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Objectives: The 4-m gait speed (4mGS) and 10-m gait speed (10mGS) tests and the 30-second sit-to-stand (30sSTS) and 5-times sit-to-stand (5xSTS) tests are commonly used and advocated in consensus recommendations. We compared these tests on their predictive and clinical value concerning the risk of prefrailty/frailty and restricted life-space mobility (RLSM)., Design: Cross-sectional study., Setting and Participants: A sample of 1235 community-dwelling adults (mean ± SD, 68 ± 7 years) participated in this prospective cohort study., Methods: At baseline assessment, participants completed a survey and functional assessment, from which gait speed, sit-to-stand performance, self-reported mobility limitation, 40-item Frailty Index, and Life Space Assessment were measured. Participants with a 40-item Frailty Index >0.15 and a Life Space Assessment <60 points were classified as having prefrailty/frailty and RLSM, respectively. At 1-year follow-up assessment, prefrailty/frailty and RLSM were evaluated., Results: Correlations between gait speed and sit-to-stand measures were high (ρ values >0.80). In multivariable ordinal models, these measures added incremental prognostic value beyond a base model comprising demographics and self-reported mobility limitation variables in predicting baseline and 1-year outcomes. Between 10mGS and 4mGS, models with 10mGS had higher concordance indices (differences, 0.005-0.009), and these differences translated to generally greater net benefit in decision curve analyses. Between 30sSTS and 5xSTS measures, no one measure consistently outperformed the other, with small net benefit differences between measures (<0.2%)., Conclusions and Implications: In community-dwelling older adults, gait speed and sit-to-stand measures meaningfully predicted prefrailty/frailty and RLSM. 10mGS provided more robust prognostic information than the 4mGS, whereas 5xSTS and 30sSTS measures showed near equivalence of performance. These findings could guide the choice of functional measures in clinical and research settings., Competing Interests: Disclosure Y.-H. Pua and R. A. Clark are involved in a provisional patent application for a gait speed assessment device. This device is not used in this study. The other authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Aims: Limited knee range-of-motion (ROM) is common following total knee arthroplasty (TKA). It is associated with functional limitations and patient dissatisfaction. Regular knee ROM assessment is important but accurate testing traditionally requires timely access to trained healthcare professionals. Although accelerometer-based smartphone goniometry has shown to provide reliable and valid joint angles, current evidence of its use still positions healthcare providers as end users instead of patients themselves. Therefore, to maximize the impact of smartphone goniometry on post-TKA care, our study aimed to examine the feasibility, reliability, and validity of patients' self-measurement of knee ROM using an accelerometer-based smartphone goniometry application., Methods: Patients were given standard instructions with a practice trial before the actual measurements. Passive knee flexion and extension ROM was measured on 2 sessions in 30 patients with TKA using 4 block-randomized methods: (i) smartphone self-assessment, (ii) long-arm goniometry by physiotherapist, (iii) smartphone assessment by physiotherapist, and (iv) extendable-arm goniometry by physiotherapist with placement adjudication. Feasibility was assessed by the number of participants who could independently perform the self-measurement. To assess intra- and inter-session reliability, we computed intraclass correlation coefficients (ICCs) from random-effects models. To assess intra- and inter-session agreement, we computed mean absolute differences (MADs) and minimum detectable change (MDC). To assess concurrent validity, we designated extendable-arm goniometry as the "gold standard" and compared other methods against it using ICCs and MADs., Results: All patients were able to comprehend and execute the assessment. 87% (n = 26) found the application easy to administer. Smartphone goniometry by patients showed excellent intra- and inter-session reliability (ICCs>0.97) and minimum variability (MAD = 0.9°-3.9°; MDC95 = 3.1°-9.0°). Smartphone or long-arm goniometry by physiotherapists did not outperform patients' self-assessment (ICC = 0.96-0.99, MAD = 0.7°-3.1°; MDC95 = 2.2°-8.0°). Compared against extendable-arm goniometry, smartphone goniometry by patients measured knee flexion and extension ROM with a MAD of 4.5° (ICC, 0.97) and 2.2° (ICC = 0.98), respectively., Conclusion: Our study demonstrates that smartphone goniometry is feasible, reliable and accurate, and can be used with confidence in the self-assessment of knee ROM post-TKA. Future studies should further explore its utility in telemonitored rehabilitation, and its possible integration into mobile health applications to enhance accessibility to care following TKA., Competing Interests: This manuscript has not been published and is not under consideration for publication elsewhere. All authors reviewed the results and approved the final version of the manuscript. The authors have declared that no competing interests exist., (Copyright: © 2024 Chew et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To determine, in patients undergoing total knee arthroplasty (TKA), whether increasing context specificity of selected items of the shortened version of the Western Ontario and McMaster Universities Osteoarthritis Index function (WOMAC-F) scale (ShortMAC-F) (1) enhanced the convergent validity of the ShortMAC-F with performance-based mobility measures (ii) affected mean scale score, structural validity, reliability, and interpretability., Design: Secondary analysis of randomized clinical trial data., Setting: A tertiary teaching hospital., Participants: Patients undergoing TKA (N=114)., Interventions: Not applicable., Main Outcome Measures: The ShortMAC-F was modified by specifying the "ascending stairs" and "rising from sitting" items to enquire about difficulty in performing the tasks without reliance on compensatory strategies, whereas the modified "level walking" item enquired about difficulty in walking 400 m. Before and 12 weeks after TKA, patients completed the WOMAC-F questionnaire, modified ShortMAC-F questionnaire, knee pain scale questionnaire, sit-to-stand test, fast gait speed test, and stair climb test. Interpretability was evaluated by calculating anchor-based substantial clinical benefit estimates., Results: The modified ShortMAC-F correlated significantly more strongly than ShortMAC-F or WOMAC-F with pooled performance measures (differences in correlation values, 0.12-0.14). Increasing item context specificity of the ShortMAC-F did not influence its psychometric properties of unidimensionality (comparative fit and Tucker-Lewis indices, >0.95; root mean square error of approximation, 0.05-0.08), reliability (Cronbach's α, 0.75-0.83), correlation with pain intensity (correlation values, 0.48-0.52), and substantial clinical benefit estimates (16 percentage points); however, it resulted in lower mean score (4.5-4.8 points lower)., Conclusions: The modified ShortMAC-F showed sufficient measurement properties for clinical application, and it seemed more adept than WOMAC-F at correlating with performance-based measures in TKA., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA)., Design: In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points)., Results: In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs., Conclusions: In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup., (Copyright © 2023 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Although self-reported measures of physical disability are strong indication criterion for total knee arthroplasty (TKA) in painful knee osteoarthritis (OA), some patients may report greater-than-observed disability. Contributing factors to this discordance are relatively unexplored. We aimed to examine whether pain and negative affect, including anxiety and depression, were associated with the discordance of self-reported measures with performance-based measures (PPM) of physical function., Methods: We used cross-sectional data (n = 212) from two randomized rehabilitation trials in knee OA. All patients were assessed for knee pain intensity and symptoms of anxiety and depression. Self-reported function was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical-function subscale. Objective performance-based measures (PPMs) of physical function were assessed by timed gait and stair tests. Continuous discordance scores were quantified by the difference in percentiles between WOMAC and PPMs (WOMAC-PPM), where a positive discordance, WOMAC-PPM >0, implied greater perceived than observed disability., Results: Around 1 in 4 patients had >20 percentile units in WOMAC-PPM discordance. In Bayesian regression analyses, knee pain intensity had >99% posterior probability of positive associations with WOMAC-PPM discordance. Among patients awaiting TKA, anxiety intensity had approximately 99% probability of positive associations with discordance, and these associations had >65% probability of exceeding 10 percentile units. In contrast, depression had low (79% to 88%) probability of any association with discordance., Conclusion: In patients who have knee OA, a sizable proportion reported substantially greater physical disability than actually observed. Pain and anxiety intensity, but not depression, were meaningful predictors of this discordance. If validated, our findings may help in refining patient selection criteria for TKA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: After a total knee arthroplasty, physical assessments of quadriceps strength and gait speed performance are often undertaken during rehabilitation. Our study aimed to improve their clinical interpretability by examining trajectory curves across levels of self-reported walking and stair climbing function., Design: A sample of 2624 patients with primary total knee arthroplasty participated in this retrospective longitudinal study. Monthly, for 4 mos after surgery, quadriceps strength and gait speed were quantified. At the month-6 time point, self-reported walking and stair climbing function was measured., Results: All physical measures improved nonlinearly over time. In mixed-effects models, greater quadriceps strength and gait speed over time were associated with higher month-6 self-reported walking and stair climbing function ( P < 0.001). Steeper gains in quadriceps strength and gait speed were associated with higher levels of walking and stair-climbing function (interaction P < 0.001). Among female patients who had great difficulty with stair ascent and ambulation, quadriceps strength trajectory curves plateaued after 8 wks after total knee arthroplasty., Conclusions: By stratifying trajectory curves across clinically interpretable functional levels, our findings potentially provide patients and clinicians a means to better interpret the continuous-scaled quadriceps strength and gait speed values. This information may be valuable when engaging patients in shared decision making and expectation setting., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Understand how self-reported walking and stair climbing abilities improved from baseline before total knee arthroplasty (total knee arthroplasty) to 6 mos postoperatively; (2) Describe the time course of the 2 performance-based measures of quadriceps strength and walking speed after a total knee arthroplasty; and (3) Relate the trajectories of post-total knee arthroplasty quadriceps strength and walking speed measurements across distinct levels of self-reported walking and stair climbing function., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article, (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The association of the modified STarT Back Tool (mSBT) psychosocial measure with gait speed and knee pain in knee osteoarthritis is not well defined. This study aimed to, in patients with knee osteoarthritis, (i) examine the convergent validity of mSBT with the Hospital Anxiety and Depression Scale (HADS) and (ii) compare the predictive validity of mSBT and HADS with gait speed and knee pain., Methods: We performed a retrospective cohort analysis of mSBT, HADS, gait speed, and knee pain outcomes data collected from 119 patients who received outpatient physical therapy. Of these patients who were evaluated at their first (baseline) physical therapy visit, 55 had available data at the Week-16 follow-up visit., Results: mSBT and HADS showed moderately strong pairwise correlations (Spearman correlation > 0.57; p  < 0.001). After adjusting for age, sex, body weight, and knee impairment variables in multivariable linear mixed-effects analyses, mSBT was associated with gait speed ( p  < 0.001) and knee pain intensity ( p  < 0.001) and it had comparable strength of association as HADS. In within-patient regression analyses, change in mSBT was associated with changes in gait speed ( p  = 0.04) and knee pain ( p  = 0.01) over 16 weeks., Conclusion: The mSBT had convergent validity with HADS and it showed predictive validity with gait speed and knee pain in knee osteoarthritis. Although broader validation is required, the 5-item mSBT psychosocial measure may be applied as part of routine clinical care to assess psychological distress in patients with knee osteoarthritis.IMPLICATIONS FOR REHABILITATIONThe 5-item psychosocial subscale of the modified STarT Back tool (mSBT) showed good convergent validity with the 14-item Hospital Anxiety and Depression Scale in patients with knee osteoarthritis.The mSBT psychosocial subscale showed predictive validity, at both cross-sectional and longitudinal levels, with gait speed and knee pain in patients with knee osteoarthritis.The mSBT can potentially be used in the busy clinical setting to assess psychological distress in patients with knee osteoarthritis.

Objective: After total knee arthroplasty, the ability to weight bear symmetrically during the sit-to-stand task provides important information regarding altered movement patterns. Despite this, comprehensive recovery curves and validity data for sit-to-stand weight-bearing symmetry are lacking in the total knee arthroplasty population. Our study aimed to (1) develop recovery curves with reference ranges, (2) identify the correlates of standard and constrained sit-to-stand weight-bearing symmetry, and (3) evaluate their predictive validity with gait speed., Design: We performed a retrospective longitudinal study of 706 patients with primary unilateral total knee arthroplasty. Monthly, for 4 mos after surgery, sit-to-stand weight-bearing symmetry, knee pain, knee range of motion, quadriceps strength, and gait speed were quantified., Results: Standard and constrained sit-to-stand weight-bearing symmetry measures improved nonlinearly over time. Standard sit-to-stand weight-bearing symmetry was most strongly associated with bilateral quadriceps strength, whereas constrained sit-to-stand weight-bearing symmetry was most strongly associated with ipsilateral quadriceps strength. Knee range of motion and contralateral knee pain were additional correlates. Both standard sit-to-stand and constrained sit-to-stand weight-bearing symmetry were independently and nonlinearly associated with gait speed in multivariable models., Conclusions: Our study provided recovery curves and validity data to support routine clinical measurement of sit-to-stand weight-bearing symmetry in total knee arthroplasty. Our results also indicate that constrained sit-to-stand may promote greater use of the operated limb than standard sit-to-stand., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Regular quadriceps strength assessment is important following anterior cruciate ligament reconstruction (ACLR). The one-leg sit-to-stand (OLSTS) test potentially overcomes the barrier of accessibility to specialised testing equipment. However, feasibility and validity testing of OLSTS is lacking in the ACLR population. This study aims to examine the feasibility, correlates, and predictive validity of OLSTS with self-reported running and jumping difficulty in individuals post-ACLR., Design: Retrospective longitudinal study., Methods: 20 patients with primary unilateral ACLR were tested at 6-months and 1-year post-ACLR. Feasibility was assessed by the number of patients who had safely performed OLSTS at both timepoints. Cross-sectional gender-adjusted Spearman correlations of OLSTS with quadriceps strength, physical impairments, and psychological variables were measured at 6-months. Predictive validity was assessed via ordinal regression, quantifying the associations of OLSTS with self-reported running and jumping difficulty across time-points., Results: All patients understood the instructions to and were able to self-administer the OLSTS test safely. OLSTS is a valid measure of quadriceps strength (gender-adjusted Spearman's ρ = 0.53, P = 0.02). Knee pain (ρ = 0.44, P = 0.046) and readiness to return-to-sport (ρ = 0.55, P = 0.02) were additional correlates. Greater OLSTS performance was associated with greater odds of better self-reported running and jumping function (interquartile-range ORs, 12.0 [95% CI: 3.6-45] and 18.5 [95% CI: 5-67], respectively)., Conclusion: OLSTS is a feasible and valid test of quadriceps strength, demonstrating predictive validity with self-reported running and jumping post-ACLR. OLSTS potentially allows independent tracking of ACLR rehabilitation progress at home - an increasingly urgent necessity in the face of a global pandemic., Competing Interests: Declaration of competing interest No competing interests have been declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: To examine knee flexion range-of-motion, quadriceps strength, and knee self-efficacy trajectory curves over 6 months after anterior cruciate ligament reconstruction (ACLR), stratified by patients' Month-6 sports activity level., Design: Prospective longitudinal study., Setting: Hospital outpatient physiotherapy department., Participants: 595 individuals after unilateral ACLR (mean age, 27 years)., Main Outcome Measures: At 2-, 3-, and 6-months post-surgery, knee flexion range-of-motion, quadriceps strength, and self-efficacy were quantified. Flexion range-of-motion was additionally measured at 2- and 4-weeks post-surgery. Sports activity levels were assessed using the Tegner Activity Score at 6-months post ACLR., Results: The various measures improved nonlinearly over time, with substantial improvements observed in the first 2-4 months post-surgery. In multivariable generalized least squares models, greater knee flexion range-of-motion, quadriceps strength, and self-efficacy over time were significantly associated with higher Month-6 Tegner levels (all P values < 0.01). Additionally, receiving a bone-patellar-tendon-bone graft or meniscal repair was associated with lower quadriceps strength trajectories (P-values<0.001) while female sex was associated with lower knee self-efficacy trajectories (P = 0.02)., Conclusions: Greater knee flexion range-of-motion, quadriceps strength, and self-efficacy were associated with higher Month-6 Tegner levels. The derived trajectory curves may be useful for effective management decision making and adequate results interpretation during the rehabilitation process., Competing Interests: Declaration of competing interest No competing interests have been declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The goal of valgus knee brace treatment is to reduce medial knee joint loading during walking, often indicated by external knee adduction moment (KAM) measures. However, existing healthy-subjects studies have been equivocal in demonstrating KAM reduction with valgus knee bracing., Research Question: What are the immediate effects of valgus bracing at different tension levels on KAM during walking at a controlled speed and does body height modify the brace-KAM associations?, Methods: Data from 32 knee-healthy participants were analysed in this randomized crossover trial. Participants performed walking trials at controlled speed (1.3 ± 0.065 m/s) both with and without an Ossür Unloader One® brace. During the bracing condition, valgus tension was incrementally increased, from zero tension to normal tension and to maximum tolerable tension., Results: Valgus bracing minimally increased knee flexion at heel-strike (P < 0.001) in a dose-dependent manner and minimally reduced gait velocity (∼0.015m/s) across all tension levels. Valgus bracing, overall, did not significantly reduce the various KAM measures. However, brace use at maximal tension was associated with a 0.04Nm/kg (9.2 %) increase in first peak KAM amongst participants with a body height of 1.75 m and a 0.03Nm/kg (7.6 %) decrease in first peak KAM amongst participants with a body height of 1.55 m., Significance: Valgus bracing did not reduce the various KAM measures during walking; however, body height may play a moderating role. Given knee brace sizes vary more in circumference than length, this result may be due to the ratio between effective moment arm length relative to limb length. A deeper understanding of the potential neuro-biomechanical effects of valgus knee bracing and how these effects are potentially modified by body height may be critical to the design of effective knee braces., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Previous studies have reported good test-retest reliability for peak knee adduction moment (KAM) during walking. However, reliability of other KAM measurements has not been established., Research Question: What is the test-retest reliability of peak KAM, KAM impulse, and KAM loading rate measurements during walking in knee-healthy individuals?, Methods: Data from 32 knee-healthy participants were analysed in this test-retest reliability study. Various KAM measurements were reported for two sessions with kinematic and kinetic data obtained from a motion capture system synchronised with force plates, with a median of 1 week between sessions., Results: For all KAM measures, intra-class correlation coefficients were above 0.90 and their lower bound 95 % confidence limits exceeded 0.81. However, absolute measurement variability differed across measures, with normalized SEM (8 %-15 %), normalized MDC 95 (20 %-40 %), intra-session MAD (10 %-18 %), and inter-session MAD (12 %-22 %) varying over a 2-fold range. Overall and first peak KAM, KAM impulse over 50 % stance, and KAM loading rate (15 frame window) showed ≤10 % and ≤15 % intra- and inter-session MAD, respectively., Significance: This study provided previously undefined test-retest reliability estimates for various KAM measures during walking. Researchers and clinicians should not assume that the various aspects of the KAM curve share similar reliability., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)