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Background: Individuals with end-stage knee osteoarthritis (OA) walk at a lower intensity (ie, slower step cadence) contributing to worse physical function. Previous literature reports daily step counts and sedentary time, with little information regarding stepping bouts or cadence. Determining relationships between daily higher stepping cadence duration and clinical outcomes can move the field toward optimal daily stepping prescription., Objective: To quantify daily physical activity patterns of individuals with end-stage knee OA and determine the contribution of high stepping cadence to explain functional capacity variability., Design: Cross-sectional analysis., Setting: Veterans Administration medical center., Participants: U.S. military veterans (n = 104; age: 67.1 years [7.2]; mean [SD]; male [89.3%]) with end-stage knee OA were enrolled., Intervention: Not applicable., Main Outcome Measure: Functional capacity (6-Minute Walk Test [6MWT]). Physical activity (activPAL wearable sensor; cadence and time sitting, standing, and stepping), pain (Western Ontario and McMaster Universities Osteoarthritis Index-pain subscale) sociodemographic variables, and comorbidities (body mass index and Functional Comorbidity Index) are the main explanatory variables., Results: Participants' wake time was mainly sitting (11.0 h/day) in ≥60-minute bouts (29.7% ± 12.7 of sitting time). Standing (3.4 hours/day) and stepping (1.4 h/day) primarily occurred in 0-5 minute bouts (standing: 87.7% ± 14.4 of standing time, stepping: 98.7% ± 12.7 of stepping time) and stepping cadence was predominantly incidental (1-19 spm; 52.9% ± 9.6 of total stepping time). Backward elimination model results indicated shorter medium-to-brisk cadence bout duration, older age, and higher pain significantly explained shorter 6MWT distance ( Adj R 2 =0.24, p < .01)., Conclusions: Individuals with knee OA spend most of their waking hours sitting, while standing and stepping occurs in short bouts at very low stepping cadence. Decreased time in high stepping cadence is associated with lower functional capacity. Future studies should explore if increasing the daily time spent in higher step cadence can improve functional capacity in this population., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Background: Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear., Objective: To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives., Design: Convergent mixed-methods., Setting: General community., Participants: Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old., Intervention: Not applicable., Main Outcome Measures: Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews., Results: Higher steps/d was moderately correlated with better TUG time (r = -.58, P < .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P > .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases., Conclusions: Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA., (© 2020 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability., Objective: To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later., Design: Cross-sectional study., Setting: General community., Participants: Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old., Interventions: Not applicable., Main Outcome Measures: Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates., Results: The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model., Conclusions: Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions., (© 2020 American Academy of Physical Medicine and Rehabilitation.)

Introduction: Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited., Objective: To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories., Design: Secondary data analysis from two randomized controlled trials., Setting: Outpatient setting., Participants: People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis., Intervention: None., Outcome: Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated., Results: Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities., Conclusion: Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring., (© 2020 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Lower-limb amputation (LLA) due to non-traumatic vascular etiology is linked to extremely low physical activity and high disability., Objective: To test the feasibility of a biobehavioral intervention designed to promote physical activity., Design: A randomized, single-blind feasibility trial with a crossover design., Setting: Veterans Administration Medical Center., Participants: Military veterans (age: 65.7 [7.8] years; mean [standard deviation]) with nontraumatic lower-limb amputation (LLA), randomized to two groups: GROUP1 (n = 16) and GROUP2 (n = 15). Both groups had similar baseline amputation characteristics (level of amputation and time since amputation)., Interventions: Twelve weekly, 30-minute telehealth sessions of physical activity behavior-change intervention, with GROUP1 participating in weeks 1-12 and GROUP2 in weeks 13-24. GROUP1 noncontact phase in weeks 13-24 and GROUP2 attention control telehealth phase in weeks 1-12., Main Outcome Measures: Feasibility (participant retention, dose goal attainment, intervention acceptability [Intrinsic Motivation Inventory [IMI] Interest and Enjoyment scale], safety) and signal of efficacy (free-living physical activity [accelerometer-based average daily step count], Late Life Function and Disability Index - Disability Scale [LLFDI-DS])., Results: Participant retention rate was high (90%), with three participants lost to follow-up during the intervention period. Dose goal attainment was low, with only 10% of participants achieving an a priori walking dose goal. Intervention was rated as acceptable, with mean IMI Interest and Enjoyment score (5.8) statistically higher than the null value of 5.0 (P = .002). There were no between-group differences in adverse event rates (falls: P = .19, lower extremity wounds: P = .60). There was no signal of efficacy for change in average daily step count (d = -0.15) or LLFDI-DS (d = -0.22 and 0.17 for frequency and limitations scales, respectively)., Conclusions: Telehealth delivered biobehavioral intervention resulted in acceptable participant retention, low dose goal attainment, high participant acceptability, and low safety risk, while having no signal of efficacy (physical activity, disability) for people with nontraumatic LLA., (© 2020 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: People with dysvascular lower limb amputation (LLA) achieve one-third of the recommended steps per day and experience severe disability. Although physical function improves with rehabilitation after dysvascular LLA, physical activity remains largely unchanged, and factors contributing to limited daily step count are unknown., Objectives: To identify factors that contribute to daily step count after dysvascular LLA., Design: Cross-sectional, secondary data analysis., Setting: Outpatient rehabilitation facilities., Participants: Fifty-eight patients with dysvascular major LLA (age: 64 ± 9 years, body mass index: 30 ± 8 kg/m 2 , male: 95%, transtibial LLA: 95%)., Methods: Data were collected by a blinded assessor after dysvascular LLA. Candidate explanatory variables included (1) demographics, (2) LLA characteristics, (3) comorbidities and health behaviors, and (4) physical function. Variables with univariate associations with log steps/day (transformed due to non-normality) were included in a multiple linear regression model using backward elimination to identify factors that explained significant variability in log steps/day., Primary Outcome Measure: The primary outcome, daily step count, was measured with accelerometer-based activity monitors worn by participants for 10 days., Results: Participants took an average (± SD) of 1450 ± 1309 steps/day. After backward elimination, the final model included four variables explaining 62% of the overall daily step count (P < .0001): 2-minute walk distance (32%), assistive device use (11%), cardiovascular disease (10%), and pre-amputation walking time (11%)., Conclusions: Average daily step count of 1450 steps/day reflects the lowest category of sedentary behavior. Physical function, cardiovascular disease, and pre-amputation walking time explain 62% of daily step count after dysvascular LLA. Although physical rehabilitation commonly focuses on improving physical function, interventions to increase daily step count after dysvascular LLA should also consider chronic disease and health behaviors that predate LLA., Level of Evidence: III., (© 2019 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Prosthesis rehabilitation after dysvascular transtibial amputation (TTA) is focused on optimizing functional capacity with limited emphasis on promoting health self-efficacy. Self-efficacy interventions decrease disability for people living with chronic disease, but the influence of self-efficacy on disability is unknown for people with dysvascular TTA., Objectives: To identify if self-efficacy mediates the relationship between self-reported functional capacity and disability after dysvascular TTA., Design: Cross-sectional, secondary data analysis., Setting: Outpatient rehabilitation facilities., Participants: Thirty-eight men (63.6 ± 9.1 years old) with dysvascular TTA., Methods: Participants had been living with an amputation for less than 6 months and using walking as their primary form of locomotion using a prosthesis. The independent variable, functional capacity, was measured using the Prosthesis Evaluation Questionnaire-Mobility Scale (PEQ-MS). The proposed mediator, self-efficacy, was measured with the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD)., Main Outcome Measure: Disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire., Results: The relationship between self-reported functional capacity and disability is partially mediated by self-efficacy. Relationships between WHODAS 2.0 and PEQ-MS (r = -0.61), WHODAS 2.0 and SEMCD (r = -0.51), and PEQ-MS and SEMCD (r = 0.44) were significant (P < .01). Controlling for SEMCD (P = .04), the relationship between PEQ-MS and WHODAS 2.0 remained significant (P < .01). Statistically significant mediation was determined by a bootstrap method for the product of coefficients (95% confidence interval: -2.23, -7.39)., Conclusions: This study provides initial evidence that the relationship between self-reported functional capacity and disability is partially mediated by self-efficacy after dysvascular TTA. The longitudinal effect of self-efficacy should be further examined to identify causal pathways of disability after dysvascular amputation. Furthermore, additional factors contributing to the relationship between self-reported functional capacity and disability need to be identified., Level of Evidence: III., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To describe physical function outcomes and modes of physical therapy intervention for a cohort of patients with dysvascular lower extremity amputation (LEA) during the prosthetic training phase of rehabilitation., Design: A retrospective cohort study., Setting: Physical rehabilitation clinics at a Veterans Affairs medical center and a university hospital., Patients: Forty-two patients (38 men, 4 women, age 60.2 ± 8.4 years) who completed outpatient physical therapy rehabilitation with prosthetic training after dysvascular LEA., Methods: All patients underwent a prosthetic training phase of rehabilitation, with standardized outcome measures performed at initiation and discharge., Main Outcome Measures: Performance-based physical function measures included Two-Minute Walk (2 MW), Timed-Up and Go (TUG), and 5-meter gait speed. Self-report physical function measures included the Prosthesis Evaluation Questionnaire-Mobility Section (PEQ-MS) and the Patient-Specific Functional Scale. Rehabilitation dose was tracked as total number of clinic visits, rehabilitation duration, and specific intervention modes., Results: There were significant improvements between initial and discharge values (mean ± SD) for the Two-Minute Walk (67.5 ± 29.9 m and 103.3 ± 45.8 m, respectively, P < .001), gait speed (0.58 ± 0.27 m/s and 0.88 ± 0.39 m/s, respectively, P < .001), TUG (34.8 ± 21.3 seconds and 18.6 ± 13.9 seconds, respectively, P < .001), PEQ-MS (2.2 ± 0.9 and 2.8 ± 0.8, respectively, P < .001), and Patient-Specific Functional Scale (3.2 ± 2.0 and 5.9 ± 2.3, respectively, P < .001). Performance-based (TUG) and self-report (PEQ-MS) changes in functional mobility from initial exam to discharge had low or no correlations with rehabilitation dose measures. The number of clinic visits was 12.7 ± 13.1 and rehabilitation duration was 13.7 ± 16.8 weeks., Conclusions: Significant improvements in performance-based and self-report measures of physical function occurred during the prosthetic training phase of physical rehabilitation after dysvascular major LEA. Despite improvements in function, gait speed, and TUG outcomes remained below clinically important thresholds, indicating patients were limited in community ambulation and at risk for falls. Lack of moderate or greater correlation between rehabilitation dose and outcome measures may indicate the need for more specific rehabilitation dose measures., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

In this article, we study a Bayesian hierarchical model for profiling health-care facilities using approximately sufficient statistics for aggregate facility-level data when the patient-level data sets are very large or unavailable. Starting with a desired patient-level model, we give several approximate models and the corresponding summary statistics necessary to implement the approximations. The key idea is to use sufficient statistics from an approximate model fitted by matching up derivatives of the models' log-likelihood functions. This derivative matching approach leads to an approximation that performs better than the commonly used approximation given in the literature. The performance of several approximation approaches is compared using data on 5 quality indicators from 32 Veterans Administration nursing homes., (2010 John Wiley & Sons, Ltd.)