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Open access publications by faculty, staff, postdocs, and graduate students in the Department of Physical Therapy.

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    Hand-Use Preferences for Reaching and Object Exploration in Children with Impaired Upper Extremity Functioning: The Role of Environmental Affordances
    (Symmetry, 2023-12-05) Babik, Iryna; Lobo, Michele A.
    Infants and young children with weakened or impaired upper extremity functioning often develop a strong hand-use “preference” for reaching and object manipulation. While “preferring” their stronger hand, they often partially or completely ignore their “non-preferred” hand. Such manual lateralization might impede complex object exploration, which would negatively affect children’s cognitive development. The question is whether environmental affordances would significantly affect children’s manifested hand-use “preferences” by promoting the use of the “non-preferred” hand. The current sample included 17 children (5 males; 13.9 ± 8.7 months at baseline) with arthrogryposis multiplex congenita (arthrogryposis). The reaching and object exploration of the children were evaluated longitudinally across a 6-month period with and without the Playskin LiftTM exoskeletal garment (Playskin). Results showed that the use of the Playskin increased both unimanual and bimanual object contact. Also, when anti-gravity support was provided to the arms by the Playskin, children significantly increased the use of their non-preferred hand, which correlated with improved quality of object play—more bimanual object interaction and greater intensity, variability, and complexity of exploration. These findings suggest that hand-use “preference” in children with arthrogryposis is quite malleable during early development. It is likely that children with impaired upper extremity functioning do not “prefer” to use a particular hand but, rather, cannot afford using both hands due to their limited muscular or manual abilities. Importantly, environmental affordances (i.e., anti-gravity support for the arms) might significantly affect the early development of manual lateralization, with potential implications for children’s quality of object exploration and future cognitive development.
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    Telehealth Versus Face-to-Face Fine Motor and Social Communication Interventions for Children With Autism Spectrum Disorder: Efficacy, Fidelity, Acceptability, and Feasibility
    (American Journal of Occupational Therapy, 2023-12-04) Su, Wan-Chun; Cleffi, Corina; Srinivasan, Sudha; Bhat, Anjana
    Importance: The efficacy of telehealth (TH) interventions needs to be studied. Objective: To compare the efficacy, fidelity, acceptability, and feasibility of face-to-face (F2F) versus TH seated play (SP) interventions among children with autism spectrum disorder (ASD). Design: As part of a larger randomized controlled trial, children were assigned to the SP group and received TH and F2F interventions over 8 wk using a pretest–posttest study design. Setting: A research lab or through videoconferencing. Participants: Fifteen children with ASD (ages 5–14 yr) were randomly assigned to the SP group and received the intervention F2F or through TH. Intervention: Children received 16 SP intervention sessions (2 sessions per week for 8 wk). Outcomes and Measures: Pretests and posttests included standardized fine motor assessments. Video coding compared socially directed verbalization during training sessions. Parents and trainers provided feedback on their experiences. Results: Seven children received the intervention F2F, whereas 8 received TH intervention. Children in both subgroups showed similar training improvements in fine motor skills and socially directed verbalizations (ps > .01). Parents rated both interventions as acceptable and feasible; however, they reported longer preparation time and effort during TH interventions (ps < .01). Trainers reported greater parental involvement but more communication and technological issues during TH interventions. Fidelity checks indicated fewer reinforcements during TH versus F2F sessions. Conclusions and Relevance: TH intervention is feasible and effective in improving fine motor and social communication performance. Clinicians should reduce parental burden and overcome technological issues. What This Article Adds: This study confirmed the efficacy, fidelity, acceptability, and feasibility of delivering seated play, standard of care interventions for children with autism spectrum disorder via telehealth. However, clinicians should work on reducing parental burden and overcoming communication and technological issues related to telehealth.
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    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, Karin
    Background: 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.
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    Pain, Balance-Confidence, Functional Mobility, and Reach Are Associated With Risk of Recurrent Falls Among Adults With Lower-Limb Amputation
    (Archives of Rehabilitation Research and Clinical Translation, 2023-12-10) Seth, Mayank; Horne, John Robert; Pohlig, Ryan Todd; Sions, Jaclyn Megan
    Objective The study evaluated whether pain intensity and extent, balance-confidence, functional mobility, and balance (eg, functional reach) are potential risk factors for recurrent falls among adults with a lower-limb amputation. Design Cross-sectional study. Setting Research laboratory. Participants Eighty-three adults with unilateral lower-limb amputation that occurred >1 year prior (26 transfemoral- and 57 transtibial-level amputation; 44.6% women; 51.8% traumatic cause of amputation; N=83). Intervention Not applicable. Main Outcome Measures Participants reported on the number of falls in the past year, as well as pain intensity in the low back, residual, and sound limbs. Balance-confidence (per the Activities-Specific Balance-Confidence Scale [ABC]), functional mobility (per the Prosthetic Limb Users Survey of Mobility ([PLUS-M]), and balance (per the Functional Reach and modified Four Square Step Tests) were obtained. Results After considering non-modifiable covariates, greater extent of pain, less balance-confidence, worse self-reported mobility, and reduced prosthetic-side reach were factors associated with recurrent fall risk. Adults reporting pain in the low back and both lower-limbs had 6.5 times the odds of reporting recurrent falls as compared with peers without pain. A 1-point increase in ABC score or PLUS-M T score, or 1-cm increase in prosthetic-side reaching distance, was associated with a 7.3%, 9.4%, and 7.1% decrease in odds of reporting recurrent falls in the past year, respectively. Conclusions Of the 83 adults, 36% reported recurrent falls in the past year. Presence of pain in the low back and both lower-limbs, less balance-confidence, worse PLUS-M score, and less prosthetic-side reaching distance were identified as modifiable factors associated with an increased odd of recurrent falls.
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    Risk Factors for Underreporting of Life-Limiting Comorbidity Among Adults With Lower-Limb Loss
    (INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 2023-10-14) Stauffer, Samantha Jeanne; Seth, Mayank; Pohlig, Ryan Todd; Beisheim-Ryan, Emma Haldane; Horne, John Robert; Smith, Sarah Carolyn; Sarlo, Frank Bernard; Sions, Jaclyn Megan
    Peripheral neuropathy (PN) and peripheral arterial disease (PAD) are life-limiting comorbidities among adults with lower-limb loss that may not be adequately addressed in current care models. The objective of this study was to evaluate underreporting of PN and PAD among adults with lower-limb loss. We conducted a secondary analysis of a cross-sectional dataset of community-dwelling adults with unilateral lower-limb loss seen in an outpatient Limb Loss Clinic (n = 196; mean age = 56.7 ± 14.4 years; 73.5% male). Individuals participated in standardized clinical examinations including Semmes-Weinstein monofilament testing to assess for PN and pedal pulse palpation to assess for PAD. Bivariate regression was performed to identify key variables for subsequent stepwise logistic regression to discern risk factors. Clinical examination results indicated 16.8% (n = 33) of participants had suspected PN alone, 15.8% (n = 31) had suspected PAD alone, and 23.0% (n = 45) had suspected PN and PAD. More than half of participants with clinical examination findings of PN or PAD failed to self-report the condition (57.7% and 86.8%, respectively). Among adults with lower-limb loss with suspected PN, participants with dysvascular amputations were at lower risk of underreporting (odds ratio [OR] = 0.2, 95% CI: 0.1-0.6). For those with suspected PAD, those who reported more medication prescriptions were at lower risk of underreporting (OR = 0.8, 95% CI: 0.7-1.0). Adults with lower-limb loss underreport PN and PAD per a medical history checklist, which may indicate underdiagnosis or lack of patient awareness. Routine assessment is highly recommended in this population and may be especially critical among individuals with non-dysvascular etiology.
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    Research Agenda for Physical Therapy From the American Physical Therapy Association
    (Physical Therapy & Rehabilitation Journal, 2023-09-15) Stevens-Lapsley, Jennifer; Hicks, Gregory E.; Zimney, Kory; Slaven, Emily J.; Manal, Tara Jo; Jeffries, Lynn M.
    Research agendas play an important role in directing scholarly inquiry in a field. The Research Agenda for Physical Therapy From the American Physical Therapy Association (APTA) outlines research priorities that are vital to advancing physical therapist practice and the profession. The development of the research agenda included multiple iterative steps and feedback from stakeholders. A research agenda subgroup (n = 6) of the APTA Scientific and Practice Affairs Committee (SPAC), with APTA staff support, gathered information on existing research agendas, developed draft priority descriptions, and gathered feedback via surveys. The subgroup first conducted an environmental scan of the research agendas in the physical therapy and rehabilitation fields. To gather information about research priorities, APTA’s Technology and Organizational Performance department distributed a survey to 3 samples. APTA staff organized the feedback, and SPAC edited and synthesized a draft agenda. This draft was sent out in survey form to the original samples and to members of the APTA Academy of Research. Concurrently, a repeat environmental scan was conducted. A final draft of the research agenda was sent for final review to a smaller cohort (n = 95) that included content experts in each of the main categories of the agenda as identified by the APTA Academy of Research. The SPAC research agenda subgroup reviewed and incorporated the information into the final draft. The final research agenda includes priorities in topical areas (population health, mechanistic research, clinical research, education/professional development research, health services research, and workforce development) identified as key in the evolution of our profession. Impact The Research Agenda for Physical Therapy From APTA identifies research priorities within the profession vital to advancing the practice and profession of physical therapy. The research agenda has 6 key areas of focus: population health research, mechanistic research, clinical research, education and professional development research, health services research, and workforce research. Researchers, funding agencies, and public policy makers can use the research agenda to concentrate research efforts around these areas.
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    Corticosteroid Injections for Symptomatic Treatment of Osteoarthritis of the Knee: A Pilot Blinded Randomized Trial
    (ACR Open Rheumatology, 2023-09-22) Baker, Joshua F.; Olave, Marianna; Leach, William; Doherty, Caleigh R.; Gillcrist, Rachel L.; White, Daniel K.; Ogdie, Alexis; England, Bryant R.; Wysham, Katherine; Quinones, Mercedes; Xiao, Rui; Neogi, Tuhina; Scanzello, Carla R.
    Objective To quantify the effect of corticosteroids compared to lidocaine-only injections over 12 weeks among patients with knee osteoarthritis (KOA). Methods Participants with KOA were randomized to receive a knee injection of methylprednisolone acetate 1 mL (40 mg) plus 2 mL lidocaine (1%) or 1 mL saline and 2 mL lidocaine. Participants and providers were blinded to treatment allocation using an opacified syringe. The outcome was the average change from baseline of the total Knee Injury and Osteoarthritis Outcome Score (KOOS) (range 0-100) assessed at 2-week intervals over 12 weeks. Participants received KOOS questionnaires on their smartphones through a web-based platform. We used linear mixed-effects regressions with robust variance estimators to evaluate the association between the intervention and change in KOOS total and subscales (ClinicalTrials.gov identifier NCT03835910; registered 2019-02-11). Results Of the 33 randomized participants, 31 were included in the final analysis. The predicted mean (SE) change in total KOOS over the 12-week follow-up was 9.4 (3.2) in the corticosteroids arm versus −1.3 (1.4) in the control arm (P = 0.003). Of participants, 47% achieved change as large as the minimal clinically important difference (16 units) in the intervention arm compared to 6% of participants in the lidocaine arm. Further, there were greater improvements in the intervention arm for KOOS subscales and for Patient Reported Outcomes Measurement Information System (PROMIS) assessments of pain intensity, behavior, and interference. Conclusion Corticosteroid injections demonstrated clinically meaningful improvements in KOA symptoms over 12 weeks of follow-up. These data support larger studies to better quantify short-term benefits.
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    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.
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    School nurses: Researcher and clinician collaborations to address paediatric health inequities
    (Journal of Advanced Nursing, 2023-08-02) Covington, Lauren B.; Hildick, Heidi; Robinson, Anastasia; Pennington, Mandy; Mansi, Suzanne; Ji, Xiaopeng; Strang, Abigail; Rani, Seema; Robson, Shannon; Lobo, Michele A.; Cuffee, Yendelela; Selekman, Janice; Taherzadeh, Sanaz; Carroll, Jill; Covey, Ann; Murray, Kenna; Zimmerman, Chriss; Horney, Jennifer A.; Sowinski, Christine; Patterson, Freda
    School nurses are front-line paediatric public health providers who are eager and poised to address paediatric health inequities. They are tasked with remaining informed about current health issues (i.e. immunization updates, surges in emerging and reemerging illnesses, novel medications and side effects, etc.), but also the disparities that arise within different populations of students (Willgerodt et al., 2018). Further, school nurses are well-positioned to be advocates for the most vulnerable students at risk for health disparities and inequities. For example, school nurses are able to identify and advocate for students who experience food and housing insecurity, lack access to medical or dental care, and/or those who live in unstable or insecure environments (Gratz et al., 2021). School nurses bridge gaps that address lack of healthcare access for their students by making referrals to social workers, public health departments or statewide agencies. School nurses are truly community engaged—sharing with community members the top issues plaguing their students, as well as listening to and addressing priority health issues afflicting the community (Gratz et al., 2021; Willgerodt et al., 2018).
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    Effect of Symptom Duration on Injury Severity and Recovery in Patients With Achilles Tendinopathy
    (Orthopaedic Journal of Sports Medicine, 2023-05-22) Hanlon, Shawn L.; Scattone Silva, Rodrigo; Honick, Brian J.; Silbernagel, Karin Grävare
    Background: Achilles tendinopathy is a common overuse condition. Distinguishing between early- and late-stage tendinopathy may have implications on treatment decisions and recovery expectations. Purpose: To compare the effects of time and baseline measures of tendon health on outcomes among patients with varying symptom durations after 16 weeks of comprehensive exercise treatment. Study Design: Cohort study; Level of evidence, 3. Methods: Participants (N = 127) were categorized into 4 groups based on the number of months since symptom onset: ≤3 months (n = 24); between >3 and ≤6 months (n = 25); between >6 and ≤12 months (n = 18); or >12 months (n = 60). All participants received 16 weeks of standardized exercise therapy and pain-guided activity modification. Outcomes representing symptoms, lower extremity function, tendon structure, mechanical properties, psychological factors, and patient-related factors were assessed at baseline and at 8 and 16 weeks after the initiation of exercise therapy. Chi-square tests and 1-way analysis of variance were used to compare baseline measures between groups.Time, group, and interaction effects were evaluated using linear mixed models. Results: The mean age of the participants was 47.8 ± 12.6 years, 62 participants were women, and symptoms ranged from 2 weeks to 274 months. No significant differences were found among symptom duration groups at baseline for any measure of tendon health. At 16 weeks, all groups demonstrated improvements in symptoms, psychological factors, lower extremity function, and tendon structure, with no significant differences among the groups (P > .05) Conclusion: Symptom duration did not influence baseline measures of tendon health. Additionally, no differences were observed among the different symptom duration groups in response to 16 weeks of exercise therapy and pain-guided activity modification.
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    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.
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    Understanding Recruitment Yield From Social Media Advertisements and Associated Costs of a Telehealth Randomized Controlled Trial: Descriptive Study
    (Journal of Medical Internet Research, 2023-05-18) Aily, Jéssica Bianca; Copson, Jennifer; Voinier, Dana; Jakiela, Jason; Hinman, Rana; Grosch, Megan; Noonan, Colleen; Armellini, Megan; Schmitt, Laura; White, Mika; White, Daniel
    Background: Recruiting study participants for clinical research is a challenging yet essential task. Social media platforms, such as Facebook, offer the opportunity to recruit participants through paid advertisements. These ad campaigns may be a cost-effective approach to reaching and recruiting participants who meet specific study criteria. However, little is known about the extent to which clicks on social media advertisements translate to the actual consent and enrollment of participants who meet the study criteria. Understanding this is especially important for clinical trials conducted remotely, such as telehealth-based studies, which open the possibility to recruit over large geographical areas and are becoming more common for the treatment of chronic health conditions, such as osteoarthritis (OA). Objective: The aim of this study was to report on the conversion of clicks on a Facebook advertisement campaign to consent to enrollment in an ongoing telehealth physical therapy study for adults with knee OA, and the costs associated with recruitment. Methods: This was a secondary analysis using data collected over the first 5 months of an ongoing study of adults with knee OA. The Delaware Physical Exercise and Activity for Knee Osteoarthritis program compares a virtually delivered exercise program to a control group receiving web-based resources among adults with knee OA. Advertisement campaigns were configured on Facebook to reach an audience who could be potentially eligible. Clicking on the advertisement directed potential participants to a web-based screening form to answer 6 brief questions related to the study criteria. Next, a research team member called individuals who met the criteria from the screening form and verbally asked additional questions related to the study criteria. Once considered eligible, an electronic informed consent form (ICF) was sent. We described the number of potential study participants who made it through each of these steps and then calculated the cost per participant who signed the ICF. Results: In sum, between July and November 2021, a total of 33,319 unique users saw at least one advertisement, 9879 clicks were made, 423 web-based screening forms were completed, 132 participants were successfully contacted, 70 were considered eligible, and 32 signed the ICF. Recruitment costed an average of US $51.94 per participant. Conclusions: While there was a low conversion from clicks to actual consent, 32% (32/100) of the total sample required for the study were expeditiously consented over 5 months with a per-subject cost well below traditional means of recruitment, which ranges from US $90 to US $1000 per participant. Trial Registration: Clinicaltrails.gov NCT04980300; https://clinicaltrials.gov/ct2/show/NCT04980300 J Med Internet Res 2023;25:e41358 doi:10.2196/41358
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    Adults with lower-limb amputation: Reduced multifidi muscle activity and extensor muscle endurance is associated with worse physical performance
    (Clinical Physiology and Functional Imaging, 2023-05-24) Sions, Jaclyn M.; Seth, Mayank; Beisheim-Ryan, Emma H.; Hicks, Gregory E.; Pohlig, Ryan T.; Horne, John R.
    Trunk muscles may be an overlooked region of deficits following lower-limb amputation (LLA). This study sought to determine the extent that trunk muscle deficits are associated with physical function following amputation. Sedentary adults with a unilateral transtibial- (n = 25) or transfemoral-level (n = 14) amputation were recruited for this cross-sectional research study. Participants underwent a clinical examination that included ultrasound imaging of the lumbar multifidi muscles, the modified Biering-Sorensen Endurance Test (mBSET), and performance-based measures, that is, the Timed Up and Go (TUG), Berg Balance Scale (BBS), and 10-m Walk Test (10mWT). Associations between trunk muscle metrics and performance were explored with regression modeling, while considering covariates known to impact performance postamputation (p ≤ 0.100). Average ultrasound-obtained, lumbar multifidi activity was 14% and 16% for transfemoral- and transtibial-level amputations, respectively, while extensor endurance was 37.34 and 12.61 s, respectively. For TUG, nonamputated-side multifidi activity and an interaction term (level x non-amputated-side multifidi activity) explained 9.4% and 6.2% of the total variance, respectively. For 10mWT, beyond covariates, non-amputated-side multifidi activity and the interaction term explained 6.1% and 5.8% of the total variance, respectively. For TUG, extensor endurance and an interaction term (level x mBSET) explained 11.9% and 8.3% of the total variance beyond covariates; for BBS and 10mWT, extensor endurance explained 11.2% and 17.2% of the total variance, respectively. Findings highlight deficits in lumbar multifidi activity and extensor muscle endurance among sedentary adults with a LLA; reduced muscle activity and endurance may be important factors to target during rehabilitation to enhance mobility-related outcomes.
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    A reliable and efficient adaptive Bayesian method to assess static lower limb position sense
    (Journal of Neuroscience Methods, 2023-05-15) Wood, Jonathan M.; Morton, Susanne M.; Kim, Hyosub E.
    Highlights - We developed a novel static lower limb position sense assessment during standing. - The method, a 2AFC task, uses a Bayesian adaptive algorithm to improve efficiency. - The method achieved reliable lower limb position sense estimates in 50 trials. - This method should serve as a useful tool for gait and balance researchers. Background Lower limb proprioception is critical for maintaining stability during gait and may impact how individuals modify their movements in response to changes in the environment and body state, a process termed “sensorimotor adaptation”. However, the connection between lower limb proprioception and sensorimotor adaptation during human gait has not been established. We suspect this gap is due in part to the lack of reliable, efficient methods to assess global lower limb proprioception in an ecologically valid context. New Method We assessed static lower limb proprioception using an alternative forced choice task, administered twice to determine test-retest reliability. Participants stood on a dual-belt treadmill which passively moved one limb to stimulus locations selected by a Bayesian adaptive algorithm. At the stimulus locations, participants judged relative foot positions and the algorithm estimated the point of subjective equality (PSE) and the uncertainty of lower limb proprioception. Results Using the Bland-Altman method, combined with Bayesian statistics, we found that both the PSE and uncertainty estimates had good reliability. Comparison with existing method(s) Current methods assessing static lower limb proprioception do so within a single joint, in non-weight bearing positions, and rely heavily on memory. One exception assessed static lower limb proprioception in standing but did not measure reliability and contained confounds impacting participants’ judgments, which we experimentally controlled here. Conclusions This efficient and reliable method assessing lower limb proprioception will aid future mechanistic understanding of locomotor adaptation and serve as a useful tool for basic and clinical researchers studying balance and falls.
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    START-Play Physical Therapy Intervention Indirectly Impacts Cognition Through Changes in Early Motor-Based Problem-Solving Skills
    (Pediatric Physical Therapy, 2023-07) Koziol, Natalie A.; Kretch, Kari S.; Harbourne, Regina T.; Lobo, Michele A.; McCoy, Sarah W.; Molinini, Rebecca; Hsu, Lin-Ya; Babik, Iryna; Cunha, Andrea Baraldi; Willett, Sandra L.; Bovaird, James A.; Dusing, Stacey C.
    Purpose: This study tested whether the Sitting Together and Reaching to Play (START-Play) physical therapy intervention indirectly impacts cognition through changes in perceptual-motor skills in infants with motor delays. Methods: Participants were 50 infants with motor delays randomly assigned to START-Play plus Usual Care Early Intervention (UC-EI) or UC-EI only. Infants' perceptual-motor and cognitive skills were assessed at baseline and 1.5, 3, 6, and 12 months post-baseline. Results: Short-term changes in sitting, fine motor skills, and motor-based problem-solving, but not reaching, predicted long-term changes in cognition. START-Play indirectly impacted cognition through motor-based problem-solving but not sitting, reaching, or fine motor skills. Conclusions: This study provided preliminary evidence that early physical therapy interventions that blend activities across developmental domains and are supported by an enriched social context can place infants on more optimal developmental trajectories.
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    Identifying Health-Related Quality of Life Domains After Upper Extremity Transplantation
    (Archives of Physical Medicine and Rehabilitation, 2023-06-01) Tulsky, David S.; Kisala, Pamela A.; Tyner, Callie E.; Slotkin, Jerry; Kaufman, Christina; Dearth, Christopher L.; Horan, Annamarie D.; Talbot, Simon G.; Shores, Jaimie T.; Azari, Kodi; Cetrulo, Curtis Jr.; Brandacher, Gerald; Cooney, Carisa M.; Victorson, David; Dooley, Mary; Levin, L. Scott; Tintle, Scott M.
    Objective To identify the most important health-related quality of life (HRQOL) domains and patient-reported outcomes after upper extremity transplantation (UET) in individuals with upper extremity amputation. Design Verbatim audio-recordings of individual interviews and focus groups were analyzed using qualitative, grounded theory-based methods to identify important domains of HRQOL and provide guidance for outcomes measurement after UET. Setting Individual interviews were conducted by phone. Focus groups were conducted at 5 upper extremity vascularized composite allotransplantation (VCA) centers in the US and at an international conference of VCA experts. Participants Individual phone interviews were conducted with 5 individuals with lived experience of UET. Thirteen focus groups were conducted with a total of 59 clinical professionals involved in UET. Interventions Not applicable. Main Outcome Measures Not applicable. Results Twenty-eight key HRQOL domains were identified, including physical functioning and medical complications, positive and negative emotional functioning, and social participation, relations, and independence. We identified key constructs for use in evaluation of the potentially substantial physical, medical, social, and emotional effects of UET. Conclusions This study provides an overview of the most important issues affecting HRQOL after UET, including several topics that are unique to individuals with UET. This information will be used to establish systematic, comprehensive, and longitudinal measurement of post-UET HRQOL outcomes.
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    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 Grävare
    Patellar 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.
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    Establishing severity levels for patient-reported measures of functional communication, participation, and perceived cognitive function for adults with acquired cognitive and language disorders
    (Quality of Life Research, 2022-12-27) Cohen, Matthew L.; Harnish, Stacy M.; Lanzi, Alyssa M.; Brello, Jennifer; Hula, William D.; Victorson, David; Nandakumar, Ratna; Kisala, Pamela A.; Tulsky, David S.
    Purpose: To empirically assign severity levels (e.g., mild, moderate) to four relatively new patient-reported outcome measures (PROMs) for adults with acquired cognitive/language disorders. They include the Communicative Participation Item Bank, the Aphasia Communication Outcome Measure, and Neuro-QoL’s item banks of Cognitive Function (v2.0) and Ability to Participate in Social Roles and Activities (v1.0). Method: We conducted 17 focus groups that comprised 22 adults with an acquired cognitive/language disorder from stroke, Parkinson’s disease, or traumatic brain injury; 30 care partners of an adult with an acquired cognitive/language disorder; and 42 speech-language pathologists who had experience assessing/treating individuals with those and other cognitive/language disorders. In a small, moderated focus-group format, participants completed “PROM-bookmarking” procedures: They discussed hypothetical vignettes based on PROM item responses about people with cognitive/language disorders and had to reach consensus regarding whether their symptoms/function should be categorized as within normal limits or mild, moderate, or severe challenges. Results: There was generally good agreement among the stakeholder groups about how to classify vignettes, particularly when they reflected very high or low functioning. People with aphasia described a larger range of functional communication challenges as “mild” compared to other stakeholder types. Based on a consensus across groups, we present severity levels for specific score ranges for each PROM. Conclusion: Standardized, stakeholder-informed severity levels that aid interpretation of PROM scores can help clinicians and researchers derive better clinical meaning from those scores, for example, by identifying important clinical windows of opportunity and assessing when symptoms have returned to a “normal” range.
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    Construct validity of movement-evoked pain operational definitions in older adults with chronic low back pain
    (Pain Medicine, 2023-03-21) Knox, Patrick J.; Simon, Corey B.; Pohlig, Ryan T.; Pugliese, Jenifer M.; Coyle, Peter C.; Sions, Jaclyn M.; Hicks, Gregory E.
    Objective: Movement-evoked pain (MeP) may predispose the geriatric chronic low back pain (LBP) population to health decline. As there are differing operational definitions for MeP, the question remains as to whether these different definitions have similar associations with health outcomes in older adults with chronic LBP. Design: Cross-sectional analysis of an observational study. Setting: Clinical research laboratory. Subjects: 226 older adults with chronic LBP. Methods: This secondary analysis used baseline data from a prospective cohort study (n = 250). LBP intensity was collected before and after the repeated chair rise test, stair climbing test, and 6-minute walk test; MeP change scores (ie, sum of pretest pain subtracted from posttest pain) and aggregated posttest pain (ie, sum of posttest pain) variables were calculated. LBP-related disability and self-efficacy were measured by the Quebec Back Pain Disability Scale (QBPDS) and Low Back Activity Confidence Scale (LOBACS), respectively. Physical function was measured with the Health ABC Performance Battery. Robust regression with HC3 standard errors was used to evaluate adjusted associations between both MeP variables and disability, self-efficacy, and physical function. Results: Greater aggregated posttest MeP was independently associated with worse disability (b = 0.593, t = 2.913, P = .004), self-efficacy (b = –0.870, t = –3.110, P = .002), and physical function (b = –0.017, t = –2.007, P = .039). MeP change scores were not associated with any outcome (all P > .050). Conclusions: Aggregate posttest MeP was linked to poorer health outcomes in older adults with chronic LBP, but MeP change scores were not. Future studies should consider that the construct validity of MeP paradigms partially depends on the chosen operational definition.
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    Neuromotor changes in participants with a concussion history can be detected with a custom smartphone app
    (PLOS ONE, 2022-12-15) Rhea, Christopher K.; Yamada, Masahiro; Kuznetsov, Nikita A.; Jakiela, Jason T.; LoJacono, Chanel T.; Ross, Scott E.; Haran, F. J.; Bailie, Jason M.; Wright, W. Geoffrey
    Neuromotor dysfunction after a concussion is common, but balance tests used to assess neuromotor dysfunction are typically subjective. Current objective balance tests are either cost- or space-prohibitive, or utilize a static balance protocol, which may mask neuromotor dysfunction due to the simplicity of the task. To address this gap, our team developed an Android-based smartphone app (portable and cost-effective) that uses the sensors in the device (objective) to record movement profiles during a stepping-in-place task (dynamic movement). The purpose of this study was to examine the extent to which our custom smartphone app and protocol could discriminate neuromotor behavior between concussed and non-concussed participants. Data were collected at two university laboratories and two military sites. Participants included civilians and Service Members (N = 216) with and without a clinically diagnosed concussion. Kinematic and variability metrics were derived from a thigh angle time series while the participants completed a series of stepping-in-place tasks in three conditions: eyes open, eyes closed, and head shake. We observed that the standard deviation of the mean maximum angular velocity of the thigh was higher in the participants with a concussion history in the eyes closed and head shake conditions of the stepping-in-place task. Consistent with the optimal movement variability hypothesis, we showed that increased movement variability occurs in participants with a concussion history, for which our smartphone app and protocol were sensitive enough to capture.
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