Publications by authors named "Clair Smith"

23 Publications

  • Page 1 of 1

Responsiveness of Outcome Measures in Non-Surgical Patients with Lumbar Spinal Stenosis: A Secondary Analysis from a Randomized Controlled Trial.

Spine (Phila Pa 1976) 2020 Dec 30. Epub 2020 Dec 30.

aDepartment of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15203, USA bDC, PhD. Institute for Health Policy, Management and Evolution, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada.

Study Design: Secondary analysis from a randomized clinical trial on non-surgical interventions for patients with lumbar spinal stenosis (LSS).

Objective: To assess responsiveness of the Self-Paced Walking Test (SPWT), Swiss Spinal Stenosis Questionnaire (SSS) and Oswestry Disability Index (ODI) and determine their Minimal Clinically Important Differences (MCID) in non-surgical LSS patients.

Summary Of Background Data: Limited information is available about responsiveness of these tests in non-surgical LSS population.

Methods: A total of 180 participants completed the SPWT, SSS and ODI at baseline, 2 and 6 months. Responsiveness was assessed by distribution-based method, including effect size and standardized response mean, and anchor-based method, using the patient global index of change (PGIC) as the external anchor to distinguish responders and non-responders. Areas under the curve (AUC) were calculated along with MCIDs for "minimal" and "moderate improvement" subgroups.

Results: The following values represent 2- and 6-month analyses of each outcome measure, respectively. Standard effect sizes: 0.48 and 0.50 for SPWT, -0.42 and -0.36 for SSS, -0.29 and -0.25 for ODI. Spearman's correlation coefficients between PGIC and outcomes: 0.44 and 0.39 for SPWT, -0.53 and -0.55 for SSS, -0.46 and -0.54 for ODI. MCIDs for the "minimal improvement" subgroup: 375.9 and 319.3 meters for SPWT, -5.3 and -5.8 points for SSS, -9.3 and -10.8 points for ODI. AUCs: 0.68 to 0.76. MCIDs for the "moderate improvement" subgroup: 344.2 and 538.2 meters for SPWT, -5.5 and -7.5 points for SSS, -9.1 and -13.6 points for ODI. AUCs ranged from 0.68 to 0.76.

Conclusions: The SPWT, SSS and ODI are responsive outcome measures to assess non-surgical patients with LSS. This finding, along with the reported MCIDs, can help clinicians to monitor changes in their patients' walking and physical function over time and make clinical decisions. They also provide researchers with reference for future studies in LSS.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003920DOI Listing
December 2020

External fixation increases complications following surgical treatment of multiple ligament knee injuries.

Knee Surg Sports Traumatol Arthrosc 2021 Feb 27. Epub 2021 Feb 27.

Department of Physical Therapy, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA, 15219, USA.

Purpose: The purpose of this study was to review post-operative complications after surgical intervention of MLKIs within the first 6 months to be better able to counsel patients before surgical intervention.

Methods: All patients who underwent surgical reconstruction for a MLKI at one institution from 2009 to 2018 were included in this study. A retrospective review was performed of all patients and post-operative complications were recorded, including motion loss (which included > 10 degree flexion loss or > 3 degree extension loss), hematoma formation, infection, iatrogenic vascular or nerve injury, deep vein thrombosis (DVT), pulmonary embolism (PE), skin lesions, symptomatic hardware, recurrent ligamentous laxity, and need for additional surgery. Knee ligament injuries were classified based on the Schenck Knee Dislocation (KD) Classification.

Results: A total of 136 patients were included in this study, 83 with KD I injuries, 40 with KD III injuries, 9 with KD IV injuries, and 4 with KD V injuries. Of these total patients, 48 (35.5%) sustained a post-operative complication: 11 out of 133 (8.3%) from 0 to 1 week, 46 out of 132 (34.8%) from 1 week to 1 month, 28 out of 124 (22.6%) from 1 to 3 months, and 26 out of 121 (21.5%) from 3 to 6 months. Out of the total complications, 99 (78.5%) occurred at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common complication was motion loss in 39 (28.6%) patients. There was a significant difference in mean number of complications between the KD I and KD III groups, as well as the KD III and KD IV-V groups. There was no significant difference in the overall prevalence of post-operative complications or occurrence of motion loss with KD grade.

Conclusion: The main finding of this study was 48 (35.5%) patients sustained a complication after surgical treatment of MLKIs, with 99 (78.5% of all complications) complications occurring at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common post-operative complication was motion loss in 39 (28.6%) patients. The KD grade was not associated with post-operative development of motion loss, but KD III had a significantly greater mean number of complications than KD I or KD IV-V grades.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06508-9DOI Listing
February 2021

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.

JAMA Netw Open 2021 02 1;4(2):e2037371. Epub 2021 Feb 1.

Department of Family Medicine, Boston Medical Center, Boston, Massachusetts.

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

Design, Setting, And Participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

Main Outcomes And Measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

Conclusions And Relevance: In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.37371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887659PMC
February 2021

Risk Factors, Screening, and Treatment Challenges in Native Septic Arthritis.

Open Forum Infect Dis 2021 Jan 18;8(1):ofaa593. Epub 2020 Dec 18.

Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for native septic arthritis and to evaluate MRSA screening in this disease.

Methods: A retrospective cohort study of native septic arthritis patients (2012-2016) was performed. Demographics, risk factors, and outcomes were compared between and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed.

Results: Two hundred fifteen cases of native septic arthritis were included. s was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74-10.81; = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01-21.38; = .032). For every 10-year increase in age, the odds of decreased (OR, 0.72; 95% CI, 0.60-0.87; = .001). For 1-unit increases in Charlson comorbidity index score, the odds of decreased (OR, 0.82; 95% CI, 0.73-0.91; = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis.

Conclusions: The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.
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http://dx.doi.org/10.1093/ofid/ofaa593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813160PMC
January 2021

A Portable System for Remote Rehabilitation Following a Total Knee Replacement: A Pilot Randomized Controlled Clinical Study.

Sensors (Basel) 2020 Oct 27;20(21). Epub 2020 Oct 27.

Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.

Rehabilitation has been shown to improve functional outcomes following total knee replacement (TKR). However, its delivery and associated costs are highly variable. The authors have developed and previously validated the accuracy of a remote (wearable) rehabilitation monitoring platform (). The present study's objective was to assess the feasibility of utilizing for the remote management of rehabilitation after TKR and to determine a preliminary estimate of the effects of the system on the value of rehabilitation. Specifically, we tested post-operative outpatient rehabilitation supplemented with (n = 13) by comparing it to a standard post-operative outpatient rehabilitation program (n = 12) using a randomized design. Attrition rates were relatively low and not significantly different between groups, indicating that participants found both interventions acceptable. A small (not statistically significant) decrease in the number of physical therapy visits was observed in the Group, therefore no significant difference in total cost could be observed. All patients and physical therapists in the Group indicated that they would use the system again in the future. Therefore, the next steps are to address the concerns identified in this pilot study and to expand the platform to include behavioral change strategies prior to conducting a full-scale randomized controlled trial. Trial registration: ClinicalTrials.gov NCT02646761 ": A Portable Joint Function Monitoring and Training System for Remote Rehabilitation Following TKA" 6 January 2016.
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http://dx.doi.org/10.3390/s20216118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663639PMC
October 2020

Comparison of Asymptomatic and Symptomatic Adverse Local Tissue Reaction in Patients With Head-Neck Taper Corrosion.

J Arthroplasty 2020 Sep 17. Epub 2020 Sep 17.

The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA; Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh; Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA.

Background: Diagnosis of adverse local tissue reaction (ALTR) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) secondary to head-neck taper corrosion is challenging. The purpose of this study is to compare differences between asymptomatic and symptomatic ALTR in an observational cohort, including presentation, metal ion differences, and metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) findings.

Methods: We performed a retrospective review of an observational cohort of 492 MoP THA patients at increased risk of developing ALTR. Ninety-four patients underwent revision arthroplasty for ALTR. Patients were stratified into symptomatic and asymptomatic ALTR groups. Presentation, metal ion levels, and imaging findings were compared.

Results: For patients with confirmed ALTR, 41% were asymptomatic. There was a statistically significant difference in the serum chromium levels between symptomatic and asymptomatic ALTR patients (2.2 μg/L vs 3.1 μg/L, P = .05). There was no statistically significant difference between the serum cobalt levels or MRI findings in these 2 groups. We observed that extracapsular disease associated with ALTR could be misinterpreted as trochanteric bursitis.

Conclusion: Almost half of the MoP THA ALTR cases identified were asymptomatic. Cobalt levels could not differentiate between symptomatic and asymptomatic pseudotumor formation. Symptomatic and asymptomatic MoP ALTRs have similar MARS MRI characteristics. Our findings suggest that it is essential to risk stratify patients who could potentially have ALTR based on implant type, symptoms, ion levels, and MARS MRI.
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http://dx.doi.org/10.1016/j.arth.2020.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7965776PMC
September 2020

Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts.

Orthop J Sports Med 2020 Jul 7;8(7):2325967120926159. Epub 2020 Jul 7.

Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR).

Purpose/hypothesis: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs.

Study Design: Cohort study; Level of evidence, 2.

Methods: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS).

Results: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 ± 1.3 m/s; side-to-side difference in anterior tibial translation, -0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC ( = .0001), from 28.8 to 32.4 points for the CKRS ( = .04), from 11.2 to 7.9 points for the Marx ( < .0001), and from 75.7 to 91.6 points for the ADLS ( < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up.

Conclusion: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.
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http://dx.doi.org/10.1177/2325967120926159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343370PMC
July 2020

Assessing the biofidelity of in vitro biomechanical testing of the human cervical spine.

J Orthop Res 2020 Apr 25. Epub 2020 Apr 25.

Ferguson Lab for Orthopaedic Research, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

In vitro biomechanical studies of the osteoligamentous spine are widely used to characterize normal biomechanics, identify injury mechanisms, and assess the effects of degeneration and surgical instrumentation on spine mechanics. The objective of this study was to determine how well four standards in vitro loading paradigms replicate in vivo kinematics with regards to the instantaneous center of rotation and arthrokinematics in relation to disc deformation. In vivo data were previously collected from 20 asymptomatic participants (45.5 ± 5.8 years) who performed full range of motion neck flexion-extension (FE) within a biplane x-ray system. Intervertebral kinematics were determined with sub-millimeter precision using a validated model-based tracking process. Ten cadaveric spines (51.8 ± 7.3 years) were tested in FE within a robotic testing system. Each specimen was tested under four loading conditions: pure moment, axial loading, follower loading, and combined loading. The in vivo and in vitro bone motion data were directly compared. The average in vitro instant center of rotation was significantly more anterior in all four loading paradigms for all levels. In general, the anterior and posterior disc heights were larger in the in vitro models than in vivo. However, after adjusting for gender, the observed differences in disc height were not statistically significant. This data suggests that in vitro biomechanical testing alone may fail to replicate in vivo conditions, with significant implications for novel motion preservation devices such as cervical disc arthroplasty implants.
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http://dx.doi.org/10.1002/jor.24702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606317PMC
April 2020

Validity and Responsiveness of Floor Sitting-Rising Test in Post-Total Knee Arthroplasty: A Cohort Study.

Arch Phys Med Rehabil 2020 08 18;101(8):1338-1346. Epub 2020 Apr 18.

Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA. Electronic address:

Objectives: To assess the construct validity and responsiveness of the floor sitting-rising test (SRT) in individuals with total knee arthroplasty (TKA).

Design: Cohort study with 6-month follow-up. Secondary analysis using data from a randomized controlled trial.

Setting: An outpatient rehabilitation research center.

Participants: Participants (N=240) enrolled in the parent study who had unilateral primary TKA.

Intervention: Participants in the parent study underwent 12 weeks of exercise programs.

Main Outcome Measures: Validity analysis correlated baseline data of participants who completed the SRT and measures of knee motion, muscle strength, performance-based tests, and patient-reported outcomes of physical and psychosocial function. Responsiveness analysis used the 3- and 6-month follow-up data. Effect sizes were calculated using changes from baseline. Areas under the receiving operating characteristics curve were calculated using a global rating of change as the external anchor.

Results: Of the 240 participants (148 women; age, 70±7y), 180 (75%) were able to perform the SRT at baseline. Performers scored significantly better in all physical function tests (P<.0001) than nonperformers. SRT scores generally converged with measures of knee impairment and performance-based tests (associations ranged from small [r=0.15; P=.0516] to moderate [r=0.52; P<.0001]). SRT scores associated with self-efficacy for function (r=0.34; P<.0001) and fear of falls (r=-0.25; P=.001). At 3 (n=174) and 6 months (n=160), SRT effect sizes were 0.38 (95% confidence interval, 0.25-0.52) and 0.42 (95% confidence interval, 0.25-0.60), and areas under the curve were 0.59 (95% confidence interval, 0.49-0.69) and 0.62 (95% confidence interval, 0.52-0.73), respectively.

Conclusions: The results add evidence to the validity of the SRT in patients after TKA. The strength of the associations suggests that the SRT measures a physical function construct not captured by the other tests. The magnitude of indices of responsiveness for the SRT were similar to other performance-based tests, indicating comparable responsiveness to more widespread tests of functional performance.
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http://dx.doi.org/10.1016/j.apmr.2020.03.012DOI Listing
August 2020

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

J Arthroplasty 2020 06 4;35(6S):S201-S206. Epub 2020 Mar 4.

Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA.

Background: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events.

Methods: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon.

Results: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77).

Conclusion: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA.

Level Of Evidence: Level III, Observational Cohort Study.
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http://dx.doi.org/10.1016/j.arth.2020.02.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239733PMC
June 2020

Maintenance of Correction of the Modified Lapidus Procedure With a First Metatarsal to Intermediate Cuneiform Cross-Screw Technique.

Foot Ankle Int 2020 04 26;41(4):428-436. Epub 2019 Dec 26.

Orthopedic Foot and Ankle Center, Worthington, OH, USA.

Background: Recurrence of deformity remains a concern when fusing the first tarsometatarsal joint for correction of hallux valgus (HV). A recently described construct adds an additional point of fixation from the plantar medial first metatarsal to the intermediate cuneiform. The purpose of this study was to determine the maintenance of correction of the first and second intermetatarsal angle, hallux valgus angle, and tibial sesamoid position after undergoing a first tarsometatarsal joint arthrodesis using the proposed construct.

Methods: A radiographic review was performed of patients with HV treated with a first tarsometatarsal joint arthrodesis with the addition of a cross-screw intermediate cuneiform construct. Three observers reviewed radiographic data, including preoperative weightbearing, first weightbearing, and final weightbearing plain-film radiographs. Initial improvement and maintenance of intermetatarsal angle, hallux valgus angle (HVA), and tibial sesamoid position were evaluated radiographically. A total of 62 patients met inclusion criteria and were included in the study. Mean follow-up time was 9.3 months (SD 6.7).

Results: Bony union was achieved in 60 of 62 patients (96.7%). Two of 62 patients required revision surgery as a result of recurrence (3.3%). Final mean improvement of the intermetatarsal angle (IMA) was 6.8 degrees (±2.9 degrees), HVA was 14.8 degrees (±7.5 degrees), and tibial sesamoid position was 2.4 (±1.4) positions. Mean loss of IMA correction was 1.5 degrees (±1.6), HVA was 2.9 degrees (±4.8 degrees), and tibial sesamoid position was 0.8 (±0.8).

Conclusion: This study showed that the cross-screw intermediate cuneiform construct for first tarsometatarsal joint arthrodesis had a good union rate, a low complication rate, and maintained radiographic correction.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100719895268DOI Listing
April 2020

Rotatory Knee Laxity Exists on a Continuum in Anterior Cruciate Ligament Injury.

J Bone Joint Surg Am 2020 02;102(3):213-220

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: The purpose of this investigation was to compare the magnitude of rotatory knee laxity in patients with a partial anterior cruciate ligament (ACL) tear, those with a complete ACL tear, and those who had undergone a failed ACL reconstruction. It was hypothesized that rotatory knee laxity would increase with increasing injury grade, with knees with partial ACL tears demonstrating the lowest rotatory laxity and knees that had undergone failed ACL reconstruction demonstrating the highest rotatory laxity.

Methods: A prospective multicenter study cohort of 354 patients who had undergone ACL reconstruction between 2012 and 2018 was examined. All patients had both injured and contralateral healthy knees evaluated using standardized, preoperative quantitative pivot shift testing, determined by a validated, image-based tablet software application and a surface-mounted accelerometer. Quantitative pivot shift was compared with the contralateral healthy knee in 20 patients with partial ACL tears, 257 patients with complete ACL tears, and 27 patients who had undergone a failed ACL reconstruction. Comparisons were made using 1-way analysis of variance (ANOVA) with post hoc 2-sample t tests with Bonferroni correction. Significance was set at p < 0.05.

Results: There were stepwise increases in side-to-side differences in quantitative pivot shift in terms of lateral knee compartment translation for patients with partial ACL tears (mean [and standard deviation], 1.4 ± 1.5 mm), those with complete ACL tears (2.5 ± 2.1 mm), and those who had undergone failed ACL reconstruction (3.3 ± 1.9 mm) (p = 0.01) and increases in terms of lateral compartment acceleration for patients with partial ACL tears (0.7 ± 1.4 m/s), those with complete ACL tears (2.3 ± 3.1 m/s), and those who had undergone failed ACL reconstruction (2.4 ± 5.5 m/s) (p = 0.01). A significant difference in lateral knee compartment translation was found when comparing patients with partial ACL tears and those with complete ACL tears (1.2 ± 2.1 mm [95% confidence interval (CI), 0.2 to 2.1 mm]; p = 0.02) and patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.9 ± 1.7 mm [95% CI, 0.8 to 2.9 mm]; p = 0.001), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.8 ± 2.1 [95% CI, -0.1 to 1.6 mm]; p = 0.09). Increased lateral compartment acceleration was found when comparing patients with partial ACL tears and those with complete ACL tears (1.5 ± 3.0 m/s [95% CI, 0.8 to 2.3 m/s]; p = 0.0002), but not when comparing patients with complete ACL tears and those who had undergone failed ACL reconstruction (0.1 ± 3.4 m/s [95% CI, -2.2 to 2.4 m/s]; p = 0.93) or patients with partial ACL tears and those who had undergone failed ACL reconstruction (1.7 ± 4.2 m/s [95% CI, -0.7 to 4.0 m/s]; p = 0.16). An increasing lateral compartment translation of the contralateral, ACL-healthy knee was found in patients with partial ACL tears (0.8 mm), those with complete ACL tears (1.2 mm), and those who had undergone failed ACL reconstruction (1.7 mm) (p < 0.05).

Conclusions: A progressive increase in rotatory knee laxity, defined by side-to-side differences in quantitative pivot shift, was observed in patients with partial ACL tears, those with complete ACL tears, and those who had undergone failed ACL reconstruction. These results may be helpful when assessing outcomes and considering indications for the management of high-grade rotatory knee laxity.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00502DOI Listing
February 2020

Talectomy as Part of Chronic Foot and Ankle Deformity Correction Procedure: A Retrospective Study.

J Foot Ankle Surg 2020 Jan - Feb;59(1):16-20. Epub 2019 Nov 5.

Professor and Chairman, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Professor, Department of Orthopaedic Surgery, University of Texas Southwestern School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.
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http://dx.doi.org/10.1053/j.jfas.2019.05.002DOI Listing
July 2020

Plantar Approach for Midfoot Wedge Resection to Reconstruct the Rocker Bottom Foot.

J Foot Ankle Surg 2019 Sep;58(5):1030-1035

Assistant Professor, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Director, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA; Chief, Podiatry Section, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA.

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.
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http://dx.doi.org/10.1053/j.jfas.2019.01.004DOI Listing
September 2019

Development of Pharmacist Independent Prescribing Clinics to Treat Opioid Analgesic Dependence in NHS Lanarkshire.

Pharmacy (Basel) 2019 Aug 22;7(3). Epub 2019 Aug 22.

NHS Lanarkshire, Addictions Services, Lanarkshire ML1 2TP, UK.

There has been an increase in opioid analgesic prescribing in general practice (GP). This is causing some concern around this contributing to dependency. NHS Lanarkshire have attempted to reduce the prescribing from GP surgeries through the development of specialised Pharmacist Independent Prescriber clinics being delivered from the practices. This article looks at the development of these services with pharmacist independent prescribers and the results from developing the services. The article aims to provide advice and recommendations for the development of other services and strategies to minimise the risks associated with Opioid Analgesic Dependence for patients.
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http://dx.doi.org/10.3390/pharmacy7030119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789752PMC
August 2019

Comparison of Standard and Right/Left International Knee Documentation Committee Subjective Knee Form Scores.

Am J Sports Med 2019 04 21;47(5):1203-1208. Epub 2019 Mar 21.

Cleveland Clinic Sports Health Center, Garfield Heights, Ohio, USA.

Background: The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) is a validated patient-reported outcome used in clinical research. No studies exist directly comparing the standard unilateral adult version (IKDC-SKF) with the bilateral adult version (R/L IKDC-SKF).

Hypotheses: The first hypothesis is that no clinically relevant difference would be observed between standard IKDC-SKF scores and involved R/L scores. The second hypothesis is that a relevant difference would be observed between involved and uninvolved scores on the R/L IKDC-SKF.

Study Design: Cohort study (Diagnosis); Level of evidence, 2.

Methods: One hundred patients were enrolled via a crossover study design. Participants were split into 2 groups per simple randomization. One group completed the standard IKDC-SKF first and the R/L IKDC-SKF second. The other group completed forms in the reverse order. A 10-minute washout period was administered between questionnaires. Participants reported their preferred form in a postquestionnaire survey. A 5-point threshold for clinical relevance was set a priori, which is less than multiple published minimal detectable change and minimal clinically important difference metrics of the standard IKDC-SKF, ranging from 6.3 to 20.5. Data were analyzed with Bland-Altman plots, paired t tests, correlations, and chi-square tests.

Results: Paired t tests between the standard IKDC-SKF and the involved R/L IKDC-SKF scores demonstrated a statistically significant mean difference of 1.4 ( P = .008; 95% CI, 0.4-2.4). However, the 95% CI falls under the clinically relevant threshold of 5. Standard and involved knee scores from the R/L IKDC-SKF were highly correlated, with a rho of 0.95. Patients consistently distinguished the injured knee from the uninjured knee across a range of scores via the R/L IKDC-SKF ( P < .001). The postquestionnaire survey showed that 55 patients preferred the R/L IKDC-SKF, 30 preferred the standard IKDC-SKF, and 15 had no preference. Post hoc analysis showed a significant preference for "R/L vs standard IKDC-SKF" ( P = .014) and "R/L IKDC-SKF vs no preference" ( P < .003).

Conclusion: No clinically relevant difference was observed between the standard IKDC-SKF and the involved knee score of the R/L IKDC-SKF. Therefore, for symptomatic unilateral knee diagnosis, either form can be used. The R/L IKDC-SKF showed a consistent and clinically relevant difference between involved and uninvolved knees. Patients in this study preferred the R/L IKDC-SKF.
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http://dx.doi.org/10.1177/0363546519829770DOI Listing
April 2019

Verification of a Portable Motion Tracking System for Remote Management of Physical Rehabilitation of the Knee.

Sensors (Basel) 2019 Feb 28;19(5). Epub 2019 Feb 28.

Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.

Rehabilitation following knee injury or surgery is critical for recovery of function and independence. However, patient non-adherence remains a significant barrier to success. Remote rehabilitation using mobile health (mHealth) technologies have potential for improving adherence to and execution of home exercise. We developed a remote rehabilitation management system combining two wireless inertial measurement units (IMUs) with an interactive mobile application and a web-based clinician portal (interACTION). However, in order to translate interACTION into the clinical setting, it was first necessary to verify the efficacy of measuring knee motion during rehabilitation exercises for physical therapy and determine if visual feedback significantly improves the participant's ability to perform the exercises correctly. Therefore, the aim of this study was to verify the accuracy of the IMU-based knee angle measurement system during three common physical therapy exercises, quantify the effect of visual feedback on exercise performance, and understand the qualitative experience of the user interface through survey data. A convenience sample of ten healthy control participants were recruited for an IRB-approved protocol. Using the interACTION application in a controlled laboratory environment, participants performed ten repetitions of three knee rehabilitation exercises: heel slides, short arc quadriceps contractions, and sit-to-stand. The heel slide exercise was completed without feedback from the mobile application, then all exercises were performed with visual feedback. Exercises were recorded simultaneously by the IMU motion tracking sensors and a video-based motion tracking system. Validation showed moderate to good agreement between the two systems for all exercises and accuracy was within three degrees. Based on custom usability survey results, interACTION was well received. Overall, this study demonstrated the potential of interACTION to measure range of motion during rehabilitation exercises for physical therapy and visual feedback significantly improved the participant's ability to perform the exercises correctly.
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http://dx.doi.org/10.3390/s19051021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6427361PMC
February 2019

Arthroscopic SLAP IIb Repair Using Knot-Tying Versus Knotless Suture Anchors: Is There a Difference?

Am J Orthop (Belle Mead NJ) 2018 Dec;47(12)

Burke and Bradley Orthopedics, University of Pittsburgh Medical Center. UPMC St. Margaret, 200 Medical Arts Building, Suite 4010, 200 Delafield Road, Pittsburgh, PA 15215 USA. Email:

The use of knotless suture anchors has increased in popularity; however, there is a paucity of literature examining the difference in clinical outcomes with traditional knotted fixation. It was hypothesized that knotless fixation would provide superior clinical outcomes, improved return to play (RTP), and lower revision rates as compared with traditional knotted fixation in the repair of SLAP IIb tears. Seventy-four athletes who underwent arthroscopic SLAP IIb repair with traditional (n = 42) and knotless anchors (n = 32) by a single surgeon were evaluated after a minimum 2-year follow. Demographic and surgical data, RTP, Kerlan-Jobe Orthopaedic Clinic (KJOC) score, American Shoulder and Elbow Surgeons (ASES) score, stability, strength, and pain scores were compared. Knotless anchors had slightly higher RTP (93.5% vs 90.2%, P = .94) and RTP at the same level (58.1% vs 53.7% P = .81) compared with knotted fixation, but the difference did not reach statistical significance. Knotless anchors were less likely to require revision surgery than traditional anchors (9% vs 17%, P = .50), but the difference was not statistically significant. When comparing knotless and traditional knotted suture anchor repair of type llb SLAP tears, knotless fixation required less revision surgery and had higher RTP, ASES, and KJOC scores; however, statistical significance was not achieved in this relatively small cohort.
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http://dx.doi.org/10.12788/ajo.2018.0101DOI Listing
December 2018

Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial.

JAMA Netw Open 2019 01 4;2(1):e186828. Epub 2019 Jan 4.

Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.

Importance: Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older US adults. There is an evidence gap about nonsurgical LSS treatment options.

Objective: To explore the comparative clinical effectiveness of 3 nonsurgical interventions for patients with LSS.

Design, Setting, And Participants: Three-arm randomized clinical trial of 3 years' duration (November 2013 to June 2016). Analysis began in August 2016. All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat.

Interventions: Medical care, group exercise, and manual therapy/individualized exercise. Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors in senior community centers. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists.

Main Outcomes And Measures: Primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes).

Results: A total of 259 participants (mean [SD] age, 72.4 [7.8] years; 137 women [52.9%]) were allocated to medical care (88 [34.0%]), group exercise (84 [32.4%]), or manual therapy/individualized exercise (87 [33.6%]). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care (-2.0; 95% CI, -3.6 to -0.4) or group exercise (-2.4; 95% CI, -4.1 to -0.8). Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates.

Conclusions And Relevance: A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.

Trial Registration: ClinicalTrials.gov Identifier: NCT01943435.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.6828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324321PMC
January 2019

Anatomic Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons Restores Quantitative Pivot Shift.

Orthop J Sports Med 2018 Dec 18;6(12):2325967118812364. Epub 2018 Dec 18.

Investigation performed at IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.

Background: It is still uncertain how surgical reconstruction of the anterior cruciate ligament (ACL) is able to restore rotatory laxity of the involved joint. The desired amount of restraint applied by the ACL graft, as compared with the healthy knee, has not been fully clarified.

Purpose: To quantify the ability of single-bundle anatomic ACL reconstruction using hamstring tendons in reducing the pivot-shift phenomenon immediately after surgery under anesthesia.

Study Design: Case series; Level of evidence, 4.

Methods: An inertial sensor and image analysis were used at 4 international centers to measure tibial acceleration and lateral compartment translation of the knee, respectively. The standardized pivot-shift test was quantified in terms of the side-to-side difference in laxity both preoperatively and postoperatively with the patient under anesthesia. The reduction in both tibial acceleration and lateral compartment translation after surgery and the side-to-side difference were evaluated using the Wilcoxon signed-rank test. Alpha was set at < .05.

Results: A total of 107 patients were recruited for the study, and data were available for 89 patients. There was a statistically significant reduction in quantitative rotatory knee laxity between preoperatively (inertial sensor, 2.55 ± 4.00 m/s; image analysis, 2.04 ± 2.02 mm) and postoperatively (inertial sensor, -0.54 ± 1.25 m/s; image analysis, -0.10 ± 1.04 mm) between the involved and healthy joints, as measured by the 2 devices ( < .001 for both). Postoperatively, both devices detected a lower rotatory laxity value in the involved joint compared with the healthy joint (inertial sensor, 2.45 ± 0.89 vs 2.99 ± 1.10 m/s, respectively [ < .001]; image analysis, 0.99 ± 0.83 vs 1.09 ± 0.92 mm, respectively [ = .38]).

Conclusion: The data from this study indicated a significant reduction in the pivot shift when compared side to side. Both the inertial sensor and image analysis used for the quantitative assessment of the pivot-shift test could successfully detect restoration of the pivot shift after anatomic single-bundle ACL reconstruction. Future research will examine how pivot-shift control is maintained over time and correlation of the pivot shift with return to full activity in patients with an ACL injury.
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http://dx.doi.org/10.1177/2325967118812364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299314PMC
December 2018

Neuromuscular Electrical Stimulation Compared to Volitional Exercise for Improving Muscle Function in Rheumatoid Arthritis: A Randomized Pilot Study.

Arthritis Care Res (Hoboken) 2019 03 12;71(3):352-361. Epub 2019 Feb 12.

University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: The aim of this study was to compare the feasibility and effectiveness of neuromuscular electrical stimulation (NMES) with that of high-intensity volitional resistance training for improving muscle structure and function and physical function in patients with rheumatoid arthritis (RA). We also compared pre-intervention and post-intervention values of myocyte characteristics.

Methods: In this 2-group, single-blind, randomized pilot study, adult patients with RA were assigned to 36 sessions of NMES (n = 31 patients) or volitional training (n = 28 patients) over 16 weeks. Outcome measures included muscle structure and function (quadriceps muscle area, density, and strength), physical function (performance-based and patient-reported), feasibility (increased pain, increased disease activity, attrition, and adherence), and myocyte characteristics (area, proportion of type I or II muscle fibers, and intramyocellular lipid content). Analysis of covariance was used to compare groups.

Results: The intervention intensity in the NMES group was less than half that in the volitional exercise group (31% versus 77% of maximum effort). Both groups experienced significant improvements in muscle structure and function (P < 0.001 to 0.019). Improvements in muscle characteristics and physical function were not different between groups. Exercise did not result in serious adverse events or increases in pain and disease activity. Attrition was 29% in the NMES group and 7% in the volitional exercise group.

Conclusion: Both NMES and high-intensity volitional resistance training can be used as effective approaches to improving muscle structure and function in patients with RA. NMES may be a viable alternative for improving muscle function in patients in whom high-intensity resistance exercise may not be tolerated or is contraindicated, but attrition must be considered when using this approach.
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http://dx.doi.org/10.1002/acr.23602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6249117PMC
March 2019

Changes in quality of life in patients with advanced cancer: evidence of response shift and response restriction.

J Psychosom Res 2005 Jun;58(6):497-504

Clinical Psychology Unit F12, School of Psychology, The University of Sydney, NSW Australia.

Objective: Response shift is a process argued to facilitate adjustment to illness. This study investigated the relationship between response shift and adjustment.

Methods: Fifty-six patients with metastatic cancer were interviewed using SEIQoL-DW and asked to nominate the five areas of most importance to them. Surviving patients were re-interviewed 3 (n=38) and 6 months (n=28) later.

Results: The majority of patients showed evidence of restricted priorities close to the diagnosis of metastatic cancer. Approximately half the sample shifted their priorities from one area to another over time. Response shift was found to be helpful for those who nominated life domains that were poorly rated, but unhelpful, for those who shifted from a highly rated life domain.

Conclusions: These results suggest that response shift is common during adjustment to illness. However, response shift can be helpful or unhelpful depending upon the context. The clinical and theoretical implications of these findings are discussed.
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http://dx.doi.org/10.1016/j.jpsychores.2005.02.017DOI Listing
June 2005

A framework for the role of Registered Nurses in the specialty practice of rehabilitation nursing in Australia.

J Adv Nurs 2002 Aug;39(3):249-57

Rehabilitation Nursing Research and Development Unit, University of Western Sydney and Royal Rehabilitation Centre Sydney, Sydney, New South Wales, Australia.

Aim Of The Study: This study sought to explore systematically the role of Registered Nurses working in rehabilitation in Australia.

Background: Rehabilitation has been identified as an important aspect of health care. However, evidence of a comprehensive investigation of the nurses' role in rehabilitation cannot be found. From Australia, in particular, no research has been published in this area.

Methods: This study used a qualitative approach by engaging 13 nurses in one-to-one interviews and a further 21 in focus group discussions. Thematic analysis was conducted on the interview and focus group data.

Findings: Seven domains of practice were identified and are suggested as a framework for the specialty practice of rehabilitation nursing. They capture the 'how' and 'what' of rehabilitation nursing practice. Central to this practice is a rehabilitative approach to patient care, teaching and coaching, and continual assessment. The nurses explained in detail how these aspects of rehabilitation nursing differentiate their practice from that of their acute care colleagues.

Conclusion: The rehabilitative approach is one of a variety of approaches to nursing care, but should not be seen as the exclusive domain of rehabilitation nurses. Rehabilitation belongs in every nurse's toolkit.
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http://dx.doi.org/10.1046/j.1365-2648.2002.02271.xDOI Listing
August 2002