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Background Approximately 20% of patients are dissatisfied with their total knee arthroplasty (TKA) at 1-year post-surgery. Met expectations have been found by some to significantly predict satisfaction. The role of met expectations in determining patient satisfaction has not been exhaustively explored. The primary aim of this study is to evaluate if met expectations moderate the relationship between pain and function variables and satisfaction. Methods Patients who underwent primary TKA for osteoarthritis were included in the study (n = 304). Patient-reported outcomes at pre-surgery and 1-year post-surgery were collected. The Knee Society Score (KSS) satisfaction subscale was used as the dependent variable. Candidate independent variables included the following: demographics, KSS, Knee injury and Osteoarthritis Outcome Score (KOOS), 12-Item Short Form Health Survey (SF-12), Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Self-Administered Comorbidity Questionnaire, and University of California Los Angeles activity score. Separate linear regression models were created to test interactions for KSS met expectations with pain and KSS met expectations with function. Results Significant predictors of satisfaction were KSS symptoms (pain), KOOS activities of daily living (function), KSS met expectations, KOOS pre-surgery activities of daily living, body mass index, and SF-12 general health. A significant interaction between met expectations and pain was found (P = .043) and the met expectations and function interaction approached significance (P = .086). For both interactions, as met expectations increased, pain and function predicted satisfaction less strongly. Conclusion Met expectations were found to moderate the relationship between pain and satisfaction. There may be more value in improving pain for patients with low met expectations. Level of evidence Level IV.

BACKGROUND Approximately 20% of total knee arthroplasty (TKA) patients are found to be dissatisfied or unsure of their satisfaction at 1-year post-surgery. This study attempted to predict 1-year post-surgery dissatisfied/unsure TKA patients with pre-surgery and surgical variables using logistic regression and machine learning methods. METHODS A retrospective analysis of patients who underwent primary TKA for osteoarthritis between 2012 and 2016 at a single institution was completed. Patients were split into satisfied and dissatisfied/unsure groups. Potential predictor variables included the following: demographic information, patella re-surfaced, posterior collateral ligament sacrificed, and subscales from the Knee Society Knee Scoring System, the Knee Society Clinical Rating System, the Western Ontario and McMaster Universities Osteoarthritis Index, and the 12-Item Short Form Health Survey version 2. Logistic regression and 6 different machine learning methods were used to create prediction models. Model performance was evaluated using discrimination (AUC [area under the receiver operating characteristic curve]) and calibration (Brier score, Cox intercept, and Cox slope) metrics. RESULTS There were 1432 eligible patients included in the analysis, 313 were considered to be dissatisfied/unsure. When evaluating discrimination, the logistic regression (AUC = 0.736) and extreme gradient boosted tree (AUC = 0.713) models performed best. When evaluating calibration, the logistic regression (Brier score = 0.141, Cox intercept = 0.241, and Cox slope = 1.31) and gradient boosted tree (Brier score = 0.149, Cox intercept = 0.054, and Cox slope = 1.158) models performed best. CONCLUSION The models developed in this study do not perform well enough as discriminatory tools to be used in a clinical setting. Further work needs to be done to improve the performance of pre-surgery TKA dissatisfaction prediction models.

Summary Background & aims Subjective Global Assessment (SGA) classifies malnutrition severity via a simple bedside assessment. Phase angle (PhA) is an indicator of cell integrity and has been suggested to be indicator of nutritional status. Objective To explore the relationship between PhA and SGA. Methods Relevant studies published through October 31, 2017 were identified using 7 electronic databases. Articles were included for review if they included comparison data between SGA and PhA within adult disease populations. Evidence quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines and methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Results 33 articles within four disease states (liver, hospitalization, oncology and renal) met inclusion criteria for review. Results were limited by restricting the database search to articles published in English only, and by the inherent difficulty of comparing 2 methods which are both influenced by the operator. Conclusion Based on GRADE guidelines, evidence quality received a grade of Low. Based on QUADAS-2, 61% of studies had high risk of bias in the index test (PhA), while all other domains had low risk. It is not possible to conclude that PhA is an accurate independent indicator of malnutrition. PROSPERO no. CRD42016050876.

© 2021 Joule Inc. or its licensors. BACKGROUND: An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it. METHODS: We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery. RESULTS: Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%–7%) at 5 years and 21% (95% CI 17%–26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12–3.45), pain (adjusted HR 0.85, 95% CI 0.75–0.96)], female sex (adjusted HR 1.67, 95% CI 1.08–2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17–1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12–1.53). INTERPRETATION: We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.

Objective To identify validated measures that capture illness perception and behavior and have been used to assess people who have knee pain/osteoarthritis. Methods A scoping review was performed. Nine electronic databases were searched for records from inception through April 19, 2015. Search terms included illness perception, illness behavior, knee, pain, osteoarthritis, and their related terms. This review included English language publications of primary data on people with knee pain/osteoarthritis who were assessed with validated measures capturing any of 4 components of illness perception and behavior: monitor body, define and interpret symptoms, take remedial action, and utilize sources of help. Seventy-one publications included relevant measures. Two reviewers independently coded and analyzed each relevant measure within the 4 components. Results Sixteen measures were identified that capture components of illness perception and behavior in the target population. These measures were originally developed to capture constructs that include coping strategies/skills/styles, illness belief, illness perception, self-efficacy, and pain behavior. Coding results indicated that 5, 11, 12, and 5 of these measures included the monitor body, define and interpret symptoms, take remedial action, and utilize sources of help components, respectively. Conclusions Several validated measures were interpreted as capturing some components, and only 1 measure was interpreted as capturing all of the components of illness perception and behavior in the target population. A measure that comprehensively captures illness perception and behavior could be valuable for informing and evaluating therapy for patients along a continuum of symptomatic knee osteoarthritis.

Objective Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the “Transitions of Care” (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions. Design Here we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study. Setting and participants All 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged ≥65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews. Results Taken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC. Conclusions and implications With comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.

Background It has been suggested that total knee replacement is being performed in people with less-severe osteoarthritis. We aimed to determine whether there were differences in the presurgery profile, symptoms and disability of 2 cohorts who underwent total knee replacement over a 10-year period. Methods Patients aged 18-85 years undergoing primary total knee replacement for osteoarthritis at 1 of 4 sites in Toronto and Strathroy, Ontario, were recruited in a cohort study during 2006-2008 (cohort 1) and 2012-2015 (cohort 2). Patients undergoing unicompartmental or revision arthroplasty were excluded. Demographic and health (body mass index [BMI], comorbidity) variables and osteoarthritis severity, as assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the disability component of the Late-Life Function and Disability Instrument (LLFDI-D), were collected before surgery. We calculated proportions, means and standard deviations with 95% confidence intervals (CIs) for all data. We constructed density plots by tertile score for the WOMAC pain and physical function subscales and the LLFDI-D limitation scale. Results There were 494 patients in cohort 1 and 251 patients in cohort 2. There were no differences in age, sex, education, living status, BMI, comorbidity, pain severity or disability between the cohorts based on overlapping 95% CIs and the density plots. More patients in cohort 1 than in cohort 2 were single (176 [35.6%], 95% CI 32.5%-41.1% v. 63 [25.1%], 95% CI 20.3%-31.0%). Patients in cohort 2 reported less limitation in higher-demand activities than did those in cohort 1 (mean score on LLFDI-D 62.3 [95% CI 60.7-63.9] v. 59.2 [95% CI 58.2-60.2]). Interpretation The patient profile and reported osteoarthritis severity were similar in 2 cohorts that had total knee replacement over a 10-year period. This suggests that increasing total knee replacement volumes over this period likely were not driven by these factors.

Background: Orthopedic surgeons recognize patient expectations of total knee arthroplasty (TKA) can be managed through education. E-learning is the application of educational technology. The objective of this study was to evaluate whether an e-learning tool could affect whether patients' expectations were met and they were satisfied 1 year following TKA. Methods: Patients with osteoarthritis from the London Health Sciences Centre, Canada, were randomly assigned to either a control group (n = 207) receiving standard patient education or an intervention group (n = 209) using the e-learning tool in addition to the standard. We used a web-based system with permuted block sizes, stratified by surgeon and first or second TKA. Preoperative measures were completed following the patients' preadmission clinic visit. Postoperative patient-reported outcome measures were completed at 6 weeks, 3 months, and 1 year after TKA. One year after TKA, risk difference was used to determine between-group differences for patient satisfaction and expectations being met. Results: One year postoperatively, the risk that expectations of patients were not met was 21.8% in the control group and 21.4% in the intervention group for an adjusted risk difference of 1.3% (95% confidence interval, -7.8% to 10.4%, P = .78). The proportion of patients satisfied with their TKA at 1 year postoperative was 78.6% in the intervention and 78.2% in the control groups. Conclusion: There was no between-group difference at 1 year between intervention and control groups for either the risk that expectations of patients were not met or the proportion of patients who were dissatisfied with their TKA. (c) 2018 Elsevier Inc. All rights reserved.

BACKGROUND: In 2012, a new Knee Society Knee Scoring System (KSS) was developed and validated to address the needs for a scoring system that better encompasses the expectations, satisfaction, and physical involvement of a younger, more active population of patients undergoing TKA. Revalidating this tool in a separate population by individuals other than the developers of the scoring system seems important, because such replication would tend to confirm the generalizability of this tool. QUESTIONS/PURPOSES: The purposes of this study were (1) to validate the KSS using a separate sample of patients undergoing primary TKA; and (2) to evaluate the internal consistency of the KSS. METHODS: Intervention and control groups from a randomized controlled trial with no between-group differences were pooled. Preoperative and postoperative (6 weeks and 1 year) data were used. Patients with osteoarthritis undergoing primary TKA completed the patient-reported component of the KSS, Knee Injury and Osteoarthritis Outcome Score (KOOS), SF-12, two independent questions about expectations of surgery, and the Patient Acceptable Symptom State (PASS) single-question outcome. This study included 345 patients with 221 (64%) women, an average (SD) age of 64 (8.6) years, a mean (SD) body mass index of 32.9 (7.5) kg/m(2), and 225 (68%) having their first primary TKA. Loss to followup in the control group was 18% and loss to followup in the intervention group was 13%. We quantified cross-sectional (preoperative scores) and longitudinal validity (pre- to postoperative change scores) by evaluating associations between the KSS and KOOS subscales using Spearman’s correlation coefficient. Preoperative known-group validity of the KSS symptoms and functional activity score was evaluated with a one-way analysis of variance across three levels of physical health status using the SF-12 Physical Component Score. Known-group validity of the KSS expectation score was evaluated with an unpaired t-test by comparing means across known expectation groups. Known-group validity of the KSS satisfaction score was evaluated with an unpaired t-test by comparing means across yes/no response groupings of the PASS single-question outcome. Internal consistency for each KSS subscale was evaluated with Cronbach’s α. RESULTS: Cross-sectional validity (ie, associations at a single point in time) was supported because correlation coefficients between KSS symptoms, functional activities, and satisfaction scores and scores on the KOOS pain subscale ranged from 0.60 to 0.73 (all correlations p < 0.01). Values were similar for associations with the KOOS function in the activities of daily living (ADL) subscale (0.66-0.69) and less (0.41-0.58) for correlations with the other three KOOS subscales. Longitudinal validity (ie, associations of change scores between two time points) was also supported because correlation coefficients between KSS symptoms, functional activities, and satisfaction change scores and the KOOS pain and ADL change scores varied from 0.63 to 0.73. Correlation coefficients were lower for the other three KOOS subscale change scores, suggesting a weaker relationship with KOOS symptoms (0.48-0.53), sports (0.47-0.51), and quality of life (0.60-0.65) (all correlations p < 0.01). Known-group validity (ie, differences between groups that are known to differ on a given characteristic) was confirmed by between-group differences for the symptoms and functional activities score comparisons as well as the comparisons with the expectations and satisfaction scores of the KSS (all p < 0.01). Cronbach’s α (ie, association among subscale items) varied from 0.68 (discretionary activities) to 0.94 (postoperative expectations) across four KSS subscales. CONCLUSIONS: Moderate-sized correlation coefficients and consistent differences between known groups support the validity of the KSS. Internal consistency values were also acceptable. The patient-reported subscales of the KSS are a valid and internally consistent outcome assessment for TKA.

Background Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests. Objectives To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment. Methods An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications. Results The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs ( P values > 0.05). Conclusion The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

Study Design Delphi panel study. Background Biomechanical parameters measured during a drop vertical jump task are risk factors for anterior cruciate ligament (ACL) injury and are targeted during rehabilitation after ACL reconstruction. A clinically feasible tool that quantifies observed performance on the drop vertical jump would help inform treatment efforts. The content and scoring of such a tool should be deliberated on by a group of experts throughout its development. Objectives To establish consensus on the content and scoring of a clinician-rated drop vertical jump scale (DVJS) for use during rehabilitation after ACL reconstruction. Methods Using a modified Delphi process, a panel of experts (researchers and clinicians) on the risk factors, prevention, treatment, and biomechanics of ACL injury anonymously critiqued versions of a DVJS. The DVJS was developed iteratively, based on the feedback from the panel, using Likert scale responses to questions and providing written comments. Three to 5 rounds were planned a priori, with a requirement of 75% agreement on included items after the final round. Results Twenty of the 31 invited experts (65%) participated. Approximately 93% agreement was achieved after the fourth round. Final items on the scale included the rating of knee valgus collapse (no collapse to extreme collapse) and the presence of other undesirable movements, including lateral trunk lean, insufficient knee flexion, and limb-to-limb asymmetry. Conclusion The Delphi process resulted in a beta version of a DVJS. Expert consensus was achieved on its content and scoring to support further clinical testing of the scale. J Orthop Sports Phys Ther 2017;47(8):557-564. Epub 6 Jul 2017. doi:10.2519/jospt.2017.7183.

Purpose: To examine the reliability, validity, and sensitivity to change of the 20-item version and the Rasch-refined 15-item version of the Upper Extremity Functional Index (UEFI-20 and UEFI-15, respectively) and to determine the impact of arm dominance on the positive minimal clinically important difference (pMCID). Methods: Adults with upper-extremity (UE) dysfunction completed the UEFI-20, Upper Extremity Functional Scale (UEFS), Pain Limitation Scale, and Pain Intensity Scale at their initial physiotherapy assessment (Time 1); 24–48 hours later (Time 2); and 3 weeks into treatment or at discharge, whichever came first (Time 3). Demographics, including working status, were obtained at Time 1. Global ratings of change (GRC) were provided by the treating physiotherapist and patient at Time 3. The UEFI-15 was calculated from relevant items in the UEFI-20. The intra-class correlation coefficient (ICC) and minimal detectable change (MDC) quantified test–retest reliability (Time 1–Time 2). Cross-sectional convergent validity was determined by the association (Pearson's r) between Time 1 measures of function and pain. Known-groups validity was evaluated with a one-way ANOVA across three levels of working status. Longitudinal validity was determined by the association (Pearson's r) between function and pain change scores (Time 1–Time 3). Receiver operating characteristic (ROC) curves estimated the pMCID using Time 1–Time 3 change scores and average patient/therapist GRC. Results: Reliability for the UEFI-20 and UEFI-15 was the same (ICC=0.94 for both measures). MDC values were 9.4/80 for the UEFI-20 and 8.8/100 for the UEFI-15. Cross-sectional, known-groups, and longitudinal validity were confirmed for both UEFI measures. pMCID values were 8/80 for the UEFI-20 and 6.7/100 for the UEFI-15; pMCID was higher for people whose non-dominant arm was affected. Conclusions: Both UEFI measures show acceptable reliability and validity. Arm dominance affects pMCID. The UEFI-15 is recommended because it measures only one dimension: UE function.

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

For older adults with complex health conditions, transitions between care settings are common and a major risk to quality of care and patient safety. Care transition interventions have shown positive impacts on continuity of care and health service use, however, most require additional human resources (e.g., transition coach), focus on one transition or “handoff”, and provide support for individual patients without addressing underlying challenges of health system integration. We sought to develop a framework for system-level enhancements to care transitions for older adults. We report a secondary framework analysis of an ethnographic investigation (the “InfoRehab” project) of care transitions for older persons who had experienced a hip fracture. The ethnographic study involved interviews, observations, and document reviews for 23 patients, 19 family caregivers, and 92 health care providers. Data were collected at each transition point (1-4/patient) along the care continuum, at three Canadian sites (large urban, mid-size urban, rural). Our framework analysis followed the approach described by Gale et al. (2013), using as cases 12 peer-reviewed papers which had reported InfoRehab results. Two researchers coded findings from each paper, then developed an analytical framework of eight themes by consensus; these include: patient involvement and choice, family caregiver involvement, patient complexity, health care provider coordination, information sharing, documentation, system constraints, and relationships. NVivo 11 was used to index findings into these themes and to generate a matrix. We are working with system stakeholders, including patients and caregivers, to apply this framework in the development of improved systems for care transitions.

Background The original 20-item Upper Extremity Functional Index (UEFI) has not undergone Rasch validation. Objective The purpose of this study was to determine whether Rasch analysis supports the UEFI as a measure of a single construct (ie, upper extremity function) and whether a Rasch-validated UEFI has adequate reproducibility for individual-level patient evaluation. Design This was a secondary analysis of data from a repeated-measures study designed to evaluate the measurement properties of the UEFI over a 3-week period. Methods Patients (n=239) with musculoskeletal upper extremity disorders were recruited from 17 physical therapy clinics across 4 Canadian provinces. Rasch analysis of the UEFI measurement properties was performed. If the UEFI did not fit the Rasch model, misfitting patients were deleted, items with poor response structure were corrected, and misfitting items and redundant items were deleted. The impact of differential item functioning on the ability estimate of patients was investigated. Results A 15-item modified UEFI was derived to achieve fit to the Rasch model where the total score was supported as a measure of upper extremity function only. The resultant UEFI-15 interval-level scale (0–100, worst to best state) demonstrated excellent internal consistency (person separation index=0.94) and test-retest reliability (intraclass correlation coefficient [2,1]=.95). The minimal detectable change at the 90% confidence interval was 8.1. Limitations Patients who were ambidextrous or bilaterally affected were excluded to allow for the analysis of differential item functioning due to limb involvement and arm dominance. Conclusion Rasch analysis did not support the validity of the 20-item UEFI. However, the UEFI-15 was a valid and reliable interval-level measure of a single dimension: upper extremity function. Rasch analysis supports using the UEFI-15 in physical therapist practice to quantify upper extremity function in patients with musculoskeletal disorders of the upper extremity.

Purpose. The purpose of this study was to investigate the test-retest reliability, relative variability, and agreement between calf bioelectrical impedance-spectroscopy (cBIS) acquired extracellular fluid (ECF), intracellular fluid (ICF), total water and the ratio of ECF : ICF, magnetic-resonance-imaging (MRI) acquired transverse relaxation times (T2), and apparent diffusion coefficient (ADC) of calf muscles of the same segment in healthy individuals. Methods. Muscle hydration measures were collected in 32 healthy individuals on two occasions and analyzed by a single rater. On both occasions, MRI measures were collected from tibialis anterior (TA), medial (MG), and lateral gastrocnemius (LG) and soleus muscles following the cBIS data acquired using XiTRON Hydra 4200 BIS device. The intraclass correlation coefficients (ICC2,1), coefficient of variation (CV), and agreement between MRI and cBIS data were also calculated. Results. ICC2,1 values for cBIS, T2, and ADC ranged from 0.56 to 0.92, 0.96 to 0.99, and 0.05 to 0.56, respectively. Relative variability between measures (CV) ranged from 14.6 to 25.6% for the cBIS data and 4.2 to 10.0% for the MRI-acquired data. The ratio of ECF : ICF could significantly predict T2 of TA and soleus muscles. Conclusion. MRI-acquired measures of T2 had the highest test-retest reliability of muscle hydration with the least error and variation on repeated testing. Hence, T2 of a muscle is the most reliable and stable outcome measure for evaluating individual muscle hydration.

Purpose: To examine information exchange by physiotherapists during care handoffs of patients with hip fracture in a rural health care setting. Methods: This qualitative ethnographic study used observation and interviews of 11 networks of patients with hip fracture (n=11), family caregivers (n=8), and health care providers (n=24). Patients were followed from acute care through each subsequent care setting. Data were supplemented by health care records and policy documents. Results: Findings revealed that handoffs were less successful when information transfer was untimely or incomplete. Family caregivers experienced challenges in obtaining information required to facilitate the handoff, especially when direct contact with physiotherapists was not possible as a result of distance or other factors. Physiotherapists had to navigate multiple data sources to retrieve important information, and managed information gaps in various ways. Information flow was often unidirectional and suggested no further clinical accountability for the discharging physiotherapist. Conclusions: Providing information in a structured and timely fashion facilitated physiotherapy handoffs. Inadequate handoffs compromised continuity of care, delayed progress in rehabilitation, and resulted in families' missing information of vital importance to their caregiving role. A multi-directional exchange of information is needed between patients, families, and health care providers across care settings.

Purpose: To determine whether activity-modifying behaviour mediates the relationship between the severity of knee pain and each of physical function and knee-related quality of life. Methods: A total of 105 participants with medial knee pain and no diagnosis of knee osteoarthritis (mean age 52.2 [SD 6.7] y) completed two self-report questionnaires. The Questionnaire to Identify Knee Symptoms assessed activity-modifying behaviour; the Knee injury and Osteoarthritis Outcome Score assessed pain severity, physical function, and knee-related quality of life. Simple mediation analysis was performed using linear regression. Results: The unstandardized regression coefficient for activity-modifying behaviour revealed partial mediation of the effect of pain severity on physical function (0.31 (SE 0.09), p

Objective: To evaluate 5-year outcomes after lower limb realignment and test the hypothesis that surgery-induced changes in selected biomechanical risk factors for medial knee osteoarthritis (OA) are associated with clinically important improvements. Design: We prospectively evaluated patient-reported outcomes, full-limb standing radiographs and gait biomechanics before, 6 months (surgery-induced change) and 5 years after medial opening wedge high tibial osteotomy (HTO) in 170 patients (46.4 +/- 8.9 years, 135 males) with knee OA and varus alignment. Logistic regression tested the associations of 6-month changes in mechanical axis angle and knee adduction moment with achieving an increase of >= 10 points in the Knee injury and Osteoarthritis Outcome Score (KOOS) 4 at 5 years, with and without adjusting for covariates. Gait data were also compared to existing data from healthy controls. Results: Mean 5-year changes (95% confidence interval (CI)) were: KOOS4: +14.2 (10.8, 17.6); mechanical axis angle: +8.21 degrees (7.58, 8.83); knee adduction moment: -1.49 % BW*Ht (-1.35, -1.63). The postoperative knee adduction moments were typically lower than values for healthy controls. When divided into quartiles, although all strata improved significantly, patients with reductions in knee adduction moment of 1.14-1.74 % BW*Ht (neither largest nor smallest changes) had highest 5-year KOOS4 scores. The 6-month change in knee adduction moment (odds ratios (OR) = 0.38; 95% CI: 0.22, 0.67), preoperative KOOS4(OR = 0.96; 95% CI: 0.94, 0.99) and preoperative medial tibiofemoral narrowing grade (OR = 0.62; 95% CI: 0.37, 1.00) were negatively associated with having a 5-year clinically important improvement (C-statistic = 0.70). Conclusions: Substantial improvements in biomechanical risk factors and patient-reported outcomes are observed 5 years after medial opening wedge HTO. The surgery-induced change in load distribution during walking is significantly associated with long-term clinically important improvement. (C) 2017 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

In previous studies, 50%-70% of patients referred to orthopedic surgeons for total knee replacement (TKR) were not surgical candidates at the time of initial assessment. The purpose of our study was to identify and cross-validate patient self-reported predictors of suitability for TKR and to determine the clinical utility of a predictive model to guide the timing and appropriateness of referral to a surgeon.We assessed pre-consultation patient data as well as the surgeon's findings and post-consultation recommendations. We used multivariate logistic regression to detect self-reported items that could identify suitable surgical candidates.Patients' willingness to undergo surgery, higher rating of pain, greater physical function, previous intra-articular injections and patient age were the factors predictive of patients being offered and electing to undergo TKR.The application of the model developed in our study would effectively reduce the proportion of nonsurgical referrals by 25%, while identifying the vast majority of surgical candidates (90%). Using patient-reported information, we can correctly predict the outcome of specialist consultation for TKR in 70% of cases. To reduce long waits for first consultation with a surgeon, it may be possible to use these items to educate and guide referring clinicians and patients to understand when specialist consultation is the next step in managing the patient with severe osteoarthritis of the knee.Dans des études précédentes, de 50 % à 70 % des patients dirigés vers des chirurgiens orthopédistes pour une arthroplastie totale du genou (ATG) n’étaient pas des candidats à la chirurgie au moment de l’évaluation initiale. Notre étude visait à recenser et à contrevalider les facteurs prédictifs de l’opportunité d’une ATG fondés sur des renseignements fournis par les patients, ainsi qu’à déterminer l’utilité clinique d’un modèle de prévision qui évaluerait le moment et la pertinence de diriger un patient vers un chirurgien.Nous avons évalué les données des patients préconsultation ainsi que les conclusions du chirurgien et ses recommandations postconsultation. Nous avons mené une analyse de régression logistique multivariée pour détecter les éléments autodéclarés qui permettraient de reconnaître les candidats pour la chirurgie.Les facteurs permettant de prédire si un patient se ferait offrir une ATG et choisirait de subir l’intervention étaient la disposition favorable du patient à se faire opérer, une douleur d’intensité élevée, des capacités physiques fonctionnelles supérieures, des antécédents d’injections intra-articulaires et l’âge.Concrètement, l’application du modèle élaboré durant notre étude réduirait le nombre de patients dirigés vers un chirurgien sans motif valable dans une proportion de 25 %, tout en permettant de reconnaître la vaste majorité des candidats à la chirurgie (90 %). À partir des renseignements fournis par les patients, nous pouvons prédire correctement le résultat d’une consultation avec un spécialiste pour une ATG dans 70 % des cas. Les conclusions de notre étude pourraient servir à réduire les longs délais d’attente pour une première consultation avec un chirurgien en aidant les professionnels de la santé et les patients à déterminer quand il convient de consulter un spécialiste pour la prise en charge d’une gonarthrose grave.

Purpose: To examine reliability and validity of the Lunge Test (LT) of dorsiflexion range of motion and determine the impact of different approaches to obtain a score on these parameters. Methods: Fifty-three patients with ankle injury/dysfunction provided initial assessment data for cross-sectional convergent and known-groups validity analysis with the Pearson coefficient (r) and paired t-test, respectively; data after 4–8 weeks of treatment for longitudinal validity analysis with coefficient r; and data 3 days later for test–retest reliability using the intra-class correlation coefficient (ICC) and minimal detectable change (MDC). LT scores were determined for the affected leg only (LTAff) and for the difference between the two limbs (LTDiff). Two strategies were used to calculate LT scores: a single series and the mean of three series of lunges. LTs were correlated with the Lower Extremity Functional Scale and Global Foot and Ankle Scale. Results: Reliability coefficients were high (ICC=0.93–0.99). The MDC=1.0/1.5 cm, LTAff/LTDiff, respectively. Cross-sectional validity was confirmed for LTDiff (r=−0.40 to −0.50). Between-limb differences (pDiff on initial assessment and either LT to assess change.

Objective Although the relationship between pain and the magnitude of medial knee loading has been previously studied, the contribution of frequency of loading has not. The objective of this study was to determine whether the addition of loading frequency (steps/day) to loading magnitude (knee adduction moment [KAM] impulse) helps explain variance in knee pain in people with knee osteoarthritis (OA). Methods Participants were adults with symptomatic knee OA with radiographic signs in the medial knee compartment (n = 38, 10 women). Pain was measured using the pain subscale of the Knee Injury and Osteoarthritis Outcome Score. Participants wore an accelerometer for 1 week to determine the average number of steps/day. The external KAM impulse was calculated from 3-dimensional gait analysis as participants ambulated at self-selected speeds. Knee extensor strength was measured with an isokinetic dynamometer. Linear regression was used to examine the relationship between pain and steps/day after controlling for the KAM impulse, knee extensor strength, and body mass index (BMI). Results After controlling for BMI (R2 = 0.02), knee extensor strength (R = 0.26, P < 0.05), and KAM impulse (R = 0.11, P < 0.05), steps/day contributed an additional 9% of variance in pain (P < 0.05). This model accounted for a total of 49% of the variance in pain (F[4,33] = 7.77, P < 0.05). Conclusion Increased knee loading frequency and magnitude were associated with increased pain. Objective measures of loading frequency should be considered when investigating the incidence and progression of knee OA.

OBJECTIVES: Evaluate the ability of the American and British Geriatrics Society fall prevention guideline's screening algorithm to identify and stratify future fall risk in community-dwelling older adults. METHODS: Prospective cohort of community-dwelling older adults (n = 117) aged 65 to 90 years. Fall history, balance, and gait measured during a comprehensive geriatric assessment at baseline. Falls data were collected monthly for 1 year. The outcomes of any fall and any injurious fall were evaluated. RESULTS: The algorithm stratified participants into 4 hierarchal risk categories. Fall risk was 33% and 68% for the "no intervention" and "comprehensive fall evaluation required" groups respectively. The relative risk estimate for falling comparing participants in the 2 intervention groups was 2.08 (95% CI 1.42-3.05) for any fall and 2.60 (95% Cl 1.53-4.42) for any injurious fall. Prognostic accuracy values were: sensitivity of 0.50 (95% Cl 0.36-0.64) and specificity of 0.82 (95% CI 0.70-0.90) for any fall; and sensitivity of 0.56 (95% CI 0.38-0.72) and specificity of 0.78 (95% Cl 0.67-0.86) for any injurious fall. CONCLUSIONS: The algorithm was able to identify and stratify fall risk for each fall outcome, though the values of prognostic accuracy demonstrate moderate clinical utility. The recommendations of fall evaluation for individuals in the highest risk groups appear supported though the recommendation of no intervention in the lowest risk groups may not address their needs for fall prevention interventions. Further evaluation of the algorithm is recommended to refine the identification of fall risk in community-dwelling older adults. Language: en

BackgroundScreening should have simple and easy-to-administer methods that identify impairments associated with future fall risk, but there is a lack of literature supporting validation for their use.ObjectiveThe aim of this study was to evaluate the independent contribution of balance assessment on future fall risk, using 5 methods to quantify balance impairment, for the outcomes “any fall” and “any injurious fall” in community-dwelling older adults who are higher functioning.DesignThis was a prospective cohort study.MethodsA sample of 210 community-dwelling older adults (70% male, 30% female; mean age=79.9 years, SD=4.7) received a comprehensive geriatric assessment at baseline, which included the Berg Balance Scale to measure balance. Information on daily falls was collected for 12 months by each participant's monthly submission of a falls log calendar.ResultsSeventy-eight people (43%) fell, of whom 54 (30%) sustained an injurious fall and 32 (18%) had recurrent falls (≥2 falls). Different balance measurement methods identified different numbers of people as impaired. Adjusted relative risk (RR) estimates for an increased risk of any fall were 1.58 (95% confidence interval [CI]=1.06, 2.35) for self-report of balance problems, 1.58 (95% CI=1.03, 2.41) for one-leg stance, and 1.46 (95% CI=1.02, 2.09) for limits of stability. An adjusted RR estimate for an increased risk of an injurious fall of 1.95 (95% CI=1.15, 3.31) was found for self-report of balance problems.LimitationsThe study was a secondary analysis of data.ConclusionsNot all methods of evaluating balance impairment are associated with falls. The number of people identified as having balance impairment varies with the measurement tool; therefore, the measurement tools are not interchangeable or equivalent in defining an at-risk population. The thresholds established in this study indicate individuals who should receive further comprehensive fall assessment and treatment to prevent falls.

Both primary total hip (THA) and knee (TKA) arthroplasty relieve pain, restore function, and increase mobility. Despite these successes, there is controversy as to whether THA or TKA provides greater or similar improvement. We therefore compared primary THA and TKA patient results in terms of (1) willingness to have surgery again; (2) WOMAC change score; (3) whether expectations were met; and (4) satisfaction. Patients undergoing primary THA were more willing to undergo their surgery again (THA 96%, TKA 89%), demonstrated greater WOMAC change scores, more frequently reported their expectations were met (THA 78%, TKA 70%), and expressed greater overall satisfaction (THA 89%, TKA 81%). In addition, patients undergoing THA expressed higher satisfaction with pain reduction while performing activities (ie, walking, stairs, and sitting/lying) and their ability to perform daily activities (ie, stairs, transportation, getting up, lying in bed, and light domestic duties) when compared with patients undergoing TKA. Our data suggest primary THA offers superior short-term outcomes when compared with primary TKA.Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Despite substantial advances in primary TKA, numerous studies using historic TKA implants suggest only 82% to 89% of primary TKA patients are satisfied. We reexamined this issue to determine if contemporary TKA implants might be associated with improved patient satisfaction. We performed a cross-sectional study of patient satisfaction after 1703 primary TKAs performed in the province of Ontario. Our data confirmed that approximately one in five (19%) primary TKA patients were not satisfied with the outcome. Satisfaction with pain relief varied from 72–86% and with function from 70–84% for specific activities of daily living. The strongest predictors of patient dissatisfaction after primary TKA were expectations not met (10.7× greater risk), a low 1-year WOMAC (2.5× greater risk), preoperative pain at rest (2.4× greater risk) and a postoperative complication requiring hospital readmission (1.9× greater risk). Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Increasingly, jurisdictions are adopting universal assessment procedures and information technology to aid in healthcare data collection and care planning. Before their potential can be realised, a better understanding is needed of how these systems can best be used to support clinical practice. We investigated the decision-making process and information needs of home-care case managers in Ontario, Canada, prior to the widespread use of universal assessment, with a view of determining how universal assessment and information technology could best support this work. Three focus groups and two individual interviews were conducted; questioning focused on decision-making in the post-acute care of individuals recovering from a hip fracture. We found that case managers' decisional process was one of a clinician-broker, combining clinical expertise and information about local services to support patient goals within the context of limited resources. This process represented expert decision-making, and the case managers valued their ability to carry out non-standardised interviews and override system directives when they noted that data may be misleading. Clear information needs were found in four areas: services available outside of their regions, patient medical information, patient pre-morbid functional status and partner/spouse health and functional status. Implications for the use of universal assessment are discussed. Recommendations are made for further research to determine the impact of universal assessment and information technology on the process and outcome of home-care case manager decision-making.

Background and Purpose Falls are a significant public health concern for older adults; early identification of people at high risk for falling facilitates the provision of rehabilitation treatment to reduce future fall risk. The objective of this prospective cohort study was to examine the predictive validity of the Berg Balance Scale (BBS) for 3 types of outcomes—any fall (≥1 fall), multiple falls (≥2 falls), and injurious falls—by use of sensitivity, specificity, receiver operating characteristic (ROC) curves, area under the curve, and likelihood ratios. Subjects and Methods A sample of 210 community-dwelling older adults received a comprehensive geriatric assessment at baseline, which included the BBS to measure balance. Data on prospective falls were collected monthly for a year. The predictive validity of the BBS for the identification of future fall risk was evaluated. Results The BBS had good discriminative ability to predict multiple falls when ROC analysis was used. However, the use of the BBS as a dichotomous scale, with a threshold of ≤45, was inadequate for the identification of the majority of people at risk for falling in the future, with sensitivities of 25% and 45% for any fall and for multiple falls, respectively. The use of likelihood ratios, maintaining the BBS as a multilevel scale, demonstrated a gradient of risk across scores, with fall risk increasing as scores decreased. Discussion and Conclusion The use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people. The predictive validity of this scale for multiple falls is superior to that for other types of falls, and the use of likelihood ratios preserves the gradient of risk across the whole range of scores.

Patient registries have been demonstrated to improve health care, and represent an important source of data to health researchers and policy-makers. Building on our previous research that tested an explanatory model of health information privacy views with pre-operative joint replacement recipients, in the present study we explored privacy views and willingness to participate in registries among post-operative joint replacement recipients. Post-operative patients were asked to complete a self-administered mailed questionnaire. One hundred and fifty-seven of 173 (91%) eligible individuals were enrolled. Bivariate analyses were conducted using t -tests and one-way ANOVAs. Multivariable analyses were conducted using multiple linear regression. Overall, our previous findings that views about health information privacy are more predictive of potential registry participation than patient characteristics or health care experiences continue to hold true post-surgery. Certain health care experiences were found to play a role in health information privacy concerns, including hip versus knee replacement, primary versus revision surgery, and surgical complications. More variance was explained in post-surgery registry participation views than pre-surgery. In addition, gender differences in R 2 values were smaller post-surgery. However, some aspects of the final models, such as gender as an effect modifier continued in the post-surgery study. Researchers and policy-makers should consider the impact of encounters with the health care system when seeking to understand patients’ privacy concerns and willingness to participate in registries.

Distal radius fractures are common injuries; however, identifying which factors are responsible for predicting outcomes remains an area of controversy. The purpose of this study was to define factors predictive of patient-reported pain and disability at 1 year in a prospective cohort of extra-articular distal radius fractures ( n=222). Data were collected at the initial visit and after 3, 6, and 12 months. The primary outcome was the 1-year patient-rated wrist evaluation (PRWE) score. The effect of baseline patient and injury characteristics on the 1-year PRWE score was assessed. Univariate and forward stepwise regression analyses both agreed that the most influential predictor of pain and disability at 1 year was injury compensation. The 1-year PRWE score was significantly higher for subjects involved with third-party claims (35.48) compared to those that were not involved in any claims (14.97), p=0.006. The regression model found that three baseline factors – injury compensation, education, and other medical comorbidities – explained 16.4% of the variance in PRWE scores at 1 year. No injury characteristic, including the degree of initial fracture displacement, was found to significantly influence the 1-year PRWE score. This study has shown that baseline patient and injury characteristics play a small role in predicting 1-year patient-reported pain and disability in extra-articular distal radius fractures. Conceptual factors outside of this biomedical model should be investigated.

Background The Questionnaire to Identify Knee Symptoms (QuIKS) was recently developed to promote activity by screening for experiences related to early symptoms in people with emergent chronic knee pain problems, such as osteoarthritis (OA) – like knee pain. The main purpose of the current study was to evaluate measurement properties of the QuIKS using Rasch analysis in a sample of people with knee symptoms consistent with symptomatic knee OA. Method This study used cross-sectional data. The sample was 200 subjects along the following knee health continuum: pain-free healthy knees (n = 55) from a university community, knee pain with no knee OA diagnosis (n = 111) from a university-affiliated medical clinic, and patients with surgeon-diagnosed symptomatic knee OA awaiting high tibial osteotomy (n = 34) from a sports medicine surgical clinic. The 13-item QuIKS was evaluated for its factor structure, item- and person-fit, item’s category response structure, differential item functioning by sex and obesity status, local item dependency, unidimensionality, and test precision. Subsequently, the QuIKS underwent known-groups analysis and convergent validity with the Knee injury and Osteoarthritis Outcome Score (KOOS). Results In the QuIKS, each item’s category response structure was modified. No differential item functioning was observed. Local item dependency informed the formation of four testlets. This refined QuIKS obtained summary fit to the Rasch measurement model, unidimensionality, reliability (person separation index = 0.82), and interval-level scoring. Subsequently, the Rasch-validated QuIKS (QuIKS-R) demonstrated excellent known-groups validity and good convergent validity with the KOOS (Spearman’s rho = 0.45 to 0.77). Conclusions The QuIKS-R provides interval-level quantification of knee symptoms-related experiences in people with knee symptoms consistent with symptomatic knee OA. Its scores might be useful for clinicians for promoting activity in individuals with early symptoms consistent with symptomatic knee OA. Electronic supplementary material The online version of this article (doi:10.1186/s12955-015-0358-6) contains supplementary material, which is available to authorized users.

subscale. Compared with the group with high pain and low function, the group with low pain and high function on average were older, less obese, more likely to be men, more highly educated, and were generally healthier, less disabled, and happier. Differences for all characteristics by groups were statistically significant at P

The objective of this literature review was to examine the relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty (TKA). Five databases were searched from inception to July 2011. Five studies were eligible on the following inclusion criteria: primary TKA, diagnosis of knee osteoarthritis, presurgery outcome measures, a measure of patient expectations and satisfaction, multivariate analysis of the relationship between expectations and satisfaction reported separately for TKA recipients, and English language. Preoperative expectations did not correlate with postoperative satisfaction. However, postoperative satisfaction was predicted by how well postoperative expectations were met after surgery. Therefore, patient education programs for managing expectations should span part of the postoperative recovery period.

Hospitals may transfer seniors with a hip fracture to various rehabilitation settings. Knowing the relationship between hospital teaching status and post-acute rehabilitation setting may help evaluations of the transfer from acute care. The purpose of this study was to determine the relationship between hospital teaching status and rehabilitation destination following acute care in seniors with a hip fracture. Hospital separations were linked with home care records to identify hip fractures and hospital-based or home care rehabilitation (n = 806). Two logistic regression models determined the likelihood of transfer to any rehabilitation destination and to hospital-based versus home care rehabilitation. Teaching hospitals were no more likely than non-teaching hospitals to discharge patients to any rehabilitation (OR 1.20, 95% CI 0.88,1.65). However, among those referred to rehabilitation, the odds of discharge to hospital-based versus home care rehabilitation were almost four times greater for patients in teaching hospitals (OR 3.76, 95% CI 2.23, 6.37). The results are consistent with the availability of post-acute rehabilitation in the planning area. Future study of post-acute rehabilitation outcomes should consider hospital teaching status as an indicator of how hospital-based factors may affect the utilization of post-acute rehabilitation.

Purpose: This practice survey describes how Fellows of the Canadian Academy of Manipulative Physiotherapy (FCAMPT) use spinal manipulation and mobilization and how they perceive their competence in performing spinal assessment; it also quantifies relationships between clinical experience and use of spinal manipulation. Methods: A cross-sectional survey was designed based on input from experts and the literature was administered to a random sample of the FCAMPT mailing list. Descriptive (including frequencies) and inferential statistical analyses (including linear regression) were performed. Results: The response rate was 82% (278/338 eligible FCAMPTs). Most (99%) used spinal manipulation. Two-thirds (62%) used clinical presentation as a factor when deciding to mobilize or manipulate. The least frequently manipulated spinal region was the cervical spine (2% of patients); 60% felt that cervical manipulation generated more adverse events. Increased experience was associated with increased use of upper cervical manipulation among male respondents (14% more often for every 10 years after certification; β, 95% CI=1.37, 0.89–1.85, p

BACKGROUND Prefracture physical function must be accurately determined to set appropriate and attainable goals for rehabilitation following hip fracture. This is especially important for people who were living independently prior to their fracture. This study determines reliability and internal consistency of a prefracture physical function questionnaire (PFPFQ) completed by both patients and knowledgeable informants (KIs). METHODS A 20-item PFPFQ, including ambulation, transfers, balance, and self-care domains, was developed using focus groups. Community-dwelling patients with a hip fracture (N = 40, 77.9 +/- 8 years) completed the PFPFQ on two occasions during postoperative acute care. Forty KIs were identified by the patients and also completed the PFPFQ on two occasions via telephone interview. Day-to-day reliability of the patients and KIs [intraclass correlation coefficients (ICC)], and internal consistency [Kuder-Richardson coefficient (KR)] of the PFPFQ were determined. RESULTS Intrarater reliability was high with ICCs (95% confidence interval) of 0.94 (0.89, 0.96) for patients and 0.96 (0.93, 0.98) for KIs. Interrater reliability on occasion 1 had an ICC of 0.81 (0.69, 0.88). Internal consistency of the patient responses on the first occasion was high (KR coefficient = 0.896). CONCLUSIONS The PFPFQ is a reliable and internally consistent instrument for determining prefracture physical function in community-dwelling people who fracture their hip. In situations where patients with a hip fracture are unable to provide this necessary information, KIs can provide reliable estimates of prefracture function to assist in setting appropriate rehabilitation goals.

Objective: The purpose of this study was to determine the relationship between physical function and fall-related self-efficacy in older patients with a hip fracture who are undergoing an intensive rehabilitation program. Design: We used a prospective cohort study over 12 mo to determine the effect of a specialized hip fracture rehabilitation program in a geriatric hospital on physical function and fear of falling. Fifty-six patients were admitted consecutively from acute care. Physical function was assessed using the Functional Independence Measure, and fall-related self-efficacy was measured using two scales: the Falls-Efficacy scale and the Activities-Specific Balance Confidence scale. We also used the Vitality scale to measure quality of life. All measures, represented by change scores, were determined at the beginning and end of the patients' rehabilitation programs. Results: Significant improvement in physical function and fall self-efficacy was observed. The Vitality scale was also improved after rehabilitation. The Falls-Efficacy scale appeared to be more sensitive to change than the Activities-Specific Balance Confidence scale, whereas no correlation was found between changes in the fall-related self-efficacy measures and the Functional Independence Measure. Conclusions: These findings may represent a discrepancy between attention of the rehabilitation program on functional outcomes and less emphasis on confidence building behaviors. Restrictions in function from a fear of falling may negate any gains made through rehabilitation, and this could limit the long-term success of these programs and patient outcomes after hip fracture.