Publications by authors named "Sara Piva"

83 Publications

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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December 2020

Transcranial direct current stimulation for fatigue in patients with Sjogren's syndrome: A randomized, double-blind pilot study.

Brain Stimul 2021 Jan-Feb;14(1):141-151. Epub 2020 Dec 17.

Rheumatologist. Discipline of Emergency and Evidence-Based Medicine, EPM - UNIFESP, São Paulo, SP, Brazil.

Background: Transcranial direct-current stimulation (tDCS) has shown promise to decrease fatigue. However, it has never been examined in primary Sjogren Syndrome (pSS).

Objective: To assess the effect of a tDCS protocol on fatigue in patients with pSS.

Methods: This is a parallel, double-blind pilot study (NCT04119128). Women aged 18-65 years, with pSS, on stable pharmacological therapy, with complaints of fatigue for at least three months, and with scores >5 on Fatigue Severity Scale (FSS) were included. We randomized 36 participants to receive five consecutive or sham tDCS sessions, with an intensity of 2 mA, for 20 min/day.

Results: After five tDCS sessions, fatigue severity assessed by the FSS (primary outcome) demonstrated a mean group difference of -0.85 [95% confidence interval (CI) -1.57, -0.13; effect size 0.80] favouring the active group. The active group presented significantly greater reductions in fatigue as measured by the EULAR Sjögren's Syndrome Patient Reported Index after five tDCS sessions [mean group difference: 1.40; 95%CI -2.33, -0.48; effect size 1.04]. Although there were no between-group differences in the secondary outcomes of sleep, mood and anxiety, within-group comparisons evidenced a small but significant difference in the active group for pain and sleep. There were no significant cortisol changes. All reported adverse events were mild and transitory.

Conclusion: tDCS seems to be safe and reduce fatigue in pSS. A differential effect on pain and sleep may underlie its effects. Further studies are needed to optimise tDCS treatment strategies in pSS.
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December 2020

Jump power, leg press power, leg strength and grip strength differentially associated with physical performance: The Developmental Epidemiologic Cohort Study (DECOS).

Exp Gerontol 2021 Mar 24;145:111172. Epub 2020 Nov 24.

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA. Electronic address:

Background: Weight-bearing jump tests that measure lower-extremity muscle power may be more strongly related to physical performance measures vs. non-weight-bearing leg press power, leg press strength and grip strength. We investigated if multiple muscle function measures differentially related to standard physical performance measures.

Materials/methods: In the Developmental Epidemiologic Cohort Study (DECOS; N = 68; age 78.5 ± 5.5 years; 57% women; 7% minorities), muscle function measures included power in Watts/kg (functional, weight-bearing: jump; mechanical: Nottingham power rig; Keiser pneumatic leg press) and strength in kg/kg body weight (Keiser pneumatic leg press; hand-held dynamometry). Physical performance outcomes included 6 m usual gait speed (m/s), usual-paced 400 m walk time (seconds), and 5-repeated chair stands speed (stands/s).

Results: Women (N = 31; 79.8 ± 5.0 years) had lower muscle function and slower gait speed compared to men (N = 25; 78.7 ± 6.6 years), though similar 400 m walk time and chair stands speed. In partial Pearson correlations adjusted for age, sex, race and height, muscle function measures were moderately to strongly correlated with each other (all p < 0.05), though the individual correlations varied. In multiple regression analyses, each muscle function measure was statistically associated with all physical performance outcomes in models adjusted for age, sex, race, height, self-reported diabetes, self-reported peripheral vascular disease and self-reported pain in legs/feet (all p < 0.05). Jump power (β = 0.75) and grip strength (β = 0.71) had higher magnitudes of association with faster gait speed than lower-extremity power and strength measures (β range: 0.32 to 0.58). Jump power (β = 0.56) had a slightly lower magnitude of association with faster 400 m walk time vs. Keiser power (β = 0.61), and a higher magnitude of association vs. Nottingham power, Keiser strength and grip strength (β range: 0.41 to 0.47). Jump power (β = 0.38) had a lower magnitude of association with chair stands speed than any other power or strength measures (β range: 0.50 to 0.65).

Conclusions: Jump power/kg and grip strength/kg may be more strongly related to faster gait speed, a standard measure of physical function and vital sign related to disability and mortality in older adults, compared to leg press power/strength. However, jump power/kg had a similar magnitude of association with 400 m walk time as Keiser power/kg and a lower magnitude of association with faster chair stands speed than the other muscle function measures. Importantly, choice of muscle function measures should carefully reflect the study focus and methodologic considerations, including population.
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March 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: NCT02646761 ": A Portable Joint Function Monitoring and Training System for Remote Rehabilitation Following TKA" 6 January 2016.
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October 2020

Extended Perineural Analgesia After Hip and Knee Replacement When Buprenorphine-Clonidine-Dexamethasone Is Added to Bupivacaine: Preliminary Report from a Randomized Clinical Trial.

Pain Med 2020 11;21(11):2893-2902

Physical Therapy-Clinical Translational Research Center, Pittsburgh, Pennsylvania.

Objective: We tested the hypothesis that buprenorphine-clonidine-dexamethasone (BCD) extends perineural analgesia compared with plain bupivacaine (BPV) nerve blocks used for hip and knee replacement surgery.

Design: Prospective, parallel-arms, randomized, double-blind trial.

Setting: A single veterans' hospital.

Subjects: Seventy-eight veterans scheduled for total hip or knee replacement with plans for spinal as the primary anesthetic.

Methods: Participants underwent nerve/plexus blocks at L2-L4 and L4-S3 in advance of hip or knee joint replacement surgery. Patients were randomized to receive BPV-BCD or plain BPV in a 4:1 allocation ratio. Patients answered four block duration questions (listed below). Time differences between treatments were analyzed using the t test.

Results: Significant (P < 0.001) prolongation of the time parameters was reported by patients after the BPV-BCD blocks (N = 62) vs plain BPV (N = 16). The time until start of postoperative pain was 26 vs 11 hours (mean difference = 15 hours, 95% CI = 8 to 21). The time until no pain relief from the blocks was 32 vs 15 hours (mean difference = 17 hours, 95% CI = 10 to 24). The time until the numbness wore off was 37 vs 21 hours (mean difference = 16 hours, 95% CI = 8 to 23). The time until the worst postoperative pain was 39 vs 20 hours (mean difference = 19 hours, 95% CI = 11 to 27).

Conclusions: BPV-BCD provided 26-39 hours of perineural analgesia in the L2-L4 and L4-S3 nerve distributions after hip/knee replacement surgery, compared with 11-21 hours for plain BPV.
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November 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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August 2020

Associations between novel jump test measures, grip strength, and physical performance: the Osteoporotic Fractures in Men (MrOS) Study.

Aging Clin Exp Res 2020 Apr 18;32(4):587-595. Epub 2019 Dec 18.

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 N. Bellefield Ave., Suite 300, Pittsburgh, PA, 15213, USA.

Background/aims: Weight-bearing jump tests measure lower extremity muscle power, velocity, and force, and may be more strongly related to physical performance than grip strength. However, these relationships are not well described in older adults.

Methods: Participants were 1242 older men (mean age 84 ± 4 years) in the Osteoporotic Fractures in Men (MrOS) Study. Jump peak power (Watts/kg body weight), force (Newton/kg body weight) at peak power, and velocity (m/s) at peak power were measured by jump tests on a force plate. Grip strength (kg/kg body weight) was assessed by hand-held dynamometry. Physical performance included 400 m walk time (s), 6 m usual gait speed (m/s), and 5-repeated chair stands speed (#/s).

Results: In adjusted Pearson correlations, power/kg and velocity moderately correlated with all performance measures (range r = 0.41-0.51; all p < 0.001), while correlations for force/kg and grip strength/kg were weaker (range r = 0.20-0.33; all p < 0.001). Grip strength/kg moderately correlated with power/kg (r = 0.44; p < 0.001) but not velocity or force/kg. In adjusted linear regression with standardized βs, 1 SD lower power/kg was associated with worse: 400 m walk time (β = 0.47), gait speed (β = 0.42), and chair stands speed (β = 0.43) (all p < 0.05). Associations with velocity were similar (400 m walk time: β = 0.42; gait speed: β = 0.38; chair stands speed: β = 0.37; all p < 0.05). Force/kg and grip strength/kg were more weakly associated with performance (range β = 0.18-0.28; all p < 0.05).

Conclusions/discussion: Jump power and velocity had stronger associations with physical performance than jump force or grip strength. This suggests lower extremity power and velocity may be more strongly related to physical performance than lower extremity force or upper extremity strength in older men.
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April 2020

Skeletal muscle fat in individuals with rheumatoid arthritis compared to healthy adults.

Exp Gerontol 2020 01 31;129:110768. Epub 2019 Oct 31.

Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, United States.

Objective: To compare skeletal muscle fat (SMF), intermuscular adipose tissue (IMAT) and subcutaneous adipose tissue (SAT) between individuals with rheumatoid arthritis (RA), and healthy individuals of the same age, and healthy individuals at least 10 years older than those with RA.

Methods: Two cross-sectional studies. In the first study, RA subjects were matched by age, sex, and BMI with healthy adults. In the second, RA subjects were matched by sex and BMI to adults 10-20 years older. SMF, IMAT and SAT were measured with Computed Tomography images of the mid-thigh region. We used parametric or non-parametric related-sample tests to compare fat accumulation between RA subjects and healthy adults.

Results: In the first study SMF was significantly higher in the RA cohort compared to their age-matched healthy counterparts (mean difference = -3.5 HU (95% -6.2, -0.9), p = 0.011), but IMAT and SAT were similar between cohorts. In the second study, SMF, IMAT and SAT were not significantly different between the RA and matched older healthy cohorts. In both studies, there were no significant differences in mid-thigh muscle area between RA subjects and healthy adults.

Conclusion: SMF accumulation in RA was higher than in healthy individuals of similar age, sex, BMI. Accumulation of fat within and around the muscles in RA was not different compared to the matched healthy older individuals, indicating that muscle fat accumulation in RA might mimic a pattern not different from healthy aging.
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January 2020

A Qualitative Study of Preparation for Lumbar Spinal Stenosis Surgery: Perceptions of Patients and Physical Therapists.

J Orthop Sports Phys Ther 2020 Apr 30;50(4):198-205. Epub 2019 Oct 30.

Objectives: To gain the perspectives of patients who underwent lumbar spinal stenosis (LSS) surgery and physical therapists who treat spine-related disorders regarding rehabilitation and other care prior to LSS surgery.

Design: Qualitative focus group study.

Methods: Sixteen patients (4 female; average ± SD age, 64.3 ± 8.8 years; time since surgery, 9.9 ± 4.4 months) and 10 physical therapists (2 female; average ± SD age, 40.9 ± 6.6 years; time in practice, 17.2 ± 7.7 years) participated. Four groups were conducted: 2 with patients post LSS surgery and 2 with physical therapists who treat spine-related disorders. Participants were asked open-ended questions by a trained facilitator regarding their perceptions of preoperative LSS education and rehabilitation. Transcripts were coded and themes were identified.

Results: Analyses revealed 4 themes within the discussions: (1) desire for helpful information, (2) benefits of preoperative rehabilitation, (3) downfalls of preoperative rehabilitation, and (4) desire for coordinated care. Varying opinions on preoperative physical therapy between patients and physical therapists were discussed, revealing that similar numbers of participants held positive and negative perceptions of preoperative physical therapy. A desire for more thorough preoperative education and care was expressed by both groups.

Conclusion: There is a clear need for standardized preoperative LSS care and education. This may decrease misunderstandings about LSS surgery and its treatments in the future as well as improve coordinated care between surgeons and physical therapists. .
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April 2020

Dose-Response Relationship Between Neuromuscular Electrical Stimulation and Muscle Function in People With Rheumatoid Arthritis.

Phys Ther 2019 09;99(9):1167-1176

Department of Physical Therapy, University of Pittsburgh.

Background: Neuromuscular electrical stimulation (NMES) is a viable intervention for improving impaired muscle function in individuals with rheumatoid arthritis (RA). However, there is limited evidence about the dose-response relationship between NMES and muscle function in these individuals.

Objective: The objectives of this study were to investigate the dose-response relationship between NMES and muscle function in individuals with RA and to establish the minimal NMES training intensity for promoting improvements.

Design: This study was a secondary analysis of data obtained before and after an NMES intervention in a randomized study.

Methods: The study took place at a research clinic. Only adults diagnosed with RA were included. The intervention consisted of 36 NMES treatment sessions for the quadriceps muscles over 16 weeks. Muscle function was measured before and after the intervention; quadriceps cross-sectional area and muscle quality were assessed using computed tomography, and strength was measured with an isokinetic dynamometer. NMES training intensity was calculated as a percentage by dividing NMES-elicited quadriceps muscle torque by the maximum voluntary isometric contraction. Improvements in muscle function were calculated using paired-sample t tests. The dose-response relationship was determined using curve estimation regression statistics. The minimum NMES training intensity was defined as that sufficient to significantly improve all muscle function measures.

Results: Twenty-four people (48 legs) participated (75% women; mean [SD] age = 58 [8] years; mean body mass index = 32 [7] kg/m2). Quadriceps cross-sectional area, muscle quality, and strength improved after the intervention. Associations between NMES training intensity and muscle quality (r2 = 0.20) and strength (r2 = 0.23) were statistically significant, but that between NMES training intensity and muscle cross-sectional area was not (r2 = 0.02). The minimum NMES training intensity necessary to improve all measures of muscle function ranged from 11% to 20% of the maximum voluntary isometric contraction.

Limitations: The relatively small sample size was a limitation.

Conclusions: The minimum NMES training intensity for significant gains in muscle function was ∼15%. Higher NMES intensities may promote better muscle quality and strength in individuals with RA.
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September 2019

Effectiveness of Later-Stage Exercise Programs vs Usual Medical Care on Physical Function and Activity After Total Knee Replacement: A Randomized Clinical Trial.

JAMA Netw Open 2019 02 1;2(2):e190018. Epub 2019 Feb 1.

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

Importance: Several functional limitations persist after total knee replacement (TKR). Intensive exercise programs could resolve these limitations but are not well tolerated by many patients until a later stage (>2 months) after surgery. Evidence for exercise at a later stage after TKR is limited.

Objectives: To compare the effectiveness of later-stage exercise programs after TKR and to explore heterogeneity of treatment effects.

Design, Setting, And Participants: Three-arm single-blind randomized clinical trial (January 7, 2015, to November 9, 2017) using an intent-to-treat approach with follow-ups at 3 months and 6 months. The setting was Allegheny County, Pennsylvania (an outpatient physical therapy clinic and 4 community centers). Participants had primary TKR performed more than 2 months previously, were 60 years or older, experienced moderate functional limitations, and were medically cleared to exercise.

Interventions: Clinic-based physical therapy exercise (physical therapy arm), community-based group exercise (community arm), and usual care (control arm). The control arm continued their usual care, whereas the exercise arms participated in supervised exercise programs lasting 12 weeks.

Main Outcomes And Measures: The primary outcome was arm differences in the Western Ontario and McMaster Universities Osteoarthritis Index-Physical Function (WOMAC-PF) at 3 months. The secondary outcomes included performance-based tests germane to knee replacement and additional surveys of physical function. Data were analyzed by linear mixed models and responder analysis.

Results: A total of 240 participants (mean [SD] age, 70 [7] years; 61.7% female) were allocated to physical therapy (n = 96), community exercise (n = 96), or control (n = 48). All 3 arms demonstrated clinically important improvement. At 3 months, between-arm analyses for the WOMAC-PF demonstrated no differences between physical therapy and community (-2.2; 98.3% CI, -4.5 to 0.1), physical therapy and control (-2.1; 98.3% CI, -4.9 to 0.7), and community and control (0.1; 98.3% CI, -2.7 to 2.9). Performance-based tests demonstrated greater improvement in the physical therapy arm compared with both the community (0.1 z score units; 98.3% CI, 0.0-0.2) and control (0.3 z score units; 98.3% CI, 0.1-0.4) arms and the community arm compared with the control arm (0.2 z score units; 98.3% CI, 0.0-0.3). The physical therapy arm had more than 17.7% responders than the community arm and more than 19.0% responders than the control arm. There was no difference in responder rates between the community and control arms.

Conclusions And Relevance: Based on the primary outcome, participation in late-stage exercise programs after TKR offered no benefit over usual care. The benefits of physical therapy identified by the secondary outcomes and responder analysis require confirmation.

Trial Registration: Identifier: NCT02237911.
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February 2019

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: Identifier: NCT01943435.
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January 2019

Dynamic knee joint stiffness and contralateral knee joint loading during prolonged walking in patients with unilateral knee osteoarthritis.

Gait Posture 2019 02 30;68:44-49. Epub 2018 Oct 30.

DOD-VA Extremity Trauma and Amputation Center of Excellence, Naval Medical Center San Diego, CA, USA. Electronic address:

Background: Long duration walking, a commonly recommended treatment option for knee osteoarthritis (OA), may lead to increased knee joint loading.

Research Question: To evaluate the effects of prolonged walking on dynamic knee joint stiffness and contralateral knee joint contact forces (KCFs) in individuals with unilateral symptomatic knee OA.

Methods: Twenty-six older adults with knee OA completed a 45-minute bout of walking on a treadmill. Dynamic knee joint stiffness, estimated KCFs, measured ground reaction forces (GRFs), and simulated muscle forces were evaluated for both the symptomatic and asymptomatic limbs at 15-minute intervals using repeated measures, analysis of variance (ANOVA).

Results: Dynamic knee joint stiffness during the early weight-acceptance phase of gait was significantly higher for the symptomatic limb throughout the 45-minute bout of walking. A significant increase in peak KCFs and simulated muscle forces were also observed during the weight-acceptance phase of gait for both limbs after 30 and 45 min of walking. Additionally, significantly elevated peak KCFs and muscle forces were observed during the late-stance phase of gait for the contralateral asymptomatic limb throughout the 45-minute bout of walking.

Significance: Walking durations of 30 min or greater lead to increased knee joint loading. Additionally, the elevated dynamic knee joint stiffness observed for the symptomatic knee during the weight acceptance phase of gait appears to be unrelated to the knee joint loading profile. Finally, the greater KCFs during the late-stance phase of gait observed for the asymptomatic limb are consistent with previously demonstrated risk factors for OA development and progression.
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February 2019

Standardized Patient Reported Outcomes Do Not Capture Functional Deficits of Patients Following Contemporary Total Knee Replacement: Descriptive Study.

J Exerc Sports Orthop 2018 5;5(1). Epub 2018 Feb 5.

Background: The physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-PF) is widely used and endorsed by professional organizations for patients with knee osteoarthritis. Its use post total knee replacement (TKR) has been challenged as it may not represent the high level of functional performance that is expected by patients who undergo contemporary TKR with more advanced techniques and care pathways.

Objective: To assess whether the items of the WOMAC-PF reflect the activity limitations identified by patients following TKR.

Design: Data for this descriptive study were obtained from baseline assessments of a randomized clinical trial comparing exercise interventions following TKR.

Methods: Participants completed the WOMAC-PF and identified activity limitations in the Canadian Occupational Performance Measure (COPM) in the same day. The responses to both questionnaires were compared.

Results: This investigation included 50 participants (36 women, mean age 63.8±6.7). The WOMAC-PF failed to capture 50% of the activity limitations identified by participants in the COPM. These activities included kneeling, squatting, carrying/lifting items, strength/endurance exercise, floor transfer, lower extremity exercise, walking up/down hills, yard work, climbing a ladder, driving, managing the environment, carrying objects up/down stairs, gait initiation, balance, and going up/down curbs. Only one activity on the WOMAC-PF (going shopping) was not identified by participant responses on the COPM.

Limitations: Participants were included if they had TKR between 3 and 6 months prior, which may limit generalizability to those immediately after TKR, and the study sample was relatively small.

Conclusions: In individuals following TKR, the WOMAC-PF failed to represent a subset of higher level, more physically demanding activities that were identified as important by patients following TKR.
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February 2018

A Stimulus-Response Framework to Investigate the Influence of Continuous Versus Interval Walking Exercise on Select Serum Biomarkers in Knee Osteoarthritis.

Am J Phys Med Rehabil 2019 04;98(4):287-291

From the Shirley Ryan AbilityLab and Northwestern University Feinberg School of Medicine, Chicago, Illinois (PJ); Shirley Ryan AbilityLab, Chicago, Illinois (JG); Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania (GAS); Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania (SRP); and DOD-VA Extremity Trauma and Amputation Center of Excellence, Navy Medical Center San Diego, California (SF).

Objective: The aim of the study was to compare changes in the concentration of serum biomarkers in response to continuous versus interval walking exercise in participants with knee osteoarthritis.

Design: This study used a two-phase sequential design. Twenty-seven participants with unilateral knee osteoarthritis completed two separate treadmill walking sessions: (1) continuous 45-min walking exercise and (2) three 15-min bouts of walking exercise separated by 1-hr rest periods for a total of 45 mins in an interval format. Participants reported their knee pain using the numeric pain rating scale and serum levels of biomarkers associated with tissue turnover (cartilage oligomeric matrix protein), inflammation (tumor necrosis factor α), and pain (neuropeptide Y) were evaluated at baseline and every 15 mins for both conditions.

Results: Continuous walking resulted in a cumulative increase in cartilage oligomeric matrix protein concentration up to 45 mins, whereas interval walking was associated with return of cartilage oligomeric matrix protein concentrations back to baseline at 45 mins. There were no significant changes in tumor necrosis factor α and neuropeptide Y concentration during walking. There was a significant increase in pain compared with baseline in the continuous walking regimen only.

Conclusions: Incorporating rest breaks in walking regimens may affect the potential deleterious effects of longer continuous bouts on the knee joint as well as limit pain during exercise.
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April 2019

Considerations for Assessment and Applicability of Studies of Intervention.

Clin Sports Med 2018 Jul;37(3):427-440

Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219-3130, USA.

Evidence-based practice changed how health care professionals are taught medical practice. Despite all best intentions, many health care professionals have limited knowledge to assess the validity and usefulness of the medical literature. The goal of this article is to review the following basic considerations while appraising studies of intervention: (1) the hierarchy of evidence and the strengths and weaknesses of clinical studies, (2) the relevant elements of study design that impact validity of study results, and (3) the spectrum of efficacy and effectiveness of clinical studies and how these influence the applicability of study results to individual patients.
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July 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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March 2019

Physical activity after total joint arthroplasty: a narrative review.

Open Access J Sports Med 2018 15;9:55-68. Epub 2018 Mar 15.

Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, PA, USA.

Background: Total joint arthroplasty (TJA) is a common procedure to treat individuals with hip and knee osteoarthritis. While TJAs are successful in decreasing pain and improving quality of life, it is unclear whether individuals who undergo TJA become more physically active after surgery. It is possible that TJA, by itself, is not sufficient to affect the behavior of patients toward physical activity (PA) participation. To increase PA participation, individuals with TJA may need to be exposed to exercise/behavioral interventions specifically aimed to promote PA (ie, in addition to the surgery).

Objectives: This narrative review aimed to assess the evidence on 1) whether TJAs change PA participation from pre- to postsurgery and 2) whether exercise/behavioral interventions delivered before or after TJA help to promote PA in these patients.

Results: For aim 1, the studies that assessed PA from pre- to post-TJA reported that PA does not change in the first 3 months postsurgery. The results of follow-ups longer than 3 months but shorter than 12 months are contradictory, and the results of follow-ups longer than 12 months provide weak evidence of increased PA. Assessment of changes in PA due to TJA is challenged by the wide variability in demographics, methods used to assess PA, and different pathways of care used across studies. The results for aim 2 were limited by a scarcity of studies that used exercise/behavioral interventions to promote PA.

Conclusion: TJA relieves joint pain and offers a unique opportunity for patients to become more physically active. However, the current evidence is limited and unable to offer definitive results of whether TJA is effective to change PA from pre- to postsurgery. Future large studies in representative samples of patients with TJA are needed to adequately answer this question.
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March 2018

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

Gait Posture 2018 03 2;61:439-444. Epub 2018 Feb 2.

Delaware Rehabilitation Institute, University of Delaware,(1) 540 South College Ave, Newark, DE 19713, United States. Electronic address:

Background: Self-reported walking difficulty is a problem among patients with knee osteoarthritis (OA), however, these patients have never been studied as a subgroup population.

Objective: The purpose of this study is to examine known knee OA gait mechanics among those with knee OA, with (Diff) and without (NoDiff) self-reported walking difficulty, as compared to age- and sex-matched controls without knee OA.

Methods: A total of 39 subjects in three groups of 13 individuals walked at a controlled gait speed during instrumented gait analysis. Gait mechanics were compared between a priori determined groups using the independent t-test.

Results: The results of the study found that among those with knee OA, knee excursion angles were not significantly different between the Diff and NoDiff groups. Whereas, external knee moments were significantly different between the Diff and NoDiff groups but not between the NoDiff and the control groups. The lack of difference between the NoDiff and control groups were especially interesting because of the moderate to severe OA in the NoDiff group. Therefore, the findings of this study suggest the importance of considering self-reported walking difficulty among those with knee OA. Perhaps patients with knee OA-related walking difficulties use alternative gait parameters that may need to be clinically addressed. Strengths of the study included a matched design and controlled walking speed, whereas limitations were the small sample size and cross-sectional design.

Conclusions: Given the relationships found among self-reported walking difficulty, OA presence, and gait parameters, addressing gait parameters specifically related to walking difficulty may be indicated in this sub-group knee OA population.
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March 2018

Association of Early Outpatient Rehabilitation With Health Service Utilization in Managing Medicare Beneficiaries With Nontraumatic Knee Pain: Retrospective Cohort Study.

Phys Ther 2017 Jun;97(6):615-624

Physical Therapy Department, University of Pittsburgh.

Background: Nontraumatic knee pain (NTKP) is highly prevalent in adults 65 years of age and older. Evidence-based guidelines recommend early use of rehabilitation; however, there is limited information comparing differences in health care utilization when rehabilitation is included in the management of NTKP.

Objectives: To describe the overall health care utilization associated with the management of NTKP; estimate the proportion of people who receive outpatient rehabilitation services; and evaluate the timing of outpatient rehabilitation and its association with other health care utilization.

Design: Rretrospective cohort study was conducted using a random 10% sample of 2009-2010 Medicare claims. The sample included 52,504 beneficiaries presenting within the ambulatory setting for management of NTKP.

Methods: Exposure to outpatient rehabilitative services following the NTKP index ambulatory visit was defined as 1) no rehabilitation; 2) early rehabilitation (1-15 days); 3) intermediate rehabilitation (16-120 days); and 4) late rehabilitation (>120 days). Logistic regression models were fit to analyze the association of rehabilitation timing with narcotic analgesic use, utilization of nonsurgical invasive procedure, and knee surgery during a 12-month follow-up period.

Results: Only 11.1% of beneficiaries were exposed to outpatient rehabilitation services. The likelihood of using narcotics, nonsurgical invasive procedures, or surgery was significantly less (adjusted odds ratios; 0.67, 0.50, 0.58, respectively) for those who received early rehabilitation when compared to no rehabilitation. The exposure-outcome relationships were reversed in the intermediate and late rehabilitation cohorts.

Limitations: This was an observational study, and residual confounding could affect the observed relationships. Therefore, definitive conclusions regarding the causal effect of rehabilitation exposure and reduced utilization of more aggressive interventions cannot be determined at this time.

Conclusions: Early referral for outpatient rehabilitation may reduce the utilization of health services that carry greater risks or costs in those with NTKP.
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June 2017

The influence of continuous versus interval walking exercise on knee joint loading and pain in patients with knee osteoarthritis.

Gait Posture 2017 07 17;56:129-133. Epub 2017 May 17.

Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.

Objective: To evaluate whether knee contact force and knee pain are different between continuous and interval walking exercise in patients with knee osteoarthritis (OA).

Methods: Twenty seven patients with unilateral symptomatic knee OA completed two separate walking exercise sessions on a treadmill at 1.3m/s on two different days: 1) a continuous 45min walking exercise session, and 2) three 15min bouts of walking exercise separated by 1h rest periods for a total of 45min of exercise in an interval format. Estimated knee contact forces using the OpenSim software and knee pain were evaluated at baseline (1st minute of walking) and after every 15min between the continuous and interval walking conditions.

Results: A significant increase from baseline was observed in peak knee contact force during the weight-acceptance phase of gait after 30 and 45min of walking, irrespective of the walking exercise condition. Additionally, whereas continuous walking resulted in an increase in knee pain, interval walking did not lead to increased knee pain.

Conclusion: Walking exercise durations of 30min or greater may lead to undesirable knee joint loading in patients with knee OA, while performing the same volume of exercise in multiple bouts as opposed to one continuous bout may be beneficial for limiting knee pain.
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July 2017

Skeletal Muscle Fat and Its Association With Physical Function in Rheumatoid Arthritis.

Arthritis Care Res (Hoboken) 2018 03 6;70(3):333-342. Epub 2018 Feb 6.

University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: To characterize skeletal muscle fat (SMF), intermuscular adipose tissue (IMAT), and subcutaneous adipose tissue (SAT) in individuals with rheumatoid arthritis (RA), and assess the associations between these fat depots and physical function and physical activity.

Methods: In a cross-sectional analysis from an RA cohort, SMF, IMAT, and SAT were measured using computed tomography imaging of the midthigh cross-sectional region. Physical function was measured using the Health Assessment Questionnaire (HAQ) and a battery of performance-based tests that included quadriceps muscle strength, gait speed, repeated chair-stands, stair ascent, and single-leg stance. Physical activity was assessed using an activity monitor. Associations between SMF, IMAT, and SAT and physical function and activity were assessed by multiple linear regression models adjusted for potential confounders such as age, sex, body mass index (BMI), muscle area, and muscle strength.

Results: Sixty subjects with RA (82% female, mean ± SD age 59 ± 10 years, mean ± SD BMI 31.79 ± 7.16 kg/m ) were included. In the adjusted models, lower SMF was associated with greater gait speed, single-leg stance, quadriceps strength, and physical activity, and less disability (R Δ range 0.06-0.25; P < 0.05), whereas IMAT was not associated with physical function or physical activity and SAT was negatively associated with disability (HAQ) (R Δ = 0.13; P < 0.05) and weakly but positively associated with muscle strength (R Δ = 0.023; P < 0.05).

Conclusion: Fat infiltration within the muscle seems to independently contribute to low physical function and physical activity, contrary to IMAT or SAT accumulation. Longitudinal studies are necessary to confirm the impact of SMF on disability and health promotion in persons with RA.
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March 2018

Effect of Comprehensive Behavioral and Exercise Intervention on Physical Function and Activity Participation After Total Knee Replacement: A Pilot Randomized Study.

Arthritis Care Res (Hoboken) 2017 12 2;69(12):1855-1862. Epub 2017 Nov 2.

University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Objective: To test the feasibility of a comprehensive behavioral intervention (CBI) program that combines intense exercises with an education program, to be implemented at a later stage (3 months) following total knee replacement (TKR), and to get a first impression of the effects of the CBI as compared to a standard of care exercise (SCE) program on the outcomes of physical function and physical activity.

Methods: A total of 44 subjects participated in a 3-month program of either CBI or SCE, followed by 3 months of a home exercise program. Outcomes of physical function and physical activity were measured at baseline and at 6-month followup. Analysis of variance was used to compare statistical differences between groups, whereas responder analyses were used for clinically important differences.

Results: The CBI was found to be safe and well tolerated. As compared to the SCE group, the CBI group had less pain (P = 0.035) and better physical function based on the Short Form 36 health survey (P = 0.017) and the single-leg stance test (P = 0.037). The other outcome measures did not demonstrate statistically significant differences between the 2 groups. Results from the responder analysis demonstrated that the CBI group had a 36% higher rate of responders in physical function as compared to the SCE group. Also, the CBI group had 23% more responders in the combined domains of physical function and physical activity.

Conclusion: The CBI program is feasible and improves physical function and physical activity in patients several months after TKR. Larger pragmatic randomized trials are needed to confirm the results of this study.
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December 2017

Responsiveness of Physical Activity Measures Following Exercise Programs after Total Knee Arthroplasty.

J Exerc Sports Orthop 2017 6;4(3). Epub 2017 Dec 6.

Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh. Address: 100 Technology Dr., Suite 210. Pittsburgh, PA 15219. USA.

Background: Few instruments that measure physical activity (pa) can accurately quantify pa performed at light and moderate intensities, which is particularly relevant to older adults. Evidence for responsiveness of these instruments after an intervention is limited.

Objectives: o estimate and compare the responsiveness of two activity monitors and one questionnaire in assessing PA after an intervention following total knee Arthroplasty.

Methods: This one-group pretest-posttest, repeated-measures study analyzed changes in duration of daily PA and the standardized response mean (SRM) to assess internal responsiveness that were compared across instruments. Correlations between changes in PA measured by the proposed instruments and the global rating of change were used to test external responsiveness. Agreement between PA instruments on identifying individuals who changed their PA based on measurement error was assessed using weighted-Kappa (K).

Results: Thirty subjects, mean age 67(6) and 73% female, were analyzed. Changes in PA measured by each instrument were small (p>0.05), resulting in a small degree of responsiveness (SRM<0.30). Global rating of change scores did not correlate with changes in PA (rho=0.13-0.28, p>0.05). The activity monitors agreed on identifying changes in moderate-intensity PA (K=0.60) and number of steps (K=0.63), but did not agree with scores from questionnaire(K≤0.22).

Conclusion: Analyzing group-based changes in PA is challenging due to high-variability in the outcome. Investigating changes in PA at the individual-level may be a more viable alternative.
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December 2017

Heavy Loads and Lifting are Risk Factors for Musculoskeletal Injuries in Deployed Female Soldiers.

Mil Med 2016 11;181(11):e1476-e1483

U.S. Army Research Institute of Environmental Medicine, 15 Kansas Street, Natick, MA 01760.

The purpose of this prospective cohort study was to investigate physical, occupational, and psychosocial risk factors for musculoskeletal injuries (MSI) in deployed female soldiers. Before deployment, participants completed performance testing and surveys and after deployment an additional survey detailing occupational demands and MSI. Data analyzed found 57/160 (36%) suffered 78 MSI. In unadjusted analyses, these factors increased the relative risk (RR, 95% confidence interval) of injury: wearing an average load >10% body weight (BW) (RR = 2.00, 1.31-4.57), wearing an average load >1 hour (RR = 2.44, 1.30-4.57), heaviest load worn >15% BW (RR = 5.83, 1.51-22.50), wearing a backpack (RR = 1.82, 1.23-2.80), wearing body armor >1 hour (RR = 1.62, 1.002-2.62), lifting objects weighing above 22.68 kg (RR = 1.96, 1.08-3.57), lifting objects one to two times (RR = 1.73, 1.002-2.97), carrying objects >7.62 m (RR = 2.01, 1.19-3.42), and Y Balance composite score <95.23 (RR = 1.71, 1.13-2.60). The best logistic regression model predicting MSI was average load as % BW (odds ratio [OR] = 1.04, 1.01-1.07), heaviest load as % BW (OR = 1.03, 1.01-1.05), average repetitions lifting objects (OR = 1.07, 1.01-1.14), and sit-ups (OR = 0.93, 0.93-0.99). Results indicate that risk of MSI in deployed female soldiers increased with heavier equipment worn and more repetitious lifting, although more performing more sit-ups on the fitness test before deployment reduced the risk.
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November 2016

The ability of preoperative factors to predict patient-reported disability following surgery for rotator cuff pathology.

Disabil Rehabil 2017 10 22;39(20):2087-2096. Epub 2016 Aug 22.

c Department of Physical Therapy , University of Pittsburgh , Pittsburgh , PA , USA.

Purpose: Minimal research has examined the prognostic ability of shoulder examination data or psychosocial factors in predicting patient-reported disability following surgery for rotator cuff pathology. The purpose of this study was to examine these factors for prognostic value in order to help clinicians and patients understand preoperative factors that impact disability following surgery.

Methods: Sixty-two patients scheduled for subacromial decompression with or without supraspinatus repair were recruited. Six-month follow-up data were available for 46 patients. Patient characteristics, history of the condition, shoulder impairments, psychosocial factors, and patient-reported disability questionnaires were collected preoperatively. Six months following surgery, the Western Ontario Rotator Cuff Index (WORC) and global rating of change dichotomized subjects into responders versus nonresponders. Logistic regression quantified prognostic ability and created the most parsimonious model to predict outcome.

Results: Being on modified job duty (OR = .17, 95%CI: 0.03-0.94), and having a worker's compensation claim (OR = 0.08, 95%CI: 0.01-0.74) decreased probability of a positive outcome, while surgery on the dominant shoulder (OR = 11.96, 95%CI: 2.91-49.18) increased probability. From the examination, only impaired internal rotation strength was a significant univariate predictor. The Fear-avoidance Beliefs Questionnaire (FABQ) score (OR = 0.95, 95%CI: 0.91-0.98) and the FABQ_work subscale (OR = 0.92, 95%CI: 0.87-0.97) were univariate predictors. In the final model, surgery on the dominant shoulder (OR = 8.9, 95%CI 1.75-45.7) and FABQ_work subscale score ≤25 (OR = 15.3, 95%CI 2.3-101.9) remained significant.

Discussion: Surgery on the dominant arm resulted in greater improvement in patient-reported disability, thereby increasing the odds of a successful surgery. The predictive ability of the FABQ_work subscale highlights the potential impact of psychosocial factors on patient-reported disability. Implications for Rehabilitation Impairment-based shoulder measurements were not strong predictors of patient-reported outcome. Having high fear-avoidance behavior scores on the FABQ, especially the work subscale, resulted in a much lower chance of responding well to rotator cuff surgery as measured by self-reported disability. Having surgery on the dominant shoulder, as compared to the nondominant side, resulted in larger improvements in disability levels.
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October 2017

Chronological Age Does not Influence Ex-vivo Mitochondrial Respiration and Quality Control in Skeletal Muscle.

J Gerontol A Biol Sci Med Sci 2017 Apr;72(4):535-542

Division of Endocrinology and Metabolism, Department of Medicine.

Background : Considerable debate continues to surround the concept of mitochondrial dysfunction in aging muscle. We tested the overall hypothesis that age per se does not influence mitochondrial function and markers of mitochondria quality control, that is, expression of fusion, fission, and autophagy proteins. We also investigated the influence of cardiorespiratory fitness (VO2max) and adiposity (body mass index) on these associations.

Methods : Percutaneous biopsies of the vastus lateralis were obtained from sedentary young (n = 14, 24±3 years), middle-aged (n = 24, 41±9 years) and older adults (n = 20, 78±5 years). A physically active group of young adults (n = 10, 27±5 years) was studied as a control. Mitochondrial respiration was determined in saponin permeabilized fiber bundles. Fusion, fission and autophagy protein expression was determined by Western blot. Cardiorespiratory fitness was determined by a graded exercise test.

Results : Mitochondrial respiratory capacity and expression of fusion (OPA1 and MFN2) and fission (FIS1) proteins were not different among sedentary groups despite a wide age range (21 to 88 years). Mitochondrial respiratory capacity and fusion and fission proteins were, however, negatively associated with body mass index, and mitochondrial respiratory capacity was positively associated with cardiorespiratory fitness. The young active group had higher respiration, complex I and II respiratory control ratios, and expression of fusion and fission proteins. Finally, the expression of fusion, fission, and autophagy proteins were linked with mitochondrial respiration.

Conclusions : Mitochondrial respiration and markers of mitochondrial dynamics (fusion and fission) are not associated with chronological age per se, but rather are more strongly associated with body mass index and cardiorespiratory fitness.
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April 2017

Reliability of Physical Activity Measures During Free-Living Activities in People After Total Knee Arthroplasty.

Phys Ther 2016 Jun 19;96(6):898-907. Epub 2015 Nov 19.

S.R. Piva, PT, PhD, OCS, FAAOMPT, Department of Physical Therapy, University of Pittsburgh.

Background: Few instruments that measure physical activity (PA) can accurately quantify PA performed at light and moderate intensities, which is particularly relevant in older adults. The evidence of their reliability in free-living conditions is limited.

Objective: The study objectives were: (1) to determine the test-retest reliability of the Actigraph (ACT), SenseWear Armband (SWA), and Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire in assessing free-living PA at light and moderate intensities in people after total knee arthroplasty; (2) to compare the reliability of the 3 instruments relative to each other; and (3) to determine the reliability of commonly used monitoring time frames (24 hours, waking hours, and 10 hours from awakening).

Design: A one-group, repeated-measures design was used.

Methods: Participants wore the activity monitors for 2 weeks, and the CHAMPS questionnaire was completed at the end of each week. Test-retest reliability was determined by using the intraclass correlation coefficient (ICC [2,k]) to compare PA measures from one week with those from the other week.

Results: Data from 28 participants who reported similar PA during the 2 weeks were included in the analysis. The mean age of these participants was 69 years (SD=8), and 75% of them were women. Reliability ranged from moderate to excellent for the ACT (ICC=.75-.86) and was excellent for the SWA (ICC=.93-.95) and the CHAMPS questionnaire (ICC=.86-.92). The 95% confidence intervals (95% CI) of the ICCs from the SWA were the only ones within the excellent reliability range (.85-.98). The CHAMPS questionnaire showed systematic bias, with less PA being reported in week 2. The reliability of PA measures in the waking-hour time frame was comparable to that in the 24-hour time frame and reflected most PA performed during this period.

Limitations: Reliability may be lower for time intervals longer than 1 week.

Conclusions: All PA measures showed good reliability. The reliability of the ACT was lower than those of the SWA and the CHAMPS questionnaire. The SWA provided more precise reliability estimates. Wearing PA monitors during waking hours provided sufficiently reliable measures and can reduce the burden on people wearing them.
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June 2016

A randomized trial to compare exercise treatment methods for patients after total knee replacement: protocol paper.

BMC Musculoskelet Disord 2015 Oct 16;16:303. Epub 2015 Oct 16.

Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Background: Although the outcome of total knee replacement (TKR) is favorable, surgery alone fails to resolve the functional limitations and physical inactivity that existed prior to surgery. Exercise is likely the only intervention capable of improving these persistent limitations, but exercises have to be performed with intensity sufficient to promote significant changes, at levels that cannot be tolerated until later stages post TKR. The current evidence is limited regarding the effectiveness of exercise at a later stage post TKR. To that end, this study aims to compare the outcomes of physical function and physical activity between 3 treatment groups: clinic-based individual outpatient rehabilitative exercise during 12 weeks, community-based group exercise classes during 12 weeks, and usual medical care (wait-listed control group). The secondary aim is to identify baseline predictors of functional recovery for the exercise groups.

Methods/design: This protocol paper describes a comparative effectiveness study, designed as a 3-group single-blind randomized clinical trial. Two hundred and forty older adults who underwent TKR at least 2 months prior will be randomized into one of the three treatment approaches. Data will be collected at baseline, 3 months, and 6 months. The wait-listed control group will be randomized to one of the 2 exercise groups after 6 months of study participation, and will complete a 9-month follow-up. Primary outcome is physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale (WOMAC-PF). Physical function is also measured by performance-based tests. Secondary outcomes include performance-based tests and physical activity assessed by a patient-reported survey and accelerometry-based physical activity monitors. Exploratory outcomes include adherence, co-interventions, attrition, and adverse events including number of falls. Linear mixed models will be fitted to compare the changes in outcome across groups. Logistic regression will identify patient characteristics that predict functional recovery in the exercise groups. Instrumental variable methods will be used to estimate the efficacy of the interventions in the presence of non-compliance.

Discussion: Results will inform recommendations on exercise programs to improve physical function and activity for patients at the later stage post TKR and help tailor interventions according with patients' characteristics.

Trial Registration: Identifier NCT02237911.
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October 2015