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BACKGROUND: Despite efforts to view electronic health records (EHR) data through an equity lens, crucial contextual information regarding patients social environments remains limited. Integrating EHR data and Geographic Information Systems (GIS) technology can give deeper insights into the relationships between patients social environments, health outcomes, and geographic factors. This study aims to identify regions with the fastest and slowest access to outpatient physical therapy services using bivariate choropleth maps to provide contextual insights that may contribute to health disparity in access. METHODS: This was a retrospective cohort study of patients access timelines for the first visit to outpatient physical therapy services (n = 10,363). The three timelines evaluated were (1) referral-to-scheduled appointment time, (2) scheduled appointment to first visit time, and (3) referral to first visit time. Hot and coldspot analyses (CI 95%) determined the fastest and slowest access times with patient-level characteristics and bivariate choropleth maps that were developed to visualize associations between access patterns and disadvantaged areas using Area Deprivation Index scores. Data were collected between January 1, 2016 and January 1, 2020. EHR data were geocoded via GIS technology to calculate geospatial statistics (Gi∗ statistic from ArcGIS Pro) in an urban area. RESULTS: Statistically significant differences were found for all three access timelines between coldspot (i.e., fast access group) and hotspot (i.e., slow access group) comparisons (p

Loss of quadriceps strength after total knee arthroplasty (TKA) is most pronounced acutely but persists long-term, negatively impacting physical function in daily activities. Neuromuscular electrical stimulation (NMES) early after surgery is an effective adjuvant to standard of care rehabilitation (SOC) for attenuating strength loss following TKA, but the mechanisms whereby NMES maintains strength are unclear. This work aimed to determine the effects of early NMES on quadriceps strength and skeletal muscle fiber size 2 weeks after TKA compared to SOC. Patients scheduled for primary, unilateral TKA were enrolled and randomized into SOC (n = 9) or NMES plus SOC (n = 10) groups. NMES was started within 48 h of TKA, with 45-min sessions twice a day for 2 weeks. Isometric quadriceps strength was assessed preoperatively and 2 weeks following TKA. Vastus lateralis muscle biopsies of the involved leg were performed at the same time points and immunohistochemistry conducted to assess muscle fiber cross-sectional area and distinguish fiber types. Groups did not differ in age, body mass index, sex distribution, or preoperative strength. Both groups got weaker postoperatively, but the NMES group had higher normalized strength. After 2 weeks, the group receiving NMES and SOC had significantly greater MHC IIA and MHC IIA/IIX fiber size compared to SOC alone, with no group differences in MHC I fiber size. These results suggest that NMES mitigates early muscle weakness following TKA, in part, via effects on fast-twitch, type II muscle fiber size. This investigation advances our understanding of how adjuvant, early postoperative NMES aids muscle strength recovery.

BackgroundAlthough evidence-based guidelines for physical therapy for patients with chronic low back pain (cLBP) are available, selecting patient-reported outcome measures to capture complexity of health status and quality of life remains a challenge. PROMIS-10 Global Health (GH) may be used to screen for impactful health risks and enable patient-centered care. The purpose of this study was to investigate the interrelationships between PROMIS-10 GH scores and patient demographics, health status, and healthcare utilization in patients with cLBP who received physical therapy.MethodsA retrospective review of de-identified electronic health records of patients with cLBP was performed. Data were collected for 328 patients seen from 2017 to 2020 in three physical therapy clinics. Patients were grouped into HIGH and LOW initial assessment scores on the PROMIS-10 Global Physical Health (PH) and Global Mental Health (MH) measures. Outcomes of interest were patient demographics, health status, and healthcare utilization. Mann-Whitney U and chi-square tests were used to determine differences between groups, and binary logistic regression was used to calculate odds ratios (OR) to determine predictors of PH-LOW and MH-LOW group assignments.ResultsThe PH-LOW and MH-LOW groups contained larger proportions of patients who were African American, non-Hispanic, and non-commercially insured compared to PH-HIGH and MH-HIGH groups (p

IntroductionTotal knee arthroplasty (TKA) reduces joint symptoms, but habitual movement compensations persist years after surgery. Preliminary research on movement training interventions have signaled initial efficacy for remediating movement compensations and restoring knee joint loading symmetry during dynamic functional tasks after TKA. The purpose of this clinical trial is to determine if physical rehabilitation that includes movement training restores healthy movement patterns after TKA and reduces the risk of osteoarthritis (OA) progression in the contralateral knee.Methods/design150 participants will be enrolled into this randomized controlled trial. Participants will be randomly allocated to one of two dose-equivalent treatment groups: standard rehabilitation plus movement training (MOVE) or standard rehabilitation without movement training (CONTROL). Movement training will promote between-limb symmetry and surgical knee loading during activity-based exercises. Movement training strategies will include real-time biofeedback using in-shoe pressure sensors and verbal, visual, and tactile cues from the physical therapist. The primary outcome will be change in peak knee extension moment in the surgical knee during walking, from before surgery to six months after surgery. Secondary outcomes will include lower extremity movement symmetry during functional tasks, physical function, quadriceps strength, range of motion, satisfaction, adherence, contralateral knee OA progression, and incidence of contralateral TKA.DiscussionThis study will provide insights into the efficacy of movement training after unilateral TKA, along with mechanisms for optimizing long-term physical function and minimizing negative sequelae of compensatory movement patterns.

The synergy between biological and bioengineering advances is critical to developing novel and impactful translational therapies. However, there currently are few opportunities for regenerative scientists to be exposed to the methodologies commonly employed in the clinic by rehabilitation professionals, and most rehabilitation scientists and clinicians are not exposed to the many advances of regenerative medicine. This disconnect has impeded the pace of progress in the field. The Eighth Annual International Symposium on Regenerative Rehabilitation brought together basic scientists, engineers, and rehabilitation clinicians to present scientifically rigorous and cutting-edge research and clinical management, focusing on new and innovative approaches that combine discoveries in tissue engineering, medical devices, and cellular therapies with rehabilitative protocols.

BackgroundTotal hip arthroplasty (THA) is a common procedure, yet persistent deficits in functional performance exist after surgery. These deficits may be related to movement compensations observed after THA, which negatively affect quality of life and may increase morbidity and health care utilization, including in the veteran population. However, the best rehabilitative approach to remediating movement compensations and physical function deficits has not been determined.ObjectiveThe objective is to determine if a functional strength integration intervention (FSI), as part of a post-THA rehabilitation program, improves movement compensation, physical function, muscle strength, and self-reported outcome measures more than a control group (CON) undergoing a standard of care exercise program.DesignThis is a 2-arm randomized, controlled clinical trial.SettingThe Veteran Affairs outpatient physical therapy clinics and academic research laboratory will be the settings.ParticipantsOne hundred veterans undergoing THA for hip osteoarthritis will be included in the study.InterventionsParticipants will be randomized to either the FSI or CON group and participate in visits of physical therapy over 8 weeks. The FSI protocol will include targeted exercise to improve muscular control and stability around the hip and trunk to minimize movement compensation during daily activity combined with progressive resistance exercise. The CON protocol will include patient education, flexibility activity, and low load resistance exercise.MeasurementsFunctional performance, muscle strength and endurance, and self-reported outcomes will be measured at baseline (prior to surgery), midway through intervention (6 weeks after surgery), at the end of intervention (10 weeks after surgery), and 26 weeks after THA.LimitationsThe inability to blind treating therapists to study arm allocation is a limitation.ConclusionsThe proposed study aims to determine if targeted FSI can affect movement compensation to improve functional outcomes after THA more than traditional rehabilitation paradigms.

Osteoarthritis (OA) progression in the contralateral limb after unilateral total knee arthroplasty (TKA) may be related to altered and asymmetrical movement patterns that overload the contralateral joints. The purpose of this study was to determine if biomechanical factors after unilateral TKA were associated with future contralateral TKA. One hundred and fifty-eight individuals who underwent unilateral TKA completed three dimensional motion analysis 6-24 months after unilateral TKA (baseline). Subjects were re-contacted for follow-up (mean 5.89 years after baseline testing) to determine if they had undergone a contralateral TKA. Biomechanical variables from gait at baseline were compared between those who did and did not undergo contralateral TKA at follow-up using one-way ANOVAs. Odds ratios were calculated for variables found to be significant in the ANOVA models. Individuals who underwent contralateral TKA had less knee flexion excursion (10.5° vs. 12.1°; p = 0.032) and less knee extension excursion (8.2° vs. 9.6°; p = 0.035) at baseline on the operated side during walking. Individuals who underwent contralateral TKA also had less knee flexion excursion on the contralateral limb at baseline (11.9° vs. 14.0°; p = 0.017). For every additional degree of knee flexion excursion on the contralateral knee at baseline, there was a 9.1% reduction in risk of future contralateral TKA. Individuals who walked with stiffer gait patterns were more likely to undergo future contralateral TKA. Clinical Significance: Altered movement patterns after surgery may increase the risk for contralateral TKA. Knee excursion is an important metric to include in outcome studies and may serve as a target of rehabilitation after TKA. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:397-402, 2019.

BackgroundDiabetic forefoot joint deformities are a known risk factor for skin breakdown and amputation, but the causes of deformity are not well understood. The purposes of this study were to determine the effects of intrinsic foot muscle deterioration and limited ankle joint mobility on the severity of metatarsophalangeal joint (MTPJ) deformity, and determine the relationships between these potential contributing factors and indicators of diabetic complications (peripheral neuropathy and advanced glycation end products).MethodsA total of 34 participants with diabetic neuropathy (average age, 59 years; range 41-73) were studied. MTPJ angle and intrinsic foot muscle deterioration were measured with computed tomography and magnetic resonance imaging, respectively. Maximum ankle dorsiflexion was measured using kinematics. Skin intrinsic fluorescence served as a proxy measure for advanced glycation end product accumulation.ResultsTotal forefoot lean muscle volume (r = -0.52, P < .01) and maximum ankle dorsiflexion (r = -0.42, P < .05) were correlated with severity of MTPJ deformity. Together they explained 35% of the variance of MTPJ angle. Neuropathy was correlated with forefoot muscle deterioration (ρ = 0.53, P < .01). Skin intrinsic fluorescence was correlated to severity of neuropathy (r = 0.50, P < .01) but not maximum ankle dorsiflexion, or forefoot deterioration when controlling for neuropathy.ConclusionThese results suggest that the interplay of intrinsic foot muscle deterioration and limited ankle mobility may be the primary contributor to the development of MTPJ deformity. Identifying these muscle and ankle motion impairments as risk factors for MTPJ deformity supports the need for targeted interventions early in the disease process to slow, or possibly stop the progression of deformity over time and reduce the risk of amputation.Level of evidenceLevel IV, case series.

BackgroundDiabetes mellitus related medial column foot deformity is a major contributor to ulceration and amputation. However, little is known about the relationship between medial column alignment and function and the integrity of the soft tissues that support and move the medial column. The purposes of this study were to determine the predictors of medial column alignment and function in people with diabetes and peripheral neuropathy.Methods23 participants with diabetes and neuropathy had radiographs, heel rise kinematics, magnetic resonance imaging and isokinetic muscle testing to measure: 1) medial column alignment (Meary's angle--the angle between the 1st metatarsal longitudinal axis and the talar head and neck), 2) medial column function (forefoot relative to hindfoot plantarflexion during heel rise), 3) intrinsic foot muscle and fat volume, ratio of posterior tibialis to flexor digitorum tendon volume, 4) plantar fascia function (Meary's angle change from toes flat to extended) and 5) plantarflexor peak torque. Predictors of medial column alignment and function were determined using simultaneous entry multiple regression.FindingsPosterior tibialis to flexor digitorum tendon volume ratio and intrinsic foot muscle volume were significant predictors of medial column alignment (P

PurposeTo describe a semi-automated program that will segment subcutaneous fat, muscle, and adipose tissue in the foot using MR imaging, determine the reliability of the program between and within raters, and determine the validity of the program using MR phantoms.Materials and methodsMR images were acquired from 19 subjects with and without diabetes and peripheral neuropathy. Two raters segmented and measured volumes from single MR slices at the forefoot, midfoot, and hindfoot at two different times. Intra- and inter-rater correlation coefficients were determined. Muscle and fat MR phantoms of known volumes were measured by the program.ResultsMost ICC reliability values were over 0.950. Validity estimates comparing MR estimates and known volumes resulted in r(2) values above 0.970 for all phantoms. The root mean square error was less than 5% for all phantoms.ConclusionSubcutaneous fat, lean muscle, and adipose tissue volumes in the foot can be quantified in a reliable and valid way. This program can be applied in future studies investigating the relationship of these foot structures to functions in important pathologies, including the neuropathic foot or other musculoskeletal problems.

BackgroundMetatarsophalangeal joint deformity is associated with skin breakdown and amputation. The aims of this study were to compare intrinsic foot muscle deterioration ratios (ratio of adipose to muscle volume), and physical performance in subjects with diabetic neuropathy to controls, and determine their associations with 1) metatarsophalangeal joint angle and 2) history of foot ulcer.Methods23 diabetic, neuropathic subjects [59 (SD 10) years] and 12 age-matched controls [57 (SD 14) years] were studied. Radiographs and MRI were used to measure metatarsophalangeal joint angle and intrinsic foot muscle deterioration through tissue segmentation by image signal intensity. The Foot and Ankle Ability Measure evaluated physical performance.FindingsThe diabetic, neuropathic group had a higher muscle deterioration ratio [1.6 (SD 1.2) vs. 0.3 (SD 0.2), P1.0 were included. Muscle deterioration ratios in individuals with diabetic neuropathy were higher for those with a history of ulcers.InterpretationIndividuals with diabetic neuropathy had increased intrinsic foot muscle deterioration, which was associated with second metatarsophalangeal joint angle and history of ulceration. Additional research is required to understand how foot muscle deterioration interacts with other impairments leading to forefoot deformity and skin breakdown.

Loss of quadriceps strength after total knee arthroplasty (TKA) is most pronounced acutely but persists long‐term, negatively impacting physical function in daily activities. Neuromuscular electrical stimulation (NMES) early after surgery is an effective adjuvant to standard of care rehabilitation (SOC) for attenuating strength loss following TKA, but the mechanisms whereby NMES maintains strength are unclear. This work aimed to determine the effects of early NMES on quadriceps strength and skeletal muscle fiber size 2 weeks after TKA compared to SOC. Patients scheduled for primary, unilateral TKA were enrolled and randomized into SOC (n = 9) or NMES plus SOC (n = 10) groups. NMES was started within 48 h of TKA, with 45‐min sessions twice a day for 2 weeks. Isometric quadriceps strength was assessed preoperatively and 2 weeks following TKA. Vastus lateralis muscle biopsies of the involved leg were performed at the same time points and immunohistochemistry conducted to assess muscle fiber cross‐sectional area and distinguish fiber types. Groups did not differ in age, body mass index, sex distribution, or preoperative strength. Both groups got weaker postoperatively, but the NMES group had higher normalized strength. After 2 weeks, the group receiving NMES and SOC had significantly greater MHC IIA and MHC IIA/IIX fiber size compared to SOC alone, with no group differences in MHC I fiber size. These results suggest that NMES mitigates early muscle weakness following TKA, in part, via effects on fast‐twitch, type II muscle fiber size. This investigation advances our understanding of how adjuvant, early postoperative NMES aids muscle strength recovery. [ABSTRACT FROM AUTHOR]