Difference in Physiotherapy Students' Training and Objective Structured Clinical Exam Performance Before and During COVID-19.

Purpose: The Objective Structured Clinical Examination (OSCE) and station examinations, in general, have been widely utilized in health professional programmes to evaluate students' clinical performance prior to advancing to a clinical placement. The COVID-19 pandemic impacted student preparation and implementation of our programme's OSCEs. The impact on changes in student OSCE performance due COVID-19 has not been well studied. This non-concurrent cohort study evaluated the difference before and during COVID-19 pandemic on Year 1 physiotherapy students' performances on an in-person OSCE by estimating the mean difference in cohort OSCE scores and safety occurrences. Methods: Two cohorts of MSc (PT) students were compared: Cohort A (not impacted by COVID-19) and Cohort B (impacted by COVID-19). Cohort scores were summarized as means and 95% CIs. Results: Overall OSCE scores for Cohort A and B were 77.9 and 81.9, respectively (d¯ = 4.0, 95% CI: 2.1, 5.8). Cohort B students were approximately 4 times more likely to demonstrate safety occurrences. Conclusion: The impact of COVID-19 did not adversely affect total OSCE scores; however, it did increase safety infractions.

Objectif: en général, les programmes pour les professionnels de la santé font largement appel à l'examen clinique objectif structuré (ECOS) et aux stations d'examen pour évaluer la performance clinique des étudiants avant leur passage au stage clinique. La pandémie de COVID-19 a nui à la préparation des étudiants et à la mise en œuvre des ECOS du programme de physiothérapie. Les effets sur les changements à la performance des étudiants à l'ECOS découlant de la COVID-19 n'ont pas été bien étudiés. La présente étude de cohorte non concomitante a permis d'évaluer la différence entre la performance des étudiants en première année de physiothérapie à un ECOS en personne avant et pendant la pandémie de COVID-19, d'après la différence moyenne des scores d'ECOS et des occurrences d'infractions aux règles de sécurité au sein des deux cohortes. Méthodologie: deux cohortes d'étudiants à la maîtrise en physiothérapie ont été comparées : la cohorte A (non touchée par la COVID-19) et B (touchée par la COVID-19). Les scores des cohortes ont été résumés sous forme de moyennes et d'IC à 95%. Résultats: les scores globaux de l'ECOS pour la cohorte A et la cohorte B s'élevaient à 77,9 et à 81,9, respectivement (d¯ = 4,0, IC à 95 % : 2,1, 5,8). Les étudiants de la cohorte B étaient environ quatre fois plus susceptibles de démontrer des occurrences d'infraction aux règles de sécurité. Conclusion: la COVID-19 n'a pas nui aux scores totaux de l'ECOS, mais les infractions aux règles de sécurité se sont accrues.

Does peak expiratory flow moderate trajectories of cognitive function among individuals with lung diseases? A longitudinal analysis of the National Health and Aging Trends Study.

INTRODUCTION: Impaired cognitive function can co-exist in chronic respiratory diseases. However, it is not clear if peak expiratory flow (PEF) impacts changes in cognitive function. Our objective was to explore whether peak expiratory flow moderates trajectories of memory, visuospatial abilities, and executive function in individuals with chronic respiratory diseases. METHODS: This was an analysis of individuals with lung diseases from the National Health and Aging Trends Study. Multivariable-adjusted generalized linear mixed models were used to estimate trajectories of immediate and delayed recall, and clock drawing over a 10-year follow-up. The interaction between PEF and time were plotted using sex-specific values for peak expiratory flow at 10th, 50th and 90th percentiles. RESULTS: In females, interactions of time-by-PEF were found for both immediate (n = 489, t = 2.73, p<0.01) and delayed recall (n = 489, t = 3.38, p<0.01). Females in the 10th vs. 90th percentile of PEF declined in immediate recall at 0.14 vs. 0.065 words/year, and 0.17 vs. 0.032 words/year for delayed recall. Among males, recall declined linearly over 10 years (immediate recall: n = 296, t = -3.08, p < 0.01; delayed recall: n = 292, t = -2.46, p = 0.02), with no interaction with PEF. There were no time-by-PEF interactions nor declines over time in clock drawing scores in both sexes (females: n = 484, t = 0.25, p = 0.81; males: n = 291, t = -0.61, p = 0.55). CONCLUSION: Females with the lowest PEF values experienced the greatest rates of decline in immediate and delayed recall over 10 years of follow-up, whereas males experienced similar declines in memory outcomes across all levels of PEF. Clock drawing scores remained stable over 10 years in both sexes.

Sex Differences in Functional Capacity in Older Adults With Stroke: An Analysis of Data From the National Health and Aging Trends Study.

OBJECTIVE: Women experience greater disability following stroke, but biological sex differences in both overall and specific domains of functional capacity are not well understood. The primary objective of this study was to examine sex differences in overall functional capacity (Short Physical Performance Battery [SPPB] score) cross-sectionally and longitudinally over a 3-year follow-up period. The secondary objective was to determine whether sex differences exist in specific domains of functional capacity of walking speed and lower extremity functional strength. METHODS: This study was a secondary analysis of data of individuals with stroke from the National Health and Aging Trends Study. For the cross-sectional analyses, general linear models were used to examine differences between 293 men and 427 women in SPPB, walking speed, and the 5-Times Sit-to-Stand Test (5XSST). For the longitudinal analysis, survey-weighted, multivariable-adjusted generalized linear mixed models were used to compare 3-year trajectories in SPPB scores between the sexes (87 men, 153 women). RESULTS: Women had lower SPPB scores at baseline (difference = 0.9, linearized SE = 0.3) and over 3 years. SPPB scores declined similarly between men and women. Women had lower walking speed (difference = 0.08 m/s, SE = 0.02) as compared with men, but men and women had similar 5XSST scores (difference = 0.6 seconds, SE = 0.5). CONCLUSION: Older women with stroke have clinically meaningfully lower overall functional capacity as compared with older men but decline at a similar rate over time. Walking speed was lower in older women with stroke, but similar between sexes in 5XSST. IMPACT: Women with stroke have poorer functional capacity compared with men, which reinforces the importance of targeted stroke rehabilitation strategies to address these sex-specific disparities. LAY SUMMARY: Women with stroke have poorer outcomes in terms of their ability to move around the community when compared with men. However, both men and women with stroke have similar physical functioning over time.

Muscle strength gains after strengthening exercise explained by reductions in serum inflammation in women with knee osteoarthritis.

Background Individuals with knee osteoarthritis have elevated circulating inflammatory markers and altered cartilage properties but it is unclear if these features adapt to exercise. We aimed to determine (1) whether inflammatory markers, cartilage transverse relaxation time and thickness mediate the effect of body mass index (BMI) on quadriceps strength at baseline; and (2) whether these changes explain variance in quadriceps strength improvements after 12 weeks of exercise in women with knee osteoarthritis. Methods This secondary analysis (17 women with clinical knee osteoarthritis) of a randomized control trial compared supervised group interventions, 3 times/week for 12 weeks (36 sessions): (a) weight-bearing progressive resistive quadriceps exercise or (b) attention control. (1) From baseline, separate linear regressions were conducted with strength (Nm/kg) as the dependent, BMI as the predictor, and c-reactive protein, tumor necrosis factor, interleukin-6, cartilage transverse relaxation time or thickness as potential mediators. (2) Multiple linear regression analyses were completed with 12-week strength change (post-pre) as the dependent, change in serum inflammatory markers and cartilage measurements as predictors, and age, BMI and adherence as covariates. Findings (1) At baseline, there was no mediation. (2) A decrease in each of interleukin-6 (ß = -0.104 (95% confidence intervals: -0.172, -0.036), R2 = 0.51, P < 0.007) and tumor necrosis factor (ß = -0.024 (-0.038, -0.009), R2 = 0.54, P < 0.005) was associated with strength gains. Interpretation At baseline, inflammatory markers and cartilage measurements do not act as mediators of BMI on quadriceps strength. After 12 weeks of exercise, reduced interleukin-6 and tumor necrosis factor were associated with increased quadriceps strength in women with knee osteoarthritis.

Development and assessment of a verbal response scale for the Patient-Specific Functional Scale (PSFS) in a low-literacy, non-western population.

PURPOSE: The Patient-Specific Functional Scale (PSFS) is a routinely used measure of physical function with a 0-10 response scale. We aimed to develop verbal response options for the PSFS, pre-test it for use in a multilingual, low-literacy country- Nepal, and compare preference and error rates between numeric and verbal scale. We hypothesized that a verbal scale would be preferred by respondents and yield fewer errors. METHOD: We interviewed 42 individuals with musculoskeletal, neurological, and cardiopulmonary conditions to understand how people describe varying levels of physical ability. Transcripts were thematically analyzed, and through consensus, we developed two sets of verbal responses for the PSFS. Next, we pre-tested the scales on an additional 119 respondents following which participants were asked to specify their preferred scale. Error rates were analyzed retrospectively using pre-specified criteria. RESULTS: Participants described their ability in terms of the quality (95%) and the quantity of task performance (88%). Although the verbal scales were preferred over the numeric scale (50% versus 12%), there was no significant difference in error rates between numeric (34%) and verbal scales (32% and 36%). Higher error rates were associated with greater age, fewer years of education, and inexperience with numeric scales. CONCLUSION: Despite a higher preference for verbal scale, 1 out of 3 patients made errors in using the PSFS, even with an interview format. The error rates were higher among participants with low literacy. The findings raise questions about the utility of PROMs in countries with low literacy rates.

How to Optimize Measurement Protocols: An Example of Assessing Measurement Reliability Using Generalizability Theory.

Purpose: This article identifies how to assess multiple sources of measurement error and identify optimal measurement strategies for obtaining clinical outcomes. Method: Obtaining, interpreting, and using information gained from measurements is instrumental in physiotherapy. To be useful, measurements must have a sufficiently small measurement error. Traditional expressions of reliability include relative reliability in the form of an intra-class correlation coefficient and absolute reliability in the form of the standard error of measurement. Traditional metrics are limited to assessing one source of error; however, real-world measurements consist of many sources of error. The measurement framework generalizability theory (GT) allows researchers to partition measurement errors into multiple sources. GT further allows them to calculate the relative and absolute reliability of any measurement strategy, thereby allowing them to identify the optimal strategy. We provide a brief comparison of classical test theory and GT, followed by an overview of the terminology and methodology used in GT, and then an example showing how GT can be used to minimize error associated with measuring knee extension power. Conclusion: The methodology described provides tools for researchers and clinicians that enable detailed interpretation and understanding of the error associated with their measurements.

Objectif : décrire comment évaluer de multiples sources d'erreur de mesure et les stratégies de mesures optimales pour obtenir des résultats cliniques. Méthodologie : il est important d'obtenir, d'interpréter et d'utiliser l'information tirée des mesures en physiothérapie. Pour que ces mesures soient utiles, leur écart-type doit être suffisamment petit. Les expressions habituelles de fiabilité incluent la fiabilité relative sous forme de coefficient de corrélation intraclasse et la fiabilité absolue sous forme d'écart-type des mesures. Les mesures habituelles sont limitées à l'évaluation d'une source d'erreur. Cependant, les mesures réelles s'associent à plusieurs sources d'erreur. La théorie de généralisabilité (TG) du cadre de mesure permet aux chercheurs de diviser les erreurs de mesure selon de multiples sources. Elle leur permet également de calculer la fiabilité relative et absolue de toute stratégie de mesure, pour parvenir à une stratégie optimale. Le présent article fournit une brève comparaison entre la théorie du test classique et la TG, puis un aperçu de la terminologie et de la méthodologie utilisées en TG. Enfin, les auteurs présentent un exemple démontrant comment utiliser la TG pour limiter l'erreur associée à la mesure de la puissance d'extension du genou. Conclusion : la méthodologie décrite fournit des outils pour les chercheurs et les cliniciens afin de parvenir à une interprétation et une compréhension détaillées des erreurs de mesure.

Assessing Arm Volume in People During and After Treatment for Breast Cancer: Reliability and Convergent Validity of the LymphaTech System.

BACKGROUND: There are challenges related to the accurate and efficient measurement of lymphedema in people with breast cancer. The LymphaTech 3D Imaging System (LymphaTech, Atlanta, GA, USA) is a mobile, noninvasive platform that provides limb geometry measurements. OBJECTIVE: The objective of this study was to estimate the reliability and validity of the LymphaTech for measuring arm volume in the context of women seeking care in a specialty breast cancer rehabilitation clinic. DESIGN: This was a cross-sectional reliability and convergent validity study. METHODS: People who had stage I to IV breast cancer with lymphedema or were at risk for it were included. Arm volume was measured in 66 participants using the LymphaTech and perometer methods. Test-retest reliability for a single measure, limb volume difference, and agreement between methods was analyzed for 30 participants. A method-comparison analysis was also used to assess convergent validity between methods. RESULTS: Both LymphaTech and perometer methods displayed intraclass correlation coefficients (ICCs) of ≥0.99. The standard errors of measurement for the LymphaTech and length-matched perometer measurements were nearly identical. Similar intraclass correlation coefficients (0.97) and standard errors of measurement (38.0-40.7 mL) were obtained for the between-limb volume difference for both methods. The convergent validity analyses demonstrated no systematic difference between methods. LIMITATIONS: The sample size was not based on a formal sample size calculation. LymphaTech measurements included interrater variance, and perometer measurements contained intrarater variance. CONCLUSIONS: The LymphaTech had excellent test-retest reliability, and convergent validity was supported. This technology is efficient and portable and has a potential role in prospective surveillance and management of lymphedema in clinical, research, and home settings.

Characterizing the recovery trajectories of knee range of motion for one year after total knee replacement.

Design: Retrospective analysis of routinely collected clinical data. Objective: This study modeled the recovery in knee flexion and extension range of motion (ROM) over 1 year after total knee replacement (TKR). Background: Recovery after TKR has been characterized for self-reported pain and functional status. Literature describing target knee ROM at different follow-up periods after TKR is scarce. Methods: Data were extracted for patients who had undergone TKR at a tertiary care hospital at 2, 8, 12, 26, and 52 weeks after TKR. A linear mixed-effects growth model was constructed that investigated the following covariates age, sex, pre-TKR range, body mass index, duration of symptoms, and their interaction with weeks post TKR. Results: Of the 559 patients included (age 64.8 ± 8.5 years), 370 were women and 189 were men. Knee ROM showed the greatest change during the first 12 weeks after TKR, plateauing by 26 weeks. For an average patient, knee flexion increased from approximately 100º 2 weeks post TKR to 117º 52 weeks post TKR. Knee extension increased from approximately 3º knee flexion 2 weeks post TKR to 1º flexion 52 weeks post TKR. Conclusions: The results showed that the maximum gains in knee ROM should be expected within the first 12 weeks with small changes occurring up to 26 weeks after TKR. In addition, age and presurgery knee ROM are associated with the gains in knee ROM and should be factored into the estimation of expected knee ROM at a given follow-up interval after TKR.

Effects of Covertly Measured Home Exercise Adherence on Patient Outcomes Among Older Adults With Chronic Knee Pain.

BACKGROUND: Assessment of home exercise adherence and the degree to which adherence influences changes in patient outcomes is limited by the use of self-reported measures. OBJECTIVES: To determine the relationship between adherence to a home strengthening program, covertly measured by accelerometers in ankle cuff weights, and changes in self-reported pain, physical function, and knee extensor strength among people with chronic knee pain. METHODS: This is a secondary analysis of data from a clinical measurement study in 54 adults, aged 45 years or older, with chronic knee pain who completed a 12-week, home-based quadriceps-strengthening program. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises to assess exercise adherence. Associations between exercise adherence and changes in pain and function (measured using the Western Ontario and McMaster Universities Osteoarthritis Index) and peak isometric knee extensor strength were examined using mixed-effects and linear regression models and fractional polynomials. RESULTS: Exercise adherence declined from a median of 90% (interquartile range, 70%-100%) in weeks 0 to 2 to 65% (interquartile range, 25%-90%) in weeks 10 to 12. Significant improvements were observed in knee pain (mean change, -3.2 units; 95% confidence interval [CI]: -2.4, -3.9 units), function (mean change, -10.1 units; 95% CI: -7.8, -12.4 units), and knee extensor strength (mean change, 0.34 Nm/kg; 95% CI: 0.26, 0.42 Nm/kg) across the group over the same period. Exercise adherence was not associated with changes in pain, function, and knee extensor strength over 2-week periods or over the entire 12 weeks. CONCLUSION: Covertly measured adherence to a home strengthening program was not associated with changes in patient outcomes. These findings challenge the notion that greater exercise adherence leads to greater improvement in patient outcomes during a short-term intervention. J Orthop Sports Phys Ther 2019;49(7):548-556. doi:10.2519/jospt.2019.8843.

Clinical Interpretation of the Neck Functional Status Computerized Adaptive Test.

BACKGROUND: Clinical interpretation of patient-reported outcome measures is an essential step in patient-centered care. Interpretation of scores derived from the Neck Functional Status Computerized Adaptive Test (NFS-CAT) has not been studied. OBJECTIVES: To (1) assess the reliability of point estimates and improvement scores, (2) determine thresholds of minimal clinically important improvement (MCII), and (3) develop a functional staging model to facilitate clinical interpretation of NFS-CAT scores. METHODS: A secondary retrospective cohort analysis was performed using data from patients aged 14 to 89 years who started an episode of care for neck impairments during 2016-2017 and completed the NFS-CAT at admission. The reliability of point estimates and of improvement scores was derived from the NFS-CAT standard error of measurement. The MCII was estimated by combining distribution- and anchor-based approaches. A functional staging model was developed to describe clinical meaningfulness of the quantitative scores provided by the NFS-CAT. RESULTS: Of 250 741 patients who completed the NFS-CAT at admission (mean ± SD age, 54 ± 16 years; 65% female), 169±039 (67%) also completed the NFS-CAT at discharge. The standard error of measurement was stable across the measurement continuum, ranging from 3.7 to 3.9 NFS-CAT points. Minimal detectable improvement was 6.8 points at the 90% confidence level. The estimate of the MCII was 8.1 points, with more change points needed to achieve the MCII for patients with lower baseline scores. Large rates of functional staging change during treatment were observed, demonstrating responsiveness of the functional staging model. CONCLUSION: This study demonstrated how the NFS-CAT can be interpreted to better assist clinicians and patients with neck impairments during outpatient rehabilitation. LEVEL OF EVIDENCE: Therapy, level 2b. J Orthop Sports Phys Ther 2019;49(12):875-886. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8862.

Labelling a Patient's Change Status: It's a Confidence Game.

Purpose: The past several decades have seen considerable interest in identifying and applying threshold change values with outcome measures commonly used by physiotherapists. The crucial question of interest to clinicians is, To what extent can valid inferences be drawn from an outcome measure's change or improvement score? To date, typical reporting by researchers includes the presentation of a validity coefficient, often in the form of the area under a receiver operating characteristic curve, and a threshold change or improvement value. A limitation of existing work is that it does not convey the confidence that a clinician can have in a decision based on applying the proposed threshold change value. Methods: This knowledge translation article presents three questions, or building blocks, to consider when making a judgment about a patient's change status: (1) to what extent does a measure assess change in the context of interest, (2) what is the threshold change value, and (3) how confident can a clinician be in making the correct decision about a patient's change status when applying the threshold change value? Results: This article provides a process for combining clinical expertise with the results from threshold value studies to enhance confidence in clinical decisions about individual patients' change status. Conclusions: The article shows how a graph can be used to efficiently translate the results from threshold value studies to convey the chance of making the correct decision about a patient's change status.

Objectif : depuis quelques décennies, on s'intéresse beaucoup à déterminer et à appliquer les valeurs seuils de changement pour mesurer les résultats cliniques qu'utilisent couramment les physiothérapeutes. Une question intéresse particulièrement les cliniciens : dans quelle mesure des inférences valides peuvent-elles être tirées d'un score de changement ou d'amélioration d'une mesure? Jusqu'à présent, les chercheurs ont surtout présenté des coefficients de validité, souvent sous forme de surface sous la courbe de la fonction d'efficacité du récepteur, et une valeur de changement ou d'amélioration du seuil. Les travaux existants comportent une limite, celle de ne pas transmettre la confiance qu'un clinicien peut porter à une décision d'après l'application de la valeur seuil de changement proposée. Méthodologie : le présent article d'application du savoir s'attarde sur trois questions (ou éléments fondamentaux) à examiner au moment d'évaluer un statut de changement du patient : 1) dans quelle mesure une mesure évalue-t-elle un changement dans le contexte d'intérêt?; 2) quelle est la valeur seuil de changement?; 3) à quel point un clinicien peut-il avoir confiance de prendre la bonne décision sur le statut de changement d'un patient lorsqu'il applique la valeur seuil de changement? Résultats : le présent rapport présente un processus pour combiner les compétences cliniques aux résultats des études des valeurs seuils pour accroître la confiance envers les décisions cliniques sur le statut de changement d'un patient donné. Conclusion : l'article démontre comment utiliser un graphique pour transmettre avec efficacité les résultats d'études de valeurs seuils pour établir la chance de prendre la bonne décision à l'égard du statut de changement du patient.

Estimating the Threshold Value for Change for the Six Dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment.

Purpose: Our purpose was to estimate a threshold value for change for the six dimensions of the Impairment Inventory of the Chedoke-McMaster Stroke Assessment and the confidence in labelling a person as having improved or not. Method: Secondary analysis of two data sets, previously reported by two research teams, consisted of two statistical analyses. The first analysis used a multiple of the standard error of measurement to calculate the threshold value for change for the six dimensions. The second analysis used the diagnostic test method to calculate a threshold improvement value and the confidence a clinician had in labelling a person as having improved or not on the leg, foot, and postural control dimensions. Results: The threshold value for change was determined to be 1 impairment point (i.e., stage) for the arm, hand, leg, foot, and postural control dimensions and 2 impairment points for the shoulder pain dimension. The positive predictive values associated with the leg, foot, and postural control dimensions were 74%, 59%, and 65%, respectively. Conclusions: Clinicians can use a change of 1 impairment point for the arm, hand, leg, foot, and postural control dimensions and a change of 2 impairment points for the shoulder pain dimension to identify true change in a patient's motor recovery.

Objectif : parvenir à une valeur seuil de changement aux six dimensions de l'inventaire des déficiences de l'évaluation Chedoke-McMaster de l'AVC ainsi que de la confiance à déclarer que l'état d'une personne s'est amélioré ou non. Méthodologie : l'analyse secondaire de deux ensembles de données, dont deux équipes de recherche avaient déjà rendu compte, s'est déclinée en deux analyses statistiques. La première faisait appel à un multiple de l'écart-type de mesure pour calculer la valeur seuil de changement aux six dimensions. La seconde puisait dans la méthode de test diagnostique pour calculer une valeur d'amélioration du seuil et la confiance du clinicien à déclarer que l'état d'une personne s'est amélioré ou non dans les dimensions du contrôle de la jambe, du pied et de la posture. Résultats : les chercheurs ont établi que la valeur seuil de changement correspondait à 1 point de déficience (phase) pour les dimensions du contrôle du bras, de la main, de la jambe, du pied et de la posture et de 2 points de déficience pour la dimension de la douleur de l'épaule. Les valeurs prédictives positives associées aux dimensions de contrôle de la jambe, du pied et de la posture s'élevaient à 74 %, 59 % et 65 %, respectivement. Conclusions : les cliniciens peuvent utiliser un changement d'1 point de déficience des dimensions de contrôle du bras, de la main, de la jambe, du pied et de la posture, et un changement de 2 points de déficience pour la dimension de la douleur de l'épaule pour déclarer un véritable changement dans le rétablissement moteur du patient.

Self-reported Home Exercise Adherence: A Validity and Reliability Study Using Concealed Accelerometers.

BACKGROUND: Accurate measurement of adherence to prescribed exercise programs is essential. Diaries and self-report rating scales are commonly used, yet little evidence exists to demonstrate their validity and reliability. OBJECTIVES: To examine the concurrent validity of adherence to home strengthening exercises measured by (1) exercise diaries and (2) a self-report rating scale, compared to adherence measured using an accelerometer concealed in an ankle cuff weight. Test-retest reliability of the self-report rating scale was also assessed. METHODS: In this clinical measurement study, 54 adults aged 45 years or older with self-reported chronic knee pain were prescribed a home quadriceps-strengthening program. Over 12 weeks, participants completed paper exercise diaries and, at appointments every 2 weeks, rated their adherence on an 11-point numeric rating scale. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises. Self-reported adherence rating scale data over each 2-week period were analyzed using descriptive statistics, the Wilcoxon signed-rank test, and a Bland-Altman plot to assess agreement, Spearman correlations for validity, and intraclass correlation coefficients for test-retest reliability. RESULTS: Exercise adherence was significantly overestimated in diaries during the 12 weeks (diary median, 220 exercises; accelerometer, 176; P<.001) and was moderately correlated with accelerometer data (r = 0.52; 95% confidence interval: 0.26, 0.69). A Bland-Altman plot indicated large between-participant variability in agreement between these measures. Self-reported adherence showed poor to fair correlations with accelerometer data (mean r = 0.23-0.39), and less than acceptable reliability (intraclass correlation coefficient = 0.79; lower 1-sided 95% confidence limit, 0.68). CONCLUSION: Exercise diaries showed questionable validity and variable levels of agreement compared with accelerometer-measured exercise completion. A self-reported adherence rating scale had limited validity and less than acceptable test-retest reliability. J Orthop Sports Phys Ther 2018;48(12):943-950. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8275.

Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy.

Background The impact of risk adjustment on clinic quality ranking for patients treated in physical therapy outpatient clinics is unknown. Objectives To compare clinic ranking, based on unadjusted versus risk-adjusted outcomes for patients with low back pain (LBP) who are treated in physical therapy outpatient clinics. Methods This retrospective cohort study involved a secondary analysis of data from adult patients with LBP treated in outpatient physical therapy clinics from 2014 to 2016. Patients with complete outcomes data at admission and discharge were included to develop the risk-adjustment model. Clinics with complete outcomes data for at least 50% of patients and at least 10 complete episodes of care per clinician per year were included for ranking assessment. The R2 shrinkage and predictive ratio were used to assess overfitting. Agreement between unadjusted and adjusted rankings was assessed with percentile ranking by deciles or 3 distinct quality ranks based on uncertainty assessment. Results The primary sample included 414 125 patients (mean ± SD age, 57 ± 17 years; 60% women) treated by 12 569 clinicians from 3048 clinics from all US states; 82% of patients from 2107 clinics were included in the ranking assessment. The R2 shrinkage was less than 1%, with a predictive ratio of 1. Risk adjustment impacted ranking for 70% or 31% of clinics, based on deciles or 3 distinct quality levels, respectively. Conclusion Important changes in ranking were found after adjusting for basic patient characteristics of those admitted to physical therapy for treatment of LBP. Risk-adjustment profiling is necessary to more accurately reflect quality of care when treating patients with LBP. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(8):637-648. Epub 22 May 2018. doi:10.2519/jospt.2018.7981.

Submaximal normalizing methods to evaluate load sharing changes in the shoulder during repetitive work.

The EMG-force relationship changes with muscle fatigue, making interpretation of load sharing between muscles challenging. The purpose of this investigation was to evaluate the efficacy of normalizing EMG to repeated, static, submaximal exertions to mitigate fatigue artifacts in EMG amplitude (increased amplitude without muscle force change). Participants completed repetitive work tasks, in 60-second cycles, until exhaustion. Surface EMG was recorded from 11 shoulder muscles (anterior, middle and posterior deltoids, infraspinatus, upper, middle and lower trapezius, latissimus dorsi, serratus anterior, sternal and clavicular heads of pectoralis major). Every 12 min, participants completed 4 submaximal reference exertions. Reference exertion EMG data were used in 6 normalizing methods including 1 standard (normalized to initial reference exertion) and 5 novel methods: (i) Fatigue Only, (ii) Linear, (iii) Cubic, (iv) Points Forward, and (v) Points Forward/Backward. Data normalized with each novel method were compared to the Standard Method using mixed effects modelling. Significant differences depended on the muscle and the number of time points included (p < .05). The cubic model correlated better to the actual data points than linear predicted values. The novel cubic normalizing method created muscle activity ratios that appear to mitigate the fatigue effects and better reflect muscular loads during fatiguing work.

Self-efficacy, pain, and quadriceps capacity at baseline predict changes in mobility performance over 2 years in women with knee osteoarthritis.

This study examined the extent to which baseline measures of quadriceps strength, quadriceps power, knee pain and self-efficacy for functional tasks, and their interactions, predicted 2-year changes in mobility performance (walking, stair ascent, stair descent) in women with knee osteoarthritis. We hypothesized that lesser strength, power and self-efficacy, and higher pain at baseline would each be independently associated with reduced mobility over 2 years, and each of pain and self-efficacy would interact with strength and power in predicting 2-year change in stair-climbing performance. This was a longitudinal, observational study of women with clinical knee osteoarthritis. At baseline and follow-up, mobility was assessed with the Six-Minute Walk Test, and stair ascent and descent tasks. Quadriceps strength and power, knee pain, and self-efficacy for functional tasks were also collected at baseline. Multiple linear regression examined the extent to which 2-year changes in mobility performances were predicted by baseline strength, power, pain, and self-efficacy, after adjusting for covariates. Data were analyzed for 37 women with knee osteoarthritis over 2 years. Lower baseline self-efficacy predicted decreased walking (ß = 1.783; p = 0.030) and stair ascent (ß = -0.054; p < 0.001) performances over 2 years. Higher baseline pain intensity/frequency predicted decreased walking performance (ß = 1.526; p = 0.002). Lower quadriceps strength (ß = 0.051; p = 0.015) and power (ß = 0.022; p = 0.022) interacted with lesser self-efficacy to predict worsening stair ascent performance. Strategies to sustain or improve mobility in women with knee osteoarthritis must focus on controlling pain and boosting self-efficacy. In those with worse self-efficacy, developing knee muscle capacity is an important target.

Baseline knee adduction moment interacts with body mass index to predict loss of medial tibial cartilage volume over 2.5 years in knee Osteoarthritis.

This study aimed to determine the extent to which changes over 2.5 years in medial knee cartilage thickness and volume were predicted by: (1) Peak values of the knee adduction (KAM) and flexion moments; and (2) KAM impulse and loading frequency, representing cumulative load, after controlling for age, sex and body mass index (BMI). Adults with clinical knee osteoarthritis participated. At baseline and approximately 2.5 years follow-up, cartilage thickness and volume of the medial tibia and femur were segmented from magnetic resonance imaging scans. Gait kinematics and kinetics, and daily knee loading frequency were also collected at baseline. Multiple linear regressions predicted changes in cartilage morphology from baseline gait mechanics. Data were collected from 52 participants (41 women) [age 61.0 (6.9) y; BMI 28.5 (5.7) kg/m2 ] over 2.56 (0.51) years. There were significant KAM peak-by-BMI (p = 0.023) and KAM impulse-by-BMI (p = 0.034) interactions, which revealed that larger joint loads in those with higher BMIs were associated with greater loss of medial tibial cartilage volume. In conclusion, with adjustments for age, sex, and cartilage measurement at baseline, large magnitude KAM peak and KAM impulse each interacted with BMI to predict loss of cartilage volume of the medial tibia over 2.5 years among individuals with knee osteoarthritis. These data suggest that, in clinical knee osteoarthritis, exposure to large KAMs may be detrimental to cartilage in those with larger BMIs. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2476-2483, 2017.

Acute changes in knee cartilage transverse relaxation time after running and bicycling.

PURPOSE: To compare the acute effect of running and bicycling of an equivalent cumulative load on knee cartilage composition and morphometry in healthy young men. A secondary analysis investigated the relationship between activity history and the change in cartilage composition after activity. METHODS: In fifteen men (25.8±4.2 years), the vertical ground reaction force was measured to determine the cumulative load exposure of a 15-min run. The vertical pedal reaction force was recorded during bicycling to define the bicycling duration of an equivalent cumulative load. On separate visits that were spaced on average 17 days apart, participants completed these running and bicycling bouts. Mean cartilage transverse relaxation times (T2) were determined for cartilage on the tibia and weight-bearing femur before and after each exercise. T2 was measured using a multi-echo spin-echo sequence and 3T MRI. Cartilage of the weight bearing femur and tibia was segmented using a highly-automated segmentation algorithm. Activity history was captured using the International Physical Activity Questionnaire. RESULTS: The response of T2 to bicycling and running was different (p=0.019; mean T2: pre-running=34.27ms, pre-bicycling=32.93ms, post-running=31.82ms, post-bicycling=32.36ms). While bicycling produced no change (-1.7%, p=0.300), running shortened T2 (-7.1%, p<0.001). Greater activity history predicted smaller changes in tibial, but not femoral, T2. CONCLUSIONS: Changes in knee cartilage vary based on activity type, independent of total load exposure, in healthy young men. Smaller changes in T2 were observed after bicycling relative to running. Activity history was inversely related to tibial T2, suggesting cartilage conditioning.

A Roland Morris Disability Questionnaire Target Value to Distinguish between Functional and Dysfunctional States in People with Low Back Pain.

PURPOSE: To estimate a threshold Roland Morris Disability Questionnaire (RMQ) value that could be used to classify patients with low back pain (LBP) as functional or dysfunctional. METHODS: In this secondary analysis of data from a study that estimated clinically important RMQ change scores, participants were adults with LBP attending one of three physical therapy clinics. Diagnostic test methodology and a reference standard of goals met were applied to estimate a threshold RMQ value that best distinguished between participants with a functional status and those whose status was dysfunctional. RESULTS: Of 143 participants, 104 (73%) met their goals. An RMQ threshold value of 4/24 best distinguished between those who met their goals and those who did not. Sensitivity and specificity for a threshold score of 4 were 94% (95% CI, 88-98) and 69% (95% CI, 52-83), respectively. CONCLUSIONS: A threshold value of 4 RMQ points provided a reasonably accurate classification of patients. Further research is necessary to cross-validate this estimate and to examine the stability of the estimated value in people with diverse functional demands.

Objectif : Estimer une valeur seuil du questionnaire Roland-Morris (QRM) qui pourrait servir à classer les patients qui souffrent de lombalgie dans les catégories de patients « fonctionnels ¼ ou « dysfonctionnels ¼. Méthodes : Dans la présente analyse secondaire de données provenant d'une étude qui faisait l'estimation des cotations de changements importants sur le plan clinique selon le QRM, les participants étaient des adultes atteints de lombalgie, qui fréquentaient l'une de trois cliniques de physiothérapie. On a appliqué la méthodologie de test de diagnostic et une norme de référence des objectifs atteints pour estimer une valeur seuil du QRM qui permettait de distinguer le plus clairement possible les participants qui étaient fonctionnels de ceux qui étaient dysfonctionnels. Résultats : Parmi les 143 participants, 104 (73%) ont atteint leurs objectifs. Une valeur seuil du QRM de 4/24 permettait de distinguer le plus clairement possible ceux qui avaient atteint leurs objectifs de ceux qui ne les avaient pas atteints. La sensibilité et la spécificité pour une cotation seuil de 4 étaient de 94% (IC de 95%, 88­98) et de 69% (IC de 95%, 52­83) respectivement. Conclusions : Une valeur seuil de 4 points selon le QRM permettait de classer les patients de façon raisonnablement exacte. Il faudra effectuer une recherche approfondie pour faire la contre-validation de cette estimation et pour examiner la stabilité de la valeur estimée chez les personnes ayant diverses demandes fonctionnelles.