A Novel Behavioral Intervention to Enhance Physical Activity for Older Veterans in a Skilled Nursing Facility.

Physical activity levels during skilled nursing facility (SNF) rehabilitation fall far below what is needed for successful community living and to prevent adverse events. This feasibility study's purpose was to evaluate the feasibility, acceptability, and preliminary effectiveness of an intervention designed to improve physical activity in patients admitted to SNFs for short-term rehabilitation. High-Intensity Rehabilitation plus Mobility combined a high-intensity (i.e., high weight, low repetition), progressive (increasing in difficulty over time), and functional resistance rehabilitation intervention with a behavioral economics-based physical activity program. The behavioral economics component included five mobility sessions/week with structured goal setting, gamification, and loss aversion (the idea that people are more likely to change a behavior in response to a potential loss over a potential gain). SNF physical therapists, occupational therapists, and a mobility coach implemented the High-Intensity Rehabilitation plus Mobility protocol with older Veterans (n = 18) from a single SNF. Participants demonstrated high adherence to the mobility protocol and were highly satisfied with their rehabilitation. Treatment fidelity scores for clinicians were ≥95%. We did not observe a hypothesized 40% improvement in step counts or time spent upright. However, High-Intensity Rehabilitation plus Mobility participants made clinically important improvements in short physical performance battery scores and gait speed from admission to discharge that were qualitatively similar to or slightly higher than historical cohorts from the same SNF that had received usual care or high-intensity rehabilitation alone. These results suggest a structured physical activity program can be feasibly combined with high-intensity rehabilitation for SNF residents following a hospital stay.

Prospective telehealth analysis of functional performance, frailty, quality of life, and mental health after COVID-19 hospitalization.

BACKGROUND: COVID-19 is a global pandemic with poorly understood long-term consequences. Determining the trajectory of recovery following COVID-19 hospitalization is critical for prioritizing care, allocating resources, facilitating prognosis, and informing rehabilitation. The purpose of this study was to prospectively evaluate recovery following COVID-19 hospitalization. METHODS: Participants age 18 years or older who were hospitalized for ≥24 h due to COVID-19 completed phone/video call virtual assessments (including the 10-time chair rise test) and survey forms at three time points (2-6, 12, and 18 weeks) after hospital discharge. Univariate logistic and linear regression models assessed the associations of the outcomes with primary predictors (categorical age, sex, race/ethnicity group, and categorical pre-hospitalization frailty) at baseline; the same were used to assess differences in change from week 2-6 (continuous outcomes) or outcome persistence/worsening (categorical) at last contact. RESULTS: One hundred nine adults (age 53.0 [standard deviation 13.1]; 53% female) participated including 43 (39%) age 60 or greater; 59% identified as an ethnic and/or racial minority. Over 18 weeks, the mean time to complete the 10-time chair rise test decreased (i.e., improved) by 6.0 s (95% CI: 4.1, 7.9 s; p < 0.001); this change did not differ by pre-hospital frailty, race/ethnicity group, or sex, but those age ≥ 60 had greater improvement. At weeks 2-6, 67% of participants reported a worse Clinical Frailty Scale category compared to their pre-hospitalization level, whereas 42% reported a worse frailty score at 18 weeks. Participants who did not return to pre-hospitalization levels were more likely to be female, younger, and report a pre-hospitalization category of 'very fit' or 'well'. CONCLUSIONS: We found that functional performance improved from weeks 2-6 to 18 weeks of follow-up; that incident clinical frailty developed in some individuals following COVID-19; and that age, sex, race/ethnicity, and pre-hospitalization frailty status may impact recovery from COVID-19. Notably, individuals age 60 and older were more likely than those under age 45 years to return to their pre-hospitalization status and to make greater improvements in functional performance. The results of the present study provide insight into the trajectory of recovery among a representative cohort of individuals hospitalized due to COVID-19.

Determination of Pain Phenotypes in Knee Osteoarthritis Using Latent Profile Analysis.

OBJECTIVE: To identify clinical phenotypes of knee osteoarthritis (OA) using measures from the following domains: 1) multimorbidity; 2) psychological distress; 3) pain sensitivity; and 4) knee impairment or pathology. DESIGN: Data were collected from 152 people with knee OA and from 31 pain-free individuals. In participants with knee OA, latent profile analysis (LPA) was applied to the following measures: normalized knee extensor strength, Functional Comorbidity Index (FCI), Pain Catastrophizing Scale (PCS), and local (knee) pressure pain threshold. Comparisons were performed between empirically derived phenotypes from the LPA and healthy older adults on these measures. Comparisons were also made between pheonotypes on pain intensity, functional measures, use of health care, and history of knee injury. RESULTS: LPA resulted in a four-group solution. Compared with all other groups, group 1 (9% of the study population) had higher FCI scores. Group 2 (63%) had elevated pain sensitivity and quadriceps weakness relative to group 4 and healthy older adults. Group 3 (11%) had higher PCS scores than all other groups. Group 4 (17%) had greater leg strength, except relative to healthy older adults, and reduced pain sensitivity relative to all groups. Groups 1 and 3 demonstrated higher pain and worse function than other groups, and group 4 had higher rates of knee injury. CONCLUSION: Four phenotypes of knee OA were identified using psychological factors, comorbidity status, pain sensitivity, and leg strength. Follow-up analyses supported the replicability of this phenotype structure, but future research is needed to determine its usefulness in knee OA care.

i-CONTENT tool for assessing therapeutic quality of exercise programs employed in randomised clinical trials.

OBJECTIVE: When appraising the quality of randomised clinical trial (RCTs) on the merits of exercise therapy, we typically limit our assessment to the quality of the methods. However, heterogeneity across studies can also be caused by differences in the quality of the exercise interventions (ie, 'the potential effectiveness of a specific intervention given the potential target group of patients')-a challenging concept to assess. We propose an internationally developed, consensus-based tool that aims to assess the quality of exercise therapy programmes studied in RCTs: the international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) tool. METHODS: Forty-nine experts (from 12 different countries) in the field of physical and exercise therapy participated in a four-stage Delphi approach to develop the i-CONTENT tool: (1) item generation (Delphi round 1), (2) item selection (Delphi rounds 2 and 3), (3) item specification (focus group discussion) and (4) tool development and refinement (working group discussion and piloting). RESULTS: Out of the 61 items generated in the first Delphi round, consensus was reached on 17 items, resulting in seven final items that form the i-CONTENT tool: (1) patient selection; (2) qualified supervisor; (3) type and timing of outcome assessment; (4) dosage parameters (frequency, intensity, time); (5) type of exercise; (6) safety of the exercise programme and (7) adherence to the exercise programme. CONCLUSION: The i-CONTENT-tool is a step towards transparent assessment of the quality of exercise therapy programmes studied in RCTs, and ultimately, towards the development of future, higher quality, exercise interventions.

Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty.

BACKGROUND: With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown. QUESTIONS/PURPOSES: (1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA? METHODS: This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence. RESULTS: Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008). CONCLUSIONS: Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoing TJA, which may include participation in preoperative rehabilitation (pre-habilitation) or more aggressive follow-up in the 30 days after surgery. Further research is needed to determine whether severe ADL dependence can be modified before surgery, and whether these changes in dependency can reduce readmission risk after TJA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Reference chart for knee flexion following total knee arthroplasty: a novel tool for monitoring postoperative recovery.

BACKGROUND: Clinicians and patients lack an evidence-based framework by which to judge individual-level recovery following total knee arthroplasty (TKA) surgery, thus impeding personalized treatment approaches for this elective surgery. Our study aimed to develop and validate a reference chart for monitoring recovery of knee flexion following TKA surgery. METHODS: Retrospective analysis of data collected in routine rehabilitation practice for patients following TKA surgery. Reference charts were constructed using Generalized Additive Models for Location Scale and Shape. Various models were compared using the Schwarz Bayesian Criterion, Mean Squared Error in 5-fold cross validation, and centile coverage (i.e. the percent of observed data represented below specified centiles). The performance of the reference chart was then validated against a test set of patients with later surgical dates, by examining the centile coverage and average bias (i.e. difference between observed and predicted values) in the test dataset. RESULTS: A total of 1173 observations from 327 patients were used to develop a reference chart for knee flexion over the first 120 days following TKA. The best fitting model utilized a non-linear time trend, with smoothing splines for median and variance parameters. Additionally, optimization of the number of knots in smoothing splines and power transformation of time improved model fit. The reference chart performed adequately in a test set of 171 patients (377 observations), with accurate centile coverage and minimal average bias (< 3 degrees). CONCLUSION: A reference chart developed with clinically collected data offers a new approach to monitoring knee flexion following TKA.

Characteristics of young and lower functioning patients following total knee arthroplasty: a retrospective study.

BACKGROUND: Rates of total knee arthroplasty (TKA) procedures in younger, more medically complex patients have dramatically increased over the last several decades. No study has examined categorization of lower and higher functioning subgroups within the TKA patient population. Our study aimed to determine preoperative characteristics of younger patients who are lower functioning following TKA. METHODS: Patients were categorized into higher and lower functioning subgroups defined using a median split of 1) postoperative Timed Up and Go (TUG) test times and 2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale scores. A split in age (65 years) was used to further classify patients into four categories: younger lower functioning, younger higher functioning, older lower functioning and older higher functioning. Measures from preoperative domains of health, psychological, physical performance and pain severity were examined for between-group differences. RESULTS: Comparing mean values, the younger lower functioning subgroup using the TUG had significantly weaker knee extensor, slower gait speed, higher body mass index and greater pain compared to other subgroups. The younger lower functioning subgroup using the WOMAC physical function subscale demonstrated higher pain levels and Coping Strategies Questionnaire-Catastrophizing Subscale scores compared to the older lower functioning subgroup. CONCLUSIONS: Poorer preoperative physical performance and pain severity appear to have the largest influence on early postoperative TKA recovery in younger lower functioning patients relative to both younger and older higher functioning patients.

Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial.

OBJECTIVE: To determine preliminary efficacy of a home-based behavior-change intervention designed to promote exercise, walking activity, and disease self-management. DESIGN: A single-blind, randomized controlled pilot trial. SETTING: One Veterans Administration and 2 regional medical centers. PARTICIPANTS: A total of 38 participants randomized to behavior-change intervention (n=19) or attention control (CTL; n=19) group. INTERVENTIONS: Weekly 30-minute telephone sessions for 12 weeks with intervention group sessions focused on health behavior change and CTL group sessions focused on health status monitoring. MAIN OUTCOME MEASURES: Physical function, walking activity (steps/d averaged over 10d), and disability were measured at baseline, 12 weeks (intervention end), and 24 weeks after baseline with the Timed Up and Go (TUG) test as the primary outcome measure. RESULTS: The TUG test was not changed from baseline in either group and was not different between groups after 12 or 24 weeks. Several exploratory outcomes were assessed, including daily step count, which increased 1135 steps per day in the intervention group compared to 144 steps per day in the CTL group after 12 weeks (P=.03). Only the intervention group had within-group increase in steps per day from baseline to 12 (P<.001) and 24 (P=.03) weeks and spent significantly less time in sedentary activity (4.8% decrease) than the CTL group (0.2% decrease) at 24 weeks (P=.04). There were no other between-group differences in physical function or disability change over time. CONCLUSION: The behavior-change intervention demonstrates promise for increasing walking activity for people with dysvascular transtibial amputation (TTA). The efficacy of implementing such intervention in the scope of conventional TTA rehabilitation should be further studied.

A Feasibility Study for Improved Physical Activity After Total Knee Arthroplasty.

Physical activity outcomes are poor following total knee arthroplasty (TKA). The purpose was to evaluate feasibility of a physical activity feedback intervention for patients after TKA. Participants completing conventional TKA rehabilitation were randomized to a physical activity feedback (PAF; n = 22) or control (CTL; n = 23) group. The PAF intervention included real-time activity feedback, weekly action planning, and monthly group support meetings (12 weeks). The CTL group received attention control education. Feasibility was assessed using retention, adherence, dose goal attainment, and responsiveness with pre- and postintervention testing. The PAF group had 100% retention, 92% adherence (frequency of feedback use), and 65% dose goal attainment (frequency of meeting goals). The PAF group average daily step count increased from 5,754 (2,714) (pre) to 6,917 (3,445) steps/day (post). This study describes a feasible intervention to use as an adjunct to conventional rehabilitation for people with TKA.

Magnitude of Deformity Correction May Influence Recovery of Quadriceps Strength After Total Knee Arthroplasty.

BACKGROUND: Malalignment of the lower extremity is commonly seen in patients with severe osteoarthritis undergoing total knee arthroplasty (TKA) and is believed to play a role in quadriceps strength loss. Deformity correction is typically achieved through surgical techniques to provide appropriate ligamentous balancing. Therefore, this study examined the influence of change in lower extremity alignment on quadriceps strength outcomes after TKA. METHODS: Seventy-three participants (36 male; mean age, 62 years; and mean body mass index, 29.7 kg/m2) undergoing primary unilateral TKA were used in this investigation. Before surgery and at 1 and 6 months after surgery, measures of isometric knee extensor strength, quadriceps activation, and long-standing plain films were collected. Using the films, measures of mechanical axis, distal femoral angle (DFA), proximal tibial angle, and patellofemoral angle were performed. Hierarchical linear regression was used to evaluate how change in alignment from baseline to 1 and 6 months influenced the change in quadriceps strength. RESULTS: DFA was found to significantly contribute to changes in quadriceps strength at 1 and 6 months after TKA above those contributed by associated covariates. None of the other measures of lower extremity alignment were found to contribute to quadriceps strength in this sample. CONCLUSION: Reductions in quadriceps strength experienced after TKA are likely to be influenced by changes in lower extremity alignment. Specifically, measures of DFA were found to significantly contribute to these changes. Future work is needed to prospectively examine measures of lower extremity alignment change and recovery after TKA.

Arthrofibrosis Associated With Total Knee Arthroplasty.

BACKGROUND: Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions. METHODS: In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined. RESULTS: Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes. CONCLUSION: Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development and the benefits and shortcomings of various interventions are essential to best restore mobility and function.

Preparing for the Future of Post-Acute Care: A Metasynthesis of Qualitative Studies.

Despite poor outcomes for older adults following hospitalization, practice patterns of post-acute care clinicians and factors impacting quality of care are not well studied, which limits advancements in clinical care. Qualitative research on the factors that influence physician practice patterns with respect to older adults has been studied and may provide a framework for hypothesizing factors relevant to other post-acute care clinicians. Three themes emerged from this qualitative metasynthesis: (1) Current medical education and clinical guidelines are not aligned with the multifaceted care needed for older adults, (2) communication gaps impact quality of care, and (3) health policies constrain quality of care. Identifying potential factors that impact practice patterns in post-acute care providers may guide future research initiatives that shape health professional education and system policies.

Men and Women Demonstrate Differences in Early Functional Recovery After Total Knee Arthroplasty.

OBJECTIVE: To investigate whether sex affects the trajectory of functional recovery after total knee arthroplasty (TKA). DESIGN: Retrospective analysis from a historical database containing data from 3 prospective clinical trials and a pilot study. SETTING: Clinical laboratory setting. PARTICIPANTS: Recruitment across studies was restricted to patients who underwent an elective unilateral TKA for the treatment of osteoarthritis and were between 50 and 85 years of age (N=301). INTERVENTIONS: Across all 4 studies, patients received a TKA and physical therapy intervention. Measures of physical function and strength were assessed before TKA and 1, 3, and 6 months after TKA. MAIN OUTCOME MEASURES: Using a repeated-measures maximum likelihood model, statistical inference was made to estimate the changes in outcomes from before surgery to 1, 3, and 6 months after TKA that were stratified by sex. Muscle strength was assessed during maximal isometric quadriceps and hamstrings contractions. Muscle activation was assessed in the quadriceps muscle. Physical function outcomes included timed Up and Go (TUG) test, stair climbing test, and 6-minute walk test (6MWT). RESULTS: Women demonstrated less decline in quadriceps strength than did men at 1, 3, and 6 months after TKA (P<.04), whereas women demonstrated less decline in hamstrings strength 1 month after TKA (P<.0001). Women demonstrated a greater decline than did men on the TUG test (P=.001), stair climbing test (P=.004), and 6MWT (P=.001) 1 month after TKA. Sex differences in physical function did not persist at 3 and 6 months after TKA. CONCLUSIONS: Sex affected early recovery of muscle and physical function in the first month after TKA. Women demonstrated better preservation of quadriceps strength but a greater decline on measures of physical function than did men.

Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial.

OBJECTIVE: To determine whether a progressive multicomponent physical therapy intervention in the home setting can improve functional mobility for deconditioned older adults following acute hospitalization. DESIGN: Randomized controlled trial. SETTING: Patient homes in the Denver, CO, metropolitan area. PARTICIPANTS: A total of 22 homebound older adults age 65 and older (mean ± SD; 85.4 ±7.83); 12 were randomized to intervention group and 10 to the control group. INTERVENTION: The progressive multicomponent intervention consisted of home-based progressive strength, mobility and activities of daily living training. The control group consisted of usual care rehabilitation. MEASUREMENTS: A 4-meter walking speed, modified Physical Performance Test, Short Physical Performance Battery, 6-minute walk test. RESULTS: At the 60-day time point, the progressive multicomponent intervention group had significantly greater improvements in walking speed (mean change: 0.36 m/s vs. 0.14 m/s, p = 0.04), modified physical performance test (mean change: 6.18 vs. 0.98, p = 0.02) and Short Physical Performance Battery scores (mean change: 2.94 vs. 0.38, p = 0.02) compared with the usual care group. The progressive multicomponent intervention group also had a trend towards significant improvement in the 6-minute walk test at 60 days (mean change: 119.65 m vs. 19.28 m; p = 0.07). No adverse events associated with intervention were recorded. CONCLUSIONS: The progressive multicomponent intervention improved patient functional mobility following acute hospitalization more than usual care. Results from this study support the safety and feasibility of conducting a larger randomized controlled trial of progressive multicomponent intervention in this population. A more definitive study would require 150 patients to verify these conclusions given the effect sizes observed.

Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial.

BACKGROUND: Tourniquet use during total knee arthroplasty (TKA) improves visibility and reduces intraoperative blood loss. However, tourniquet use may also have a negative impact on early recovery of muscle strength and lower extremity function after TKA. QUESTIONS/PURPOSES: The purpose of this study was (1) to determine whether tourniquet use affects recovery of quadriceps strength (primary outcome) during the first 3 postoperative months; and (2) to examine the effects of tourniquet application on secondary outcomes: voluntary quadriceps activation, hamstring strength, unilateral limb balance as well as the effect on operative time and blood loss. METHODS: Twenty-eight patients (mean age 62 ± 6 years; 16 men) undergoing same-day bilateral TKA (56 lower extremities) were enrolled in a prospective, randomized study. Subjects were randomized to receive a tourniquet-assisted knee arthroplasty on one lower extremity while the contralateral limb underwent knee arthroplasty without extended tourniquet use. In the former group, the tourniquet was inflated just before the incision was made and released after cementation; in the latter group, a tourniquet was not used (10 of 28 [36%]) or inflated only during component cementation (18 of 28 [64%]). The choice of no tourniquet or use just during cementation was based on surgeon choice, because some surgeons felt a tourniquet during cementation was necessary to achieve a dry surgical field to maximize cement fixation. A median parapatellar approach and the identical posterior-stabilized TKA design were used by all four fellowship-trained knee surgeons involved. Isometric quadriceps strength, hamstring strength, voluntary quadriceps activation, and unilateral balance were assessed preoperatively, 3 weeks, and 3 months after bilateral knee arthroplasty. Other factors, including pain, range of motion, and lower extremity girth, were assessed for descriptive purposes at each of these time points as well as on the second postoperative day. RESULTS: Quadriceps strength was slightly lower in the tourniquet group compared with the no-tourniquet group (group difference = 11.27 Nm [95% confidence interval {CI}, 2.33-20.20]; p = 0.01), and these differences persisted at 3 months after surgery (group difference = 9.48 Nm [95% CI, 0.43-18.54]; p = 0.03). Hamstring strength did not differ between groups at any time point nor did measures of quadriceps voluntary activation or measures of unilateral balance ability. There was less estimated intraoperative blood loss in the tourniquet group (84 ± 26 mL) than in the no-tourniquet group (156 ± 63 mL) (group difference = -74 mL [95% CI, -100 to -49]; p < 0.001). However, there was no difference in total blood loss between the groups (group difference = -136 mL [95% CI, -318 to 45]; p = 0.13). CONCLUSIONS: Patients who underwent TKA using a tourniquet had diminished quadriceps strength during the first 3 months after TKA, the clinical significance of which is unclear. Future studies may be warranted to examine the effects of tourniquet use on long-term strength and functional outcomes. LEVEL OF EVIDENCE: Level I, therapeutic study.

Corticospinal and intracortical excitability of the quadriceps in patients with knee osteoarthritis.

Deficits in voluntary activation of the quadriceps muscle are characteristic of knee osteoarthritis (OA), contributing to the quadriceps weakness that is also a hallmark of the disease. The mechanisms underlying this central activation deficit (CAD) are unknown, although cortical mechanisms may be involved. Here, we utilize transcranial magnetic stimulation (TMS) to assess corticospinal and intracortical excitability in patients with knee OA and in a comparably aged group of healthy older adults, to quantify group differences, and to examine associations between TMS measures and pain, quadriceps strength, and CAD. Seventeen patients with knee OA and 20 healthy controls completed testing. Motor evoked potentials were measured at the quadriceps by superficial electromyographic recordings. Corticospinal excitability was assessed by measuring resting motor threshold (RMT) to TMS stimulation of the quadriceps representation at primary motor cortex, and intracortical excitability was assessed via paired-pulse paradigms for short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). No statistically significant differences between patients with knee OA and healthy controls were found for RMT, SICI or ICF measures (p > 0.05). For patients with knee OA, there were significant associations observed between pain and RMT, as well as between pain and ICF. No associations were observed between CAD and measures of corticospinal or intracortical excitability. These data suggest against direct involvement of corticospinal or intracortical pathways within primary motor cortex in the mechanisms of CAD. However, pain is implicated in the neural mechanisms of quadriceps motor control in patients with knee OA.

Muscle strength and functional recovery during the first year after THA.

BACKGROUND: Patients undergoing total hip arthroplasty (THA) often are satisfied with the decrease in pain and improvement in function they achieve after surgery. Even so, strength and functional performance deficits persist after recovery, but these remain poorly characterized; knowledge about any ongoing strength or functional deficits may allow therapists to design rehabilitation programs to optimize recovery after THA. QUESTIONS/PURPOSES: The purposes of this study were to (1) evaluate postoperative muscle strength, function, and quality of life during the first year after THA; and (2) compare strength and function in patients 1 year after THA with a cohort of healthy peers. METHODS: Twenty-six patients undergoing THA were assessed 1, 3, 6, and 12 months postoperatively, and 19 adults with no hip pathology were tested as a control group. Isometric muscle strength (hip flexors, extensors, abductors, knee extensors, and flexors), functional performance (stair climbing, five times sit-to-stand, timed-up-and-go, 6-minute walk, and single-limb stance tests), and self-reported function (Hip Disability and Osteoarthritis Score, SF-36, and UCLA activity score) were compared. RESULTS: One month after THA, patients had 15% less hip flexor and extensor torque, 26% less abductor torque, 14% less knee extensor and flexor torque, and worse performance on the stair climbing, timed-up-and-go, single-limb stance, and 6-minute walk. Compared with healthy adults, patients 12 months after THA had 17% less knee extensor and 23% less knee flexor torque; however, the functional testing (including stair climbing, five times sit-to-stand, and the 6-minute walk) showed no significant differences with the patient numbers available between individuals undergoing THA and healthy control subjects. SF-36 Physical Component Scores, although significantly improved from preoperative levels, were significantly worse than healthy adults 1 year after THA (p < 0.01). CONCLUSIONS: Patients experience early postoperative strength losses and decreased functional capacity after THA, yet strength deficits may persist after recovery. This may suggest that rehabilitation may be most effective in the first month after surgery.

Admission Cognition and Function Predict Change in Physical Function Following Skilled Nursing Rehabilitation.

OBJECTIVES: Many older adults are discharged from skilled nursing facilities (SNFs) at functional levels below those needed for safe, independent home and community mobility. There is limited evidence explaining this insufficient recovery. The purpose of this secondary analysis was to determine predictors of physical function change following SNF rehabilitation. DESIGN: Secondary analysis of a prospective observational cohort study. SETTING AND PARTICIPANTS: Across 4 SNFs, data were collected from 698 adults admitted for physical rehabilitation following an acute hospitalization. METHODS: Physical function recovery was evaluated as change from admission to discharge in Short Physical Performance Battery (SPPB) scores (N = 698) and gait speed (n = 444). Demographic and clinical characteristics collected at admission served as potential predictors of physical function change. Following imputation, a standardized model selection estimator was calculated for predictors per physical function outcome. Predictor estimates and 95% CIs were calculated for each outcome model. RESULTS: Higher cognitive scores [standardized ß (ßSTD) = 0.11, 95% CI: 0.0004, 0.20] and higher activities of daily living (ADL) independence at admission (ßSTD = 0.22, 95% CI: 0.05, 0.34) predicted greater SPPB change; higher SPPB scores at admission (ßSTD = -0.26, 95% CI: -0.35, -0.14) predicted smaller SPPB change. Higher ADL independence at admission (ßSTD = 0.17, 95% CI: 0.01, 0.37) predicted greater gait speed change; faster gait speed at admission (ßSTD = -0.30, 95% CI: -0.44, -0.15) predicted smaller gait speed change. CONCLUSIONS AND IMPLICATIONS: Admission cognition, ADL independence, and physical function predicted physical function change following post-hospitalization rehabilitation. Inverse findings for admission physical function and ADL independence predictors suggest independence with ADL is not necessarily aligned with mobility-related function. Findings highlight that functional recovery is multifactorial and requires comprehensive assessment throughout SNF rehabilitation.

The past and future of peri-operative interventions to reduce arthrogenic quadriceps muscle inhibition after total knee arthroplasty: A narrative review.

Total knee arthroplasty (TKA) improves patient-reported function by alleviating joint pain, however the surgical trauma exacerbates already impaired muscle function, which leads to further muscle weakness and disability after surgery. This early postoperative strength loss indicates a massive neural inhibition and is primarily driven by a deficit in quadriceps muscle activation, a process known as arthrogenic muscle inhibition (AMI). To enhance acute recovery of quadriceps muscle function and long-term rehabilitation of individuals after TKA, AMI must be significantly reduced in the early post-operative period. The aim of this narrative review is to review and discuss previous efforts to mitigate AMI after TKA and to suggest new approaches and interventions for future efficacy evaluation. Several strategies have been explored to reduce the degree of post-operative quadriceps AMI and improve strength recovery after TKA by targeting post-operative swelling and inflammation or changing neural discharge. A challenge of this work is the ability to directly measure AMI and relevant contributing factors. For this review we focused on interventions that aimed to reduce post-operative swelling or improve knee extension strength or quadriceps muscle activation measured by twitch interpolation. For individuals undergoing TKA, the use of anti-inflammatory medications, tranexamic acid, cryotherapy, intra-articular drains, torniquets, and minimally invasive surgical techniques for TKA have limited benefit in attenuating quadriceps AMI early after surgery. However, interventions such as inelastic compression garments, voluntary muscle contractions, and neuro-muscular electrical stimulation show promise in mitigating or circumventing AMI and should continue to be refined and explored.

Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption.

OBJECTIVE: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. METHODS: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. RESULTS: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. CONCLUSION: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. IMPACT: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.