic pain post total joint arthroplasty (TJA). METHODS: This study was a survey of a cohort of individuals who had undergone primary, unilateral total knee, or hip joint arthroplasty. The questionnaires were administered by mail. The time interval from operation to the completion of the postal survey varied from 1.5 to 3.5 years post-surgery. Receiver Operating Characteristic (ROC) analysis was used to assess the overall diagnostic power and determine the optimal threshold value of the NP-MPQ (SF-2) in identification of neuropathic pain. RESULTS: S-LANSS identified 19 subjects (28%) as having neuropathic pain (NP), while NP-MPQ (SF-2) subscale identified 29 (43%). When using the S-LANSS as the reference standard, a Receiver Operating Characteristic (ROC) analysis for NP-MPQ (SF-2) had an area under the curve of 0.89 (95% CI: 0.82, 0.97); a cut off score of 0.91 NP-MPQ (SF-2) maximized sensitivity (89.5%) and specificity (75.0%). Correlation between the measures was moderate (r = 0.56; 95% CI: 0.40, 0.68). CONCLUSION: These finding suggest some conceptual overlap but some variability in diagnosis of NP which may relate to scale-tapping into different dimensions of the pain experience, or the different scoring metrics.

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome.

OBJECTIVES: One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome. METHODS: In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios. RESULTS: Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations. CONCLUSIONS: Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study.

INTRODUCTION: There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists. OBJECTIVES: The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework. DESIGN: Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke. RESULTS: Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs). CONCLUSION: This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Obesity, Comorbidities, and the Associated Risk among Patients Who Underwent Total Knee Arthroplasty in Alberta.

Obesity, a common risk factor for osteoarthritis (OA), accelerates joint deterioration resulting in the need for early total knee arthroplasty (TKA). The role of obesity in the management of OA remains a controversial topic. In this study, we examined whether obesity along with other comorbidities is associated with peri/postoperative complications in patients who underwent primary unilateral TKA in Alberta, Canada. A retrospective secondary analysis was performed on data extracted from data repository of patients (n = 15,151) who underwent TKA between 2012 and 2016. The sample was divided into five groups based on body mass index (BMI) classification developed by the World Health Organization. The associations between dependent variable (presence or absence of a complication or comorbidity) with the independent variables (year of surgery, age, sex, length of surgery, and BMI groups) were examined using binomial logistic regression. Results showed that obese classes I, II, and III, irrespective of other covariates, were more likely to have diabetes and pulmonary embolism (p < 0.001) compared with the normal BMI group. Patients with obese class III compared with the patients in normal BMI group were more likely to have deep wound infection (p = 0.04). Patients with comorbidities were more likely to have a blood transfusion, infection, pulmonary embolism, and readmission. Patients in higher BMI groups or with comorbidities were more likely to experience peri/postoperative complications following TKA, though the level of risk depends on the severity of obesity. These findings may be used by health care providers to educate patients in higher BMI groups about the risks of TKA and optimize comorbidities prior to the surgery.

Does obesity affect patient-reported outcomes following total knee arthroplasty?

BACKGROUND: There is an existing perception that obesity has a negative impact on complications following total knee arthroplasty (TKA). However, data on the impact of obesity levels on patient-reported outcomes (PROMs) is sparse. We investigated the association between different obesity classes with PROMs among patients who underwent TKA. METHODS: We performed retrospective secondary analyses on data extracted from the total joint replacement data repository (Alberta, Canada) managed by the Alberta Bone and Joint Health Institute (ABJHI). Patients had WOMAC and EQ5D scores measured at baseline in addition to 3 and/or 12 months following TKA. Patients were stratified according to the World Health Organization (WHO) classification, into five body mass index (BMI) groups of normal, overweight, BMI class I, BMI class II, and BMI class III. The association between BMI and mean changes in WOMAC subscales (pain, function, and stiffness) and EQ-5D-5L index over the time intervals of baseline to 3 months and 3 to 12 months following TKA was assessed. Linear mixed-effects models were used, and the models were adjusted for age, sex, length of surgery, comorbidities, year of surgery, and geographical zone where the surgery was performed. RESULTS: Mean age was 65.5 years (SD = 8.7). Postoperatively, there was a significant improvement (p < 0.001) in WOMAC subscales of patient-reported pain, function, and stiffness, as well as EQ-5D-5L regardless of BMI group. Although, patients in BMI class II and class III reported significantly improved pain 3 months after TKA compared to those with normal BMI, all BMI groups attained similar level of pain reduction at 12 months after TKA. The greatest improvement in all WOMAC subscales, as well as EQ5D index, occurred between baseline and 3 months (adjusted p < 0.0001). CONCLUSION: The findings indicate that patients reported improved pain, function, and stiffness across all BMI groups following TKA. Patients with BMI classified as obese reported similar benefits to those with BMI classified as normal weight. These results may help health care providers to discuss expectations regarding the TKA recovery in terms of pain, function, and quality of life improvements with their TKA candidates.

Prevalence of Persistent Pain of the Neuropathic Subtype after Total Hip or Knee Arthroplasty.

Purpose: This study aimed to (1) estimate the point prevalence of persistent postoperative pain (PPP) identified using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) after unilateral primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using data from a registry of total joint arthroplasty (TJA) patients in Ontario, (2) estimate the effect of PPP on function, (3) estimate the prevalence of neuropathic pain (NP) features among patients with persistent pain, (4) determine participant characteristics in order to estimate the potential predictors of NP classification among individuals with persistent pain after TJA, (5) estimate the extent to which the estimates of prevalence depended on the measure used (i.e., S-LANSS vs. NP sub-scale of the Short-Form McGill Pain Questionnaire 2 [NP-SF-MPQ-2]), and (6) determine the difference in characteristics between those with and without NP. Method: This was a prospective follow-up study of a historical cohort of individuals who had undergone primary unilateral THA or TKA. Persistent pain was operationally defined as pain rated as 3 or more (out of 5) on the Oxford Pain Questionnaire 6 months or 1 year after THA or TKA. Participants with persistent pain completed the S-LANSS and the NP-SF-MPQ-2. Results: A total of 1,143 participants were identified as having had a TJA, 148 (13%) of whom had PPP. A total of 67 recipients completed the S-LANSS and the NP-SF-MPQ-2. Of these, an NP subtype was identified among 19 (28%; those with an S-LANSS score ≥ 12) to 29 (43%; those with an NP-SF-MPQ-2 score ≥ 0.91). Individuals with persistent pain of the NP subtype after TJA reported severe pain intensity and higher disability levels 1.5-3.5 years after surgery compared with those without persistent pain. Conclusions: A significant proportion of patients have persistent pain post-unilateral THA or TKA.

Objectif : 1) évaluer la prévalence ponctuelle de la douleur postopératoire persistante indéterminée au moyen de l'évaluation autoadministrée des signes et symptômes de la douleur neuropathique de Leeds (S-LANSS) après une intervention unilatérale primaire sous forme d'arthroplastie totale de la hanche (ATH) ou d'une arthroplastie totale du genou (ATG), à partir d'un registre de patients ayant subi une arthroplastie par prothèse totale (APT) en Ontario; 2) évaluer l'effet de cette douleur sur la fonction; 3) évaluer la prévalence des manifestations de douleur neuropathique (DN) chez les patients souffrant des douleurs persistantes; 4) déterminer les caractéristiques des participants pour évaluer les prédicteurs potentiels de DN chez les personnes qui souffrent de douleur persistante après une APT; 5) évaluer dans quelle mesure les évaluations de prévalence dépendaient de la mesure utilisée (S-LANSS ou sous-échelle de DN du questionnaire court de la douleur de McGill 2 [SF-MPQ-2 ou NP-SF-MPQ-2]); 6) déterminer la différence entre les caractéristiques de ceux qui souffrent de DN et de ceux qui n'en souffrent pas. Méthodologie : étude prospective de suivi auprès d'une cohorte historique de personnes ayant subi une ATH ou un ATG unilatérale primaire. La douleur persistante était définie sur le plan opérationnel comme une douleur d'au moins 3 sur 5 au questionnaire de la douleur d'Oxford, de six mois à un an après l'ATH ou l'ATG. Les participants souffrant de douleur persistante ont rempli l'évaluation S-LANSS et la sous-échelle NP-SF-MPQ-2. Résultats : il a été établi que 148 des 1 143 participants ayant subi une APT ont souffert de douleur postopératoire persistante (13 %). Au total, 67 ont rempli l'évaluation S-LANSS et la sous-échelle NP-SF-MPQ-2. De ce nombre, 19 (28 %; S-LANSS ≥ 12) à 29 (43 %; NP-SF-MPQ-2 ≥ 0,91) personnes ont présenté un sous-type de DN. Les personnes souffrant de douleur persistante du sous-type des DN après une APT ont déclaré une douleur d'intensité marquée et un taux d'incapacité élevé de 1,5 à 3,5 ans après l'opération par rapport à ceux qui ne souffraient pas de douleur persistante. Conclusion : une forte proportion de patients souffre de douleurs persistantes après une ATH ou une ATG unilatérale.

Relationship Between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One-Year Follow-Up.

OBJECTIVE: To determine the relationship between patients' preoperative readiness for total knee arthroplasty (TKA) and surgical outcome at 1 year post-TKA. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) who were ≥30 years and were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who underwent primary unilateral TKA completed questionnaires prior to TKA to assess pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical disability using the Knee Injury and Osteoarthritis Outcome Score physical function short form, perceived arthritis coping efficacy, general self-efficacy, depressed mood using the Patient Health Questionnaire 8, body mass index, comorbidities, and TKA readiness (patient acceptable symptom state; willingness to undergo TKA); these same individuals also completed the above questionnaires 1 year post-TKA to assess surgical outcomes. A good TKA outcome was defined as an individual having improved knee symptoms, measured using the Osteoarthritis Research Society International-Outcome Measures in Rheumatology responder criteria, and overall satisfaction with results of the TKA. Poisson regression with robust error estimation was used to estimate the relative risk (RR) of a good outcome for exposures, before and after controlling for covariates. RESULTS: Of 1,272 TKA recipients assessed at 1 year post-TKA, 1,053 with data for the outcome assessed in the study were included (mean ± SD age 66.9 ± 8.8 years; 58.6% female). Most patients (87.8%) were definitely willing to undergo TKA and had "unacceptable" knee symptoms (79.7%). Among patients who underwent TKA, 78.1% achieved a good outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms, and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with a greater likelihood of a good TKA outcome, with adjusted RRs of 1.18 (95% confidence interval [95% CI] 1.04-1.35) and 1.14 (95% CI 1.02-1.27), respectively. CONCLUSION: Among patients who underwent TKA for knee OA, patients' psychological readiness for TKA and willingness to undergo TKA were associated with a greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate the use of TKA.

Advanced practice in physiotherapy: a global survey.

INTRODUCTION: Advanced practice in physiotherapy represents a development in the practice of physiotherapy and has developed in different ways around the world. There is growing evidence to support advanced physiotherapy practice. In May 2019, the member organisations adopted the first World Physiotherapy policy on advanced practice in physiotherapy. However, to date, there is no evidence on the nature and extent of this practice globally. OBJECTIVES: To investigate the extent to which advanced practice is present within the global physiotherapy community, to document the titles used, to describe the pathway to become an advanced physiotherapy practitioner and to investigate the barriers and facilitators to the development of the roles. DESIGN: An online cross-sectional survey was sent to the various national associations of the World Physiotherapy. PARTICIPANTS: Participants were the member organisations of World Physiotherapy. INSTRUMENT: The survey comprised 14 questions. The questions were developed based on a review of the evidence around advanced practice and in-depth discussions with the expert group set up by World Physiotherapy. RESULTS: A total of 82/112 MOs responded to the survey representing a 73% response rate. Fourteen respondents (14/82, 17%) indicated that they had formal roles in their country/territory. The terms specialist and advanced physiotherapy practitioner were often used interchangeably and were a source of confusion. Seventy-nine (11/14, 79%) percent stated that most advanced physiotherapy practitioners have a combination of clinical practice and a Master's or Doctoral degree. The major facilitators to the development and sustainability of the role were the research evidence, advocacy by the professional organisation, the need to reduce cost and the support received by the advanced physiotherapy practitioners from their employers. CONCLUSION: The outcomes of this study provide a clearer understanding of how member organisations of World Physiotherapy defined advanced practice in physiotherapy and what titles are used. It provides insights into the barriers and facilitators to the development of advanced practice in physiotherapy.

Competing Risks Methods Are Recommended for Estimating the Cumulative Incidence of Revision Arthroplasty for Health Care Planning Purposes.

Cumulative incidence of revision provides a measure of the failure rate of joint replacements and can be used to project demand for revisions. The most commonly applied survival analysis method (Kaplan-Meier [KM]) does not account for competing risks (eg, death). The authors compared the cumulative incidence function (CIF), a competing risks method, with the KM method through application to population-based cohorts. They measured time to revision, death, or censoring for unilateral total hip arthroplasty (THA; n=12,496) and total knee arthroplasty (TKA; n=19,172) cohorts in administrative databases in Alberta and TKAs (n=80,177) in the Swedish Knee Arthroplasty Register. The authors compared relative differences between the KM and CIF. They fitted Cox, Fine and Gray, and Royston and Parmar regression models and compared coefficients, standard errors, and P values. On sensitivity analysis, the authors included staged bilateral operations. Kaplan-Meier estimates exceeded the CIF at each time point. The magnitude of overestimation increased with follow-up time and was greatest for the Swedish cohort. At 5 years, relative differences between KM and CIF estimates for the Alberta THA and TKA and Swedish TKA cohorts were 1.8%, 2.3%, and 3.8%, respectively. These differences increased to 3.1%, 5.8%, and 8.2%, respectively, at 9 years, reaching 39.1% at 20 years (Swedish cohort). On sensitivity analysis (including staged bilateral operations), the Fine and Gray subdistribution hazard ratio differed from the Cox and Royston and Parmar hazard ratios. When the frequency of competing risks is high, competing risks methods are recommended to obtain accurate cumulative incidence estimates for informing health care planning and decision making. [Orthopedics. 2021;44(4):e549-e555.].

Associations Between Self-Reported Weight History and Sarcopenic Obesity in Adults with Knee Osteoarthritis.

OBJECTIVE: The purpose of this study was to examine associations between self-reported weight history and sarcopenic obesity in adults with advanced knee osteoarthritis (OA). METHODS: Self-reported weight history was collected from n = 151 adults (58.9% female) with knee OA and BMI ≥30 kg/m2 in a cross-sectional study. Body composition was assessed using dual-energy x-ray absorptiometry. Sarcopenic obesity was defined as appendicular skeletal muscle mass, adjusted by BMI, <0.51 kg/m2 in females and <0.79 kg/m2 in males; prevalence was 27.2%. Weight gain in the preceding year, weight gain ≥5% of body weight in the past decade, and multiple weight cycling events in life-span (loss of ≥10 lb [4.5 kg] with regain ≥3 times) were examined using logistic regression (adjusted by age, sex, and %fat mass), with the dependent variable of sarcopenic obesity presence. RESULTS: Weight gain in the preceding year was associated with sarcopenic obesity (odds ratio [OR]: 2.45, 95% CI: 1.02-5.87). No associations were found with weight gain in the past decade (OR: 1.04, 95% CI: 0.43-2.5) or weight cycling (OR: 0.86, 95% CI: 0.37-2.01). CONCLUSIONS: In adults with obesity and advanced knee OA, self-reported weight gain in the preceding year was associated with sarcopenic obesity. This patient population may benefit from recommendations that prioritize prevention of weight gain.

Clinical screening and identification of sarcopenic obesity in adults with advanced knee osteoarthritis.

BACKGROUND AND AIMS: Sarcopenic obesity (defined as low muscle mass and strength with high adiposity) requires attention in adults with advanced knee osteoarthritis (OA) due to implications on treatment outcomes. This study aimed to identify muscle function measures and patient characteristics associated with the presence of low muscle mass that could be used to screen and detect sarcopenic obesity in patients with knee OA in the clinical setting. METHODS: Cross-sectional study of patients with knee OA and a body mass index (BMI) ≥30 kg/m2. Body composition was measured in n = 151 patients (59% female, mean age 65.1 ± 7.9 years) using dual-energy x-ray absorptiometry. Appendicular skeletal muscle mass (ASM) adjusted by BMI and below established sex-specific cut-points was used to differentiate low muscle mass. Muscle function was assessed by 4-m gait speed, 6 min walk test, and maximal grip strength (absolute, and relative, adjusted by BMI). Logistic regression was used to assess the relationship between muscle function measures, patient characteristics, and low muscle mass. Receiver operating characteristic curves and area under the curve (AUC) were used to examine the final model and identify potential clinical cut-points. RESULTS: Sex and relative grip strength were associated with low muscle mass (AUC 0.774, p < 0.001). Cut-points for low relative grip strength (<0.65 kg/m2 in females and <1.1 kg/m2 in males) were distinguished and used in combination with low muscle mass to screen and identify sarcopenic obesity. Patients with both low relative grip strength and low muscle mass (sarcopenic obesity) had impaired mobility and quality of life. CONCLUSION: Relative grip strength shows promise as a clinical screening measure for sarcopenic obesity in patients with knee OA.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care.

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium.

OBJECTIVES: To develop an evidence-based definition of sarcopenia that can facilitate identification of older adults at risk for clinically relevant outcomes (eg, self-reported mobility limitation, falls, fractures, and mortality), the Sarcopenia Definition and Outcomes Consortium (SDOC) crafted a set of position statements informed by a literature review and SDOC's analyses of eight epidemiologic studies, six randomized clinical trials, four cohort studies of special populations, and two nationally representative population-based studies. METHODS: Thirteen position statements related to the putative components of a sarcopenia definition, informed by the SDOC analyses and literature synthesis, were reviewed by an independent international expert panel (panel) iteratively and voted on by the panel during the Sarcopenia Position Statement Conference. Four position statements related to grip strength, three to lean mass derived from dual-energy x-ray absorptiometry (DXA), and four to gait speed; two were summary statements. RESULTS: The SDOC analyses identified grip strength, either absolute or scaled to measures of body size, as an important discriminator of slowness. Both low grip strength and low usual gait speed independently predicted falls, self-reported mobility limitation, hip fractures, and mortality in community-dwelling older adults. Lean mass measured by DXA was not associated with incident adverse health-related outcomes in community-dwelling older adults with or without adjustment for body size. CONCLUSION: The panel agreed that both weakness defined by low grip strength and slowness defined by low usual gait speed should be included in the definition of sarcopenia. These position statements offer a rational basis for an evidence-based definition of sarcopenia. The analyses that informed these position statements are summarized in this article and discussed in accompanying articles in this issue of the journal. J Am Geriatr Soc 68:1410-1418, 2020.

Low back pain and radiographic severity as predictors in hip osteoarthritis patients receiving steroid injection therapy.

INTRODUCTION: We investigated the effects of lower back pain (LBP) on measures of pain, disability, and function in highly symptomatic hip OA patients receiving intra-articular steroid injection (IASI) therapy. We also investigated the effect of radiographic severity of hip OA for comparison to LBP. METHODS: 97 consenting subjects with symptomatic hip OA presenting for IASI were evaluated at baseline, assessed over an 8-week period, and followed at least 1 year later for new arthroplasty. At baseline and 8 weeks follow-up patient demographics, presence/absence of back pain, physical function tests, a single anteroposterior pelvis x-ray, and subjective scores of pain, stiffness and function (VAS and WOMAC) were collected. We also followed which subjects proceeded to obtain total hip arthroplasty in the examined hip. RESULTS: Cohorts with LBP reported significantly worse scores for all of VAS pain and WOMAC questionnaires but showed no difference in ROM and were not more likely to proceed to arthroplasty. Cohorts with severe radiographic OA had significantly worsened scores for stiffness (χ2 = 6.74, p = 0.009), decreased ROM (p < 0.01), and were more likely to proceed to arthroplasty (χ2 = 9.79, p = 0.044). DISCUSSION: Back pain has a substantial effect on clinical parameters relevant to assessment of severity of hip OA, especially self-reported pain and function. This finding highlights LBP as a significant confounding factor in hip OA patient assessments and will inform future studies to determine the most effective treatment strategies for hip OA patients.

Do Quebec Physiotherapists Follow Evidence-Based Guidelines for Treating Knee Osteoarthritis?

Purpose: The aim of this study was to document the types of treatment that Quebec physiotherapists use for knee osteoarthritis (OA), to assess whether treatment choices are consistent with current practice guidelines, and to explore the factors associated with using certain treatments. Method: Physiotherapists in Quebec answered a cross-sectional survey that was sent through licensing bodies and social media contacts. The respondents were asked which treatments they would use for a typical case of knee OA. We used descriptive statistics to determine the proportions of physiotherapists who chose each treatment and explored the associations between the use of treatments and demographic factors. Results: A total of 195 Quebec physiotherapists participated in this study, 74.9% of whom were women. The most common treatment choices were mobility exercises (96.4%), followed by education (93.8%), strengthening exercises (85.1%), thermotherapy and cryotherapy (72.3%), manual therapy (53.3%), and electrotherapy (42.1%). Selecting either manual or electrotherapy was significantly associated with working in private practice. Conclusions: The great majority of physiotherapists included mobility and strengthening exercises, both of which are the recommended approaches for treating knee OA. Physiotherapists in private practice were more likely to select manual therapy and electrotherapy.

Objectif : exposer les types de traitements qu'utilisent les physiothérapeutes du Québec pour l'arthrose du genou, afin d'évaluer si leurs choix respectent les directives cliniques actuelles, et explorer les facteurs associés à l'utilisation de certains traitements. Méthodologie : les physiothérapeutes du Québec ont participé à un sondage transversal qui leur a été transmis par leurs organismes de réglementation et les médias sociaux. Les répondants ont été invités à indiquer quel type de traitement ils utiliseraient dans un cas typique d'arthrose du genou. Les chercheurs ont utilisé des statistiques descriptives pour déterminer les proportions de physiothérapeutes choisissant chaque traitement et ont exploré les associations entre des traitements sélectionnés et des facteurs démographiques. Résultats : au total, 195 physiothérapeutes du Québec, dont 74,9 % de femmes, ont participé à la présente étude. Les traitements les plus choisis étaient les exercices de mobilité (96,4 %), l'éducation (93,8 %), les exercices de renforcement (85,1 %), la thermothérapie et la cryothérapie (72,3 %), la thérapie manuelle (53,3 %) et l'électrothérapie (42,1 %). Le choix de la thérapie manuelle ou de l'électrothérapie était significativement associé au travail en pratique privée. Conclusion : la grande majorité des physiothérapeutes ont sélectionné les exercices de mobilité et de renforcement, qui représentent les approches recommandées pour le traitement de l'arthrose du genou. Les physiothérapeutes en pratique privée étaient plus susceptibles de sélectionner la thérapie manuelle et l'électrothérapie.

Establishing the Link Between Lean Mass and Grip Strength Cut Points With Mobility Disability and Other Health Outcomes: Proceedings of the Sarcopenia Definition and Outcomes Consortium Conference.

BACKGROUND: Lack of consensus on how to diagnose sarcopenia has limited the ability to diagnose this condition and hindered drug development. The Sarcopenia Definitions and Outcomes Consortium (SDOC) was formed to develop evidence-based diagnostic cut points for lean mass and/or muscle strength that identify people at increased risk of mobility disability. We describe here the proceedings of a meeting of SDOC and other experts to discuss strategic considerations in the development of evidence-based sarcopenia definition. METHODS: Presentations and panel discussions reviewed the usefulness of sarcopenia as a biomarker, the analytical approach used by SDOC to establish cut points, and preliminary findings, and provided strategic direction to develop an evidence-based definition of sarcopenia. RESULTS: The SDOC assembled data from eight epidemiological cohorts consisting of 18,831 participants, clinical populations from 10 randomized trials and observational studies, and 2 nationally representative cohorts. In preliminary assessments, grip strength or grip strength divided by body mass index was identified as discriminators of risk for mobility disability (walking speed <0.8 m/s), whereas dual-energy X-ray absorptiometry-derived lean mass measures were not good discriminators of mobility disability. Candidate definitions based on grip strength variables were associated with increased risk of mortality, falls, mobility disability, and instrumental activities of daily living disability. The prevalence of low grip strength increased with age. The attendees recommended the establishment of an International Expert Panel to review a series of position statements on sarcopenia definition that are informed by the findings of the SDOC analyses and synthesis of literature. CONCLUSIONS: International consensus on an evidence-based definition of sarcopenia is needed. Grip strength-absolute or adjusted for body mass index-is an important discriminator of mobility disability and other endpoints. Additional research is needed to develop a predictive risk model that takes into account sarcopenia components as well as age, sex, race, and comorbidities.

Associations between interim patient-reported outcome measures and functional status at discharge from rehabilitation for non-specific lumbar impairments.

PURPOSE: Identify impact of frequency and timing of interim Patient-Reported Outcome Measures (PROMs) assessments during episodes of care for rehabilitation services in outpatient clinical settings on functional status (FS) outcomes at discharge for patients with low back pain. METHODS: FS outcomes of patients who had no interim PROMs were compared to outcomes of six patient groups defined by interim timing (early, mid, late) and frequency (1, 2 or more). For each comparison, patients were matched using propensity score matching for variables known to be associated with FS outcomes and for episode duration (days) and number of visits. FS was assessed using the lumbar computerized adaptive test (LCAT) where scores range from 0 to 100 with higher scores representing better physical function. RESULTS: A sample of 140,336 patients was considered for matching (mean age = 58 [SD = 17] range 18-89; 60% females) with 83,101 patients (59%) having no interim PROMs. Patients who had only one interim PROM, administered during early (first 2 weeks), mid (weeks 3-4), or late (week 5 or later) timing, had 4.6, 2.7, and 1.0 additional FS score points at discharge compared to those without an interim PROM, respectively (p < 0.001). Having two or more interim PROMs was associated with an additional 1.2 FS points compared to having only one interim assessment, but only if the first interim was administered early. CONCLUSIONS: Optimal utilization of interim PROM assessment during clinical practice to enhance treatment outcomes was related to administering the first interim PROM within the first 2 weeks after the initial evaluation.