Publications by authors named "Sue Ann Sisto"

35 Publications

Recommendations for Reporting on Rehabilitation Interventions.

Am J Phys Med Rehabil 2021 01;100(1):5-16

From the Moss Rehabilitation Research Institute, Einstein Healthcare Network, Elkins Park, Pennsylvania (JW, MF); Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, Michigan (MPD); MGH Institute of Health Professions, Boston, Massachusetts (SEF, JHVS); Department of Occupational Therapy, Spaulding Rehabilitation Hospital, and Sargent College of Health and Rehabilitation Sciences, Department of Occupational Therapy, Boston University, Boston, Massachusetts (LWK); Department of Neurological Rehabilitation, Scripps Memorial Hospital, Encinitas, California (SN); Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada (EP); Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, North Carolina (SMP); School of Public Health and Health Professions, Department of Rehabilitation Science, University at Buffalo, Buffalo, New York (SAS); Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts (JHVS); and School of Health and Rehabilitation Sciences, Division of Occupational Therapy, The Ohio State University, Columbus, Ohio (LW).

Abstract: Clear reporting on rehabilitation treatments is critical for interpreting and replicating study results and for translating treatment research into clinical practice. This article reports the recommendations of a working group on improved reporting on rehabilitation treatments. These recommendations are intended to be combined with the efforts of other working groups, through a consensus process, to arrive at a reporting guideline for randomized controlled trials in physical medicine and rehabilitation (Randomized Controlled Trials Rehabilitation Checklist). The work group conducted a scoping review of 156 diverse guidelines for randomized controlled trial reporting, to identify themes that might be usefully applied to the field of rehabilitation. Themes were developed by identifying content that might improve or enhance existing items from the Template for Intervention Description and Replication. Guidelines addressing broad research domains tended to define reporting items generally, from the investigator's perspective of relevance, whereas those addressing more circumscribed domains provided more specific and operationalized items. Rehabilitation is a diverse field, but a clear description of the treatment's separable components, along with distinct treatment theories for each, can improve reporting of relevant information. Over time, expert consensus groups should develop more specific guideline extensions for circumscribed research domains, around coalescing bodies of treatment theory.
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http://dx.doi.org/10.1097/PHM.0000000000001581DOI Listing
January 2021

Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries.

JAMA Netw Open 2020 03 2;3(3):e201204. Epub 2020 Mar 2.

Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York.

Importance: Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types.

Objective: To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US.

Design, Setting, And Participants: This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019.

Exposures: Medicare insurance plan type, TM or MA.

Main Outcomes And Measures: Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge.

Results: The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, -0.15 to -0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, -0.21 to -0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs within an acute care hospital) and patient alternative payment sources other than Medicare (none vs other) partially explained the differences between insurance types.

Conclusions And Relevance: This study suggests that MA enrollees experience shorter length of stay and better outcomes for postacute care than do TM beneficiaries in IRFs. The magnitude of the differences depends on treatment deferability, patient sociodemographic subgroups, and facility characteristics.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.1204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081121PMC
March 2020

Archives of Physical Medicine and Rehabilitation and ACRM Recognize the Elizabeth and Sidney Licht Award Winner and Nominees for Excellence in Scientific Writing.

Authors:
Sue Ann Sisto

Arch Phys Med Rehabil 2020 04 30;101(4):722-727. Epub 2020 Jan 30.

Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY.

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http://dx.doi.org/10.1016/j.apmr.2019.12.001DOI Listing
April 2020

Biomechanics and Pinch Force of the Index Finger Under Simulated Proximal Interphalangeal Arthrodesis.

J Hand Surg Am 2017 Aug 4;42(8):658.e1-658.e7. Epub 2017 May 4.

Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY.

Purpose: To analyze the effect of simulated proximal interphalangeal (PIP) joint arthrodesis on distal interphalangeal (DIP) joint free flexion-extension (FE) and maximal voluntary pinch forces.

Methods: Five healthy subjects were tested with the PIP joint unconstrained and constrained to selected angles to produce (1) free FE movements of the DIP joint at 2 selected angles of the metacarpophalangeal joint, and (2) maximal voluntary tip (thumb and index finger) and chuck (thumb, index, and middle fingers) pinch forces. Kinematic data from a motion analysis system, pinch force data from a mechanical pinch meter, and electromyography (EMG) data recorded from 2 flexor and extensor muscles of the index finger were collected during free FE movements of the DIP joint and pinch tests for distinct PIP joint constraint angles.

Results: The EMG root mean square (RMS) values of the flexor digitorum profundus (FDP) and extensor digitorum (ED) did not change during free FE of the DIP joint. The extension angle of the range of motion of the DIP joint changed during free FE. It increased as the PIP constraint angle increased. The EMG RMS value of FDP and ED showed maximum values when the PIP joint was unconstrained and constrained at 0° to 20° of flexion during tip and chuck pinch. Neither the index finger metacarpophalangeal and DIP joint positions nor pinch force measurements differed with imposed PIP joint arthrodesis.

Conclusions: The PIP joint arthrodesis angle affects DIP joint extension. A minimal overall impact from simulated PIP arthrodesis in muscle activity and pinch force of the index finger was observed. The EMG RMS values of the FDP and ED revealed that a PIP arthrodesis at 0° to 20° of flexion leads to a more natural finger posture during tip and chuck pinch.

Clinical Relevance: This study provided a quantitative comparison of free FE motion of the DIP joint, as well as FDP and ED forces during pinch, under simulated index finger PIP arthrodesis angles.
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http://dx.doi.org/10.1016/j.jhsa.2017.04.002DOI Listing
August 2017

Experimental study of the optimal angle for arthrodesis of fingers based on kinematic analysis with tip-pinch manipulation.

J Biomech 2016 12 3;49(16):4009-4015. Epub 2016 Nov 3.

Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY 11790, United States.

To evaluate the appropriate angle for arthrodesis of the index finger proximal interphalangeal (PIP) joint, the functional range of motion (ROM) of the joints and manipulabilities at three selected tip-pinch manipulation postures of the finger were studied experimentally under imposed PIP joint arthrodesis angles. A kinematic model of the index finger was used in experiments which involved three postures. Experiments were conducted using seven healthy subjects in tip-pinch manipulation tasks to obtain the measurements of finger motions under imposed angles of joint constraint, including the functional ROM of the joints and the three criteria of kinematic manipulability. Data show that the functional ROM and the shape of the kinematic manipulability ellipses at the fingertip were influenced significantly by the imposed PIP joint constraint in the tip-pinch manipulation tests. Results suggest that a PIP arthrodesis angle between 40° and 60° led to the optimal performance of fingers in grasping and manipulation of fine objects. This theoretical and experimental study can help surgeons and clinicians to make more informed decisions on the appropriate constraint angles before the arthrodesis operation, and to customize this angle for individual patients in order to enhance not only the capability of manipulation of the finger but also the quality of life after such intervention.
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http://dx.doi.org/10.1016/j.jbiomech.2016.10.047DOI Listing
December 2016

INTERVENTION AT THE FOOT-SHOE-PEDAL INTERFACE IN COMPETITIVE CYCLISTS.

Int J Sports Phys Ther 2016 Aug;11(4):637-50

School of Health Technology and Management, Stony Brook University, NY, USA.

Background: Competitive cyclists are susceptible to injury from the highly repetitive nature of pedaling during training and racing. Deviation from an optimal movement pattern is often cited as a factor contributing to tissue stress with specific concern for excessive frontal plane knee motion. Wedges and orthoses are increasingly used at the foot-shoe-pedal-interface (FSPI) in cycling shoes to alter the kinematics of the lower limb while cycling. Determination of the effect of FSPI alteration on cycling kinematics may offer a simple, inexpensive tool to reduce anterior knee pain in recreational and competitive cyclists. There have been a limited number of experimental studies examining the effect of this intervention in cyclists, and there is little agreement upon which FSPI interventions can prevent or treat knee injury. The purpose of this review is to provide a broader review of the literature than has been performed to date, and to critically examine the literature examining the evidence for FSPI intervention in competitive cyclists.

Methods: Current literature examining the kinematic response to intervention at the FSPI while cycling was reviewed. A multi-database search was performed in PubMed, EBSCO, Scopus, CINAHL and SPORTdiscus. Eleven articles were reviewed, and a risk of bias assessment performed according to guidelines developed by the Cochrane Bias Methods Group. Papers with a low risk of bias were selected for review, but two papers with higher risk of bias were included as there were few high quality studies available on this topic.

Results: Seven of the eleven papers had low bias in sequence generation i.e. random allocation to the test condition, only one paper had blinding to group allocation, all papers had detailed but non-standardized methodology, and incomplete data reporting, but were generally free of other bias sources.

Conclusions: Wedges and orthoses at the FSPI alter kinematics of the lower limb while cycling, although conclusions about their efficacy and response to long-term use are limited. Further high quality experimental studies are needed examining cyclists using standardized methodology and products currently used to alter SPFI function.

Level Of Evidence: 3.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970853PMC
August 2016

Are the 10 meter and 6 minute walk tests redundant in patients with spinal cord injury?

PLoS One 2014 1;9(5):e94108. Epub 2014 May 1.

The Ohio State University, School of Allied Medical Professions, Center for Brain and Spinal Cord Repair, Columbus, Ohio, United States of America.

Objective: To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).

Design: Prospective observational cohort.

Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants: 249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179) and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011.

Interventions: Locomotor training using body weight support and walking on a treadmill, overground and home/community practice.

Main Outcome Measure(s): 10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge.

Results: The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests.

Conclusions: While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0094108PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006773PMC
December 2014

Instilling a research culture in an applied clinical setting.

Arch Phys Med Rehabil 2013 Jan 7;94(1 Suppl):S49-54. Epub 2012 Nov 7.

Virginia C. Crawford Research Institute, Shepherd Center, College of Architecture, Georgia Institute of Technology, Atlanta, GA 30309, USA.

This article offers a framework and practical advice to nurture development of a research culture within a clinical setting. Information is presented on research education, infrastructure, and helping clinicians develop a scientific mindset. Economical ways to facilitate a scientist-practitioner approach to clinical practice are described, as well as metrics to gauge the success of these efforts.
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http://dx.doi.org/10.1016/j.apmr.2012.04.038DOI Listing
January 2013

Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation.

Arch Phys Med Rehabil 2012 Sep;93(9):1588-97

Department of Neurological Surgery, Kentucky Spinal Cord Research Center, University of Louisville, Louisville, KY, USA.

Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.
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http://dx.doi.org/10.1016/j.apmr.2012.04.032DOI Listing
September 2012

Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers.

Arch Phys Med Rehabil 2012 Sep;93(9):1578-87

Department of Physical Therapy, Division of Rehabilitation Sciences, Stony Brook University, Stony Brook, NY 11794-6018, USA.

Objective: To examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score.

Design: Cross-sectional study.

Setting: Seven outpatient rehabilitation clinics.

Participants: Individuals (N=350) with incomplete AIS classification C and D were included in this analysis.

Interventions: Not applicable.

Main Outcome Measures: Heart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge.

Results: CV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence.

Conclusions: Resting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.
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http://dx.doi.org/10.1016/j.apmr.2012.04.033DOI Listing
September 2012

Ambulation and balance outcomes measure different aspects of recovery in individuals with chronic, incomplete spinal cord injury.

Arch Phys Med Rehabil 2012 Sep;93(9):1553-64

Human Performance and Engineering Laboratory, Kessler Foundation Research Center, West Orange, NJ, USA.

Objective: To evaluate relationships among ambulation and balance outcome measures over time for incomplete spinal cord injury (SCI) after locomotor training, in order to facilitate the selection of effective and sensitive rehabilitation outcomes.

Design: Prospective observational cohort.

Setting: Outpatient rehabilitation centers (N=7) from the Christopher and Dana Reeve Foundation NeuroRecovery Network.

Participants: Patients with incomplete SCI (N=182) American Spinal Injury Association Impairment Scale level C (n=61) and D (n=121).

Interventions: Intensive locomotor training, including step training using body weight support and manual facilitation on a treadmill followed by overground assessment and community integration.

Main Outcome Measures: Six-minute and 10-meter walk tests, Berg Balance Scale, Modified Functional Reach, and Neuromuscular Recovery Scale collected at enrollment, approximately every 20 sessions, and on discharge.

Results: Walking and standing balance measures for all participants were strongly correlated (r≥.83 for all pairwise outcome correlations), standing and sitting balance measures were not highly correlated (r≤.48 for all pairwise outcome correlations), and walking measures were weakly related to sitting balance. The strength of relationships among outcome measures varied with functional status. Correlations among evaluation-to-evaluation changes were markedly reduced from performance correlations. Walk tests, when conducted with different assistive devices, were strongly correlated but had substantial variability in performance.

Conclusions: These results cumulatively suggest that changes in walking and balance measures reflect different aspects of recovery and are highly influenced by functional status and the utilization of assistive devices. These factors should be carefully considered when assessing clinical progress and designing clinical trials for rehabilitation.
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http://dx.doi.org/10.1016/j.apmr.2011.08.051DOI Listing
September 2012

Life care planning projections for individuals with motor incomplete spinal cord injury before and after locomotor training intervention: a case series.

J Neurol Phys Ther 2012 Sep;36(3):144-53

Shepherd Center, 2020 Peachtree Rd, NW, Atlanta, GA 30309, USA.

Background/purpose: We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention.

Case Description: The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively.

Interventions: Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks.

Outcomes: The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between $150,247.00 and $199,654.00. Following LT, the estimated costs decreased to between $2010.00 and $2446.00 (a decrease of $148,237.00 and $197,208.00). Similarly, the 4-year-old boy had estimated lifetime costs for equipment, home renovation, and transportation between $535,050.00 and $771,665.00 prior to LT. However, the estimated costs decreased to between $97,260.00 and $200,047.00 (a decrease of $437,790.00 and $571,618.00) following LT.

Discussion: The lifetime financial costs associated with equipment, home renovations, and transportation following a motor-incomplete SCI were decreased following an intensive LT program for the 2 cases presented in this article. The LCP, including costs of rehabilitation and long-term medical and personal care costs, may be an effective tool to discern cost benefit of rehabilitation interventions.
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http://dx.doi.org/10.1097/NPT.0b013e318262e5abDOI Listing
September 2012

Establishing the NeuroRecovery Network: multisite rehabilitation centers that provide activity-based therapies and assessments for neurologic disorders.

Arch Phys Med Rehabil 2012 Sep 20;93(9):1498-507. Epub 2011 Jul 20.

Department of Neurological Surgery, Kentucky Spinal Cord Research Center, University of Louisville, Louisville, KY, USA.

The mission of the NeuroRecovery Network (NRN) is to provide support for the implementation of specialized centers at rehabilitation sites in the United States. Currently, there are 7 NRN centers that provide standardized activity-based interventions designed from scientific and clinical evidence for recovery of mobility, posture, standing, and walking and improvements in health and quality of life in individuals with spinal cord injury. Extensive outcome measures evaluating function, health, and quality of life are used to determine the efficacy of the program. NRN members consist of scientists, clinicians, and administrators who collaborate to achieve the goals and objectives of the network within an organizational structure by designing and implementing a clinical model that provides consistent interventions and evaluations and a general education and training program.
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http://dx.doi.org/10.1016/j.apmr.2011.01.023DOI Listing
September 2012

Evaluation of wheelchair tire rolling resistance using dynamometer-based coast-down tests.

J Rehabil Res Dev 2009 ;46(7):931-8

Kessler Foundation Research Center, West Orange, NJ 07052 , USA.

The objective of this study was to compare the rolling resistance of four common manual wheelchair tires (two pneumatic and two airless solid) and the solid tires used on a commercially available force- and moment-sensing wheel. Coast-down tests were performed with a wheelchair positioned on a two-drum dynamometer. Within each of three load conditions, tire type had a significant effect on rolling resistance (p < 0.001). The pneumatic tires had smaller rolling resistances and were less affected by load increases than the solid tires. Within the two tire types, higher air pressure or firmness and lower profile tread corresponded to less rolling resistance. Wheelchair users, clinicians, and researchers must consider the effect of tire type on wheelchair rolling resistance when selecting a manual wheelchair tire.
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http://dx.doi.org/10.1682/jrrd.2008.10.0137DOI Listing
April 2010

Redefining the manual wheelchair stroke cycle: identification and impact of nonpropulsive pushrim contact.

Arch Phys Med Rehabil 2009 Jan;90(1):20-6

Kessler Medical Rehabilitation Research and Education Center, West Orange, NJ 07052, USA.

Objectives: To create a comprehensive definition of the manual wheelchair stroke cycle, which includes multiple periods of pushrim contact, and to show its improved clinical benefit to wheelchair propulsion analyses.

Design: Cross-sectional biomechanics study.

Setting: Three motion analysis laboratories.

Participants: Persons (N=54) with paraplegia who use a manual wheelchair.

Interventions: Not applicable.

Main Outcome Measures: Pushrim forces, axle moments, and contact angles measured during wheelchair propulsion.

Results: Total force on the pushrim was used to define pushrim contact and positive axle moment was used to identify the included period of propulsive contact. During most strokes, periods of nonpropulsive contact existed before and after propulsive contact. Within these periods, braking moments were applied to the pushrim, resulting in negative power output, or power loss. Including nonpropulsive data decreased mean stroke moment and power. The magnitude and the angle over which braking moments and power loss occurred increased with wheel speed. Mean braking moment and power loss within the initial contact period were significantly (P<.001) related to stroke pattern.

Conclusions: The proposed definition of the stroke cycle provides a thorough and practical description of wheelchair propulsion. Researchers and clinicians should use this definition to understand and minimize the impact of nonpropulsive contact throughout the stroke.
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http://dx.doi.org/10.1016/j.apmr.2008.07.013DOI Listing
January 2009

Comparison of kinematics, kinetics, and EMG throughout wheelchair propulsion in able-bodied and persons with paraplegia: an integrative approach.

J Biomech Eng 2009 Feb;131(2):021015

Rehabilitation Engineering Analysis Laboratory, Human Performance and Movement Analysis Laboratory, Kessler Medical Rehabilitation Research and Education Center, 1199 Pleasant Valley Way, West Orange, NJ 07052, USA.

A systematic integrated data collection and analysis of kinematic, kinetic, and electromyography (EMG) data allow for the comparison of differences in wheelchair propulsion between able-bodied individuals and persons with paraplegia. Kinematic data from a motion analysis system, kinetic data from force-sensing push rims, and electromyography data from four upper-limb muscles were collected for ten push strokes. Results are as follows: Individuals with paraplegia use a greater percentage of their posterior deltoids, biceps, and triceps in relation to maximal voluntary contraction. These persons also reached peak anterior deltoid firing nearly 10 deg earlier on the push rim, while reaching peak posterior deltoid nearly 10 deg later on the push rim. Able-bodied individuals had no triceps activity in the initial stages of propulsion while their paraplegic groups had activity throughout. Able-bodied participants also had, on average, peak resultant, tangential, and radial forces occurring later on the push rim (in degrees). There are two main conclusions that can be drawn from this integrative investigation: (1) A greater "muscle energy," as measured by the area under the curve of the percentage of EMG throughout propulsion, results in a greater resultant joint force in the shoulder and elbow, thus potentially resulting in shoulder pathology. (2) Similarly, a greater muscle energy may result in fatigue and play a factor in the development of shoulder pain and pathology over time; fatigue may compromise an effective propulsive stroke placing undue stresses on the joint capsule. Muscle activity differences may be responsible for the observed kinematic and kinetic differences between the two groups. The high incidence of shoulder pain in manual wheelchair users as compared to the general population may be the result of such differences, although the results from this biomedical investigation should be examined with caution. Future research into joint forces may shed light on this. Further investigation needs to focus on whether the pattern of kinematics, kinetics, and muscle activity during wheelchair propulsion is compensatory or evolutionary by tracking individuals longitudinally.
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http://dx.doi.org/10.1115/1.2900726DOI Listing
February 2009

Neuromotor and musculoskeletal responses to locomotor training for an individual with chronic motor complete AIS-B spinal cord injury.

J Spinal Cord Med 2008 ;31(5):509-21

Kessler Medical Research and Education Center, West Orange, NJ 07052, USA.

Background/objective: To determine the effects of locomotor training (LT) using body weight support (BWS), treadmill, and manual assistance on muscle activation, bone mineral density (BMD), and body composition changes for an individual with motor complete spinal cord injury (AIS B), 1 year after injury.

Methods: A man with chronic C6 AIS B (motor complete and sensory incomplete) spinal cord injury (SCI), 1 year after injury, completed 2 blocks of LT over a 9-month training period (35-session block followed by 8.6 weeks of no training and then a 62-session block).

Results: Before training, muscle activation was minimal for any muscle examined, whereas after the 2 blocks of LT (97 sessions), hip and knee muscle activation patterns for the bilateral rectus femoris, biceps femoris, and gastrocnemius were in phase with the kinematics. Mean EMG amplitude increased for all bilateral muscles and burst duration increased for rectus femoris and gastrocnemius muscles, whereas burst duration decreased for the biceps femoris after 62 LT sessions. Before LT, left biceps femoris had a pattern that reflected muscle stretch, whereas after training, muscle stretch of the left biceps femoris could not totally account for mean EMG amplitude or burst duration. After the 62 training sessions, total BMD decreased (1.54%), and regional BMD decreased (legs: 6.72%). Total weight increased, lean mass decreased (6.6%), and fat mass increased (7.4%) in the arms, whereas fat mass decreased (3.5%) and lean mass increased (4%) in the legs.

Conclusions: LT can induce positive neural and body composition changes in a nonambulatory person with chronic SCI, indicating that neuromuscular plasticity can be induced by repetitive locomotor training after a motor complete SCI.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607123PMC
http://dx.doi.org/10.1080/10790268.2008.11753646DOI Listing
April 2009

Validation of a musculoskeletal model of wheelchair propulsion and its application to minimizing shoulder joint forces.

J Biomech 2008 Oct 19;41(14):2981-8. Epub 2008 Sep 19.

Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA.

The majority of manual wheelchair users (MWUs) will inevitably develop some degree of shoulder pain over time. Previous research has suggested a link between the shoulder joint forces associated with the repetition of wheelchair (WC) propulsion and pain. The objective of this work is to present and validate a rigid-body musculoskeletal model of the upper limb for calculation of shoulder joint forces throughout WC propulsion. It is anticipated that when prescribing a WC, the use of a patient-specific computational model will aide in determining an axle placement in which shoulder joint forces are at a minimum, thus potentially delaying or reducing the shoulder pain that so many MWUs experience. During the validation experiment, 3 subjects (2 individuals with paraplegia and one able-bodied individual) propelled a WC at a self-selected speed, during which, kinematics, kinetics, and electromyography (EMG) activity were measured for the contact phase of 10 consecutive push strokes. The measured forces at the push rim and the 3-D propulsion kinematics drove the model, and the computationally calculated muscle activities were compared with the experimental muscle activities, resulting in an average mean absolute error (MAE) of 0.165. Further investigation of the shoulder joint forces throughout propulsion demonstrate the effect of axle placement on the magnitude of these forces. The present work serves to validate the patient-specific upper limb model for use as a prescriptive tool for fitting a subject to their WC. Minimizing joint forces from injury onset may prolong a MWU's pain-free way of life.
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http://dx.doi.org/10.1016/j.jbiomech.2008.07.032DOI Listing
October 2008

Technology for mobility and quality of life in spinal cord injury.

IEEE Eng Med Biol Mag 2008 Mar-Apr;27(2):56-68

Division of Rehabilitation Sciences, School of Health Technology & Management, Stony Brook University, Stony Brook, NY 11790-8340, USA.

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http://dx.doi.org/10.1109/EMB.2007.907398DOI Listing
June 2008

Shoulder biomechanics during the push phase of wheelchair propulsion: a multisite study of persons with paraplegia.

Arch Phys Med Rehabil 2008 Apr;89(4):667-76

Human Engineering Research Laboratories, VA Rehabilitation Research and Development Center, VA Pittsburgh Healthcare Systems, Pittsburgh, PA 15206, USA.

Objectives: To present a descriptive analysis and comparison of shoulder kinetics and kinematics during wheelchair propulsion at multiple speeds (self-selected and steady-state target speeds) for a large group of manual wheelchair users with paraplegia while also investigating the effect of pain and subject demographics on propulsion.

Design: Case series.

Setting: Three biomechanics laboratories at research institutions.

Participants: Volunteer sample of 61 persons with paraplegia who use a manual wheelchair for mobility.

Intervention: Subjects propelled their own wheelchairs on a dynamometer at 3 speeds (self-selected, 0.9m/s, 1.8m/s) while kinetic and kinematic data were recorded.

Main Outcome Measures: Differences in demographics between sites, correlations between subject characteristics, comparison of demographics and biomechanics between persons with and without pain, linear regression using subject characteristics to predict shoulder biomechanics, comparison of biomechanics between speed conditions.

Results: Significant increases in shoulder joint loading with increased propulsion velocity were observed. Resultant force increased from 54.4+/-13.5N during the 0.9m/s trial to 75.7+/-20.7N at 1.8m/s (P<.001). Body weight was the primary demographic variable that affected shoulder forces, whereas pain did not affect biomechanics. Peak shoulder joint loading occurs when the arm is extended and internally rotated, which may leave the shoulder at risk for injury.

Conclusions: Body-weight maintenance, as well as other interventions designed to reduce the force required to propel a wheelchair, should be implemented to reduce the prevalence of shoulder pain and injury among manual wheelchair users.
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http://dx.doi.org/10.1016/j.apmr.2007.09.052DOI Listing
April 2008

Multisite comparison of wheelchair propulsion kinetics in persons with paraplegia.

J Rehabil Res Dev 2007 ;44(3):449-58

Human Engineering Research Laboratories, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15206, USA.

A multisite collaborative study is being conducted on the association between propulsion biomechanics and upper-limb injuries. This substudy compared subject characteristics and pushrim kinetics across three sites and identified early on in the main study any differences that could affect interpretation of the findings or data pooling. A total of 42 manual wheelchair users with paraplegia (14 from each site) performed 0.9 m/s and 1.8 m/s steady state propulsion trials and an acceleration-brake-coastdown trial on a wheelchair dynamometer while propulsion forces and moment about the hub were measured with a SmartWheel. Significant differences between two sites were found in peak and average resultant force (p < 0.05), peak and average moment at the slower steady state speed (p < 0.005), and peak and average torque at the faster steady state speed (p = 0.06). Subjects at the site with significantly lower forces and torques had a slower deceleration rate during coastdown compared with the subjects at the other two sites (p < 0.001). These results imply that rolling resistance is lower at one of the sites and likely due to differences in dynamometer properties. A mechanical method was used to site-normalize the data and enable data pooling for future analyses.
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http://dx.doi.org/10.1682/jrrd.2006.05.0048DOI Listing
May 2009

Arm crank ergometry and shoulder pain in persons with spinal cord injury.

Arch Phys Med Rehabil 2007 Dec;88(12):1727-9

Kessler Medical Rehabilitation Research and Education Center, West Orange, NJ 07052, USA.

Objective: To determine whether a primary fitness program utilizing arm crank ergometry would cause increased shoulder pain in persons with spinal cord injury (SCI).

Design: Cohort study.

Setting: Clinical research center.

Participants: People (N=23) with chronic SCI (>1 y) who were participating in a weight loss study to compare the effectiveness of diet only (1000 kcal/d for 12 wk) versus diet with arm crank ergometry (1000 kcal/d and arm crank ergometry 3 times a week for 12 wk).

Intervention: Arm crank ergometry.

Main Outcome Measure: Changes in shoulder pain intensity using the Wheelchair User's Shoulder Pain Index (WUSPI).

Results: After adjusting for baseline scores, there was no significant difference between the 2 groups on postintervention WUSPI scores (F(1,20)=.85, P=.37, partial eta2=.04). The strength of the relationship between group assignment (diet only vs diet and arm crank ergometry) and final WUSPI score was weak, as assessed by a partial eta2, with group assignment accounting for 4% of the variance on the WUSPI. The adjusted means were lower in the diet and arm crank ergometry group (mean, 7.84) than in the diet only group (mean, 12.22); however, these differences did not appear to be clinically significant.

Conclusions: A primary fitness program using arm crank ergometry does not increase shoulder pain in people with SCI who use wheelchairs. Further investigation with a larger group and what constitutes clinically significant changes on the WUSPI is warranted to confirm our results.
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http://dx.doi.org/10.1016/j.apmr.2007.07.043DOI Listing
December 2007

Dynamometry testing in spinal cord injury.

J Rehabil Res Dev 2007 ;44(1):123-36

Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA.

Persons with a spinal cord injury (SCI) demonstrate strength deficits that can limit their functional ability to perform activities of daily living. For a specific lesion level, performance of functional activities is related to the level of muscle strength. Consequently, in clinical practice, we need reliable measures of muscle strength to determine mobility and self-care ability. Muscle-strength testing is used to document recovery or loss of motor function early in SCI, as well as measure improvements in strength in chronic SCI. We also need such measures for research purposes to determine the efficacy of clinical trials. Several methods are available for testing muscle strength of persons with SCI, such as handheld, handgrip, and isokinetic dynamometers. This article provides an overview of muscle-contraction definitions and testing methodologies and discusses the reliability of these testing methods and dynamometry devices.
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http://dx.doi.org/10.1682/jrrd.2005.11.0172DOI Listing
May 2009

Upper-limb joint power and its distribution in spinal cord injured wheelchair users: steady-state self-selected speed versus maximal acceleration trials.

Arch Phys Med Rehabil 2007 Apr;88(4):456-63

Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98053, USA.

Objective: To compare upper-limb joint power magnitude and distribution between the shoulder, elbow, and wrist during maximal acceleration (MAC) versus steady-state, self-selected speed (SSS) manual wheelchair propulsion.

Design: Cross-sectional biomechanic study.

Setting: Research university and teaching hospital.

Participants: Volunteer sample of 13 manual wheelchair users with spinal cord injury below T1.

Interventions: Not applicable.

Main Outcome Measures: Propulsive joint power magnitude and fractional distribution among upper-limb joints.

Results: Wilcoxon signed-rank testing revealed shoulder power was larger for MAC versus SSS (median peak, 101.5W; interquartile range [IQR], 74.6; median peak, 37.7W; IQR, 22.9; respectively) (P<.01). Elbow and wrist power were unchanged. Peak shoulder power fraction was larger for MAC versus SSS (median peak, 1.055; IQR, .110 vs peak, .870; IQR, .252) (P<.01). Peak elbow power fraction was smaller for MAC versus SSS (median peak, -.012; IQR, .144 vs peak, .146; IQR, .206) (P<.05). Peak wrist power fraction was smaller for MAC versus SSS (median peak, -.058; IQR, .057 vs peak, -.010; IQR, .150) (P<.05).

Conclusions: Power at the shoulder was larger than at other joints. Peak shoulder joint power and power fraction was larger during MAC versus SSS propulsion. Elbow and wrist power fractions were smaller for MAC versus SSS propulsion. Higher joint power, present under MAC, may predispose manual wheelchair users to injury, particularly at the shoulder.
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http://dx.doi.org/10.1016/j.apmr.2007.01.016DOI Listing
April 2007

Osteoarthritis and therapeutic exercise.

Am J Phys Med Rehabil 2006 Nov;85(11 Suppl):S69-78; quiz S79-81

Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey, USA,

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http://dx.doi.org/10.1097/01.phm.0000245509.06418.20DOI Listing
November 2006

Pushrim biomechanics and injury prevention in spinal cord injury: recommendations based on CULP-SCI investigations.

J Rehabil Res Dev 2005 May-Jun;42(3 Suppl 1):9-19

Department of Physical Medicine and Rehabilitation, University of Pittsburgh, PA 15213, USA.

Over 50 percent of manual wheelchair users with spinal cord injury (SCI) are likely to develop upper-limb pain and injury. The majority of studies related to pain have implicated wheelchair propulsion as a cause. This paper draws from a large multisite trial and a long-standing research program to make specific recommendations related to wheelchair propulsion that may decrease the risk of upper-limb injury. The studies include over 60 subjects over 1 yr after a traumatic SCI below the second thoracic level. Specific aspects of the propulsive stroke that may relate to injury include cadence, magnitude of force, and the pattern of the hand during the nonpropulsive part of the stroke. Lower peak forces, slower cadence, and a circular propulsive stroke in which the hand falls below the pushrim during recovery may help prevent injury. In addition, wheelchair users should use the lightest weight adjustable wheelchair possible. Future work should include interventional trials and larger studies that allow for more complex statistical models that can further detail the relationship between wheelchair propulsion, user characteristics, and upper-limb injuries.
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http://dx.doi.org/10.1682/jrrd.2004.08.0103DOI Listing
April 2006

The intra- and interrater reliability of hip muscle strength assessments using a handheld versus a portable dynamometer anchoring station.

Arch Phys Med Rehabil 2004 Apr;85(4):598-603

Eastern Virginia Medical School, Norfolk VA, USA.

Objective: To compare the inter- and intrarater reliability of a portable dynamometer anchoring station (DAS) to a handheld dynamometer (HHD).

Design: Repeated-measures design.

Setting: Human performance and movement analysis laboratory.

Participants: Fifteen healthy participants, ages 23 to 44 years.

Interventions: Not applicable.

Main Outcome Measures: Three consecutive measures of peak bilateral isometric strength were obtained for hip abduction, extension, and flexion by 2 investigators by using the DAS and the HHD after a 1-hour rest period. This testing scenario was repeated 1 week later. Intraclass correlation coefficients (ICCs) were used to determine reliability.

Results: Interrater ICCs of average peak strength ranged from.84 to.92 (hip flexors),.69 to.88 (hip abductors), and.56 to.80 (hip extensors). Intrarater ICCs ranged from.59 to.89 for tester A and from.72 to.89 for tester B using the DAS, and from.67 to.81 for the HHD across muscle groups.

Conclusions: The DAS showed good intrarater reliability for hip flexion and abduction, whereas the HHD demonstrated higher reliability for hip extension. The results support the use of dynamometers that are quick and reliable and that reduce tester bias during hip strength assessment.
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http://dx.doi.org/10.1016/j.apmr.2003.07.013DOI Listing
April 2004

Dynamic stability during walking following unilateral total hip arthroplasty.

Gait Posture 2004 Apr;19(2):141-7

Hunter College Physical Therapy Program, City University of New York, 425 East 25th Street, NY 10010 [corrected] USA.

The purpose of this study was to examine dynamic stability, defined as the vertical projection of the center of mass (COM) to the base of support (BOS) mediolaterally during walking in 16 healthy and 16 unilateral total hip arthroplasty (THA) persons. There was a significant effect of side for double limb support (DLS) for the healthy group and between groups but not significant for single limb support. The dynamic stability pattern for the THA group was to hold the COM in the midline during a longer DLS phase demonstrating a different motor control strategy compared to healthy adults.
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http://dx.doi.org/10.1016/S0966-6362(03)00039-0DOI Listing
April 2004
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