Diminished vibration perception and greater pressure pain sensitivity are associated with worse knee osteoarthritis outcomes across sex and race.

OBJECTIVE: To examine associations of vibration sensitivity and pressure pain sensitivity with knee osteoarthritis (OA) outcomes across sex and race, which may relate to known sex and race disparities in clinical outcomes. DESIGN: Data were from the 2013-2015 visit of the Johnston County Osteoarthritis Project. Exposures were vibration perception threshold (VPT) measured at the bilateral medial femoral condyle (MFC) and first metatarsophalangeal joint (MTP), and pressure pain threshold (PPT) measured at the bilateral upper trapezius. Outcomes were knee pain severity and presence of knee symptoms, radiographic knee OA, and symptomatic knee OA in each knee. Cross-sectional associations of the exposures with the outcomes were examined using logistic regression models, overall and separately by sex and race. RESULTS: In the VPT and PPT analyses, 851 and 862 participants (mean age 71 years, 68% female, 33% Black, body mass index 31 kg/m2) and 1585 and 1660 knees were included, respectively. Higher VPT (lower vibration sensitivity) at the MFC and first MTP joint was associated with all outcomes. Lower PPT (greater pressure pain sensitivity) was associated with greater knee pain severity. Associations of VPT and PPT with all outcomes were similar among females and males and Black and White individuals. CONCLUSIONS: Diminished vibration perception and greater pressure pain sensitivity were cross-sectionally associated with worse knee OA outcomes. Despite differences in VPT and PPT among females and males and Black and White adults, associations with knee OA outcomes did not differ by sex or race, suggesting neurophysiological differences do not relate to established disparities.

Predictors of research productivity among physical therapy programs in the United States: an observational study.

BACKGROUND: This study targeted the association of program characteristics of 203 Doctor of Physical Therapy (DPT) programs in the United States (US) reported by the Commission on Accreditation in Physical Therapy Education (CAPTE) in their 2017 Annual Accreditation Report (AAR) with measures of core faculty research volume. The association of institutional, program, and faculty characteristics of an institution with core faculty research volume was investigated. METHODS: This observational study analyzed data provided in the AAR about program research volume. Predictor variables included institutional, program and faculty characteristics. Research volume was measured as a ratio of 1) number of peer-reviewed publications, 2) National Institutes of Health (NIH) funding, and 3) faculty with grants, per number of core faculty. Research volume was stratified by quartiles and analyzed using logistic regression analyses. The highest 25% were analyzed against the lowest 75%. RESULTS: In the multivariate logistic regression analyses, research Carnegie classification was positively associated with NIH funding (OR = 4.04; 95% CI = 1.92, 8.48) and number of peer reviewed publications (OR = 7.63; 95% CI = 3.39, 17.14). Square footage of research space was positively associated with number of peer reviewed publications (OR = 4.58; 95% CI = 2.08, 10.11). Private status was negatively associated with NIH funding (OR = 0.37; 95% CI = 0.17, 0.83) and faculty holding grants (OR = 0.38; 95% CI = 0.19, 0.76). CONCLUSIONS: There is strong evidence that research culture (e.g., research Carnegie status and dedicated research space) is related to research productivity in DPT programs in the US. Private status was indicative of a non-research intensive environment, which may be reflective of a current trend of small, non-research based private institutions initiating DPT programs.

Differences in Characteristics and Downstream Drug Use Among Opioid-Naïve and Prior Opioid Users with Low Back Pain.

BACKGROUND: Recent clinical practice guidelines have suggested conservative treatment approaches, including physical therapy, are indicated as first-line treatment for patients with low back pain (LBP); however, LBP continues to be managed with opioids, despite decreases in function, morbidity, and insignificant improvements in pain. OBJECTIVE: The primary purpose was to compare characteristics and downstream medication use between patients with LBP with prior opioid exposure vs. those who were opioid-naïve. The secondary purpose was to explore the role of prior opioid use by LBP disability. METHODS: Seven hundred and nine participants in a LBP self-management class were evaluated utilizing self-report data at baseline and longitudinal claims data from the Military Health System Data Repository. Participants were dichotomized into opioid-naïve and prior opioid use groups and then further divided into low and high disability groups based on Oswestry Disability Index (ODI) scores. Patient characteristics, comorbidities, and medication use were compared between groups. RESULTS: Prior opioid users had significantly higher baseline ODI and Fear Avoidance Beliefs Questionnaire physical activity subscale and work subscale scores as well as pre-index instances of mental health disorders, chronic pain, and insomnia than opioid-naïve individuals. Prior opioid users filled significantly more pain medication prescriptions in the year after the index date than did opioid-naïve individuals. Prior opioid users were significantly more likely to be taking opioids at 1 year after the index date, regardless of disability level. CONCLUSION: In patients presenting with LBP, prior opioid exposure appears to be related to increased analgesic use (opioid and non-opioid) and longitudinal analgesic utilization at 1 year after the index date.

Relations of C-reactive protein and obesity to the prevalence and the odds of reporting low back pain.

OBJECTIVE: To assess the odds of reporting low back pain (LBP) as related to systemic inflammation and obesity. DESIGN: Cross-sectional analysis of the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES). SETTING: National database analysis. PARTICIPANTS: Population-based sample of 15,322 participants in the 1999 to 2004 NHANES databases. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Systemic inflammation was measured by C-reactive protein (CRP) and fibrinogen. Obesity was quantified by body mass index and waist circumference (WC). LBP was identified by self-report. Analysis included logistic regression to assess the odds of reporting LBP as related to systemic inflammation and obesity. RESULTS: It was hypothesized that obesity and systemic inflammation would increase the odds of reporting LBP. Participants with elevated CRP (>3.0mg/dL) had 1.74 (95% confidence interval [CI], 1.04-2.91) greater odds of reporting LBP. Those who were obese (≥30kg/m(2)) with elevated CRP had 2.87 (95% CI, 1.18-6.96) greater odds of reporting LBP than those without elevated CRP. When using WC as the measure of obesity, participants with high WC values had significantly greater odds of reporting LBP (odds ratio=2.39; 95% CI, 1.09-5.21). CONCLUSIONS: To our knowledge, this is the first study showing that high levels of CRP may increase the odds of reporting LBP, especially in those who are obese. These findings warrant further investigation of the interrelations among obesity, systemic inflammation, and LBP.

Lumbopelvic neuromuscular training and injury rehabilitation: a systematic review.

OBJECTIVE: The aim of this systematic review was to assess the evidence for lumbopelvic neuromuscular training (LNMT) in individuals after musculoskeletal (MSK) injury. DATA SOURCES: A literature search of PubMed and EMBASE databases was performed for English studies from January 1990 to March 2012. Search terms including and related to trunk, core, stability, injury, and LNMT were used. STUDY SELECTION: All studies directly involving LNMT for MSK injuries were reviewed by 2 authors. These articles were assessed based on the inclusion criteria and if appropriate selected for further analysis. Expert opinion, review articles, and articles involving non-MSK injuries were excluded. Four authors then scored the selected articles for methodological quality. A total of 2312 articles were initially identified. Twenty-nine articles met the inclusion criteria for review and were divided into categories of lower extremity (LE), lumbar, and upper extremity (UE). No trials involving the UE met the inclusion criteria. DATA EXTRACTION: Data including subject demographics (age, height, weight, gender, etc), injury type, intervention type, and outcome measurements were extracted from the relevant articles. A variety of baseline and follow-up scores were extracted including pain levels, patient satisfaction, disability questionnaires, and other functional outcomes. DATA SYNTHESIS: Two out of 3 LE randomized controlled trials (RCTs) and 9/26 lumbar RCTs were rated with high methodological quality based on the scoring system described by van Tulder et al. The average quality score for the LE RCTs was 6.3 (range = 4-9) and for the lumbar RCTs was 5.1 (range = 2-9). The evidence for the effectiveness of the 3 LE studies was rated as conflicting, whereas 24 lumbar studies demonstrated moderate-to-strong evidence. Unfortunately, heterogeneity of populations, interventions, and outcomes precluded a quantitative meta-analysis and specific clinical recommendations. CONCLUSIONS: High-quality evidence is lacking to make specific clinical recommendations for or against the use of LNMT in the rehabilitation of individuals after MSK injury. Based on this review, future research should focus on well-defined, homogeneous populations, interventions specifically addressing neuromuscular activation of the lumbopelvic musculature, patient-specific clinical outcomes, measures of motor control, biomechanics, and return to specific activities.

Explanatory multivariate modeling for disability, pain, and claims in patients with spine pain via a physical therapy direct access model of care.

BACKGROUND: Direct access physical therapy (DAPT) may result in improved patient outcomes and reduced healthcare costs. Prognostic factors associated with spine-related outcomes and insurance claims with DAPT are needed. OBJECTIVE: To identify factors that predict variations in outcomes for spine pain and insurance claims using DAPT. METHODS: Individuals (N = 250) with spine pain were analyzed. Outcomes were classified into High, Low, or Did Not Meet minimal clinically important difference (MCID) scores. Claims were categorized into low, medium, or high tertiles. Prognostic variables were identified from patient information. RESULTS: Females were more likely to meet High MCID (odds ratio [OR] 2.84 (95% CI = 1.32, 6.11) and Low MCID (OR 2.86, 95% CI = 1.34, 6.10). Higher initial ODI/NDI scores were associated with High MCID (OR 1.04, 95% CI = 1.07, 1.22) and Low MCID (OR 0.91, 95% CI = 0.77, 1.07). Odds of a high claim were lowered by the absence of imaging (OR 0.04, 95% CI = 0.02, 0.09) and an active versus passive treatment (OR 0.38, 95% CI = 0.18, 0.80). CONCLUSION: Females and higher initial disability predicted favorable outcomes. The novel introduction of claims into the prognostic modeling supports that active interventions and avoiding imaging may reduce claims.

Timed Up and Go test is predictive of Patient-Reported Outcomes Measurement Information System physical function in patients awaiting total knee arthroplasty.

BACKGROUND: The Patient Reported Outcomes Measurement Information System (PROMIS) Computerized Adaptive Test (CAT) physical function rapidly assesses self-reported function capability. The Timed Up and Go (TUG) test is often used in clinical practice, but administration may be impeded by space and patient limitations. PROMIS CAT can potentially address these limitations, but we lack evidence if TUG and health indicators are predictors of PROMIS CAT. This study assessed whether TUG, body mass index (BMI), numeric pain rating scale (NPRS), and smoking status were predictors of PROMIS CAT in total knee arthroplasty (TKA) candidates. METHODS: Sixty-five TKA candidates completed the PROMIS CAT physical function test using an iPad application. TUG, NPRS, BMI, and smoking status were obtained at the clinic visit or from medical records. Univariate and multiple regression analyses identified the strongest predictors of PROMIS CAT. RESULTS: TUG was the best predictor of PROMIS CAT physical function based on simple regression (r = -0.43, 95% CI = -0.62 to -0.20) or multiple regression ( ß Ë†  = -0.45, 95% CI = -0.73 to -0.17) analyses. BMI and NPRS did not incrementally help predict the PROMIS score beyond TUG. Smoking status did not contribute to the prediction of the PROMIS CAT score. CONCLUSIONS: The findings suggest that the PROMIS CAT physical function is not a surrogate for the TUG performance-based measure in candidates for TKA. However, TUG was the best predictor of PROMIS physical function compared with BMI, NPRS, and smoking status. Clinicians should consider both patient-reported and performance-based measures when evaluating function for TKA outcomes.

Effects of an Intervention Program on Lower Extremity Biomechanics in Stop-Jump and Side-Cutting Tasks.

BACKGROUND: Anterior cruciate ligament (ACL) injury is one of the most common injuries in sport. To reduce the risk of noncontact ACL injury, it is critical to understand the effects of an intervention program on neuromuscular control-related biomechanical risk factors. HYPOTHESIS: A newly developed 4-week intervention program would significantly increase the knee flexion angle at peak impact posterior ground-reaction force and would significantly decrease the peak impact posterior and vertical ground-reaction forces in the stop-jump and side-cutting tasks, while the intervention effects would be retained after the training was completed. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 22 male and 18 female collegiate basketball and volleyball players with biomechanical characteristics associated with increased risk of ACL injury were recruited and randomly assigned to either the intervention group or the control group. The intervention group executed a program to improve landing techniques through strength and plyometric training 3 times a week for 4 weeks while participating in their regular training. The control group participated in only their regular training for 4 weeks. Three-dimensional kinematic and kinetic data in the stop-jump and side-cutting tasks were collected at week 0 (the beginning of the study) and at the ends of weeks 4, 8, 16, and 20. Knee flexion angle and ground-reaction forces were calculated. Analyses of variance with a mixed design were performed to determine the intervention effects and the retention of intervention effects for each sex. RESULTS: Male participants in the intervention group significantly increased the knee flexion angle at peak impact posterior ground-reaction force in the stop-jump task at weeks 8, 12, and 20 when compared with that at week 0 and with the male control group ( P ≤ .002). No significant intervention effects on knee flexion angle and ground-reaction force were found in the side-cutting task for male participants. No significant interaction effects on takeoff velocities were detected in any task for male participants. No significant intervention effects on knee flexion angle and ground-reaction force were found in any task for female participants. Vertical takeoff velocity in the stop-jump task was significantly lower in the intervention group at week 20 compared with the control group ( P = .011). CONCLUSION: A 4-week intervention program significantly increased the knee flexion angle at peak impact posterior ground-reaction force of male collegiate athletes in the stop-jump task without significant effect on the performance of the task. This intervention effect was retained for at least 16 weeks after the training was completed. The intervention program, however, did not affect knee flexion angle and ground-reaction force in any task for female collegiate athletes. A reduction in vertical takeoff velocity of the stop-jump task was observed for female collegiate athletes 16 weeks after the intervention. CLINICAL RELEVANCE: The intervention program with strength conditioning and plyometric exercises could modify landing biomechanics of male collegiate athletes in a stop-jump task. The intervention program may be a useful tool for preventing noncontact ACL injury for male collegiate athletes.

Trunk muscle reflex amplitudes increased in patients with subacute, recurrent LBP treated with a 10-week stabilization exercise program.

Altered trunk muscle reflexes have been observed in patients with low back pain (LBP). Altered reflexes may contribute to impaired postural control, and possibly recurrence of LBP. Specific stabilization exercise (SSE) programs have been shown to decrease the risk of LBP recurrence in a select group of patients with acute, first episode LBP. It is not known if trunk muscle reflex responses improve with resolution of subacute, recurrent LBP when treated with a SSE program. A perturbation test was used to compare trunk muscle reflexes in patients with subacute, recurrent LBP, before and after 10 weeks of a SSE program and a group of matched control subjects (CNTL). The LBP group pre therapy had delayed trunk muscle reflexes compared with the CNTL group. Post therapy reflex latencies remained delayed, but amplitudes increased. Increased reflex amplitudes could limit excessive movement of the spine when perturbed; potentially helping prevent recurrence.

Randomized controlled trial of the effects of a trunk stabilization program on trunk control and knee loading.

BACKGROUND: Many athletic maneuvers involve coordination of movement between the lower and upper extremities, suggesting that better core muscle use may lead to improved athletic performance and reduced injury risk. PURPOSE: To determine to what extent a training program with quasistatic trunk stabilization (TS) exercises would improve measures of core performance, leg strength, agility, and dynamic knee loading compared with a program incorporating only resistance training (RT). METHODS: Thirty-seven male subjects were randomly assigned to either an RT-only or a resistance and TS training program, each lasting 6 wk. Core strength and endurance, trunk control, knee loading during unanticipated cutting, leg strength, and agility were collected pre- and posttraining. RESULTS: Between-group analyses showed that the TS group significantly improved only core endurance when compared with the RT group (side bridge, P = 0.050). Within-group analyses showed that the TS group improved lateral core strength (maximum pull, cable on nondominant side; 44.5 ± 61.3 N, P = 0.037). Both groups increased leg strength (deadlift 1 repetition maximum; TS: 55.1 ± 46.5 lb, P = 0.003; RT: 33.4 ± 17.5 lb, P < 0.001) and decreased sagittal plane trunk control (sudden force release test; cable in front; TS: 2.54° ± 3.68°, P = 0.045; RT: 3.47° ± 2.83°, P = 0.004), but only the RT group decreased lateral trunk control (sudden force release; cable on dominant side; 1.36° ± 1.65°, P = 0.029). The RT group improved standing broad jump (73.2 ± 108.4 mm, P = 0.049) but also showed increased knee abduction moment during unanticipated cutting (1.503-fold increase (percentage body weight × height), P = 0.012). CONCLUSIONS: Quasistatic TS exercises did not improve core strength, trunk control, or knee loading relative to RT potentially because of a lack of exercises, including unexpected perturbations and dynamic movement. Together, these results suggest the potential importance of targeted trunk control training to address these known anterior cruciate ligament injury risk factors.