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Open access publications by faculty, staff, postdocs, and graduate students from the Biomechanics & Movement Science Program.
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Item Using deep learning to classify developmental differences in reaching and placing movements in children with and without autism spectrum disorder(Scientific Reports, 2024-12-05) Su, Wan-Chun; Mutersbaugh, John; Huang, Wei-Lun; Bhat, Anjana; Gandjbakhche, AmirAutism Spectrum Disorder (ASD) is among the most prevalent neurodevelopmental disorders, yet the current diagnostic procedures rely on behavioral analyses and interviews, without objective screening methods to support the diagnostic process. This study seeks to address this gap by integrating upper limb kinematics and deep learning methods to identify potential biomarkers that could be validated in younger age groups in the future to enhance the identification of ASD. Forty-one school-age children, with and without an ASD diagnosis (mean age ± SE: TD group: 10.3 ± 0.8, 8 males and 7 females; ASD group: 10.3 ± 0.5, 21 males and 5 females), participated in the study. A single Inertial Measurement Unit (IMU) was affixed to the child’s wrist as they engaged in a continuous reaching and placing task. Deep learning techniques were employed to classify children with and without ASD. Our findings suggest differential movement kinematics in school-age children compared to healthy adults. Compared to TD children, children with ASD exhibited poor feedforward/feedback control of arm movements as seen by greater number of movement units, more movement overshooting, and prolonged time to peak velocity/acceleration. Unique movement strategies such as greater velocity and acceleration were also seen in the ASD group. More importantly, using Multilayer Perceptron (MLP) model, we demonstrated an accuracy of ~ 78.1% in classifying children with and without ASD. These findings underscore the potential use of studying upper limb movement kinematics during goal-directed arm movements and deep learning methods as valuable tools for classifying and, consequently, aiding in the diagnosis and early identification of ASD upon further validation of their specificity among younger children.Item Using a tablet to understand the spatial and temporal characteristics of complex upper limb movements in chronic stroke(PLoS ONE, 2024-11-18) Austin, Devin Sean; Dixon, Makenna J.; Hoh, Joanna E.; Tulimieri, Duncan Thibodeau; Cashaback, Joshua G. A.; Semrau, Jennifer A.Robotic devices are commonly used to quantify sensorimotor function of the upper limb after stroke; however, the availability and cost of such devices make it difficult to facilitate implementation in clinical environments. Tablets (e.g. iPad) can be used as devices to facilitate rehabilitation but are rarely used as assessment tools for the upper limb. The current study aimed to implement a tablet-based Maze Navigation Task to examine complex upper-limb movement in individuals with chronic stroke. We define complex upper-limb movement as reaching movements that require multi-joint coordination in a dynamic environment. We predicted that individuals with stroke would have more significant spatial errors, longer movement times, and slower speeds compared to controls with increasing task complexity. Twenty individuals with chronic stroke who had a variety of arm and hand function (Upper extremity Fugl-Myer 52.8 ± 18.3) and twenty controls navigated eight pseudorandomized mazes on an iPad using a digitizing stylus. The task was designed to elicit reaching movements engaging both the shoulder and elbow joints. Each maze became increasingly complex by increasing the number of 90° turns. We instructed participants to navigate each maze as quickly and accurately as possible while avoiding the maze’s boundaries. Sensorimotor behavior was quantified using the following metrics: Error Time (time spent hitting or outside boundaries), Peak Speed, Average Speed, and Movement Time, Number of Speed Peaks. We found that individuals with stroke had significantly greater Error Time for all maze levels (all, p < 0.01), while both speed metrics, Movement Time and Number of Speed Peaks were significantly lower for several levels (all, p < 0.05). As maze complexity increased, the performance of individuals with stroke worsened only for Error Time while control performance remained consistent (p < 0.001). Our results indicate that a complex movement task on a tablet can capture temporal and spatial impairments in individuals with stroke, as well as how task complexity impacts movement quality. This work demonstrates that a tablet is a suitable tool for the assessment of complex movement after stroke and can serve to inform rehabilitation after stroke.Item Infant Motor Milestones: Analysis of Content and Variability Among Popular Sources for Parents(Pediatric Physical Therapy, 2024-10-08) Orlando, Julie M.; Cunha, Andrea B.; Namit, Samantha; Banoub, Abram; Alharbi, Bashayer M.; Lobo, Michele A.Purpose: Evaluate the content and variability of infant motor milestone education provided to parents in popular sources. Methods: Sources were screened for inclusion, and their motor milestone content was coded. Descriptive and inferential analyses were performed. Results: Content from 241 websites, applications, and books was evaluated; 6984 motor milestones were extracted, representing 146 unique milestone codes across 14 categories. Books and applications had more milestone content than websites. There was variability in the milestones mentioned and their associated ages across the sources and relative to the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) content. Several frequently mentioned milestones were behaviors that facilitate early learning. Conclusions: There is variability among sources in the motor milestones they provide to parents of infants. The AAP and CDC content likely has some influence on the broader content available, but there is substantial deviation from the information they provide. WHAT THIS EVIDENCE ADDS Current evidence: Education about developmental milestones can positively impact parental knowledge and confidence and enhance discussions between parents and healthcare providers.1 In addition to health care providers, parents report commonly accessing popular sources, including internet searches, websites, books, and mobile applications (apps), to learn about child development.2-5 Gap in the evidence: Parents are more likely to encounter information about milestones than suggestions for play activities or toys when searching about infant milestones, development, and play in popular sources.5 Yet, the nature of this motor milestone content has not been previously studied. How does this study fill this evidence gap? This study comprehensively describes which infant motor milestones parents are educated about by popular sources (ie, apps, books, and websites) and when those milestones are mentioned throughout infants’ first year of life. The study also evaluates whether the content available among popular sources besides those authored by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) varies from the information provided by the AAP and CDC. Implication of all the evidence: There is a large amount of variable information about infant’s motor milestones available to parents in popular sources, with similarities but also deviations and expansions from the AAP and CDC content. The results provide a comprehensive picture of the motor milestones that parents are likely to encounter in popular sources from birth through 1 year. They highlight behaviors parents are less likely to learn about on their own, suggesting health care providers might consider more active education if they want parents to be knowledgeable about these behaviors. Health care providers might suggest apps or books to parents seeking greater amounts of information yet may consider offering education periodically in concurrence with expected developmental skills.6Item Evaluation of the Movement and Play Opportunities and Constraints Associated With Containers for Infants(Pediatric Physical Therapy, 2024-10-01) Alghamdi, Zainab S.; Orlando, Julie M.; Lobo, Michele A.Purpose: Containers (eg, strollers, bouncers) are an important part of infants’ environment but may negatively impact infant development and health. This study evaluated movement and play opportunities, constraints, and manufacturers’ developmental claims for infant containers. Methods: Containers were identified through Amazon.com. A content analysis of identified products was conducted to identify movement and visual-manual play opportunities, constraints, and developmental claims. Results: Content was analyzed for 460 containers. Containers varied in their movement and play opportunities; however, most did not incorporate toys and restricted trunk movement, self-directed locomotion, and independent head and trunk control. Containers, especially those with built-in toys, often had claims related to gross motor, sensory, and fine motor development. Conclusion: These findings demonstrate the variability of movement and play opportunities observed across and within categories of infant containers. General recommendations about container use may be less effective than more specific education to parents about selecting and implementing containers. WHAT THIS EVIDENCE ADDS Current evidence: Infant containers such as strollers, jumpers, and floor seats are commonly used by caregivers in home and daycare settings.1,2 Caregivers’ reports of container use indicate that infants spend hours in containers each day.1,3 Although containers are a significant component of infants’ physical environment, their prolonged use has been discouraged by some professional organizations to prevent the negative developmental and health outcomes associated with container baby syndrome (CBS).4 However, manufacturers often make claims about the developmental benefits of their products. These claims, which may or may not align with current literature, can influence parents’ beliefs and purchasing decisions.5 Gap in the evidence: Containers may negatively impact infant development and health by limiting movement and environmental exploration opportunities; however, the opportunities and constraints provided by commercially available containers have not been evaluated. Additionally, the developmental claims made by manufacturers have not been examined. How does this study fill this evidence gap? In this study, we performed a systematic content analysis of the movement and play opportunities, constraints, and developmental claims made by manufacturers of a large sample of commercially available containers. Implication of all the evidence to clinicians: Most containers place young infants in supine or reclined, restrict trunk movement, limit independent support of the head, do not allow self-locomotion, and lack built-in toys. These findings provide insight into potential mechanisms by which containers may result in CBS. Varying levels of movement and play opportunities for containers were observed. The results can inform clinicians and others when supporting parents selecting containers and suggest recommendations for use should depend upon the container rather than being global. Manufacturers of many containers made claims related to motor, cognitive, sensory, and physical development. Clinicians’ awareness of these claims may support education efforts with parents since claims influence parents’ beliefs and purchasing decisions.Item Roles and interplay of reinforcement-based and error-based processes during reaching and gait in neurotypical adults and individuals with Parkinson’s disease(PLoS Computational Biology, 2024-10-14) Roth, Adam M.; Buggeln, John H.; Hoh, Joanna E.; Wood, Jonathan M.; Sullivan, Seth R.; Ngo, Truc T.; Calalo, Jan A.; Lokesh, Rakshith; Morton, Susanne M.; Grill, Stephen; Jeka, John J.; Carter, Michael J.; Cashaback, Joshua G. A.From a game of darts to neurorehabilitation, the ability to explore and fine tune our movements is critical for success. Past work has shown that exploratory motor behaviour in response to reinforcement (reward) feedback is closely linked with the basal ganglia, while movement corrections in response to error feedback is commonly attributed to the cerebellum. While our past work has shown these processes are dissociable during adaptation, it is unknown how they uniquely impact exploratory behaviour. Moreover, converging neuroanatomical evidence shows direct and indirect connections between the basal ganglia and cerebellum, suggesting that there is an interaction between reinforcement-based and error-based neural processes. Here we examine the unique roles and interaction between reinforcement-based and error-based processes on sensorimotor exploration in a neurotypical population. We also recruited individuals with Parkinson’s disease to gain mechanistic insight into the role of the basal ganglia and associated reinforcement pathways in sensorimotor exploration. Across three reaching experiments, participants were given either reinforcement feedback, error feedback, or simultaneously both reinforcement & error feedback during a sensorimotor task that encouraged exploration. Our reaching results, a re-analysis of a previous gait experiment, and our model suggests that in isolation, reinforcement-based and error-based processes respectively boost and suppress exploration. When acting in concert, we found that reinforcement-based and error-based processes interact by mutually opposing one another. Finally, we found that those with Parkinson’s disease had decreased exploration when receiving reinforcement feedback, supporting the notion that compromised reinforcement-based processes reduces the ability to explore new motor actions. Understanding the unique and interacting roles of reinforcement-based and error-based processes may help to inform neurorehabilitation paradigms where it is important to discover new and successful motor actions. Author summary Reinforcement-based and error-based processes play a pivotal role in regulating our movements. Converging neuroanatomical evidence show interconnected reinforcement-based and error-based neural circuits. Yet is unclear how reinforcement-based and error-based processes interact to influence sensorimotor behavior. In our past work we showed that reinforcement-based and error-based processes are dissociable. Building on this work, here we show that these process can also interact to influence trial-by-trial sensorimotor behaviour.Item Location of Measurement Matters: Unveiling Regional Dynamics and Sex Differences in Patellar Tendon Strain In Vivo(Scandinavian Journal of Medicine & Science in Sports, 2024-08-08) Ito, Naoaki; Scattone Silva, Rodrigo; Grävare Silbernagel, KarinPatellar tendinopathy is more prevalent in males versus female athletes and commonly presents in the medial region of the tendon. Separate measures of patellar tendon strain in the medial, central, and lateral regions of the tendon, however, have not been quantified. The purpose was to investigate the differences in tendon strain between the medial, lateral, and central regions of the patellar tendon in healthy men and women. Strain in the medial and lateral regions of the patellar tendon in healthy participants (10 males, 10 females) was evaluated using ultrasound during isometric quadriceps contractions at 20%, 40%, 60%, 80%, and 100% of maximum voluntary contraction (MVIC) in 60° and 90° of knee flexion. Central strain was also measured at 60% MVIC in 90° of knee flexion. Mixed models were used to determine strain between tendon regions and sex at 60% MVIC in 90° of knee flexion. Sequential modeling was used to fit region, sex, %MVIC, and angle to predict strain. The central region had less strain compared with both medial and lateral regions. The lateral region had higher strain compared with the medial region regardless of sex. Females had higher strain compared with males, regardless of region. Knee position did not influence tendon strain. Patellar tendon strain differs by region and sex. The varying prevalence between sex and in location of patellar tendinopathy may in part be explained by the unbalanced strains. Differential assessment of regional patellar tendon strain may be of importance for understanding injury risk and recovery with exercise.Item Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy(Orthopaedic Journal of Sports Medicine, 2024-02-07) Alghamdi, Nabeel Hamdan; Pohlig, Ryan T.; Seymore, Kayla D.; Sions, Jaclyn Megan; Crenshaw, Jeremy R.; Grävare Silbernagel, KarinBackground: Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function. Purpose: To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT). Study Design: Case series; Level of evidence, 4. Methods: Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance. Results: Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P < .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear. Conclusion: Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.Item Autism-Related Differences in Cortical Activation When Observing, Producing, and Imitating Communicative Gestures: An fNIRS Study(Brain Sciences, 2023-09-04) Su, Wan-Chun; Culotta, McKenzie; Mueller, Jessica; Tsuzuki, Daisuke; Bhat, Anjana N.Children with autism spectrum disorder (ASD) have difficulties in gestural communication during social interactions. However, the neural mechanisms involved in naturalistic gestural communication remain poorly understood. In this study, cortical activation patterns associated with gestural communication were examined in thirty-two children with and without ASD (mean age: 11.0 years, SE: 0.6 years). Functional near-infrared spectroscopy (fNIRS) was used to record cortical activation while children produced, observed, or imitated communicative gestures. Children with ASD demonstrated more spatial and temporal errors when performing and imitating communicative gestures. Although both typically developing (TD) children and children with ASD showed left-lateralized cortical activation during gesture production, children with ASD showed hyperactivation in the middle/inferior frontal gyrus (MIFG) during observation and imitation, and hypoactivation in the middle/superior temporal gyrus (MSTG) during gesture production compared to their TD peers. More importantly, children with ASD exhibited greater MSTG activation during imitation than during gesture production, suggesting that imitation could be an effective intervention strategy to engage cortical regions crucial for processing and producing gestures. Our study provides valuable insights into the neural mechanisms underlying gestural communication difficulties in ASD, while also identifying potential neurobiomarkers that could serve as objective measures for evaluating intervention effectiveness in children with ASD.Item Validating the measurement of upper limb sensorimotor behavior utilizing a tablet in neurologically intact controls and individuals with chronic stroke(Journal of NeuroEngineering and Rehabilitation, 2023-09-01) Austin, Devin Sean; Dixon, Makenna J.; Tulimieri, Duncan Thibodeau; Cashaback, Joshua G. A.; Semrau, Jennifer A.Background Intact sensorimotor function of the upper extremity is essential for successfully performing activities of daily living. After a stroke, upper limb function is often compromised and requires rehabilitation. To develop appropriate rehabilitation interventions, sensitive and objective assessments are required. Current clinical measures often lack precision and technological devices (e.g. robotics) that are objective and sensitive to small changes in sensorimotor function are often unsuitable and impractical for performing home-based assessments. Here we developed a portable, tablet-based application capable of quantifying upper limb sensorimotor function after stroke. Our goal was to validate the developed application and accompanying data analysis against previously validated robotic measures of upper limb function in stroke. Methods Twenty individuals with stroke, twenty age-matched older controls, and twenty younger controls completed an eight-target Visually Guided Reaching (VGR) task using a Kinarm Robotic Exoskeleton and a Samsung Galaxy Tablet. Participants completed eighty trials of the VGR task on each device, where each trial consisted of making a reaching movement to one of eight pseudorandomly appearing targets. We calculated several outcome parameters capturing various aspects of sensorimotor behavior (e.g., Reaction Time, Initial Direction Error, Max Speed, and Movement Time) from each reaching movement, and our analyses compared metric consistency between devices. We used the previously validated Kinarm Standard Analysis (KSA) and a custom in-house analysis to calculate each outcome parameter. Results We observed strong correlations between the KSA and our custom analysis for all outcome parameters within each participant group, indicating our custom analysis accurately replicates the KSA. Minimal differences were observed for between-device comparisons (tablet vs. robot) in our outcome parameters. Additionally, we observed similar correlations for each device when comparing the Fugl-Meyer Assessment (FMA) scores of individuals with stroke to tablet-derived metrics, demonstrating that the tablet can capture clinically-based elements of upper limb impairment. Conclusions Tablet devices can accurately assess upper limb sensorimotor function in neurologically intact individuals and individuals with stroke. Our findings validate the use of tablets as a cost-effective and efficient assessment tool for upper-limb function after stroke.Item Contact or Collision Sport History, Repetitive Neurotrauma, and Patient-Reported Outcomes in Early to Midadulthood(Journal of Athletic Training, 2023-12-18) Hunzinger, Katherine J.; Caccese, Jaclyn B.; Mannix, Rebekah; Meehan, William P.; Swanik, C. Buz; Buckley, Thomas A.Context Data on the early to midlife effects of repetitive neurotrauma on patient-reported outcomes have been delimited to homogeneous samples of male athletes without comparison groups or accounting for modifying factors such as physical activity. Objective To determine the effect of contact or collision sport participation and repetitive neurotrauma on patient-reported outcomes among early to middle-aged adults. Design Cross-sectional study. Setting Research laboratory. Patients or Other Participants A total of 113 adults (53 [46.9%] men, 60 [53.1%] women; age = 34.88 ± 11.80 years) in 4 groups: (1) physically inactive individuals with no repetitive head impact (RHI) exposure (NON); (2) noncontact sport athletes and nonathletes with no RHI exposure who were currently physically active (NCA); (3) former high-risk sport athletes with an RHI history who were physically active (HRS); and (4) former rugby players with prolonged RHI exposure who remained physically active. Main Outcome Measure(s) The 12-Item Short-Form Health Survey (SF-12), Apathy Evaluation Scale–self-rated version (AES-S), Satisfaction With Life Scale (SWLS), and Sport Concussion Assessment Tool–5th Edition (SCAT5) Symptom and Symptom Severity Checklist. Results The NON group had worse self-rated physical function than the NCA group as assessed by the SF-12 physical component summary (P = .03) and worse self-rated apathy (AES-S) and satisfaction with life (SWLS) than the NCA (P = .03 for both) and HRS groups (P = .03 and P = .040, respectively). We observed no group differences for self-rated mental health (SF-12 mental component summary; P = .26) or symptoms (SCAT5; P = .42). Career duration was not associated with any patient-reported outcomes. Conclusions A history of contact or collision sport participation and career duration did not negatively affect patient-reported outcomes in physically active, early to middle-aged adults. However, physical inactivity status was negatively associated with patient-reported outcomes in these individuals in the absence of an RHI history. Key Points - The midlife and later-life effects of repetitive head impacts paired with physical activity on patient-reported outcomes need to be elucidated. - Contact or collision sport participation and career duration were unrelated to worse patient-reported outcomes in early to midadulthood among physically active individuals. - Physical inactivity may be a more important modifier of patient-reported outcomes in early to midadulthood than repetitive neurotrauma exposure.Item Visual accuracy dominates over haptic speed for state estimation of a partner during collaborative sensorimotor interactions(Journal of Neurophysiology, 2023-07-01) Lakesh, Rakshith; Sullivan, Seth R.; Germain, Laura St.; Roth, Adam M.; Calalo, Jan A.; Buggeln, John; Ngo, Truc; Marchhart, Vanessa R. F.; Carter, Michael J.; Cashaback, Joshua G. A.We routinely have physical interactions with others, whether it be handing someone a glass of water or jointly moving a heavy object together. These sensorimotor interactions between humans typically rely on visual feedback and haptic feedback. Recent single-participant studies have highlighted that the unique noise and time delays of each sense must be considered to estimate the state, such as the position and velocity, of one’s own movement. However, we know little about how visual feedback and haptic feedback are used to estimate the state of another person. Here, we tested how humans utilize visual feedback and haptic feedback to estimate the state of their partner during a collaborative sensorimotor task. Across two experiments, we show that visual feedback dominated haptic feedback during collaboration. Specifically, we found that visual feedback led to comparatively lower task-relevant movement variability, smoother collaborative movements, and faster trial completion times. We also developed an optimal feedback controller that considered the noise and time delays of both visual feedback and haptic feedback to estimate the state of a partner. This model was able to capture both lower task-relevant movement variability and smoother collaborative movements. Taken together, our empirical and modeling results support the idea that visual accuracy is more important than haptic speed to perform state estimation of a partner during collaboration. NEW & NOTEWORTHY Physical collaboration between two or more individuals involves both visual and haptic feedback. Here, we investigated how visual and haptic feedback is used to estimate the movements of a partner during a collaboration task. Our experimental and computational modeling results parsimoniously support the notion that greater visual accuracy is more important than faster yet noisier haptic feedback when estimating the state of a partner.Item Limitations in utilization and prioritization of standardized somatosensory assessments after stroke: A cross-sectional survey of neurorehabilitation clinicians(Topics in Stroke Rehabilitation, 2023-04-16) Hoh, Joanna Eskander; Borich, Michael R.; Kesar, Trisha M.; Reisman, Darcy S.; Semrau, Jennifer A.Background and Purpose Somatosensory impairments are common after stroke, but receive limited evaluation and intervention during neurorehabilitation, despite negatively impacting functional movement and recovery. Objectives Our objective was to understand the scope of somatosensory assessments used by clinicians in stroke rehabilitation, and barriers to increasing use in clinical practice. Methods An electronic survey was distributed to clinicians (physical therapists, occupational therapists, physicians, and nurses) who assessed at least one individual with stroke in the past 6 months. The survey included questions on evaluation procedures, type, and use of somatosensory assessments, as well as barriers and facilitators in clinical practice. Results Clinicians (N = 431) indicated greater familiarity with non-standardized assessments, and greater utilization compared to standardized assessments (p < 0.0001). Components of tactile sensation were the most commonly assessed modality of somatosensation (25%), while proprioception was rarely assessed (1%). Overall, assessments of motor function were prioritized over assessments of somatosensory function (p < 0.0001). Discussion Respondents reported assessing somatosensation less frequently than motor function and demonstrated a reliance on rapid and coarse non-standardized assessments that ineffectively capture multi-modal somatosensory impairments, particularly for proprioceptive deficits common post-stroke. In general, clinicians were not familiar with standardized somatosensory assessments, and this knowledge gap likely contributes to lack of translation of these assessments into practice. Conclusions Clinicians utilize somatosensory assessments that inadequately capture the multi-modal nature of somatosensory impairments in stroke survivors. Addressing barriers to clinical translation has the potential to increase utilization of standardized assessments to improve the characterization of somatosensory deficits that inform clinical decision-making toward enhancing stroke rehabilitation outcomes.Item Information Available to Parents Seeking Education about Infant Play, Milestones, and Development from Popular Sources(Behavioral Sciences, 2023-05-19) Orlando, Julie M.; Cunha, Andrea B.; Alghamdi, Zainab; Lobo, Michele A.Parents commonly seek information about infant development and play, yet it is unclear what information parents find when looking in popular sources. Play, Milestone, and Development Searches in Google identified 313 sources for content analysis by trained researchers using a standardized coding scheme. Sources included websites, books, and apps created by professional organizations, commercial entities, individuals, the popular press, and government organizations/agencies. The results showed that for popular sources: (1) author information (i.e., qualifications, credentials, education/experience) is not consistently provided, nor is information about the developmental process, parents’ role in development, or determining an infant’s readiness to play; (2) milestones comprise a majority of the content overall; (3) search terminology impacts the information parents receive; (4) sources from the Milestone and Development Searches emphasized a passive approach of observing developmental milestones rather than suggesting activities to actively facilitate learning and milestone development. These findings highlight the need to discuss parents’ online information-gathering process and findings. They also highlight the need for innovative universal parent-education programs that focus on activities to facilitate early development. This type of education has potential to benefit all families, with particular benefits for families with children who have unidentified or untreated developmental delays.Item Clinical Mental Health Measures and Prediction of Postconcussion Musculoskeletal Injury(Journal of Athletic Training, 2023-07-31) Buckley, Thomas A.; Bryk, Kelsey N.; Enrique, Alexander L.; Kaminski, Thomas W.; Hunzinger, Katherine J.; Oldham, Jessie R.Context The rate of lower extremity musculoskeletal injury (LE MSK) is elevated after concussion; however, the underlying mechanism has not been elucidated. Physical characteristics have been investigated despite poorer mental health being a common postconcussion complaint and linked to MSKs. Objective To evaluate the role of mental health as a predictor of postconcussion LE MSK. Design Case-control study. Setting Intercollegiate athletic training facility. Patients or Other Participants A total of 67 National Collegiate Athletic Association Division I student-athletes (n = 39 females) who had been diagnosed with a sport-related concussion. Main Outcome Measure(s) The Brief Symptom Inventory-18, Hospital Anxiety and Depression Scale, and Satisfaction With Life Scale (SWLS) measures were completed at baseline (preseason) and on the day participants were cleared for unrestricted return to play (RTP) after a concussion. Two binary logistic regressions were used to predict postconcussion LE MSK within a year, one for the baseline time point and the second for the RTP time point. A 2 (group: LE MSK, no LE MSK)-by-2 (time: baseline, RTP) repeated-measures analysis of variance compared performance between baseline and RTP. Results Subsequent LE MSKs were sustained by 44 participants (65.7%). The only significant predictor of postconcussion LE MSK was the SWLS score at RTP, with Exp(B) = 0.64, indicating that an increased (improved) SWLS score was associated with a lower LE MSK rate. No significant interactions were present between mental health measures and subsequent MSK (P values = .105–.885). Conclusions Limited associations were evident between postconcussion LE MSK and scores on commonly used measures of anxiety, depression, and satisfaction with life. Reported increased satisfaction with life was associated with a decreased injury risk, which warrants further attention. Our results suggest that these measures of anxiety, depression, and satisfaction with life have limited value in assisting sports medicine clinicians with determining which student-athletes are at elevated risk of postconcussion LE MSK. Key Points Measures of anxiety and depressive symptoms were not predictive of elevated postconcussion lower extremity musculoskeletal injury. Greater satisfaction with life was associated with a decreased risk of postconcussion lower extremity musculoskeletal injury.Item The nervous system tunes sensorimotor gains when reaching in variable mechanical environments(iScience, 2023-06-16) Maurus, Philipp; Jackson, Kuira; Cashaback, Joshua G.A.; Cluff, TylerHighlights: • The control of reaching is altered when facing time-varying physical disturbances • The changes in control increase responses to proprioceptive and visual feedback • Responses to feedback are tuned to the variability of the time-varying disturbances Summary: Humans often move in the presence of mechanical disturbances that can vary in direction and amplitude throughout movement. These disturbances can jeopardize the outcomes of our actions, such as when drinking from a glass of water on a turbulent flight or carrying a cup of coffee while walking on a busy sidewalk. Here, we examine control strategies that allow the nervous system to maintain performance when reaching in the presence of mechanical disturbances that vary randomly throughout movement. Healthy participants altered their control strategies to make movements more robust against disturbances. The change in control was associated with faster reaching movements and increased responses to proprioceptive and visual feedback that were tuned to the variability of the disturbances. Our findings highlight that the nervous system exploits a continuum of control strategies to increase its responsiveness to sensory feedback when reaching in the presence of increasingly variable physical disturbances. Graphical abstract available at: https://doi.org/10.1016/j.isci.2023.106756Item Challenging the assumption of uniformity in patellar tendon structure: Regional patellar tendon morphology and mechanical properties in vivo(Journal of Orthopaedic Research, 2023-04-08) Ito, Naoaki; Scattone Silva, Rodrigo; Sigurðsson, Haraldur B.; Cortes, Daniel H.; Silbernagel, Karin GrävarePatellar tendons are assumed to be uniform in morphology and mechanical properties despite a higher prevalence of tendinopathies observed in the medial region. The purpose of this study was to compare the thickness, length, viscosity, and shear modulus of the medial, central, and lateral regions of healthy patellar tendons of young males and females in vivo. B-mode ultrasound and continuous shear wave elastography were performed on 35 patellar tendons (17 females, 18 males) over three regions of interest. A linear mixed-effects model (α = 0.05) was used to determine differences between the three regions and sexes followed by pairwise comparisons for significant findings. The lateral region (mean [95% confidence interval] = 0.34 [0.31–0.37] cm) was thinner compared with the medial (0.41 [0.39–0.44] cm, p < 0.001), and central (0.41 [0.39–0.44] cm, p < 0.001) regions regardless of sex. Viscosity was lower in the lateral (19.8 [16.9–22.7] Pa-s) versus medial region (27.4 [24.7–30.2] Pa-s, p = 0.001). Length had a region-by-sex interaction (p = 0.003) characterized by a longer lateral (4.83 [4.54–5.13] cm) versus medial (4.42 [4.12–4.72] cm) region in males (p < 0.001), but not females (p = 0.992). Shear modulus was uniform between regions and sexes. The thinner, and less viscous lateral patellar tendon may reflect the lower load the tendon experiences explaining the differences in regional prevalence of developing tendon pathology. Statement of Clinical Significance: Healthy patellar tendons are not uniform in morphology or mechanical properties. Considering regional tendon properties may help guide targeted interventions for patellar tendon pathologies.Item Clinically relevant subgroups exist among athletes who have ruptured their anterior cruciate ligaments: A Delaware-Oslo Cohort Study(Arthritis Care & Research, 2023-03-01) Arhos, Elanna K.; Pohlig, Ryan T.; Di Stasi, Stephanie; Risberg, May Arna; Snyder-Mackler, Lynn; Grävare Silbernagel, KarinObjective: To identify subgroups of individuals with anterior cruciate ligament (ACL) injuries based on patient characteristics, self-reported outcomes, and functional performance at baseline, and to associate subgroups with long-term outcomes after ACL rupture. Methods: A total of 293 participants (45.7% male, mean ± SD age 26.2 ± 9.4 years, days from injury 58 ± 35) were enrolled after effusion, pain, and range of motion impairments were resolved and quadriceps strength was at least 70% of the uninvolved limb. Mixture modeling was used to uncover latent subgroups without a prior group classification using probabilistic assignment. Variables include demographics, functional testing, and self-reported outcome measures. Radiographic evidence of osteoarthritis (OA; i.e., Kellgren/Lawrence grade of ≥1) in the involved knee at 5 years after injury was the primary outcome of interest. Chi-square tests assessed differences in the presence of radiographic OA in the involved knee between subgroups at 5 years after ACL rupture. Secondary outcomes of interest included radiographic OA in the uninvolved knee, return to preinjury sport by 2 years, operative status, and clinical OA (classified using Luyten et al criteria) at 5 years. Results: Four distinct subgroups exist after ACL rupture (younger good self-report, younger poor self-report, older poor self-report, older good self-report) with 30%, 31%, 47%, and 53%, respectively, having involved knee OA. The percentage of radiographic OA was not significantly different between the groups (P = 0.059). Conclusion: The prevalence of OA in all subgroups is highly concerning. These results suggest there are unique subgroupings of individuals that may guide treatment after ACL rupture and reconstruction by providing support for developing a patient-centered approach.Item Comparing an Expanded Versus Brief Telehealth Physical Therapist Intervention for Knee Osteoarthritis: Study Protocol for the Delaware PEAK Randomized Controlled Trial(Physical Therapy & Rehabilitation Journal, 2023-02-01) Jakiela, Jason T.; Voinier, Dana; Hinman, Rana S.; Copson, Jennifer; Schmitt, Laura A.; Leonard, Tara R.; Aily, Jéssica B; Bodt, Barry A.; White, Daniel K.Objective The purpose of this study is to investigate whether a remotely delivered physical therapist intervention increases physical activity (PA) over 12 weeks, compared with existing web-based resources, in adults with knee osteoarthritis (OA). Methods This will be a single-center, randomized controlled trial with 2 parallel arms: (1) the Expanded Intervention (Delaware PEAK [Physical Exercise and Activity for Knee osteoarthritis]), which includes five 45- to 60-minute video conference-based sessions of supervised exercise (strengthening exercises, step goals) that are remotely delivered over 12 weeks by a physical therapist; or (2) the Brief Intervention (control group), a website that includes prerecorded videos directing participants to web-based resources for strengthening, PA, and pain management for knee OA that are freely available. The trial will enroll 100 participants who meet the National Institute for Health and Care Excellence OA clinical criteria (≥45 years old, have activity-related knee pain, and have no morning stiffness or it lasts ≤30 minutes), reside in the contiguous United States (excluding Alaska and Hawaii), and are seeking to be more physically active. Outcomes include PA (time in moderate-to-vigorous and light PA, steps per day), sedentary behaviors, treatment beliefs, and self-efficacy for exercise. Our primary outcome is moderate-to-vigorous PA. Outcomes will be measured at baseline, 12 weeks, and 24 weeks. Impact This protocol focuses on the remote delivery of physical therapy via telehealth to adults with knee OA and comes at a critical time, because the burden of inactivity is of particular concern in this population. If successful, the findings of this work will provide strong support for the broad implementation of Delaware PEAK, highlight the utility of telehealth in physical therapy, and address the critical need to utilize exercise to manage adults with knee OA through physical therapists.Item Markerless motion capture: What clinician-scientists need to know right now(Journal of Science and Medicine in Sport Plus, 2022-11-14) Ito, Naoaki; Sigurðsson, Haraldur B.; Seymore, Kayla D.; Arhos, Elanna K.; Buchanan, Thomas S.; Snyder-Mackler, Lynn; Grävare Silbernagel, KarinMarkerless motion capture (mocap) could be the future of motion analysis. The purpose of this report was to describe our team of clinicians and scientists’ exploration of markerless mocap (Theia 3D) and share data for others to explore (link: https://osf.io/6vh7z/?view_only=c0e00984e94a48f28c8d987a2127339d). Simultaneous mocap was performed using markerless and marker-based systems for walking, squatting, and forward hopping. Segment lengths were more variable between trials using markerless mocap compared to marker-based mocap. Sagittal plane angles were most comparable between systems at the knee joint followed by the ankle and hip. Frontal and transverse plane angles were not comparable between systems. The data collection experience using markerless mocap was simpler, faster, and user friendly. The ease of collection was in part offset by the added data transfer and processing times, and the lack of troubleshooting flexibility. If used selectively with proper understanding of limitations, markerless mocap can be exciting technology to advance the field of motion analysis.Item Reliability of Continuous Shear Wave Elastography in the Pathological Patellar Tendon(Journal of Ultrasound in Medicine, 2022-10-27) Ito, Naoaki; Sigurðsson, Haraldur B.; Pohlig, Ryan T.; Cortes, Daniel H.; Grävare Silbernagel, Karin; Sprague, Andrew L.Objectives Patellar tendon injuries occur via various mechanisms such as overuse, or due to surgical graft harvest for anterior cruciate ligament reconstruction (ACLR). Quantified patellar tendon stiffness after injury may help guide clinical care. Continuous shear wave elastography (cSWE) allows for the assessment of viscosity and shear modulus in tendons. The reliability of the measure, however, has not been established in the patellar tendon. The purpose of this study was to investigate the interrater reliability, intrarater reliability, and between-day stability of cSWE in both healthy and pathological patellar tendons. Methods Participants with patellar tendinopathy (n = 13), history of ACLR using bone-patellar tendon-bone autograft (n = 9), and with no history of patellar tendon injury (n = 13) were recruited. cSWE was performed 4 times by multiple raters over 2 days. Intraclass correlations (ICC) and minimum detectable change (MDC95%) were calculated. Results Good to excellent between-day stability were found for viscosity (ICC = 0.905, MDC95% = 8.3 Pa seconds) and shear modulus (ICC = 0.805, MDC95% = 27.4 kPa). The interrater reliability measures, however, were not as reliable (ICC = 0.591 and 0.532). Conclusions cSWE is a reliable assessment tool for quantifying patellar tendon viscoelastic properties over time. It is recommended, however, that a single rater performs the measure as the interrater reliability was less than ideal.