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Background: Long-term musculoskeletal complications represent a growing burden for survivors of childhood acute lymphoblastic leukemia (cALL). This study aimed to describe impairments, activity limitations, and participation restrictions of survivors of cALL at highest risk for late morbidity (PETALE cohort). Procedure: This retrospective study, using cross-sectional observational data from the PETALE cohort, included a subgroup of survivors who presented extreme phenotypes of late effects. Participants completed bilateral hip magnetic resonance imaging (MRI), assessment of maximal isometric muscle strength (MIMS), range of motion (ROM), Near Tandem Balance (NTB), 6-Minute Walk Test (6MWT), Five Time Sit-to-Stand Test (FTSST)), and quality of life (QOL). Descriptive statistics and regression analyses were performed. Results: 97 survivors were included in this study. The selected survivors (24.2 ± 6.7 years old) trended toward lower scores for most outcomes compared to available expected values referenced from a healthy population except for QOL. Thirteen participants (14.6%, 18 hips) had hip ON (53.8% male). Female survivors had hip ON with higher severity score (66.7% female vs. 22.2% male). Survivors with hip ON had reduced hip external rotation ROM compared to those without (p

Rose Gagnon,1,2 Kadija Perreault,1,2 Jason R Guertin,3,4 Simon Berthelot,4– 6 Bertrand Achou,7 Luc J Hébert1,2,8 1Centre for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de La Capitale-Nationale, Quebec City, Quebec, Canada; 2Department of Rehabilitation, Université Laval, Quebec City, Quebec, Canada; 3Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada; 4Centre de recherche du CHU de Québec – Université Laval, Quebec City, Quebec, Canada; 5Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Quebec, Canada; 6CHU de Québec – Université Laval, Quebec City, Quebec, Canada; 7HEC Montreal, Montreal, Quebec, Canada; 8Department of Radiology and Nuclear Medicine, Université Laval, Quebec City, Quebec, CanadaCorrespondence: Luc J Hébert, Cirris, CIUSSS de la Capitale-Nationale, 525 Boulevard Wilfrid-Hamel, H-1410, Quebec City, Quebec, G1M 2S8, Canada, Tel +1 418 529-9141 ext 6579, Email lucj.hebert@fmed.ulaval.caBackground: Musculoskeletal disorders (MSKDs) are among the most disabling and costly non-fatal health conditions. They may lead to long-term consequences such as chronic pain, physical limitations, and poorer quality of life. They also account for a significant proportion of emergency department visits, representing between 18% and 25% of all visits, depending on country.Purpose: To assess the health-related quality of life of patients presenting to the emergency department with a MSKD, to convert their answers to utility scores and to explore the association between diverse socio-demographic and clinical variables and patients’ health-related quality of life.Patients and Methods: This is an analysis of cross-sectional data obtained during the baseline assessment performed as part of a 6-month pragmatic randomized controlled trial conducted in an academic emergency department. We included patients aged 18– 80 years with a minor MSKD. The main outcome measures were health-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (− 0.148 – worse than death, 0 – dead, 0.949 – perfect health) measured with the EQ-5D-5L. Possible associations were explored by comparing scores across subgroups based on certain socio-demographic (eg, age, gender, triage score) and clinical factors (eg, pain interference on function, pain intensity) and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ2 tests.Results: Sixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were, respectively, 0.536 (95% CI: 0.479– 0.594) and 0.531 (IQR: 0.356– 0.760). Participants with higher levels of pain (< 4/10: 0.741, 95% CI: 0.501– 0.980; 4– 7/10: 0.572, 0.500– 0.644; > 7/10: 0.433, 0.347– 0.518) or pain interference on function (< 4/10: 0.685, 95% CI: 0.605– 0.764; 4– 7/10: 0.463, 0.394– 0.533; > 7/10: 0.294, 0.126– 0.463) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics.Conclusion: In patients with MSKDs who present to the emergency department, higher levels of pain or pain interference are associated with decreased health-related quality of life. These findings need to be confirmed on a larger scale.Keywords: EQ-5D-5L, quality of life, pain, emergency services, musculoskeletal disorders

Patients with posttraumatic stress disorder (PTSD) display several structural brain differences when compared with healthy individuals. However, findings are particularly inconsistent for soldiers with PTSD. Here, we characterized the brain morphometry of 37 soldiers from the Canadian Armed Forces with adulthood war-related PTSD using structural magnetic resonance imaging. We assessed time since trauma, as well as PTSD, depressive, and anxiety symptoms with the Modified PTSD Symptoms Scale, Beck Depression Inventory, and Beck Anxiety Inventory, respectively. Whole-brain morphometry was extracted with FreeSurfer and compared with a validated normative database of more than 2700 healthy individuals. Volume and thickness from several regions differed from the norms. Frontal regions were smaller and thinner, particularly the superior and rostral middle frontal gyri. Furthermore, smaller left rostral middle frontal gyrus, left pericalcarine cortex, and right fusiform gyrus were associated with more recent trauma. All subcortical structures were bigger, except the hippocampus. These findings suggest a particular brain morphometric signature of PTSD in soldiers. Smaller and thinner frontal and larger subcortical regions support impaired top-down and/or downregulation of emotional response in PTSD. Finally, the correlation of smaller frontal, temporal, and occipital regions with more recent trauma might inform future therapeutic approaches.

Background This study aimed to describe lower limbs impairments, balance and activity limitations related to indoor mobility in adult walkers with autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS). Results Twenty-five participants were recruited with a mean age of 32.2 (± 10.4) years with 45.7% using a walking aid. There is a significant difference between participants with and without a walking aid in terms of lower limbs coordination, balance and mobility. Although participants who walk without a walking aid perform better than the others and they are below predictive or reference values. Despite significant mobility limitations, only mild spasticity and passive range of motion limitations were observed. However, there is a significant difference between unaffected individuals and participants with ARSACS for lower limb muscle cocontraction. Conclusions Results show a high level of lower limb impairments, balance and mobility limitation in adults’ participants with ARSACS that are still walking, including people not using a walking aid. One of the most original finding is the presence of excessive cocontraction and a relatively mild level of spasticity in the lower limbs muscles. Results of this study better circumscribes the impairments and activities that should be the focus of intervention including rehabilitation in ARSACS.

Introduction and hypothesis There is a high prevalence of urinary incontinence among endometrial cancer survivors. They are also known to present with pelvic floor muscle alterations. Evidence on the effects of conservative interventions for the management of UI is scarce. This study aims at verifying the effects of an in-home rehabilitation program, including the use of a mobile technology, to reduce UI severity in endometrial cancer survivors. Methods This study used a single-case experimental design with replications. Primary outcome for UI severity was the pad test, and secondary outcomes were the ICIQ-UI SF questionnaire and 3-day bladder diary. Pelvic floor muscle function was assessed using 2D-transperineal ultrasound and intravaginal dynamometry. Adherence was documented using mobile technology and an exercise log. Visual and non-parametric analyses of longitudinal data were conducted. Results Results show a reduction in UI severity for 87.5% of participants, with a significant relative treatment effect of moderate size (RTE: 0.30). Significant small relative treatment effects were found for the quick contraction and endurance dynamometric tests. Conclusion This study provides new evidence that endometrial cancer survivors can improve the severity of their UI following an in-home rehabilitation program, including the use of a mobile technology. This mode of delivery has the potential to address a gap in access to pelvic floor physiotherapy services for survivors of EC living in rural and remote communities.

Objectives1) To compare the average cost of an emergency department (ED) visit for various minor musculoskeletal disorders between two models of care (physiotherapist and ED physician or ED physician alone); 2) To evaluate the incremental cost-effectiveness ratio (ICER) of these two models of care over a 3-month period post-initial visit; and 3) To estimate the ICER of three ED models of care (physiotherapist and ED physician, ED physician alone, physiotherapist alone) over a two-year period.MethodsA randomized clinical trial was conducted among individuals (n=78) aged 18 to 80 years presenting with a musculoskeletal disorder at a Quebec City (Canada) hospital in 2018-2019. Two models of care were compared: management by a physiotherapist and an ED physician versus usual management by an ED physician. Participants follow-ups were conducted at 1 and 3 months post-initial ED visit. Obj.1: The health care costs incurred by the two groups during their ED visit will be calculated using the Time-Driven Activity-Based Costing (TDABC) method and compared using generalized linear models. Obj. 2: The cost-utility analysis over a 3-month time horizon will combine economic and clinical variables (estimated through quality-adjusted life years) using a Societal perspective. The results of the cost-utility analysis will be reported using an ICER. Obj. 3: The ICER will be estimated using a hybrid decision tree (0-3 months post-visit) and Markov model (3-24 months post-visit); the analysis will be conducted from a Societal perspective over a two-year time horizon.ConclusionThis study will help to determine which model of care is most efficient for the management of individuals who come to the ED with minor musculoskeletal disorders. The increased involvement of various health professionals in the management of patients in the ED paves the way for the development of new avenues of practice and more efficient organization of services.

Background: Myotonic dystrophy type 1 (DM1) is a multisystemic neuromuscular disorder causing a plea of impairments, of which fatigue and apathy are some of the most frequent non-muscular symptoms. No curative treatment exists to date, and patients only have access to limited effective care, which are intended to decrease the burden of specific symptoms in daily life. Objective: This study aimed to assess whether a 12-week strength training program has an impact on fatigue/daytime sleepiness, apathy, and disease bruden in men with DM1. Methods: Eleven participants completed the Fatigue and Daytime Sleepiness Scale (FDSS) and the Myotonic Dystrophy Health Index (MDHI) at baseline, at 6 and 12 weeks, and at 6 and 9 months. Also, the Apathy Evaluation Scale (AES) was filled out at baseline, at 12 weeks, and at 6 and 9 months. Results: Results show significant effects of the training program both on apathy and fatigue/daytime sleepiness, effects that are respectively greater at three and six months after the end of the program than at its very end. However, no difference was observed regarding the overall disease burden. Conclusion: These findings are promising for patients with DM1 considering that few non-pharmacological treatments are available.

Aims To investigate the intra- and inter-rater reliability of two-dimensional (2D) transperineal ultrasound imaging (USI) measures of bladder wall thickness (BWT), urethral length (UL), and parameters related to levator plate length (LP) and transient changes in LP during pelvic floor muscle (PFM) contraction, and on Valsalva in women who received radiation therapy (RT) for treatment of pelvic cancer. Methods Twenty women with a history of RT for the treatment of pelvic cancer were assessed independently by two raters on the same day. Five outcomes were assessed for reliability: BWT, UL, and LP at rest (LP-R), during a maximal voluntary contraction of the PFMs (LP-MVC), and during a maximal-effort Valsalva maneuver (LP-MVM). Reliability was determined using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Measurement error was determined using standard error of the measurement (SEM) and minimal detectable difference. Results Intra-rater reliability was very good for LP-R, LP-MVC, LP-MVM, and UL (ICC: 0.97 [0.93-0.99], 0.95 [0.88-0.98], 0.84 [0.59-0.94], and 0.96 [0.89-0.98], respectively). Inter-rater reliability was very good for LP-R (ICC: 0.82 [0.55-0.93]), and good for LP-MVC, LP-MVM, and UL (ICC: 0.79 [0.46-0.92], 0.79 [0.49-0.92], and 0.75 [0.36-0.90], respectively). BWT had poor intra- and inter-rater reliability. The variability between measurements was the smallest for LP-R, LP-MVC, and UL for intra-rater assessments, and for LP-R and UL for inter-rater assessments. SEM values for intra-rater assessments were LP-R: 1.5 mm, LP-MVC: 1.84 mm, LP-MVM: 4.33 mm, and UL: 1.16 mm. Conclusions Although these results support the reliability of 2D-transperineal USI for the evaluation of UL and PFM parameters, they do not support its use for the assessment of BWT.

Study design Single-blind parallel group randomized clinical trial. Objectives To compare the effects of neurocryostimulation (NCS) with those of traditional ice application on functional recovery, pain, edema and ankle dorsiflexion range of motion (ROM) in individuals receiving physiotherapy treatments for acute lateral ankle sprains (LAS). Background Ankle sprain is a very common injury and its management is often costly, with important short- and long-term impacts on individuals and society. As new methods of therapy using cold (cryotherapy) are emerging for the treatment of musculoskeletal conditions, little evidence exists to support their use. NCS, which provokes a rapid cooling of the skin with the liberation of pressured CO2, is a method believed to accelerate the resorption of edema and recovery in the case of traumatic injuries. Methods Forty-one participants with acute LAS were randomly assigned either to a group that received in-clinic physiotherapy treatments and NCS (experimental NCS group, n = 20), or to a group that received the same in-clinic physiotherapy treatments and traditional ice application (comparison ice group, n = 21). Primary (Lower Extremity Functional Scale - LEFS) and secondary (visual analog scale for pain intensity at rest and during usual activities in the last 48 h, Figure of Eight measurement of edema, and weight bearing lunge for ankle dorsiflexion range of motion) outcomes were evaluated at baseline (T0), after one week (T1), two weeks (T2), four weeks (T4) and finally, after six weeks (T6). The effects of interventions were assessed using two-way ANOVA-type Nonparametric Analysis for Longitudinal Data (nparLD). Results No significant group-time interaction or group effect was observed for all outcomes (0.995 ≥ p ≥ 0.057) following the intervention. Large time effects were however observed for all outcomes (p Conclusion Results suggest that neurocryostimulation is no more effective than traditional ice application in improving functional recovery, pain, edema, and ankle dorsiflexion ROM during the first six weeks of physiotherapy treatments in individuals with acute LAS. Level of evidence Therapy, level 1b. Trial registration ClinicalTrials.gov, NCT02945618. Registered 23 October 2016 - Retrospectively registered (25 participants recruited prior to registration, 17 participants after).

Background: Proprioception, our sense of joint awareness, is a sub-category of somatosensation, known as our “sixth sense”. It is part of our neuromuscular system, responsible for maintaining joint stability and preventing injury, particularly amongst shoulders. Proprioception is affected by injury and a decreased sense of proprioception can cause a predisposition to injury. Despite the importance of proprioception for shoulder stability, there remains no confident way to measure shoulder proprioception in a clinic. Purpose: To present a new clinical tool – The Shoulder Proprioception Reaching Test (SPReT) and to establish the discriminant validity, intra-rater and absolute reliability properties. Study Design: Cross-sectional clinical measurement study. Methods: A convenience sample of forty healthy participants was used. A single session (120 minutes) involved two bilateral evaluations of reaching movements using the SPReT, with a 30-minute rest period. Twenty participants were randomly selected to further perform a shoulder fatigue protocol of the dominant shoulder, immediately followed by a third SPReT evaluation. The SPReT involves active reaching movements in standing and with eyes closed, towards 7 targets in a star formation (active joint position sense). Discriminant validity (paired t tests), intra-rater reliability (intraclass correlation coefficients [ICC]) and absolute reliability (standard error of measurement [SEM] and minimal detectable change [MDC]) were determined. Results: The SPReT supports moderate (ICC = 0.45 – 0.71) to good (ICC = 0.77) intra-rater reliability with SEMs ranging from 1.17 to 2.63 cm and MDC90 from 2.72 to 6.12 cm for all targets. A fatigue effect was found with the superior and the superior-lateral right targets (P < .05), suggesting possible discriminant validity with the SPReT tool during elevated reaching movements.Conclusions: The superior target demonstrated the highest discriminant validity, intra-rater and absolute reliability properties and takes less than 5 minutes to evaluate. The evaluation of the superior target only may be suitable for clinical practice upon further methodological investigation for validity, reliability and responsiveness. Future research in encouraged and continues to be ongoing amongst a pathological population. Level of evidence: Level III cross-sectional study.

AIM To assess effects of growth on lower limb maximal isometric muscle strength (MIMS) development in children with developmental coordination disorder (DCD). METHOD This observational study used hand-held dynamometry to evaluate MIMS (hip abductors, flexors, extensors; knee flexors and extensors; ankle dorsiflexors) in children with DCD (n=33, 12 females, 21 males, 6-12y, mean [SD] age 9y [2y]). Regression analysis compared changes in MIMS for similar changes in growth (height or body mass) for children with DCD and typically developing children (pre-existing database, n=183), controlling for age and sex. RESULTS For the same height gain, the gain in muscle strength was 37.3% to 69.2% less in children with DCD compared with typically developing children, with significantly lower slopes (p-value between

Objective Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities. Methods We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted. Results Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy ( n = 11), occupational therapy ( n = 2), prosthetics ( n = 1), exercise physiology ( n = 1) and multidisciplinary ( n = 4) services. The methodological quality varied ( n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services. Conclusions This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Objectives To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care. Methods and analysis In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1—a single session or 2—multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants’ healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system. Ethics and dissemination Ethics approval has been obtained from theComité d’éthique de la recherche du CIUSS de l’Est-de-l’Île-de-Montréal(FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences. Protocol version V.4 August 2021. Trial registration number NCT04868591; Pre-results.

OBJECTIVES The objective was to evaluate the effects of direct-access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources. METHODS We conducted a randomized controlled trial in an academic ED in Quebec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two-way analyses of variance, log-linear analysis, and chi-square tests. RESULTS Seventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over-the-counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow-up for imaging tests, other professionals consulted, and hospitalization rates. CONCLUSION Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.

Although approximately 45% of adults with Autosomal Recessive Spastic Ataxia of Charlevoix-Saguenay (ARSACS) are permanent wheelchair users, this sub population has been less studied. The purpose of this study was to document wheelchair mobility, motor performance, and participation in a cohort of adult wheelchair users with ARSACS.We recruited 36 manual and powered wheelchair users with ARSACS, aged between 34 and 64 years, for this cross-sectional study. Participants completed measures regarding wheelchair mobility (Wheelchair Skills Test Questionnaire [WST-Q-F], Wheelchair Use Confidence Scale [WheelCon-F] and Wheelchair Outcome Measure [WhOM-F]), motor performance (Scale for the Assessment and Rating of Ataxia [SARA], Disease Severity Index for adults with ARSACS [DSI-ARSACS], Upper Extremity Performance Test for the Elderly [TEMPA], Standardised Finger to Nose Test [SFNT], grip strength, pinch strength, Lower Extremity Motor Coordination Test [LEMOCOT], Berg Balance Scale [BBS], Timed Up and Go [TUG] and 10-meter Walk Test [10mWT]), and participation (Barthel Index, LSA-F and LIFE-H). Results were compared between age groups (≤49 years and ≥50 years), types of wheelchair used, and available reference values. Correlations were computed between wheelchair mobility, upper limb function, and participation.Participants presented limitations regarding wheelchair skills, motor performance, and participation in daily activities. Despite preserved upper limb strength, wheelchair skills, upper and lower limb coordination, standing balance, and functional independence were generally more impaired after 50 years of age and among powered wheelchair users. Significant moderate correlations were found between wheelchair skills and self-efficacy, upper limb strength and coordination, and participation in daily and social activities.This study provided the first data sets describing specific characteristics of manual and powered wheelchair users with ARSACS. It supports a need to offer wheelchair skills training interventions to adults with ARSACS, which could increase their daily and social participation.IMPLICATIONS FOR REHABILITATIONAdult wheelchair users with ARSACS present with limited wheelchair skills, significantly impaired motor performance, and reduced participation that generally decreases with age. This profile may serve as comparative data for clinicians to anticipate disease progression.This study provides the first data on distinguishing characteristics between PWC users and MWC users with ARSACS. The main characteristics of PWC users include more severe functional limitations and motor impairments, as well as limited grip strength that contrasts with the general preservation of this function among other adults with ARSACS.There is a need to offer and evaluate wheelchair skills training interventions in the future for adults with ARSACS. The general preservation of grip and pinch strength observed in this population suggests a potential for improvement. Considering the associations found between wheelchair mobility and participation, such interventions may increase users' daily and social participation.

QuestionWhat is the level of diagnostic concordance between physicians and physiotherapists for patients consulting in an emergency department (ED) with musculoskeletal disorders (MSKDs)?DesignSecondary analysis of data obtained through a pragmatic randomized controlled trial, physiotherapist (PT) and emergency physicians (EPs) unblinded, per-protocol analysis.Participants78 participants aged 18 to 80 years presenting with a minor MSKD were recruited and data from the 40 participants randomized in the intervention group were used (mean age 36.6 yrs (SD: 17.3, IQR: 22.0; 46.8); women: 55%).Outcome measuresDiagnostic concordance was established using the International Classification of Diseases 11 (ICD-11) and examined between EP and PT using raw agreement and Gwet’s first-order agreement coefficient (AC1).ResultsForty participants were recruited and 36 were assessed by the PT and EP (36.8 ± 18.2 years old; 55.6% women). Overall raw agreement was 86.1% and an almost perfect diagnostic concordance was observed between PT and EP (Gwet’s AC1: 0.84, 95% CI: 0.69 – 0.98). The most common reason for disagreement was suspected bone fracture or contusion in comparison with ligament or meniscus disorder.ConclusionResults from this study indicate that overall diagnostic concordance between PT and EP in the ED for patients consulting with MSKDs is almost perfect. These results tend to support the safety of such models of care. However, more studies are needed to confirm these results as the EP wasn’t always independent and the classification used was imprecise.Registration#NCT04009369

ObjectivesThe purpose of this study was to assess utility scores of patients presenting to the emergency department (ED) with a musculoskeletal disorder and to explore the influence of diverse factors on health-related quality of life.DesignSecondary analysis of data obtained before randomization during a pragmatic randomized controlled trialSettingAcademic ED in Quebec City (Canada)ParticipantsParticipants aged 18-80 years old presenting with a minor MSKD.Main Outcome MeasuresHealth-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (0 – dead, 100 – perfect health), measured with the EQ-5D-5L, were compared between subgroups and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ2 tests.ResultsSixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were respectively 0.536 (95% CI: 0.479-0.594) and 0.531 (IQR: 0.356-0.760). Participants with higher levels of pain (7/10: 0.433) or pain interference on function (7/10: 0.294) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics. The mean overall VAS score was 58.1 (95% CI: 52.2-64.0).ConclusionsIn patients with MSKDs presenting to the ED, higher levels of pain and pain interference on function may influence perceived health-related QoL. These findings need to be confirmed on a larger scale.Trial RegistrationThis trial was registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04009369 on July 5, 2019

ContextIn several countries, physiotherapists (PT) have been integrated within emergency departments (EDs) to help manage patients with musculoskeletal disorders (MSKDs). Still, research on the effects of such initiatives is scarce.ObjectivesTo evaluate the effects of direct access PT on MSKD patients consulting the ED in terms of clinical outcomes and use of health care resources.Design, Setting, ParticipantsRandomized controlled trial, academic ED in Quebec City (Canada), participants 18-80 years presenting with a minor MSKD.InterventionDirect access PT at the EDControlEmergency Physicians lead management (EP).Main Outcome MeasureClinical outcomes (pain, interference of pain on function) and use of resources (ED return visit, interventions, diagnostic tests, consultations) were compared between groups at ED discharge and after 1 and 3 months using two-way ANOVAs, log-linear analysis and χ2 tests.ResultsSeventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). Participants in the PT group (n=40) had statistically lower levels of pain and pain interference at 1- and 3-months. They were recommended fewer imaging tests (38% vs. 78%; pConclusionPatients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge. The results of this study support the implementation of such models of care for the management of this population.Trial RegistrationThis trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT04009369Ethical approvalThis trial was approved by the Research Ethics Committee of the CHU de Québec - Université Laval #MP-20-2019-4307

To establish the reliability and construct validity of two French-Canadian versions of assessment tools for manual (MWC) and powered wheelchair (PWC) users with autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS): the Wheelchair Skills Test Questionnaire (WST-Q-F) version 5.0 and the Wheelchair Use Confidence Scale (WheelCon-F) Short Form. We recruited 32 MWC and PWC users with ARSACS aged between 34 and 64 years. Participants completed measures twice within 2 weeks for test–retest reliability and to determine the standard error of measurement. Construct validity was established by verifying hypothesized relationships between wheelchair use scores and other variables regarding personal factors, body functions, and activities. Participants’ scores were also compared with those of MWC and PWC users with other diagnoses to explore known-groups validity. Adequate to excellent test–retest reliability values were found for all questionnaires (intraclass correlation coefficients between 0.506 and 0.995). SEMs were acceptable, ranging from 3.3 to 9.1 on the WST-Q-F and from 0.7 to 1.2 on the WheelCon-F. Moderate to excellent correlations supported construct validity for the WST-Q-F and the WheelCon-F. Compared with other populations, adults with ARSACS reported limited wheelchair skills, but similar wheelchair confidence. The WST-Q-F and the WheelCon-F have excellent test–retest reliability, acceptable measurement errors, and support for construct validity in adults with ARSACS. This study was the first to evaluate these assessment tools in this population, and the results support a need to implement wheelchair skills training interventions in this population.IMPLICATIONS FOR REHABILITATIONThe WST-Q-F version 5.0 and the WheelCon-F Short Form are reliable and valid assessment tools to measure manual and powered wheelchair skills and self-efficacy in adults with autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS).The WST-Q-F version 5.0 and the WheelCon-F Short Form can be used to evaluate and describe wheelchair skills and wheelchair use self-efficacy in clinical practice and are recommended for future research in adults with ARSACS. These outcome tools may be especially useful to measure the effects of a wheelchair training program. The WST-Q-F version 5.0 and the WheelCon-F Short Form are reliable and valid assessment tools to measure manual and powered wheelchair skills and self-efficacy in adults with autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS). The WST-Q-F version 5.0 and the WheelCon-F Short Form can be used to evaluate and describe wheelchair skills and wheelchair use self-efficacy in clinical practice and are recommended for future research in adults with ARSACS. These outcome tools may be especially useful to measure the effects of a wheelchair training program.

Background In Myotonic Dystrophy type 1 (DM1) patients, ankle muscles are affected early and this impairment is reported to be a good biological marker for longitudinal studies. Objective To characterize the ankle dorsiflexion (DF) and eversion (EV) maximal isometric muscle strength changes in adult DM1 patients over 5 years using a standardized handheld dynamometer protocol and the Myoankle method, compare the changes measured with both methods and to the standard error of measurement, and verify the relationship between ankle muscle strength and gait performance. Methods The maximal isometric muscle strength of ankle DF and EV in DM1 patients from Quebec and Lyon was assessed at baseline, 18, 36 and 60 months using a handheld dynamometer (HHD) protocol and the MyoAnkle method. Results There was a decrease of torque in DF/EV of 36.0% /31.3% and 27.7% /35.5% for the Quebec and Lyon cohorts respectively (p≤0.01), but not in a linear way. In most cases (82.5%), the changes observed were greater than the standard error of measurement. DF torque measures taken by the two methods (HHD and MyoAnkle) were highly correlated (rp = 0.97-0.98, p Conclusion Muscle strength ankle impairments are clinically meaningful in DM1 and can be accurately monitored using quantitative testing to measure the efficacy of therapeutic trials.

BACKGROUND Although adult and late-onset DM1 phenotypes DM1 present distinct lower limb weaknesses portraits, resulting physical limitations have never been described separately for each phenotype. OBJECTIVE To characterize the lower limb weaknesses and physical limitations among the DM1 adult and late-onset phenotypes separately and to document the contribution of weaknesses on mobility to optimize the management of this population. METHODS The strength of four muscle groups among 198 participants was quantified. Participants were categorized according to the severity of their muscular involvement using the Muscular Impairment Rating Scale (MIRS). Physical limitations were assessed using the Timed up-and-go (TUG), Berg Balance Scale (BBS) and 10 meters comfortable walking speed (10MWT). Multiple linear regressions were performed to identify the contribution of each muscle group to the mobility tests scores. RESULTS Late-onset demonstrated less weakness and physical limitations (p < 0.001 - 0.002) than the adult phenotype, but 21.9-47.5% of participants with this phenotype showed mobility scores below reference values. Physical limitations were observed in the first two MIRS grades (37.5-42.1% of the participants) for the TUG and 10MWT. Ankle dorsiflexors and knee extensors were the two muscle groups that showed the strongest relationships with mobility scores. CONCLUSION Although less impaired, the late-onset phenotype shows significant lower limb muscle weakness associated with physical limitations. The surprising presence of quantitative lower limb muscle weakness in the first two MIRS grades needs to be considered when using this scale. Both ankle dorsiflexors and knee extensors appear to be good indicators of physical limitations in DM1.

Myotonic dystrophy type 1 (DM1) is a neuromuscular disorder presenting with major muscle impairments. However, few studies have addressed muscle strength progression using quantitative methods. The aims of this study were to document muscle strength changes in eight muscle groups among adults with DM1 over a 9-year period, and to compare this progression between phenotypes (adult and late-onset) and sex. Patients with a genetic diagnosis of DM1 with the late-onset or the adult phenotype were recruited at baseline through the clinical registry of the Saguenay Neuromuscular Clinic. The maximum isometric muscle strength was measured at baseline and 9 years later using a standardized protocol of quantitative muscle testing. Muscle groups included were shoulder abductors, elbow flexors/extensors, wrist extensors, hip flexors, knee flexors/extensors, and ankle dorsiflexors. For the whole group, a mean loss of 24.5-52.8% was observed over the 9-year period for all muscle groups, except for hip flexors which remained stable. Generally, men were stronger and showed a significant greater rate of decline of muscle strength than women. The adult and late-onset phenotypes taken separately also showed a significant and similar decline over the 9-year period, except for the wrist and knee extensors where muscle strength of participants with the adult phenotype decreased faster than in the late-onset phenotype. The similar rate of decline of muscle strength loss observed between phenotypes highlights the need to develop interventions to prevent this decline, even for patients with the late-onset phenotype who are often considered as mildly impaired, and therefore neglected by the rehabilitation services.

Background Total knee arthroplasty (TKA) reduces knee extensor muscle strength (KES) in the operated limb for several months after the surgery. Immediately after TKA, compared to either inguinal femoral nerve block or placebo, adductor canal block (ACB) better preserves KES. Whether this short-term increase in KES is maintained several weeks after surgery remains unknown. We hypothesized that 48 hours of continuous ACB immediately after TKA would improve KES 6 weeks after TKA, compared to placebo. Methods Patients scheduled for primary unilateral TKA were randomized to receive either a continuous ACB (group ACB) or a sham block (group SHAM) for 48 hours after surgery. Primary outcome was the difference in maximal KES 6 weeks postoperatively, measured with a dynamometer during maximum voluntary isometric contraction. Secondary outcomes included postoperative day 1 (POD1) and day 2 (POD2) KES, pain scores at rest and peak effort, and opioid consumption; variation at 6 weeks of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of hospital stay. Results Sixty-three subjects were randomized and 58 completed the study. Patients in group ACB had less pain at rest during POD1 and during peak effort on POD1 and POD2, consumed less opioids on POD1 and POD2, and had higher median KES on POD1. There was no significant difference between groups for median KES on POD2, variation of Knee Osteoarthritis Outcome Score, patient satisfaction, and length of stay. There was no difference between groups in median KES 6 weeks after surgery (52 Nm [31-89 Nm] for group ACB vs 47 Nm [30-78 Nm] for group SHAM, P= .147). Conclusions Continuous ACB provides better analgesia and KES for 24-48 hours after surgery, but does not affect KES 6 weeks after TKA. Further research could evaluate whether standardized and optimized rehabilitation over the long term would allow early KES improvements with ACB to be maintained over a period of weeks or months.

Objective: To assess changes and responsiveness in outcome measures of mobility, balance, muscle strength and manual dexterity in adults with myotonic dystrophy type 1. Design: A 9-year longitudinal study conducted with 113 patients. Methods: The responsiveness of the Timed Up and Go test, Berg Balance Scale, quantitative muscle testing, grip and pinch-grip strength, and Purdue Pegboard Test was assessed using criterion and construct approaches. Patient-reported perceived changes (worse/stable) in balance, walking, lower-limb weakness, stair-climbing and hand weakness were used as criteria. Predefined hypotheses about expected area under the receiver operating characteristic curves (criterion approach) and correlations between relative changes (construct approach) were explored. Results: The direction and magnitude of median changes in outcome measures corresponded with patient-reported changes. Median changes in the Timed Up and Go test, grip strength, pinch-grip strength and Purdue Pegboard Test did not, in general, exceed known measurement errors. Most criterion (72%) and construct (70%) approach hypotheses were supported. Promising responsiveness was found for outcome measures of mobility, balance and muscle strength. Grip strength and manual dexterity measures showed poorer responsiveness. Conclusion: The performance-based outcome measures captured changes over the 9-year period and responsiveness was promising. Knowledge of measurement errors is needed to interpret the meaning of these longitudinal changes.

Performance-based assessments of physical function are essential in people with myotonic dystrophy type 1 (DM1) to monitor disease progression and evaluate interventions. Commonly used are the six-minute walk test, the 10 m-walk test, the timed up-and-go test, the timed-stands test, grip strength tests and the nine-hole peg test. The number of trials needed on a same-day test occasion and whether the first, best or average of trials should be reported as result is unknown. Thus, the aim was to describe and explore differences between trials in these measures of walking, mobility and fine hand use in 70 adults with DM1. Three trials were performed for each test except for the six-minute walk test where two trials were allowed. There were statistical significant differences over trials in all tests except for the 10 m-walk test and grip strength tests. Pair-wise comparisons showed that the second and third trials were in general better than the first, although effect sizes were small. At which trial the individuals performed their best differed between individuals and tests. People with severe muscular impairment had difficulties to perform repeated trials. Intraclass correlation coefficients were all high in analyses exploring how to report results. The conclusion and clinical implication is that, for a same-day test occasion, one trial is sufficient for the 10 m-walk test and grip strength tests, and that repeated trials should be allowed in the timed up-and-go test, timed-stands test and nine-hole peg tests. We recommend that two trials are performed for these latter tests as such a protocol could accommodate people with various levels of impairments and physical limitations.

INTRODUCTION Myotonic dystrophy type 1 (DM1) is a multisystemic neuromuscular disease that causes balance problems. The objective of this study was to assess the construct validity of the Mini-BESTest among adults with DM1. METHODS Fifty-nine individuals with late-onset or adult phenotypes of DM1 were recruited. Participants performed the Mini-BESTest, 10-Meter Walk Test (10mWT), 6-Minute Walk Test (6MWT), and Timed Up & Go (TUG) and were questioned on their tendency to lose balance and whether they fell in the past month. RESULTS Scores on the Mini-BESTest were significantly different between phenotypes and CTG repeat numbers (P

Background : Myotonic dystrophy type 1 (DM1) is the most prevalent degenerative neuromuscular disease in adults. Knee extensor (KE) maximal strength loss is a strong indicator of physical limitations in DM1. A reliable, precise and accessible maximal strength evaluation method needs to be validated for this slowly progressive disease. Objective : This paper aims to assess the intra-rater reliability, the standard error of measurement (SEM), the minimal detectable change (MDC), and the concurrent validity of quantified muscle testing (QMT) using a handheld dynamometer with a gold standard: the Biodex isokinetic device. Methods:Nineteen men with the adult form of DM1 participated in this study by attending 2 visits spaced by one week. The evaluation of KE muscle strength with QMT was completed on the first visit and the same QMT evaluation in addition to the maximal muscle strength evaluation using an isokinetic device were performed on the second visit. Results : The intra-rater reliability was excellent with an intraclass correlation coefficient (ICC) of 0.98 (0.96–0.99 : 95% confidence interval). SEM and MDC values were 1.05 Nm and 2.92 Nm, respectively. Concurrent validity of QMT of KE muscle group with the Biodex was also excellent with a Spearman’s correlation of ρ= 0.98. Conclusions : The excellent concurrent validity and intra-rater reliability, and the small SEM and MDC of the QMT make this test a method of choice, in either a clinical or research setting, to precisely evaluate muscle strength impairments of the KE in men with DM1.

Introduction. Lower limb strength has never been characterized separately for late-onset and adult Myotonic Dystrophy Type 1 (DM1) phenotypes. Methods. The purpose was to: 1) describe and compare lower limb strength between the 2 DM1 phenotypes, and 2) compare the impairment profiles obtained from 2 assessment methods [manual (MMT) and quantitative (QMT) muscle testing], among 107 patients. Results. Both MMT and QMT showed more pronounced weakness in the adult phenotype. In the late-onset phenotype, although MMT showed normal strength, QMT revealed a loss of 11.7-20.4%. Participants with grade 1 or 2 on the Muscle Impairment Rating Scale had weakness detected using QMT, which suggests earlier muscle impairment than MMT alone would suggest. Conclusion. Physical activity recommendations should be made for the late-onset phenotype and in the early stages of the disease in the adult phenotype, in order to avoid muscle wasting. The use of MMT is not recommended in clinical trials. This article is protected by copyright. All rights reserved.

This proof of concept study tested the ability of a dual task walking protocol using a recently developed avatar-based virtual reality (VR) platform to detect differences between military personnel post mild traumatic brain injury (mTBI) and healthy controls.The VR platform coordinated motion capture, an interaction and rendering system, and a projection system to present first (participant-controlled) and third person avatars within the context of a specific military patrol scene. A divided attention task was also added. A healthy control group was compared to a group with previous mTBI (both groups comprised of six military personnel) and a repeated measures ANOVA tested for differences between conditions and groups based on recognition errors, walking speed and fluidity and obstacle clearance.The VR platform was well tolerated by both groups. Walking fluidity was degraded for the control group within the more complex navigational dual tasking involving avatars, and appeared greatest in the dual tasking with the interacting avatar. This navigational behaviour was not seen in the mTBI group.The present findings show proof of concept for using avatars, particularly more interactive avatars, to expose differences in executive functioning when applying context-specific protocols (here for the military). Implications for rehabilitation Virtual reality provides a means to control context-specific factors for assessment and intervention. Adding human interaction and agency through avatars increases the ecologic nature of the virtual environment. Avatars in the present application of the Virtual Reality avatar interaction platform appear to provide a better ability to reveal differences between trained, military personal with and without mTBI.

Report of the second Outcome Measures in Myotonic Dystrophy type 1 (OMMYD-2) international workshop San Sebastian, Spain, October 16, 2013 Cynthia Gagnon *, Giovanni Meola , Luc J. Hebert , Luc Laberge , Mario Leone , Chad Heatwole i a Groupe de Recherche Interdisciplinaire sur les Maladies Neuromusculaires (GRIMN), Centre de Sante et de Services Sociaux de Jonquiere, Jonquiere, Quebec, Canada b Faculty of Medicine and Health Sciences, Universite de Sherbrooke, Sherbrooke, Quebec, Canada c Department of Neurology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy d Faculty of Medicine, Universite Laval, Laval, Quebec, Canada e Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec, Quebec, Canada f ECOBES, Cegep de Jonquiere, Jonquiere, Quebec, Canada g Centre Hospitalier Universitaire de Chicoutimi, Chicoutimi, Quebec, Canada h Department of Health Sciences, Universite du Quebec a Chicoutimi, Chicoutimi, Quebec, Canada i Department of Neurology, The University of Rochester Medical Center, Rochester, NY, USA Received 19 December 2014

In myotonic dystrophy type 1 (DM1), leg muscle weakness is a major impairment. There are challenges to obtaining a clear portrait of muscle strength impairment. A systematic literature review was conducted on lower limb strength impairment in late-onset and adult phenotypes to document variables which affect strength measurement. Thirty-two articles were reviewed using the COSMIN guidelines. Only a third of the studies described a reproducible protocol. Only 2 muscle groups have documented reliability for quantitative muscle testing and only 1 total score for manual muscle testing. Variables affecting muscle strength impairment are not described in most studies. This review illustrates the variability in muscle strength assessment in relation to DM1 characteristics and the questionable validity of the results with regard to undocumented methodological properties. There is therefore a clear need to adopt a consensus on the use of a standardized muscle strength assessment protocol.

Introduction: Non-specific chronic low back pain (cLBP) is a significant concern for the Canadian Armed Forces (CAF). Some CAF members develop pain-related fear of movement that is difficult to treat. The goal of this pilot study was to test the feasibility of applying a virtual reality exercise program using the Computer Assisted Rehabilitation Environment (CAREN) with CAF members with cLBP and kinesiophobia. Methods: Participants were randomized into one of two treatment groups or a control group. The treatment groups received 10 CAREN sessions over 2.5 weeks (high intensity) or over 5 weeks (low intensity), and the control group received exercise instruction alone. A standard CAREN protocol using five applications was used to encourage trunk movement and stability. Results: Eleven participants were recruited. Both CAREN treatment protocols were feasible, with 100% attendance, and CAREN performance continued to improve over the 10 sessions with no plateau. CAREN participants showed stable or slightly improved scores on outcome measures from baseline to post-intervention. Participants showed no consistency on the physical performance measures, with ceiling effects or variability noted between participants. Discussion: Significant inferences regarding effectiveness cannot be made because of the low number of participants. The CAREN treatment protocol was shown to be feasible and well tolerated at these intensities. The outcome measures that show the most promise for future study include the Oswestry Disability Index, Fear of Daily Activities Questionnaire, Edgren Side Step Test, and 30-second chair stand. Future randomized controlled trials to study the effectiveness of the CAREN intervention should include military-relevant outcomes and cost efficiency.

article i nfo Background: The assessment of muscle function is a cornerstone in the management of subjects who have sustained a lateral ankle sprain. The ankle range of motion being relatively small, the use of preloading allows tomeasuremaximalstrengththroughoutthewholeamplitudeandthereforetobettercharacterizeankle muscles weaknesses. This study aimed to assess muscle strength of the injured and uninjured ankles in subjects with a lateral ankle sprain, to document the timeline of strength recovery, and to determine the influence of sprain grade on strength loss. Methods: Maximal torque of the periarticular muscles of the ankle in a concentric mode using a protocol with maximal preloading was tested in 32 male soldiers at 8 weeks and 6 months post-injury. Findings: The evertor muscles of the injured ankles were weaker than the uninjured ones at 8 weeks and 6 months post-injury (P b 0.0001, effect size = 0.31-0.42). Muscle weaknesses also persisted in the plantarflexors of the injured ankles at 8 weeks (P = 0.0014, effect size = 0.52-0.58) while at 6 months, only the subjects with a grade II sprain displayed such weaknesses (P b 0.0001, effect size 0.27-0.31). The strength of the invertor and dorsiflexor muscles did not differ between sides. Interpretation: The use of an isokinetic protocol with preloading demonstrates significant but small strength deficits in the evertor and plantarflexor muscles. These impairments may contribute to the high incidence of recurrence of lateral ankle sprain in very active individuals.

International audience; In myotonic dystrophy type 1, several studies have suggested causal relationships between CTG repeat length and the severity of symptoms, such as weakness or myotonia. We aimed to explore these relationships in a large population of 144 DM1 patients. All patients underwent clinical and functional assessments using a standardized test for grip strength and myotonia assessment. Myotonia was assessed using a fully automatic software based on mathematical modeling of relaxation force curve. CTG repeat length was statistically correlated with both myotonia and grip strength, which are two major primary neuromuscular symptoms of DM1 patients. However, these relationships are not clinically meaningful and not predictive at the individual level.

The Star Excursion Balance Test (SEBT) has frequently been used to measure motor control and residual functional deficits at different stages of recovery from lateral ankle sprain (LAS) in various populations. However, the validity of the measure used to characterize performance—the maximal reach distance (MRD) measured by visual estimation—is still unknown.Objectives:To evaluate the concurrent validity of the MRD in the SEBT estimated visually vs the MRD measured with a 3D motion-capture system and evaluate and compare the discriminant validity of 2 MRD-normalization methods (by height or by lower-limb length) in participants with or without LAS (n = 10 per group).Results:There is a high concurrent validity and a good degree of accuracy between the visual estimation measurement and the MRD gold-standard measurement for both groups and under all conditions. The Cohen d ratios between groups and MANOVA products were higher when computed from MRD data normalized by height.Conclusion:The results support the concurrent validity of visual estimation of the MRD and the use of the SEBT to evaluate motor control. Moreover, normalization of MRD data by height appears to increase the discriminant validity of this test.