The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults.

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Self-reported walking difficulty influences gait characteristics in patients with medial compartment knee osteoarthritis.

BACKGROUND: To differentiate gait strategies per knee osteoarthritis and self-reported walking difficulty during self-selected regular and fast gait speeds. We hypothesize that knee osteoarthritis gait characteristics during self-selected regular and fast gait speeds will be most accentuated by the osteoarthritis and walking difficulty group, followed by osteoarthritis and no walking difficulty, and least in the control group. METHODS: Prospective study of community-dwelling older adults (n = 39) who walk at functional speeds (≥1.0 m per second) were age and sex matched across the three groups. Gait strategies including knee excursion and moments, muscle activation and co-contraction, and limb dynamics (linear acceleration and jerk) were compared between groups during self-selected regular and fast gait speed trials. Significant group differences were defined as P < 0.05 and an effect size greater than small. FINDINGS: Based on walking difficulty, adduction moments (P-range = 0.00-0.03; effect size range,r = 0.42-0.52) and lateral quadriceps-gastrocnemius co-activations (P = 0.01;r = 0.36) were significant during regular gait speeds; and extension (P = 0.03;d = 0.59) and adduction (P-range = 0.00-0.02;d = 0.86;r = 0.40) moments were significant during fast trials. Per knee osteoarthritis presence, adduction moment(P = 0.01;r = 0.49), medial-quadriceps (P = 0.00;d = 1.04;r = 0.61), lateral-hamstrings (P = 0.04;d = 0.55), medial-gastrocnemius (P = 0.02;r = 0.40), medial quadriceps-hamstrings (P = 0.02;r = 0.38), medial quadriceps-gastrocnemius (P = 0.00;r = 0.56), and all limb dynamics (P = 0.00-0.01;d = 1.13-1.18;r = 0.35-0.47) were significant during regular gait speeds. Extension excursion (P = 0.02;d = 0.63), adduction moment (P = 0.01;d = 0.85) and medial-quadriceps (P = 0.01;r = 0.38) were significant during fast trials. INTERPRETATION: Many gait strategies during regular speeds that differ per walking difficulty and knee osteoarthritis attenuated at fast speeds. Perhaps gait training at fast speeds for those with knee osteoarthritis related walking difficulty is biomechanically and functionally beneficial.

Lessons Learned and Future Actions: Modifying a Stroke Specific Self-Management Program.

Background: Self-management programs have been shown to be effective at providing support to individuals who want to manage chronic health conditions independently. It has been shown that adapting self-management programs for different diagnostic groups, such as stroke, is essential. Objective: To report modifications made during trial implementation, the barriers identified during the delivery of an evidence based, stroke-specific self-management program and minor data (including strategies made) from a small cohort of stroke survivors with multiple chronic conditions. Methods: Prospective type III hybrid implementation-effectiveness trial for stroke survivors, with chronic conditions, living in the community, and interested in self-management. Modifications were reported by the following: (1) researcher reflections (2) barriers to implementation and (3) strategies used to address the barrier using the Consolidated Framework for Implementation Research (CFIR) guidelines from field notes. Results: Twenty-five individuals consented (42% of eligible sample) at the time of acute stroke and five were interested in continuing at the 3-month call. Multiple barriers to implementation were identified, resulting in modifications. For example, before the group sessions began, the COVID-19 pandemic necessitated changes to the intervention delivery. The protocol was modified to an online mode of delivery. In total, there were seven modifications made. Conclusions: The CFIR was a facilitative tool to report barriers and strategies and emphasized the importance of comprehensive reporting. The modifications to the study were an essential first step to address the research climate and needs of this stroke cohort. Next steps include continued research with a larger cohort to implement effective strategies and answer the clinical question of effectiveness of the adapted and modified intervention.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients.

OBJECTIVE: To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA). DESIGN: Prognosis systematic review. LITERATURE SEARCH: We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019. STUDY SELECTION CRITERIA: We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes. DATA SYNTHESIS: For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis. RESULTS: We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low. CONCLUSION: Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.

Validating Wearable Sensors Using Self-Reported Instability among Patients with Knee Osteoarthritis.

BACKGROUND: Self-perceived instability among patients with knee osteoarthritis (OA) is defined as giving way, buckling, or shifting of the knee during activities, especially walking. Although instability is a leading cause of mobility decline with knee OA, methods for quantifying the symptom, determining the mechanisms, and establishing effective interventions remain unclear. Recently, data outputs (ie, linear acceleration and its time-derivative, jerk) from wearable sensors are showing strong associations with self-perceived instability among patients with other knee pathologies and may offer insight into OA-related instability. OBJECTIVE: To examine discriminant and convergent validity of using data outputs from wearable sensors to quantify self-reported instability among patients with knee OA. DESIGN: Secondary analysis of a cross-sectional study. SETTING: Primary recruitment from an institutional outpatient physical therapy clinic and collection completed in an institutional research laboratory. PATIENTS: Thirty-nine total participants. The OA group included 26 participants with radiographic evidence of moderate to severe knee OA in the medial compartment; knee pain >3 out of 10, and a walking speed of ≥1.0 m/s. The control group included 13 participants with no history of knee OA. Participants with current or history of low back, hip, or foot/ankle injury; knee replacement; skeletal realignment surgery; or comorbidities that limit walking, pregnancy, and inability to walk without an assistive device were excluded. INTERVENTIONS: N/A MAIN OUTCOME MEASURES: Data output from wearable sensors at the tibia. RESULTS: Midstance acceleration (P = .01) and jerk (P = .04) were significantly greater for those with than without knee OA. Acceleration was significantly associated with self-reported instability (Spearman's rho = -0.63, P < .01). CONCLUSIONS: Data from wearable sensors are a valid measurement for exploring the mechanisms and risks of instability among patients with knee OA.

Impact of Diabetes on 90-Day Episodes of Care After Elective Total Joint Arthroplasty Among Medicare Beneficiaries.

BACKGROUND: In an effort to improve quality and reduce costs, reimbursement for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in the United States is being based on the value of care provided, with adjustments for some qualifying comorbidities, including diabetes in its most severe form and excluding many diabetes codes. The aims of this study were to examine the effects of diabetes on elective TKA or THA complications and readmission risks among Medicare beneficiaries. METHODS: Complication (n = 521,230) and readmission (n = 515,691) data were extracted from Medicare files in 2013 and 2014. Diabetes status (no diabetes, controlled-uncomplicated diabetes, controlled-complicated diabetes, and uncontrolled diabetes) was identified with ICD-9 (International Classification of Diseases, 9th Revision) codes. TKA or THA complications and readmission odds based on diabetes status were estimated using logistic regression and adjusted for sociodemographic and clinical characteristics, including comorbidities. RESULTS: Compared with no diabetes, the odds ratio (OR) of TKA complications was significantly higher for uncontrolled diabetes (1.29, 95% confidence interval [CI] = 1.06 to 1.57). The OR of THA complications was significantly higher for controlled-complicated diabetes (1.45, 95% CI = 1.17 to 1.80). The OR of readmission was significantly higher for all diabetes groups (1.21 to 1.48 for TKA, 1.20 to 1.70 for THA). CONCLUSIONS: Readmission odds were higher in all diabetes categories. The uncontrolled-diabetes group had the greatest TKA readmission and complication odds. The controlled-complicated diabetes group had the greatest THA readmission and complication odds. The findings suggest that including diabetes and associated systemic complications in cost adjustments in alternative payment models for arthroplasty should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Considerations for Return to Driving a Car following a Total Knee or Hip Arthroplasty: A Systematic Review.

AIM: The purpose of this study is to systematically review patient characteristics and clinical determinants that may influence return to driving status and time frames following a primary TKA or THA and provide an update of the current literature. METHODS: This review was completed per the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Final electronic database searches were completed in October 2019 in Medline/PubMed, Medline/OVID, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library using preselected search terms. Manuscripts of prospective and nonrandomized studies that examined the return to driving a car after a primary knee or hip arthroplasty patients were included. The Methodological Index for Non-Randomized Studies was used to measure study quality. Two authors selected studies and assessed their qualities. All disagreements were resolved through discussion and, as needed, a third reviewer. Data on study title, author(s), country, year, study design, sample size, inclusion and exclusion criteria, age, BMI, gender, statistical analyses, driving measure, follow-up time, surgical approach, laterality, and postoperative management were extracted from each study. RESULTS: A total of 23 studies were eligible, including 12 TKA studies (n = 654) with mean ages between 43 and 82 years, 9 THA studies (n = 922) with mean ages between 34 and 85 years, and 2 combined TKA and THA (TKA, n = 815; THA, n = 685), yielded MINORS scores between 6 and 12. Most patients achieved or exceeded preoperative response times between 1 and 8 weeks following a TKA and 2 days to 8 weeks following a THA, and/or self-reported return to driving between 1 week and 6 months. Influences on return to driving time included laterality and pain, but gender was mixed. Discussion/. CONCLUSIONS: Study results were consistent with previous systematic reviews in that return to driving a car after a primary TKA or THA is highly variable, and most commonly occurs around 4 weeks, but can range between 2 and 8 weeks. While various patient and clinical factors can influence return to driving for a TKA or THA, the most common contributing facts were pain and laterality. The heterogeneous nature of the studies prevented a meta-analysis for determining contributions of return to driving following a primary TKA or THA. Regardless, this study updates previous systematic reviews and presents insight on patient and clinical factors beyond generalized timeframes for return to driving a car. This information and results from future studies are essential to guide clinical recommendations and patient and clinician expectations for return to driving a car after a primary TKA or THA.

Clinical Characteristics of Patients with Type 2 Diabetes Mellitus Receiving a Primary Total Knee or Hip Arthroplasty.

AIM: The purpose of this study is to explore clinical characteristics of patients with T2DM receiving a primary knee (TKA) or hip (THA) arthroplasty to patients without T2DM receiving a TKA or THA and patients with T2DM with no history of osteoarthritis (OA). METHODS: The study included a retrospective database review of 500 consecutive primary TKA or THA identified with ICD-9 codes and 100 consecutive T2DM patients. Patients who received a TKA or THA were screened for inclusion and exclusion and divided into with or without T2DM groups. A comparison group of patients with T2DM only without arthroplasty was screened to exclude patients with a history of OA or arthroplasty. All groups were compared based on demographic and relevant comorbidity differences. OA characteristics, including OA and previous arthroplasty of the involved and contralateral joints, were compared between patients with and without T2DM receiving a TKA or THA. Finally, patients with T2DM with and without TKA or THA were compared for T2DM differences. RESULTS: Study results found that among those receiving a primary arthroplasty, patients with T2DM were more likely to be obese and older and reported cardiovascular, urinary, dyslipidemia, and peripheral neuropathy than those with T2DM. Among the T2DM individuals, those receiving an arthroplasty surgery were older and obese and more likely to report peripheral neuropathy; however, those with T2DM with no OA were more likely to report atherosclerosis and cardiovascular disease. Within the arthroplasty subgroup of individuals with T2DM, those requiring antidiabetic medication were 4.5 times more likely to have contralateral OA or arthroplasty. CONCLUSIONS: The results of this study suggest that patients with T2DM requiring a primary arthroplasty are a unique subgroup that requires careful considerations as they are often older, have obesity, and specific comorbidities predisposing to worse postoperative outcomes than their non-T2DM arthroplasty counterparts. Therefore, clinical practice and future studies must consider strategies that would limit OA and arthroplasty management delays while accounting for comorbidities and patient characteristics.

Self-reported walking difficulty and knee osteoarthritis influences limb dynamics and muscle co-contraction during gait.

Knee osteoarthritis (OA) gait is characterized by simultaneous flexor and extensor use, or co-contraction. Co-contraction can stabilize and redirect joint forces. However, co-contraction can push and pull on the femur and tibia that exacerbate OA symptoms and make walking difficult. Such movements are quantifiable by limb dynamics (i.e., linear acceleration and jerk); thus, this study examines limb dynamics and its relationship with co-contraction and OA related walking difficulty. Three groups of age-and-sex-matched subjects with and without OA and walking difficulty (N = 13 per group) walked with electromyography (EMG) on the knee extensors and flexors and inertial measurement units (IMUs) at the femur and tibia. We calculated co-contraction from antagonistic EMG signals and linear acceleration and its derivative jerk from IMUs. We determined group differences using one-way ANOVAs, nonparametric equivalence, and effect sizes, and main and interaction effects of walking difficulty with regression modeling. Medium effect sizes and differences for femoral acceleration (d = 0.64; P = .02) and jerk (d = 0.51; P = .01) were observed between with and without knee OA. Medium to large effect sizes (r = 0.33 to 0.51 and d = 0.81 to 0.97) and differences (P = .01 to 0.05) for tibial acceleration and jerk were obsevered between with and without walking difficulty. Walking difficulty moderated the relationship between tibial jerk and co-contraction (p < .05). Tibial jerk differences were observed based on walking difficulty. The significant interaction effect suggested that walking difficulty explained the relationship between limb dynamics and co-contraction. Perhaps co-contraction levels used by those with knee OA and no walking difficulty are optimal as compared to those with walking difficulty.

Influences of knee osteoarthritis and walking difficulty on knee kinematics and kinetics.

BACKGROUND: Self-reported walking difficulty is a problem among patients with knee osteoarthritis (OA), however, these patients have never been studied as a subgroup population. OBJECTIVE: The purpose of this study is to examine known knee OA gait mechanics among those with knee OA, with (Diff) and without (NoDiff) self-reported walking difficulty, as compared to age- and sex-matched controls without knee OA. METHODS: A total of 39 subjects in three groups of 13 individuals walked at a controlled gait speed during instrumented gait analysis. Gait mechanics were compared between a priori determined groups using the independent t-test. RESULTS: The results of the study found that among those with knee OA, knee excursion angles were not significantly different between the Diff and NoDiff groups. Whereas, external knee moments were significantly different between the Diff and NoDiff groups but not between the NoDiff and the control groups. The lack of difference between the NoDiff and control groups were especially interesting because of the moderate to severe OA in the NoDiff group. Therefore, the findings of this study suggest the importance of considering self-reported walking difficulty among those with knee OA. Perhaps patients with knee OA-related walking difficulties use alternative gait parameters that may need to be clinically addressed. Strengths of the study included a matched design and controlled walking speed, whereas limitations were the small sample size and cross-sectional design. CONCLUSIONS: Given the relationships found among self-reported walking difficulty, OA presence, and gait parameters, addressing gait parameters specifically related to walking difficulty may be indicated in this sub-group knee OA population.