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BACKGROUND: Lower extremity weight bearing is a key determinant in maintaining bone density and strength. Approximately 60% of individuals with chronic spinal cord injury use a wheelchair long-term as their primary mode of locomotion—leading to a substantial reduction in lower extremity weight bearing. Unfortunately, this contributes to the development of severe sub-lesional osteoporosis, particularly at the femur and tibia, with fragility fracture rates twice those reported among the general population. Overground exoskeleton-assisted walking programs provide a novel opportunity to increase lower extremity weight bearing and mobility which may strengthen bone and mitigate fracture risks and associated complications. OBJECTIVES: To measure the immediate effects of an exoskeleton assisted walking program on lower-extremity bone strength and serum bone biomarkers in individuals with a spinal cord injury who use a wheelchair as their primary mode of locomotion. METHODS: Ten participants completed a 16-week exoskeleton assisted walking program incorporating 34 individualized 1-hour sessions, progressing from 1 to 3 sessions per week. Outcomes were measured immediately before and after completion of the intervention (±7 days). Mechanical bone properties (density, mineral content, geometry and strength indexes) were assessed using dual-energy X-ray absorptiometry (left hip, left arm, left leg) and peripheral quantitative tomography (25% left femur, 66% left tibia). Bone turnover biomarkers (bone formation = osteocalcin, bone resorption = telopeptide-c collagen) and 25-hydroxyvitamine D were assessed using fasting blood samples. Wilcoxon signed-ranked tests were used to determine pre versus post differences ( p This work was supported by the Fonds de recherche du Québec - Santé (FRQS, grant #252532) and the John R. Evans Leaders Fund of the Canada Foundation for Innovation (grant #36243). This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Objective:The current study aimed to assess the relationship between protein intake and bone parameters among dynapenic-obese older adults.Design:The current study is a secondary analysis with an a posteriori and exploratory design.Setting:Subjects were recruited from the community via social communication (flyers and meetings in community centres) in the Great Montreal area.Participants:Twenty-six subjects were divided a posteriori into two groups according to their usual protein intake: PROT−: < 1 g/kg per d (n 13; women: 53·8 %; 66·5 (sd 3·3) years) and PROT+: > 1·2 g/kg per d (n 13; women: 61·5 %; 67·2 (sd 2·7) years).Results:Both groups were comparable for age (PROT−: 66·5 (sd 3·3) v. PROT+: 67·2 (sd 2·7) years, P = 0·61) and gender (women: PROT−: n 7; 53·8 % v. PROT+: n 8; 61·5 %, P = 0·69). The PROT− group had a higher marrow area (P = 0·049), a greater bone compressive strength (P = 0·048) and a larger total bone area (P = 0·045) than the PROT+ group. However, no significant difference between the two groups was observed regarding body composition (fat and lean masses) or muscle composition.Conclusions:A lower protein intake seems to be associated with bone sizes, which influence bone strength, but do not influence bone density among dynapenic-obese older people.

Background Advanced practice physiotherapy has emerged as a promising solution to improve health care access because access to orthopedic care is limited in several countries. However, evidence supporting advanced practice physiotherapy models for the management of shoulder pain remains scarce. The purpose of this study was to establish diagnostic, surgical triage, and medical imaging agreement between advanced practice physiotherapists (APPs) and orthopedic surgeons (OSs) for the management of patients with shoulder disorders in an outpatient orthopedic clinic. Methods Patients referred to an OS for shoulder complaints were recruited and independently assessed by an OS and an APP. Each provider completed a standardized form indicating diagnosis, imaging test requests, and triage of surgical candidates. Patient satisfaction with care was recorded with the 9-item Visit-Specific Satisfaction Questionnaire (VSQ-9). Inter-rater concordance was calculated with the Cohen κ, prevalence-adjusted bias-adjusted κ, and associated 95% confidence interval (CI). We used χ2 tests to compare differences between providers in terms of treatment plan options and Student t tests to compare patient satisfaction between providers. Results Fifty participants were evaluated. Good diagnostic agreement was observed between providers (κ, 0.80; 95% CI, 0.67-0.93). Agreement for triage of surgical candidates was moderate (κ, 0.46; 95% CI, 0.21-0.71) as APPs tended to refer patients more often to OSs for further evaluation. Imaging test request agreement was moderate as well (κ, 0.42; 95% CI, 0.19-0.66). Patient satisfaction with care was high, with no significant differences found between providers (P = .70). Conclusion APPs could improve access to orthopedic care for shoulder disorders by safely initiating patient care without compromising satisfaction. These results support further development and evaluation of APP care for orthopedic patients presenting with shoulder disorders.

OBJECTIVE The 6-Min Manual Wheelchair Propulsion Test is proposed to easily and rapidly assess aerobic fitness among long-term (≥3 mos) manual wheelchair users with spinal cord injury. However, aerobic responses to this test have not been established. This study aimed (1) to characterize aerobic responses during the 6-Min Manual Wheelchair Propulsion Test, (2) to establish parallel reliability between the 6-Min Manual Wheelchair Propulsion Test and the Maximal Arm Crank Ergometer Test, and (3) to quantify the strength of association between the total distance traveled during the 6-Min Manual Wheelchair Propulsion Test and peak oxygen consumption. DESIGN Twenty manual wheelchair users with a spinal cord injury completed both tests. Aerobic parameters were measured before, during, and after the tests. Main outcome measures were peak oxygen consumption and total distance traveled. RESULTS Progressive cardiorespiratory responses, consistent with guidelines for exercise testing, were observed during both tests. Similar peak oxygen consumption values were obtained during both tests (6-Min Manual Wheelchair Propulsion Test: 20.2 ± 4.9 ml/kg·min; Maximal Arm Crank Ergometer Test: 20.4 ± 5.0 ml/kg·min), were highly correlated (r = 0.92, P < 0.001), and had a good agreement (mean absolute difference = 0.21, 95% confidence interval = -0.70 to 1.11, P = 0.639). The peak oxygen consumption and total distance traveled (mean = 636.6 ± 56.9 m) during the 6-Min Manual Wheelchair Propulsion Test were highly correlated (r = 0.74, P < 0.001). CONCLUSIONS The 6-Min Manual Wheelchair Propulsion Test induces progressive aerobic responses consistent with guidelines for exercise testing and can be used to efficiently estimate aerobic fitness in manual wheelchair users with a spinal cord injury. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain how to administer the Six-Minute Manual Wheelchair Propulsion Test in long-term manual wheelchair users with a spinal cord injury; (2) Contrast how the workload is developed between the Six-Minute Manual Wheelchair Propulsion Test and the Maximal Arm Crank Ergometry Test and recognize how these differences may affect physiological responses; and (3) Explain why caution is advised regarding the use of the Six-Minute Manual Wheelchair Propulsion Test if aiming to estimate aerobic fitness. LEVEL Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Many individuals with spinal cord injury (SCI) rely on wheelchairs as their primary mode of locomotion leading to reduced weight-bearing on the lower extremities, which contributes to severe bone loss and increased risk of fragility fractures. Engaging in a walking program may reverse this vicious cycle, as this promotes lower extremity weight-bearing and mobility, which may reduce bone loss and fragility fracture risk. However, fragility fracture risk associated with the use of wearable robotic exoskeletons (WREs) in individuals with SCI needs consideration. A 35-year-old man with chronic complete sensorimotor SCI (neurological level = T6) and low initial bone mineral density enrolled in a 6- to 8-week WRE-assisted walking program after successfully completing an initial clinical screening process and two familiarization sessions with the WRE. However, after the first training session with the WRE, he developed bilateral localized ankle edema. Training was suspended, and a CT-scan revealed bilateral calcaneal fractures, which healed with conservative treatment over a 12-week period. Opportunities for improving clinical screening and WRE design are explored. The relevance of developing clinical practice guidelines for safe initiation and progression of intensity during WRE-assisted walking programs is highlighted. This case of bilateral calcaneal fractures illustrates that aiming for "zero risk" during WRE-assisted walking programs may not be realistic. Although WREs are a relatively new technology, current evidence confirms their potential to greatly improve health and quality of life in individuals with chronic SCI. Hence, ensuring their safe use remains a key priority.

Background Knee disorders are highly prevalent and may be a disabling condition. An accurate diagnosis is necessary to guide toward a rapid and efficient management of knee disorders. However, the ability to make a valid diagnosis is often complex for clinicians and evidence is mainly focused on clinician cognitive biases or errors produced during clinical reasoning. The aim of this secondary exploratory analysis is to identify patient-specific characteristics associated with diagnostic discordance between health care providers in making a diagnosis for a new knee disorder. Methods We performed a secondary analysis of a diagnostic study comparing the diagnostic ability of a physiotherapist to medical musculoskeletal specialists. Patients’ socio-demographic, psychosocial and clinical characteristics were compared between the concordant and discordant diagnostic groups. Psychosocial symptoms were evaluated using the validated Kessler 6 (K6) questionnaire. We performed multivariable logistic regressions using the Bayesian Information Criterion to identify the most probable model including patients’ characteristics associated with diagnostic discordance. Overall probability of identified variables to explain diagnostic discordance and associated odd ratios (OR) with 95% credibility intervals (95% CrI) were calculated. Results Overall, 279 participants were evaluated by a physiotherapist and medical musculoskeletal specialists. The mean age of the participants was 49.1 ± 15.8 years and 57.7% were female. The most common disorder was osteoarthritis (n = 117, 18.8% of cases were discordant). The most probable model explaining diagnostic discordance (11.13%) included having depressive symptoms, which was associated with an increased probability of diagnostic discordance (OR: 3.9; 95% CrI: 1.9 – 8.0) and having a higher number of comorbidities, which was associated with a decreased probability of diagnostic discordance (OR: 0.6; 95% CrI: 0.5 – 0.9). The depression item of the K6 questionnaire had a 99.4% chance to be included in a model explaining diagnostic discordance. Other variables taken separately had less than 50% chance to be included in a model explaining diagnostic discordance and cannot be considered significant. Conclusion Our results suggest that depressive symptoms may increase the risk of knee diagnostic discordance. Clinicians may be more likely to make diagnostic errors and should be more cautious when evaluating patients with knee disorders suffering from psychological distress.

BackgroundIn wheelchair users with a chronic spinal cord injury (WUSCI), prolonged nonactive sitting time and reduced physical activity—typically linked to this mode of mobility—contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton may be a promising physical activity intervention to counter these detrimental health effects.ObjectiveThis study’s overall goals are as follows: (1) to determine the effects of a 16-week wearable robotic exoskeleton–assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors and (2) to determine self-reported satisfaction and perspectives with regard to the intervention and the device.MethodsA total of 20 WUSCI, who have had their injuries for more than 18 months, will complete an overground wearable robotic exoskeleton–assisted walking program (34 sessions; 60 min/session) supervised by a physiotherapist over a 16-week period (one to three sessions/week). Data will be collected 1 month prior to the program, at the beginning, and at the end as well as 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia, and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users’ satisfaction levels and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures.ResultsThis study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in the spring of 2021.ConclusionsThe results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based wearable robotic exoskeleton–assisted walking programs offered in the community, and to initiate a reflection regarding the use of wearable robotic exoskeletons during initial rehabilitation following a spinal cord injury.Trial RegistrationClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752International Registered Report Identifier (IRRID)DERR1-10.2196/19251

BACKGROUND In wheelchair users with a chronic spinal cord injury (WUSCI), prolonged nonactive sitting time and reduced physical activity—typically linked to this mode of mobility—contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton may be a promising physical activity intervention to counter these detrimental health effects. OBJECTIVE This study’s overall goals are as follows: (1) to determine the effects of a 16-week wearable robotic exoskeleton–assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors and (2) to determine self-reported satisfaction and perspectives with regard to the intervention and the device. METHODS A total of 20 WUSCI, who have had their injuries for more than 18 months, will complete an overground wearable robotic exoskeleton–assisted walking program (34 sessions; 60 min/session) supervised by a physiotherapist over a 16-week period (one to three sessions/week). Data will be collected 1 month prior to the program, at the beginning, and at the end as well as 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia, and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users’ satisfaction levels and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures. RESULTS This study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in the spring of 2021. CONCLUSIONS The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based wearable robotic exoskeleton–assisted walking programs offered in the community, and to initiate a reflection regarding the use of wearable robotic exoskeletons during initial rehabilitation following a spinal cord injury. CLINICALTRIAL ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/19251