Publications by authors named "Jeff Houck"

64 Publications

Do clinical criteria based on PROMIS outcomes identify acceptable symptoms and function for patients with musculoskeletal problems.

Musculoskelet Sci Pract 2021 Oct 5;55:102423. Epub 2021 Jul 5.

George Fox University, Newberg, OR, USA.

Background: Understanding how symptoms influence patient judgements of their health informs providers where to direct care. Patient reported physical outcomes (physical function, pain interference) and self-efficacy of symptom management (SEsm)) predict a patient's health state (i.e. patient acceptable symptom state (PASS)). However, it's unclear if therapist should consider a psychological outcome like SEsm separately or combine this outcome with other physical outcomes for clinical decisions.

Objective: To determine if patient reported outcome information system (PROMIS) SEsm scale when combined with PROMIS physical function or pain interference is able to accurately predict a patient's health state defined by PASS.

Methods: One hundred ninety-six patients (initial sample (n = 94) and separate sample (n = 102)) were surveyed by phone after care for a musculoskeletal problem. Patients completed PASS, PROMIS physical function, pain interference and SEsm outcomes. Logistic regression was used to estimate odds ratios (OR) for determining PASS in the initial sample. Criteria for determining PASS developed from the regression analysis were applied to a separate sample to assess accuracy. Accuracy for PASS status were also assessed at 1-7 days and 45-60 days.

Results: Three combinations including SEsm/pain interference and SEsm/physical function showed significant OR's (<0.1) and varied from 2.5 to 4.2 for predicting PASS status. Criteria to predict PASS in the separate sample at 1-7 days and 45-60 days showed accuracies from 74.5% to 83.6%.

Conclusion: This study demonstrates that utilizing SEsm in combination with common physical outcomes used to assess patients with musculoskeletal diagnoses improves prediction of a patient's acceptable level of symptoms and activity.
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http://dx.doi.org/10.1016/j.msksp.2021.102423DOI Listing
October 2021

Overall Health and the Influence of Physical Therapy on Physical Function Following Total Ankle Arthroplasty.

Foot Ankle Int 2020 Nov 4;41(11):1383-1390. Epub 2020 Aug 4.

Illinois Bone & Joint Institute, Glenview, IL, USA.

Background: The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy.

Methods: People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain scores that scored below the population mean were examined with multiple linear regression or ordinal regression.

Results: The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean [SD]: 40.0 [35.3] months). Physical function and ability to participate in social roles and activities domain scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 [11.0] visits) and found it helpful (7.2 [3.0]). Participant characteristics were minimally predictive of physical function and social participation scores. Number of physical therapy visits predicted physical function scores ( = .03).

Conclusions: Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1177/1071100720942473DOI Listing
November 2020

Prediction of post-interventional physical function in diabetic foot ulcer patients using patient reported outcome measurement information system (PROMIS).

Foot Ankle Surg 2021 Feb 11;27(2):224-230. Epub 2020 May 11.

Department of Orthopaedics and Rehabilitation, University of Rochester, United States. Electronic address:

Background: Infected diabetic foot ulcer (DFU) patients present with an impaired baseline physical function (PF) that can be further compromised by surgical intervention to treat the infection. The impact of surgical interventions on Patient Reported Outcomes Measurement Information System (PROMIS) PF within the DFU population has not been investigated. We hypothesize that preoperative PROMIS scores (PF, Pain Interference (PI), Depression) in combination with relevant clinical factors can be utilized to predict postoperative PF in DFU patients.

Methods: DFU patients from a single academic physician's practice between February 2015 and November 2018 were identified (n = 240). Ninety-two patients met inclusion criteria with complete follow-up and PROMIS computer adaptive testing records. Demographic and clinical factors, procedure performed, and wound healing status were collected. Spearman's rank correlation coefficient, Chi-Squared tests and multidimensional modelling were applied to all variables' pre- and postoperative values to assess patients' postoperative PF.

Results: The mean age was 60.5 (33-96) years and mean follow-up was 4.7 (3-12) months. Over 70 % of the patients' initial PF were 2-3 standard deviations below the US population (n = 49; 28). Preoperative PF (p <  0.01), PI (p < 0.01), Depression (p <  0.01), CRF (p <  0.02) and amputation level (p <  0.04) showed significant univariate correlation with postoperative PF. Multivariate model (r = 0.55) showed that the initial PF (p =  0.004), amputation level (p =  0.008), and wound healing status (p =  0.001) predicted postoperative PF.

Conclusions: Majority of DFU patients present with poor baseline PF. Preoperative PROMIS scores (PF, PI, Depression) are predictive of postoperative PROMIS PF in DFU patients. Postoperative patient's physical function can be assessed by PF = 29.42 + 0.34 (PF) - 5.87 (Not Healed) - 2.63 (Amputation Category). This algorithm can serve as a valuable tool for predicting post-operative physical function and setting expectations.
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http://dx.doi.org/10.1016/j.fas.2020.04.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655606PMC
February 2021

Can Patient-Reported Outcomes Measurement Information System® (PROMIS) measures accurately enhance understanding of acceptable symptoms and functioning in primary care?

J Patient Rep Outcomes 2020 May 20;4(1):39. Epub 2020 May 20.

George Fox University, 414 N. Meridian St., Newberg, Oregon, USA.

Background: Value-based healthcare models will require prioritization of the patient's voice in their own care toward better outcomes. The Patient-Reported Outcomes Measurement Information System® (PROMIS) gives patients a voice and leads providers to actionable treatments across a broad range of diagnoses. However, better interpretation of PROMIS measures is needed. The purpose of this study was to evaluate the accuracy of PROMIS Physical Function (PF), Self-Efficacy for Managing Symptoms (SE), Pain Interference (PI), Fatigue, and Depression measures to discriminate patient acceptable symptom state (PASS) in primary care, determining if that accuracy is stable over time and/or retained when PROMIS score thresholds are set at either ½ or 1 SD worse than the reference population mean.

Methods: Primary care patients completed the five PROMIS measures and answered the PASS yes/no question at intake (n = 360), 3-14 days follow-up (n = 230), and 45-60 days follow-up (n = 227). Thresholds (optimal, ½ SD, and 1 SD worse than reference values) for PROMIS T-scores associated with PASS were determined through receiver-operator curve analysis. Accuracy was calculated at the three time points for each threshold value. Logistic regression analyses were used to determine combinations of PROMIS measures that best predicted PASS.

Results: PROMIS PF, SE, PI, and Fatigue optimal score thresholds (maximizing sensitivity and specificity) yielded area under the curve values of 0.77-0.85, with accuracies ranging from 71.7% to 79.1%. Accuracy increased minimally (1.9% to 5.5%) from intake to follow-ups. Thresholds of 1 SD worse than the mean for PROMIS PF and PI measures and ½ SD worse for SE and Fatigue overall retained accuracy versus optimal (+ 1.3% to - 3.6%). Regression models retained SE, PI, and Fatigue as independent predictors of PASS, and minimally increased accuracy to 83.1?%.

Conclusions: This study establishes actionable PROMIS score thresholds that are stable over time and anchored to patient self-reported health status, increasing interpretability of PF, SE, PI, and Fatigue scores. The findings support the use of these PROMIS measures in primary care toward improving provider-patient communication, prioritizing patient concerns, and optimizing clinical decision making.
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http://dx.doi.org/10.1186/s41687-020-00206-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239962PMC
May 2020

Operative Intervention Does Not Change Pain Perception in Patients With Diabetic Foot Ulcers.

Clin Diabetes 2020 Apr;38(2):132-140

Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY.

Researchers investigated pain perception in patients with diabetic foot ulcers (DFUs) by analyzing pre- and postoperative physical function (PF), pain interference (PI), and depression domains of the Patient-Reported Outcome Measurement Information System (PROMIS). They hypothesized that ) because of painful diabetic peripheral neuropathy (DPN), a majority of patients with DFUs would have high PROMIS PI scores unchanged by operative intervention, and ) the initially assessed PI, PF, and depression levels would be correlated with final outcomes. Seventy-five percent of patients with DFUs reported pain, most likely because of painful DPN. Those who reported high PI and low PF were likely to report depression. PF, PI, and depression levels were unchanged after operative intervention or healing of DFUs.
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http://dx.doi.org/10.2337/cd19-0031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164984PMC
April 2020

Bernstein et al reply to Dr Terwee.

J Hand Surg Am 2019 12;44(12):e7

Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY.

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http://dx.doi.org/10.1016/j.jhsa.2019.10.029DOI Listing
December 2019

Role of Patient-Reported Outcome Measures on Predicting Outcome of Bunion Surgery.

Foot Ankle Int 2020 02 8;41(2):133-139. Epub 2019 Nov 8.

Department of Orthopaedics, University of Rochester, Rochester, NY, USA.

Background: Prior studies have suggested preoperative patient-reported outcome scores could predict patients who would achieve a clinically meaningful improvement with hallux valgus surgery. Our goal was to determine bunionectomy-specific thresholds using Patient-Reported Outcomes Measurement Information System (PROMIS) values to predict patients who would or would not benefit from bunion surgery.

Methods: PROMIS physical function (PF), pain interference (PI), and depression assessments were prospectively collected. Forty-two patients were included in the study. Using preoperative and final follow-up visit scores, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) analyses were performed to determine if preoperative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve an MCID with 95% sensitivity.

Results: PROMIS PF demonstrated a significant AUC and likelihood ratio. The preoperative threshold score for failing to achieve MCID for PF was 49.6 with 95% sensitivity. The likelihood ratio was 0.14 (confidence interval, 0.02-0.94). The posttest probability of failure to achieve an MCID for PF was 94.1%. PI and depression AUCs were not significant, and thus thresholds were not determined.

Conclusion: We identified a PF threshold of 49.6, which was nearly 1 standard deviation higher than previously published. If a patient is hoping to improve PF, a patient with a preoperative score >49.6 may not benefit from surgery. This study also suggests the need for additional research to delineate procedure-specific thresholds.

Level Of Evidence: Level III, retrospective comparative series.
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http://dx.doi.org/10.1177/1071100719886286DOI Listing
February 2020

Prevalence of Patellar Tendinopathy and Patellar Tendon Abnormality in Male Collegiate Basketball Players: A Cross-Sectional Study.

J Athl Train 2019 Sep 19;54(9):953-958. Epub 2019 Aug 19.

School of Physical Therapy, George Fox University, Newberg, OR.

Context: Patellar tendinopathy (PT) is a degenerative condition known to affect athletes who participate in sports such as basketball and volleyball. Patellar tendinopathy is a challenging condition to treat and may cause an athlete to prematurely retire from sport. The prevalence of PT in male collegiate basketball players is unknown.

Objective: To determine the prevalence of PT and patellar tendon abnormality (PTA) in a population of male collegiate basketball players.

Design: Cross-sectional study.

Setting: National Collegiate Athletic Association Divisions II and III, National Association of Intercollegiate Athletics, and Northwest Athletic Conference male collegiate basketball teams were assessed in a university laboratory setting.

Patients Or Other Participants: Ninety-five male collegiate basketball players (age = 20.0 ± 1.7 years).

Main Outcome Measure(s): A diagnostic ultrasound image of an athlete's patellar tendon was obtained from each knee. Patellar tendinopathy was identified based on a player's symptoms (pain with palpation) and the presence of a hypoechoic region on an ultrasonographic image.

Results: A majority of participants, 53 of 95 (55.8%), did not present with pain during palpation or ultrasonographic evidence of PTA. Thirty-two basketball players (33.7%) displayed ultrasonographic evidence of PTA in at least 1 knee; 20 of those athletes (21.1%) had PT (pain and tendon abnormality). Nonstarters were 3.5 times more likely to present with PTA (odds ratio = 3.5, 95% confidence interval = 1.3, 9.6; = .017) and 4 times more likely to present with PT (odds ratio = 4.0, 95% confidence interval = 1.1, 14.8; = .038) at the start of the season.

Conclusions: One in 3 male collegiate basketball players presented with either PT or PTA. Sports medicine professionals should evaluate basketball athletes for PT and PTA as part of a preseason screening protocol.
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http://dx.doi.org/10.4085/1062-6050-70-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795094PMC
September 2019

Do Patient Sociodemographic Factors Impact the PROMIS Scores Meeting the Patient-Acceptable Symptom State at the Initial Point of Care in Orthopaedic Foot and Ankle Patients?

Clin Orthop Relat Res 2019 Nov;477(11):2555-2565

D. N. Bernstein, J. F. Baumhauer Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA K. Mayo, C. Dasilva, K. Fear University of Rochester Medical Center, Rochester, NY, USA J. R. Houck George Fox University, Newberg, OR, USA.

Background: Patient-reported outcome measures such as the Patient-Reported Outcomes Measurement Information System (PROMIS) allow surgeons to evaluate the most important outcomes to patients, including function, pain, and mental well-being. However, PROMIS does not provide surgeons with insight into whether patients are able to successfully cope with their level of physical and/or mental health limitations in day-to-day life; such understanding can be garnered using the Patient-acceptable Symptom State (PASS). It remains unclear whether or not the PASS status for a given patient and his or her health, as evaluated by PROMIS scores, differs based on sociodemographic factors; if it does, that could have important implications regarding interpretation of outcomes and fair delivery of care.

Questions/purposes: In a tertiary-care foot and ankle practice, (1) Is the PASS associated with sociodemographic factors (age, gender, race, ethnicity, and income)? (2) Do PROMIS Physical Function (PF), Pain Interference (PI), and Depression scores differ based on income level? (3) Do PROMIS PF, PI, and Depression thresholds for the PASS differ based on income level?

Methods: In this retrospective analysis of longitudinally obtained data, all patients with foot and ankle conditions who had new-patient visits (n = 2860) between February 2015 and December 2017 at a single tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression survey and answer the following single, validated, yes/no PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your functional impairment, do you consider that the current state of your foot and ankle is satisfactory?" Of the 2860 new foot and ankle patient visits, 21 patient visits (0.4%) were removed initially because all four outcome measures were not completed. An additional 225 patient visits (8%) were removed because the patient chart did not contain enough information to accurately geocode them; 15 patients visits (0.5%) were removed because the census block group median income data were not available. Lastly, two patient visits (0.1%) were removed because they were duplicates. This left a total of 2597 of 2860 possible patients (91%) in our study sample who had completed all three PROMIS domains and answered the PASS question. Patient sociodemographic factors such as age, gender, race, and ethnicity were recorded. Using census block groups as part of a geocoding method, the income bracket for each patient was recorded. A chi-square analysis was used to determine whether sociodemographic factors were associated with different PASS rates, two-way ANOVA analyses with pairwise comparisons were used to determine if PROMIS scores differed by income bracket, and a receiver operating characteristic (ROC) curve analysis was performed to determine PASS thresholds for the PROMIS score by income bracket. The minimum clinically important difference (MCID) for PROMIS PF in the literature in foot and ankle patients ranges from about 7.9 to 13.2 using anchor-based approaches and 4.5 to 4.7 using the ½ SD, distribution-based method. The MCID for PROMIS PI in the literature in foot and ankle patients ranges from about 5.5 to 12.4 using anchor-based approaches and about 4.1 to 4.3 using the ½ SD, distribution-based method. Both were considered when evaluating our findings. Such MCID cutoffs for PROMIS Depression are not as well established in the foot and ankle literature. Significance was set a priori at p < 0.05.

Results: The only sociodemographic factor associated with differences in the proportion of patients achieving PASS was age (15% [312 of 2036] of patients aged 18-64 years versus 11% [60 of 561] of patients aged ≥ 65 years; p = 0.006). PROMIS PF (45 ± 10 for the ≥ USD 100,000 bracket versus 40 ± 10 for the ≤ USD 24,999 bracket, mean difference 5 [95% CI 3 to 7]; p < 0.001), PI (57 ± 8 for ≥ USD 100,000 versus 63 ± 7 for ≤ USD 24,999, mean difference -6 [95% CI -7 to -4]; p < 0.001), and Depression (46 ± 8 for the ≥ USD 100,000 bracket versus 51 ± 11 for ≤ USD 24,999, mean difference -5 [95% CI -7 to -3]; p < 0.001) scores were better for patients in the highest income bracket compared with those in the lowest income bracket. For PROMIS PF, the difference falls within the score change range deemed clinically important when using a ½ SD, distribution-based approach but not when using an anchor-based approach; however, the score difference for PROMIS PI falls within the score change range deemed clinically important for both approaches. The PASS threshold of the PROMIS PF for the highest income bracket was near the mean for the US population (49), while the PASS threshold of the PROMIS PF for the lowest income bracket was more than one SD below the US population mean (39). Similarly, the PASS threshold of the PROMIS PI differed by 6 points when the lowest and highest income brackets were compared. PROMIS Depression was unable to discriminate the PASS.

Conclusions: Discussions about functional and pain goals may need to be a greater focus of clinic encounters in the elderly population to ensure that patients understand the risks and benefits of given treatment options at their advanced age. Further, when using PASS in clinical encounters to evaluate patient satisfaction and the ability to cope at different symptom and functionality levels, surgeons should consider income status and its relationship to PASS. This knowledge may help surgeons approach patients with a better idea of patient expectations and which level of symptoms and functionality is satisfactory; this information can assist in ensuring that each patient's health goal is included in shared decision-making discussions. A better understanding of why patients with different income levels are satisfied and able to cope at different symptom and functionality levels is warranted and may best be accomplished using an epidemiologic survey approach.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000000866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903865PMC
November 2019

Minimal Clinically Important Differences for PROMIS Physical Function, Upper Extremity, and Pain Interference in Carpal Tunnel Release Using Region- and Condition-Specific PROM Tools.

J Hand Surg Am 2019 Aug 22;44(8):635-640. Epub 2019 May 22.

Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY. Electronic address:

Purpose: Uncertainty exists about what change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores represents a clinically relevant improvement (minimal clinically important difference [MCID]) in hand surgery care. Using a region-specific patient-reported outcome measure (PROM) (Michigan Hand Question [MHQ]) and a condition-specific PROM (Boston Carpal Tunnel Questionnaire [BCTQ]), MCID values were determined for PROMIS Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) computerized adaptive testing among patients undergoing carpal tunnel release (CTR).

Methods: Patients undergoing CTR with a single surgeon from November 2014 to April 2017 were asked to complete the BCTQ, MHQ, and PROMIS PF, UE, and PI at each visit. Patients who had completed questionnaires both at a preoperative and either a 6-week or a 3-month postoperative visit were included. The PROMIS PF, UE, and PI MCID values were calculated using previously determined MCID estimates in the literature with both region- (ie, MHQ) and condition-specific (ie, BCTQ) PROM anchors. The PROMIS domain MCID estimates were also determined using the distribution-based method.

Results: A total of 70 patients fit our inclusion criteria. Using MHQ Function and Pain, PROMIS UE, PF, and PI MCIDs were 6.3, 1.8, and -8.9, respectively. Using the average of the 2 BCTQ domains, PROMIS UE, PF, and PI MCIDs were 8.0, 2.8, and -9.7, respectively. Using the distribution-based method, PROMIS UE, PF, and PI MCIDs were 4.2, 2.7, and -4.1, respectively.

Conclusions: Using region- and condition-specific PROMs, we were able to provide MCID estimates of PROMIS UE, PF, and PI for patients undergoing CTR.

Clinical Relevance: Estimating PROMIS UE, PF, and PI MCIDs in CTR using validated region- and condition-specific PROMs provides hand surgeons a way to evaluate CTR outcomes not previously described in the literature. Surgeons should understand that these values are only estimates and future work is needed to verify whether they reflect clinical improvement.
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http://dx.doi.org/10.1016/j.jhsa.2019.04.004DOI Listing
August 2019

Responsiveness of the PROMIS and its Concurrent Validity with Other Region- and Condition-specific PROMs in Patients Undergoing Carpal Tunnel Release.

Clin Orthop Relat Res 2019 Nov;477(11):2544-2551

D.N. Bernstein, Office of Medical Education, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA J.R. Houck, Department of Physical Therapy, George Fox University, Newberg, OR, USA B. Mahmood, W.C. Hammert, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.

Background: The Patient-reported Outcome Measurement Information System (PROMIS) continues to be an important universal patient-reported outcomes measure (PROM) in orthopaedic surgery. However, there is concern about the performance of the PROMIS as a general health questionnaire in hand surgery compared with the performance of region- and condition-specific PROMs such as the Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire (BCTQ), respectively. To ensure that PROMIS domains capture patient-reported outcomes to the same degree as region- and condition-specific PROMs do, comparing PROM performance is necessary.

Questions/purposes: (1) Which PROMs demonstrate high responsiveness among patients undergoing carpal tunnel release (CTR)? (2) Which of the PROMIS domains (Physical Function [PF], Upper Extremity [UE], and Pain Interference [PI]) demonstrate concurrent validity with the HHQ and BCTQ domains?

Methods: In this prospective study, between November 2014 and October 2016, patients with carpal tunnel syndrome visiting a single surgeon who elected to undergo CTR completed the BCTQ, MHQ, and PROMIS UE, PF, and PI domains at each visit. A total of 101 patients agreed to participate. Of these, 31 patients (31%) did not return for a followup visit at least 6 weeks after CTR and were excluded, leaving a final sample of 70 patients (69%). We compared the PROMIS against region- and condition-specific PROMs in terms of responsiveness and concurrent validity. Responsiveness was determined using Cohen's d or the effect-size index (ESI). The larger the absolute value of the ESI, the greater the effect size. Using the ESI allows surgeons to better quantify the impact of CTR, with a medium ESI (that is, 0.5) representing a visible clinical change to a careful observer. Concurrent validity was determined using Spearman's correlation coefficient with correlation strengths categorized as excellent (> 0.7), excellent-good (0.61-0.70), good (0.4-0.6), and poor (< 0.4). Significance was set a priori at p < 0.05.

Results: Among PROMIS domains, the PI demonstrated the best responsiveness (ESI = 0.74; 95% CI, 0.39-1.08), followed by the UE (ESI = -0.66; 95% CI, -1.00 to -0.31). For the MHQ, the Satisfaction domain had the largest effect size (ESI = -1.48; 95% CI, -1.85 to -1.09), while for the BCTQ, the Symptom Severity domain had the best responsiveness (ESI = 1.54; 95% CI, 1.14-1.91). The PROMIS UE and PI domains demonstrated excellent-good to excellent correlations to the total MHQ and BCTQ-Functional Status scores (preoperative UE to MHQ: ρ = 0.68; PI to MHQ: ρ = 0.74; UE to BCTQ-Functional Status: ρ = 0.74; PI to BCTQ-Functional Status: ρ = 0.67; all p < 0.001), while the PROMIS PF demonstrated poor correlations with the same domains (preoperative PF to MHQ; ρ = 0.33; UE to BCTQ-Functional Status: ρ = 0.39; both p < 0.01).

Conclusions: The PROMIS UE and PI domains demonstrated slightly worse responsiveness than the MHQ and BCTQ domains that was nonetheless acceptable. The PROMIS PF domain was unresponsive. All three PROMIS domains correlated with the MHQ and BCTQ, but the PROMIS UE and PI domains had notably stronger correlations to the MHQ and BCTQ domains than the PF domain did. We feel that the PROMIS UE and PI can be used to evaluate the clinical outcomes of patients undergoing CTR, while also providing more robust insight into overall health status because they are general PROMs. However, we do not recommend the PROMIS PF for evaluating patients undergoing CTR.

Level Of Evidence: Level II, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000000773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903856PMC
November 2019

Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy?

Am J Sports Med 2019 05 10;47(6):1396-1403. Epub 2019 Apr 10.

Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York, USA.

Background: The Patient Reported Outcomes Information System (PROMIS) is an efficient metric able to detect changes in global health.

Purpose: To assess the responsiveness, convergent validity, and clinically important difference (CID) of PROMIS compared with disease-specific scales after knee arthroscopy.

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

Methods: A prospective institutional review board-approved study collected PROMIS Physical Function (PF), PROMIS Pain Interference (PI), International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) results in patients undergoing knee arthroscopy. The change from preoperative to longest follow-up was used in analyses performed to determine responsiveness, convergent validity, and minimal and moderate CID using the IKDC scale as the anchor.

Results: Of the 100 patients enrolled, 76 were included. Values of the effect size index (ESI) ranged from near 0 to 1.69 across time points and were comparable across scales. Correlations of the change in KOOS and PROMIS with IKDC ranged from r values of 0.61 to 0.79. The minimal CID for KOOS varied from 12.5 to 17.5. PROMIS PF and PI minimal CID were 3.3 and -3.2. KOOS moderate CID varied from 14.3 to 18.8. PROMIS PF and PI moderate CID were 5.0 and -5.8.

Conclusion: The PROMIS PF and PI showed similar responsiveness and CID compared with disease-specific scales in patients after knee arthroscopy. PROMIS PI, PROMIS PF, and KOOS correlations with IKDC demonstrate that these scales are measuring a similar construct. The ESIs of PROMIS PF and PI were similar to those of KOOS and IKDC, suggesting similar responsiveness at 6 months or longer (ESI >1.0). Minimum and moderate CID values calculated for PROMIS PF and PI using IKDC as an anchor were sufficiently low to suggest clinical usefulness.

Clinical Relevance: PROMIS PF and PI can be accurately used to determine improvement or lack thereof with clinically important changes after knee arthroscopy.
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http://dx.doi.org/10.1177/0363546519832546DOI Listing
May 2019

A Comparison of PROMIS UE Versus PF: Correlation to PROMIS PI and Depression, Ceiling and Floor Effects, and Time to Completion.

J Hand Surg Am 2019 Oct 4;44(10):901.e1-901.e7. Epub 2019 Feb 4.

Department of Physical Therapy, George Fox University, Newberg, OR. Electronic address:

Purpose: This study aimed to (1) determine the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with PROMIS Upper Extremity (UE) and compare the correlations of PF and UE with PROMIS Pain Interference (PI) and PROMIS Depression; (2) compare the ability of PF and UE to capture health outcomes across the spectrum in patients seeking hand care; and (3) compare the time to completion for PROMIS PF to that for PROMIS UE.

Methods: Patients presenting to a hand clinic between October, 2015 and October, 2017 were asked to complete PROMIS PF, UE, PI, and Depression computerized adaptive tests. Spearman correlation coefficients (ρ) were calculated between the domains. Ceiling and floor effects and time to completion of each domain were compared.

Results: A total of 20,489 unique visits representing 10,344 patients met inclusion criteria. On average, PROMIS UE demonstrated more functional disability than did PROMIS PF (PF: 43.9 [95% confidence interval (CI), 43.7-44.0] vs UE: 38.5 [95% CI, 38.4-38.7]). PROMIS PF and UE were positively correlated (ρ = 0.79) and both were inversely correlated with PROMIS PI (PF: ρ = -0.72; UE: ρ = -0.72). PROMIS PF and UE were both inversely correlated with PROMIS Depression (PF: ρ = -0.44; UE: ρ = -0.44). PROMIS PF demonstrated better ceiling (0.6% vs 7.5%) and floor effects (0.07% vs 0.4%). The PROMIS UE CAT was completed in about the same time as the PROMIS PF CAT (UE: 59.8 seconds [95% CI, 59.3-60.3 seconds] vs PF: 54.1 seconds [95% CI, 53.8-54.5 seconds]).

Conclusions: PROMIS PF captures functional outcomes similar to those of the UE domain with better performance (ie, ceiling and floor effects) in patients with hand pathologies.

Clinical Relevance: Hand surgeons should consider the trade-off of using PROMIS PF instead of PROMIS UE or vice versa when selecting a domain for patient care. Although PROMIS PF may capture slight variations in function at the extremes better than the current PROMIS UE, this may not be as clinically important as capturing large changes in upper-extremity function more specifically, which PROMIS UE accomplishes.
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http://dx.doi.org/10.1016/j.jhsa.2018.12.006DOI Listing
October 2019

Improving Interpretation of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Scale for Specific Tasks in Community-Dwelling Older Adults.

J Geriatr Phys Ther 2020 Jul/Sep;43(3):142-152

School of Medicine and Dentistry, Department of Orthopaedics, University of Rochester, Rochester, New York.

Background And Purpose: New generic patient-reported outcomes like the Patient-Reported Outcomes Measurement Information System (PROMIS) are available to physical therapists to assess physical function. However, the interpretation of the PROMIS Physical Function (PF) T-score is abstract because it references the United States average and not specific tasks. The purposes of this study were to (1) determine convergent validity of the PROMIS PF scale with physical performance tests; (2) compare predicted performance test values to normative data; and (3) identify sets of PROMIS PF items similar to performance tests that also scale in increasing difficulty and align with normative data.

Methods: Community-dwelling older adults (n = 45; age = 77.1 ± 4.6 years) were recruited for this cross-sectional analysis of PROMIS PF and physical performance tests. The modified Physical Performance Test (mPPT), a multicomponent test of mostly timed items, was completed during the same session as the PROMIS PF scale. Regression analysis examined the relationship of mPPT total and component scores (walking velocity, stair ascent, and 5 times sit to stand) with the PROMIS PF scale T-scores. Normative data were compared with regression-predicted mPPT timed performance across PROMIS PF T-scores. The PROMIS PF items most similar to walking, stair ascent, or sit to stand were identified and then PROMIS PF model parameter-calibrated T-scores for these items were compared alongside normative data.

Results And Discussion: There were statistically significant correlations (r = 0.32-0.64) between PROMIS PF T-score and mPPT total and component scores. Regression-predicted times for walking, stair ascent, and sit-to-stand tasks (based on T-scores) aligned with published normative values for older adults. Selected PF items for stair ascent and walking scaled well to discriminate increasing difficulty; however, sit-to-stand items discriminated only lower levels of functioning.

Conclusions: The PROMIS PF T-scores showed convergent validity with physical performance and aligned with published normative data. While the findings are not predictive of individual performance, they improve clinical interpretation by estimating a range of expected performance for walking, stair ascent, and sit to stand. These findings support application of T-scores in physical therapy testing, goal setting, and wellness plans of care for community-dwelling older adults.
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January 2021

COMPARISON OF NON-CONTACT AND CONTACT TIME-LOSS LOWER QUADRANT INJURY RATES IN MALE COLLEGIATE BASKETBALL PLAYERS: A PRELIMINARY REPORT.

Int J Sports Phys Ther 2018 Dec;13(6):963-972

Clackamas Community College, Oregon City, OR, USA.

Background: Male collegiate basketball (BB) players are at risk for musculoskeletal injury. The rate of time-loss injury in men's collegiate BB, for levels of National Collegiate Athletic Association (NCAA) competition, ranges from 2.8 to 4.3 per 1000 athletic exposures (AE) during practices and 4.56 to 9.9 per 1000 AE during games. The aforementioned injury rates provide valuable information for sports medicine professionals and coaching staffs. However, many of the aforementioned studies do not provide injury rates based on injury mechanism, region of the body, or player demographics.

Hypothesis/ Purpose: The purpose of this study is two-fold. The first purpose of this study was to report lower quadrant (LQ = lower extremities and low back region) injury rates, per contact and non-contact mechanism of injury, for a cohort of male collegiate basketball (BB) players. The second purpose was to report injury risk based on prior history of injury, player position, and starter status.

Study Design: Prospective, descriptive, observational cohort.

Methods: A total of 95 male collegiate BB players (mean age 20.02 ± 1.68 years) from 7 teams (NCAA Division II = 14, NCAA Division III = 43, NAIA = 21, community college = 17) from the Portland, Oregon region were recruited during the 2016-2017 season to participate in this study. Each athlete was asked to complete an injury history questionnaire. The primary investigator collected the following information each week from each team's athletic trainer: athletic exposures (AE; 1 AE = game or practice) and injury updates.

Results: Thirty-three time-loss LQ injuries occurred during the study period. The overall time-loss injury rate was 3.4 per 1000 AE. Division III BB players had the highest rates of injury. There was no difference in injury rates between those with or without prior injury history. Guards had a significantly greater rate of non-contact time-loss injuries ( = 0.04).

Conclusions: Guards experienced a greater rate of LQ injury than their forward/center counterparts. Starters and athletes with a prior history of injury were no more likely to experience a non-contact time-loss injury than nonstarters or those without a prior history of injury. These preliminary results are a novel presentation of injury rates and risk for this population and warrant continued investigation.

Level Of Evidence: 2.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6253759PMC
December 2018

Psychometric evaluation of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function and Pain Interference Computer Adaptive Test for subacromial impingement syndrome.

J Shoulder Elbow Surg 2019 Feb 18;28(2):324-329. Epub 2018 Oct 18.

Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, USA. Electronic address:

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test (CAT) was previously validated for rotator cuff disease and shoulder instability. This study evaluated the psychometric properties of the PROMIS Physical Function (PF) CAT, PROMIS Pain Interference (PI) CAT, and the American Shoulder and Elbow Surgeons (ASES) Shoulder Function Score for subacromial impingement syndrome.

Methods: PROMIS PF CAT, PI CAT, and ASES (Pain, Function, Total) were collected on all visits for 2 surgeons between January 2016 and August 2016. New patients, aged 18 years and older, were selected by International Classification of Diseases code for impingement syndrome of the shoulder. The mean number of questions answered determined efficiency. Person-item maps were created to determine ceiling and floor effects as well as person reliability. Convergent validity was determined by comparison of PROMIS domains to ASES scores with Pearson correlations.

Results: For PROMIS PF CAT, the mean number of items answered was 4.54 (range 4-12). The ceiling effect was 1.56%, and the floor effect was 3.13%. The person reliability was 0.94. Pearson correlation coefficients between the PF CAT and ASES were 0.664 (ASES Function), 0.426 (ASES Pain), and 0.649 (ASES Total). For PROMIS PI CAT, the mean number of items answered was 4.27 (range 3-11). The ceiling effect was 4.69%, and the floor effect was 8.33%. The person reliability was 0.92. Pearson correlation coefficients between the PI CAT and ASES were: 0.667 (ASES Function), 0.594 (ASES Pain), and 0.729 (ASES Total).

Conclusions: The psychometric properties of PROMIS PF and PI CATs were favorable for subacromial impingement syndrome.
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http://dx.doi.org/10.1016/j.jse.2018.07.024DOI Listing
February 2019

Ability of Patient-Reported Outcomes to Characterize Patient Acceptable Symptom State (PASS) After Attending a Primary Care Physical Therapist and Medical Doctor Collaborative Service: A Cross-Sectional Study.

Arch Phys Med Rehabil 2019 01 13;100(1):60-66. Epub 2018 Sep 13.

Providence Medical Group, Newberg, OR.

Objectives: To determine if the Patient-Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, self-efficacy, and global rating of normal function (GRNF) scales are able to accurately characterize a patient's acceptable symptom state (PASS).

Design: A cross-sectional analysis, using receiver operator curves and chi-square analysis to explore criteria to determine thresholds (80% and 95% sensitivity/specificity) for PASS that are applicable to PROMIS and GRNF scales.

Setting: Phone survey after primary care.

Participants: Patients (N=94) attending primary care for musculoskeletal problems.

Interventions: Not applicable.

Main Outcomes Measures: Accuracy and proportion of patients classified as PASS Yes or No.

Results: Receiver operator curve analysis showed significant area under the curve (AUC) values for each PROMIS scale (AUC>.72) and the GRNF rating (AUC=.74). Identified PROMIS thresholds suggested PASS was achieved when scores were at or slightly worse than the US population average. A score of ≥7 and ≤4 characterized patients that were PASS Yes and No, respectively, on the GRNF rating. A moderate (80%) specificity/sensitivity criteria yielded 72.3%-73.5% accuracy for a majority of participants (>69.9%).

Conclusion: This analysis suggests the PROMIS and GRNF scales are able to characterize PASS status with moderate accuracy (∼70%) for a large portion of patients (∼70%). New to this study is the association of self-efficacy with PASS status. PROMIS scales at or slightly worse than the US population average characterized PASS status.
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January 2019

Preoperative Patient Reported Outcomes Measurement Information System Scores Assist in Predicting Early Postoperative Success in Lumbar Discectomy.

Spine (Phila Pa 1976) 2019 03;44(5):325-333

Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, New York.

Study Design: Retrospective review of prospective data.

Objective: Determine whether patient reported outcome (PRO) data collected prior to lumbar discectomy predicts achievement of a minimal important difference (MID) after surgery. Compare ability of PRO and clinical information to predict achievement of MID in short term follow-up after discectomy.

Summary Of Background Data: We investigated the ability of patient reported outcomes measurement information system (PROMIS) and clinical factors at the preoperative time point to determine patients achieving MID after surgery.

Methods: PROMIS physical function (PF), pain interference (PI), and depression (D) scores were assessed at evaluation and follow-up for consecutive visits between February, 2015 and September, 2017. Patients with preoperative scores within 30 days prior to surgery and with scores 40 days or more after surgery who completed all PROMIS domains were included yielding 78 patients. MIDs were calculated using a distribution-based method. A multivariate logistic regression model was created, and the ability to predict achieving MID for each of the PROMIS domains was assessed. Cut-off values and prognostic probabilities were determined for this model and models combining preoperative PROMIS with clinical data.

Results: Preoperative PROMIS scores modestly predict reaching MID after discectomy (areas under the curve [AUC] of 0.62, 0.68, and 0.76 for PF, PI, and D, respectively). Preoperative cut-off scores show patients who have PF and PI scores more than 2 standard deviations, and D more than 1.5 standard deviations worse-off than population mean are likely to achieve MID. The combination of PROMIS with clinical data was the most powerful predictor of reaching MID with AUCs of 0.87, 0.84, and 0.83 for PF, PI, and D.

Conclusion: PROMIS scores before discectomy modestly predict improvement after surgery. Preoperative PROMIS combined with clinical factors was more predictive of achieving MID than either clinical factors or PROMIS alone.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002823DOI Listing
March 2019

Preoperative PROMIS Scores Predict Postoperative PROMIS Score Improvement for Patients Undergoing Hand Surgery.

Hand (N Y) 2020 03 3;15(2):185-193. Epub 2018 Aug 3.

University of Rochester Medical Center, NY, USA.

Patient-Reported Outcomes Measurement Information System (PROMIS) can be used alongside preoperative patient characteristics to set postsurgery expectations. This study aimed to analyze whether preoperative scores can predict significant postoperative PROMIS score improvement. Patients undergoing hand and wrist surgery with initial and greater than 6-month follow-up PROMIS scores were assigned to derivation or validation cohorts, separating trauma and nontrauma conditions. Receiver operating characteristic curves were calculated for the derivation cohort to determine whether preoperative PROMIS scores could predict postoperative PROMIS score improvement utilizing minimal clinically important difference principles. In the nontrauma sample, patients with baseline Physical Function (PF) scores below 31.0 and Pain Interference (PI) and Depression scores above 68.2 and 62.2, respectively, improved their postoperative PROMIS scores with 95%, 96%, and 94% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 49.5 and 39.5, respectively, did not substantially improve their postoperative PROMIS scores with 94%, 93%, and 96% sensitivity. In the trauma sample, patients with baseline PF scores below 34.8 and PI and Depression scores above 69.2 and 62.2, respectively, each improved their postoperative PROMIS scores with 95% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 46.6 and 44.0, respectively, did not substantially improve their postoperative scores with 95%, 94%, and 95% sensitivity. Preoperative PROMIS PF, PI, and Depression scores can predict postoperative PROMIS score improvement for a select group of patients, which may help in setting expectations. Future work can help determine the level of true clinical improvement these findings represent.
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http://dx.doi.org/10.1177/1558944718791188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076609PMC
March 2020

Validity of Visual Assessment of Sit to Stand After Hip Fracture.

J Geriatr Phys Ther 2020 Jan/Mar;43(1):12-19

Doctor of Physical Therapy Program, George Fox University, Newberg, Oregon.

Background And Purpose: When treating older adults post-hip fracture, physical therapists routinely assess the sit-to-stand (STS) task using observational analysis. Studies have demonstrated that significant movement asymmetries in ground reaction force production of the fractured lower limb persist during STS, even though individuals may rise independently. To date, the validity of therapist judgments of lower limb force during STS has not been addressed. The purpose of this observational cohort study was to determine the accuracy of physical therapists' observational assessments of STS for detecting the involved limb and its ground reaction force contribution in older adults post-hip fracture.

Methods: Eighteen home health physical therapists assessed 10 videotapes of older adults post-hip fracture rising from sitting and judged the side of involvement and the amount of ground reaction force generated by the fractured lower limb. Each videotape was synchronized with its respective force data. A wide spectrum of asymmetry in rising was represented in the test videos. Before making these judgments, the therapists viewed a separate set of training videos and received instructions in the use of specific visual cues to assist with subsequent judgments.

Results And Discussion: Therapists judged the involved side correctly 74% of the time. Mean accuracy in judging ground reaction force output was 39% across all therapists. Force symmetry did not significantly influence accuracy of force judgments. Inaccurate judgments of force may limit therapeutic intensity and minimize the potential for developing motor strategies that favor force production of the involved limb. Augmenting observational analysis of STS with quantitative data could assist in optimizing restorative function.

Conclusion: Judgments of lower limb ground reaction force output during STS based on observation alone are not valid and may need to be supplemented with quantitative data.
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http://dx.doi.org/10.1519/JPT.0000000000000197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218325PMC
December 2020

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018.

J Orthop Sports Phys Ther 2018 05;48(5):A1-A38

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.
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May 2018

Validation and Generalizability of Preoperative PROMIS Scores to Predict Postoperative Success in Foot and Ankle Patients.

Foot Ankle Int 2018 07 5;39(7):763-770. Epub 2018 Apr 5.

1 University of Rochester, Rochester NY, USA.

Background: A recent publication reported preoperative Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) scores to be highly predictive in identifying patients who would and would not benefit from foot and ankle surgery. Their applicability to other patient populations is unknown. The aim of this study was to assess the validation and generalizability of previously published preoperative PROMIS physical function (PF) and pain interference (PI) threshold t scores as predictors of postoperative clinically meaningful improvement in foot and ankle patients from a geographically unique patient population.

Methods: Prospective PROMIS PF and PI scores of consecutive patient visits to a tertiary foot and ankle clinic were obtained between January 2014 and November 2016. Patients undergoing elective foot and ankle surgery were identified and PROMIS values obtained at initial and follow-up visits (average, 7.9 months). Analysis of variance was used to assess differences in PROMIS scores before and after surgery. The distributive method was used to estimate a minimal clinically important difference (MCID). Receiver operating characteristic curve analysis was used to determine thresholds for achieving and failing to achieve MCID. To assess the validity and generalizability of these threshold values, they were compared with previously published threshold values for accuracy using likelihood ratios and pre- and posttest probabilities, and the percentages of patients identified as achieving and failing to achieve MCID were evaluated using χ analysis.

Results: There were significant improvements in PF ( P < .001) and PI ( P < .001) after surgery. The area under the curve for PF (0.77) was significant ( P < .01), and the thresholds for achieving MCID and not achieving MCID were similar to those in the prior study. A significant proportion of patients (88.9%) identified as not likely to achieve MCID failed to achieve MCID ( P = .03). A significant proportion of patients (84.2%) identified as likely to achieve MCID did achieve MCID ( P < .01). The area under the curve for PROMIS PI was not significant.

Conclusions: PROMIS PF threshold scores from published data were successful in classifying patients from a different patient and geographic population who would improve with surgery. If functional improvement is the goal, these thresholds could be used to help identify patients who will benefit from surgery and, most important, those who will not, adding value to foot and ankle health care.

Level Of Evidence: Level II, Prospective Comparative Study.
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http://dx.doi.org/10.1177/1071100718765225DOI Listing
July 2018

Ankle and Midfoot Power During Walking and Stair Ascent in Healthy Adults.

J Appl Biomech 2018 Aug 14;34(4):262-269. Epub 2018 Jul 14.

3 George Fox University.

Ankle power dominates forward propulsion of gait, but midfoot power generation is also important for successful push-off. However, it is unclear if midfoot power generation increases or stays the same in response to propulsive activities that induce larger external loads and require greater ankle power. The purpose of this study was to examine ankle and midfoot power in healthy adults during progressively more demanding functional tasks. Multisegment foot motion (tibia, calcaneus, and forefoot) and ground reaction forces were recorded as participants (N = 12) walked, ascended a standard step, and ascended a high step. Ankle and midfoot positive peak power and positive total power, and the proportion of midfoot to ankle positive total power were calculated. One-way repeated-measures analyses of variance were conducted to evaluate differences across tasks. Main effects were found for ankle and midfoot peak and total powers (all Ps < .01), but not for the proportion of midfoot-to-ankle total power (P = .33). Ankle and midfoot power significantly increased across each task. Midfoot power increased in proportion to ankle power and in congruence to the external load of a task. Study findings may serve to inform multisegment foot modeling applications and internal mechanistic theories of normal and pathological foot function.
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http://dx.doi.org/10.1123/jab.2017-0095DOI Listing
August 2018

Asymmetries Identified in Sit-to-Stand Task Explain Physical Function After Hip Fracture.

J Geriatr Phys Ther 2018 Oct/Dec;41(4):210-217

Department of Physical Therapy, College of Health, University of Utah, Salt Lake City, Utah.

Background: Several known demographic and functional characteristics combine to predict physical function after hip fracture. Long-term weight-bearing asymmetries, evident during functional movements after hip fracture, contribute to limited mobility and large asymmetries in muscle function are linked to a high rate of injurious falls. Although postfracture mobility is commonly measured as whole body movement, a force-plate imbedded chair can identify individual limb contributions to an important task like moving from a sitting to standing position. The modified Physical Performance Test (mPPT) and stair climb test (SCT) are reliable, valid measures of function that predict independence after hip fracture. The purpose of this study was to determine to what extent asymmetry during a sit-to-stand task (STST) predicts function (mPPT, 12-step SCT), above and beyond other known predictors.

Methods: Thirty-one independent community-dwelling older adults, recently discharged from usual care physical therapy (mean [standard deviation], 77.7 [10.5] years, 10 male), within 2 to 8 months postfracture, volunteered for this study. Participants performed an STST on a force-plate-imbedded chair designed to identify individual limb contributions during an STST. Asymmetry magnitude during the STST was determined for each individual. In addition, mPPT and SCT were assessed and regression analyses were performed to determine the contribution of asymmetry to the variance in these physical function scores beyond other factors predicting function.

Results: Demographic factors (sex, time since fracture, repair type, and body mass index) were not significantly related to function in this sample. Age, gait speed, knee extension strength, balance confidence, and functional self-report were each significantly related to both mPPT (r = 0.43-0.86) and SCT (r = 0.40-0.83), and were retained in the regression model. Included variables accounted for 83.4% of the variance in mPPT score, and asymmetry during the STST did not significantly contribute to explaining variability in mPPT (P = .23). Variables in the regression model accounted for 78.0% of the variance in SCT score, and STST asymmetry explained 7.1% (P < .005) of the variance in SCT score.

Discussion: In this small sample, asymmetry contributed significantly to explaining the variability in SCT performance, but not mPPT score. The SCT requires greater unilateral strength and control than the battery of items that comprise the mPPT. This contributes to the disproportionate number of falls occurring during stair ambulation (>10% of all fall-related deaths), relative to the minimal time typically involved in stair negotiation. Our results indicate potential benefit to identifying injured limb asymmetries as they predict function in challenging, high-risk functional tasks after hip fracture.

Conclusion: Although gait speed is the best explanator of physical function in older adults after hip fracture, lower extremity asymmetry during an STST provides a unique contribution to explaining high-level ambulatory performance after hip fracture. Efforts to reduce weight-bearing asymmetry during rehabilitation following hip fracture may improve function and recovery.
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September 2019

Patients With Insertional Achilles Tendinopathy Exhibit Differences in Ankle Biomechanics as Opposed to Strength and Range of Motion.

J Orthop Sports Phys Ther 2016 Dec 29;46(12):1051-1060. Epub 2016 Oct 29.

Study Design Controlled laboratory study; cross-sectional. Background Little is known about ankle range of motion (ROM) and strength among patients with insertional Achilles tendinopathy (IAT) and whether limited ankle ROM and plantar flexor weakness impact IAT symptom severity. Objectives The purposes of the study were (1) to examine whether participants with IAT exhibit limited non-weight-bearing dorsiflexion ROM, reduced plantar flexor strength, and/or altered ankle biomechanics during stair ascent; and (2) to determine which impairments are associated with symptom severity. Methods Participants included 20 patients with unilateral IAT (mean ± SD age, 59 ± 8 years; 55% female) and 20 individuals without tendinopathy (age, 58.2 ± 8.5 years; 55% female). A dynamometer was used to measure non-weight-bearing ROM and isometric plantar flexor strength. Three-dimensional motion analysis was used to quantify ankle biomechanics during stair ascent. End-range dorsiflexion was quantified as the percentage of non-weight-bearing dorsiflexion used during stair ascent. Group differences were compared using 2-way and 1-way analyses of variance. Pearson correlations were used to test for associations among dependent variables and symptom severity. Results Groups differed in ankle biomechanics, but not non-weight-bearing ROM or strength. During stair ascent, the IAT group used greater end-range dorsiflexion (P = .03), less plantar flexion (P = .02), and lower peak ankle plantar flexor power (P = .01) than the control group. Higher end-range dorsiflexion and lower ankle power during stair ascent were associated with greater symptom severity (P<.05). Conclusion Patients with IAT do not experience restrictions in non-weight-bearing dorsiflexion ROM or isometric plantar flexor strength. However, altered ankle biomechanics during stair ascent were linked with greater symptom severity and likely contribute to decreased function. J Orthop Sports Phys Ther 2016;46(12):1051-1060. Epub 29 Oct 2016. doi:10.2519/jospt.2016.6462.
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December 2016

Preoperative PROMIS Scores Predict Postoperative Success in Foot and Ankle Patients.

Foot Ankle Int 2016 Sep 16;37(9):911-8. Epub 2016 Aug 16.

Department of Orthopaedics, University of Rochester, Rochester, NY, USA

Background: The use of patient-reported outcomes continues to expand beyond the scope of clinical research to involve standard of care assessments across orthopedic practices. It is currently unclear how to interpret and apply this information in the daily care of patients in a foot and ankle clinic. We prospectively examined the relationship between preoperative patient-reported outcomes (PROMIS Physical Function, Pain Interference and Depression scores), determined minimal clinical important differences for these values, and assessed if these preoperative values were predictors of improvement after operative intervention.

Methods: Prospective collection of all consecutive patient visits to a multisurgeon tertiary foot and ankle clinic was obtained between February 2015 and April 2016. This consisted of 16 023 unique visits across 7996 patients, with 3611 new patients. Patients undergoing elective operative intervention were identified by ICD-9 and CPT code. PROMIS physical function, pain interference, and depression scores were assessed at initial and follow-up visits. Minimum clinically important differences (MCIDs) were calculated using a distribution-based method. Receiver operating characteristic (ROC) curves were calculated to determine whether preoperative PROMIS scores were predictive of achieving MCID. Cutoff values for PROMIS scores that would predict achieving MCID and not achieving MCID with 95% specificity were determined. Prognostic pre- and posttest probabilities based off these cutoffs were calculated. Patients with a minimum of 7-month follow-up (mean 9.9) who completed all PROMIS domains were included, resulting in 61 patients.

Results: ROC curves demonstrated that preoperative physical function scores were predictive of postoperative improvement in physical function (area under the curve [AUC] 0.83). Similarly, preoperative pain interference scores were predictive of postoperative pain improvement (AUC 0.73) and preoperative depression scores were also predictive of postoperative depression improvement (AUC 0.74). Patients with preoperative physical function T score below 29.7 had an 83% probability of achieving a clinically meaningful improvement in function as defined by MCID. Patients with preoperative physical function T score above 42 had a 94% probability of failing to achieve MCID. Patients with preoperative pain above 67.2 had a 66% probability of achieving MCID, whereas patients with preoperative pain below 55 had a 95% probability of failing to achieve MCID. Patients with preoperative depression below 41.5 had a 90% probability of failing to achieve MCID.

Conclusion: Patient-reported outcomes (PROMIS) scores obtained preoperatively predicted improvement in foot and ankle surgery. Threshold levels in physical function, pain interference, and depression can be shared with patients as they decide whether surgery is a good option and helps place a numerical value on patient expectations. Physical function scores below 29.7 were likely to improve with surgery, whereas those patients with scores above 42 were unlikely to make gains in function. Patients with pain scores less than 55 were similarly unlikely to improve, whereas those with scores above 67 had clinically significant pain reduction postoperatively. Reported prognostic cutoff values help to provide guidance to both the surgeon and the patient and can aid in shared decision making for treatment.

Level Of Evidence: Level II, prognostic study.
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September 2016

Utility of Ultrasound for Imaging Osteophytes in Patients With Insertional Achilles Tendinopathy.

Arch Phys Med Rehabil 2016 07 29;97(7):1206-9. Epub 2015 Dec 29.

Department of Orthopedic Surgery, University of Rochester, Rochester, NY.

Objectives: To examine (1) the validity of ultrasound imaging to measure osteophytes and (2) the association between osteophytes and insertional Achilles tendinopathy (IAT).

Design: Case-control study.

Setting: Academic medical center.

Participants: Persons with chronic unilateral IAT (n=20; mean age, 58.7±8.3y; 10 [50%] women) and age- and sex-matched controls (n=20; mean age, 57.4±9.8y; 10 [50%] women) participated in this case-control study (N=40).

Interventions: Not applicable.

Main Outcome Measures: Symptom severity was assessed using the Foot and Ankle Ability Measure, the Victorian Institute of Sport Assessment-Achilles questionnaire, and the numerical rating scale. Length of osteophytes was measured bilaterally in both groups using ultrasound imaging, as well as on the symptomatic side of the IAT group using radiography. The intraclass correlation coefficient was used to examine the agreement between ultrasound and radiograph measures. McNemar, Wilcoxon signed-rank, and Fisher exact tests were used to compare the frequency and length of osteophytes between sides and groups. Pearson correlation was used to examine the association between osteophyte length and symptom severity.

Results: There was good agreement (intraclass correlation coefficient, ≥.75) between ultrasound and radiograph osteophyte measures. There were no statistically significant differences (P>.05) in the frequency of osteophytes between sides or groups. Osteophytes were larger on the symptomatic side of the IAT group than on the asymptomatic side (P=.01) and on the left side of controls (P=.03). There was no association between osteophyte length and symptom severity.

Conclusions: Ultrasound imaging is a valid measure of osteophyte length, which is associated with IAT. Although a larger osteophyte indicates tendinopathy, it does not indicate more severe IAT symptoms.
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http://dx.doi.org/10.1016/j.apmr.2015.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921278PMC
July 2016

Multi-joint foot kinetics during walking in people with Diabetes Mellitus and peripheral neuropathy.

J Biomech 2015 Oct 21;48(13):3679-84. Epub 2015 Aug 21.

University of Rochester, Department of Orthopaedics, 601 Elmwood Ave, Rochester, NY 14642, USA.

Neuropathic tissue changes can alter muscle function and are a primary reason for foot pathologies in people with Diabetes Mellitus and peripheral neuropathy (DMPN). Understanding of foot kinetics in people with DMPN is derived from single-segment foot modeling approaches. This approach, however, does not provide insight into midfoot power and work. Gaining an understanding of midfoot kinetics in people with DMPN prior to deformity or ulceration may help link foot biomechanics to anticipated pathologies in the midfoot and forefoot. The purpose of this study was to evaluate midfoot (MF) and rearfoot (RF) power and work in people with DMPN and a healthy matched control group. Thirty people participated (15 DMPN and 15 Controls). An electro-magnetic tracking system and force plate were used to record multi-segment foot kinematics and ground reaction forces during walking. MF and RF power, work, and negative work ratios were calculated and compared between groups. Findings demonstrated that the DMPN group had greater negative peak power and reduced positive peak power at the MF and RF (all p≤0.05). DMPN group negative work ratios were also greater at the MF and RF [Mean difference MF: 9.9%; p=0.24 and RF: 18.8%; p<0.01]. In people with DMPN, the greater proportion of negative work may negatively affect foot structures during forward propulsion, when positive work and foot stability should predominate. Further study is recommended to determine how both MF and RF kinetics influence the development of deformity and ulceration in people with DMPN.
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http://dx.doi.org/10.1016/j.jbiomech.2015.08.020DOI Listing
October 2015

Individual metatarsal and forefoot kinematics during walking in people with diabetes mellitus and peripheral neuropathy.

Gait Posture 2015 Oct 22;42(4):435-41. Epub 2015 Jul 22.

University of Rochester, Department of Orthopaedics, 601 Elmwood Ave, Rochester, NY 14642, USA. Electronic address:

The purpose of this study was to compare in-vivo kinematic angular excursions of individual metatarsal segments and a unified forefoot segment in people with Diabetes Mellitus and peripheral neuropathy (DMPN) without deformity or ulceration to a healthy matched control group. Thirty subjects were recruited. A five- segment foot model (1st, 3rd, and 5th metatarsals, calcaneus, tibia) was used to examine relative 3D angular excursions during the terminal stance phase of walking. Student t-tests were used to assess group differences in kinematics. Pearson correlations and cross-correlations were used to assess relationships between the motion of the individual metatarsals and the unified forefoot. Significant reductions of DMPN group sagittal plane angular excursions were detected in all individual metatarsals and the unified forefoot (p < 0.01). Frontal plane 3rd metatarsal excursion was reduced (p = 0.04) in the DMPN group. The 3rd and 5th metatarsal and the unified forefoot excursions were reduced (p ≤ 0.02) in the DMPN group in the transverse plane. In both groups, coupling of individual metatarsal and unified forefoot motion was strongest in the sagittal plane. This study illustrates that multiple individual metatarsals have reduced motion in people with DMPN. Differences in the magnitude and coupling between individual metatarsal motion and unified forefoot motion supports the use of a two segment forefoot modeling approach in future kinematic analyses. Further study is recommended to determine if the observed kinematic profile is related to the development and location of deformity and tissue breakdown in people with DMPN.
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http://dx.doi.org/10.1016/j.gaitpost.2015.07.012DOI Listing
October 2015

Randomized Controlled Trial Comparing Orthosis Augmented by Either Stretching or Stretching and Strengthening for Stage II Tibialis Posterior Tendon Dysfunction.

Foot Ankle Int 2015 Sep 9;36(9):1006-16. Epub 2015 Apr 9.

University of Rochester Medical Center, Department of Orthopedic Surgery, Rochester, NY, USA.

Background: The value of strengthening and stretching exercises combined with orthosis treatment in a home-based program has not been evaluated. The purpose of this study was to compare the effects of augmenting orthosis treatment with either stretching or a combination of stretching and strengthening in participants with stage II tibialis posterior tendon dysfunction (TPTD).

Methods: Participants included 39 patients with stage II TPTD who were recruited from a medical center and then randomly assigned to a strengthening or stretching treatment group. Excluding 3 dropouts, there were 19 participants in the strengthening group and 17 in the stretching group. The stretching treatment consisted of a prefabricated orthosis used in conjunction with stretching exercises. The strengthening treatment consisted of a prefabricated orthosis used in conjunction with the stretching and strengthening exercises. The main outcome measures were self-report (ie, Foot Function Index and Short Musculoskeletal Function Assessment) and isometric deep posterior compartment strength. Two-way analysis of variance was used to test for differences between groups at 6 and 12 weeks after starting the exercise programs.

Results: Both groups significantly improved in pain and function over the 12-week trial period. The self-report measures showed minimal differences between the treatment groups. There were no differences in isometric deep posterior compartment strength.

Conclusions: A moderate-intensity, home-based exercise program was minimally effective in augmenting orthosis wear alone in participants with stage II TPTD.

Level Of Evidence: Level I, prospective randomized study.
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http://dx.doi.org/10.1177/1071100715579906DOI Listing
September 2015
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